# Altered Mental Status Scenario



## CPRinProgress (Apr 21, 2013)

I am in a EMTB class in nj.  Today we had a scenario where I, a first responder, respond to unknown medical.  On arrival pt was sitting up against a wall.  When I introduced myself the pt was obviously altered with no by bystanders.  To open his airway I layed him down and applied o2.  Checked CTC bleeding signs of shock etc.  When others arrived someone did a rapid trauma while I took vitals.  Pt had back neck pain so we back boarded.  After my instructor asked why I played the pt down and I said I did it to open his airway but he said that was wrong.  My question is how should I have managed the airway.


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## STXmedic (Apr 21, 2013)

If he was breathing on his own and maintaining his own airway (sounds like it if he's sitting up and talking), then don't do anything but put some oxygen on. Being confused isn't necessarily a reason to maintain his airway.

Sometimes scenarios are a little hard because you can't get a good picture of what the instructor is envisioning; they aren't always good at making it clear. It'll be a little more obvious on needs when it's a real patient and not a poor actor.


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## CPRinProgress (Apr 21, 2013)

PoeticInjustice said:


> If he was breathing on his own and maintaining his own airway (sounds like it if he's sitting up and talking), then don't do anything but put some oxygen on. Being confused isn't necessarily a reason to maintain his airway.



I guess I just did feel right to just leave it because in most scenarios they beet it in to us that we need to manage airway.  How should we backboard a sitting pt just slide him onto the board and lay him down slowly?


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## Handsome Robb (Apr 21, 2013)

Like poetic said, he's protecting his own airway and frankly, it'll be better protected with him sitting up allowing secretions or any emesis that presents to drain.

Did he have any trauma? Unfortunately the "gold standard" of prehospital trauma care (the backboard) is counter productive in patients with head injuries/increased ICP since, ideally, we want those patients sitting up at a 30-45* angle but that's not always possible.

Remember AEIOUTIPS.


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## STXmedic (Apr 21, 2013)

Yeah, that would work. Just make sure you don't move anything more than it needs moving. Excess manipulation is a failure I believe.


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## STXmedic (Apr 21, 2013)

Robb said:


> Did he have any trauma? Unfortunately the "gold standard" of prehospital trauma care (the backboard) is counter productive in patients with head injuries/increased ICP since, ideally, we want those patients sitting up at a 30-45* angle but that's not always possible.



I almost went there, but figured I'd let him out of class first


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## CPRinProgress (Apr 21, 2013)

Robb said:


> Like poetic said, he's protecting his own airway and frankly, it'll be better protected with him sitting up allowing secretions or any emesis that presents to drain.
> 
> Did he have any trauma? Unfortunately the "gold standard" of prehospital trauma care (the backboard) is counter productive in patients with head injuries/increased ICP since, ideally, we want those patients sitting up at a 30-45* angle but that's not always possible.
> 
> Remember AEIOUTIPS.



After a rapid trauma, we found a glucometer so we administered glucose he started to come around and said he was upstairs and he fell down the stairs.  I understand that if he is maintaining his own airway to leave it but his head was leaning forward so I figured that it had the potential to close and I thought the ams could have been caused by lack of oxygen. Just what I thought


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## STXmedic (Apr 21, 2013)

CPRinProgress said:


> After a rapid trauma, we found a glucometer so we administered glucose he started to come around and said he was upstairs and he fell down the stairs.  I understand that if he is maintaining his own airway to leave it but his head was leaning forward so I figured that it had the potential to close and I thought the ams could have been caused by lack of oxygen. Just what I thought



Well you're kind of contradicting yourself here. If he wasn't able to maintain his own airway and needed airway maneuvers, you wouldn't have wanted to give him oral glucose...


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## CPRinProgress (Apr 21, 2013)

PoeticInjustice said:


> Well you're kind of contradicting yourself here. If he wasn't able to maintain his own airway and needed airway maneuvers, you wouldn't have wanted to give him oral glucose...



You are right he did start to come to after we gave oxygen but I shouldn't have laid him down


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## Achilles (Apr 21, 2013)

PoeticInjustice said:


> Well you're kind of contradicting yourself here. If he wasn't able to maintain his own airway and needed airway maneuvers, you wouldn't have wanted to give him oral glucose...



