# Lets try some scenarios..shall we



## piranah

ok... you come across an MVA involving three vehicles. one is a minivan with a woman slumped over the steering wheel who is unconscious with some front end damage there are two children in the back of the vehicle crying but fine...one of the other vehicles is badly damaged and there is a conscious 17 yr old complaining of neck and back pain...and in the third vehicle there is a 74 yr old man with rapid shallow respirations and seems to be unconscious, diapheretic with cool skin...the steering wheel seems to have impacted his abdomen...(sorry bout any spell errors).......what are your coarse of actions and why ....you are the first EMS vehicle on scene...


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## John E

*Is everyone breathing...*

you didn't mention that.

As for the spelling errors, you might as well start working on writing better now, it only gets harder as you get older.

John E.


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## Emt /b/

John E said:


> you didn't mention that.
> 
> As for the spelling errors, you might as well start working on writing better now, it only gets harder as you get older.
> 
> John E.



The woman in the first van is the only one that we don't know is breathing or not.


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## Meursault

Your signature confirms what I had suspected. Did we forget Rule 1?

1. Additional units, preferably at least one ALS.
2. Get the woman's head stabilized and airway open.
3. Quick assessments and c-collars on everybody else.
4. Check to see if the 17 y/o can be extricated.
5. With help, who should have arrived by now, get the old guy with the likely abdominal bleed rapid extricated and on a backboard pending ALS attention.
6. I don't know the woman's status. If she's not breathing, ignore the previous steps and bag her while your partner makes sure no one else is critical.
7. Once more experienced providers are on scene, give them command and take the apparently non-critical 17 y/o in.


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## piranah

well john im typing on a site...im actually quit a good writer just not a typer ( but thank you anyway)........the woman is breathing adequately...good....good....lol you didnt say scene safety BSI lol jk...(by the way i think it helps all of us to see other EMT explanations to scenarios...thats why i like doing this)......ok someone else


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## lcbjr3000

If i was the first person on scene i believe i would start to triage. You dont want to just jump right in and grab c spine cause once you do you got for the trip. Triage will allow you to determine who needs the most immediate attention and when your back up does arrive the perform there duties with that in mind


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## piranah

also very valid point....actually i would have to agree with 3000...when your resources are not enough you need to triage to make sure that you dont miss a critical patient because you couldnt leave the c-spine because that would be abandonment...so in that case 3000 was correct but i also think that conspiracy had a great thought process....ok someone else create a scenario....keep it goin..:b


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## certguy

*Scenerio*

1. scene safety - Is my scene safe ? Where do I spot my rig for best protection ? 

2. Size up - 3 vehicles , heavy damage on one ( possible pin - in ) , children crying in the minivan and unconscious driver . At this point you have at least 1 immediate ( if she's breathing ) , a rescue problem , and multiple pts. Time to order additional resources . FD rescue response , 2 additional ambulances , medivac on standby , CHP for traffic control . 

3. Triage - Senior partner IC , junior partner triage officer . You have 2 immediates ( if female breathing ) launch medivac and make sure FD notified to set up LZ . 

4. Begin initial treatment , starting with the immediates , do what you can till the calvary arrives . Put any spontaneous volunteers to work  till you get help . 

5 . Continue size up and retriage after initial treatment . Be ready to turn over IC when first responders arrive . 


How's that ????


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## JPINFV

Type of area(boondocks, suburban, rural, urban, etc)?
ETA to for additional units?
ETA to nearest trauma center?
Air ambulance available and ETA [dependent of course, on the above two factors?
Any extraction problems or is everyone easily accessible (if not,roll a fire engine)? 
How many rescuers are on scene right now (is your crew a standard 2 man crew, 3 man crew, etc)?
Depending on ETA of additional resources, are there bystanders offering assistance?
Is minivan women breathing?


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## certguy

*Scenerio*

Here's one for you guys and gals ,

   It's 7:00 am on a weekday and you're driving the freeway to work when you suddenly see a large cloud of smoke and dust between 1/4 and 1/2 mile ahead . Immediately , the traffic comes to a complete stop . After several minutes a lone PD cruiser responds up the center divide to the scene . It soon becomes apparent the first responders are delayed getting to the scene due to traffic . You decide to respond and do what you can . As you approach the scene , you're shocked to see that a GTO that was going eastbound has gone through the center divider , gone airborne in the process , and pretty much head - on'd a transam with 2 women in it . There is debris almost 200 feet from the scene . The LEO tells you to start with the transam .


