EMS I: Introduction to Pre-Hospital Care and Emergency Medicine Vanderbilt University School of Medicine Spring 2006 David H Sewell, EMT-P Nashville Fire Department Paramedic/EMS Bureau Judy Jean Chapman, RN, MN, EMT-IV Department of Emergency Medicine Faculty and Staff Teaching Assistants Karl Bezak, VMS I Akshay Shaw, VMS I CONTENTS 1. Course Coordinator List 2 2. Course Schedule 3 3. Welcome 4 4. Acronyms 5 5. Goals 6 6. Course Design & Structure 7 7. Ride Guidelines 8 8. Emergency Department Guidelines 9 9. How to Cancel Rides 10 10. Safety 10 11. Overview of Emergency Medical Services 12 12. C-Spine Precautions 14 13. Patient Assessment & Vital Signs 15 14. First Death, E. Fowlie 18 15. Ambulance Item List 19 16. Directions to Firehalls 20 17. Sample EMS Scenarios and Answers 21 18. The 10 Commandments of Emergency Medicine, K. Wrenn, C.M. Slovis 28 19. Assessment Acronyms 30 20. Run Sheet 31 1. Course Coordinators Office Beeper Cell Home David Sewell, District Chief 862-5459 960-2861 480-1169 333-1999 Joyce Barnett, Assistant 936-1324 Karl Bezak, VMS I, TA Akshay Shaw, VMS I, TA This version of the EMS I course booklet was revised by Rahul Nayak, VMS IV in 7/02, José Hagan, VMS II in 1/03, and Atuhani Burnett, MSTP G1 in 1/04. The students who teach this course owe a debt of gratitude to those whose efforts have helped create the course which you now enjoy, and these predecessors include: Neil Harris, MD (Class of 2001) Austin Garza, MD (Class of 2000), Rob Matthias (Class of 2000), Judd Glasser, MD (Class of 1999), Paul Biddinger, MD (Class of 1998), Elizabeth Fowlie Mock, MD (1997), and Thane Blinman, MD (1996), Judy Jean Chapman, EMT-IV. EMS I-Spring 2006 Page 3 EMS 1 Spring 2006 Required Attendance for Class COURSE SCHEDULE Classes in Room 419 ABCD Revised 01-10-06 DATE TOPIC SPEAKERS January11, 2006 Orientation / Sign ups David Sewell, EMT-P, Metro Fire Department, EMS Division ER Tour Judy Jean Chapman, RN, MN, EMT-IV 1:00 pm - 3:00 pm Ambulance ride intro Teaching Assistant(s) Skills lab (B/P) EM Resident(s) January 18, 2006 David Sewell, EMT-P, Metro Fire Department, EMS Division Judy Jean Chapman, RN, MN, EMT-IV 1:00 pm – 3:00 pm EMS Overview Teaching Assistant(s) January 25, 2006 1:00 pm – 2:00 pm ABC‘s of EM Dr. Corey M. Slovis, MD and Chairman, Department of Emergency Medicine 2:00 pm – 3:00 pm Skills Lab (B/P) David Sewell, EMT-P ; Judy Jean Chapman, RN, MN, EMT-IV; Teaching Assistant(s); EM Resident(s) February 1, 2006 Assessment and Ambulance Tour/Lab Metro-Nashville Paramedics 1:00 pm – 3:00 pm February 8, 2006 David Sewell, EMT-P, Metro Fire Department, EMS Division Airways Management and Judy Jean Chapman, RN, MN, EMT-IV 1:00 pm 3:00 pm Intubation Lab Shannon Snyder, MD, Department of Emergency Medicine Ken Palm, MD, Department of Emergency Medicine Teaching Assistant(s) EM Resident(s) February 15, 2006 David Sewell, EMT-P, Metro Fire Department, EMS Division Judy Jean Chapman, RN, MN, EMT-IV 1:00 pm - 3:00 pm Wound Care and Suture Lab Shannon Snyder, MD; Department of Emergency Medicine Greg Jacobson, MD, Department of Emergency Medicine Ken Palm, MD, Department of Emergency Medicine Teaching Assistant(s) EM Resident(s) February 22, 2006 NO CLASS No Electives for first and second year students March 1, 2006 NO CLASS SPRING BREAK March 8, 2006 David Sewell, EMT-P, Metro Fire Department, EMS Division Judy Jean Chapman, RN, MN, EMT-IV 1:00 pm – 3:00 pm Ortho Injuries and Splinting Lab Shannon Snyder, MD, Department of Emergency Medicine Greg Jacobson, MD, Department of Emergency Teaching Assistant(s) EM Resident(s) March 15, 2006 1:00 pm - 2:00 pm Trauma as a Disease Jeff Guy, M.D., Assistant Professor Surgery Division of Trauma and Surgical Critical Care 2:00 pm - 3:00 pm Patient‖ Packaging‖ and Movement David Sewell, EMT-P ;with Teaching Assistant(s); EM Resident(s) March 22, 2006 1:00pm – 3:00 pm EKG Shannon Snyder, M.D. Department of Emergency Medicine March 29, 2006 Altered Mental Status / Drugs and Corey M. Slovis, M.D., Chairman, Department. of Emergency Medicine 1:00 pm - 2:00 pm Alcohol - Street Drugs & Inhalants Keith Wrenn, MD, Department of Emergency Medicine including the ―Date Rape@ Drugs 2:00 pm – 3:00 pm Patient Situations EM Resident April 5, 2006 1:00 pm - 2:00 pm How Pediatric Patients are Different Andrea Bracikowski, MD, Department of EM 2:00 pm - 3:00 pm Wilderness Medicine Ian Jones, M.D., Department of Emergency Medicine April 12, 2006 1:00 pm – 1:30 pm Geoff Hayden, MD, Department of Emergency Medicine Middle TN Medical Reserve Corps 1:30 pm – 3:00 pm David Sewell, EMT-P, DC with Metro Fire Dept, / EMS Division, Department of EM Triage / Mass Casualty Incident April 19, 2006, 1: 00 pm - 2:00 pm Death and Dying Michele Stratton, RN, EMT-P, Department of Radiology 2:00 pm – 3:00 pm Mary Fran Hazinski, RN, MSN, Department of Pediatrics and Division of Trauma Prevention of Pediatric Emergencies April 26, 2006 1:00 pm - 2:00 pm Course Overview Corey M. Slovis, M.D., Chairman, Department of Emergency Medicine 2:00 pm – 3:00 pm Course Evaluations & Wrap up Teaching Assistant(s) EMS I-Spring 2006 Page 4 3. Welcome!!! On behalf of the faculty and students who help make this elective an enduring success, let me welcome you to what I feel is one of the highlights of the first year of medical school-this elective! First year will be filled with new faces, new friends, and new facts, and the last thing we want to do is burden you with more minutiae and monotony—that is the domain of your first year faculty. Our aim is instead to offer a clinical elective that allows you to listen to award-winning professors, to see the real world that is Nashville, TN beyond the ―Vandy Loop‖, and lastly, to do. Put aside thoughts of anatomy or histology, and just enjoy being a medical student, laying hands on real patients, and learning good ‗doctor‘ skills. At the same time, realize how valuable your position is as a student in this class. You will receive lectures from dedicated faculty who are as skilled as they are committed to medical education. The Emergency Department faculty is a perennial favorite for the Shovel Award (given annually by the 4th year class to the outstanding teacher at Vanderbilt Med). As a residency, Emergency Medicine at Vanderbilt is among the top in the country, and truly attracts a great pool of applicants. You will remember these faces and personalities when, as a fourth year medical student, you get to spend a month down in the E.D. on your Emergency Medicine rotation. Lastly, I hope you enjoy your exposure to the field of Emergency Medicine. Emergency medicine is not ER. E.M. rewards those who love it all, who are equally at ease treating a cranky 3 year old vomiting as they are at stabilizing the airway in a MVA trauma victim. Want to be a jack of all trades? Don‘t want to choose just one field? E.M. has a little bit of everything. If you feel like you can think on your toes, thrive in pressure-packed situations, and work really hard while you‘re on, and then totally turn off your doctor- side when you‘re home (i.e., no beeper, no staying late and missing your child‘s ballgame), E.M. is for you. Not surprisingly, increasing numbers of applicants are seeking this specialty, and as an emergency physician, yours will be an ever-expanding job description. No longer are patients admitted for the work-up or the intervention-often times, the diagnosis has been made, the myocardial infarction ruled out via a nuclear study, or the comminuted fracture reduced by the time they leave your E.R, never needing a hospital bed. The bottom line is this: have fun, enjoy yourself (but be safe), and ask yourself if this is something you like. Talk to the Teaching Assistants or Chief Sewell, and talk to the faculty. Talk to the Paramedics and EMTs in the field. Ask questions, be assertive. We can talk to you about medical school, specialties, residency stuff, and anything else that your little heart may desire. Remember that medical school is about as painful as you make it, and have a great year. -Atuhani Burnett, January 2004 (updated August2004 d. sewell) EMS I-Spring 2006 Page 5 4. Helpful Emergency Medicine Acronyms and Jargon As with anything in medicine, when in doubt, a little common sense goes a long way! This is far from being a complete list of all medical acronyms you'll see during this course, but it includes most of those unique to EMS. Remember, the first years of medical school are just spent learning the language! A/C Ambulance Center ACLS Advanced Cardiac Life Support AED Automatic External Defibrillator AMS Altered Mental Status ATLS Advanced Trauma Life Support BLS Basic Life Support BP Blood Pressure BCLS Basic Cardiac Life Support CPR Cardiopulmonary Resuscitation EMS Emergency Medical Services EMT Emergency Medical Technician EMT-P Paramedic The hierarchy of EMT's in terms of procedural capabilities and training is as follows: EMT (kinda like a VMS I) < EMT-IV (as in "I-V", not '4') < EMT-P Please see page 10 for more info on the various EMT's. FF/EMT Firefighter EMT GCS Glasgow Coma Scale GSW Gun shot wound MedCom Medical Communications (Metro Dispatch - '911') Medic Usually followed by a #, this is both the station and ambulance (e.g., Medic 12 en route to Vandy with 23 yo WM s/p MVA…) Metro Metropolitan Nashville-Davidson County MAST Medical Anti-shock Trousers MI Myocardial Infarction MCA Motorcycle accident MVA Motor vehicle accident (as in s/p MVA) NFD Nashville Fire Department