Treat My Patient

[Ridryder911]

I as well agree with most of your thoughts. However; we continue to make excuses than to address the problems. Typical EMS solutions.

I am far from being an English teacher however; poor and sloppy grammar and spelling is non-tolerable. Period. One of the ways a profession is judged upon on is how well they are able to communicate.

When I first entered EMS forums, it was almost disgraceful on the poor writing skills most EMT's presented. Fortunately, most other posters have became non-tolerable on grossly presentations. Can one imagine the opinion one would have reading a physician or nurse forum and reading poorly written statements and misspelling of common medications?

Part of the problem is that we in EMS do not expect anything better and will tolerate such. We do not even require EMS instructors to have formal education, even though we require kindergartners to have an instructor with a degree. Why should we expect much better from the current education level?

Do we really eat our young? I have seen both sides. Yes, I believe it goes back to the educational system again. Most graduates are not properly educated and definitely not prepared for the workforce. Expectations and the reality is far from what they expected.

We push and ingrain memory tricks to pass skill trauma skill stations, yet we never discuss the majority of calls are not ALS or trauma rather mundane and medical. Ever read the posts here on this forum? Congrat's and salutations on passing the EMT class/ tests, then later only to read where they were discouraged or already "burned out" in a such a short period of time

You are right many EMS administrators (whom themselves are usually poorly educated) sometimes only care if their personnel have a "pulse and a patch". Yet, again did we as educators really prepare the students for the workforce or just the ability to treat patients?

I do believe we need to "toughen" up our students. Intimidation is subjective. If one becomes easily intimidated over a forum, then I can assure you they will be very intimidated the first time they get their arse chewed out by a physician. Preparing and educating the student that this job is no rose garden, and one needs to mentally prepare and be prepared to grow with such occurrences. Review the way medical students and even nursing students are demanded to present information and perform under scrutiny, as well as they are expected to "bounce back" and improve one self.

We need to be sure that EMS students realize that they are only taught the minimal level. This allows them to obtain a license, certification to then to grow and improve upon. Although, I do not believe in total intimidation for teaching, but rather EMS and medicine is very intimidating in itself. It can be from peers, family, and the scene itself. As you can recall from your ACLS event you probably never forgot to monitor your Isuprel again thus the purpose of it all.

It is the responsibility of the Field Training Officer to make sure that they are able to operate and function at their designated level within the system. It again has both sides. New graduates need to recognize that they have an obligation to learn and preceptors have an obligation to "mentor" and guide newbies. Excessive pressure is undo and not warranted. Yes, I have seen too many "egos" get in the way, not remembering what it was like when they first started out.

Part of this job is persistence. Being able to justify your treatment or lack of, presenting a professional image, and supporting increased and improved education through out your career.

R/r 911

 

[VinBin]

I agree Rid, but it appears that dtermnd is stated to be a "student" and his level is not stated. I think he is far from being a lone practitionar and could just be reciting a common algorithm for an unstable rhythm.

 

[mdymes]

The comment about the schools was not intended to excuse but my obviously poor attempt at sarcasm toward the government schools. Mike

 

[Aileana]

to be honest, I have no idea as to what I would do in this case. Septic shock from the infection pt had is the only thing I can come up with with my current level of education in this field. Out of curiousity, how did you treat this patient, and what was the diagnosis?

 

[medic5740]

AMI? CHF? or Infection?

I was wondering if nitro wouldn't be a good test for what is going on with this patient. If a SL nitro did any good, perhaps repeat administration of SL nitro or a nitro drip might help this patient. It's hard to imagine this patient with good breath sounds with all the other descriptions. What was his temperature? What other drugs was he taking? Anything for the infection? Did you attempt another IV? How far from the hospital?
In our rural area, we would continue to attempt to establish an IV. With your description, our med control docs would probably go with a nitro drip if that helped improve the respirations. Our protocol would require assisting ventilations via BVM with respirations much above 40 by our basic EMTs as well as medics.

What was the final diagnosis?

 

[KEVD18]

airway airway airway. with that resp rate he is circling the drain. knock him down and tube him. manage everything else after you have his breathing controlled.

