# Pretty wicked call today.



## Handsome Robb (Jan 5, 2011)

I work in an odd form of EMS, I ski patrol at a local mountain, operating as a Basic. Before I get started, we respond with minimal equipment, just a basic first aid/rescue kit/cpr mask we carry in our vests, then can call for transport, additional resources with more equipment and what not.

Today responded to an accident, only information was young child, multiple people on scene. I arrive on scene to a gaggle of people surrounding a little girl around the age of 12.  

U/A I make my presence known and take control of the scene, getting people to give me room to work. The child was unresponsive with a GCS of 3, slightly tachy(can't give you a number, I didn't take the time to find out exactly but it was fast) No BP on the hill, too many clothes to get around respirations around 14 a minute and shallow, left pupil was dilated, around 4mm in direct sunlight, skin is pink, cool and dry, partially I'm sure had to due with the weather.

Immediately I called for additional units and our trauma pack. (airway kit, O2, trauma dressings yadda yadda) and grabbed c-spine with my knees and called dispatch for an ALS ambulance. My backup arrived and we dropped an OPA with a NRB at 12 lpm because we were afraid the portable bottle would run out before we reached our base area, rapid trauma assessment showed nothing of real interest besides a few minor facial lacerations/abrasions/bruising. Boarded her and took off, transfered her to the ALS EMS unit at the base.

Its not a super interesting call from the basics, but the fact she was the first sick sick kid I have ever been the lead responder on really got to me. It doesn't help that it turned out to be a hit and run accident, she had been hit by a snowboarder and he didn't even stop.

Sorry I just had to type this out, I can't talk to my girl about it she hates it when I talk about work. It really got to me that there wasn't more I could be doing as I waited for backup, even though this time it only took about 90 seconds to get there.

What more could I have done for this poor little tyke? It's so different being out in the elements alone, with minimal gear, when your backup could be as far away as 15 minutes and thats just to get a transport unit there, no packaging included.


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## C.T.E.M.R. (Jan 5, 2011)

Wow id say thats a crazy day! it surprises me how little you carry on your person especially on ski patrol. What type of training are all the staff there required to have in order to have a medical position?


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## Handsome Robb (Jan 5, 2011)

You physically can't carry much more. We work all day long, not just running calls, hill safety, padding snow making equipment, setting fence lines, boundary lines and so forth. Some carry OPAs in their personal kit, but with all the rescue/self evacuation gear we have to carry space is very limited.

I asked for a HEMS standby, due to her GCS, MOI and distance, an hour plus by ground, to a trauma center. The EMS personnel came up on our radio channel and we chatted for a bit and the medic decided to get her en route to the local ED towards more definitive care and then to medivac from there if need be.

There are professional patrollers and volunteer patrollers. The professionals carry an EMT-B certification, I am the only one that is an I. The volunteers all have what is called Outdoor Emergency Care or OEC. It is an 80 hour program, focused mostly on trauma and wilderness first aid, with a little medical training, similar to a first responder. 

On top of of this call I was dispatched a couple hours later to a snowboarder vs. equipment on the hill, but surprisingly he was fine, just a possible torn MCL. Well, fine compared to the little girl.


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## Jay (Jan 6, 2011)

NVRob,

First off, it sounds like a rough day, I am so sorry that you really didn't have anyone to talk to because after something like that you really need to whether it's a friend or supervisor or chaplain, whoever it is, you need to get this off your chest. I personally would follow up at the hospital, I don't know if it is a real good habit or a real bad habit but I try to follow up with patients even if it means stopping by the ED a few hours later. As you can see by this post, I don't sleep much anyhow.

Now, as for your question if you could have done anything else. If her GCS was an actual 3 than probably not especially with limited equipment. The sad fact is that a GCS that low suggests severe neurological complications that if there is a somewhat positive outcome it will be extremely slow, sometimes taking months or even years after the initial coma and even then the patient will only have a limited quality of life. A full recovery from a coma is Hollywood, and unfortunately the lower the GCS the worse the long term odds. Aside from seeing this in EMS, I had a family member pass on after 3 weeks in a coma and did much research on the subject because I did not like the answers that I was hearing in the hospital. 

My questions is, was she posturing? What kind? Aside from the unequal pupils this may tell us something... Was there any reactivity at all in the pupils?

As an EMT-I, I would have intubated instead of simply dropping an OPA because of the extremely low GCS and the muscle rigidity that would come secondarily. 

