# Disagreement on a scenario



## ironguy321 (Jan 8, 2008)

since my friend and I have not been hired yet as EMT-B's (we're both in firefighter school) we always drill each other on different scenarios. We were drilling each other last night when we came up with a scenario we disagree on:

You have a 25 year old male who is unresponsive. No medical history, medication bottles., bystanders, bracelets, etc. around; just a dark alley and an unresponsive man. He has a stab wound to his upper right abdomen. Vitals are respirations 8 shallow, Blood pressure is 100/60, pulse is 126 rapid, skin is cool. What do you do?

My response: Get him onto the ambulance and use a BVM at 100% oxygen. Request ALS. Once they arrive, patch up the wound, have the medic start an IV, continue to use BVM.
Friends response: Have your partner use a BVM 100% oxygen while you patch up the wound on scene. Load and go. No need for ALS.

What would you do in this situation?


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## Ridryder911 (Jan 8, 2008)

First what is the response time of ALS, second what type of services are provided by the ED and the response time to the ED. The correct answer is dependent upon more information. 

If there is a close ALS response, or the ED is delayed or not rated accordingly to Level II or I , then I would await for ALS. Since the patient has to be ventilated the patient needs secure airway, as well possible fluid and IV access, while enroute. 

Another alternative answer is meet and rendezvous with the ALS unit, so both of you are correct.

p.s.. the patient does need ALS.


R/r 911


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## Asclepius (Jan 8, 2008)

You need to implement shock protocol. Get the patient in a trendelenburg position. Initiate an ALS intercept. Begin transport immediately. Of course, you should have taken spinal precautions. What are the patients lung sounds? Is he moving air on the right side? Is the wound sucking? I know you said abdomen, but where at on the abdomen? What is skin condition? Is he perfusing with the amount of air he is moving? Definately assist his respirations. If the patient is unresponsive some kind of airway adjunct is appropriate. 

There is no question that this is a load and go scenario. Treatment is supportive and should be focused on definitive care ASAP. Ask for the intercept if your transport time requires it. Can you do glucose monitoring or EKG on your BLS rig? If so, and you have time, those are always a plus.


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## JPINFV (Jan 8, 2008)

Asclepius said:


> You need to implement shock protocol. Get the patient in a trendelenburg position.



I would have to disagree with this treatment. There is very little to no evidence that the trendelenburg position actually increases blood pressure, while some studies points to the position increasing intracranial pressure as well as making breathing more difficult.


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## Asclepius (Jan 8, 2008)

JPINFV said:


> I would have to disagree with this treatment. There is very little to no evidence that the trendelenburg position actually increases blood pressure, while some studies points to the position increasing intracranial pressure as well as making breathing more difficult.



The BP is 100 which is where you want it to stay. You're BLS and so you have nothing to keep the BP at that level except the trendelenburg position. It isn't going to hurt this patient and it might buy you some time until you get the ALS intercept. The patient is already decompensating based on his level of consciousness and intercranial pressure does not seem to be an issue with this patient based on both the MOI and the systolic and diastolic bp.

Whether you do the TP or not, the answer to your question is he does indeed need ALS ASAP. Whether that is in the form of an intercept or a rapid transport to the ED based on distance and time.


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## JPINFV (Jan 8, 2008)

Asclepius said:


> The BP is 100 which is where you want it to stay. You're BLS and so you have nothing to keep the BP at that level except the trendelenburg position. It isn't going to hurt this patient and it might buy you some time until you get the ALS intercept. The patient is already decompensating based on his level of consciousness and intercranial pressure does not seem to be an issue with this patient based on both the MOI and the systolic and diastolic bp.





If it comes between treating my patient's with a technique with, at best, shoddy evidence that also shows harm or not treating a patient past a ride to the hospital or paramedic intercept, then I'll choose the latter. Now, if there are studies that can show that the trendelenburg does increase a patient's blood pressure, then I'm all for it. Until then, it is about time that EMS starts moving towards evidence based practices and away from the dark ages. 



> Conclusion
> 
> The Trendelenburg position is taught in schools and on the wards as an initial treatment for hypotension. Its use has been linked to adverse effects on pulmonary function and intracranial pressure. Recognizing that the quality of the research is poor, that failure to prove benefit does not prove absence of benefit, and that the definitive study examining the role of the Trendelenburg position has yet to be done, evidence to date does not support the use of this time-honoured technique in cases of clinical shock, and limited data suggest it may be harmful. Despite this, the ritual use of the Trendelenburg position by prehospital and hospital staff is difficult to reverse, qualifying this as one of the many literature resistant myths in medicine.



