Divemedic

We found her on the toilet. For some reason, when people become REALLY sick, they go sit on the pot. In this case, she was on the pot in a bathroom that was only accessible by passing through a hallway that was about 36 inches wide, and had stacks of junk and knick-knacks along both walls, reducing the shipping channel down to about 20 inches. This still would have only been an annoyance, except that she weighed about 310 pounds, and was 5 foot 2.

She is pale, her lips are blue, and her jugular veins are prominent. He legs are oozing fluid, and have large blisters on them. Cellulitis? Maybe. Her arms are swollen. Her complaint is shortness of breath, which she says she has had for about 4 days. She has a history of high blood pressure and hypothyroidism. She has been taking norvasc, lasix, lopressor, and synthroid for several years, and claims compliance. She has no known drug allergies.

Her vitals are as follows: HR78, SaO2 60% on room air, BP 81/50, EtCO2 is 80 with a normal appearance to the waveform. Lung sounds are clear, but diminished bilaterally. She is in a sinus rhythm, and her 12 lead is unremarkable.

My thoughts? The chief complaint in this case is supported by the cyanosis and the low O2 sats. The diminished lung sounds with the absence of wheezing, along with the JVD, the high CO2, and the hypotension lead me to believe that what we are dealing with is congestive heart failure. Since I have previously stated that CPAP is the flippity floppity floop, we went ahead and applied CPAP at 8cm and started an IV. While IV access was obtained, her O2 sats climbed to about 96%, and her EtCO2 fell to 60.

With the respiratory problem under our (temporary) control, it was time to turn our attention to the decompensating cardiogenic shock, so a Dopamine drip was hung. We hit our effect at about 800mcg/minute. I know that sounds like alot, but remember that the patient weighed in at 140kgs. Her BP climbed to 94/60, and I left it there.

When we got to the ER, the doctor on duty (same Doc from this post) wanted to know why we didn’t give albuterol/atrovent by nebulizer. I pointed out that she was not wheezing, that albuterol is only to be used with caution in CHF patients, and that she was taking beta blockers. I told him that she seemed to improve with CPAP, so I saw no point in giving the albuterol. He proceeded to tell me how wrong I was, and said that diminished lung sounds were a form of wheezing. He took her off the CPAP, and ordered the nebulizer. I left.

There is an old saying that if everyone around you seems wrong, maybe it isn’t them. I see so many cases of Doctors telling me things that contradict what I have been taught, and what I have been teaching to my own medic students, that I sometimes wonder if I am the one who is wrong. It has been known to happen. I had a junior medic with me on the call who now thinks I am an idiot, and a doctor who is trash talking me to the ER staff.

Maybe they are more current, maybe the people who taught me were wrong. What do you think?

To sum up Hazmat Awareness in a simple post, we can forget using the DOT guide, and just go for the copometric system of hazard identification. In order to do this, simply park a safe distance from the scene, and view the cops through a pair of binoculars:

If the cop car is running, and the cop is lying on the ground, you are dealing with a toxic atmosphere.

If the cop car has stalled, and the cop is down, you are dealing with an oxygen depleted atmosphere.

If the cop and car are both on fire, you are dealing with a flammable atmosphere.

If both the cop car and the cop are melting, you have corrosives to deal with.

Hope this helps.

Or, how do you teach a medical class without mentioning parts of human anatomy?

Last week, I was teaching a class on intubation to a group of aspiring paramedics. I was covering the class for another instructor who was out sick. When discussing the procedure, I used the following youtube video to teach the anatomy:

I pointed out that the landmark the students would be looking for was anatomically similar to the vagina (I actually said vagina, and did not use any vulgarities), and then went on to explain the procedure.

A female student, an 18 year old who finished high school 6 months ago, and who became an EMT less than a month ago, filed a complaint. When the director of the school spoke to me about it, she said the student had been in tears, and stated that no one had ever spoken to her like that before, and she felt violated.

The administrator knows me. We are friends, and I have been teaching for this school for going on 5 years. My wife and I have gone on vacation in the past with her and her husband. She is good people. To her credit, she knows nothing about medical procedures, so I showed her the video. All of our lectures are taped. She viewed the tape. She agreed that I had done nothing improper, but the girl is threatening legal action.

