# ALS Scenario



## Ridryder911 (Dec 6, 2006)

True Call.. Last October. 

0035 After a hot day, you and your partner are dispatched to a residential area for chest pain, just outside the outskirts of town. Partly rural, partly urban area. You & your partner are aggravated over several things. 1)that this is not in your district 2) It is 0035 and you have been on shift since 0700 without any rest so far... 3) You are level 0 (no other available EMS units for other calls 4) F.D is not responding because it is after 2300 (they only respond to MVC's etc. & other calls if requested) 

As you drive down an old highway... searching for county numbers (which most are not posted) you finally approach the general location. You enter a long drive way, which is over grown with tall grass and abandoned cars, farm machinery etc.. There are overgrown trees hanging down and you barely can make the outline of the house, with no lights and it is a moonless night. You catch in the corner of your eye an outline of man sitting down outside smoking a cigarette.

You notify dispatch of arrival at scene and the eery situation. You and your partner look at each other with that same look of oh.. feces!.. The hair on your neck raises up.. you notify LEO and the nearest officer is about 20 minutes away. You contact Field Supervisor and advise of situation. He inquires if you will be transporting ?(since you are at level 0) and with aggravation you re-abreast the situation and he advises to use judgement & handle with caution. 

You instruct your partner to turn the unit around slightly facing the driveway, so you will have reflected light, but not projecting an outline of yourself as you exit the unit. 

Okay, now what ?


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## jeepmedic (Dec 6, 2006)

If I do not feel safe I will back out an wait for LEO. Scene Safety for myself and my partner comes first. 

Now next thing I would do is LIGHT UP THE WORLD. I have spot lights and hand lights on the truck. I would use them to my advantage. But I would not use the scene lights yet. But like I said to begin with I would back out and wait for LEO. This would be my best point of action.


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## trauma1534 (Dec 6, 2006)

Well... I kind of can't help but ask why a non-certified crew is responding.  Can you explain more on this one?  Was there anything certified onboard?


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## Ridryder911 (Dec 6, 2006)

Both EMS personal are Critical Care Paramedics. .. 

After a quick discussion, and a few spot light into the area, no dangers were noted. There appears only to be a single person sitting in a tripod position... asked if he was the patient, he informed he was having chest pain and he felt he could breathe better outside. 

R/r 911


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## Firechic (Dec 6, 2006)

I would also inform him that he would probably breathe better without the cigarette in his mouth!


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## Ridryder911 (Dec 6, 2006)

As you carefully approach the figure, you see a mid 50's male. You can smell odor of "old" alcohol (the type chronic alcoholics have), and ask him to extinguish his cigarette & he complies. You ask him again ..What is going on".. he tells you."I started having chest pain, tonight".. You noticed his voice being hoarse and it is very difficult to understand him. He is very disheveled in appearance, and strong body odor.

Since you were being careful, you only took your kit with you and your partner now goes to retrieve the stretcher & oxygen. The patient is attempting to walk which you inform him to stop, (You note that his gait is unsteady as well).

He mumbles that it started tonight, and you cannot understand him. It appears, talking makes him short of breath.. he points to his chest sternal; when asked where he hurts the most. 

R/r 911


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## trauma1534 (Dec 7, 2006)

Ridryder911 said:


> As you carefully approach the figure, you see a mid 50's male. You can smell odor of "old" alcohol (the type chronic alcoholics have), and ask him to extinguish his cigarette & he complies. You ask him again ..What is going on".. he tells you."I started having chest pain, tonight".. You noticed his voice being hoarse and it is very difficult to understand him. He is very disheveled in appearance, and strong body odor.
> 
> Since you were being careful, you only took your kit with you and your partner now goes to retrieve the stretcher & oxygen. The patient is attempting to walk which you inform him to stop, (You note that his gait is unsteady as well).
> 
> He mumbles that it started tonight, and you cannot understand him. It appears, talking makes him short of breath.. he points to his chest sternal; when asked where he hurts the most. R/r 911



Is the pain radiating anywhere else?  What are his lung sounds?  Is there any pitting edema present?  What about his O2 sats or CO2 Level?  What is the monitor showing?  Does nausea/vomiting accompany his symptoms?  We need to establish if this chest pain is secondary to dyspnea, or if the dyspnea is secondary to the chest pain.  What is the quality of the pain?  Is it a sharp, dull, crushing, pressure feeling?  What does he discribe?  What is his skin like?  Is he on any meds?  Allergies?  What was he doing before the pain started?  What kind of vitals do you have so far?  After this info is given, I'll take a shot at this.


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## Ridryder911 (Dec 7, 2006)

You load the patient onto the stretcher, and as he attempting to speak it appears his tongue is extremely swollen. There is leaves & debris on the back of his shirt and note small abrasion and very minor skin tears on his left forearm. 