Johnson, S., Henderson, S. O. "Myth: The Trendelenburg position improves circulation in cases of shock."  Can J Emerg Med 2004;6(1):48-9. 



> OBJECTIVE: To review the literature on use of the Trendelenburg position as a position for resuscitation of patients who are hypotensive. METHODS: PubMed online, cited bibliographies, critical care textbooks, and Advanced Cardiac Life Support guidelines were searched for information on the position used for resuscitation. Because of the heterogeneity of the data, only pertinent articles and chapters were summarized. RESULTS: Eight peer-reviewed publications on the position used for resuscitation were found. Pertinent information from 2 critical care textbooks and from the Advanced Cardiac Life Support guidelines was included in the review. Literature on the position was scarce, lacked strength, and seemed to be guided by "expert opinion." CONCLUSION: The general "slant" of the available data seems to indicate that the Trendelenburg position is probably not a good position for resuscitation of patients who are hypotensive. Further clinical studies are needed to determine the optimal position for resuscitation.



Bridges N, Jarquin-Valdivia AA. "Use of the Trendelenburg position as the resuscitation position: to T or not to T?" Am J Crit Care. 2005 Sep;14(5):364-8.

If wanted, I'll see if I have access to these journal articles at school and will post them later.


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## enjoynz (Jan 8, 2008)

We were taught to place an unresponsive Pt in the recovery position in the ambulance. 
Of course if you are assisting breathing with a BVM, they would be supine!
I agree with the load and go, meet the ALS in route, if you are a distance from hospital.
Also cover the wound before you take off!
Cheers Enjoynz


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## Grady_emt (Jan 8, 2008)

Asclepius said:


> Of course, you should have taken spinal precautions.



Why would you have to take C-Spine precautions. Its an isolated wound to the abdomen?  You also have other issues to deal with (resp rate, potentailly becoming hypo-vol.) why waste the time C-spining when the pt needs rapid transport to an appropriate trauma facility with trauma surgeons.  I could see possibly throwing him on a LBB for ease of movement from the ground scene and as a hard surface for compressions should he arrest.

Assist breathing, NPA/OPA or Combitube/ETT as tolerated and allowed by protocal
ALS Intercept (dont wait for them, meet them on the way)
Big IV's
Continuous monitoring enroute with rapid transport.


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## VentMedic (Jan 8, 2008)

Grady_emt said:


> Why would you have to take C-Spine precautions.



Unwitnessed fall to the ground.  

The stab wound may not have been the only injury, especially in a violent attack, but was the most obvious to distract.  

Florida case in the 1980s set a precedent.  Two private ambulance EMTs got a new career mowing lawns and the hospital had the deep pockets.  Fire Rescue Paramedics, who released the patient to BLS transport, had limited liability by being an entity of the government.  And, the patient was a quad. 

There was also another famous case in NYC involving an intoxicated person falling and suffering a C-Spine fx.

Currently in California, there is a C-spine case involving an elderly person, who had fallen, arriving to the ER by EMS on a back board for a hip fx.  No C-spine precautions.  It was assumed his decrease in sensation and mobility was from the hip fx and/or old age. He had two C-spine vertebrae broken.


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## MSDeltaFlt (Jan 8, 2008)

These guys are right.  ALS unit or Level II/I ER; the closest wins.  Package the pt.  Leave flat.  No Trendelenburg.  Bandage the wound.  Get an airway.  Bag him.  Not necessarily in that order.


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## Asclepius (Jan 8, 2008)

Grady_emt said:


> Why would you have to take C-Spine precautions. Its an isolated wound to the abdomen?  why waste the time C-spining when the pt needs rapid transport to an appropriate trauma facility with trauma surgeons.  I could see possibly throwing him on a LBB for ease of movement from the ground scene and as a hard surface for compressions should he arrest.


An example of an isolated injury would be someone who slips off a curb twisting their ankle. That is an isolated injury. Someone found unresponsive in an alley with no other information and an obvious stab wound is a trauma patient. Trauma patients get spinal precautions, period. We have no way of knowing just how he was assaulted. We only know for sure that he has a puncture wound in his abdomen. This EMT basic stuff. You're walking a dangerous and potentially career ending line if you're so tunnel visioned on just the obvious injury.