PALS Pediatric Advanced Life Support R/O "Rule out"; used on ED flow board to indicate diagnosis until proven otherwise RR Respiratory Rate S/P Status Post EMS I-Spring 2006 Page 6 5. Goals The underlying aim of this course is for you to have a fun, safe, and interesting experience that will distract you from your daily studies and remind you why you wanted to study medicine. In this course you will: • gain hands-on experience and skills pertinent to emergency medicine and prehospital care • have the opportunity to learn about prehospital care by experiencing life as an EMT or paramedic responding to 911 calls • learn from the sharing of prehospital experiences with classmates • learn the fundamentals of care for common clinical presentations to the ER • be introduced to the specialty of Emergency Medicine and the emergency physician's role in supervising prehospital care. This class will impart an awareness that will be invaluable to you during later rotations in the ER. The differences between patient care "out there" and in the hospital are better experienced than described. In general, we believe that being shown is better than being told, and being allowed to do is better than being shown. The first thing we hope you take away from this course is a new perspective (that of the paramedics). It is hoped that this perspective will allow the medical student to better anticipate the needs, abilities, and deficits of EMS personnel when the student works in the future as a physician. For example, a physician familiar with EMS may better recognize the skill displayed in delivering a patient from a burning wreck to the hospital and not be so quick to ask "Why does this patient only have one IV?" Or a physician familiar with EMS standard operating protocols won't ask "Why does this guy have c-spine immobilization?" He or she will know from experience that the medics were following protocol. Finally, you will see how field protocols merge with emergency department practices to deliver rapid care to the emergency patient. The second objective we have is for you to gain is specific skills and knowledge. Many students have been struck by the absurdity of their practical ignorance at the end of their second year. This course teaches basic emergency skills to help correct this deficit and give you a certain competence if you suddenly find yourself in an emergency. Unfortunately, this is not a trauma and life support course, and many skills and techniques that are both interesting and useful must be omitted. Still, there are many simple but useful skills that may come in handy while you are on the ambulance rides or if you are alone in an emergency. These include: • Scene safety • Vital Signs • Basic Life Support (BLS) • Splinting and bandaging • Airway management • Suturing • C-spine precautions In addition, students are encouraged to milk the paramedics for whatever knowledge they can get. This course is designed for those who take the initiative! Lastly, we hope you will gain an understanding of EMS. You will be given an introduction to the operations of a metropolitan emergency medical system. At the end of the course, you should understand: • What EMS is, and how it interacts with the Fire Department • How citizens access EMS • How EMS is deployed and dispatched • The capabilities of EMS • The relationship of EMS to the various hospital emergency departments EMS I-Spring 2006 Page 7 6. Course Design and Structure The intent of the course directors is to provide students with a broad introductory exposure to emergency medicine and prehospital care along with specific, useful skills not usually learned in the first two years. Instructors include many of the faculty of the Department of Emergency Medicine and they have been encouraged to use case presentations as learning tools, to actively solicit (and expect) student participation and to avoid boring lectures that are endured in other courses. This course is an active, participatory experience which is about useful learning and focuses on "doing". Attendance at and participation in class meetings is expected. Field experiences are a unique opportunity. You must complete and log three (3) four-hour rides. You will be able to schedule these rides entirely to your liking, thereby allowing you to avoid tests or important social events. We do, however, get greatly perturbed when students don't show up for a ride. Make sure you know how to properly cancel a ride (i.e. you just need to let us know). We will make every effort to have a surplus of ride times available so you can schedule an extra ride if you wish or if you become a "white cloud" (a sort of positive jinx that gives the ambulance a quiet night). Regarding tests, these Western thinkers said it best: "It is nothing short of a miracle that the modern methods of instruction have not entirely strangled the holy curiosity of inquiry...It is a grave mistake to think that the enjoyment of seeing and searching can be promoted by means of coercion and a sense of duty." --Einstein "Knowledge which is acquired under compulsion obtains no hold on the mind." --Plato There will, therefore, be neither midterm nor final. It is also our belief that your other first and second year classes will satisfy any test-taking desires you have. This class truly is learning for the sake of learning-but aren't they all supposed to be like that?!? TO PASS THIS CLASS: 1. Show up and participate on Wednesdays 2. Complete three ambulance rides 3. Spend two nights in the ED 4. One District Chief ride (Optional) 5. Turn in completed ―Run Sheets‖ during the class following ride 6. Don't be AWOL for a ride (i.e. cancel in the prescribed manner) 7. Have fun! 8. BE SAFE!!! EMS I-Spring 2006 Page 8 7. Ride Guidelines Times: All rides will be from 6 pm until 10 pm (option to stay until midnight). You will be assigned to arrive about 15 minutes before a shift change. This gives you a better chance of catching the crew and ambulance before they go off to a call, leaving you to sit around at the station and waste time. The Fire Department requires that no medical students remain in the station after midnight, so you may not stay later unless you are out on a call. Please respect your privileges and when midnight rolls around, prepare to leave. If the crew invites you to stay longer, thank them, but politely decline. If it is significantly past the time you need to leave and the ambulance continues to receive calls before returning to the station, you may ask the crew if they could have a District Chief meet up with you to get you back to the station so you can head home. Clothing: The Fire Department asks all ride-alongs to wear dark pants (navy blue or black - no jeans) and a plain white shirt with a collar (polo/golf type or button-up). If it's cold, try to wear the closest thing to a dark, solid-colored jacket. If rain is in the air, a raincoat will come in handy. In addition, you must wear "smart" shoes: no pumps, dress flats, clogs, Birkenstocks, Tevas, etc. We recommend leather shoes, work or hiking boots. Remember, you will be walking around emergency call scenes with broken glass, twisted metal, blood, etc. Also, your clothes may be subject to getting blood, vomitus, etc. on them (yuck! but it does happen). Dress accordingly. In addition, your Vanderbilt ID tag should always be visible, above waist-level while on calls! Responsibilities: Although you will learn some basic skills in this class, you will not be required to perform any procedures. However, it is to your advantage to make yourself useful; we learn best by doing. Try to learn the location and operation of important equipment before going out on a call so you can participate in the delivery of care. Go ahead and try the following: * Take vital signs * Assist with c-spine precautions * Complete an ambulance supply inventory * Carry equipment * Hook up the cardiac monitor * Put on the oxygen saturation probe * Help with CPR * Help clean up after the call (this will really be appreciated!) In general, you will gain the most by acting like a third crew member; don't get in the way, but don't wait to be told. Absolutely ask as many questions as you want (but recognize that timing is important). Prohibitions: Although you are covered by Vanderbilt malpractice insurance during these rides, and although we do encourage active participation in patient care, some aspects of care are forbidden (even if you've done them before). In short, do not perform any invasive procedures. *** Do not start IVs *** *** Do not administer drugs *** *** Do not intubate *** *** Do not defibrillate *** It is unlikely that you will be asked to do any of these things, but if you are, refuse and blame these guidelines. Also, you are prohibited from riding on the fire engines (they'll tell you it's OK, but it's not). EMS I-Spring 2006 Page 9 8. Emergency Department Guidelines Getting around in the E.D. is much easier if you know two access codes. One is the universal hospital code, 0160 (which is also the E.D. phone number) which gets you in the "back door" of the E.D. by the radiology room. The other code that is helpful is "119" (911 backwards, duh) which permits you to go into the waiting room and back out again. Time : Each student in this elective will spend two shifts in the emergency department from 9 p.m. to 1 a.m. during the semester. You should report to one of the two attending physicians on duty that evening when you first arrive. He