May I suggest one thing, in order to save O2 and to know when it is truly necessary and in what quantity, I carry a pocket-sized SpO2 meter that I can throw on a finger and get a reading in about 10 seconds. I also keep two tanks in my trauma bag so I have a backup ready. I also would have considered 10 LPM in order to save O2 if need be, it is the low end and would be just as effective. Remember that SpO2 has its advantages and disadvantages and you should be treating the condition of the patient and not her numbers but at the very least you would get some good feedback for charting and to see if there is effectiveness in the oxygen delivery. Also, remember that things are changing with O2 on both the state and national level and some studies (unrelated to this) even show a negative impact with some MI/stroke patients. Go figure.

I do wish you and your patient luck because you never know the outcome, it may just surprise you. Please make sure not to hold this in and to talk it out if you need to. I would only do so myself. 

Best wishes!


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## MrBrown (Jan 6, 2011)

You did what was appropriate.  Brown thinks some sort of neurogenic cause for coma.

Yes hello it's Medivac entering class C airspace overhead the mall this time from the south, be transiting 1,000' or below on track hospital ... call you airborne agian.

Do you like helicopter rides?


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## clibb (Jan 6, 2011)

Was there family on scene? People are born with unequal pupils, so you can't really take that for granted until you know her history. Also, unequal pupils is usually a pretty late sign of a traumatic brain injury.
If she accepted the OPA without any struggle or gag reflex I would be really concerned. I wouldn't drop if I didn't have suction and if she was breathing fine before it. 

Personally, I would had called HEMS as soon as I'm done with the PT assessment especially how long the trauma. Remember the Golden Hour starts when the accident happens, not when you roll up on scene.

Other than that, I think you did an awesome job. I know that Ski Patrol don't carry much stuff which I agree with 100%. You would have back problems after a week skiing with an ALS kit around you all day.


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## Luno (Jan 6, 2011)

Wow, you guys only carry vests... Hmmm....   My pack is 25lbs with the CamelBak empty.  But that's carrying steth/bp cuff/glucometer/thermometer, bleeding control, splinting material, self evac gear, shovel/probe, aspirin/glucose/epi, and personal emergency crap.  Just reviewing your post, I'd say you did a good job, based on the situation.  12 vs 15, and depending on your time to bb/cc the patient you were probably good to run 15, but it's not that significant of a difference given the option of running out.  BTW, don't compare OECs to first responders, they really hate that, they honestly believe that they are on par with EMTs...   But in all seriousness, sounds like you did good, unconscious patients suck, unconscious little patients really suck.  From a basic level, you hit the main points.  My only suggestion is that if your girl doesn't like to hear about it, spend more time drinking with your patroller buddys... 8)  (I'm kinda in the same sorta deal, she'll listen, but doesn't get it, and can't really relate, but it helps me to listen to her problems, because I don't have to concentrate on mine.)  So do you guys usually follow up on these kind of incidents?  It'd be interesting to hear how she's recovering, especially since skier/snowboarder collisions have become a large issue since the incident in Wyoming on Christmas eve.


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## Veneficus (Jan 6, 2011)

It is not the equipment you carry, it is the decisions you make, and it sounds like today all the decisions were very good.

I agree with the military perspective on intubation in the field. Simply Don't.

There is too much movement and the primary focus needs to be on evacuation, not baby sitting a tube pretending to be a Neuro ICU on a mountain somewhere. If an OPA or NPA is inserted, then what needs to be accomplished has been.

As for not having anyone to talk to at home, I know how that goes. Many times my wife has asked me to tell her about my bad days because she wanted to show she cared enough to listen and support me. Usually it caused her so much distress and anguish I ended taking care of her which made more work for me. After a few times she decided it was best to let me cope in my own way.

There is nobody who understands emergency work outside of emergency, in the same way there is nobody who understands the effects of war except those who have been in it. 

The best support comes from peers. (and my sarcastic gallows humor)

I also find spending a few hours focusing on me helps. There is a lot of giving in medicine, and from people of my psych profile, so taking some time to be removed from focusing on others actually helps a lot.


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## firetender (Jan 6, 2011)

You are part of a larger system that has been designed to provide care on a "tier" level. You are the first line of intervention. What you do is dependent on the second line showing up quickly enough. You have your back covered in that respect. So, you did exactly what you were supposed to do and provided the support the little girl needed.

Now, the patient is YOU!

In this moment and until you actually find out what the end result was, you're just spinning your own wheels. Realize what you did was the best you could do, you fulfilled your role and the outcome, once you released her, is NOT up to you. It's up to a much more complex WHATEVER.

The necessary intervention is to NOT cause YOURSELF any more trauma than you already experienced. First step, right here is a good one. Next is to seek flesh and blood (and willing) ears.

But in this field you also must remember there's zero difference between the life of a child and the life of an adult, or YOU for that matter. We are ALL expendable and your job is to do what you can when you can to ease the experience of being traumatized. That includes shifting your focus from worrying, in retrospect, to contributing where you can.