The trendelenburg position is arguable, I guess. Until protocols start changing as an EMT basic who is dealing with hypovolemia this is your only option. You have to keep the organs perfusing and you do that with the only tools you have available.


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## ironguy321 (Jan 8, 2008)

you guys bring up a lot of interesting points. next time, ill try and be more specific about everything. we were taught in basic "the ABC's" so what i was trying to hit hard on was the fact that his breathing wasn't good but at the same time he was bleeding from his Abd. (was trying to see if he would suspect the liver). i can see how protocols play a major role in this.

this is a side question on it but if your partner is driving and your using a BVM, how do you notify the hospitial ?


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## Asclepius (Jan 8, 2008)

Well, you can have your partner radio ahead or you can have your dispatcher notify the receiving hospital/ALS unit. Hopefully, you'll have some other help, like FD or PD that can help.


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## medic001918 (Jan 8, 2008)

Grady_emt said:


> Why would you have to take C-Spine precautions. Its an isolated wound to the abdomen?



Can you tell how deep that knife went?  Or what it hit inside the abdominal cavity?  If the answer is no (and in a stabbing that's more than likely the case), then you should immobilize this patient.  Anything less isn't really acceptable.

Shane
NREMT-P


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## Flight-LP (Jan 8, 2008)

Or take additional help with you to the ER. If you are bagging someone, you need more than one person in the back. One person ventilations with a BVM are ineffective, ideally you want three people..............

Apply SMR, give him a little O2, DO NOT place him in trendelenburg on the board, be happy with a 100 systolic BP as it is more than fine, bandage as necessary, go to an ALS unit or hospital as quickly as safely possible. This patient needs to be intubated and an NG tube placed, as simple BVM ventilation will possibly cause further issue due to over inflation of the gut.


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## JPINFV (Jan 9, 2008)

Flight-LP said:


> be happy with a 100 systolic BP as it is more than fine,



Doh, I totally didn't see that and connect it with permissive hypotension.


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## Asclepius (Jan 9, 2008)

Flight-LP said:


> DO NOT place him in trendelenburg on the board, be happy with a 100 systolic BP as it is more than fine


I should have specified myself. Yes, the 100 systolic is great. They're actually teaching now to keep it around 90. The TP was a suggestion meant more for if his pressure continued to fall.


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## Flight-LP (Jan 9, 2008)

He could have a non-prefusing MAP and I still wouldn't put him in a trendelenberg position. For one, there is no evidence supporting it. Two, it will cause an increase in ICP. Three, it makes the LBB that you pt. is lying on and the stretcher less secure and unsafe for transport. No benefit and multiple risks, seems like a no brainer to me...................


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## Ridryder911 (Jan 9, 2008)

Before it became too deep (since it is on a basic level) I was going to suggest to  perform a better assessment, while enroute. Pressure systolic of 100 and really a mild tachycardia of 120's, I would be looking for another underlying cause of unresponsiveness. Since it does not appear to be compensated, at the time. 

I would personally leave well enough alone with a stab wound in the right upper quadrant. Laceration of liver and potential of laceration of portal artery, mesenteric artery, bowel and kidney. Personally, I would prefer not to raise the BP any higher, and would be concern of possible other injury of the < LOC. But, contributed the scenario to that a scenario.. 

Trendelenburg or not, really won't matter and waste of time, it does not work.. but it makes providers feel better that they did something. The body works best if you sometimes leave it alone, such as good ole supine, or even lateral. As discussed "permissive hypotension" and watch the MAP and Cerebral perfusion, and of course coronary perfusion, etc.. 

Let's not make it any more cloudy, to be able to see the trees past the forest. 

R/r 911


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## certguy (Jan 9, 2008)

*Scenerio*

In all cases of major trauma c - spine precautions should be taken not only because of the unwitnessed fall but also the length of the weapon used and the angle of entry as well as the amount of force used in the attack are all unknown . There could possibly be spinal cord damage . In our county  , there's only 1 trauma center ( 60 miles out at least  through a windy canyon road )  , so I would consider a medivac transport depending on weather conditions . I would , in addition to c - spine and getting ALS ( air and ground ) enroute , insert an NPA ( if no evidence of head trauma to contraindict it ) assist ventilations , dress the wound , monitor v/s closely , and haul booty for the LZ . As a BLS unit , unless protocol is changed , TP is the only real option I can use to increase b/p reguardless of controversy , so I would use it . Has anyone thought to check for exit wounds ? For all we know , the weapon could've been a machete . I would also grab a FF for extra manpower in case he codes ( c - spine would also put a coding pt. already on the board for a firm CPR surface )


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## certguy (Jan 9, 2008)

*Scenerio*

Okay guys , 

    2 questions . 
      1. How would TP increase intercranial pressure if there's no head trauma ?
      2. What is MAP ?