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## lcbjr3000

Well some more info is needed. Are the vehicles on fire, if so not going near it till fire gets there. If im on my way to work then I am off duty and under no obligation to respond. And with that much mechanism your gonna need special tools for extraction. There isnt a whole lot you can do by yourself in my opinion.


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## JPINFV

Laugh, go back to car, drive to work.

Without, at the very least gloves, it's not worth the risk to be exposed to their fluids. 

Without c-spine gear, your not going to move them.

Without a portable suction, you aren't going to be clearing any airways. 

Without a BVM you aren't going to be assisting any respirations.

Without a face mask, you aren't going to be helping a patient in respiratory arrest. 

Edit:
Finally, -5 for thread jacking. A new scenarios by different person should get its own thread.


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## certguy

*Scenerio*

In the trans am you find both females pinned in . Driver is pinned in at mid thigh by the dashboard , restrained ,  resp. > 30 and labored , windshield starred , steering wheel bent , near amputation of right foot at the ankle , no access to lower extremities . Passenger is restrained , resp. > 30 , radial pulse very weak , decreasing LOC . Pt. complaining of severe abd pain . Abd. rigid .  Door won't open due to damage . 


1 occupant outside the GTO on your arrival , male , mid 20's , resp. < 30 , good radial pulse , obeys command to squeeze your fingers , 3 inch laceration on right forehead area , no other apparent injuries , but appears to be under the influence of alcohol ( strong odor ) and possible drugs . His vehicle also has major damage . Steering wheel bent , no starring on windshield , minimal space intrusion .


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## certguy

You have a well - equipped personal jump kit with o2 ( this happened before the FDA said we can't carry it off duty )  and c - collars , yes , you do have gloves , there is no fire and correct me if I'm wrong , but I think the post originator asked for more scenerios to keep things going so this wasn't a thread jacking HA !


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## JPINFV

Sorry about that... I didn't see that the OP passed off the story line.


ETA of additional EMS crews as well as extrication?
ETA to trauma center?
ETA for air ambulance?
Number of available air ambulances [depending on ETAs and extraction times, both TransAms are worth of an outrageously helicopter bill. Neither are going to get better prior to reaching the hospital, especially the passenger.

Since you can't access the occupants of the TransAm, you won't be able to do anything for them till the fire department arrives. 

So, pending any changes with the drunk driver, I'd c-spine and babysit him since, unless I'm missing a part of the scenario, he's the only one you can actually do something for prior to backup.


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## certguy

No problem . You're forgiven . This was a real situation I came across on the way to work . 
The freeway I drove was notorious for nasty accidents and I came across several . The GTO driver was drunk and wired on meth .


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## piranah

good job guys exactly what i wanted to happen....ok next scenario...


your walking to your car with your buddy and you witness a sudden "man- down" you tell your friend to get your backpack out of your car containing gloves,pocket mask, and bp cuff, stethescope(lol what i carry) you run to the mans aide and find him in cardiac arrest... his wife yells he has a history of heart disease(non-specified)............on your mark.....get set........GO!!!



(by the way i like how this is coming out it shows constructive ideas along with strong opinions...i call it a round table....good study tool with some buddies.)


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## AZFF/EMT

Call/have someone call 911
position airway
expose chest
check for pulses
begin compressions

 u/a of buddy with some gear......

stop compressions and check abc's
have buddy take over compressions/verify they are adequate.
Place and OPA/NPA(prob not unless on duty, I'm not sure about the legalities of using an airway adjunct off duty) and ventilate at 30/2 until ems arrives
continue CPR.


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## TKO

Witnessed man down?  No pulse?  Position and...

THUMP!


Unwitnessed and 9-1-1 not even dispatched?  Check pt hasn't isn't dead.  Position and...

THUMP!


Begin compressions.  Rock-paper-scissors for who will do mouth-to-mouth.  LOL!  Then pull out the pocket mask.  Do CPR until EMS arrives.

And that's all we can do.  And some of you aren't even allowed to do that....who can't do a precordial anyway?


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## piranah

well...to reply to my own scenario..........