I was upset, and offered to resign, or take a leave of absence. She then told me that she has no desire to terminate me, and does not want to see me leave. She asked if I would promise to stop saying controversial things, but I pointed out that you cannot teach a medical class without mentioning parts of the anatomy, and that being adult education, the girl should get over it. What will happen when the class gets to the OB/GYN lectures? At any rate, I will not be teaching paramedic for awhile. It looks like I will be back to doing ConEd (for the same school) until this girl (and I mean girl, she certainly isn’t a woman) either graduates or fails out.

Teenage girls seem to thrive on drama, and what is better than the drama of watching everyone jump at your command?

The latest from Britain, the Doctors who make housecalls now will inspect your home to make sure it is a safe place for you to live in. They are looking to make sure you have smoke detectors, stair gates, hot water temperature restrictors, oven guards and window and door locks.

The guidance aims to “encourage all practitioners who visit families and carers with children and young people aged under 15 to provide home safety advice and, where necessary, conduct a home risk assessment”. It continues: “If possible, they should supply and install home safety equipment.” British officials claim that this will safeguard about 100,000 children that are admitted to hospital each year for home injuries and save £146m.

Since Britain is already the most security camera heavy country in the world, it makes me wonder how long it will be before big brother installs video cameras inside homes.

I take two lessons from this:

1 Government run healthcare will allow the government to intrude upon every aspect of your life, all in the name of spending money. That is the cost- loss of your freedom.

2 Once the right to keep and bear arms goes, as it did in Britain a few years back, the rest of your rights will begin to disappear as well.

Recently, I was called to a local apartment complex for difficulty breathing. When we arrived, I entered the apartment and I could hear the wheezing from the entry hall. The patient is a 58 year old male who is sitting at his dining room table, puffing on a nebulizer. He looks pretty bad- JVD, cyanosis, accessory muscles, the works. This guy could have been a picture in a textbook on respiratory distress.

His roommate tells us that he has used 3 breathing treatments in the last 2 hours, and has been getting worse. My partner asks the roommate if our patient has ever been intubated before. The patient uses what breath he has to say “No tube” and goes back to huffing his inhaler.

Since I am the engine paramedic, there are 5 of us there, including the rescue crew. Of the 5, four of us are medics, and I am the senior ranking of the four. I remark to my partner that we are probably gonna need some Mag Sulfate for this one. The problem is that our protocol specifically states that we need orders to give Mag for asthma.

We get him in the truck, and his vitals are: HR: 120, BP 189/154, RR 36, SaO2(room air) is 67%, EtCO2 is 80 (that is the highest I have ever seen on an actual patient). We place him on CPAP and give 125mg of Solumedrol. His EtCO2 is now 65 and his SaO2 is 84%.

I call dispatch and get them to page our medical director. I want him, because you never know what Doc is on duty in the ED, and they don’t always want to give orders for meds. After a few minutes, the medical director still hasn’t answered, so we call the receiving hospital for orders. Denied. Instead, he orders .25mg of sub-Q Epi. (I had considered that, but I thought the Mag would be a better choice, especially in light of his hypertension)

When we get there, our medical director is standing in the entry to the ED. Assuming that he was the ED doc, I walk up to him as the rest of the crew is unloading the patient, intending to give a report. Before I can say anything, ha says, why didn’t you give Mag? I told him the protocol says I need orders. He tells me, “Funny, you ignore protocol all the time, why start now? Next time, if he needs it, give it. Just give me a call later and let me know, so I can cover for you.” I love him. He is the best medical director ever.

The patient is fine. He was discharged 2 hours later.

Edited to add: 24 hours after he was discharged, another crew brought him in while he was in full respiratory arrest. He was intubated, and sent to ICU.

This article claims that the citizens of Atlanta are about to elect a white mayor. The claim is that Atlanta’s demographics have changed, and the citizens are about to elect a white mayor.

The contest is posing some delicate questions for a city that has long prided itself on its progressive racial attitudes – the “city too busy to hate.”

The funny thing is that the white candidate leads in the polls- even among black voters (who make up 59% of the electorate). Of course, the black politician’s supporters had this to say:

[A] memo, written by political science professors William Boone and Keith Jennings, warned that black Atlantans need to act quickly to thwart a Norwood victory and maintain black political control of the top job in the city.

“With the ‘Black Mayor First’ approach, there is an unstated assumption that having a black mayor in Atlanta is equal to having a black social, economic and political agenda, or at least someone in office who would be sensitive to that agenda if not a full promoter of that agenda,” the memo said.