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## VentMedic (Jan 9, 2008)

Trendelenburg and an unsecured airway can also present problems.  Even with a tube it can present problems.


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## Ridryder911 (Jan 9, 2008)

certguy said:


> Okay guys ,
> 
> 2 questions .
> 1. How would TP increase intracranial pressure if there's no head trauma ?
> 2. What is MAP ?



1. One does not have to have a head injury to raise intracranial pressure (ICP). Actually even sneezing could cause death, if it was not such a short duration of ICP. Raising the head to a 30 degree angle can drastically reduce ICP as well as placing the head lower than the body (TP) will increase it. (Ever hung upside down and feel the pressure?) It seems simplistic in which it is, but many never consider such basic things such as positioning. 

2.Mean Arterial Pressure (MAP) is the average arterial pressure during a single cardiac cycle.
One can easily obtain the MAP by doing the formula (MAP= [(2 x diastolic)+systolic] / 3) and most ECG monitors have it already calculated on electronic BP cuffs. 
MAP should be closely monitored and personally I rather know the MAP as I believe it is the fifth vital sign. Understanding the perfusion pressure, is just as important as the blood pressure itself. 

R/r 911


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## iamjeff171 (Jan 9, 2008)

it is my understanding that you are also supposed to treat for shock based on MOI.  the pt is also exhibiting some early signs of shock with skin that is cool to the touch.  isnt a drop in BP a very late sign of shock and at that point the pt is already decompensating.  we are taught to place pts with signs/symptoms of shock into TP.  i was curious how you would explain the reasoning for not following your protocols in court when a pt dies. somehow i dont think "well there are some studies that show it may not help" will pass.  or maybe it would.  it just seems to me like you could get in a lot of legal trouble by not following protocols backed by lots of lawyers and medical professionals


-Jeff


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## MSDeltaFlt (Jan 9, 2008)

Since we're talking about MAP's and ICP's, we're actually discussing Cerebral Perfusion Pressure (CPP).  The Americal College of Surgeons teach in ATLS, PHTLS, and BTLS that the CPP=MAP-ICP.  You need at least a CPP = 60mmHg to perfuse the brain.  Even a transient decrease is dangerous.  So, no Trendelenburg.  You don't even stand on the breaks while enroute to the hospital.

Here's the reasoning (yes, we may have gotten off track, but here we go):

The pt in the scenario has a BP of 100/60.  That gives us a MAP of 73.  Normal ICP is 0-10.  If your pt has a decrease in LOC with a drop in GCS of 2 or more points, you can easily have an ICP of 15-20 (this is a safe assumption since we don't place ICP monitors in the field).

Let's bring that formula back in.  CPP=MAP-ICP.  CPP=73-15=58.  CPP=73-20=53.  Even a transient decrease is dangerous.  This means that the risk increased that our poor pt will be doing good, if he survives the stabbing, to relearn how to tie his shoes; let alone go to the bathroom by himself.

Food for thought.  Stay safe.


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## Flight-LP (Jan 9, 2008)

IAmJeff said:


> it is my understanding that you are also supposed to treat for shock based on MOI.  the pt is also exhibiting some early signs of shock with skin that is cool to the touch.  isnt a drop in BP a very late sign of shock and at that point the pt is already decompensating.  we are taught to place pts with signs/symptoms of shock into TP.  i was curious how you would explain the reasoning for not following your protocols in court when a pt dies. somehow i dont think "well there are some studies that show it may not help" will pass.  or maybe it would.  it just seems to me like you could get in a lot of legal trouble by not following protocols backed by lots of lawyers and medical professionals
> 
> 
> -Jeff



The key here is having an actual understanding of WHY this occuring in a patient, not "this is what we are taught and what the protocols say". This is why EMT-B's are ineffective on a 911 ambulance, because they do not understand the concept, they just go off of what they are told. As others have stated, Trendelenburg does not work and will cause an increase in ICP. Think of basic physics, namely Newton's laws. An object (blood, air, any organ of mass, etc.) once in motion will remain in motion and follow the path of least resistance. Simply put, everything at the bottom of the patient will move up towards the head. The head is now supporting all of the weight from that mass. Don't you think that will increase some pressure on or in the head? That is 6th grade science stuff, if it still isn't understood, then you need to step away from EMS.....................