or she may ask you to follow them around for the evening, or you may be assigned to a resident. Clothing : You should wear clean scrubs if you have them. No formalin-soaked pairs from anatomy lab. You should wear your white coat and your ID tag to help identify you as a medical student. Responsibilities : The purpose of your time in the emergency department is to introduce you to what happens to patients after you drop them off at a hospital following an emergency call. As with the ambulance rides, you will learn the most by asking questions and by doing. Please keep in mind that Vanderbilt is a Level I trauma center and can get very busy, so don't get upset if people seem harried or ask you to hold your questions for a little while. As time and people allow, try some of the following while you're in the ED: * Take more vital signs * Follow a resident into a room for a patient examination * Learn how to read the patient board * Observe a trauma resuscitation (but ask first!) * Learn about the equipment in the different rooms * Find the radiologists' reading room Prohibitions : The same prohibitions apply in the ED that are listed in the ambulance ride section. Many of the residents assume that all medical students in the ED are fourth year students and may ask you to do things beyond your training. Please refuse and again blame these guidelines. (No drugs, no IV‘s, no defibrillation). Bear in mind, however, that it is highly encouraged for you to show some initiative during your night in the Emergency Department-if a resident is not too busy, ask him if you can watch him tap a knee, drain a peritonsilar abscess, or sew up a laceration. While we will conduct skills labs in which you learn how to splint and throw some instrument ties, there is nothing like the real thing for learning. Ask the resident if you can watch him throw some stitches, then throw some yourself. It is never too early to begin practicing the trinity of medical education: Watch one, Do One, Teach One. EMS I-Spring 2006 Page 10 9. How to Cancel Rides 1. Talk to David Sewell or a TA during class or page them anytime (well, not in the middle of the night). This is the best way to take care of it. 2. If it's the day of your ride and you can't get any of us to answer the page (highly unlikely) and you've left one of us a message to that effect, call the Assistant Chief at 862-5374 to inform him/her you cannot ride. Later, you can reschedule. David Sewell: Office 862-5459, Pager 960-2861, Cell 480-1169. Text message by e- mail to: email@example.com TAs: Pager/cell phone numbers listed above Joyce Barnett: 936-1324 Beeper etiquette: When calling pagers, put in your call back number followed by "#". If you have a beeper, too, put your call back number as above, hit "*" then type in your beeper number, then finish as above with "#". 10. Safety Seatbelts. If this class doesn't convert you to a 100% of the time seatbelt wearer, nothing will. The minute you get into the back of the ambulance, buckle up. All of the captain's chairs have belts, although you may have to fish around for them. Approximately 10,000 emergency vehicles get into accidents while running emergency traffic (lights and siren) to calls each year. While caring for patients, it's often impractical to use the seatbelts. However, make sure you're always seated or holding on to the monkey bar. In the event of an accident, report it to a class coordinator immediately. If injured, have them take you to Vanderbilt. Also, if you have any tendency toward motion sickness, take Dramamine before you go. You'll be in the back of the ambulance, facing backward and traveling at high rates of speed. On the scene: Every EMT and paramedic is trained that the very first step before the primary survey is the scene survey. This means he or she must perform a careful evaluation of the environment to identify hazards before charging in to treat a patient. The hazards include such things as downed power lines, noxious chemicals, oncoming traffic, or even armed individuals. On any scene, take your cue from the medics, and use your own eyes and ears from the first instant you are on the scene until the end of the call. It is easy to fall into "tunnel vision"--where you see only the patient on a call. Guard against this always. Paramedics have standard operating procedures for these situations. For example, the ambulance (or a fire truck) will be parked "upstream" in traffic to protect the patient and rescue personnel at an accident scene. As another example, paramedics will not approach the scene of a shooting unless police are on scene as the attacker may still be in the area. Gloves: WEAR GLOVES FOR EVERY PATIENT! Every ambulance has several boxes of exam gloves. Know where they are. The paramedics will put gloves on while en route to every call (instead of fumbling for them once they see a bleeding patient); follow their example. Don't worry--the gloves are free (well, with your tax dollars at work) and in vast supply. It is a good idea to always have an extra pair of gloves with you in your pocket. Make sure you dispose of any body fluid contaminated materials in the red trash can. Never leave any trash (plastic wrappers, 4x4's, etc.) at the scene--always pick up everything and dispose of it in the ambulance. Goggles. You should purchase a pair of safety goggles at the book store ($3) and bring them with you on the ambulance (it's a good idea to write your name and VMS on them). Goggles are required (per Universal Precautions) in the following instances: large wounds involving lots of blood, when starting IV's (you won't be doing this, but you may be watching closely), when intubating (ditto), suctioning or any time there could be EMS I-Spring 2006 Page 11 splashing of body fluids. Unfortunately, the EMT/-P's rarely use goggles but we're counting on you to set a good example and to protect yourself (even if you feel like a goon!). Sharps: "Sharp" items include needles, lancets, scalpels, etc. Sticking yourself with a sharp that has been contaminated by a patient's blood exposes you to HIV, hepatitis, or some other disease. For this reason, here are some rules to follow regarding sharps. Although some of these rules won't apply to you for these rides since you will not be doing invasive procedures, you will be expected to follow them for the rest of your medical career. Also, you will soon realize that conditions in the field sometimes make alternative methods of universal precautions/sharps disposal safer. Use common sense and try to stick to these rules as much as possible: 1. Always dispose of your own sharps immediately. Never, ever leave them with other trash for someone else to pick up--they can be stuck. By the same token, never volunteer to dispose of them for someone else; this is their responsibility. Try to let the paramedics dispose of their own sharps. Remind them if they forget. Keep a mental count of all sharps that are "opened" and all that are properly disposed of. 2. Sharps may only be disposed of in the special red sharps boxes. There should be one at every hospital bed. There is one on each ambulance at the front end of the bench (they are actually white instead of red). Never ever throw away sharps in ordinary trash cans. 3. Never, ever recap needles. This is the #1 way to stick yourself. When you finish with any sharp, place it directly into a red sharps container. 4. Never stick a sharp into a bed mattress (or seat cushion) "just for a second" until you can throw it away properly. The risk here is obvious. The sharps container should be within as easy reach as any spot on the bed. Make sure the red sharps box is nearby before you begin a procedure using sharps. What to do if you get stuck: Don't panic. You have already received two or three shots of vaccine against Hepatitis B. Immunoglobulin against Hepatitis C is available. Your chances of contracting HIV from needle sticks are small, but real (0.5% if stuck with infected needle). You must go to the emergency room at Vanderbilt IMMEDIATELY and go through the needle stick protocol that includes hepatitis and HIV testing (if you consent) and information about what to do. This service is paid for by Vanderbilt. In the unlikely event you contract a disease, documentation of the stick will be important! TB. Tuberculosis is in a period of resurgence due largely to patient non-compliance and the emergence of HIV. Ideally, patients with TB will tell you when you arrive that they are infected. This is not always the case, however, and you should therefore ASSUME TB with any homeless, emaciated, inebriated or HIV+ person with a cough (it's not contagious unless they're coughing it up). If you are a first-year and thus you have not been fitted with an appropriate anti-TB mask, ride up front and avoid patient contact completely. Report even suspected exposures to the course coordinators (they'll follow up on the patient for you). You don't need to go to the ER immediately after an exposure since you've already had a pre-exposure TB test. EMS I-Spring 2006 Page 12 11. Overview of Emergency Medical Services Some information from Trauma, 2ed., Mattox, Moore, Feliciano; Appleton and Lange 1991 The education and patient care skills of ambulance personnel differ. As a physician, you will need to be familiar with the different skill-level designations of emergency medical technicians (EMT's). Although the specific skills taught at each level vary from state to state (there are 