I would first have someone call 911 check abc's open airway asses breathing(absent) and check a corotid pulse(none) i would then give 2 rescue breaths (w/pocket mask )and begin compressions 30:2 i would allow my friend to give the respirations after 5 cycles i would switch to respirations and allow a break...after recieving the AED i would stop compressions and clear the PT for analyzation and if its a shockable rythm shock him and go further per american heart association protocol...

so..any other good scenarios?


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## TKO

I follow my provincial rules (PCT) and Canadian Heart & Stroke guidelines.  I like CH&S better than the AHA, as it makes more sense.  Which is odd because the new CPR really was born out of Seattle (Good job, WA EMS!!).

We don't typically thump an unwitnessed, but things have really changed recently for us.  We have a con-ed course that is all about new approaches to treatment guidelines.  Things like, PCT for unwitnessed pts if you are only a few minutes getting to the party because it won't hurt the pt and you still have a good chance it's going to be helpful at this point.  We also can shock children if nothing else is working.  Protocols say we only shock kids if they have a cardiac hx, victim of blunt trauma to the chest or electrical injury....but now we can shock if we've done everything else.

This new Think Outside the Box approach is great for us.  No more, "Well, it's outside the protocol so I can't" or just not close enough - here's your cigar.  Like, pt is hypoglycemic but not diabetic?  Give a tube of glucogel anyway.

D'uh!  Finally a real first aid approach to BLS.


OK, here is a scenario:  63 y/o m pt c/o chest pain x 3 hrs and worsening.  Pt doesn't really know their hx too well, but has 4 y/o NTG sprayer in with their meds, and it is in their name but they don't have a current script for it.

Your partner started O2 via NRB@15 Lpm and tells you B/P = 160/100, pulse=90, RR=24 (SPO2@RA=89%).

What do you do with this?


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## TKO

OH, I have another one for people who want to try other.  I think this is a good one because I really don't think many rescuers are adequately trained when dealing with burns.  I'm really eager to hear Rid weigh in on this one.

You are called to a fire.  Pt brought to you by FD found inside, UnCx.  RBS reveals 3rd degree burns to most of L arm and L chest.  No other injuries.  lungs are AE=AE x4.

Go!


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## lcbjr3000

For the first one with the 63 yo with chest pain, Have him rate the pain, ask what he was doing when the pain started. I forgot to call for ALS backup since it is more than likely a cardiac problem. Check if pain has improved after O2 therapy. Reasses vitals and check lung sounds. As for the nitro spray, im not too familiar with the shelf of nitro but im pretty sure 4 years is too long. If you carry nitro you can contact med control and advise them on pts condition and more than likely you will be told to give nitro. Moniter vitals and transport. Hopefully and als intercept along the way.


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## Ridryder911

TKO said:


> OH, I have another one for people who want to try other.  I think this is a good one because I really don't think many rescuers are adequately trained when dealing with burns.  I'm really eager to hear Rid weigh in on this one.
> 
> You are called to a fire.  Pt brought to you by FD found inside, UnCx.  RBS reveals 3rd degree burns to most of L arm and L chest.  No other injuries.  lungs are AE=AE x4.
> 
> Go!



I'll await for others to answer and reply before answering...


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## lcbjr3000

2nd scenario. First of all with unconscious you have to protect the airway. Insert OPA/NPA assist ventilations with bvm connected to high flow O2 at rate of 12-20/min. cover the wounds with dry sterlie dressing. Get vitals. If you have the ability to, start an IV preferably Lactated Ringers, but saline will do. transport to hospital. Im not sure what you meant by lungs are AE=AE x4 probably something simple but im not familiar with the abbreviation


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## piranah

well is the burn PT breathing?1.dress the wounds and get ALS to start some fluid lines.2. put on O2 via NRB at 15 lpm ,3.transport ,I would be concerned with possible inhalation burns....not enouph info in that segment..


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## TKO

Any of you need to cool the burns for 10 minutes?  Burns are extremely painful and cooling is the best thing for that pain.  Hypothermia and infection are serious issues.  But I digress as I believe that Rid will give us a better rundown of how to handle burn pts and why (and I'm rather eager as I consider myself inadequately prepared for serious burns, as most other rescuers are since few can ever give me straight answers).



Chest pain scenario: in your focused, palpate around sternum and ask if it hurts?  No?  Not muscular.  Ask pt to take a deep breath?  No?  Not pleuritic (especially check if SOB ).  Pt *had* a script for NTG, that is now expired; you should call your ED and get orders for the nitro since pt previously had a script.  Everything else looks good, just ask the pt why they don't still take nitro.  
Now if ED says No, give ASA and transport.