You shouldn't care what a piece of paper says. Don't be a cookbook EMT, do what is right for your patient and understand why it was right................. 



			
				VentMedic said:
			
		

> Trendelenburg and an unsecured airway can also present problems. Even with a tube it can present problems



Great point................



			
				MSDeltaFlt said:
			
		

> Since we're talking about MAP's and ICP's, we're actually discussing Cerebral Perfusion Pressure (CPP). The Americal College of Surgeons teach in ATLS, PHTLS, and BTLS that the CPP=MAP-ICP. You need at least a CPP = 60mmHg to perfuse the brain. Even a transient decrease is dangerous. So, no Trendelenburg. You don't even stand on the breaks while enroute to the hospital.
> 
> Here's the reasoning (yes, we may have gotten off track, but here we go):
> 
> ...



Awesome response! You probably lost a couple of people, but this good info to remember........


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## JPINFV (Jan 9, 2008)

IAmJeff said:


> it is my understanding that you are also supposed to treat for shock based on MOI.  the pt is also exhibiting some early signs of shock with skin that is cool to the touch.  isnt a drop in BP a very late sign of shock and at that point the pt is already decompensating.  we are taught to place pts with signs/symptoms of shock into TP.  i was curious how you would explain the reasoning for not following your protocols in court when a pt dies. somehow i dont think "well there are some studies that show it may not help" will pass.  or maybe it would.  it just seems to me like you could get in a lot of legal trouble by not following protocols backed by lots of lawyers and medical professionals
> 
> 
> -Jeff



Well, I think you're assuming a lot by assuming a lot. 

First, Trendelenburg is not in everyone's shock protocol. (Linky: http://www.ochealthinfo.com/docs/medical/ems/treatment_guidelines/t05.pdf  Yes, it is the paramedic protocol, but, technically speaking, Orange County, CA doesn't have a written protocol for EMT-Basics to follow. If you need a protocol to tell you when you need to put a patient on oxygen then you probably shouldn't be on an ambulance in the first place). 

Second, your assuming that a patient's blood pressure in a traumatic injury is supposed to be kept at 120. Let me ask you a question, which of the following is worse. Dumping a patient's hemocrit or hypoprofusion? Furthermore, along those lines, higher blood pressures can interfere with a patient's body's ability to control their own bleeding. Sure, it might not save them in the long run, but all the body has to do is survive till it reaches an operating room.

Third, while arguable geared more for paramedics than basics, you're assuming that protocols are a cookbook. (ex, Riverside, CA ALS protocol. First sentence: http://www.rivcoems.org/downloads/downloads_documents/Protocol102904/7000.pdf) A fairly large number of service's protocols start off with a statement that goes along the lines of calling treatment protocols a guide, not a recipe.


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## iamjeff171 (Jan 9, 2008)

first i will have to apologize for being a lowly emt student (last time i checked, this was the BLS forum)...

is it standard to tell ppl who question you to get out of ems and compare them to 6th graders???

If you read carefully, my post never doubted the ineffectiveness of trendelenburg or its effects on ICP.  they taught me a good deal about newtons laws in engineering school, and i agree it is pretty basic.  if im not mistaken trendelenburg is supposed to help compensate for shock based on these same principles; but that is beside the point and i understand studies show this doesnt actually help shock.  I never once stated that his BP was a concern at the moment.  My questions pertained to the legal aspect of being a basic and not performing an intervention (one of the few basics have at our disposal for shock) on a patient that fits the criteria.  This is all based on the national registry, and i understand that different areas may not have trendelenburg in their protocols.  my particular area does have it tho, as do many others i am sure.

i'll rephrase my question: lets say there is no als available.  lets say you dont put this pt in TP, but you package, give him O2, control bleeding and transport/reassess. well, on the way to the ED the pt goes hypotensive and eventually dies.  well now the family is unhappy and decided to sue.  would an emt-b really have any leg to stand on legally for not performing an intervention on a pt that had no contraindications to it?  i definitely dont advocate or want to be a "cookbook EMT", and this is a serious question about the legal aspects.  hopefully someone will try to answer it without the flames.  or maybe i should just quit asking questions and get out now 

-Jeff


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## MSDeltaFlt (Jan 9, 2008)

If you follow your protocols, then you have nothing to worry about.  Someone could sue you all day long, but they won't get very far.