You ask him if he had fallen, or recent trauma, recent "stings" or "medications" or potential allergens.. in which he denies. Attempts to describe, that he has only had chest pain.. described as substernal and non-radiating. His face appears swollen as well... V.S. 134/90 P-112, R/r 16 Sp02 96%.. ECG- Sinus Tach without ectopi..

No previous PMHX, NKDA, no med.'s, obviously a smoker & ETOH

After applying oxygen, your partner is preparing to establish a saline lock.. 

R/r 911


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## trauma1534 (Dec 7, 2006)

ridryder 911 said:


> You load the patient onto the stretcher, and as he attempting to speak it appears his tongue is extremely swollen. There is leaves & debris on the back of his shirt and note small abrasion and very minor skin tears on his left forearm.
> 
> You ask him if he had fallen, or recent trauma, recent "stings" or "medications" or potential allergens.. in which he denies. Attempts to describe, that he has only had chest pain.. described as substernal and non-radiating. His face appears swollen as well... V.S. 134/90 P-112, R/r 16 Sp02 96%.. ECG- Sinus Tach without ectopi..
> 
> ...



Well... I'm not concerned about the abrasions at this point.  Saline lock Hell... hang a bag of saline, KVO.  Sounds to me like a weird anaphalaxis.  Ok... his toungue is swollen and his face too.  We need to get some Benadryl on baord, see what that does.  I would start with 25mg, IV.  I still don't know what his lung sounds are like, but I would suspect that there is some upper airway wheezing, more in the trachea area, taking place.  Depending on how bad he is wheezing with this, I would possably administer 2.5 Albuterol, via Neb.  If condition is not improving rapidly enough with this treatment, I would give the other 25 of Benadryl IM, and break out some Epi 1:1000.  We need to get on top of this before the airway get's anymore compromised, toungue is swelling already, no time to play.  So if we can reverse it fast enough, we are ok.  I think his chest pain is secondary to the dyspnea, associated with an anaphilactic reaction to something.  Am I close on this?  Give me more information.


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## jeepmedic (Dec 7, 2006)

What hit him in the chest? Is this a Drug Lab? Did he get toxic overdose while "cooking" his Drugs? Did his Lab blow up? Does he have S&S of burns to the face? If so Secure the Airway, (RSI or MAI) Transport to Trauma/Burn Center.


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## DT4EMS (Dec 7, 2006)

What were the events just prior to him calling? Was he able to answer if anyone else was in the house?

Is he a true poor hisrotian or do I believe there is more than he is willing to tell. ABC's are still promary concern. Did a secondary reveal anything (while applying EKG electrodes, placing O2 etc.)

Tongue may also be swollen secondary to something he ingested. What do I hear if I auscultate over the trachea?


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## Ridryder911 (Dec 7, 2006)

After more assessment and attempting to gather more information, you see the face is swelling more and more. Subglottic swelling is occurring rapidly, patient still immently denies any trauma.. stings.. No erythematous discoloration, papillary rash, or urticaria is not noted.. 

Within less of two minutes of loading the patient, your partner informs you this patients hand is severely swollen and upon palpation you notice this to be subcutaneous emphysema. You immediate open his shirt, and now notice within the past 30 seconds large amount of sub-q emphysema from neck down caudilly. Throat area is now palpable with sub-q emphysema and appears to be swelling by the second.. Head: Normal cephalic, slightly rubor in appearance. Sub-q in facial area. PEARLA, EOM's intact, sclera, icterus, wnl . Facial Symmetry, oral cavity tongue now approximately double size of normal tongue. Absent of adventatious sounds in tracheal area, and absent of carotid bruits and clicks, whistles and absent of thrill.  

Chest reveals symmetrical chest wall movement, absent bruising echymoses, denies pain upon palpation of chest wall (anterior & posterior) Lung sounds are shallow in lower lobes bi-laterally with scant expiratory wheezes, but are present respectfully. Patient has a oxygen saturation of 96% with EtCo2 of 35mm/hg. Patient continues to deny S.O.B. only sub-sternal chest pain.

Abdomen -slightly, palpable liver outline noted, other wise unremarkable

Extremities: Moves all extrememities well, there is sub-q in right hand to middle forearm, absent rashes, uticaria, grade +2 pulses, and there is clubbing noted.  Left forearm has two to three superficial skin tears, and abrasions with minimal bleeding

Lower extr.- unremarkable 

XII Lead reveals Sinus tachycardia without ectopi, no axis deviation or ST changes. 

IV is established successfully. 

Again, patient is questioned about trauma, coughing.. patient denies. Patient is able to describe pain as "pressure" in center of chest, still denies S.O.B. 

