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Case #36 The Inadequacy Of The Requesting Description Can Kill.


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#21 RoadieRN

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Posted 08 February 2008 - 02:19 AM

Gotta agree with Speed on this one. With someone of this girth and the picture painted here, I would have in my differential the following:
MI
ACS
PE
Alcohol intoxication
CVA
Electrolyte imbalances out of the wahzoo(medical diagnosis by the way :D )
Aspiration pneumonia
Respiratory failure/arrest
and the almighty etc.
I think depending on what your 12 lead and FSBS show you dictates your tx. If you can get a decent hx from the fam, you can direct your care accordingly, in addition to, what your 12 lead and FS show. Also, I would be hestitant to BVM someone who is breathing in the 20s w/a very full stomach of all things nasty and wretched. If their effort isn't adequate, despite textbook normal RR, then I would consider ETT. However, with an apparent large amount of secretions, a potential ginormous panus(sp?), and a serious case of the no neck, this guy is not going to be your average intubation. Once you lay this guy down and if he is big enough, he could very well go into respiratory arrest from his sheer size and his craptulecent amount of secretions, making a very sticky situation. Not only do you go from a potential good use for RSI to a crash airway, once you start and depending on your induction agent(s) you are truly commited to going for this airway and/or bagging this guy until his respiratory drive resumes, big assumption there by the way.

Flying this guy in almost any RW aircraft could be quite interesting, let alone an AStar. An AZ classic!!!!

Fly safe everyone.

Take care,
Nick Crusius RN, BSN
Flight Nurse
PHI/Airevac 23, Marana, AZ
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Nick Crusius RN, BSN

Keep the rubber(or skid, if it applies) side down!

#22 fiznat

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Posted 08 February 2008 - 03:16 AM

What are your contraindications for withholding? Granted his BP isn't really indicative of a "classic" narcotic ingestion, and he wasn't said to have convulsions prior to collapse (Wernicke's/ETOH), but the historian doesn't sound too reliable. To me it's just something else to rule out easily on an unconscious person. FSBS and D50% (if indicated) included would be an intermediate protocol for an unresponsive person. Just friendly brain jogging... would like to know your thoughts.



Only that I don't feel we have enough information at this point to start making treatment decisions like this. We've basically been given initial impressions only, which in my opinion is not enough to decide on a course of treatment. Additionally, I am hesitant about the practice of "trying" drugs just to see if they work or not "coma cocktail" style. Before I give Narcan I'd like to know more about his respiratory effort, pupils, history, and availability of any suspect opiates. Thiamine has fallen out of favor lately in my area, but also I feel I would like to know more about this patient's history and presentation before we start down that road.

I'm happy for the friendly brain jogging-- thats what this is all about!
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#23 Jeff Smith

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Posted 08 February 2008 - 03:29 AM

You know... I'm not the medic who intubates just to intubate... but... Altered LOC and frothy sputum bubbling from his mouth... He is going to get a tube. Better to do it electively now before he strokes or occludes or whatever he is going to do in Mike's next post. At least then you can checkoff A and B from your ABCs. Makes it easier to suction too. Of course you need IV access first.

As far as my suggestion for transport...
If its weight the pilot is worried about, I'll volunteer to stay on scene and let my partner transport by air. Ive already had my CF for the week.
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Jeff Smith BS, NREMTP, CCEMTP, FP-C, Rockstar

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#24 Speed

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Posted 08 February 2008 - 04:33 PM

Only that I don't feel we have enough information at this point to start making treatment decisions like this. We've basically been given initial impressions only, which in my opinion is not enough to decide on a course of treatment. Additionally, I am hesitant about the practice of "trying" drugs just to see if they work or not "coma cocktail" style. Before I give Narcan I'd like to know more about his respiratory effort, pupils, history, and availability of any suspect opiates. Thiamine has fallen out of favor lately in my area, but also I feel I would like to know more about this patient's history and presentation before we start down that road.

I'm happy for the friendly brain jogging-- thats what this is all about!


Gotcha. And I agree. Thiamine use in emergent situations will have very specific indications (my trigger is seizures c/ appropriate hx). But with these unconscious folks that have a lot of unknowns I usually do give a trial of narcan just to "see what happens". Maybe his pupils would talk me out of it. Like I said, his BP is a little too high to point directly to a narcotic reaction, maybe if he's just started to occlude his airway and his HR and BP are on the initial rise from that? (Plus he's a whale) We'll see.
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Mike Williams CCEMT-P/FP-C

#25 Mike MacKinnon

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Posted 08 February 2008 - 08:03 PM

heheh the whole thing was a cluster... ill get to that later.