He could have given it rectally though, if needed.


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## CPRinProgress (Apr 21, 2013)

Achilles said:


> He could have given it rectally though, if needed.



I don't believe we are allowed to do that


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## STXmedic (Apr 21, 2013)

Achilles said:


> He could have given it rectally though, if needed.



Yes, but I'm trying to keep the line of though consistent with EMT class and passing his scenarios. I've yet to see an EMT-B book that advocates that (they may, but I haven't seen it)


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## Achilles (Apr 21, 2013)

PoeticInjustice said:


> Yes, but I'm trying to keep the line of though consistent with EMT class and passing his scenarios. I've yet to see an EMT-B book that advocates that (they may, but I haven't seen it)



Well than you would want to inform the student not to give anything orally per AMS


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## STXmedic (Apr 21, 2013)

Achilles said:


> Well than you would want to inform the student not to give anything orally per AMS






PoeticInjustice said:


> Well you're kind of contradicting yourself here. If he wasn't able to maintain his own airway and needed airway maneuvers, you wouldn't have wanted to give him oral glucose...


Yes?


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## Achilles (Apr 21, 2013)

PoeticInjustice said:


> Yes?



Well I was actually joking, hence the tongue sticking out. But since you pointed it out, you are correct. On the conterary, my statement is also factual.


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## CPRinProgress (Apr 21, 2013)

Achilles said:


> Well than you would want to inform the student not to give anything orally per AMS



Well We were told that we can give glucose to someone with ams as long as they are able to swallow.


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## Melclin (Apr 25, 2013)

God what a pain in the arse this sort of vocational education must be. All these absolutes that bear no relation to medical fact, common sense or the real world.

This reminds me of a person at uni who attended a pt who had smacked their head on an over head cupboard. She immobilised quoting head strike as the reason and stated the person couldn't be cleared on account of the laceration being a distracting injury. She just didn't seem to be able to wrap her head around the idea that not all head strikes were made equal. This was the same person who wasn't aware that MI and cardiac arrest were different things in second year uni. You've gotta wonder where she'd been for the past year and a half. 

Anyways, I'm not having a go at you OP, but at a system that creates rules that you have to follow so rigidly that you jettison all common sense and reason and do things like maintain the airway of a person who is sitting up talking to you. "Always maintain the airway" comes with a caveat that remains unwritten because it is so obvious, "If the pt can't do it for themselves".


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## Melclin (Apr 25, 2013)

CPRinProgress said:


> Well We were told that we can give glucose to someone with ams as long as they are able to swallow.



Absolutely. 

If you couldn't give oral glucose to someone who had an altered mental status, you'd just about never give it. If they didn't have AMS, you probably wouldn't be there :wacko:

The "can't give it to a person with AMS" is an over simplification. Its generally accepted that its not a great idea to give a PO drug if the pt is too out of it to swallow said drug. People can have all kinds of altered mental status and still swallow, although some may not.  I suppose its just easier to make blanket statements like this when you've only got 15 seconds to educate a provider before they're out on the road. Obeying commands may be a good indicator. If you say, "Hey idiot, swallow", and they swallow, wicked good, give them some sugar.


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## Carlos Danger (Apr 26, 2013)

CPRinProgress said:


> Well We were told that we can give glucose to someone with ams as long as they are able to swallow.



That is true. The reflexes that protect the airway are the "last to go", which is why even unresponsive patients often can't be intubated without sedation. 

As long as the patient is not completely obtunded, chances are very slim that a small amount of glucose gel is going to cause an aspiration. 




Melclin said:


> God what a pain in the arse this sort of vocational education must be. All these absolutes that bear no relation to medical fact, common sense or the real world.
> 
> This reminds me of a person at uni who attended a pt who had smacked their head on an over head cupboard. She immobilised quoting head strike as the reason and stated the person couldn't be cleared on account of the laceration being a distracting injury. She just didn't seem to be able to wrap her head around the idea that not all head strikes were made equal. This was the same person who wasn't aware that MI and cardiac arrest were different things in second year uni. You've gotta wonder where she'd been for the past year and a half.
> 
> Anyways, I'm not having a go at you OP, but at a system that creates rules that you have to follow so rigidly that you jettison all common sense and reason and do things like maintain the airway of a person who is sitting up talking to you. "Always maintain the airway" comes with a caveat that remains unwritten because it is so obvious, "If the pt can't do it for themselves".