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## Ridryder911 (Jan 9, 2008)

The good thing about Basic is that since it is simplistic there is very little litigation against them except the inability to recognize wounds & injuries, and movement and transfer of patients. 

The more you know the more they sue... 

As well, don't just bank on protocols to C.Y.A. mine have always included ..."_ discretion and judgement of the Paramedic"..._ I personally will not work for one that has step by step procedures and direction. Protocols should be for guidance and suggestions only...

R/r 911


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## Vanatta67 (Jan 10, 2008)

ABC then immediate life threats.


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## JPINFV (Jan 10, 2008)

Vanatta67 said:


> ABC then immediate life threats.



Ok, this thread was on it's third page and has expanded into a side conversation regarding patient positioning and protocol issues. Even if your post was on page one, a generic answer like this does absolutely nothing to answer the original poster's question. Hell, "ABC then immediate life threats" is more generic than the answer for most medical scenarios in EMT-B classes (high flow O2, position of comfort, call paramedics, immediate transport).


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## Vanatta67 (Jan 10, 2008)

JPINFV said:


> Ok, this thread was on it's third page and has expanded into a side conversation regarding patient positioning and protocol issues. Even if your post was on page one, a generic answer like this does absolutely nothing to answer the original poster's question. Hell, "ABC then immediate life threats" is more generic than the answer for most medical scenarios in EMT-B classes (high flow O2, position of comfort, call paramedics, immediate transport).



Was just posting but by the way nice job being a ****


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## byun01 (Jan 10, 2008)

I am going to have to disagree with a few of the people's responses, respectfully.  As a former medic and currently a medical student, this "patient" who got stabbed will need surgery.  Contrary to popular belief, a medic will do very little in helping this patient, besides an IV.  An EMT-B's responsibility is to respond, package, and transport. ALS if available should be called for and intercepted.  Nevertheless, you should never wait on scene for this type of patient.  He or she needs a surgeon's knife, not a paramedic's IV.


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## Vanatta67 (Jan 10, 2008)

The golden hour!


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## Flight-LP (Jan 10, 2008)

The "golden hour" is a myth.




















I figured since we are now keeping posts under 10 words, that this would sum it up. What do y'all think?


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## Ridryder911 (Jan 11, 2008)

byun01 said:


> I am going to have to disagree with a few of the people's responses, respectfully.  As a former medic and currently a medical student, this "patient" who got stabbed will need surgery.  Contrary to popular belief, a medic will do very little in helping this patient, besides an IV.  *An EMT-B's responsibility is to respond, package, and transport.* ALS if available should be called for and intercepted.  Nevertheless, you should never wait on scene for this type of patient.  He or she needs a surgeon's knife, not a paramedic's IV.



Unfortunately, we have BLS services, and within that BLS EMT's.  As well, IV's (alone) have never been proven to be beneficial for most trauma cases prehospital or even in a ER. Rather, as you described trauma is a surgical disease. 

Fluid resuscitation has been demonstrated not to be effective, however; there is reasons for Paramedic care. In-depth assessment and clinical diagnosis to treat possible underlying cause, to recognize other potential and associated injuries on trauma (i.e. tension pneumo) and securement of airway with utilization of RSI as in TBI and those with increasing ICP. So in realistic and accurate treatment modality it is not the IV that is main reason the Paramedic is needed. It is the treatment that can be performed, by having that IV is why ALS is needed. 

R/r 911


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## EMTMandy (Jan 11, 2008)

Ridryder911 said:


> Before it became too deep (since it is on a basic level) I was going to suggest to  perform a better assessment, while enroute. Pressure systolic of 100 and really a mild tachycardia of 120's, I would be looking for another underlying cause of unresponsiveness. Since it does not appear to be compensated, at the time.



Yes...before this thread turned into the true monster of all monster threads (in which case, I should have been here before the wandering and insults DAYS ago haha) I'd like to take a minute to stress the importance of further assessment.  Aside from obviously securing the airway, visible bleeding control and C-spine precautions for Thispatient, I'm a strong believer in Every patient getting at least a Primary assessment (which takes little to no time at all) and in this case, preferrably a rapid (RAPID) trauma assessment on scene before packaging. as Ridryder911 said, conducting a more thorough one en route after the rondezvous with necessary help is also a great idea.  There could be in fact a Major underlying cause that would otherwise be stepped over if nothing else.

also-

To quote *CERTGUY* 
"Has anyone thought to check for exit wounds ?"

Or any other serious wounds?

