# Response to Machine Shop



## spinnakr (Nov 18, 2009)

You are a relatively new basic with approximately 3 months of transport experience, as well as roughly 6 months of response experience with your campus EMS squad.  You are off-duty, working a second job as a teaching assistant / machinist at the student machine shop on campus.

You are in a side room - a large office with no machinery - working on the computer when you notice a fellow TA helping a student towards the door.  Just as they are about to turn in, something happens, they overshoot the door, and she goes limp.  You notice a slight contraction of her right upper- and lower-arm as her eyes roll back and her legs go completely limp.  The other TA catches her, and then, roughly 10 seconds later, she regains function and is able to stand on her own.  She is extremely disoriented and does not remember anything after feeling faint - other than her stomach hurting.  The other TA brings her into the office, and once you are sure she is in the office and out of the danger of industrial machinery, you immediately call campus emergency services.  While trying to relay information to the dispatcher, your boss is telling you that "she's fine, she just needs some water," and in addition to the uncertainty of what ACTUALLY just happened, there are at least 3 other people trying to talk to you while you speak with dispatch.  For whatever reason, you tell the dispatcher that there was a student that "passed out," despite your initial suspicion that she has been seizing.  Because of the confusion, you are unable to get accurate, concise, and complete information to the dispatcher before she hangs up.

Once the student is seated in a chair, with someone standing behind her in case she has another 'episode,' you notice she is clutching her right index finger, and you start asking a few questions.  You discover that she hit her finger with a ball-peen hammer while stamping a workpiece, and then felt a strange pain in her stomach, felt light-headed, and then remembers being seated on the floor with the TA helping her up.  She is extremely pale, and denies that there is any problem.  She is very insistent that she is okay, when she has another 'episode.'  You notice the same muscle contraction and the same eye-roll.  Her eyes, again, remain open during the episode, which again lasts roughly 10-15 seconds.  You call back dispatch, update them of the situation, and clarify a few details.  Because the student squad (for which you are a shift officer) is not currently in-service, city EMS is en-route.

What would you do as

the off-duty witness?
the responding EMS crew?


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## firecoins (Nov 18, 2009)

Thes responding crew should do an assessment, vitals signs, O2, call for ALS and transport.  

As a witness, you already called 911.  There isn't much to do.


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## spinnakr (Nov 18, 2009)

In hindsight, barring other complications, your job as a witness is, as you said, already done.  So I'll leave that one alone for now.  However, as for the crew: I was looking for a little more detail.  What are your suspicions, for ALS, what meds would you consider pushing, etc.

For the record:  at our campus, I have never once seen Cleveland EMS send anything BUT an ALS truck.  In other words, there was no ALS call to be made because ALS was the first onscene.  However, I think this is a call that BLS could have handled no-problem, especially given our proximity to multiple hospitals.


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## spinnakr (Nov 18, 2009)

One thing I forgot to mention: when the patient regained muscle control, she was very jerky - with deliberate but frantic head movements - for roughly 15 seconds.

So, look at it this way:  ALS dispatched for 2x syncopal episodes, 20/F.  Updated enroute that the patient has had another episode.  Your response time is about 8-10 minutes.

You arrive onscene to find the patient seated in a chair in an office.  She is very pale, but not cyanotic and not ashen.  Events are described as above.  Witnesses state that patient slid down a wall when she hit her finger; she never hit her head.  No neck or back pain.  Right index finger is bleeding slightly; presents ~1cm contusion on nailbed.  Patient states no pain, except R index finger, which she rates as a sharp 5/10 with no radiation.  Patient is A&Ox3 when you arrive.  She is able to talk in complete sentences but isn't sure if she would be able to stand.

As for vitals:
HR 80, regular pulse but a bit on the weak side
Respirs 14
BP roughly 110/75
Sp02 98%
Blood glucose at roughly 80; patient admits to skipping lunch (it's now ~2pm)
PERL
Skin is cool and dry; no tenting or turgur noted.

Assessment:
Signs and symptoms as above.  No further s&s noted.
NKDA
Patient denies medications.
Patient denies medical history.  Also, patient denies having ever fainted or seized prior to incident.
Last oral intake breakfast: toast, coffee, granola bar, juice.  Again, it is now ~2pm.
Events prior as described.

