Live from Peachtree
Presenter ~ Jeff Brosius, NREMT-P
Peachtree Street ~ a rough and tumble area of Atlanta
that produces a wide variety of EMS runs.
No Joke "
Hilton Head, SC.
You show up for duty at 0745, get yourself a cup of coffee and put a bagel
in the toaster. Moments later, your supervisor walks in and says, "What are you
"I work here." you reply.
"You're at Station 6 today."
You abandon your bagel, grab your gear bag, and head back out to your car.
You arrive at Station 6 at 0801 and the Captain says, "Hurry up and get
dressed. Medic 6 just went on a call. We'll take you there on Truck 6."
You're very accustomed to practical jokes. "Yeah, right."
"I'm serious. Do you see Medic 6?" You don't. "Get dressed. Hurry up."
Five minutes later you are pulling up on scene as Medic 6 is pulling away.
Truck 6 stops and lets you out. You run over to Medic 6 and open the side
door. You jump inside to see a large man sitting up, dry heaving into a red
bag. A nervous and diaphoretic paramedic is taking a knee and looking for IV
"What do you need?"
"Look at the monitor." You look and see [ Field Strip Lead
II in a new window]
"The Captain wanted me to take the call so you could go home."
The nervous looking paramedic flies out the back door of the ambulance
before you can stop him, and you are left with an EMT Basic. Another is driving the
ambulance, and you start moving again immediately. You know you are only 5
minutes from the hospital.
Skin: Dusky, diaphoretic.
Respirations: Intractable vomiting (dry heaves).
Pulse: 80 (never budged) Patient denied pacemaker.
pSO2: 92% RA
Increased to 97% with NRB mask.
Denies chest pain.
Admits to mild dyspnea.
Nauseated for 24 hours.
Vomiting since 0500.
Patient feels "awful".
Has "never felt this bad" before.
All questions are anwswered between dry heaves.
[ EKG on
arrival at the ER in a new window ]
[ 12 lead
EKG in a new window ]
Sorry I've been so slow getting the results to you on the case. There are
lots of things happening in the EMS world (you'll see what I'm talking about
shortly,) and I've been trying to get things done.
Also, it is with much sadness that I report that this will be the last "Live
from Peachtree Street" case review. I'm overwhelmed with work, both on the
ambulance, and on another project, and neither Valerie or myself has the
time to get the cases available. There will be a case review forthcoming on
another website, and when it's ready, I'll drop ya a line to let you know.
I want to thank each and every one of you for your input on the previous
cases, discussion, and efforts to improve EMS. It's folks like you that
make me proud to be a part of the EMS community.
Valerie will archive this site soon so you
can still review the cases or send others to
Anyway, if you recall, we have the case of the month from Tom in Hilton
Head: Adult male, c/o nausea and vomiting, with poor vital signs and one
very ugly EKG. The 12-lead was posted.
According to Tom, here's the lab values from the ER:
K+ ^ 7.8 (3.3 - 5.1)
Sodium v 128 (133 - 145)
Chloride v 90 (96 - 108)
CO2 v 19 (22 - 29)
Creatinine 1.7 (0.4 - 1.2)
BUN 44 (6 - 19)
Glucose 206 (70 - 110)
CPK 146 (24 - 195)
CKMB 4.3 (0.0 - 5.0)
Troponin < 0.15 (0.0 - 1.50)
K+ ^ 8.2 (3.3 - 5.1)
DIG ^ 2.6 (0.8 - 2.0)
WBC ^ 13.2
Yellow, turbid appearance
+ Large Blood
+ Large Protein
CxR > Generalized cardiac enlargement w/moderate pulmonary congestion.
Impression: moderately severe CHF.
Abdomen: Negative series.
So, does this help any?
It does, and if you look at the lab values, he's severly
hyperkalemic, moderately hyponatremic, and is also in acute renal failure.
Hyperkalemia is a lethal condition that can progress VERY rapidly.
Typically, increased potassim will first manifest as tall, narrow, and spike
T waves. As it progresses, the P waves will flatten out (or become absent,)
the QRS complex will widen, and eventually he EKG will become a "Sine Wave."
The EKG changes might be hidden or altered due to any underlying pathology
(i.e. bundle branch block, other conduction defects,) and clinical
presentation may vary, but every hyperkalemic patient has one thing in
common: They don't have much time left if you don't catch it and treat it
quickly. Standard care of hyperkalemia in the prehospital setting includes
rapid transport, along with pharmocology interventions: Sodium Bicarb, 50%
Dextrose, Insulin, and Calcium Carbonate (these meds consititute the
"Hyperkalemia Cocktail," and work by facilitating the transport of sodium
across the cellular membrane.)
Adjunctive treatment includes Albuterol Inhalers (large volume
nebulizers,) and kayexelate retention enemas. The only long term treatment is
hemodialysis...obviously not an option in the EMS setting.
So...standard supportive care in the form of Oxygen, IV access, EKG monitor,
and transport. 12-lead if possible, meds as mentioned (with the approval of
medical control if necessary,) and get thee to an ER promptly.
Thanks a million to Tom for the case, and thanks even more to all of you who
helped me bring this Website to fruition. It's been a fun ride. Keep in
I'll be seeing you in all the old familiar places.
With best regards,
Jeff Brosius, of course
I wonder how long before we have a case about his own head trauma
-MOI falling texts?
The 'grand poopah of nothing' who tries to keep Jeff in
cases are archived. No new cases will be posted here as of March
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will announce it here when it is ready. Please do not join the
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