Hello again, everyone. Sorry I've been away from the list so long, but it's not my fault. The telephone lines into my apartment were down for a week, so I had no web access. It was nice to not have any telemarketers call, however. 

This month's case was submitted by list member Larry Davis, EMT-P.  Thanks, Larry!

Dispatch info: Motor Vehicle Collision, possibly 5 patients, one patient possibly ejected. Four lane road, suburban area. 

Responding units include BLS engine, ALS engine, and ALS Fire-Rescue (all of whom arrived on scene first.) Distance to call approximately 3 miles. Four ambulances enroute, one EMS supervisor enroute. Level II trauma hospital about 4 miles away. 
Hot sunny day. EMS is directed by Fire Dept to ejected patient.

Scene Size Up: Patient lying supine on ground, Oxygen by non-rebreather mask applied. Multiple abrasions and contusions to legs, large contusion to 
lateral occiput, R arm deformity, appears unconscious. Vehicle demolished.

Patient assessment: 
Pt. lying supine, eyes open, unresponsive to any stimuli. Airway open, breath sounds clear in 4 fields, respiratory rate 24. 
Radial pulses present, rate = 110, B/P 100 systolic. Pupils equal and reactive, but small. 
No JVD, no tracheal deviation. Old chest scar noted. 
Nitro patch to chest wall. 
Medical Bracelet noting a history of "Cardiac" and "Diabetes." 
Abdomen soft, non-tender. Pelvis stable. 
Extremities normal except acute angulated fracture of R arm. EKG = Sinus Tachycardia. Serum Glucose = 80-120 mg/dL. Enroute to ER, patient began seizure activity, lasting about 3 minutes.

What do you guys think happened here? And further, how are you going to treat it?

   Outcome

You all had a good train of thought on this, but make sure to give Larry a round of applause when you see him next. He stumped every single one of you. 

According to Larry, here's what he did for treatment: 

Oxygen was continued throughout the transport, and IV access was attempted. The patient started seizing, and priority changed from IV to Airway. The seizure lasted about 2 min, 45 sec. then subsided. Airway was suctioned, and removed a good amount of saliva. No stomach or mucus in airway. EKG showed sinus tach without ectopy. Glucose was normal. Arrived at the hospital shortly thereafter, and the patient had another seizure. The ER 
was unable to get much in the way of IV access, but finally got a vein in the foot. Ativan 4 mg total was given, to no effect. Enroute, Larry tried to get an OPA (oral airway) placed, but the patient would not accept this, and RSI (rapid sequence intubation) was not available in the field.

The patient received a central line in the ER, and was paralyzed with norcuron and intubated. They (the ER staff) finally managed to contact the family of the patient, and they confirmed the medical history of the patient....cardiac and diabetes. Oh yeah....they also mentioned that he has 
a seizure history, and he takes Dilantin.

OK, OK, I know what you're all saying..."This information wasn't available, so how could I have known?" Well, you couldn't. But it shouldn't have made a bit of difference in your treatment. He'd still need O2, EKG, IV, and Spinal Packaging, along with the ABCs. However, I was taught by a wise medic who hammered into me "There is a reason for EVERY MVC/MVA. It may be weather, it may be inattention, but it may be something else." I took this as Gospel. An MVC may be caused by someone talking on the cell phone, doing their make-up, trying to attend to a crying child, bright sunlight, zero visibility, ETOH, etc. But until the patient tells me "I dropped my cigarette, and when I looked down for it, I hit the other car," I try to assume the collision was caused by one of four things: Seizure, hypoglycemia, CVA, or Acute MI. Of these, you can check for two of them, and treat for all of them. Granted, everyone on the list treated for the worse-case scenario, and that is to be commended, but don't get tunnel vision. Bet you've never heard that before?!?!?

Comments about this case from the  submitter, Larry Davis

**JEFF now takes the quizzes and we are publishing his scores and comments. What a sport, eh? Maybe Larry should have to do this since he submitted this case?

"Who's on First" case quiz results for Jeff-Missed one on the MCI quiz (the one about who coordinates the movement of ambulances...near the end. I went for Transport Officer. You wanted Staging officer.) Missed one on the Head injury quiz. 

OK, I'm not sure how Valerie managed to sucker me into this idea of posting my test results on the list. Maybe she won't notice me sneaking a peek at the test of the person next to me....oh wait, that was grade school....**sigh**

I missed the question about the dosage of Mannitol. Number 14, I think it was. And to think, I give Manntiol SO FREQUENTLY... ;)
Many thanks to Val for taking the time to write the quizzes. I think they are a great idea.
Regards,
Jeff Brosius

Thanks Jeff, Larry and all participants. Looking forward to posting the next one!

Brief quiz related to the  'I feel so ejected' case (opens in a new window)
NOTE about the quizzes: Valerie writes the quizzes to accompany the cases. I got  a few comments on the last quiz. In almost all cases the problem was the tester not reading closely. Read carefully- but if you feel the quiz answer is incorrect or incomplete, do feel free to send your comments to me. ;-) 

The 'From Good to Bad' Case

Howdy, gang. Not much in the way of discussion on the end result of our last case, which was kinda surprising. Did you think it was unfair or misleading? Not enough information? If y'all have feedback, please let myself or Valerie know, so that we can make adjustments as necessary. We want this list to work, and can only do so with your input.

