# Practice scenario help



## heatherabel3 (Jul 27, 2012)

This scenario was in a study guide I'm doing and I don't understand why the answer is what it is so was hoping you guys could help me out. 

Male patient is suffering from a suspected abdominal aortic aneurysm. 30 minutes away from the hospital he begins to deteriorate. Would you A) continue transport and alert the receiving hospital or B) consider requesting a rendezvous with ALS? Why?

I'll tell you what I thought and why after a few of you answer.


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## STXmedic (Jul 27, 2012)

Continue on. If a AAA ruptures, there's not a damn thing a medic is going to do about it.


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## Handsome Robb (Jul 27, 2012)

PoeticInjustice said:


> Continue on. If a AAA ruptures, there's not a damn thing a medic is going to do about it.



What he said.  Maybe consider calling ahead to get a chopper ready for your arrival if the hospital isn't capable of the surgical intervention this guy needs. If that's the case his goose is pretty much cooked anyways.


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## heatherabel3 (Jul 27, 2012)

That is exactly what I thought. There is nothing a medic can do, the guy is bleeding to death. There are a ton of questions on this test prep thing that make no sense whatsoever.


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## NYMedic828 (Jul 27, 2012)

If you called me to inform me you need ALS for your patient with a suspected deteriorating aortic dissection, I would tell you drive faster.


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## PVC (Jul 27, 2012)

I suspect that the correct answer to the question is to call for ALS intercept.

Although it is true that you cannot extend the life of this patient in a pre-hospital setting and the ALS crew would not be able to do much more, in most systems Basic EMT's cannot make diagnostic decisions. 

Then again if your medical direction is at the hospital then they could advise as to the proper decision to make regarding this patient. 

I suppose that only the writer knows what the thought process is behind the question.


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## STXmedic (Jul 28, 2012)

PVC said:


> Although it is true that you cannot extend the life of this patient in a pre-hospital setting and the ALS crew would not be able to do much more, in most systems Basic EMT's cannot make diagnostic decisions.


Explain?


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## JPINFV (Jul 28, 2012)

PoeticInjustice said:


> Explain?




I'm thinking he's thinking along the lines of bypassing the closest for a specialty hospital. For example, since an EMT crew can't diagnose a STEMI, they have to take chest pains to the closest hospital whereas a paramedic crew can diagnose a STEMI, thus giving reason to bypass the closest hospital for a cardiac hospital.


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## PVC (Jul 28, 2012)

PoeticInjustice said:


> Explain?



In your area a Basic can independently decide that a patient has an AAA and make a 30 min transport decision without involving ALS or medical direction? I mean if they can that is really cool.

A basic would be able to tell that a patient is decompensating. I think more advanced skills would make for a "providing a best care possible". Considering that there are different degrees of arterial dissection, with varying degrees of arterial leakage an ALS intercept would be in order.

It seems that the delicate balance between fluid administration and not increasing the bleed is definitely a ALS skill. Considering that we want to keep the patient as calm as possible many would avoid lights and sirens. 

Also can a basic know that the patient is decompensating because of a blown aorta or is there some other condition that a basic is not prepared to find? Does this patien require IV fluids? Medication for pain? Sedation? RSI?

As a patient advocate I would call for ALS and give medical direction the operational decision for this patient.


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## heatherabel3 (Jul 28, 2012)

Thanks for the explanation. I understand better why you would meet with ALS. I still think it would make more sense if the hospital was an hour away vs 20 minutes. If you stop, by the time you have moved from one rig to the other, given the report, and them gone on their way you could be at the hospital. But like you said, I guess the difference is that basics wouldn't technically know if he was dissecting or not.


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## PVC (Jul 28, 2012)

heatherabel3 said:


> Thanks for the explanation. I understand better why you would meet with ALS. I still think it would make more sense if the hospital was an hour away vs 20 minutes. If you stop, by the time you have moved from one rig to the other, given the report, and them gone on their way you could be at the hospital. But like you said, I guess the difference is that basics wouldn't technically know if he was dissecting or not.



To be honest, I am not sure that anyone could "know" he was dissecting without an ultrasound. I do think ALS is better equipped for the differential diagnosis and appropriate interventions.

My fear would be for the patient to die in my care without having alerted ALS. I expect there would at least be an investigation and possibly a lawsuit that would end badly.


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## Anjel (Jul 28, 2012)

I would call medical control. And ask if they want us to intercept. 