32 variations of the EMT-intermediate in the United States), the following main designations are broadly consistent: Basic Emergency Medical Technician (EMT) The EMT has completed an 110-hour course of instruction (9 semester credit hours at some community colleges). The skills learned by the EMT include: CPR, basic airway management, suctioning, administration of oxygen, splinting, spinal immobilization, bandaging, extrication, emergency childbirth, patient transfer techniques, and epinephrine administration (for anaphylaxis). Emergency Medical Technician--Intermediate (EMT-I) The EMT-I level (150-200 hours training beyond EMT) is not yet recognized in Tennessee. However, there is a watered-down version known as EMT-IV (50 additional hours of training). This intermediate level is designed to train EMTs who serve in rural areas where paramedics may be scarce to administer IV-fluids and to better treat shock and cardiac emergencies. Emergency Medical Technician--Paramedic (EMT-P) The paramedic attends college courses for 12-15 months (minimum of 460 hours after basic EMT training). The paramedic is trained in these additional skills: intubation (advanced airway management), chest decompression (for pneumothorax), EKG interpretation, defibrillation and the administration of various drugs. The Nashville Fire Department (NFD) The NFD employs both EMTs and EMT-Ps (paramedics) in its Paramedic/EMS Bureau. Ambulances are staffed either by an EMT and a paramedic or by two paramedics--both combinations create an Advanced Life Support (ALS) unit. Basic Life Support (BLS) units consisting of two EMTs are more common in rural areas. Nashville firefighters are also trained as basic EMTs. In Metro (Nashville), a fire engine is usually dispatched concurrently with the ambulance, and since there are three times as many fire engines as ambulances, the fire engine usually arrives at the scene sooner. The FF-EMT's provide BLS and may use automated external defibrillators (AED) for a patient in cardiac arrest before the ambulance arrives. In addition, they assist the medics and will frequently ride in the ambulance during a code (heart attack; full cardiac arrest) or with an extremely ill patient. Recently, the Fire Department has upgraded 10 of their Engine Companies to ALS status by staffing the Fire Engine with Fire Fighter/Paramedics. In rural EMS systems, First Responders (completed a 48 hour course which includes BLS and basic First Aid) play a greater role in patient stabilization until the arrival of an ambulance. LifeFlight Vanderbilt LifeFlight serves as Middle Tennessee's medevac helicopter. Occasionally, army helicopters from Fort Campbell will fly patients to Nashville. As you will learn, the nurses who staff LifeFlight are RN's with many additional certifications and 3-5 years experience. They must also be certified at least as an EMT and many are EMT-Ps. The flight nurses can do everything EMT-Ps can do, as well as give many more drugs, give blood, and do surgical cricothyrotomies ("crics") for airway control. Frequently, the LifeFlight nurses have had more experience in managing critically ill patients than the rural physicians from whom they receive the patients. EMS I-Spring 2006 Page 13 LifeFlight is used on occasion in Davidson County--usually outside the perimeter formed by Old Hickory Boulevard. In other counties, LifeFlight is an essential part of the trauma management team. Emergency Medical Technician--Tactical (EMT-T) This specialized area of EMS involves mainly paramedics. They receive a type of cross training in law enforcement/ SWAT tactics. They are on call for incidents such as drug raids and hostage situations. The publicity about EMT-Ts is extremely limited for the reason that these same medics work in non-SWAT situations the majority of the time. Additional types of specialized EMT training include: rescue/extrication, high angle rescue, cave rescue, wilderness medicine, urban search and rescue, and water rescue. Some of the paramedics who assist us in class are involved in these specialized areas. EMS I-Spring 2006 Page 14 12.C-Spine Precautions This section is included because many of the trauma patients you see will be placed "in c-spine." 'C' here stands for "cervical" but the technique is actually used to protect the patient's entire spine, not just the especially vulnerable 7 cervical and first thoracic vertebrae. C-spine precautions are employed any time the rescuer feels the spine may have been injured. Once a patient has been placed in c-spine, they must be continuously attended since they risk aspiration and asphyxiation should they vomit. Once in place, C-spine stabilizations may only be removed after an emergency physician has appropriately "cleared" the c-spine. One note of interest, a C-Spine clearing protocol has recently been adopted for the Paramedic level providers to follow. INDICATIONS FOR C-SPINE PRECAUTIONS/SPINAL IMMOBILIZATION: 1. Vehicle accident with associated head, neck or back pain 2. Diving accident 3. Fall from a height 4. Injury to head, neck or face 5. Massive trauma from any source (i.e. gun-shot wound or stabbing) 6. Injury producing loss of consciousness 7. Any suspicion that spinal injury may be present The technique essentially consists of "splinting" the entire patient to a stiff backboard (or "spineboard") so that they can be transported with minimal risk of disrupting a potential spinal injury. First, one rescuer "holds c- spine" traction. Next, a rigid cervical collar is placed on the patient who is then carefully transferred (often ―log-rolled‖) onto the backboard. The rescuers must always take care to move the person "as a unit," keeping the spine as motion-free and straight as possible. Next, some method is used to brace the head on the board-- Metro uses a disposable head immobilization device that quickly attaches to the board. Other braces may include rolled towels or foam cushions placed on either side of the patient's head. Then the patient's head is secured to the braces and board using disposable Velcro strips or adhesive tape (not directly on skin). Finally, straps are used to snugly secure the patient's body to the board and the body/board unit on the stretcher. EMS I-Spring 2006 Page 15 13. Patient Assessment and Vital Signs Adapted from Emergency Medical Treatment: A Text for EMT-As, Nancy Caroline, MD; Little Brown and Company, Boston, 1982. Patient assessment. If you have completed BLS (CPR) training, you already know the Primary Survey. PRIMARY SURVEY: to detect acutely life-threatening problems A Airway with attention to C-spine B Breathing C Circulation/cardiovascular stability --pulses --profuse bleeding D Disability i.e. neurologic status E Expose You will hear much more about these all-important steps throughout your training. Once the ABCs are evaluated and secured, then the rescuer can move on to the secondary survey. SECONDARY SURVEY: to detect problems that do not pose an immediate threat to life but that can become more serious or life-threatening if not treated 1. Medical History A Allergies M Medications P Past medical/surgical history L Last meal, meds, menstrual period, tetanus E Events of illness/injury 2. Head-to-Toe Physical Assessment (including vital signs) Obtaining vitals early during a rescue is important for two reasons: (i) Vital signs provide a reasonable "snapshot" of the patient's physiologic status, and (ii) When compared to repeat vitals taken later during the call or at the hospital, vital signs may suggest a trend, i.e. is the patient improving or deteriorating? Vital signs: There are five vital signs in emergency medicine: 1. Pulse 2. Blood pressue 3. Respiratory rate 4. Temperature 5. Oxygen saturation Be sure to always record the time vital signs were taken. PULSE Measurement of the pulse includes: RATE, RHYTHM, and FORCE. RATE: Measure the rate by feeling for the radial pulse with two fingers (not your thumb) and counting beats for 15 seconds. Multiply by four to give beats per minute. EMS I-Spring 2006 Page 16 RHYTHM: Without a heart monitor, you can make only one of two statements about rhythm: regular or irregular. FORCE: There are three qualities here. A normal pulse is described as full. A pulse that is extremely strong (as in after exercise) is described as bounding. Finally, a pulse that is very difficult to palpate is called thready. When you describe the pulse, always include rate, rhythm and force. BLOOD PRESSURE This is reported as the systolic over the diastolic pressures (as in "120 over 80" or 120/80 mmHg). See the chart of normal values at the end of this section. Blood pressure is measured with the sphygmomanometer. Its use will be demonstrated in class, and you should make use of the chance to practice. Briefly described: you place the cuff around the upper arm, place your stethoscope over the brachial artery, and rapidly inflate the cuff to about 150--200 mmHg; don't over inflate--it hurts! Slowly release the air in the cuff. When you hear the first beat, that is the systolic pressure. When you stop hearing the beats, that is the diastolic pressure. A word about finesse: The tick marks on the gauge are almost always in even numbers only, so giving blood pressure as "135/93" might imply more precision than you actually have. Blood pressures taken manually are usually given as even numbers only. Palpating blood pressure: If you are in a noisy ambulance, or you are pinched for time, or if you simply can't hear the