Let's see what happens with this next case. Admittedly, I got burned with this one....

To assist our participants, click on the underlined word to bring up a box of word reminders. Close the 'reminders window' after reading. 

Dispatch info: 64 y/o Male with a complaint of chest pain. ALS ambulance is only responding unit.

History of event: 
The pain started while moving the lawn. He went inside the house, sat down, and had a glass of water, but felt no relief, and his wife called 9-1-1. It is early September in Atlanta, and still a warm time of the year. The pain is worsened with exertion, but it is not totally relieved with rest, just lessened. There is no radiation of the pain. His last meal was about four hours ago at breakfast. He has a history of mild hypertension, controlled with diet and exercise. He takes Tylenol for arthritis, and has no drug or medical allergies. He is in otherwise good health.

Physical Exam: 
Alert and oriented adult black male, sitting upright in a chair. Skin is warm and dry, with good turgor. 
VS: 
B/P 134/88, P 94 and regular, R 18 clear and non-labored, SpO2 96% on room air. 
HEENT: 
Clear of trauma, Pupils are PERRL. There is no JVD or carotid bruits. Airway is patent. Chest rise symmetrical. Abdomen is non tender and soft, with no masses, rigidity, or distention present. Distal CMS is normal, and 
capillary refill is brisk at 1 second. Serum Glucose is 84 mg/dL, and the EKG shows normal sinus rhythm with a mild ST depression in lead II.

Treatment given: 
Oxygen was provided at 4 lpm via nasal cannula. The cardiac monitor was applied, and a saline lock IV line was inserted (18G, left forearm, no infiltrate.) The patient was been placed on the stretcher in mid-fowlers position, and transport begun to the ER, approximately 20 minutes away non-emergency. The patient was given 362 mg Aspirin PO, and Nitroglycerine 0.4 mg SL after the ASA was chewed and swallowed. Once the NTG was given, the patient became unresponsive, and his skin became cool and clammy. Recheck of the VS: B/P 88/60, P 110 regular, R 12, SpO2 99%.

What happened? And further, how do you fix it?

Enjoy, 
Jeff

   Outcome

Wow. Good discussion again on the case of the month. I must admit...y'all  are much smarter than I am. Anyone want to take over the monthly case  submissions? ;)

Somebody give Rachel a high five for the great thought regarding Viagra.  Although it was not the actual cause of this guy's hypotension, it was an excellent thought, and worthy of praise. Who said EMT's weren't smart people anyway?

I made a typo error, and though it does not change the substance of the case, it should be mentioned. I said the patient was given 362 mg ASA, but that is wrong. He was given 324 mg ASA (four tablets of baby aspirin at 81 
mg each.) My fault, and I apologize.

For what it is worth, I did not have 12-lead capability in the field. Stuck with a LP 10. And although a variety of leads can be examined with a LP 10 (see Kelly Grayson's great presentation "12 Lead with a 3 Lead" on the House 
of DeFrance web site,) I chose to mention only the Lead II tracing. Didn't want to make this easy. :)

For those of you who talked about Right Ventricular Infarct, give yourselves a pat on the back, puff your chest out, and walk proudly. It was a case of an isolated RVI, and that caused him to be so sensitive to the Nitroglycerine.

Let's review the events:

64 year old male who complained of chest pain unrelieved with rest. His vital signs were: 134/88, 94, 18, 96%. He was provided Oxygen, placed on the EKG monitor, and received an IV line. ASA was given, andthen Nitroglycerine. The nitro caused his blood pressure to drop significantly (88/60,) and his mental status dropped as well.

Right Ventricular Infarcts are *usually* seen in conjunction with inferior wall infarcts, but not always (something the ER doc was quick to point out to me.) They are very pre-load dependant, and as NTG works by reducing the preload, you will often cause a dramatic drop in blood pressure with the  administration of NTG. Morphine can also cause the blood pressure to drop, though usually not as dramatically nor as quickly.

So, we know what happened. More importantly, how are we gonna fix it so we don't look like a total fool when we get to the ER? Everyone had pretty much the right idea, and it's exactly what I did: I upped the oxygen level to 12 lpm via mask, dropped the head, raised the feet (Trendelenberg,) and 
switched the IV lock to a fluid drip. I gave him a 300 mL bolus of Saline, and waited. After an agonizing five minute wait, his eyes opened up, he shook his head a little, looked at me, and asked me: "Please promise me you won't do that again." No problem, buddy...

The patient arrived at the hospital without further incident. He stopped in the ER for a quick lab draw and chest film, then was taken straight to the cath lab. PTCA (Percutaneous Transluminal Coronary Angioplasty) was performed to relieve a blockage, and he was admitted to the CCU for 
observation. Four days later, he went home.

Best,

Jeff Brosius

Valerie recommends- 
A GOOD EKG BEGINNERS PRIMER FOR THE EMT B 

I missed the bonus question (a VERY good bonus question, I might add,) and number 25 and 26. I liked the picture of the heart with the "Name that structure" questions and I also think the EKG was a excellent touch.
Thanks to Valerie for all her hard work. Jeff

Thanks Jeff, this quiz took a long time to make but was fun! Valerie

Brief quiz related to the
 'From Good to Bad' Case

The "Shake, Rattle and Roll" Case
note: beginning with this case, a list of abbreviation 
are available and will open in a new window.