# The man by the pool



## DesertMedic66 (Jul 13, 2018)

Since there hasn't been any scenarios posted in a little while I will toss one out here. I do not have the final outcome of the patient because it is a fairly recent call. For anyone who would like to play along I will start will some basic call information and will provide more information as requested. Keep in mind I am in CA so my treatment options are limited. Its not a super complex call with no zebras as of right now.

It is around noon on a hot summer day. You are on an ALS ambulance and are called out via 911 for a subject laying next to a pool. You are met outside by family who state they haven't seen the patient in 30+ minutes so they went searching and found the patient laying next to the pool. You arrive and see a body covered by a towel that is slightly shaking. You lift up the towel and see a naked male who is between 60-80 years old laying prone with vomit around his mouth, slightly shaking, with pale skins, and 2nd degree burns on his right shoulder, elbow, forearm, hip, knee, calf, and ankle. He is breathing at a normal rate with a good tidal volume, from what you can see. That is where we will start off at. What do you want to know? What do you want to asses? What do you want to do?


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## PotatoMedic (Jul 14, 2018)

Well to start,  What does his skin color look like besides the burns?  pink warm dry?  pale?  Flush?  Hot to the touch?  How does his pulse feel?  Things I will do quickly are probably suction the airway since he has vomited, get a set of vitals and look for any obvious trauma or injuries.  Vitals I want are BP, pulse rate, 4 lead (will want a 12 lead when convenient) SPO2, a BGL, responsiveness (AVPU), and a GCS to start.  Burn care will probably be pretty minor, just kerlex wrapping once I have identified any life threats and addressed them.

Treatments I am considering are aggressive airway management (MAI/RSI).

Causes I am thinking are heat stroke, seizure, cardiac event.  Things I want to know from family are history, meds, allegies.  Other things I want to know are where did the burns come from?  Do they appear to be bad sun burns?  Or are they possibly pool chemical related?


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## StCEMT (Jul 14, 2018)

Quick ABC check to make sure that's all good, suction out airway if needed. GCS. 

Any immediate scene observations? Potential trauma? Does the shaking appear seizure like? Potential causes of burn and what they look like? Signs of drug or alcohol use? 

4 lead, BGL, BP, RR, SpO2, EtCO2, temp, lungs, pupils. 

History/allergies/meds from family.

Tx: Scale airway management as necessary, NPA to RSI based on what I see. IV access. Basic wound care of the burns for now.

Figure out the rest with more info.


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## DesertMedic66 (Jul 14, 2018)

PotatoMedic said:


> Well to start,  What does his skin color look like besides the burns?  pink warm dry?  pale?  Flush?  Hot to the touch?  How does his pulse feel?  Things I will do quickly are probably suction the airway since he has vomited, get a set of vitals and look for any obvious trauma or injuries.  Vitals I want are BP, pulse rate, 4 lead (will want a 12 lead when convenient) SPO2, a BGL, responsiveness (AVPU), and a GCS to start.  Burn care will probably be pretty minor, just kerlex wrapping once I have identified any life threats and addressed them.
> 
> Treatments I am considering are aggressive airway management (MAI/RSI).
> 
> Causes I am thinking are heat stroke, seizure, cardiac event.  Things I want to know from family are history, meds, allegies.  Other things I want to know are where did the burns come from?  Do they appear to be bad sun burns?  Or are they possibly pool chemical related?



Aside from the burns on the right side the rest of his skin is pale, profusely sweating, and hot to the touch. Jaw is locked down so suction is attempted with a flexible cath with no return. Patients lungs are clear and you hear no gurgling on his respirations. 

The only trauma noted are the 2nd degree burns which a quick Palmer estimate is ~15%. 

Family is of no help. They don’t know Hx, meds, allergies, and the time they last saw him keeps changing from 10 mins to 15 mins to 30 minutes and so on. They know his name and his age and that is all. 

Patient has weak radial and weak carotid pulses that are fast. SpO2 is 93% Room air. Patients respiratory rate is in the mid 20s with good/moderate tidal volume and clear lungs. BP is unable to be obtained at the current moment. GCS is 4 (2,1,1). 

The burns do not appear to be sun burns and do not appear to be chemical related. Our guess is probably from the ground. 



