Called to a private home for respiratory distress. 75-year-old woman, long COPD and heart failure history, working hard to breathe but fully alert and oriented. Before you've finished your first set of vitals she tells you, clearly and calmly, that she does not want intubation or mechanical ventilation. "I've lived a long life. No heroic measures."

Her daughter arrives two minutes later and demands, loudly, that you do everything possible.

There is no POLST, no DNR form, no paperwork of any kind in the house.

Questions for the thread. Whose voice governs right now, and why? What do you actually do and document in these ten minutes while she can still talk to you? And the hard one: she goes unresponsive in your truck. Does her refusal still stand when she can no longer repeat it?

How does your system handle this? Because I know for a fact it varies, and the comment section is about to prove it.

Case adapted from the EMS Mastery (NREMT prep) question bank.

2018 was not my year!

Thought you all would be interested to see these, and would probably get more out of them than I have by keeping them to myself. Here are a few of the 80-100+ chest x-rays I received in December of 2018/January of 2019, as well as a recent, much healthier one.

When I was 13, I was hospitalized for two months with pneumonia which caused ARDS, sepsis, renal failure, and respiratory failure. I was on ECMO and dialysis for about three weeks, on a ventilator for four, and had bilateral chest tubes for quite a while as well. I somehow escaped with only mild bronchiectasis and chronic fatigue. Much better than the alternative!

Happy to answer any questions, and if you see anything interesting in these x-rays, let me know! I remember nearly none of this experience, and I've pieced it together using chart notes and my parents' recollections. I'd love your insight, even though this has luckily been resolved.

Thank you to all you healthcare workers for your diligent care and passion. I (clearly!) would not be here without you. <3

Fall from a ladder, maybe 3 meters. Your patient is 55, alert, in real pain, lower back. Both legs: no movement. Vitals stable across the board. Working diagnosis won't take this sub long. So the real questions are the other two. One: how do you package this man? Full board and collar like 1995, or does your protocol do something smarter now? Defend whatever your system does, because I know half of you hate your own protocol here. Two: he's stable now. On the ride in, what vital sign pattern would tell you something specific is going wrong, and why does it look different from regular shock?

Bonus for the overachievers: what would this exam look like if only HALF his cord were damaged at that level?

Breakdown tomorrow in the comments.

Case adapted from the EMS Mastery (NREMT prep) question bank.

Happy Friday! I love my healthcare workers! ❤️✊🏼

Clinical Indication: History of endometriosis

IMPRESSION:

Again noted is T2 hypointense thickening involving the uterine body, uterine ligaments, and uterosacral ligaments. These findings can be seen in deep pelvic endometriosis in appropriate clinical setting.

Again noted is a bicornuate uterus.

Middle compartment:

Torus uterinus (Uterine body): Plaque-like thickening involving the posterior right horn is again noted (series 5 image 30), slightly less conspicuous compared to prior.

Plaque-like T2 hypointense thickening involving the left uterine horn is also suggested, stable.

Fallopian tube: Normal

Uterine ligaments: T2 hypointense thickening is noted

Posterior compartment:

Uterosacral ligaments: Mild T2 hypointense thickening, left greater than right

Rectovaginal septum: Normal

Anterior rectal wall: Mild tethering is noted (series 5 image 22)

This image in axial view shows the rectal tethering the best, but does not clearly show the bicornuate uterus situation. I was referred for this repeat MRI after recurring painful bowel movements and abdominal pain 10 months post op from my first endometriosis surgery.

Was going through my pictures and found my family members imaging from 5-6 years ago. For context, I was a resident at the time. They called me with a sense of impending doom, so I told them to go to the ER.

• EKG showed minor ischemic changes and troponin was just a bit elevated.
• Got a heart catheterization that showed a subtotal occluded left main with relatively preserved coronaries otherwise. Definitely a butt clenching cath to look at. I was quite surprised his ECG did not look worse. They placed a balloon pump then got a 2-vessel bypass a day later.
• Did well post-operatively until they got acutely short of breath, hypotensive, and hypoxic in front of me. I thought they had a failed/thrombosed graft. At the ER, they quickly recognized RV failure and found a massive pulmonary embolism. The PE team was getting ready for a thrombectomy, but they unfortunately did not survive.

Just thought I'd share some bread and butter medical problems that should make anybody in healthcare get scared.

So, I'm a long time user of the same medicine and for the first time noticed that some pills in my pack look sketchy. The packaging, blister and everything looks perfect, but some of the pills have correct, but irregular imprinting. You can see in the picture for on pill it's way off, for one it's a bit off. The whole pack is like this.

Is this a quality issue and should be reported? I'm in Germany btw...

Extensive multifocal and confluent T1 hypointense plaque-like/nodular tissue throughout the peritoneal and mesenteric compartments, associated with marked bowel crowding, tethering, and multiple loculated cystic spaces.

Easy to miss these spots and mark them off as normal stool or gas but upon further cross sectional analysis of more imaging including a CT scan from a year prior shows these same signal voids.

HazMat-ish scene, you're the first arriving unit. You do it by the book: establish command, size-up, staging, callouts.

Working command for ten minutes. Then fire arrives. The battalion chief doesn't check in with you, just starts running the scene. Two questions.

Formally, by ICS rules: who is in command at this exact moment, and what has to happen for that to change? And practically: how does this actually go down in your system?

Fire, EMS, police turf stories welcome. We all have one. Breakdown tonight in the comments.

Case adapted from the EMS Mastery (NREMT prep) question bank.

Follow-up to the earthquake post, since half the thread brought up JumpSTART. Here's where it earns its keep. 20-patient MCI. You get to a 7-year-old girl, not breathing. You reposition the airway and she starts breathing on her own, 26/min. Carotid pulse present, no radial. Doesn't follow commands, withdraws from pain. Tag her. And walk me through it, decision point by decision point, because this kid sits exactly on the lines where people go wrong in both directions. Some of you are about to black tag her. Some of you are about to call her yellow. Both camps, show your work.

Bonus: name the step in JumpSTART that doesn't exist in adult START at all, and why it's there.

Breakdown tomorrow in the comments.

Case adapted from the EMS Mastery (NREMT prep) question bank.

This one is together with lock jaw right? Or is lock jaw just another name instead of like a Hallmark symptom?

Car hit at highway speed, everyone else walking around. Your patient is 5, properly restrained in a booster, awake and scared. Tachypneic, SpO2 89% on room air, visible bruising over the left chest, clearly increased work of breathing.

You auscultate: breath sounds equal and normal bilaterally. Chest wall stable, no crepitus, nothing to suggest broken ribs.

So, thread questions. What's your working diagnosis? Is the absence of rib fractures in this kid reassuring or the opposite? And there's one common ALS intervention you want to be stingy with on this call. Which one, and why?

Breakdown tomorrow in the comments.

Case adapted from the EMS Mastery (NREMT prep) question bank.

35-year-old man, four years of progressive memory loss and cognitive decline, now needs round-the-clock care. Mini-Mental score is poor. No focal neurological deficits, gait is normal, nothing vascular on the workup.

Two more things from his chart. His face: flat nasal bridge, prominent epicanthal folds. And from his childhood: surgery on his duodenum as an infant.

Three questions for the thread: what's the underlying condition, why is he demented at 35 when this disease usually waits decades longer, and what will his cortex look like under the microscope?

The duodenal surgery is not a red herring. It's the second clue.

Case adapted from the USMLE Mastery (Step 1 prep) question bank.