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## paccookie

lcbjr3000 said:


> 2nd scenario. First of all with unconscious you have to protect the airway. Insert OPA/NPA assist ventilations with bvm connected to high flow O2 at rate of 12-20/min. cover the wounds with dry sterlie dressing. Get vitals. If you have the ability to, start an IV preferably Lactated Ringers, but saline will do. transport to hospital. Im not sure what you meant by lungs are AE=AE x4 probably something simple but im not familiar with the abbreviation



Agree with the above, except for a couple of things.

Call for ALS back up immediately due to unconscious patient who likely will need an advanced airway, among other ALS skills.  Cover the wounds with a cool, wet dressing - sterile 4x4s wet with sterile water would work.  Definitely start an IV, 2 if you can.  I think I remember reading that 1 bag NS and 1 bag LR is a good idea.  Estimate the area of the burn and start the Parkland (?) formula for fluid resusitation.  Call medical control for any further orders and transport emergency to the nearest APPROPRIATE facility.

I don't have much experience with burns, so I will be interested to read the other responses as well.


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## Outbac1

On the c/p call, investigate the type and location of pain more and hx while getting vitals. Rule out pleurtic and muscular, rule in cardiac if this is where hx and dx takes you, for now I'll assume cardiac. O2 via n/c at 4lpm, 4 lead ecg, set monitor to diagnostic (instead of monitor mode, we use a lifepac 12) and set leads to 11, 111, AVF. This gives a quick rt sided picture while you set up for a 12 lead. ASA if no allergy. IV if allowed,(lock or tko). Nitro sl 0.4mg if bp >90s, (personaly I prefer a pressure greater than 110s). Transport to hosp. Depending on pain and relief with nitro, (I can give 0.4mg sl x3), info from ecgs, patient stability and transport time call ALS as required. If the pt. is pain free now and has no other priorty symptoms we transport w/o ALS.


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## certguy

*2nd car crash scenerio*

Just because you don't have your rig with all it's fancy gear doesn't mean there's nothing you can do for the women in the trans am . You guys are spoiled rotten .  Though by mechanism , the bonehead that hit them should go to the trauma center , for now , he's a delayed pt. . Your priorities are the red tags  . You have O2  , c - collars , basic gear , and the means to take baseline vitals  . Though you can't open the doors or fully access the pts. , you do have limited access through the windows . You can have PD get the helo in the air and save some time there also .  As with most MVA's there are probably some spontaneous volunteers willing to help . Put them to work stabilizing c - spine , writing down pt. info , and post a lookout with a fire extinguisher for safety  , and  babysitting the other driver ,  to free you up to do what you can . In the initial post , I said traffic's at a complete stop , and you're in uniform on the way to work . You're not getting there any time soon and you can't get off the freeway . You have lifesaving skills and the basic gear to get things rolling till first responders get there . It's flat wrong for EMS people to let people die in this type of situation without lifting a finger because of fear of a lawsuit . It amazes me there's this much fear going around that it would cloud your judgement .


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## Outbac1

The burn pt needs ALS enroute ASAP. The u/c pt needs a definative airway and fluid mgt. Start with a NPA/OPA and bag with 100% O2, Prepare pt for transport and get moving. Remove clothing, except what is stuck and cover with sterile sheets. Vitals now if not already gotten. I assume lung sounds are equal and clear x 4 fields. Doesn't mean they will stay this way, monitor for changes often. Radio hosp early so they can prepare, smaller hosps don't get that many burn pts. I would quick estimate burn as 18 - 20%, Arm 9%, Ant. L side chest 9%, round off to 20%. If L side posterior chest included add another 9%, total 27%. Parkland would indicate 20% x 4ml = 80ml x kg of pt. If pt 80kg(176lb) would equal 6400 ml in first 24hrs. 50% in first 8 hrs. 3200ml / 8 = 400ml/hr = 400gtt/min with 60gtt set or 70gtt/min with 10gtt set, (just over 1 gtt/sec). That should keep you busy until ALS arrives or you get to hosp.