I will leave that call to them, regardless if medics can do anything. At least the guy could be on a monitor and you could watch him decompensate better.


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## Handsome Robb (Jul 28, 2012)

I guess you can call for the intercept and let them know you are rolling hot the the hospital. 

Avoiding lights and sirens in this situation, in our society with their expectations, isn't an option. If they have a history of a triple A and are now showing signs of a rupture or thoracic dissection I can pretty much guarantee that you would catch flack for not going code 3 to the hospital. They always teach to not use RLS with a STEMI patient yet I have yet to find a system that doesn't transport STEMIs code 3. 

Sure ALS can watch them decompensate better with the monitor and possible give fluids, which I'd be very very hesitant to do in this situation, but the fact of the matter is if this guy codes prehospitally you aren't getting him back, I don't care if a doctor is in the back of the ambulance with you it's just not happening. 

I'd call for an ALS intercept, get an ETA and rendezvous set up then call medical control and see if they want you to pass off to the ALS crew, bypass their facility or just "get 'em here fast" or any combination of the above.


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## Aidey (Jul 28, 2012)

ALS may not be able to provide much treatment, but they can "prep" the patient better than BLS. Bilateral IV*s, airway control if necessary. This could result in shorter ED times and allow the patient to get to the OR faster. Similar to what can happen with stroke and cardiac activations. We will take some significant CVA patients straight to CT if we already have an IV and airway established.

*Not saying to dump in a few liters, just having 2 IVs in anticipation of the pt getting blood or going to the OR.


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## Handsome Robb (Jul 28, 2012)

Aidey said:


> ALS may not be able to provide much treatment, but they can "prep" the patient better than BLS. Bilateral IVs, airway control if necessary. This could result in shorter ED times and allow the patient to get to the OR faster. Similar to what can happen with stroke and cardiac activations. We will take some significant CVA patients straight to CT if we already have an IV and airway established.



You bring up a valid point. 

I don't think that way since all of our units are ALS, no BLS so we don't have to worry about intercepts.


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## Sublime (Jul 29, 2012)

While some good points were made, you guys are way over thinking this. For these exam questions you can't read too much in to them like that.

I'd be willing to put money on A. 

The pt. is having a AAA and needs a SURGEON not a paramedic, continue to the hospital.


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## bahnrokt (Jul 29, 2012)

The answer is B.  You can suspect AAA, but as a BLS crew your protocols likely dictate that a pt in or headed toward hypovolemic shock gets ALS.  

Deciding that the best care for your pt is to jump protocol and skip ALS is playing cowboy.  It's especially risky considering the high mortality rate of AAA patients and your decisions will go under the microscope.


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## Veneficus (Jul 29, 2012)

I'll take it even farther.

If this person has a ruptured TAA or AAA they are dead no matter who is sitting in the back with them.

Some of the best stats posted for ruptured AAA survival carry an 87% mortality rate after 30 days in the ICU.

The prehospital mortality of a ruptured TAA or AAA is 99%.

Giving fluids to it is not a viable solution. It is even suggested in surgical and anesthesia texts that no fluid is to be administered untill the surgical team is actually ready to cut.(then it should be blood products) Because the fluid actually causes harm by several mechanisms that any experienced clinician has observed in the real world.

Paralysis from spinal ischemia in the TAA is one of the more dreaded complications. (when there is insufficent collateral supply and the clamp shuts down blood flow to the artery of adamkiewicz (adam kay vich) which supplies the anterior spinal cord.) In these select cases, arterial bypass and shunting are part of the procedure to preserve neural function and take time. (which is not usually in great supply)

When there is an incomplete tear in the aorta, you will most likely find the patient is compensating. But when they crash, it will be fast and final. The goal in a rupture is either bypass or cross clamp and repair in 19 minutes or less from first incision. (neither procedure holds statistical advantage over the other)

Ruptured aneurysm is one of my pet projects. The treatments have changed twice since 1960. (the second time in 1985 and the outcomes were better in the 1960s by almost 10%)

In the scenario you were given, they want you to call for an ALS intercept. Not because it is the right thing to do. Not because ALS can help. Not because it is what anyone with a brain would actually do;

They want you to call because the cretin (who probably doesn't know much about aneurysms anyway) who wrote that scenario, wants to teach you that anytime you think the patient is in serious trouble, you should call for help not try to be The Lone Ranger.


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