Welcome to American EMS education :sad:

It's not the OP's fault. He is a layperson just doing as he has been trained, and probably somewhat confused by conflicting information in the curriculum. Things that seem really obvious and "common sense" to us often are not obvious to those without our experience.


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## CPRinProgress (Apr 26, 2013)

Halothane said:


> That is true. The reflexes that protect the airway are the "last to go", which is why even unresponsive patients often can't be intubated without sedation.
> 
> As long as the patient is not completely obtunded, chances are very slim that a small amount of glucose gel is going to cause an aspiration.
> 
> ...



The thing that annoys me is how the book is written by a bunch of doctors that have probably never been in the field and how there is nothing about improvisation in the book or that we even learn about.  The real world have people falling in the smallest bathroom you have ever seen not the middle of a gym


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## Anjel (Apr 26, 2013)

Achilles said:


> Well than you would want to inform the student not to give anything orally per AMS



Per Oakland County protocol 

If patient is NOT ALERT or vital signs are unstable:
A. 

Evaluate and maintain airway, provide oxygenation and support ventilations
as needed.

B. If no suspected spinal injury, place the patient on either side.

C. Administer small amounts of oral glucose paste,buccal or sublingual.

SO... That is technically what I am supposed to do. However with an average time of 2-3 min for ALS to arrive, I think I would hold off on putting frosting in an unconscious persons mouth.


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## chaz90 (Apr 26, 2013)

Anjel said:


> SO... That is technically what I am supposed to do. However with an average time of 2-3 min for ALS to arrive, I think I would hold off on putting frosting in an unconscious persons mouth.



I've actually seen that exact thing on a call. Unconscious diabetic, and the family completely stuffed the woman's mouth with thick frosting to try to get her BGL up. My partner had to use the Yankauer as a spoon and scoop goop out of the ladies mouth. Frosting really hasn't appealed to me since...


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## kaisardog (Apr 27, 2013)

so  as  a  summary  for  us students:  BSI  gloves, is scene  safe,  , No.  of  Pts =1,  call  ALS due  to  high  index  of  suspicion  for  head/neck  injury from  fall, GI =young  man sitting  , ao4,  having fallen down  stairs   20  ft , w/  suspect  head/neck/cSp  injuries due  to   Mechanism of Injury ( which is   significant  due  to  height), (BSNAGi  survey  thus  complete.)

now  put  ghost  EMT  holding  manual  C  Sp, then student assesses and   Rxs  ABC's -primary  life  threats:  1 ghost  EMT holds  manual  stabilize  of   Head/neck  while student  is  assessing head/neck/chest  for need  for   Rx  for  life  threats Airway  Breathing . these   are   OK  as pt  is  talking  , GCSv=4 , AO4  (answering ?s,   name ,   can  swallow, =airway, OK)  breathing is  normal  since  air  going  in  and  out  , lungs bilaterally inflate/deflate  w/   normal  Resp rate  and  depth after  check  with  stethoscope, chest  neg  for  DCAPTbls,  no adventitious  sounds. Circulation assessed as normal by  pulse/  color/temp /turgor and  no visible bleeds.    student  applies  C  Sp collar after ABC/head/neck  , instructing  ghost  how  to  release  head/neck  stabilization. student   continues    rapid  trauma  90 sec  assessment for  rest of  body   while  ghost is  instructed  to   prepare   to apply  o2  NRB 15  L.   student  finishes  neg  RapTrau assessment for  head/neck/other  trauma  injuries,  student begins OPQRTS/SAMPLE trauma  w/ focused neuro  assessment  for  CSp=hd  injury. reassess C  Collar,,  checking  PMS  on  all  extremities. Then  begin  medical  assessment  w/  focused assessments  on   Diabetic  issues,   check  pt's  own  glucometer   since  EMTs  in  our state  can't  carry  them, Rx of  buccal  Glu  since  AO4  and  swallowing.  Package:  don't  want  full  supine B/B  as  supine  increases  ICpressure,  so  apply  KED  or  short b/b  and  position  in  semi  Fowler  on wheeled  stretcher, rapid transport  due  to  CSp /neuro  issues complicated  by  Db. ,  vitals  every  15 , reassess  ABCs  and  interventions ? 