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## piranah

well....there is a thing called the "good sumaritan act" its a law protecting off-duty health care workers or just anyone who helps at emergency scenes.im not sure if this is just RI though.it was basically an incentive for regular people to help at scenes without the fear of a lawsuit.....i myself help at any scene i can and im legally obligated as a EMS worker in RI to stop at any scene that no help has arrived yet....not that anyone would ever know if i drove by but i still feel like its my job.....and i like doing it anyway...


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## Ridryder911

I realize burns are pretty scary. I had worked in the field for about twelve years before working as a burn nurse at one of the largest burn centers in the world. We had 10 ICU burn beds and about 20 burn beds, and two HBO units. I truthfully can say I learned a lot about different emergencies. 

Ironically, I learned that NO one usually dies from burns themselves, but that they died from burn complications. I was amazed at the different levels of and types of shock syndromes I have witnessed. I only thought I knew shock physiology. As well, I witnessed a whole different way of resuscitation in a cardiac arrest of 31 year old. Very little to no cardiac medications were administered, and a successful result was from infusing and administrations of electrolytes, again treating the cause not just the effect. Again, a real eye opener. 

Here is a very good web site with the American Burn Association (ABA)guidelines from the Advanced Burn Life support Course (ABLS). 

http://www.saems.net/Downloads/50152_Burn Center2col_f.pdf

I highly suggest looking through it and then attempt to treat the scenario accordingly..I will review and clarify if needed. 

Good luck, 

R/r 911


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## Ridryder911

piranah said:


> well....there is a thing called the "good sumaritan act" its a law protecting off-duty health care workers or just anyone who helps at emergency scenes.im not sure if this is just RI though.it was basically an incentive for regular people to help at scenes without the fear of a lawsuit.....i myself help at any scene i can and im legally obligated as a EMS worker in RI to stop at any scene that no help has arrived yet....not that anyone would ever know if i drove by but i still feel like its my job.....and i like doing it anyway...




Actually, it is called the _Good Samaritan Act_ (from the Bible). Which was enacted from an article in the _Reader's Digest_ during the early 50's. It was described that physicians were not stopping at MVA's off duty and people were dying. Ironically, there had not been any medical negligence law suits until after that article had been published (good idea?). 

It does cover those that do not have a _duty to act_ (was summoned) but usually not those that are associated with volunteers and professional services. Although, technically anyone can sue for anything. Then again, as long one acts accordingly to the level for off duty (first responder level); no matter what level or license; except medical physicians. 

There are different interpretations of the law, but the general consensus is the same idea. 

R/r 911


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## DesertRatetteEMT

AZFF/EMT said:


> Call/have someone call 911
> position airway
> expose chest
> check for pulses
> begin compressions
> 
> u/a of buddy with some gear......
> 
> stop compressions and check abc's
> have buddy take over compressions/verify they are adequate.
> Place and OPA/NPA(prob not unless on duty, I'm not sure about the legalities of using an airway adjunct off duty) and ventilate at 30/2 until ems arrives
> continue CPR.


This is extremely helpful to me as a student. They are really not too generous on providing scenario solving exercises in class at my school, and it is quite frustrating. Having a team of people here asking and answering more questions than the one-a-chapter in the book is refreshing and thought provoking. Keep it going! It's great!


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## enjoynz

Just with regards to the burns scenario.
(And I will check out the site you have suggested looking at Rid).

Our protocol for the treatment of burns pt's has changed recently.
We have to cool the burns for 20 minutes now, instead of 10 mins.
And we cover the burns with Cling film (Glad wrap) to protect loss of fluids, infection control and also for the fact that you can still see the burns through the film.

I know in the case of this scenario the pt is unconscious, so you wouldn't be hanging around to long on scene. 
But I'd be interested to know if any other services use cling film for burns pt's and their cooling times?

Cheers Enjoynz


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## BossyCow

Here's one from my archives.  

Toned out to man found unresponsive in vehicle outside laundromat at 03:00. Arrive to find male, late 60's, sitting on ground next to vehicle. He is only alert to verbal and the only info we can get out of him is his first name. Diaphoretic, flushed, no visible sign of trauma.  Pulse rapid, thready/ BP was 108/palp.


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## TheAfterAffect

BossyCow said:


> Here's one from my archives.
> 
> Toned out to man found unresponsive in vehicle outside laundromat at 03:00. Arrive to find male, late 60's, sitting on ground next to vehicle. He is only alert to verbal and the only info we can get out of him is his first name. Diaphoretic, flushed, no visible sign of trauma.  Pulse rapid, thready/ BP was 108/palp.