So you are handed the 12 lead for our patient here.

Posted Image
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Mike MacKinnon MSN CRNA
WWW.NURSE-ANESTHESIA.ORG

"What gets us into trouble is not what we don't know
It's what we know for sure that just ain't so" - Mark Twain

#26 MSDeltaFlt

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Posted 08 February 2008 - 08:33 PM

Dammit. Orca's havin' a heart attack. Can he fit in the bird? We gotta go.
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Mike Hester, RRT/NRP/FP-C
Courage is resistance to fear, mastery of fear - not absence of fear -- Mark Twain

#27 STPEMTP

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Posted 09 February 2008 - 01:11 AM

Well, the EKG shows minimal criteria for STEMI in I and AVL (had to blow picture up to 400% to see lines to confirm). Also P waves have a odd apperance.... L atrial hypertrophy??? Not so sure that cardiac is the cause of pt's presentation. Lotta of cardiac symptoms without a lot of cardiac changes by EKG. Only seen this presentation with massive Anterior infarcts, not a lateral infarct. :unsure:

Questions for wife: any recent trauma, in particular head trauma up to 1 week prior? What medical history does he have? any diet restrictions that he is "suppose" to be following?
Assessment: Pupils? any edema? bruises? JVD?

Differencial (sp?) dx:
1. head bleed with neurogenic pulmonary edema (inverted t waves in V1-V3 leads with tachycardia and sudden onset)
2. MI with CHF

I'll post more when I have a little more time......
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#28 MSDeltaFlt

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Posted 09 February 2008 - 01:51 AM

I was going Posterior due to positive V1 with ST depression in V2-V3. Not to mention the septoinferiolateral T inversion.
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Mike Hester, RRT/NRP/FP-C
Courage is resistance to fear, mastery of fear - not absence of fear -- Mark Twain

#29 jjones1418

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Posted 09 February 2008 - 05:03 AM

Funny... We had a patient who had an MI during the 4th quarter of the game. Drank a bunch of beer too, and coded in flight. Fun times. But back to the case...

You asked to start with the short final. I'm calling it out, because the pilot probably can't see those horses if they're at 4 o'clock. I would communicate it to the LZ guys on the ground, albeit Fire/LEO/EMS. Discuss possibilities of an alternate LZ.

People already covered the basic assesment stuff. I'll jump to the ECG.

I agree with MSDelta. It's looking like a posterior MI with positive deflection in V1, ST depression in the anteroseptal leads. Brotha needs a cath lab. Based on how he's looking now,

Nothing would screw this up worse than the horse running into the T/R. Well, I say that, but it is a MacKinnon case on Flightweb........
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Jason Jones, EMT-P

#30 Speed

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Posted 09 February 2008 - 07:28 AM

The first thing I see is poor "R" wave progression, so I'll check the leads. If that's OK, yeah there's some funky "T" wave abnormalities, now I sound like a drunk ECG machine (guilty as charged). Ha! Axis looks off, and with the flat "T" wave in lead three I think I'm seeing some S1T3Q3 phenomena. The "P" waves look a little big and funky so that could be "P-pulmonale" and with the Hx it would go great with a PE (chest pain, tachycardia, dyspnea), but the SPO2 is kinda high for a bad PE. Maybe just right heart strain for some reason? You can never really R/O AMI in someone like this. If it was this bad though I'd expect to see some "bigger" ECG changes. Also, in leads V4 and V5 I think I may be seeing some "u" waves after those downed "T"'s... hypo Mg/K? With the ETOH on board it's gonna be hard to absolutely forget a neuro cause either. Still haven't seen a finger stick result? I'd like to know exactly how the term "confused" is being used. Inappropriate answers or just lethargic? Short / long term memory? Weakness / hemiparesis?
If I don't start seeing a quicker development of a VQ mismatch, I'll back off that and start thinking about treating that BP.
Anyway, absolutely push oxygen on him and be ready for him to crash (might get to do a cric). We need to make sure that there is an ambulance standing by yesterday. Let the pilot know the weight and start looking at the closest facilities, making multiple transport options / plans.
I think I may have been mistaken in thinking this guy was unconscious? Just confused? Can't scroll back to page one.
What's next?
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Mike Williams CCEMT-P/FP-C