Back to the murky details of the ORIGINAL post...which seems miles away and buried from mine...

It never stated whether the patient was bleeding profusly from the visible wound or not. It also never stated the weather conditions.  this may seem like a far reach but suppose it was cold outside so the bleeding was controlled until in the back of the rig. patient starts to warm up and bleed out not only from the visible wound, but an exit wound or any others that were missed. 

As a very wise instructor of mine has always said--

"More is missed by not seeing than by not knowing"


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## MSDeltaFlt (Jan 11, 2008)

Threads evolve.


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## EMTMandy (Jan 11, 2008)

I am aware of that.


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## TKO (Jan 12, 2008)

ironguy321 said:


> You have a 25 year old male who is unresponsive. No medical history, medication bottles., bystanders, bracelets, etc. around; just a dark alley and an unresponsive man. He has a stab wound to his upper right abdomen. Vitals are respirations 8 shallow, Blood pressure is 100/60, pulse is 126 rapid, skin is cool.
> 
> What would you do in this situation?



Well, the idea that he is tachycardic but bradypneic is a little baffling, but hey, medicine is like that, right?

So anyway, my answer would be (in likely order of findings):

test LOC. > partner on C-SPINE.
A.B.C. > Skin & O2 > grab sandbags from unit > OPA and BVM to partner.
RBS > find puncture (or knife?) in RUQ > radio for immediate police backup > clean wound with sterile H20 or N/S and dress.
Cervical collar > package pt on clamshell or spineboard (full immobilization) > load into bus.
Partner continues bagging > check LOC, ABC > perform Vitals > check treatment > place pillow under lower legs > prime a bag> take over bagging and go.


If BP was less than 90 I would start an IV, but I wouldn't delay at the scene for one unless the pt was hypovolemic.  I'd just prime a bag instead, only takes a couple of seconds and is ready for me if I need to start a line enroute.  My main consideration for the moment is supporting respirations.  Once resps and HR both go brady, then cardiac arrest is imminent.

I immobilize because there is no history, as should everyone else; if you don't know what happened to a pt, then you don't know for certain that they don't have a spinal injury.  I think people are too lax on that point too, forgetting that we don't look for reasons to spinal trauma pts, we look for reasons not to.

I also raise the legs in the bus because it is more comfortable for a pt with an abdominal injury if for no other reason, but shock considerations are good reasons too.


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## TKO (Jan 12, 2008)

I just replied to the original question, I didn't read the other posts past the first page really.  I hadn't heard the new studies on the TP.  I never really bother with the TP anyway, I've always regarded it like the PASG/MAST (shock pants) -- bothersome and obtrusive.  BUT a pillow under the knees is such a small change that it really won't affect any numbers, but can make the pt that much more comfortable (should they come around).

Like others have said, this is a load & go situation.  A good assessment must be done; I don't know what an RBS is like in the US but we pretty much perform a head-to-toe in just under 90 seconds here up north.  We really just don't perform any neuro/C.M.S and injury specific tests as we would with the head-to-toe exam.  The RBS should visually examine the whole body, look for any of the deadly dozen, pertinent findings, blood loss, pain with palpation, etc.  The whole DCAP-BLS-TIC in 90 seconds.

Like I said, I don't know how it is done in the US.  I remember back in the day when people used to just look and feel for DCAP-BTLS and for blood, but then we changed our standards and created different paramedic licenses.  The US EMT-B is our EMR (a fulltime 12 day course).  

Gotta go!  Gotta call!


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## EMTMandy (Jan 13, 2008)

TKO said:


> test LOC. > partner on C-SPINE.
> A.B.C. > Skin & O2 > grab sandbags from unit > OPA and BVM to partner.
> RBS > find puncture (or knife?) in RUQ > radio for immediate police backup > clean wound with sterile H20 or N/S and dress.



So how would you maintain this patients cervical spine if there was only two of you? I'm assuming your partner hold it with his/her knees while bagging? 



TKO said:


> I immobilize because there is no history, as should everyone else; if you don't know what happened to a pt, then you don't know for certain that they don't have a spinal injury.  I think people are too lax on that point too, forgetting that we don't look for reasons to spinal trauma pts, we look for reasons not to.



Well said.  I'd say if it can be helped with ABC concerns etc., which shouldnt be a problem Patients such as these should absolutely 100% of the time should have c-spine precautions taken.  no questions asked.  I can personally say it would suck to be kept alive because someone kept a patent airway on me, but I was paralyzed because they didn't take c-spine precautions. what kind of life would that be?