Load em onto a stretcher, Fowlers Position (since he was found sitting and apparently thats his position of comfort), 15 LPM  O2 Via NRB, request ALS Support to meet up during transport if possible. Transport to nearest hospital, and check Vitals every 2 minutes along the way.


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## lcbjr3000

Assess respirations and start some O2 10-15nrb. Get your glucometer and get a blood sugar reading. If the person is responsive enough get a history and find out what happened so early this morning. Check lung sounds as well. Also it would be a good idea to run him through the cinncinatti stroke scale. Alert ALS possibly for the need of naxalone. Also the als will be able to set up cardiac moniter and see if this is a cardiac event. If diabetic they will need D50. I wouldnt try oral sugar because he could go unresponsive again then your just making things worse. Thats all i got for now im sure i missed something.


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## paccookie

BossyCow said:


> Here's one from my archives.
> 
> Toned out to man found unresponsive in vehicle outside laundromat at 03:00. Arrive to find male, late 60's, sitting on ground next to vehicle. He is only alert to verbal and the only info we can get out of him is his first name. Diaphoretic, flushed, no visible sign of trauma.  Pulse rapid, thready/ BP was 108/palp.



If not ALS unit, call for ALS back up immediately due to LOC.  Check blood glucose immediately.  Administer O2 15L NRB.  Cardiac monitor.  If blood glucose is low, start an IV, hang normal saline at wide open rate, and administer thiamine & D50 or glucagon if unable to obtain IV.  If IV obtained, KVO normal saline used to administer D50.  Recheck vitals and blood glucose en route to hospital.  Assess for stroke and drug use, obtain history as patient becomes more responsive.


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## lcbjr3000

I understand why all the drugs and cardiac monitoring are needed but this is supposed to be a bls scenario since it is in the bls section. I think its important we remeber that when doing these scenarios. Its very easy to forget the basics when we are als trained or in als training


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## BossyCow

Blood sugar and O2 sat wnl. Also, pt become less responsive rather than more during transport. No history available, able to find out from bystanders that the man's car was seen in the parking lot of the laundromat since 4pm the day before. No one talked to him or heard any complaints. Until passer by saw him sitting next to the car the next morning. Cell phone in the car with 20 or so 'missed calls' starting around 6pm the night before. Man is breathing well on his own, just extremely disoriented and barely conscious.  Stroke test shows only some very slight left side weakness to left hand/arm only. ... So far you guys have all missed what both the medic and I missed so I don't feel so bad.....


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## reaper

Look at the cell phone and see if all the missed calls are from the same person. If so, call them. They may be able to give you his hx.


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## lcbjr3000

I would say now go through a trauma assesment. Take off all the clothes and see if there is some underlying trauma. Maybe when he lost consciousness from the previous day he became hypothermic. Start breaking hot packs and put them on neck armpits and groin. Put in shock positon. Does the man have any medications on him or any kind of medic alert bracelet.


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## BossyCow

You are on the right track.... sort of... it was temperature related.  No visible signs of trauma. Calls to the number on the cell get no answer. We take the guy to the ED and they took the one vital sign that I'll never forget to take again after this call..... his temperature.. temp was 104.  We put him in the ER room, went to write our reports and Nurse comes in.. "You guys want to come see? Doc is intubating that guy you brought in"... It was Septic Shock. 

Pt died in ICU 2 days later. The left side weakness was from a stroke some 10years earlier. He had left home to meet up with his buddies for a fishing trip. Never made it to his buddies, cell phone calls were from his friends who camped in a site with no cell tower coverage. He pulled in to the parking lot, feeling a bit off, decided to take a nap, got worse instead of better.  Was starting total system shut down and multi organ failure by the time we found him.


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## reaper

You would have felt that the pt was warm to the touch. This would be noted right away.


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## BossyCow

reaper said:


> You would have felt that the pt was warm to the touch. This would be noted right away.



Found the guy outside in 30 degree temp.  Issues of his LOC were primary. Wearing gloves (BSI) and our selves being bundled against the cold meant we didn't really notice the temp.


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## piranah

people who are writing these scenarios have to realize that we aren't there and they have to be general scenarios and not specific because you can't see,feel, use your professional intuition here because its just not possible so make it more..."visual"explanations..its goin well guys


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## AZFF/EMT

Thank you, I would suggest asking your instructors if you guys can have a little time t go over scenarios. It will help yu a lot for national reg. as well. You should be going over trauma assmt., med assmt. ect anyways. 