EDIT TO REMOVE PERSONAL ATTACK

 

[Ridryder911]

Edit to remove personal attack

Sorry, you feel this way. As a so proclaimed student, I would think you particularly would be the first to want everyone to know the current and correct therapy. While also supporting the knowledge to not defib a non-shockable rhythm (possibly causing a fatality) in this case, and to at least know the correct spelling of the medication(s) when discussing treatment(s). Endorsing such, even on forum sites only support ignorance and poor knowledge. If we can not even correct ourselves, would we prefer to have another professional do it for us later? What does that say about our demeanor?

Airway is correct, however many current literature is NOT recommending RSI and intubation, unless it cannot be controlled by any other measures. This is definitely a difficult case in determining that it is pneumonia/URI versus CHF or even both. Recent literature as well has demonstrated that medics may misdiagnose CHF up to 80%. Thus the reason so many is pulling RSI, Lasix, etc. I support RSI treatment , in certain situation(s) it is a progressive treatment and definitely has its role, one should be sure all other methods have been exhausted before even considering such procedure. Placing a patient on a ventilator has more detrimental effects than most medics are aware of and should be again a last measure.

Truthfully, I just don't sit around and shoot off from an emotional thought. As well feel like others, get tired of having to explain that I prefer that my profession be such.. a profession staffed by professionals. I do want EMS to be what it can be and should be, rather than just a vocation and hobby. There are many alike me that have worked, and attended more a than few months of trade school or junior college, and wish EMS to be respected, and treated as such. This of course only comes from us demonstrating as educated and knowledgeable professionals.

The difference between me and many others EMS professionals, is that many others never do participate in EMS forums, many have explained per IM's to me it is due to the type of similar postings and ideology. There are a few other Paramedics on here such as Vent, Flight, DT4EMS, AK, etc (to name a few, there are others.. )that attempt to bring professional and current medical and clinical knowledge to this site. Many of other professional medics describe being amused or worse yet, scared of some of the postings in many of the EMS forums.

Does it not seem strange from the thousands and thousands of Paramedics only a few handful ever participate in EMS forums? ... Have you not wondered why?

R/r 911


R/r 911

 

[DwayneW]

I'm confused as to the use of CPAP and intubation here, though I'm a student with no street experience, so I'm just airing my logic to see how it flies...

Elderly pt, respiratory distress @ 44 (or so), stamina failing, SPO2 94% on 15L, clear lungs, possible eschemia or worse on the monitor...it seems like we need the most immediate, decent chance to ventilate this man, no?

Why would CPAP even be considered before assisted vents were used to attempt to control his rate and volume?

And why intubate at this point? I'm guessing he's not been eating or drinking much in the last several hours, he seems able to protect his airway (has been doing it for at least the last two hours), what is to be gained with intubation?

Those that haven't read my posts before will soon find I'm not the brightest bulb on the tree...so I'm not attempting to disrespect anyone's opinions, only trying to see if my thinking is off in the ditch somewhere...

Have a great day all!

Dwayne

 

[Ridryder911]

Dwayne, as usual you bring out some very interesting points. This scenario is a confusing one, and as of yet have not been clear of the final diagnosis. Of course like in real life, there were probably multiple diagnosis, just like most of our patients.

You are correct, I too would not had suggested CPAP as this patient lung sounds and other symptamology was not indicative of CHF. Side note; we do need to remember though, the shift from right to left side CHF, patients may compensate and actually clear up for a short period of time. Until the left side is unable to compensate, then one will be in trouble. In this case though, it appear to have an URI (upper respiratory infection) or pneumonia, with the pedal edema being probably position dependent. However, I did not see any febrile or even temp changes, even subtemp is not unusual in sepsis.

One diagnosis that I have not seen discussed, and truthfully believe should be considered is a pulmonary embolus ( Hx. of URI, confinement). This could be the presentations tachypnea, ischemia changes, clear lungs, and diaphoresis as well. PE's are misdiagnosed in about 80% of the cases.