#31 Mike MacKinnon

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Posted 09 February 2008 - 02:21 PM

speed send me an email since i cant PM u one here: mmackinnon123@gmail.com
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Mike MacKinnon MSN CRNA
WWW.NURSE-ANESTHESIA.ORG

"What gets us into trouble is not what we don't know
It's what we know for sure that just ain't so" - Mark Twain

#32 ST RN/PM

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Posted 09 February 2008 - 05:37 PM

I'm with Speed in his considerations. The first thing....airway airway airway.....what is the gurgling from?......
.Next....large P waves.....low pulse ox on 2 lpm..........PE
The 12 lead is highly suspicious for Posterior MI, Septal/Anterior/Lateral ischemia, as well as I/aVL slight elevation....he's holdin his chest, MAP of 150 with 220/115....gurgling? SO far, others' responses have covered all that come to mind.....assess lung sounds, check blood sugar....although with all that food, prolly high.....have the horses secured, speak with the pilot re: fuel, lift capability....Start with 100% 02 via NRB. Medic 36 is correct....get a feel for whether or not this is a cerebral event before reducing the pressure. If it seems to be non-Neurogenic.....and if lung sounds are adventitious ie crack-a-lackin, consider CPAP (if capable), NTG (sprays/infusion) to go with the picture of LV failure (hypertensive,hypoxic). This should help with the shootin pains in his chest and the hypertension. Metoprolol to slow rate and increase the filling ime, decrease the MV02. Neuro exam as well (as stated previously) to assess for ETOH vs. bleed which could account for EKG changes, pulmonary edema, hypertension....
Body habitus is going to make intubation difficult, so in preparation for airway control, have backups ready (combi/King/Cric)...I just can't shake the feeling that I'm missing something........Mike......

Steve
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Steve T. RN, PM

#33 LZone

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Posted 09 February 2008 - 11:41 PM

I agree with speed as far as the 12 lead goes, I dont like the R wave progression either so I would check lead placement first. I don't want to set up camp in this guys trailer here but it dosen't seem likely that we are getting out of there anytime within the next few minutes so if the leads were OK I would take a quick look at a right sided version. Also, because of those low lying T waves it is hard to tell in lead II but it seems as though his QT is prolonged. I would worry about some out of whack lytes, it would be nice to have an iSTAT. As far as treatment and differential dx, everyone already seems to have it covered. Nice case.
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#34 LZone

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Posted 10 February 2008 - 01:02 AM

A shot in the dark here because the limited information currently available, but one more thing to ask, any possiblility of an AICD?
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#35 Mike MacKinnon

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Posted 10 February 2008 - 01:28 PM

Ok to answer the questions first ;)


[quote]1. On final get VFD personnel to resolve horse issue or find alternative LZ away from horse hazard. (Who would think that would be a problem?)

2. Determine from pilot the available weight for transport.

3. From bystanders- Amount of ETOH ingested by patient, other drug use (Rx and illicit), patient complaints/behavior before calling 911.

4. Assessment- ABC's, lung sounds, ECG, glucose check and neuro exam if oriented enough to follow directions.

6. From wife- medical history, medications ( and compliance with same) and allergies. Any recent illness. Input/output? DNR? (Hehe!)[/quote]


Some of the family members take care of the horses. One appears to have broken its leg trying to get over the fence.

Today your flying with your largest pilot and crew. You can effectively carry 370. Unfortunately you dont think the "rotundness" of this pt will fit in the aircraft and allow the door to shut...

Pt had complaints of SOB. The amount of ETOH was said to be "ginormous".

Airway= clear (no obs)
Lungs = minor crackles
Glucose = 290
Neuro = pt is following commands but is anxious and hard to keep focused. Pupils normal

The response "He is healthy as a horse, they dont see no doctors since they said he has the sugars."


[quote]Ground ambulance on scene? Closest time for cath and chest cutter destination?[/quote]

The 1970's ambo is on scene and it will be a 90 minute ride to the closest cath center.


[quote]Do you have comms with the LZ command?[/quote]


Exactly the problem there wasent one. No initial radio contact with ground but through dispatch they said to "go ahead and land" seems they need an LZ class.

[quote]Is there secretions in the patient's airway or is it the gurgling from the edema that is giving us the "bubbling" sound[/quote]

He does have secretions. He is drooling (yuk).