question: do  you apply  C  Collar   and  O2, as  part  of  ABC,  then only  after  finishing  full  trauma/med   secondary  survey OPQRSTSAMPLE     give  the  Glu ? and is  this  pt  an  ALS  and   rapid  transport ?

now  same  MOI, but  sitting  patient,  very  altered  AMS  ie  making  no sense  AOx 2  or  less,  GI  now  poor/ AO2 sitting  pt  having  fallen  w  possible  head/neck  C  Sp  and  AOx2,  can't  answer  'Can you  swallow'   question  so  no  oral  glu, suspect  fall  and  hit  head  from  environmental/ bystander  MOI info, so   definiately call  ALS  in  d/t AMS all  the r est  is  the  same except  no  glucose  because  of  AMS and   vitals  every   5 not  15..reassess  all  interventions  after KED  app.

am  i  forgetting  anything?  this  is  a  combined  trauma/med  scenario  which i  don't  think  i  really  understand  too  well,    because  our  book  AAOS  only  has a  few  pages  on  what  you  are  supposed  to  do...  
thanks  as  usual for  your  insights.  you may  not  realize  how  extremely  helpful  the  advice  from   this  board  has  been  in  our   scenario   exams..


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## SpecialK (Apr 27, 2013)

Your post makes absolutely no sense because I cannot understand half of the abbreviations you are using so have a very poor idea of what you are on about.

So, a patient fell 20 feet down some stairs.  This is indeed a "fall from height" and there is significant potential for traumatic brain injury, fractures to long bones or the spine, or damage to organs such as the liver, lungs, spleen or kidneys.  If the fall is associated with a decreased level of consciousness that is more than being a bit "dazed and blurry eyed" for a minute or so i.e. somebody who is unconscious post-fall and remains unconscious, or who does not regain consciousness completely then the patient has a traumatic brain injury until proven otherwise.  

If the patient has a normal (or near normal) level of consciousness then you can leave them sitting up in whatever position is most comfortable for them; if they have a decreased level of consciousness with airway needing intervention then they should be flat on their back, receiving a good two handed jaw thrust and airway management as appropriate noting that the airway always takes precedence over the cervical spine; always, always, always with absolutely no exceptions.  

In this patient the cervical spine should be immobilised unless the patient is awake with no altered neurological signs and has a completely normal motor examination and no midline cervical tenderness.  It is important to note that lateral muscle tenderness is not cervical spine injury and that if the patient is conscious they can have a well fitted hard collar applied but they do not need their head held; the best person to keep the patients head still is themselves!

There is no role for the KED in this patient; they should be combi-carried to the stretcher (or whatever extrication device you use) and allowed to lay flat on the stretcher in the nose-to-toes position.  

You should immobilise the cervical spine if it is indicated after the primary survey has been completed i.e. the patient has a patent airway established and any major bleeding has been extinguished.  

It would be appropriate to give the patient oxygen provided they are hypoxic i.e. have an SpO2 of < 96% on room air (noting there are several reasons why a patient may be hypoxaemic on oximetery but have a normal level of oxygen bound to their Hb e.g. CO poisoning, so clinical judgement is required) however we need to get away from the historic dogma of giving oxygen to everybody who looks a bit sick or has something more serious than a cut finger, indeed patients who have significant supratherepautic levels of oxygen administered are at risk of having their capillary and arteriolar bloodflow attenuated due to vasoconstriction; remember when back in first year hari kari seemed like a good idea because one of the million seemingly useless facts that had to be learnt was that the lone controller of the precapillary sphincter was CO2 saturation, well it just came in handy.

It would also be appropriate to check a blood sugar on this patient; a dysglycaemic incident could have triggered the fall noting that it is overwhelmingly likely to be hypoglycemia as the vast, vast majority of patients who have an acute hypergylcemia problem (i.e. DKA or HHNK) have a normal level of consciousness and if they are that sick to have an altered level of consciousness they've been unwell for some time (think days) and are likely to feel so unwell they aren't up and about moving around; but never the less, check a blood sugar.