You are also correct in describing to assist the patient ventilation's. The difficulty in this case is determining if the ventilatory status is sufficient in allowing the patient for Vq and perfusion level. Does one control the breathing, increase the oxygen level, control the airway or attempt to do all at one time?

These are difficult questions, & obviously hard to determine without a better clinical presentation as well, even then multiple disciplinary interventions can be thought of, none being wrong or the most correct. I don't think CPAP is most appropriate treatment in this patient, at this time from the clinical picture. In fact if it is a P.E., could be potentially detrimental.

Many are correct one can assist the ventilatory system and be correct, as well as consider "knocking down" the respiratory drive and controlling it by RSI and intubation. The goal of course is not "securing" the airway as much as controlling the gas exchange. Again, one needs to understand the full impact, when doing so. Like other treatments, it does have some major side effects (good and bad) patients when placed on a vent to control the respiratory pattern. My point in previous posts is to be sure to fully understand the risks. It might help the immediate problem only to cause more
detrimental effects in the end.


Many still do not understand CPAP. Many still believe that it still "blows fluid" back into the alveoli (in some ways it does) but actually CPAP reduces stroke volume, and some, but not all, some studies have shown a fall in cardiac output. This response may be the result of reduced venous return and thus stroke volume, it has also been proposed that the CPAP-mediated reduction in the work or breathing may also offer an explanation for the associated fall in cardiac output. It has also been shown that CPAP improves left ventricular afterload by reducing transmural (wall) left ventricular pressure. In conjunction with these studies, another study demonstrated a significant reduction in those of near end point of death and the need for transplantation in CHF patients. So CPAP is very beneficial with frank pulmonary edema, CHF.

R/r 911

 

[Pablo the Pirate]

well heres my 2 cents for what its worth, and regards to that is one of the crappiest 12 leads i've seen.(no offense) I don't know what i'd settle on calling it other than a wide tachycardia with on demand pacing. I see some p waves although they do not all look unifocal. also the qt seems quite wide, and no i didn't count to see if it was. please correct me if i'm wrong. I have a question as to rather or not someone actually physically checked his pulse. were all those beats perfusing? what did it feel like? checkin a pulse can give you alot of info without even hooking up the moniter. I also agree with r/r on the toss out the pulse ox at this point... regardless of what it reads the man can't breathe. plus with a recent lung infection how much of his lungs is he actually using? I believe i would try the CPAP also before I hauled off and RSI'd this guy. I know that alot of recent literature is questioning the use of nebs on CHF, but what are his current meds? is there a history of asthma or copd? and do his lungs "sound clear" because he's so tight and not moving good air. obviously with a rate of 40 something its hard to tell. My main priority in any case would be get his breathing under control, not waste time on scene, and "drive fast and take chances"

 

[DwayneW]

Hey Pablo,

I'm just not seeing physiologically how CPAP is going to help him much, or at all...what am I missing here?

Dwayne

 

[Pablo the Pirate]

ummm...nothing im just willing to try it before knockin him down. I'm really curious to know if it helped. plus i've seen CPAP work on someone that i thought for sure would end up tubed but it was an asthmatic.

 

[Pablo the Pirate]

one more thing...if this guy started feeling short of breath and then worked himself into a real tissy (which is possible but not probable givin other signs and symtoms) it would help

 

[Arkymedic]

Oh how I wish...

I wish we had CPAP protocol and recognition by the state of Ark. I also wish we were able to RSI pts but that would be inappropriate in this case in my opinion. Since I don't have either option I would do assessment, v/s, and airway mgmt and the only things I really could do would be universal CHF algorithm of:
Lasix
Morphine
Nitro
Oxygen
Position

and transport.

I also am worried about the post about unstable VT but I also asked some stupid questions when I was a student and learned a lot by asking those ?s...

 

[coolidge]

adverse drug reaction(s)

Author originally stated, "however states he has just recently been put on Lasix for his "lung infection."

Can you clarify the patient's medications? Was there a possible adverse drug reaction in the making, ie is there a temporal relationship between the drug the patient just started for his lung infection? Was there excessuve use of his inhalers?

Pharmacist Bob