ErikWeeWoo

EMS Report EMS brings the patient into the assigned room and transfers her to the bed via sheet drag. "This is Kayleigh; she's 11 years old and coming from home today. Parents report she has been 'acting strange' for a few days now, quieter than normal, and agitated yesterday. This morning they called 911 because she had a fever of 103.4° F and is now mostly nonverbal, stiff, cannot follow commands, and refusing food & drink. Baseline is talkative, alert & oriented x4. No medical history aside from being on the autism spectrum, no medications. Blood sugar normal at 105, sinus tach on the monitor at 135, 12 lead sinus tach otherwise normal, a little hypertensive at 132/86 manual, oxygen saturation 100%, respirations 24. 22g IV in the left A/C, that's all we got". Upon further questioning, you learn she also didn't react upon insertion of the IV. History Patient has no significant medical history. No allergies, no daily/regular medications. Mom states she gave oral suspension Tylenol this morning, unknown dose. Family history Epilepsy, hypertension, bipolar disorder type 2 with psychotic features, and substance use disorder. Exam Vital signs remain unchanged - (spo2 100%, pulse 130s, bp 130s/80s, rr 24-26) Skin is pink, warm, and profusely diaphoretic. Patient is generally rigid, staring with gaze fixed ahead, and nonverbal aside from the occasional one-word response to some questions. Eyes appear glassy: glossed over. Pupils are mildly dilated, equal, round, reactive to light Mucus membranes moist, rapid respirations noted. Lungs are clear to auscultation, bilaterally normal air entry without any stridor or wheezing. Aside from tachycardic rate, cardiac auscultation is unremarkable with no murmurs noted. Abdomen is soft and non-distended Deep tendon reflexes intact. When limbs are manually moved, there is slight resistance, and they retain their position after being moved This is based on a real case with a known outcome. Some details such as names are changed for privacy compliance. Let's discuss this case study! Please provide: Differential diagnosis Investigations with rationale Immediate treatment maneuvers/options Other treatments/options

Just have to share this one, it's too crazy to not... 20yo male college student arrived in police custody by police cruiser, local campus PD on a domestic violence charge. Moderately disoriented to place/situation and intermittently unconscious at times, but easily rousable and obeyed commands for the most part. Some obvious evidence of IVDU, ended up finding a fairly impressive site infection. BP 66/palp manual, HR 133, lactic 2.9mmol/l... UA returned with positive for benzo, opiate, etoh. Labs came back... ETOH 0.73, blood glucose 16mg/dl... extended tox panel showed +ketamine too... somehow this guy was conscious enough to do a domestic battery

I work occasionally in psych emergency department as an RN, used to be a psych tech for both adult & peds units back when I was an EMT. I definitely found working with the kiddos to be more difficult, not really at any fault of the children. I really hated dealing with the parents though. Same story currently in psych ED, same challenges but then factor in parents.

I honestly think you did a pretty good job. Her co-workers may or may not of had duty to act, failure to act on their part is no reflection on you and likely something that nobody can or will be held accountable for. Depending on the laws of your state, you probably did have duty to act. You intervened when you were made aware there was a problem, you provided a reasonable assessment, and you took reasonable actions. I'm not sure what else anyone would expect of you, just make sure the school district pays for your crystal ball and magic wand if they want more. Just keep up with documentation, make those above you aware of any safety concerns, and maybe seek advice regarding specifics from someone in a supervisory nursing role there. Honestly I wouldn't be surprised, but there's not a lot you can do about that aside from speculate to yourself. Keep in mind there's a difference between malingering and munchausens. Munchausens patients are usually much more extreme for reasons that are harder to determine, malingering patients usually just want some benefit or avoidance of responsibility. Maybe it's neither, maybe it's one, maybe it's a little bit of both.

