# Psych Case, Scene not Secure



## ah2388 (Mar 18, 2010)

You and your partner are toned out on the quiet for a psych case, scene not secure.

You stage a couple block away until given the all clear by LEO's on scene.

No other dispatch information is given.

As you pull up you recognize that site access is going to be difficult due to the roadway being occluded by LEO's and a civilian vehicle.  You exit the ambulance, 5 or so houses away from residence while your partner turns the truck around.  As you walk up the driveway, you hear an LEO say, "Come on buddy, wake up, and then start counting 1-2-3-4."  You arrive to see the patient lying supine on a garage floor, AED pads attached with the officers doing CPR.  Scene sizeup reveals several pill bottles, containing what is presumably Benzo's..all empty sitting around the patient.  911 Caller states that she heard a bang in the garage, came out to investigate and then called 911.  LEO's also advise that the patient had hung himself, the cord having been looped twice and double knotted around the neck.  PD had cut him down.  You assess for breathing and the patient is breathing, with a good strong radial/carotid pulse.

VS are as follows.

BP: 124/78        P: 84         R:24x/min       Sa02: 92% RA.

What would your initial management of this pt be, I will give more info about pt condition as this thread progresses


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## Shishkabob (Mar 18, 2010)

Initial:  NRB with oxygen, OPA if tolerated, NPA if not.  IV with lock.


VS seem fine even with the empty benzos.  Guess you could keep Flumazenil on hand, but it's not really needed right now.



Pupils?  AVPU?  Family around for history?


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## ah2388 (Mar 18, 2010)

k, initial management on this call was.

NRB 15lpm, ECG monitor, and a 16g in the LAC.  Pupils equal/sluggish, family was to hysterical to be of any use in the way of hx.

pt withdrawals to pain

theres a missing piece to this puzzle though, i hope SOMEONE catches it, as we missed it on this call as well...and its very important.

Anyway, pt loaded onto stretcher, starts puking on the way to the ambulance.

Now enroute, whats your management


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## Dominion (Mar 19, 2010)

Quick question, if the patient is breathing and has strong peripheral and central pulses why was PD performing CPR?  Are we talking about ROSC as you're walking up to the scene or just poor assessment/freaking out by PD.  It this isn't an oversight in the scenario, I would attempt to obtain why PD started CPR.  BTW what do I get on the EKG and what are our vitals?


Enroute: Full head to toe expose patient entirely.  If they heard a bang from the garage would also be looking for any sort of gsw anywhere.  The bang may have been from a chair or something falling, or it may have been the pt attempting a hat trick. Pills, hanging, and shooting themselves.  Supportive care, C-3 transport to nearest appropriate facility.  For me that would be a Level 1 Trauma center.


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## Veneficus (Mar 19, 2010)

Not sure how the scene is not secure with all the cops around?

If he hung himself and he was cut down, there exists a strong suspicion for a C-2 “hangman’s” fracture. Might want to take some precautions for that.

Most squads don’t carry flumazanil, and the pts vitals don’t really indicate a need for acute reversal. Also “presumably benzos” doesn’t really sound definitive enough to start playing mad scientist and mixing chemicals in his blood.

A GCS is a really helpful finding. But I am a fan of NPAs.
What was the need for the 16 guage? Expecting a neurogenic shock? I think a 18 or 20 would have been fine. Maybe a second one if I thought he looked bad. 

Was the “bang” in the garage a gunshot? Exposing the pt would be good. 
Put him on some O2, hook up an EKG, maybe run a 12 lead to be complete.
What was the physical exam findings?


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## ah2388 (Mar 19, 2010)

Freakout by PD, they never checked for a pulse..attached AED bc the guy was unresponsive..when no shock advised the AED advised them to start CPR.

ECG shows a NSR which coincides with your pulse check.

Head to toe assessment reveals nothing out of the ordinary..
ligature (SP?) from the rope is the only abnormal finding during your physical assessment.

VS are in the OP, and they remained as such during transport.

Still missing that piece I was talking about


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## Veneficus (Mar 19, 2010)

I am hoping somebody took whatever was around his neck off.

If you have a really decked out rig you could give him some charcoal and lavage him with an NG tube.


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## ah2388 (Mar 19, 2010)

Veneficus said:


> Not sure how the scene is not secure with all the cops around?
> 
> *If he hung himself and he was cut down, there exists a strong suspicion for a C-2 “hangman’s” fracture. Might want to take some precautions for that.*
> 
> ...