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## JPINFV (Jan 13, 2008)

IAmJeff said:


> first i will have to apologize for being a lowly emt student (last time i checked, this was the BLS forum)...



Science doesn't stop with "ALS" (ALS/BLS distinction is only found in EMS. Elsewhere it is just called "patient care"). Afterall, my EMS education is currently sitting on the EMT-Basic level, but that doesn't stop me from trying to become as educated as possible about the effectiveness of the interventions that I can do. The problem is that medicine changes as more information is produced. Unfortunately, I remember the information in my basic class being taught as if it were scripture and was never going to change.




> is it standard to tell ppl who question you to get out of ems and compare them to 6th graders???


 Well, the EMT-Basic course work and science content is consistant with what people learn in middle school. The vast majority of interventions are taught to boy scouts every year (bleed control, splinting, etc). So, comparing people who think that they need a written protocol for when to give oxygen and when to splint is sadly appropriate. This is not brain surgery, but unfortunately EMT-Basic courses do a really poor job on preparing students to take care of patients.


> If you read carefully, my post never doubted the ineffectiveness of trendelenburg or its effects on ICP.


So, if you doubt the effectiveness of a treatment, why would you use that treatment? 


> they taught me a good deal about newtons laws in engineering school, and i agree it is pretty basic.  if im not mistaken trendelenburg is supposed to help compensate for shock based on these same principles; but that is beside the point and i understand studies show this doesnt actually help shock.  I never once stated that his BP was a concern at the moment.  My questions pertained to the legal aspect of being a basic and not performing an intervention (one of the few basics have at our disposal for shock) on a patient that fits the criteria.


As stated above, not all locations have trendelenburg in it's treatment protocol, as well as most protocols state that they are a guideline, not a cookbook. 



> This is all based on the national registry,


National Registry is a testing agency. Different states may decide to defer their certification tests to the National Registry, but NREMT doesn't set treatment policies. 


> and i understand that different areas may not have trendelenburg in their protocols.  my particular area does have it tho, as do many others i am sure.
> 
> i'll rephrase my question: lets say there is no als available.  lets say you dont put this pt in TP, but you package, give him O2, control bleeding and transport/reassess. well, on the way to the ED the pt goes hypotensive and eventually dies.


Trendelenburg would not have stopped this anyways.



> well now the family is unhappy and decided to sue.  would an emt-b really have any leg to stand on legally for not performing an intervention on a pt that had no contraindications to it?  i definitely dont advocate or want to be a "cookbook EMT", and this is a serious question about the legal aspects.  hopefully someone will try to answer it without the flames.  or maybe i should just quit asking questions and get out now
> 
> -Jeff



They should have the same defence that any other medical provider has when there is no evidence that an intervention works. Science.


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## TKO (Jan 13, 2008)

EMTMandy said:


> So how would you maintain this patients cervical spine if there was only two of you? I'm assuming your partner hold it with his/her knees while bagging?



That's where the sandbags come in.  To elaborate, after assessing the ABCs and knowing that an airway is necessary, I would place an OPA (suction PRN) and assuming that the bus is right behind me in that alley, I would jump up and grab the sandbags from the outer compartment.  Then I would take over C-Spine so my partner could place the sandbags beside the head.  Then my partner is free to take over ABCs on their own (with the OPA in and head stabilized, no further need for modified jaw thrust).

All of this assumes that we are the only ones on scene.


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## EMTMandy (Jan 13, 2008)

TKO said:


> That's where the sandbags come in.  To elaborate, after assessing the ABCs and knowing that an airway is necessary, I would place an OPA (suction PRN) and assuming that the bus is right behind me in that alley, I would jump up and grab the sandbags from the outer compartment.  Then I would take over C-Spine so my partner could place the sandbags beside the head.  Then my partner is free to take over ABCs on their own (with the OPA in and head stabilized, no further need for modified jaw thrust).
> 
> All of this assumes that we are the only ones on scene.




Never heard of using sandbags before. that's nifty B)


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## TKO (Jan 13, 2008)

yeah, didn't do it until I got to the province of British Columbia, but you know, if the pt is UnCx, then why not?  As long as someone is always near the head until the pt has a collar on, having your hands free just makes sense.

Our sandbags are these small blue cylinder bags that can carry sand or even N/S bags with stuffing in them.  They work very well, infact, we use them on the clamshell with the collar and some tape for immobilization.  They don't move and are pretty moldable.


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