[quote]What medication does he take and is he compliant with the Rx?[/quote]

He is on a "sugar" pill which the wife brings a bottle for that is empty. Its dated 6 months ago and is a 3 month dose.
Also on a "high pressure" pill which she does not have the bottle for.
He does get the "chest pains" and has a script for nitro for that which he has never filled.

[quote]2) Lets get a good idea of this man's mental status. When did it change, and to what extent?[/quote]

He started getting SOB about 3 years ago they tell you. (heheh) He seemed to gt 'sleepy' about an hour before you arrived but noone really noticed since they were watching tv (and drinking). He often falls off to sleep when he is drinking and "gurgles" his wife says.

[quote]Pedal edema present?
Physical exam to look for signs of trauma or infection
Pupils[/quote]

He is fat everywhere but only mild edema.
no trauma or infection obvious
Pupils normal but sluggish


[quote]NRB, throw a nasal air way in, if I had a portable sxn I'd like to clean out his oropharynx,[/quote]

NRB on and nasal airway in (which is what happened) . See below for next set of events.
No JVD ;)
While he takes some time to follow commands he appears not to have a CVA

[quote]I'll go ahead a give 'em narcan and thiamine. What do his pupils look like?

The first thing I see is poor "R" wave progression, so I'll check the leads. If that's OK, yeah there's some funky "T" wave abnormalities, now I sound like a drunk ECG machine (guilty as charged). Ha! Axis looks off, and with the flat "T" wave in lead three I think I'm seeing some S1T3Q3 phenomena. The "P" waves look a little big and funky so that could be "P-pulmonale" and with the Hx it would go great with a PE (chest pain, tachycardia, dyspnea), but the SPO2 is kinda high for a bad PE.[/quote]

Narcan and thiamine in with no obvious change. No D50 since you know his BS now.

Classic PE picture on the EKG... Hmm sats are that low...

So the interpretation:
Tachycardia
P-pulmonale = RAH
RVH
Right axis deviation (axis + 120)
PE

Ok


More info: Below is a pic to give you an idea how this guy looks
Posted Image


As the NPA is placed and he is suctioned a little you hear a high pitched stridor sound. His chest is "pulling" in as he is clearly fighting to intake air. His sat drops to 90, 85, 80 over the span of a minute (no reserve (FRC) with this guy).

What now?
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Mike MacKinnon MSN CRNA
WWW.NURSE-ANESTHESIA.ORG

"What gets us into trouble is not what we don't know
It's what we know for sure that just ain't so" - Mark Twain

#36 MSDeltaFlt

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Posted 10 February 2008 - 03:55 PM

Immediately upon insertion of the NPA? Is the NPA too big and in too far? Does it need to be pulled back? Is he showing signs of anaphylaxis? Does he need to be cric'd? The stridor indicates "airway" compromise in some fashion. Right now we are stuck on "A".
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Mike Hester, RRT/NRP/FP-C
Courage is resistance to fear, mastery of fear - not absence of fear -- Mark Twain

#37 MedicNurse

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Posted 10 February 2008 - 05:36 PM

Airway is EVERYTHING!

Mike Hester - You Rock! :P Based on the picture above - I'm not sure that "cric" would even be part of my vocabulary.

I'm with everyone else -

Tough calls on everything!

When in doubt - get the basics and get out! By whatever means necessary. I'd rather explain the best of a bunch of bad options and since you cannot FIX this - GO!!!

I think this guy may just die regardless - hate it, but it still happens in HEMS (maybe more so than on the ground!)

Horses scare me!

:o
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#38 RoadieRN

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Posted 10 February 2008 - 05:50 PM