Take the time to learn what happened with the kid, and, if it feels right, offer a little support to the family. Such devastating experiences have a beginning, middle, and an end because now, it's part of YOUR story as well. Don't get stuck in the beginning


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## Veneficus (Jan 6, 2011)

firetender said:


> Take the time to learn what happened with the kid, and, if it feels right, offer a little support to the family. Such devastating experiences have a beginning, middle, and an end because now, it's part of YOUR story as well. *Don't get stuck in the beginning*



This is perhaps the best advice ever given.


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## wyoskibum (Jan 6, 2011)

*Not a reality....*



> NVRob,As an EMT-I, I would have intubated instead of simply dropping an OPA because of the extremely low GCS and the muscle rigidity that would come secondarily.



Not all EMT-I's can intubate in every state.  Usually, ALS providers on Ski Patrol are working at a BLS level. 

Being on the side of a mountain in a cold, snowy environment, doesn't facilitate providing ALS interventions.  Getting the patient out of the environment to ALS provider in a more stable environment is the priority. 

Sounds like the OP provided the appropriate care and transport.  Strong work NVRob!


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## wyoskibum (Jan 6, 2011)

> Wow id say thats a crazy day! it surprises me how little you carry on your person especially on ski patrol. What type of training are all the staff there required to have in order to have a medical position?



Most ski patrols work at a EMR or EMT-B level.  The National Ski Patrol has their Outdoor Emergency Care (OEC) certification which is not quite equivalent of EMT-B, but much more than EMR.

The emphasis is on packaging and rapid transport.


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## Luno (Jan 6, 2011)

Veneficus said:


> I agree with the military perspective on intubation in the field. Simply Don't.



Your perspective of army perspective on intubation in the field is pretty much correct, but the definitive airway in the field is accomplished via cricothyroidotomy...


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## Veneficus (Jan 6, 2011)

Luno said:


> Your perspective of army perspective on intubation in the field is pretty much correct, but the definitive airway in the field is accomplished via cricothyroidotomy...



Yea, I often get to see the trauma care guidlines and revisions before they are published


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## Handsome Robb (Jan 6, 2011)

wyoskibum said:


> Not all EMT-I's can intubate in every state.  Usually, ALS providers on Ski Patrol are working at a BLS level.
> 
> Being on the side of a mountain in a cold, snowy environment, doesn't facilitate providing ALS interventions.  Getting the patient out of the environment to ALS provider in a more stable environment is the priority.



This was the case. We have no ALS providers on the mountain, even though I am an Intermediate, I operate as an Basic, minus any medications. We are allowed to assist with the administration of prescribed NTG, which I have my arguments with since we do not carry BP cuffs. We have an RN in the Medic room at the base, usually, but yesterday, unfortunately, this was not the case, however by the time we got her transported Paramedics were on scene.

As for the follow up, I called the family, as the hospital will not release information to us. She was being transferred to a hospital in a neighboring state, was still unresponsive, and had some sort of inter-cranial bleed. The father was very distraught and I did not want to push him so I gave him my number and email and asked him to let me know how she was doing if he was OK with that.

I got pretty lucky today with some self time, 0 calls, bluebird day, very quiet. I got to ski pretty much all day, alone, which to some may sound odd but skiing is my release. It definitely helped me calm myself down to a degree, my mother's boyfriend is a MD so I'm hoping to get together with him this weekend and talk to him about it. 

Thanks for the support guys, I just hope that there wasn't something I could have done that would have improved her chances at a positive outcome that I missed, even with the support from you I keep racking my brain. It is a very odd situation in the fact that I am the youngest patroller on staff and the highest trained, minus a few of the volunteers, so people tend to look to me for advice and it honestly scares me a little bit with all the responsibility. Is this a sign?


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## Handsome Robb (Jan 8, 2011)

I think that I may be overthinking this. Yesterday, I eneded up backboarding and my good friend and sending her to the ER in another ambulance. I hope that I get better at dealing with these things as I get more experienced, as I am just starting my career in EMS.

She's fine, sprained neck and a pretty good concussion, no further word on the little tyke though, unfortunately.


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## Veneficus (Jan 8, 2011)

NVRob said:


> We are allowed to assist with the administration of prescribed NTG, which I have my arguments with since we do not carry BP cuffs. We have an RN in the Medic room at the base, usually, but yesterday, unfortunately, this was not the case, however by the time we got her transported Paramedics were on scene.




Let me put your mind at ease. 

10's of thousands take nitro everyday. (up to 3 doses before even seeking medical aid) Most never take their blood pressure at all.