ER is approximately 5 miles away....
R/r 911


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## trauma1534 (Dec 7, 2006)

Ridryder911 said:


> After more assessment and attempting to gather more information, you see the face is swelling more and more. Subglottic swelling is occurring rapidly, patient still immently denies any trauma.. stings.. No erythematous discoloration, papillary rash, or urticaria is not noted..
> 
> Within less of two minutes of loading the patient, your partner informs you this patients hand is severely swollen and upon palpation you notice this to be subcutaneous emphysema. You immediate open his shirt, and now notice within the past 30 seconds large amount of sub-q emphysema from neck down caudilly. Throat area is now palpable with sub-q emphysema and appears to be swelling by the second.. Head: Normal cephalic, slightly rubor in appearance. Sub-q in facial area. PEARLA, EOM's intact, sclera, icterus, wnl . Facial Symmetry, oral cavity tongue now approximately double size of normal tongue. Absent of adventatious sounds in tracheal area, and absent of carotid bruits and clicks, whistles and absent of thrill.
> 
> ...



Well, if the ER is only 5 min. away, let's rapid transport.  Throw the O2 to him. Still wondering about the toungue swelling.  Makes me think still there is some sort of alergic reaction.  Lets keep the fluids flowing, and ge him to the ER.  Let's just watch this airway.  This is a strange one.  Is there any treachea diviation?  Let's just get him out of my truck and into the ER.  Maybe someone else will have more ideas.  I would call the ER and talk to the doc and see what he wants.  By the time I could play with this guy, I would have him there.  So let's not waste any time.  Sounds like we might be facing an airway compromise.  It's hard to say how we should handle this without looking at this patient.  I want to also lean toward there infact was some sort of trauma... he's not telling us the whole story.  What was the outcome?  I always treat by looking at my patient.  This is a hard one.  Still want to say allergy related though, that's my gut feeling.  ?????  He definatly has several things going on.


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## DT4EMS (Dec 7, 2006)

The Sub-Q emphysema all the way to the hand in a new one on me..........

I am almost starting to take the path of some sort of tracheal tear or him being an old school smoker.......

How are the lung sounds? Is it appearing we may want to start considering RSI to protect his airway? 

His airway is my primary concern right now. The 12 Lead being unremarkable he could still be having an NSTEMI but either way........if in 2 minutes the swelling has changed that much.............airway is #1.

His chest pain may be secondary to the same problem causing the sub-q emphysema. 

Could it have been a tumor he didnt' know about that tore the trachea somewhere?


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## trauma1534 (Dec 8, 2006)

DT4EMS said:


> The Sub-Q emphysema all the way to the hand in a new one on me..........
> 
> I am almost starting to take the path of some sort of tracheal tear or him being an old school smoker.......
> 
> ...



Ok... I agree with the RSI.  We need to get ahead of it.  Don't let that airway shut off, however, let's not waste too much time playing at the scene.  Remember the hospital is only 5 min. away... but I do agree that we need to stay on top of this airway!!!


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## jeepmedic (Dec 8, 2006)

Swelling of the Tongue, Sub-Q emphysema, and chest pain. Add to that the unwillingness to alow you to enter the house.  Drug Lab, or some other illegal activity. Truama to the chest and facial area.  Maintain Airway, notify Burn Center. X-Port. Oh buy the way this Pt. needs coupious amounts of Diesel Therpy.


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## FFEMT1764 (Dec 8, 2006)

If its a tracheal tear then intubation may be harder than you think, espicially if when you look down there and get a spray of blood from the tear, of course he could also have some wierd pnuemothorax from something he wont tell you about. I would load and go, IV is nice and all, but airway seems to be a culprit...does he smell like anything other than the cigs and stale booze?? Who knows, this old guy could have had his still blow up on him.


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## Ridryder911 (Dec 8, 2006)

We agreed after establishing IV, oxygen levels beginning dropping to start transport (scene time <5 min) lung sounds still present however becoming decreased bi-laterally.. withing 1 minute sub-q is now increased subglottic that trachea now can not be palpated, the tongue appears to be "pushed up" by the swelling and facial sub-q is now increasing so much peri-orbital, eyes are closing... chest wall as well is becoming full of sub-q... oxygen level is now 90% ...no significant changes in ECG and vital signs; ER is about 3 minutes. 

ER is abreast of the situation for preparedness of PCXR, thoracotomy tray and chest tube set up. 

In regards of RSI, this was discussed, but not performed due to the severity of the swelling of the sub-glottic area. Although intubation was knowingly to be accomplished, this was going to be an airway from hell... and personally did not want to start to have to crich..... 

Ironically, the patient still denies shortness of breath and only complains of sternal chest pain...