Presumption was made due to the labelling on the pill bottles, 911 caller stated he took "150 pills."  We dont carry flumazenil, and I agree that in this situation starting to play chemist is prob a bad idea.  16ga was a combination of "macho medic", and bc of the vomiting, incase the hospital decided to rapidly fluid resusc I presume.  The "bang" in the garage was presumably him hitting the floor as PD advised when they cut him down he was only hanging a couple inches from the ground.


Im glad you mentioned the C Spine precautions as thats what we missed initially and was the first thing the ER physician stated upon our arrival.

This was about how it went...

We walked up to the scene w/o any of our equipment excluding our "rescue" bag...which has our airway/meds in it.  Monitor, Trauma Bags, C Spine stuff was all left in the truck.

NPA, NRB, 16ga IV, and baseline vitals/ECG was about all we had time for as as I stated we basically scooped him and ran.

Leave it to the future doc to notice the C Spine thing

We prepared to snow/intubate en route but by the time we got everything else established we were already at the hospital.

Also have to mention that this was definitely one of those "oh :censored::censored::censored::censored:" calls that kinda took us by suprise


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## Veneficus (Mar 19, 2010)

*some will find this helpful, some will not.*

without assigning blame to the OP or respondants if I could point out:


The reasons people fall into the traps that lead to mistakes like this is because some time ago, some cretin (I like this word, From the French root of Christian and used to mean: too stupid to sin) started making an artificial separation between trauma and medical problems.

I guess this was done as a memory aid originally but then the facts were lost and only the memory aid persisted.

ALL trauma is a medical problem. 

ALL Medical problems have a traumatic component.

the only distinction is which one was the cause and which was the effect.

Take for example the National Registry position. Look at the skill sheets.

You are tested on:

"Trauma assessment" which is really nothing more than a physical exam. (a poor one at that)

You are separately tested on "medical assessment," which is really the history taking component of a patient interview.

a history without a physical exam is worthless. A physical without a history is the minimum you need to go on during a patient encounter. 

I suggest consider the mechanism of *pathology* on all patients to create an index of suspicion of what could be wrong. the physical exam and history are interchangeable, you have to manage life threats as you find them. Since not all are apparent you have to be very diligent to know what occult conditions there are and take special care to make every effort to explore for them. It is also important to know which conditions occur over time and during reassessment making checking those a priority.

Start from scratch. The reason the ED staff assess patients from square one isn’t because they don't trust you or your report was bad.  The benefits of this to the patient and provider are overwhelming.

If you are an EMT you should reassess a patient a MFR or lay person hands you from the beginning. Your assessment is more detailed. A paramedic should do the same when receiving a patient from an EMT. I can assure you the doctor starts from the beginning when a paramedic drops off a patient at the ED. Just like the intensivist reassesses the emergency physician's patient.

If somebody is reassessing the patient you hand off, do your part and don't take it personally. It is not about you. 

The patient will start to get agitated from this. It sometimes helps to explain to them why everyone keeps asking the same questions and doing the same thing. I have found a patient you explain things to is a happy patient.


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## EMSLaw (Mar 19, 2010)

Veneficus is absolutely right (For once? ) 

What's always amusing is how the patient's story will change with each provider they talk to.


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## Veneficus (Mar 19, 2010)

EMSLaw said:


> Veneficus is absolutely right (For once? )
> 
> What's always amusing is how the patient's story will change with each provider they talk to.



(yea I get lucky every now and again )

I especially love "hey doc can I talk to you for a second?"

I know they didn't tell the nurse they had a leak, a drip, a sore, and  burning when they were flirting with her in triage.


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## rescue99 (Mar 19, 2010)

ah2388 said:


> Freakout by PD, they never checked for a pulse..attached AED bc the guy was unresponsive..when no shock advised the AED advised them to start CPR.
> 
> ECG shows a NSR which coincides with your pulse check.
> 
> ...



What was the "bang" noise? Gunshot?


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## rescue99 (Mar 19, 2010)

ah2388 said:


> Presumption was made due to the labelling on the pill bottles, 911 caller stated he took "150 pills."  We dont carry flumazenil, and I agree that in this situation starting to play chemist is prob a bad idea.  16ga was a combination of "macho medic", and bc of the vomiting, incase the hospital decided to rapidly fluid resusc I presume.  The "bang" in the garage was presumably him hitting the floor as PD advised when they cut him down he was only hanging a couple inches from the ground.
> 
> 
> Im glad you mentioned the C Spine precautions as thats what we missed initially and was the first thing the ER physician stated upon our arrival.
> ...