pulses, you may be able to palpate a blood pressure. The procedure is generally the same except you feel for the radial pulse. Inflate the cuff, then slowly release the air. The first pulse you feel is the systolic pressure. Report this as "130 palpated" or "130 over palp" and write it as "130/P." When palpating a pressure, you do not get a diastolic reading. RESPIRATIONS Count the RATE right after you take the pulse. Keep your fingers on the wrist and count breaths for 30 seconds. Multiply by two to give breaths per minute. The reason for keeping your fingers on the patient's wrist is to avoid calling attention to their breathing. It is impossible to breathe "normally" if one thinks about it. Other things to consider regarding respirations: RHYTHM (regular or irregular), EASE (labored?, painful?), DEPTH (deep, regular or shallow), ABNORMAL NOISES, ABNORMAL ODOR (alcohol, fruity). As an aside, respiratory rate is rarely measured, and is often "eyeballed" instead. ("Yeah, it's 16.") This is a clumsy practice. Merely eyeballing the rate encourages forgetting all the other questions about breathing that are important. TEMPERATURE In the field, temperature is rarely measured. EMS personnel describe skin signs. However, temperature is an important vital sign and is measured upon arrival to the hospital. EMS I-Spring 2006 Page 17 SKIN SIGNS COLOR: Pale, normal, or flushed. TEMPERATURE: Hot, warm or cool MOISTURE: Wet (clammy), diaphoretic (sweaty) or dry OXYGEN SATURATION An indirect, easily obtainable measurement is made by attaching a probe with an infrared beam over a nail bed. It is also referred to as pulse oximetry. This vital sign is more useful as a trend (i.e. is it increasing or decreasing over time). An absolute measurement of blood oxygen saturation must be obtained from lab tests on arterial blood (this is done only in the hospital). NORMAL RESTING VALUES PULSE Adults 60-80/min Children 80-100/min Infants 80-160/min RESPIRATIONS Adults 12-20/min Children 18-26/min Infants 25-36/min BLOOD PRESSURE Adult male Systolic: 100 + Age Diastolic: 65-90 Adult female Systolic & Diastolic: 8-10 less than male of same age TEMPERATURE 37°C (98.6°F) OXYGEN 97-100% SATURATION EMS I-Spring 2006 Page 18 First year medical student fill out the forms I wake up elective class what is her name Saturday night where did she come from you know what? trauma team no one prayed for her her husband shot her no one prayed for her soul LifeFlight coming I did not pray for her soul 15 minutes out TV camera is outside I did not pray for his CPR in progress 12:25 a.m., oh, it's my talk to dad 37 year old woman birthday today talk to a friend gunshot wound to the chest happy birthday write it down light a candle for her get the room ready we are done here talk to mom wait for her anesthesia resident got a pizza it‘s my birthday Want some? all of a sudden she‘s there Monday in class very white round in the SICU before reading the paper arm hanging limply sleep looking for the story blood everywhere on her it‘s been 1.5 hours bare chest since the first death it is there her child was there nurses trade CPR all of a sudden too wet to shock I am not here her sister lives try epinephrine all is going away same town as mine have to leave 1200 miles away try again can‘t let them see I won‘t let go her grandmother lives nothing more we can do Go away stars you can‘t have in my small hometown 12:05 a.m. me 1100 miles away see my head is between my residents probe the hole legs too bizarre Want to look? too strange why is this happening to me? too close to me think it got the pulmonary no blood any more artery smell is gone too talk to my teacher check her back don‘t worry 1.5 hours after the first death it‘s ok to feel upset my God, she was shot in the it‘s ok to cry back I just want to go home now but I‘m not sad blood pours out I want to sleep in my bed it‘s just so weird No, I don‘t want to learn any time for me to leave the room more tonight you‘ll always remember for a minute I have learned too much she says, I do cleaning the body I just want to go now and you‘ll see it again taking out the tubes go to my bed cover her with a sheet call for sleep it was my birthday, but not over her head the first death. sleep is reluctant coming leave her there but comes, without looking EJF all alone back 3/22/93 EMS I-Spring 2006 Page 19 Suggested Ambulance [ ] 1L & 500cc D5W bags [ Rigid splints ] Check-Out Sheet [ ] 14, 16, 18, 20, 22 g IV [ Vac splints ] catheters [ Padded board splints ] General: [ ] Butterfly needles [ Adult traction splint ] [ ] Stethoscope [ ] IV tubing & extension [ Padi traction splint ] [ ] BP Cuffs: S,M,L sets [ Cervical collars ] [ ] Trauma scissors [ ] Syringes Pedi,S,M,L,XL [ ] Bandage scissors General Medical: Pharmacology: [ ] ―Jump‖ bags [ ] EtOH preps [ ] Epi 1:1,000 [ ] Latex gloves [ ] Batadine [ ] Epi 1:10,000 Airway Management: [ ] Neosporin [ ] Atropine [ ] Adult ambu bag & [ ] Tourniquets [ ] Lidocaine mask [ ] Oral glucose [ ] Bretylium [ ] Padi ambu bag & mask [ ] Ipecac [ ] Na HCO3 Adult oxygen masks: [ ] Charcoal [ ] Albuterol [ ] Non-rebreathers [ ] Chem strips [ ] D50W [ ] Simple face masks [ ] Thermometer [ ] Benadryl [ ] Nasal cannulas [ ] Obstetrical kit [ ] Narcan Pediatric oxygen masks: [ ] Burn sheets [ ] Valium [ ] Non-rebreathers [ ] Sterile water [ ] Morphine [ ] Simple face masks [ ] Sterile gloves [ ] NTG spray [ ] Nasal cannulas [ ] Ammonia inhalants [ ] ASA [ ] Nebulizers and tubing [ ] Hot & cold packs Safety: [ ] Oral Airways (1-5) [ ] Urinal, bed pan, [ ] Coveralls [ ] PTL airways emesis basins [ ] Face masks [ ] Nasal Airways [ ] Blnkets, sheets & [ ] Sharps containers [ ] ET tubes (3.0-9.0) pillows [ ] Eye protection [ ] Stylets [ ] Towels [ ] Infectious waste bags [ ] Laryngoscope w/ [ ] Body bag and container blades Trauma: [ ] Spare gloves [ ] Main oxygen tank [ ] 4x4 gauze pads [ ] Disinfectant spray PSI__________ [ ] Multi trauma pads [ ] Portable tank [ ] Bandaids PSI__________ [ ] Vaseline gauze pads [ ] Wall suction unit [ ] Triangular bandages [ ] Portable suction unit [ ] Kerlix rolls [ ] Rigid suction catheters [ ] 1/2, 1, 2 inch tape [ ] Oxygen saturation [ ] MAST trousers monitor Immobilization: Cardiac Management: [ ] Long spine boards w/ [ ] Cardiac monitor straps [ ] EKG electrodes [ ] XP-1 / KED [ ] 12-lead EKG [ ] Scoop stretcher IV Therapy: [ ] Pediatric immobilizer [ ] 1L & 500cc normal [ ] Short board saline bags [ ] Head [ ] 1L & 500cc lactated immobilizers/towel ringer‘s bags rolls EMS I-Spring 2006 Page 20 Fire Station locations, phone numbers, and map links. Station Address Phone Link 862-5350 Ambulance Center 50 Hermitage Avenue 37210 Ambulance Center 862-5374 th Central Police Station 6 & Broadway (Gaylord Entertainment Ctr) 862-7611 Central PD State of TN Center for 743-1800 850 R.S. Gass Blvd. 37216 Med Examiner Forensic Medicine 743-1802 rd Lentz Public Health Ctr. 311 23 Ave. N. 37203 Lentz Ctr Emergency CommCenter 2060 15th Ave South 37212 862-5412 Emerg Comm Ctr Station 4 5111 Harding Place 37211 331-3588 Medic 04 Station 3 840 Meridian St. 37207 254-8030 Medic 03 Station 10 15530 Old Hickory Blvd 37211 834-4937 Medic 10 Station 11 1745 Dr. D.B. Todd Blvd 37208 320-1259 Medic 11 Station 12 101 Polk Ave. 37210 242-9296 Medic 12 Station 15 1320 Vultee Blvd. 37217 885-1778 District or Triage 15 Station 17 3911 West End Ave. 37205 292-2493 District 17 Station 18 1151 East Cahal Avenue 37206 228-8377 Medic 18 st Station 19 349 21 Ave. N. 37203 320-5583 Medic 19 Station 20 2025 Richard Jones Rd. 37205 298-1666 Medic 20 833-7588 Station 21 320 Joyner Avenue 37211 Medic 21 834-6472 Station 23 6215 Centennial Blvd. 37209 350-8537 Medic 23 228-5809 Station 25 2589 Whites Creek Pike 37207 Medic 25 228-8314 Station 28 2394 Lebanon Rd. 37214 889-1826 Medic 28 228-4125 Station 29 4201 Gallatin Rd. 37216 Medic 29 228-8179 Station 30 3646 Old Clarksville Highway 37080 876-0970 Medic 30 Station 31 224 Madison St. 37115 865-0428 Medic 31 Station 32 4031 Plantation Drive 37076 889-6343 Medic 32 Station 37 646 Colice Jeanne Road 37221 646-3442 Medic 37 EMS I-Spring 2006 Page 21 EMS I Sample EMS Scenarios for Discussion To the VMS Students: The following case scenarios are provided to help you learn from the Paramedics and EMTs during the ―down time‖ which may happen during your ride-along activities. They are purely educational and are not a test for either you or the Medics. You may feel a little intimidated discussing these cases with the Medics because of your relative lack of practical medical training at this point in your career. That‘s O.K.! In fact, that‘s the reason you should be talking to the medics about these cases. Hopefully, by analyzing various examples of EMS responses, you‘ll get to review a wider variety of calls than just the ones you‘ll see on you ride-along nights. Perhaps you‘ll even develop a basic feel for the priorities on each call, and the types of equipment and skills used to treat each patient. In any event, we hope that these sheets are helpful to you and that you use these cases as learning tools and discussion starters if your nightly call volume gets low. To the NFD EMS Personnel: These scenarios are given to the student as a tool to help them use their ―down time‖ with you between calls more efficiently. The scenarios are designed purely to facilitate discussion and teaching and are in no way part of any test or research project, now, or in the future. The students