R/r 91


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## DT4EMS (Dec 8, 2006)

Ridryder911 said:


> We agreed after establishing IV, oxygen levels beginning dropping to start transport (scene time <5 min) lung sounds still present however becoming decreased bi-laterally.. withing 1 minute sub-q is now increased subglottic that trachea now can not be palpated, the tongue appears to be "pushed up" by the swelling and facial sub-q is now increasing so much peri-orbital, eyes are closing... chest wall as well is becoming full of sub-q... oxygen level is now 90% ...no significant changes in ECG and vital signs; ER is about 3 minutes.
> 
> ER is abreast of the situation for preparedness of PCXR, thoracotomy tray and chest tube set up.
> 
> ...



What caused the sub-q emphysema?


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## Ridryder911 (Dec 8, 2006)

With about a minute, out I decided to decompress the right lung. Using a 3" needle I was unable to reach muscle tissue or even rib due tothe depth of sub-q. 

Arriving into ER I was only met by the nursing staff... I went into the fishbowl (ER Doc office) and informed them.. (unfortunately, the staff only reported swelling of arm) respectfully, both ER docs immediately went to assess the patient. 

They too were perplexed.. an immediate PCXR was performed, while RSI equipment was prepared. The patient was still alert.. and attempting to tell us about his "chest pain". I was instructed to attempt to decompress the right side with a "spinal needle" until x-rays were returned. 

I anesthetized with lido and was able to decompress with immediate return of air... again, lung sounds verified by physicians.. becoming distant but audible. 

X-ray revealed right clavicular fxr and rib fxr's of 1,2 and 3.. with only about a 30% pneumothorax on the right side.

Patient was RSI and severe difficulties were encountered and a tracheotomy had to be performed. Chest tube was inserted with approximately 300 ml of blood and sangeous fluid return. Patient was placed ventilator and continuous sedation. Central line placement was placed in the right femoral with a triple lumen. Sub-cutaneous emphysema was even beginning to be noted to occur in the scrotal area. 

Due to the suspicious nature and unknown etiology a CT of head, chest  & abdomen was performed 

It was at this time another pneumothorax was detected by the radiologist on the left side while in the ICU and another chest tube was placed. 

We had to respond to another call .. and later returned to checked on him. 

He was later weaned off the ventilator and it was determined that he apparently had become intoxicated and fell outside striking unknown object and passing out?... later to only awaken with the chest pain. 

After four days off ventilator patient acutely became worse, placed back on ventilator and developed ARDS. The patient subsequently later died due to respiratory complications of pneumonia/ARDS about a week later. 

I felt this call was unique for several reasons:

Patient chief complaint NEVER met with injuries, symptoms, history of events or even etiology.

There was no significant external clues that would indicate underlying injuries, bruising only started occurring approximately 3-4 hours after occurrence. 

My partner is a well educated and experienced Paramedic. We both agreed that we felt that was not much more that we could change or do on this call. This was one of the fastest most rapidly sub-q development I have ever seen. Within 5 minutes, sub-q had developed from isolated area to diffuse. Even in the ER sub-q had developed into the orbital area so much conjunctiva was exposed. 

We discussed maybe a faster decompression or could had occurred, but with bi-lateral lung sounds it was difficult to determine which was the affected side (albeit it turned out to be bi-lateral). We both agreed it would had not been productive to enter ER with bi-lateral decompression with unsure knowing of which was the true affected side. The reason I mad the right was due to the inital sub-q on the right side.

As well if we were further from hospital we would had to attempted RSI, but both of us agree that we were glad it was not us that had performed RSI. Seeing the difficulty that occurred is something we were glad that we avoided.

Like I always say .. "one learns something every day ".........

R/r 911


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## DT4EMS (Dec 8, 2006)

Great call Rid!! Thanks for sharing. This is one of those "Who'd a thunk it" kinda runs. SOme of the ones we would never hear about.


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## trauma1534 (Dec 8, 2006)

Ridryder911 said:


> With about a minute, out I decided to decompress the right lung. Using a 3" needle I was unable to reach muscle tissue or even rib due tothe depth of sub-q.
> 
> Arriving into ER I was only met by the nursing staff... I went into the fishbowl (ER Doc office) and informed them.. (unfortunately, the staff only reported swelling of arm) respectfully, both ER docs immediately went to assess the patient.
> 
> ...




Very interesting call Ridryder!!!  Thank you for sharing this with us.  This is why I say look at your patient before you automaticly assume a treatment plan.  It's hard for anyone to take a shot at a call like this, just by hearing the signs and symptoms of whatever.  It was obvious that his airway was in trouble.  It all just didn't match up!  The sad part is, we will face calls like this from time to time (meaning, calls that we are just puzzled by).  

Keep them comming.  These are real learning threads.  Thanks again!


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## jeepmedic (Dec 8, 2006)

Well I was half right. There was some Trauma. 

Good Scenario their Ridryder


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