If they are unwilling to do so, try to find people who will help, Like a local fire department, ems agency. Most of the time they will be more than willing to help. Just study your national reg. check sheets and have them present you with a scenario, and go for it.


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## piranah

a good thing some of my friends like to do is exactly what were doing here....it really does work so..get some friends(if you have none im sorry) and sit around have some beers and do this its really fun once you try to slip some of your friends up..


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## certguy

*Scenerio*

Okay guys , here's another welcome to the hot seat ;

      Your company has the ambulance contract for a major healthcare provider . You and your partner are responded code 3 to one of thier clinics for a 19 y/o female down in the lunchroom , no other details provided .You are a BLS crew in a CCT equipped ambulance . You have no nurse .  On your arrival , you're surprised to see medics and engine co. leaving w/o pt. Medics quickly explain that the pt.'s friend called 911 after she collapsed while waiting for her appointment , which was delayed several hours . Code team responded and are providing care . Medics were ordered off the scene by dr.s treating the pt. because they already had a rig responding . Medics also state per friend , pt. was c/o headaches increasing in duration and intensity over the past month and has had no oral intake over the past 24 hrs. due to increasing nausea . When you enter , the scene is pandimonium . The  pt. is seizing violently , code team is unable to get IV access . She's vomiting and the airway is comprimised . The team can't get thier suction to work , so you run for your laerdol . You get the airway cleared  . The DR orders you to immediately transport to thier facility across town 20 - 25 min. ETA . Your nearest facility is a trauma center 7-10 min. away . IV finally established , meds given ,pt. still not intubated ,  seizures finally subsiding but pt's vitals are bad . b/p 180/120 , pulse approx. 60 , resp. 8 , pupils dialated and sluggish , skins flushed and dry , pt. is still unresponsive . Though meds have been pushed , staff will not accompany you , don't want to wait for an RN , and are adament they don't want medics and you are to take her to thier facility .


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## lcbjr3000

First off make sure to document the hell out of this. It seems like gross negligence that they do not want medics who can do certain things that will help in the treatment of this pt. The fact they do not want als is absurd. Anyway, put in an airway adjunct to secure the airway. If you have one insert a combi tube since thats as advanced of an airway you can get with bls.(might be someother kind im not sure just going from my units protocols) assist ventilations to 12-20/minute with high flow oxygen. If the dr ordering the transport to a hospital 20 min away is your medical director than i say you have to do it if not then he has no say on where you bring your pt. This pt. needs advanced care and may have some sort of reaction to drugs that were pushed on scene that you can not deal with cause your bls. Just because the nearest hospital is a trauma center does not mean you cant bring a pt with a problem thats not trauma. I say bring them there. Besides with the violent seizing there might be some trauma to the head anyway. Check for head trauma consider c spine immobilization and back board.  Reasses vitals enrout. I might be way of base here with the hospital decision but thats why we are here to learn. Sorry i got wordy on this.


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## JPINFV

If your able to snag the medics, do so. This is not a BLS patient. 

Assuming that medics have left, the patient is still an ALS patient and now the question is, which is going to be faster, calling ALS [even if you get in, drive to the other side of the parking lot, and wait], or transporting emergently to the nearest paramedic receiving center [the trauma center in this case]. In the end, any on-scene physician orders need to go through medical control if they are contrary to the needs of the patient [ALS transport in this case]. If online medical control is not an option at the BLS level, then you need to revert back to the written protocols which should state to obtain the nearest ALS provider [hospital or medic].


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## certguy

*Scenerio*

Yes folks , this was an actual call my partner and I responded to . This call gave me the willies , and you can bet your bottom dollar we documented EVERYTHING . I'll fill in the blanks later , but how would YOU treat this pt. and handle the transport issue as well as the fact a DR is passing off an unstable pt. to you . Can anyone venture a guess as to what we're dealing with here ?


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## certguy

Sorry , I forgot to give you a little more info . No obvious indication of head trauma . When pt. collapsed , a bystander caught her and eased her to the ground .