will be handed out ―answer keys‖ later in the semester which represents our best analyses of how to treat a given case. The students will bring the keys with them on their last rides of the semester. Please feel free to disagree with the ―keys‖ and give us feedback if you would like to help us improve these cases. We would certainly appreciate input from you! Again, we would like to thank you for taking the time to help teach these Medical Students about the skills and capabilities of EMS in Nashville. EMS I-Spring 2006 Page 22 Case Scenarios for Discussion 1. You receive a call from Stallworth Rehab about a 60 y/o female who is 2 weeks s/p hip replacement and now complains of chest pain and shortness of breath. On your arrival she looks pale, anxious and diaphoretic. What do you do? P: 115 BP: 160/100 R: 36 O2 Sat: 88% Temp: Warm/Dry 2. You are dispatched to treat a 25 y/0 male who has reportedly been shot. You find him face down in the middle of the street, with entrance wounds from approximately 30 shotgun pellets on his right flank and buttocks. His respirations are shallow and rapid. Treat the patient. P: 120 BP: Weak radial pulse R: 40 O2 Sat: 95% Temp: Warm/Wet 3. A passerby uses his cellular phone to call for help for a man down in the corner of an ATM lobby downtown. You arrive and are able to awaken the man, but he remains stuporous and lethargic in your presence despite vigorous stimulation. He looks as though he may be homeless and he smells vaguely of liquor and urine. He looks like he is probably in his forties. What do you do? P: 60 BP: 170/100 R: 8 O2 Sat: 88% Temp: Warm/Dry 4. A frantic mother calls 911 because her 3 y/o girl just got into mom‘s closet and took some of mother‘s prenatal vitamins. On your arrival the little girl is crying and complains of a stomach ache. Treat the patient and the mother. P: 120 BP: 90/50 R: 24 O2 Sat: 99% Temp: Warm/Dry 5. You arrive on the scene of a two car head-on MVA and choose to treat the driver of vehicle #1 as the most critical patient. Each car was estimated to be traveling at about 5o mph before impact. Your patient was unrestrained in a vehicle without an airbag. There is significant encroachment of the engine compartment into the passenger compartment. The steering wheel is deformed. The windshield (prior to its removal by the rescue/extrication crew) was ―starred‖ in front of the driver. Your patient is semi-conscious, does not remember the accident, and complains of some difficulty breathing and diffuse tenderness of the neck and right thigh. On exam, you note numerous facial abrasions, PEARL, lung sounds diminished on the left with some paradoxical chest wall movement on the left, a soft, non-tender abdomen, and gross deformity of the right thigh. The rest of your exam is unremarkable. The rescue/extrication crew informs you that the extrication will take fifteen minutes. What do you do before and after extrication to treat the patient? P: 130 BP: Strong radial pulse R: 30/Shallow O2 Sat: 88% on 100% O2 Temp: Cool/Clammy 6. A local nursing home calls 911 for a patient one of the night aids cannot wake up. You arrive and find a 71 y/o female in bed, cool and pulseless. On a quick-look EKG you see fine ventricular fibrillation. The patient has no DNR paperwork. What do you do? P: 0 BP: 0 R: 0 O2 Sat: NA Temp: Cool 7. A terrified father calls 911 for his 18 month old baby who has had a fever for the last day and now has become ―floppy‖ and difficult to arouse. Help the baby and father. EMS I-Spring 2006 Page 23 P: 160 BP: Thready brachial pulse R: 40 O2 Sat: 80% Temp: Hot/Dry 8. An 18 y/o woman was stung by several bees. She had never been stung before. She is now feeling hot and itchy and a little short of breath. Her past medical history is remarkable for asthma and Tetrology of Fallot (a congenital defect of the heart). Her mother called 911. Treat the patient. P: 130 BP: 80/40 R: 30 O2Sat: 92% Temp: Warm/Dry, Cool hands & feet 9. A very nice little-old-lady eats at Shoney‘s every Thursday because of the senior citizen‘s menu. After her usual meal alone, the waitress tries to give the little-old- lady the check and asks her to pay, but the lady appears confused and cannot speak. You, the ambulance crew, are in the next booth on duty and witness this. What action should be taken? P: 80 BP: Has a radial pulse R: Difficult to assess O2 Sat: NA Temp: Cool/Clammy 10. A babysitter calls 911 and says she found her 2 y/o charge lethargic in bed. You arrive and must treat the patient. What do you do? P: 80 BP: 130/50 R: 12 O2 Sat: 90% Temp: Cool/Dry 11. A 47 y/o male calls 911 from his car phone after pulling over to the side of the road because the pressure in his chest was too much to bear. You find him in his car pale and diaphoretic and clearly anxious. He describes this as the worst feeling he has ever had in his life, like an elephant sitting on his chest. He has no remarkable medical history. The monitor shows sinus tachycardia with frequent PVCs. Treat the patient. P: 110 BP: 140/90 R: 24 O2 Sat: 95% Temp: Cool/Clammy EMS I-Spring 2006 Page 24 “Answers” to EMS I Sample Case Scenarios A quick note: These answers are intended for the paramedics and medical students to review together. First and second year medical students are not expected to be familiar with many of the concepts presented in these answers. However, these ―solutions‖ do address the treatment priorities and differential diagnoses of the various scenarios and as such should help the medical students to begin to think critically about given patient situations. The paramedics should feel free to elaborate on the topics presented and even disagree with the presentations.. For that matter, if either the students or the medics have some thoughts on the cases, we‘d love your input! Case 1: The diagnosis in this case is pulmonary embolism until proven otherwise. Given the scenario, other most likely possibilities include pneumonia and myocardial infarction. The key to treatment (as always) is to remember the ABCs: Specific Points: 1) Administer empiric 100% O2 by mask. Don‘t dilly-dally with nasal O2, regardless of O2 sat reading. 2) Remember to assess for equal breath sounds, then quickly apply cardiac and pulse oximetry monitors. 3) IF sats correlate with pulse well (i.e. monitor reads correctly) and sats are >90% on 100% O2 and pt. is alert, it is possible to defer the need for intubation to ED. If the pt. is somnolent or sats are <90% on 100% O2, then the pt. likely needs intubation soon. A pre-hospital priority should always be to protect the airway and optimize oxygenation. Empiric nebulized bronchodilators would be a reasonable move, even if the pt. is not audibly bronchoconstricted. 4) Since MI is a possibility and BP is not low, sublingual NTG 0.4 mg is a good move, as is chewing 4 baby ASA. 5) Diaphoresis doesn‘t really guide your therapy, but should alert you that this is a seriously ill patient. This ain‘t costochondritis! 6) Get a 12-lead EKG. Case 2: Trauma of any kind, blunt or penetrating, accompanied by hypotension is hemorrhagic shock until proven otherwise. Tachypnea is from pneumothorax and/or hemothorax until proven otherwise. ABCs: A. Given mechanism, attend to airway with attention to c-spine precautions (remember the patient is found prone). Auscultate for equal breath sounds. If unequal, decompress with 12 or 14 G needle at 2nd intercostals space, midclavicular line on the affected side. B. Administer 100% O2, apply sat and cardiac monitors, assist with BVM if necessary and anticipate the need to intubate if pt. dsats or fatigues. C. 2 large bore IVs with NS, 2L bolus. D. & E. Assess for neurologic disability and expose to find any ―hidden‖ injuries. Remember that even though the pt. is shot, his depressed mental status can also be from other causes. Narcan and glucose should be considered, but prehospital EMS I-Spring 2006 Page 25 administration of Narcan should only be to patients who have both a strongly suspected narcotic overdose and depressed vital signs (decr. BP or respiratory effort). If a suspected narcotic OD pt. is stable, defer Narcan to ED to avoid creating a ―monster‖. In your examination, remember that GSWs to the buttocks and flank can easily go into the abdomen, chest and pelvic arteries. Buttock wounds can lead to death by exsanguination. Given the location of the patient‘s wounds, document his neurological status in the lower extremities after initial stabilization. Case 3: Remember the altered mental status algorithm (NGT). Chemstrip the pt. and consider Narcan. A. Airway with attention to c-spine; assume the worst and immobilize. B. Listen for stridor, wheezing and symmetry of breath sounds. Check O2 sats serially or give 100% O2. C. Check quickly for a radial pulse. (An easy though rough rule of thumb is a radial pulse is present if systolic BP is >90, femoral if >70, carotid if >60). D. Assume PERRL, patient‘s general affect appears sluggish E. Occipital hematoma noted You find the pt. progressively awakens en route with a chemstrip of 120-180 and complains of a headache. Suddenly, he projectile vomits then slumps over and you note unequal pupils. What has happened? Diagnosis is an alcoholic with a subdural hematoma (see by CT at the ED). Remember that alcohol can co-present with and mask CNS bleeds. Case 4: After checking the ABCs, you should note that the most dangerous aspect of this case is the ingestion of iron. If the ingestion were within 30 minutes and the patient