StCEMT said:


> Quick ABC check to make sure that's all good, suction out airway if needed. GCS.
> 
> Any immediate scene observations? Potential trauma? Does the shaking appear seizure like? Potential causes of burn and what they look like? Signs of drug or alcohol use?
> 
> ...



No really abnormal scene observations. No signs of drug or alcohol use. The shaking almost appears to resemble muscle fasculations.


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## DesertMedic66 (Jul 14, 2018)

You hook the patient up on the 4 lead and this is your rhythm


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## Summit (Jul 14, 2018)

I think he was electrocuted from a compromised wire or there was just a lightning storm that nobody mentioned. There could be EXTENSIVE internal burns not indicated by his superficial burns. He is breathing on his own and lungs are clear, which is good, he didn't have a wet drowning, but could have aspirated vomit, he could have been apneic for a while before arrival. He also could have quite a bit of internal volume loss, electrolyte derangement, postictal/postapneic acidosis, and even myocardial burns from presumed electrocution/sz.

I'd take a BP before trying to cardiovert the SVT. I'd be wary that it is compensatory SVT that might benefit from preload over electricity. But I might want to convert it. I wager this patient would do well with good suction, airway control, and hyperventilation. I'd check glucose and give a benzo for his fasciculation/trismus. I'd monitor etCO2 but I'd love a gas.


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## DesertMedic66 (Jul 14, 2018)

Summit said:


> I think he was electrocuted from a compromised wire or there was just a lightning storm that nobody mentioned. There could be EXTENSIVE internal burns not indicated by his superficial burns. He is breathing on his own and lungs are clear, which is good, he didn't have a wet drowning, but could have aspirated vomit, he could have been apneic for a while before arrival. He also could have quite a bit of internal volume loss, electrolyte derangement, postictal/postapneic acidosis, and even myocardial burns from presumed electrocution/sz.
> 
> I'd take a BP before trying to cardiovert the SVT. I'd be wary that it is compensatory SVT that might benefit from preload over electricity. But I might want to convert it. I wager this patient would do well with good suction, airway control, and hyperventilation. I'd check glucose and give a benzo for his fasciculation/trismus. I'd monitor etCO2 but I'd love a gas.


No evidence of a pool malfunction. Patient was found with his head pointing away from the pool and his feet about 5 ft away from the edge of the pool. 

Our intial rhythm was V-tach. Due to the patients ALOC and weak pulses we decided to cardiovert the patient. BGL came back in a normal range.


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## PotatoMedic (Jul 15, 2018)

Sinus tach.  How's the pulse?  Are we able to get a blood pressure now? Reassess ABC's.  If all are present my plan is to move him on to my gurney and load him up.  IV access and going to nasal tube the guy just to secure the airway.  12 lead at this point.  Vitals will dictate, but that is my train of thought at this point.


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## DesertMedic66 (Jul 15, 2018)

PotatoMedic said:


> Sinus tach.  How's the pulse?  Are we able to get a blood pressure now? Reassess ABC's.  If all are present my plan is to move him on to my gurney and load him up.  IV access and going to nasal tube the guy just to secure the airway.  12 lead at this point.  Vitals will dictate, but that is my train of thought at this point.



Patient was moved to the gurney prior to cardioversion due to the ground temp being extremely hot. After the cardioversion the patients rhythm is now sinus tach with runs of V-tach and frequent PVCs. 

Airway- patient’s jaw is still unable to be opened 
Breathing- patient has spontaneous respirations in the low 20 range. 97% SpO2 that are being assisted via BVM with an EtCO2 of 35mmHg. 
Circulation- patients radial pulses become slightly stronger and an accurate BP of 110/60. HR is in the 140-150 range. 

18G IV is established and an overzealous fire medic drills an IO after the IV is already placed. 

No nasal intubation in protocols. 

12-lead:


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## StCEMT (Jul 15, 2018)

Don't agree with afib RVR, V3/4 are good to see what looks like p waves and it is regular aside for some ectopics. It's hard to verify STEMI since I don't have small boxes to see if this is everything blended together or if I suspect a true MI, which right now I'm leaning towards possibly not until I can get a better repeat.

Nasal would be an option here. If he is having semi regular runs of VT, then amio would also be an option, one I'd have thought about starting with.