I'm going to geek out a bit if that's okay, hopefully others find this interesting. Basically everything about the avian respiratory system is really cool and unique. The avian respiratory cycle actually consists of 2 inhalations and 2 exhalations. On the first inspiration, fresh air is pulled through the trachea down to air sacs around their bum. On that first exhalation, the fresh air is moved into the lungs where the air exchange happens. On the second inspiration the now "stale" air is pulled into air sacs around their head/neck/chest, then on the second exhalation the stale air actually leaves the body. They have no diaphragm, it's the muscles around those air sacs that control inspiration or exhalation. As you might imagine, they get a lot more oxygen in air exchange from one respiratory cycle. Intubation can be a pretty difficult, but it's mostly because more things have to happen in a smaller space - pull the tongue out, pressure like a lever on the beak (it's like head-tilt chin-lift with cricoid pressure in one movement), and pass an uncuffed ET tube through the syrinx (birds don't have a larynx). Downside is that pneumonia can get bad, because it can spread from the air sacs into the bone very easily. Initial induction isn't that hard. Gas anesthesia is preferred in birds, usually isoflaurane in my experience. They don't really do IVs as much in birds, usually it's IOs. Ketamine, midazolam, and propofol are the common anesthetics. Opioid analgesia.

I don't have that many intubations, but I have more than most of my EMS coworkers and I'm pretty comfortable with it, I'm not doing it daily either. I'd agree with you that normal canid anatomy is generally conducive to a relatively easy intubation as far as the "mechanical" part of the intubation, however there's a very high incidence of preexisting cardiac disease in many breeds which can make maintenance of anesthesia pretty interesting as well as a pretty high occurrence of upper airway obstructions and deviations from normal anatomy. Cats are a whole different ballgame though entirely - feline airways are extremely fragile in general, harder to visualize, very high incidence of laryngeal spasm in cats, very high incidence of regurgitation, anesthesia tolerance is lower, moderately high incidence of sudden hypotension (60% if I remember correctly). Hypothermia is also frequent, and temperature management is harder in cats than dogs. Ruminants, small exotics, reptiles, and birds are almost universally pretty difficult to intubate but maintenance of anesthesia is a breeze, aside from horses which the entire thing is pretty scary. Crocodilians are actually very simple minus their tracheal rings, but it's pretty objectively terrifying that your forearm through a PVC pipe is the laryngoscope.

Given how medicine works right now, never because it's usually considered an MD skill - however, once upon a time in history even IVs were considered an MD only skill. If it was a nursing skill though (both in the eyes of legal scope of practice & culturally), I'd be fairly regularly in some areas. Specifically ED or ICU - we have intubations in the ED on a regular basis around here. I could also see it being quite useful in surgery environments, or for rapid responses.

When I was in high school, I worked at an animal sanctuary/wildlife park. They wanted me to be a vet tech, so I was going to a vet tech program at the community college during my senior year in high school. That program wasn't even 2 years, so I was working as an active vet tech at the aforementioned wildlife park before I was even 19 – and I had some degree of exposure to the vet field as early as 14 years old, from being in the volunteer program at that park. While I was working there after my vet tech licensure, I got the opportunity to do all sorts of intubations (yes intubation is within a vet techs scope). I got to tube all sorts of animals ranging from large mammals to small reptiles & birds. It's definitely a perishable skill, but it isn't super difficult. I had double digits successful intubations before I got to medic school. Aside from that fact, paramedics can intubate (and I completed medic school & my first 2 years of nursing school together while working part time). I don't understand why intubation isn't a nursing skill. Nursing school is 4 years, there's plenty of unnecessary nursing theory fluff that could be replaced by clinical skills like intubation. If nurses can manage a ventilator (which is 100x harder than intubation), or titrate critical care meds, we should 100% having intubation included in our education and scope of practice. Especially when COVID-19 is running rampant, hospitalists should be doing much more ventilator management and nurses should be doing way more intubation. Just a rant post.

I've been active in EMS for 8 years and have been active as an RN for 6 years. I don't understand where all the tension between RNs and Paramedics comes from. It's very much so two different specialties, but there's significant overlap. It seems like when I'm working ED, paramedics (especially outside the EMS agency I work for) seem to like to cop an extremely unnecessary attitude. When I'm on the ambulance, it seems like RNs (especially in other hospitals aside from the ED I work in) always do the exact same. It's to the level that I get treated completely differently based only on what badge buddy I wear. I have very little issue with anyone that I've actually worked with. I avoid drama, am relatively well liked among my coworkers. Transfer of care is a pain in the rear for everybody regardless of whom to whom, but what's with all of the drama? Does anyone else relate?

This isn't happening just in Africa. Vaccine experiments are happening in the US and other countries as well. It's important to test something like this among many populations, and I don't understand why one primarily black population is an ethical issue. Assuming that there's the same or very similar processes of informed consent, there shouldn't be a problem.