is alert and not at risk to become sleepy from the ingestion, then administration of ipecac to induce vomiting is reasonable. Do not give ipecac if: ingestion occurred more than 30 minutes ago pt. is somnolent or ingestion is likely to affect mental status (i.e. ant-depressants, benzos, anticholinergics, etc.) ingested material is caustic (i.e. Drano) or a petroleum distillate (i.e. paint thinner) you are uncertain what was ingested You should reassure the mother the child is stable and transport rapidly to the ED for serial exams and tests of appropriate drug levels. Charcoal is not helpful in an iron ingestion. Always try to bring the actual bottles of pills to the ED; in any ingestion/OD this is very useful! Case 5: Before extrication you should assess and stabilize the ABCs with attention to c-spine. Give 100% O2. Apply O2 sat monitor and start an IV in the free arm. If respiratory status worsens, needle decompress chest to treat assumed pneumothorax. Coordinate efforts with extrication to minimize scene time. Transport without delay! Presumptive diagnosis in this case includes: concussion, r/o CNS bleed, r/o neck fracture flail chest, r/o pnuemothorax (PTX)/hemothorax (HTX), early PTX? EMS I-Spring 2006 Page 26 rignt femur fx possible aortic injury Case 6: Assuming in this case the ABCs are negative, check for dependant lividity or rigomortis. If they are not present and there is no DNR order readily apparent, begin the CPR/ACLS protocol. For those who are not yet ACLS certified, remember the central theme of ACLS for v-fib is SHOCK, SHOCK, SHOCK, DRUG SHOCK (electricity is the key). In the given subset of patients, the chances for neuro recovery are slim, but remember the general principal of survival that the electricity must arrive before 10 minutes after the arrest for any reasonable hope of survival. Case 7: Fever plus altered mental status = meningitis and/or sepsis until proven otherwise. The ED management will be to draw blood, give abx., and check all other labs later (like CSF). This is the ―pull-push‖ approach to infectious emergency care: the abx. must be given as soon as possible, so immediately after you ―pull‖ the blood out, ―push‖ the drugs to empirically treat the presumed meningitis. Also remember that altered mental status, regardless of how strongly you suspect trauma or infection as the cause, always means NGT (chemstrip the pt., consider giving Narcan). Note in this case you have an 80% O2 sat, but next you note that it correlates poorly with the pulse reading. This should tip you off to the weakness of pulse-ox monitors: 1) They are usually not more accurate than +/- 4% 2) A rapid pulse or low BP can give false readings; if in doubt about the validity of a reading, give 100% O2 3) Remember, if smoke inhalation or carbon monoxide exposure is suspected, the pulse- ox can‘t distinguish hemoglobin binding oxygen from bound cyanide or carbon monoxide and will thus give misleadingly high readings. Case 8: In your airway check, listen for stridor or hoarseness of voice (hoarse = laryngeal edema and is bad). Look for symmetry in resoiratory effort. In this case there is not altered mental status, so no NGT. Presumptive diagnosis is early/impending anaphylaxis. Treatment includes oxygen and IV fluid bolus, but EPI is the key here. The adult dose of epi is 0.3-0.4 cc 1:1000 IM. (Note the difference between this epi and cardiac epi which is 1 mg/amp). IV benadryl (12.5 mg) would also be appropriate (25-50 mg doesn‘t add much to antihistamine effect and makes patient much sleepier and tougher to assess serially). Solumedrol, 125 mg IVP, would also be appropriate. Case 9: Any patient who was eating, then can‘t talk and who has an altered mental status or appears anxious has a foreign body airway obstruction until proven otherwise. Empirically attempt the Heimlich maneuver if you confirm that the patient can‘t talk or breathe. EMS I-Spring 2006 Page 27 After the Heimlich maneuver, and given the pt. looks better but is still anxious, what do you do? Transport her to the hospital, ideally on her right side on the stretcher, and observe her airway patency and oxygenation for trouble. Case 10: For A & B treatment, place child on 100% O2. For C, note that this is a low pulse and a high BP for a two-year-old, and assume elevated intracranial pressure. Get IV access if possible. Remember D & E in all patients. In this case with a thorough physical examinationyou would have found scratches and fresh bruises on the lower back and buttocks (only by stripping the patient) and an outer ear hematoma (easily missed). What do you suspect? Diagnosis is child abuse resulting in a closed head injury. CT would show multiple punctuate hemorrhages consistent with ―shaken baby syndrome‖. Beyond the physical abuse, you must consider that the child may be neglected with possible toxic ingestion. Look for bottles, etc. for clues and bring them to the ED if found. Also remember c-spine precautions as soon as you have reason to suspect trauma. In this case you must notify DHS or the police, but don‘t leave the sitter home alone, or tip her off before the authorities are present. Leave a first responder ―for support‖ or use some other excuse, or bring the sitter to the hospital. This is a potential crime scene and should not be left unattended until police arrive. Case 11: A. 100% O2 B. Assess for wheezing/symmetry/effort/rate. C. Check peripheral pulses. Get one or (preferably) two good IVs. The presumptive diagnosis is acute myocardial infarction. Other possibilities exist, the most serious of which are: aortic dissection, pneumothorax, pulmonary embolism, and esophageal spasm/rupture (spasm would also be helped by NTG). Specific treatment involves 4 chewed and swallowed baby ASA, sublingual NTG spray 0.4 mg/spray q 5 min. until at ED if systolic BP > 90. Obtain (and transmit) a 12-lead EKG and rapidly transport to appropriate ED without delay. Treat ectopy with )2 and nitrates first, not with antiarrhythmics. If the patient‘s ventricular ectopy subsequently worsens, administer appropriate antiarrhythmic drug. EMS I-Spring 2006 Page 28 EDITORIALS The Ten Commandments of Emergency Medicine INTRODUCTION CONSIDER OR GIVE One of the most insidious serious Emergency physicians approach NALOXONE, GLUCOSE, AND errors is to diminish the magnitude of patients differently than their THIAMINE the patient‘s complaint. Often this counterparts in other specialties The need for naloxone, glucose, and happens because there is peer pressure because of time constraints and thiamine (NGT) should be assessed in to not admit patients. At other times, a because they deal with critically ill every patient with altered mental patient‘s complaint is downplayed patients without the benefit of an status. A single 2-mg IV dose of because of a negative attitude toward ongoing relationship. The potential naloxone almost never causes toxicity his ―emotional overstatement‖ of pain. for error is therefore great. We in an adult emergency department During the initial evaluation, we developed the following ten patient. Blood glucose should be should take all complaints at face commandments of emergency assessed immediately by an accurate value and not make subjective medicine to help others avoid these and rapid fingerstick method, or D50W judgments. It is a bad idea to project errors. We believe that remembering should be administered in the rare our expectations onto our patients. these commandments could improve event that a fingerstick blood glucose patient care, physician-patient cannot be performed. Rapid IV DO NOT SEND UNSTABLE relations, and risk management. administration of 100 mg thiamine has PATIENTS TO RADIOLOGY been demonstrated to be very safe and Portable radiographs are not as good SECURE THE ABCs should be provided to any cachectic or as radiographs performed in the The emergency physician should malnourished patent, including all radiology department. Radiologists, initially direct attention to the patency alcoholics, patients with however, do not treat unstable patients of the patient‘s airway, the adequacy malabsorption or cancer, and young as frequently as do emergency of the patient‘s breathing, and the patients with AIDS or anorexia physicians. Their skills may be rusty, assurance of cardiovascular stability. nervosa. and life-saving drugs and equipment Securing the ABCs in every patient may be inaccessible in the radiology every time is essential, whether the GET A PREGNANCY TEST department. Unstable patients who patient appears to have trivial Because the reproductive, must have films in radiology must be complaints or is severely ill. contraceptive, and menstrual histories accompanied by a person trained to We have expanded the ABCs to of patients in their child-bearing years manage their condition should it ABC2DEFG2. The steps represented are unreliable, it is necessary to deteriorate. by the letters A through E are well consider obtaining a pregnancy test in understood by the emergency every patient who has a functioning LOOK FOR THE COMMON RED physicians. ―F‖ stands for fetal heart uterus. It is difficult to treat most FLAGS tones because the vital signs of a complaints of reproductive-age Because the Ed evaluation of a pregnant patient are not complete women if their pregnancy status is patient must take place quickly, it is without listening for fetal heart tones. unknown. Likewise, inappropriately important to keep some recurring ―red Likewise, in pregnant patients, the obtaining radiographs in patients who flags‖ in mind. First and foremost, need for rhogam (the first ―G‖) are pregnant can be dangerous. The there are four vital signs;, all four must should always be considered. The easiest way to rule out an ectopic always be evaluated, and any second ―G‖ represents the guard rails pregnancy in the ED is with a abnormal vital sign must be explained on the stretchers, which are all too pregnancy test. in writing. Emergency physicians often left down. Even alert patients must be careful in interpreting axillary may roll off a bed; the elderly or ASSUME THE WORST and oral temperatures that may be confused patient is guaranteed to ―go We must always rule out the most misleadingly low. Orthostatic blood to ground.