+ pucker sign for starters! Eesh, this guy has gone from bad to worse. I agree w/Delta's thought about pulling the NPA back a little to see what happens. If he doesn't improve, this guy needs a tube and fast. His neck is probably bigger than my thigh, so DL this guy is going to be interesting. I would be very hestiant to lay this guy flat d/t the amount of SQ fat around his airway. I would seriously consider dropping a nasal ET or a Combi on this guy. I need something down and dirty easy to secure this guy's airway. If any of those don't work, either try to BVM him or possibly set up for a cric. My only hestitancy w/a cric on this guy is the sheer quantity of SQ neck fat and my landmarks. Now granted, if push came to shove, you can do the pinky finger at the suprasternal notch and put your four fingers together(read: everything but the thumb) see where your index finger winds up. Bear in mind, you need to spread his neck girth the best you can and then cut a whole lot to find the cricoid tissue. As far as RSI goes, I would consider giving him a dose of Etomidate just to relax him enough to let me pass my nasal ET or combi. Now if we have to resort to a cric, I would make sure he has enough Fentanyl and Versed on board to not give a rat's rear to what is happening. I'm hestitant to give any NMBAs d/t our potential difficulty getting this guy's airway. Also, if his sats are dropping this fast, his LOC is likely right behind it, making for a relatively easier tube :blink: .Once our airway is secured then I knock his butt out and keep him comfy.
Once a is secured, then comes our next big dilemna: To go by ground or by air. I don't know how wise it would be, but you could attempt to get our pt into the aircraft, sitting up so his chest girth doesn't crush his chest wall and ability to bag or put the pt on the vent and effectively ventilate this guy. Now, if that doesn't work you're have to get in the ground ambulance start making our way to the cath center 90 minutes away. I would start to transport this guy and continue to monitor him en route. I would consider giving Metoprolol and/or NTG IV to get this guy's BP and HR under control. I'm concern that guy might have more clots hanging on by the slightest bit of fibrin just waiting to go to the brain and have this guy check out for good.

Good times!!!!!


Nick Crusius RN, BSN
PHI/Airevac 23, Marana, AZ
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Nick Crusius RN, BSN

Keep the rubber(or skid, if it applies) side down!

#39 bertmict

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Posted 10 February 2008 - 08:19 PM

Okay, first off, I may get cussed for the following BUT....I have to think that part of scene safety is my own (and my partner's) safety. I am going to be looking at the exits. Is there any way we are going to be able to carry this guy out of the mobile home using lots of help? Is there a cargo sized door? If "no" to either, I am thinking I would like to use his last efforts to help us get him out side. That said, he can hopefully walk out to where the cot is sitting at the bottom of the make-shift stairs. If he codes after that, it is better than coding in the house, then stopping everything for 5-10 minutes while we try to find a way to butter him up and squeeze him out the door. I doubt the family will let us take a chain saw to the side of their Mobile Manor! If we think he will actually fit into the rotor, we may need the pilot to lift and burn off a little fuel while we are moving him.

If we are sure he won't fit in the helicopter, get to the ambulance with all of our stuff and start transport. We have 90 minutes to play. Speaking of which, we better double check their ambulance for fuel and O2 levels. As a side thought, is there a service (maybe even yours) in the area that could get a fixed wing to a nearby airport to take him...if he will fit into their plane???

Just thought I would interject some of my BLS thoughts while everyone else is working on their ALS thoughts.....
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#40 Mike MacKinnon

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Posted 10 February 2008 - 10:27 PM

Bert

Never downplay your BLS skills. All good ALS is 100% based on a solid BLS foundation. One of the biggest frustration among medic instructors (myself included) is how quickly they look down upon (and forget) basic BLS skills which are NEVER unimportant!

You can certainly get the patient out the door with the cadre of help here. The rotor wont hold the patient tho (too rotund). He wont be walking out in his current condition but likely on a board.

Have to stay in the house until we manage the current airway emergency but afterward moving would be ok.

Unfortunately the closest airfield is farther than the closest facility away so no luck there!

Okay, first off, I may get cussed for the following BUT....I have to think that part of scene safety is my own (and my partner's) safety. I am going to be looking at the exits. Is there any way we are going to be able to carry this guy out of the mobile home using lots of help? Is there a cargo sized door? If "no" to either, I am thinking I would like to use his last efforts to help us get him out side. That said, he can hopefully walk out to where the cot is sitting at the bottom of the make-shift stairs. If he codes after that, it is better than coding in the house, then stopping everything for 5-10 minutes while we try to find a way to butter him up and squeeze him out the door. I doubt the family will let us take a chain saw to the side of their Mobile Manor! If we think he will actually fit into the rotor, we may need the pilot to lift and burn off a little fuel while we are moving him.

If we are sure he won't fit in the helicopter, get to the ambulance with all of our stuff and start transport. We have 90 minutes to play. Speaking of which, we better double check their ambulance for fuel and O2 levels. As a side thought, is there a service (maybe even yours) in the area that could get a fixed wing to a nearby airport to take him...if he will fit into their plane???

Just thought I would interject some of my BLS thoughts while everyone else is working on their ALS thoughts.....


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Mike MacKinnon MSN CRNA
WWW.NURSE-ANESTHESIA.ORG

"What gets us into trouble is not what we don't know
It's what we know for sure that just ain't so" - Mark Twain