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## PotatoMedic (Jul 15, 2018)

Lidocaine 1mg/kg bolus, 0.5mg/kg after that till the runs of vtach stop, then appropriate maintenance infusion.

Fluids at 500ml per hour (my protocol as we don't use parkland for some odd reason).  

ABC's see to be doing well so code three transport to our trauma center since we don't have a burn unit.


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## DesertMedic66 (Jul 15, 2018)

StCEMT said:


> Don't agree with afib RVR, V3/4 are good to see what looks like p waves and it is regular aside for some ectopics. It's hard to verify STEMI since I don't have small boxes to see if this is everything blended together or if I suspect a true MI, which right now I'm leaning towards possibly not until I can get a better repeat.
> 
> Nasal would be an option here. If he is having semi regular runs of VT, then amio would also be an option, one I'd have thought about starting with.


Amio drip was started which eliminated the runs of V-tach and the PVCs. 


PotatoMedic said:


> Lidocaine 1mg/kg bolus, 0.5mg/kg after that till the runs of vtach stop, then appropriate maintenance infusion.
> 
> Fluids at 500ml per hour (my protocol as we don't use parkland for some odd reason).
> 
> ABC's see to be doing well so code three transport to our trauma center since we don't have a burn unit.


Amio was given as it is the preferred option out here which stabilized his rhythm. Patient was transported to the local STEMI/Trauma center. During transport we are able to get a temp on the patient which is 107.7 F.


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## PotatoMedic (Jul 15, 2018)

Pack those groins with ice.  Do you know the outcome?  Really interesting call.


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## DesertMedic66 (Jul 15, 2018)

PotatoMedic said:


> Pack those groins with ice.  Do you know the outcome?  Really interesting call.


As of right now I do not know. I am still waiting for a follow up. The patients armpits, groin, and neck had cold packs applied and cool saline was started during transport.


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## StCEMT (Jul 15, 2018)

Did his heart rate ever slow down enough with treatment to get a better 12 lead?


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## DesertMedic66 (Jul 15, 2018)

StCEMT said:


> Did his heart rate ever slow down enough with treatment to get a better 12 lead?


We had a very short transport from the scene. Our onscene time was about 8 minutes and transport time was about 3 minutes so we didn’t see any major changes. At the ED he was RSIed. BP was holding steady in the 120 systolic area with a pulse in the 130s


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## StCEMT (Jul 15, 2018)

Interesting...curious to see what the follow up finds.


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## Jim37F (Jul 15, 2018)

I feel like those burns are gonna be a major clue as to what the docs eventually figure to be going on. It'd have to be on beck of a sunburn for that much 2nd degree burns...and I'm doubting there were any nearby tanning booths lol...any other potential thermal sources? Maybe came in contact with a water heater for the pool somehow? Electrical? You said he was found on the ground, but was he wet like was in the pool itself, got shocked, but was able to get out before collapsing? Or a chemical burn? Plenty chemicals near pools that could cause that...once again maybe he was in a maintenance room/shed/whatever, got injured and then tried to move to get help and ended collapsing where he did away from the site of injury? 
(Idk, I'm just spitballing, only really glanced at the other posts so sorry if I'm repeating something...with the posts about his funky heart rhythm, combined with the burns, I'm more leaning towards an electrical injury myself)


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## E tank (Jul 15, 2018)

Not that you would have done anything at all differently (receiving ER would, tho) I wonder what meds he was on and his medical history. A core temp of about 108 is stupid high and lethal and makes me wonder about a neurologic,  genetic (unlikely for a guy in his 60's) or drug induced hyperthermia.


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## DesertMedic66 (Jul 15, 2018)

Jim37F said:


> I feel like those burns are gonna be a major clue as to what the docs eventually figure to be going on. It'd have to be on beck of a sunburn for that much 2nd degree burns...and I'm doubting there were any nearby tanning booths lol...any other potential thermal sources? Maybe came in contact with a water heater for the pool somehow? Electrical? You said he was found on the ground, but was he wet like was in the pool itself, got shocked, but was able to get out before collapsing? Or a chemical burn? Plenty chemicals near pools that could cause that...once again maybe he was in a maintenance room/shed/whatever, got injured and then tried to move to get help and ended collapsing where he did away from the site of injury?
> (Idk, I'm just spitballing, only really glanced at the other posts so sorry if I'm repeating something...with the posts about his funky heart rhythm, combined with the burns, I'm more leaning towards an electrical injury myself)


The burns were isolated to his right arm/shoulder and right hip/leg and only on the lateral aspect. I doubt chemical burns would present that way.