You can give somebody glucose or glucose containing food so long as they are awake enough to swallow them so an altered level of consciousness if not an absolute contraindication but you should be careful.  Something like a jam sandwich, soft drink or sugar in water is often a quick fix for somebody who has had a hypo; although in this situation if the patient is hypoglycaemic it would be more appropriate to give them some glucagon, or glucose parenterally if you have it as part of your scope of practice.  

This patient should be referred to the emergency department and should be taken there by you.  Just because they fell 20 feet down some stairs does not mean you need to race them to hospital at breakneck speed with sirens blasting as if they had a normal or near normal level of consciousness (GCS > 9) and normal or near-normal physiological signs then they by definition do not meet major trauma criteria however a discretionary trauma call can be placed at the decision of the person on the other end of your hospital call; however, if the patient has an altered level of consciousness with GCS < 9 then they meet major trauma criteria and conveying them to hospital on a 1 might not be a bad idea.  While we are on the subject of transport; I can see people jumping up and down and getting all bug eyed and screaming for a helicopter if the scene is more than a stones throw from the hospital; remember, to actually save time with a helicopter the total time to transport the patient to hospital must be greater than one hour unless of course you need the helicopter anyway for backup e.g. for RSI.


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## Melclin (May 5, 2013)

SpecialK said:


> This patient should be referred to the emergency department and should be taken there by you.  Just because they fell 20 feet down some stairs does not mean you need to race them to hospital at breakneck speed with sirens blasting as if they had a normal or near normal level of consciousness (GCS > 9) and normal or near-normal physiological signs then they by definition do not meet major trauma criteria however a discretionary trauma call can be placed at the decision of the person on the other end of your hospital call; however, if the patient has an altered level of consciousness with GCS < 9 then they meet major trauma criteria and conveying them to hospital on a 1 might not be a bad idea.  While we are on the subject of transport; I can see people jumping up and down and getting all bug eyed and screaming for a helicopter if the scene is more than a stones throw from the hospital; remember, to actually save time with a helicopter the total time to transport the patient to hospital must be greater than one hour unless of course you need the helicopter anyway for backup e.g. for RSI.



Not to derail the thread but that seems like some pretty conservative trauma activation criteria. You wouldn't consider a person with that mechanism who did have a GCS of 15 and then say dropped fairly rapidly to 13 and vomited several times to be a good candidate for a trauma centre? I assume you do but is that sort of thing not written into the official criteria somehow? I'd be interested to her about it if you wanna PM.


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## SpecialK (May 5, 2013)

Melclin said:


> Not to derail the thread but that seems like some pretty conservative trauma activation criteria. You wouldn't consider a person with that mechanism who did have a GCS of 15 and then say dropped fairly rapidly to 13 and vomited several times to be a good candidate for a trauma centre? I assume you do but is that sort of thing not written into the official criteria somehow? I'd be interested to her about it if you wanna PM.



Sorry, the GCS for activating a trauma call is < 13.   

GCS 14 or 15 is considered "normal" LOC and a "minor" problem
GCS 10-13 is considered an "abnormal" LOC and a "serious" problem
GCS of 13 or less is considered "coma" and a "critical" problem

I reckon the GCS is a bit of a misnomer to be honest, a GCS of 10 might be made up of a E4, V5 and M1 yet if we accept that motor score is the most important prognostic component then this patient is arguably far more time urgent than somebody who has has a GCS of E1, V1 and M6 yet the latter would get priority.


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## Trailrider (May 5, 2013)

CPRinProgress said:


> I am in a EMTB class in nj.  Today we had a scenario where I, a first responder, respond to unknown medical.  On arrival pt was sitting up against a wall.  When I introduced myself the pt was obviously altered with no by bystanders.  To open his airway I layed him down and applied o2.  Checked CTC bleeding signs of shock etc.  When others arrived someone did a rapid trauma while I took vitals.  Pt had back neck pain so we back boarded.  After my instructor asked why I played the pt down and I said I did it to open his airway but he said that was wrong.  My question is how should I have managed the airway.






Altered how?GCS?PHI?stroke scale?diabetic? what causes altered states?

So the patient has a sore neck and back,how ?MOI? what would warrant you to collar him and board him? Are you able to put patient in semi fowlers on the board? what were his vitals?

