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					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: 6159602861@page.metrocall.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.

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