The outside temps were in the 112 degree range with no cloud cover or shade in the backyard. Every summer we routinely have patients who fall outside who end up with severe burns from the ground. The burns on this patient were constant with someone who would lay on their right lateral position on the hot ground. 

Here are some of many news articles about 2nd to 3rd degree burns being caused by asphalt: https://www.google.com/amp/amp.miamiherald.com/news/nation-world/national/article162761098.html

https://www.google.com/amp/s/patch....m-warns-dangers-2nd-degree-burns-hot-pavement


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## StCEMT (Jul 15, 2018)

If memory serves me right, asphalt/concrete can hit 130+ with days this hot. Between 112 air temp and what I imagine is a significantly higher ground temp, 108 doesn't surprise me at all with an unknown down time.


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## VFlutter (Jul 15, 2018)

Serotonin Syndrome, because why not.


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## StCEMT (Jul 15, 2018)

VFlutter said:


> Serotonin Syndrome, because why not.


You always come in with the zebras lol


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## PotatoMedic (Jul 16, 2018)

Lupus... As Dr. House would say.


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## Summit (Jul 16, 2018)

nuts to the desert! 
I'll stick to complaining about it being above 80F more than 5 days in one summer as an unbearable heat wave


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## VentMonkey (Jul 16, 2018)

Summit said:


> nuts to the desert!
> I'll stick to complaining about it being above 80F more than 5 days in one summer as an unbearable heat wave


Have fun freezing your nether regions off the other 10 months of the year.


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## Summit (Jul 16, 2018)

VentMonkey said:


> Have fun freezing your nether regions off the other 10 months of the year.


See... that's the thing... I can always put more clothes on... but I can only take so many clothes off before security is summoned! (And it can still be too hot)


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## PotatoMedic (Jul 16, 2018)

Summit said:


> See... that's the thing... I can always put more clothes on... but I can only take so many clothes off before security is summoned! (And it can still be too hot)


You could start NUTS EMS.  Naked Urgent Transport Services.


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## Jim37F (Jul 16, 2018)

Summit said:


> nuts to the desert!
> I'll stick to complaining about it being above 80F more than 5 days in one summer as an unbearable heat wave





VentMonkey said:


> Have fun freezing your nether regions off the other 10 months of the year.


Or just move to where it's 80 year round 

But yeah, makes sense otherwise for the burns. Guess that would be a sufficient thermal source at those temps...didn't think of that because even when I was in LA that wasn't an issue I had run across before. Note to self, don't pass out on the concrete in the Inland Empire in summertime....


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## DesertMedic66 (Jul 16, 2018)

It’s something that we have to adjust to our in this area. For patients who are on the ground we will usually assess c-spine and then move directly to the gurney for all treatments. If we have lay on the ground to secure the airways there is a strong possibility that we will get burned ourselves.


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## Summit (Jul 16, 2018)

DesertMedic66 said:


> It’s something that we have to adjust to our in this area. For patients who are on the ground we will usually assess c-spine and then move directly to the gurney for all treatments. If we have lay on the ground to secure the airways there is a strong possibility that we will get burned ourselves.


Its a good reminder for me to think outside my box. The idea of being severely burned from the ground didn't immediately crossed my mind. I just jumped to "what can burn you without chemicals, fire, or radiation? Electricity!


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## PotatoMedic (Jul 16, 2018)

Summit said:


> Its a good reminder for me to think outside my box. The idea of being severely burned from the ground didn't immediately crossed my mind. I just jumped to "what can burn you without chemicals, fire, or radiation? Electricity!


Dragons...


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## Jim37F (Jul 16, 2018)

PotatoMedic said:


> Dragons...


Which can be prevented if you would just bend the knee...


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## NomadicMedic (Jul 17, 2018)

I came into this late, but burns from the hot ground were right at the top of my list when I first read this. It wasn’t exactly “common” in Georgia, but I saw it following an unresponsive call in a hot parking lot.


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