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## Jay (Jan 8, 2011)

Veneficus said:


> Let me put your mind at ease.
> 
> 10's of thousands take nitro everyday. (up to 3 doses before even seeking medical aid) Most never take their blood pressure at all.



What about the contraindications relative to BP?


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## Veneficus (Jan 8, 2011)

Jay said:


> What about the contraindications relative to BP?



It is a relative contra indication.

Certainly there are times when it is harmful, but the effect is only about 5 minutes.

I think it is important to draw attention to administering NTG and "assisting" a patient to take a medication prescribed by a doctor, to be taken when specific symptoms are experienced for an already diagnosed pathology.

The former expects that the provider has made a risk/benefit analysis based on the patient presentation.

The latter expects the patient already has a prescription, has the presence of mind to self determine to take it, and just lacks the ability to retrieve it or the manual dexterity to self administer.


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## firetender (Jan 8, 2011)

*An Open Letter to NVRob*



> Thanks for the support guys, I just hope that there wasn't something I  could have done that would have improved her chances at a positive  outcome that I missed, even with the support from you I keep racking my  brain. It is a very odd situation in the fact that I am the youngest  patroller on staff and the highest trained, minus a few of the  volunteers, so people tend to look to me for advice and it honestly  scares me a little bit with all the responsibility. Is this a sign?



Brother(s and Sisters), this job is about the moment.

You are called to a scene and you are in the midst of a relentless barrage of moments.

Each one either builds on or disrupts the moments before it. _*Oftentimes RECOVERY occupies most of your time!

In*_ the moment, you make decisions BASED _*on *_the moments you are in the midst of. Your art is to string moments into a cohesive whole that benefits the life of your patient, and if possible, others nearby. Very often, your art is all about getting to the next moment without screwing anything else up!

No matter how you cut it, you are responding to an INCOMPLETE picture. There are things happening at the time, all around you, that are out of your sight and control. _*You NEVER have ALL the information there is. *_Monday Morning Quarterbacking is all about seeing the things now that you were incapable of seeing then.

The decisions you make become FIXED in time, never to be repeated or modified. They were products of circumstances that have come and gone and, in reality, have very little if anything at all to do with the moment that you are in _*right now!*_

Since right now is where you must live, at some point you must acknowledge that what happened then happened then. Obsessing about what you can do better next time may very well interfere with your responding appropriately to the moments you are in.

By all means, take a little time to review yourself and actions and how you handled yourself, and especially don't avoid looking at how you did as a human being doing human's work.

If there are moments nagging you from back then, face them. But ultimately, since "time heals all wounds", anyway, you'll come to the place where you just let it all go because being in the present moment is what is most important.

And don't forget, even if the moments you lived through were screwed up by someone else, "time wounds all heels" as well, so you can let that go, too!

I don't know if you noticed, but I think this EMS stuff is a very Zen thing!


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## zmedic (Jan 8, 2011)

I'd second launching the chopper, especially if you are a ways away from the level 1 trauma center. She sounds like someone who needs a neurosurgeon. Also don't think I would have intubated her in the field. If she was still breathing well on her own with the OPA I would have just transported like you did.


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## Handsome Robb (Jan 13, 2011)

Closest trauma center is a level 2 about an hour away via ground, as long as the roads are clear going over the pass, can be a lot longer with winter weather. As I said, I requested it but the way our protocols and SOPs are written, it is the EMS units choice on whether to call for it or not. 

Haven't heard anything back from the family and I feel like it would be inappropriate to try and contact them again. I hope the little girl makes a recovery.


On another note, had a guy take a 15 foot fall to flat today. C/O middline back pain, SOB and pain 10/10 with the worst pain he ever felt being a 26 foot fall to pavement with multi-system trauma 5 years ago. Good distal CMS though...He got whisked off to the trauma center real quick today. Don't call your last run when your boarding or skiing people!


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## wildrivermedic (Jan 15, 2011)

NVRob said:


> it honestly scares me a little bit with all the responsibility. Is this a sign?



You could see it that way... as a sign that you're doing well in difficult situations. I'd be more worried if you weren't a bit scared! It_ is_ a lot of responsibility but from your post it seems you can handle it. You took control of the scene and did what could be done -- mostly getting her out of there fast.

On another note, can anyone comment on the use of pulse ox in cold environments? Anyone use them on ski patrol? Personally when my hands are cold my cap refill approches infinity...


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## Handsome Robb (Jan 17, 2011)

I know a few of our vollys have them, I can't attest to their effectiveness though, but they seem to like them. 
 I don't usually even check cap refill, because, as you said it is greatly altered by the cold environment.


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