‖ Emergency physicians are serious potential cause of a patient‘s pressure and pulse measurements must often the worst offenders when they symptoms and be certain that adequate be considered in any patient at risk for leave the bedside after examining a attention has been given to the most volume depletion or acute blood loss. patient. catastrophic probabilities, even if they Orthostatic vital signs, however, are are unlikely. Then, and only then, can never indicated in a hemodynamically we ascribe a patient‘s complaint to a unstable patient. less severe and more likely possibility. 20:10 October 1991 Annals of Emergency Medicine 1146/137 EMS I-Spring 2006 Page 29 Second, age, especially extremes of It is important to keep an open mind. The ―do unto others‖ commandment age, should alert the clinician to the Many of our worst errors have also applies to coworkers. Treating presence of potential comorbid occurred when we adopted a mindset colleagues, interns, residents, nurses, conditions. The presence of HIV risk about the patient and refused to let aides, emergency medical technicians, factors is another red flag that signals other opinions or data change our and secretaries with respect should be the need for aggressive workup. HIV initial perception. Emergency integral to our approach. Treating risk factors are present in all physicians should not be afraid to ask anyone with disrespect might return to socioeconomic levels and ages. for help or admit uncertainty. Family, haunt you. Emergency physicians must ask the friends, nurses, and medical students ―embarrassing‖ questions about sexual often provide cogent observations that WHEN IN DOUBT, ALWAYS ERR preference and activity as well as those can positively alter the course of the ON THE SIDE OF THE PATIENT concerning the use of illicit drugs. patient‘s illness. No advice should be There is no getting away from an Third, any unscheduled return to the rejected out of hand; hubris is a element of uncertainty in medicine. ED for the same complaint is another physician‘s worst enemy. As physicians, our ultimate goals red flag. The initial problem may have Institutional tradition and lore are should be relief of symptoms and been inappropriately or incorrectly areas that commonly introduce an optimal patient outcome. When treated, and for patients to be seen element of bias. Institutions tend to significant uncertainty exists, again in the chaos of the ED setting become inbred. There is often more emergency physicians must be sure gives special significance to the than one way to approach a specific that their decisions take into account complaint. complaint, and old traditions die hard. the potential for a bad outcome. We Last, there are three questions that Lore must be validated by the should always err in a way by which th must be asked of every ED patient; a scientific method. Always maintain an e patient will suffer the least. negative answer to any one represents element of skepticism about old Decisions to admit or discharge, a red flag. First, ―Have you ever had adages or new trends. perform another test, or call a this complaint before?‖ If the consultant should always be made complaint is new, it clearly requires a LEARN FROM YOUR MISTAKES with the patient‘s best interests and different approach diagnostically than E all make mistakes of varying safety as the major deciding factors. if the complaint is chronic. Second, severity, regardless of our level of Our ultimate goal should not be to ―Can the patient take adequate experience. The key to dealing save money, keep hospital beds open, nutrition by mouth,‖ and third, ―Can appropriately with mistakes is not to or protect our peers. the patient walk?‖ If the patient is deny them but rather to embrace them unable to provide for himself but and learn from them. It is not health CLOSING THOUGHTS could previously, he should not be to dwell on mistakes. As a colleague, These ten commandments are an routinely discharged home. it is also incumbent to not be too outgrowth of our experience as judgmental. We should learn from emergency physicians. As with the TRUST NO ONE, each other‘s mistakes, not use them to original Ten Commandments, no one BELIEVE NOTHING impugn one another. will be able to observe all of them all (NOT EVEN YOURSELF) of the time. There are probably many Errors are often made when we DO UNTO OTHERS AS YOU examples of exceptions and additions depend on assumptions. Important WOULD YOUR FAMILY (AND to these commandments. Exceptions decisions must be based on facts, not THAT INCLUDES COWORKERS) are fine, as long as they are made with heresay or someone else‘s perception When confronted with a difficult awareness. The number of exceptions that is presented as ―fact.‖ A decision or an ethical dilemma, we any physician makes should relate physician‘s or nurse‘s words are not a should consider how we would like directly to his level of expertise. We substitute for written medical records. one of our family members to be welcome input on what we may have An ECG or radiographic report is not a treated. Patients are not the enemy. overlooked. It is our belief that substitute for viewing the tracing or At times they may have habits or keeping some form of these ten film. behaviors that we do not like, but commandments in mind will prevent This commandment is also meant to every patient must be treated within mistakes and improve patient care and be a caution against blind trust in the the context of his illness. satisfaction. expertise or opinions of others. It is Unfortunately, the illness may have always comforting to have the advice many comorbid contributors, Keith Wrenn, MD, FACP of a subspecialist, but emergency including psychiatric disease, Corey M. Slovis, MD, FACEP, FACP physicians must remember that they addiction, family problems, and job Division of Emergency Medicine often know the most about the patient stresses. We are here to treat, not to University of Rochester School of at that time. judge. Medicine Rochester, New York 138/1147 Annals of Emergency Medicine 20:10 October 1991 EMS I-Spring 2006 Page 30 Assessment Acronyms ABCDE: Used in performing a Primary Assessment A – Airway B – Breathing C – Circulation D – Disability (Level of Consc.) / Delicate CNS (Cervical Spine/Cord Protection) E – Expose AVPU: Used in assessing gross level of consciousness / disability A – Alert... pt. is awake and responding appropriately V – Verbal... verbal stimuli required to elicit a response P – Pain... tactile or painful stimuli required to elicit a response U – Unresponsive... pt. is unresponsive SAMPLE: Used to gather basic patient history S – Signs and Symptoms A – Allergies M – Medications/Medical Alert Tags P – Prior or Previous Medical History L – Last oral intake, Last medication dose, Last menstrual period E – Events... leading up to and surrounding present problem OPQRST: Used to expound on patient‘s complaint(s) O – Onset... when did it start? P – Provocation... what produced/provoked/caused onset of symptoms or problem? Q – Quality... what is the quality of the pain: sharp, dull, cramping, burning, etc. R – Radiation... does it (pain) stay in one place or does it move or radiate? Relief... has medication or action taken (rest, position of comfort) brought relief? S – Severity... how severe is the symptom? T – Time... when did it start, is it constant, comes and goes, ever had it before? DCAP (decapitation) BLS (basic life support) TIC (time is crucial): what to look for during physical exam of a trauma patient D – Deformity B – Burns, Bleeding T – Tenderness C – Contusions L – Lacerations I – Instability A – Abrasions S – Swelling C – Crepitus P – Punctures, Penetrations EMS I-Spring 2006 Page 31 Emergency Medicine Run Sheet for Emergency Department/Field Experiences in EMS David H. Sewell B: 960-2861 O: 862-5459 C: 480-1169 Name: _________________________________________________________________ Page ____ of ____ Date: ___________________________________________ Medic or Chief‘s unit number: ________________________ RIDE/CLINICAL TYPE: (check one that applies) ER ٱ AMBULANCE ٱCOMMUNICATIONS CENTER ٱTRAUMA ٱ POLICE ٱ TRIAGE CAR ٱ DISTRICT CHIEF ٱ LIFEFLIGHT ٱ NEONATAL VAN ٱ Name(s) of EMS or Physician Medical Staff: _____________________________________________________________________ What was the most useful learning experience that you had during this ride-along / rotation? ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Describe each patient experience which you encountered during the learning opportunity. Use back or additional pages as needed. See course manual for example. 1. 2. 3. 4. 5.
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