The ad hoc group, called the Black Leadership Forum, suggested that blacks unite around Mrs. Borders, calling her the most electable black candidate.

This is a racist attitude that I find reprehensible. Can you imagine the outrage if a white candidate’s supporters circulated a memo espousing a “white Mayor first” approach? Why can’t we have a pro-citizen approach? A minimum government approach? Why does American politics equal screwing one group to the benefit of the other?

Wow. If a Republican had called a woman a whore, there would be screams from the Dems about how the man was insensitive to women and needed to be impeached. Instead, Alan Grayson has lowered the bar that is political discourse in this country even further than it was already, by calling a lobbyist a ‘K street whore’ and then Huffpo backs him up with this headline:

Alan Grayson calls a whore a whore– Beltway whores freak out & defend Enron lobbyist working at the Fed

The funny thing is- I want to see an audit of the Fed, and I happen to agree with Mr Grayson on that issue, however, I think that the current administration’s tactic of shutting down all who disagree is a scary, scary thing. (and before anyone comments or sends me nasty emails, I didn’t like it when the last president did the same thing, either, but this is a new administration. Time to live in the now.)

Of course, Mr Grayson has been on local TV claiming that since the Dems ‘won’ the last election, that they should be allowed to do whatever they wish, and everyone else should just ‘shut up.’ This comment kills me, because the Democrats sure didn’t shut up when the Republicans won three elections in a row. I would also point out that we elected REPRESENTATIVES to REPRESENT us, and if we are to simply elect a political party to be our masters, then why not abolish congress, and elect a king every four years. Sure would save money. Or is it that congress is intended to be a debating society where matters are given all the weight and discussion required before a decision is made?

For those comments and others, Mr Grayson gets my douche of the week award. Douche. How is that for political discourse? Nyah!!! (Now that the bar is so low, I guess I can do it, too.)

Let me begin this post by saying that I have no strong feelings on abortion, except to say that it should be a State issue and not a Federal one. I can see merits on both sides of the discussion: the unborn can still be considered a person (especially after the fetus is viable) and deserves all of the protections and rights that other persons receive, and I can also see the opposing view that a fetus is not yet a person, and the government does not have the power to regulate a person’s body.

One thing I cannot stand is to see the law enforced both ways, as is the case here. A man is being arrested for causing the death of an unborn fetus that is supposed to be his. The thing that angers me about this, is that he is being arrested for doing something that many fight to allow the mothers to do: kill an unborn child for their own convenience. Explain to me how it is any different when a father, as opposed to a mother, does so…

One of the reasons, if not THE reason, for Universal Health care is that no one can afford it, as seeing a doctor has become so expensive. This story will illustrate one reason why care has become so expensive. Today’s will be the first:

A doctor that I know was working in the Emergency Room of a local hospital. One patient was a 23 year old female complaining of lower abdominal pain with vaginal bleeding. A uterine pregnancy test was negative. The doctor ordered a quantitative blood test to see if the young lady was pregnant. The test showed elevated levels of hCG, but the levels were not high enough to say for certain that the patient was pregnant. A lower abdominal ultrasound did not show any signs of pregnancy. The Doctor was concerned that her problem was an ectopic pregnancy. Calculating from her last period, it was determined that if she was pregnant, it was less than 5 weeks pregnant. After a consult with the on call OB/GYN, it was decided that the female would be sent home with orders to see the OB/GYN in his office in 2 days, so that she could be retested.

The patient never showed up for her follow up visit. Six weeks later, she passed out and was taken to the hospital with a ruptured fallopian tube, caused by an ectopic pregnancy. She filed suit, claiming that the ER doctor was at fault for not following up to ensure that the woman went to her appointment.

In Florida, if a Doctor loses more than three malpractice suits, he loses his license to practice medicine. This makes it highly unlikely that a Doctor will go to trial. This provision of law is a boon to the lawyers who practice in medical malpractice land. This case was no different. The doctor settled out of court for $125,000.

Expenses like these must be passed on to consumers. The costs of these lawsuits are passed on to the consumers in higher prices. Who passes them on? Doctors, pharmaceutical companies, medical equipment manufacturers, and anyone else who makes medical equipment, supplies, and devices. Funny how insurance companies and the government, who often decide what procedures and therapies you get, are exempt from lawsuits.