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## Outbac1

I agree the pt needs ALS. I'd put in an OPA and a NPA. If the pt seizes again they may dislodge the OPA a bit but it should still keep their jaw from clenching tight so you still have suction access. The NPA should give you good air flow, if its not blocked by vomit. The nearest center would be my choice of destination. Here, the sending Dr. is responsible for the pt until they are recieved and accepted by another DR. For them to not accompany or provide further care could be considered negligence. About the best you can do is bag, call for assistence and transport to an appropriate facility. 
 Do you know what drugs and dose was given? Our ALS has an order to give versed 5mg intranasel or buccal ( between gums and cheek). Valium 5mg can also be admin. rectally (pr) if an IV canot be established.


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## BossyCow

You said she was seizing, how long did the seizure last and did she have a hx of seizure disorder? Is she a diabetic? What was she in the clinic for?  Just the headaches? I would also check the vomit. Is she vomiting volumes of liquid or down to just slimy bile. If the latter, I would suspect possible dehydration, electrolyte imbalance due to not eating, nausea x several days. I would also add into the r/o possible poisoning and check on possible head injury, drug abuse or other toxicity. 

As far as the transport issue, the doc is not in charge in my ambulance. Not unless he is my MPD. I will listen to his 'recommendations' and then, once in the ambulance, would determine pt care based on my protocols and my assessment of the pt's condition.

This is an ALS call. I would attempt to determine if the pt is truly unconscious or merely postictal. Airway adjunt and left lateral recumbent just in case the puking starts again, Keep the suction handy and get ALS coming.


I would let the doc get as mad as he likes regarding the transport issue, because I would be going to the nearest facility. I would probably call medical control first and ask for their recommendation just as a CYA. 
But I would paint as ugly a picture as I could of the pt's condition to slant it towards MPD saying to bring them to the nearest facility. Let the original doc, if he has the chutzpah, complain that his critital ALS pt was given best care in spite of his recommendation.


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## certguy

It's been a long time since I ran this call , but I believe it was valium and versed that were given . After loading the pt. , while my partner was dropping an airway , I was on the horn to dispatch telling them the situation and the fact that we were diverting to the trauma center. We contacted them online and they concurred . After we arrived , in addition to our normal paperwork , the radio RN had us each write a statement on what had occured . We also had a talk with our manager . A couple of hours later we were at the hospital dropping off another pt. when our seizure pt.'s friend and her parents came up to us , thanked us for our help , and let us know she had died . She never regained consciousness . They also said we did a great job but they were sueing the healthcare provider . The DX was subarachnoid hemmorage . We were told county EMS also investigated but didn't hear the outcome . To this day , I'm amazed that we weren't summoned to testify . What a mess !!!!


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## DesertRatetteEMT

Talk about Gross Negligence!!!! Woooww..... I can't believe that. We actually just recieve an important lesson in class last night about the nightmare that Docs and nurses are on a scene. Can't wait....


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## BossyCow

DesertRatetteEMT said:


> Talk about Gross Negligence!!!! Woooww..... I can't believe that. We actually just recieve an important lesson in class last night about the nightmare that Docs and nurses are on a scene. Can't wait....



I would amend that to the nightmare *SOME* Docs and nurses can be on a scene. I have run calls with both on scene and had them realize pretty quickly that they were out of their element and the responders were in theirs.  One of my husband's first calls was to a cardiac arrest in a doc's office. Doc was doing CPR and was so relieved to have EMS take over. I think the funniest one was a nurse we all knew who recently retired from the ER where we take our patients. Pt was telling the medic what meds to give and in what dosages all the way in.


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## certguy

Over my years in the field this and 2 other calls really stand out where DR.s were out of thier element and botched it , putting the pt. in danger and me and my partner in extreme CYA mode . One was a child abuse / attempted murder on a 2 week old infant , and the other was an orthopedic surgeon playing HS football team DR that blew every trauma protocol we have on a head injury pt.


On the other hand , on my very first CCT our 27 y/o male with CP coded as our RN arrived . I never saw a DR. work so hard to save a pt. I was impressed . This was the kind of DR. I'd want fighting for me or my family . We had a sucessful resuscitation , and the doc never left his pt's side . He assumed care and treated the pt. all the way in , working very well with our crew the whole time . 

In our last CERT class , we had a public health RN who had formerly worked as a surgical nurse , but never did any ER time . She was a humble and eager learner and I think she'll work well in a disaster , now that she knows how we operate . 

I believe DRs and RNs should be educated on what to expect when working with field personnel  and what our protocals are .


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