It seems you and your partner would have known to c-spine the guys. That was way too easy. Thought you were talking about something other than the obvious!!


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## reaper (Mar 19, 2010)

Yes, The c-spine is a given in a hanging. That is more packaging and not treatment.


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## FLEMTP (Mar 19, 2010)

sounds like a head/neuro injury to me.. the bang was prolly him falling to the floor and smackin his head. vomiting on the way to the truck would be consistant with a head injury or a bleed. 

Please tell us more!


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## Sasha (Mar 20, 2010)

> Guess you could keep Flumazenil on hand,



I had asked about using Romazicon awhile ago in private, I have never personally used it, but I was told unless you are CERTAIN that the person OD'd on Benzos, it would be wise to leave playing Chemist to the doctor, at the risk of causing irreversible seizures.



> Scene sizeup reveals several pill bottles, containing what is presumably Benzo's..all empty sitting around the patient.



"Presumably" benzos or the presence of empty pill bottles by a hanging victim is not enough confirmation for me 

For a benzo OD you can provide supportive care and take the patient to the hospital.


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## EMSLaw (Mar 20, 2010)

reaper said:


> Yes, The c-spine is a given in a hanging. That is more packaging and not treatment.



This.  

After all, we are talking about a direct insult to the spine here.  In addition to the possible C1-C2 fracture, there is a strong possibility of other damage from the compression of the carotid (cerebral ischemia, for example, or carotid sinus reflex) and jugular, depending on how long he was hanging.

Interesting quirk of English usage - People are hanged.  Pictures are hung.


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## ah2388 (Mar 21, 2010)

obv it was a pretty serious oversight, i was a student on this call and the scene was kind of a cluster:censored::censored::censored::censored:..

Vene your post is gold


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## armywifeemt (Apr 1, 2010)

All the new practical skills sheets I have seen have "consider c-spine stabilization" as one of the very first critical criteria, for both medical and trauma. Maybe it is a state thing? It comes before the ABCs though.. so they're really trying to put some hardcore focus on it. 


Also.. Veneficus I liked your point. 

We had our regional EMS symposium last weekend and we had an instructor who really hit on the whole medical/trauma all being one big thing. 

Maybe that MVA was caused by a seizure or a diabetic emergency, ya know? 

Kinda hard to tell when they are FUBAR and unconscious whether the lack of consciousness came from the trauma or something else. 

Similarly... Syncopal episode could mean injuries that the patient isn't really complaining about (as unlikely as it is for a patient to *not* complain).. Better to check and rule it out then go "oh crap" later...


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## JPINFV (Apr 1, 2010)

EMSLaw said:


> Interesting quirk of English usage - People are hanged.  Pictures are hung.


Of course context counts because both words can be used to describe humans.


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## Veneficus (Apr 1, 2010)

*clarification of point*



armywifeemt said:


> All the new practical skills sheets I have seen have "consider c-spine stabilization" as one of the very first critical criteria, for both medical and trauma. Maybe it is a state thing? It comes before the ABCs though.. so they're really trying to put some hardcore focus on it.
> 
> 
> Also.. Veneficus I liked your point.
> ...



My point was not that an incident involving trauma had a medical precursor. It was there is really no distinction between a medical and trauma pathology.

Let me offer some examples. 

The thrombus or embolus leading to an infarction of an organ is caused by physical damage to the vascular endothelium or thrombus respectively.

An autoimmune disease is antibodies or cytotoxic cells physically destroying body tissue.

A neoplasm can cause pressure necrosis and obstruct airways and blood flow.
Interstitial pneumonia is physically damaging to alveolar structures. 

Many microorganisms physically disrupt cells and tissue in addition to releasing toxins.

You can have fibrous scarring of organs such as the liver without ever suffering a blunt or penetrating injury from an outside force.

You can develop acute GI ulcers as a result of stress from outside injuries such as getting stabbed in the head.

Damage to muscle tissue from catabolic metabolism or outside injury can lead to renal failure by the exact same mechanism. 

Cell lysis from hyper/hypotonicity/osmoality is physical damage caused by water.

PH abnormalities cause a physical reshaping and consequent loss of function of proteins.

The list can go on for as many pathologies as are known to man. 

The distinction between “trauma” and “medical” is artificial. The cellular structures, cells, tissues, organs, systems, organism suffers the same type of damage and responds to any damage in exactly the same way for as long as it is able prior to decompensating. The difference in treatment comes in recognizing what the primary cause is.


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