So you layed him down,applied o2,did a trauma assessment,vitals then a collar? I would likely get the collar on prior to a patent airway,but that's just me.


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## CPRinProgress (May 5, 2013)

Trailrider said:


> Altered how?GCS?PHI?stroke scale?diabetic? what causes altered states?
> 
> So the patient has a sore neck and back,how ?MOI? what would warrant you to collar him and board him? Are you able to put patient in semi fowlers on the board? what were his vitals?
> 
> So you layed him down,applied o2,did a trauma assessment,vitals then a collar? I would likely get the collar on prior to a patent airway,but that's just me.



Well we didn't get dispatched as unknown medical so I was thinking that I would do ABC's and when I did rapid trauma, pt moaned when I palpated his neck and Back, that is why I didn't put the collar on right away.  Apparently we were at the base of a staircase but they didn't tell us that until after.  He was supposed to have fallen and that is what caused AMS.  Vitals were within normal range and gcs was 11


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## Handsome Robb (May 5, 2013)

CPRinProgress said:


> Well we didn't get dispatched as unknown medical so I was thinking that I would do ABC's and when I did rapid trauma, pt moaned when I palpated his neck and Back, that is why I didn't put the collar on right away. * Apparently we were at the base of a staircase but they didn't tell us that until after. * He was supposed to have fallen and that is what caused AMS.  Vitals were within normal range and gcs was 11



I bolded an important learning point above when it comes to testing.

You need to ask about your surroundings in your scene size up. Where are we? Do I see any source of potential mechanism? Any drugs/paraphernalia around? Any medications visible we can look at? Anyone see a glucometer? Did we find insulin in the fridge?

Scenarios are tough because everything needs to be vocalized. You may be thinking all these things but the proctor can't read your mind.

You were correct to board this patient. Worst case you board him, fix the hypoglycemia, he becomes a&o and denies neck/back pain and can be cleared with either CSS or NEXUS or flat out refuses treatment and you take the collar and board off. 

Another key point, you keep talking about what you were dispatched to. Wipe that out of your head. If I had a nickel for every time dispatch was wrong about the complaint I'd have bought a brand new truck rather than my 06... I'd say they're correct probably 1/3rd of the time, it's not they're fault they have to go off the information they're given from the RP.


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## Melclin (May 5, 2013)

Robb said:


> You need to ask about your surroundings in your scene size up. Where are we? Do I see any source of potential mechanism? Any drugs/paraphernalia around? Any medications visible we can look at? Anyone see a glucometer? Did we find insulin in the fridge?
> 
> Scenarios are tough because everything needs to be vocalized. You may be thinking all these things but the proctor can't read your mind.



Hells yes, I love getting my law and order on and going through people's rubbish and personal affects looking for clues. Maybe I'm in the wrong job. 

But yeah, +1 one on this in general OP, for scenarios time constraints usually come second to getting an accurate picture of whats going on. You might spend 3 minutes discussing the scene before actually doing anything, where as in real life you could just see it all and dive in.


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## Handsome Robb (May 6, 2013)

Melclin said:


> Hells yes, I love getting my law and order on and going through people's rubbish and personal affects looking for clues. Maybe I'm in the wrong job.



Glad I'm not the only one. 

As far as trauma center criteria, here any patient with a GCS <13 is a "Trauma Red", one of the most "severe" categories only second to a trauma pre alert that spins an OR and brings anesthesia to the trauma bay.


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## Handsome Robb (May 6, 2013)

It won't let me edit my last post for some reason.

With that said about the GCS, if you have something like hypoglycemia present you have to fix that problem to make sure it isn't what's causing the ALOC before reporting to the TC that they're severely altered.


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## Tigger (May 6, 2013)

Robb said:


> Glad I'm not the only one.
> 
> As far as trauma center criteria, here any patient with a GCS <13 is a "Trauma Red", one of the most "severe" categories only second to a trauma pre alert that spins an OR and brings anesthesia to the trauma bay.



GCS equal or less than 12 will bring the full trauma alert hear, with nothing else provided it makes sense (i.e. the person is not usually GCS=12). Went to a talk the other day given by a local trauma center regarding callins and trauma alerts (two levels; full and merit), mental status plays by far the biggest roll in it for them, which I was not aware of.

I thought they had a genie next to the radio that told them what to call.


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