Patient adamantly believes she does not need to go to the hospital, but has not explicitly said she does not _want_ to.


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## firecoins (Nov 18, 2009)

no ALS meds needed.  She is not actively seizing. She isn't currently altered.  80 is a sufficient BSL and she could could take a glass of juice if needed. Her  breathing fine.  Start a line, draw blood if permitted, put her on the monitor and provided we don't see any weird arrythmias, transport. Due to the unexplained syncope, convince her to go.


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## exodus (Nov 18, 2009)

firecoins said:


> no ALS meds needed.  She is not actively seizing. She isn't currently altered.  80 is a sufficient BSL and she could could take a glass of juice if needed. Her  breathing fine.  Start a line, draw blood if permitted, put her on the monitor and provided we don't see any weird arrythmias, transport. Due to the unexplained syncope, convince her to go.



Seriously? No ALS needed? Get a line started in case she does start seizing again, then you can push drugs if needed... 

Chest pain? No ALS needed either, they're not arresting right now are they?


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## spinnakr (Nov 18, 2009)

exodus said:


> Seriously? No ALS needed? Get a line started in case she does start seizing again, then you can push drugs if needed...
> 
> Chest pain? No ALS needed either, they're not arresting right now are they?



I think in this particular case I would argue that a BLS squad would be an acceptable transport.  THAT IS NOT TO SAY THAT ALS WOULD NOT BE HELPFUL!

The reason I say that BLS would be acceptable:  this happened within a 3-minute flow-of-traffic transport to two different hospitals.  The response time (from call to contact) of Cleveland EMS to our campus is usually on the order of 10-12 minutes, whereas the response time of the on-campus BLS crew (when in-service) is usually about 4-6 minutes.  By the time CEMS arrived, the patient could have already been in the ED.

I am a firm believer that more thought should be put into transport decisions (ALS vs. BLS, or intercept, etc) than just the type of call.  For example: it's pretty stupid to have a fully-equipped 3-person BLS squad wait for ALS or an intercept on a full arrest when they're less than 2 minutes (running hot) from the hospital.

But this is all irrelevant to why I posted this in the first place.  If you were the paramedic crew responding to this, what, if anything, would you suspect as a mechanism?


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## Shishkabob (Nov 19, 2009)

exodus said:


> Seriously? No ALS needed? Get a line started in case she does start seizing again, then you can push drugs if needed...
> 
> Chest pain? No ALS needed either, they're not arresting right now are they?



Fire said no MEDS needed, not 'no ALS', and right after, said a line was to be started.


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## firecoins (Nov 19, 2009)

exodus said:


> Seriously? No ALS needed? Get a line started in case she does start seizing again, then you can push drugs if needed...
> 
> Chest pain? No ALS needed either, they're not arresting right now are they?



reading is your friend.  I said no ALS meds.  I also said start a line. Hmmm


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## reaper (Nov 19, 2009)

exodus said:


> Seriously? No ALS needed? Get a line started in case she does start seizing again, then you can push drugs if needed...
> 
> Chest pain? No ALS needed either, they're not arresting right now are they?



Monitor and transport. I saw no signs of seizures in this pt. Vitals, Iv, and monitor.

More then likely this was a pain response to hitting finger with a hammer!


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## Melclin (Nov 19, 2009)

spinnakr said:


> For example: it's pretty stupid to have a fully-equipped 3-person BLS squad wait for ALS or an intercept on a full arrest when they're less than 2 minutes (running hot) from the hospital.



Not necessarily. The most important thing is good chest compressions. Everyman and his dog will tell you that CPR whilst transporting leads to rubbish CPR and increased danger for the providers as well. 

While it may depend to some extent on the cause of the arrest, for the most part, an ED probably won't be doing terribly much more than an good ALS crew will, so its better to sit and give the pt good compressions and wait for ALS.

Maybe there is some sufficiently short transport time when you could just say, bugger it, I'm going. But just something to keep in mind.


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## spinnakr (Nov 19, 2009)

Melclin said:


> an ED probably won't be doing terribly much more than an good ALS crew will, so its better to sit and give the pt good compressions and wait for ALS.
> 
> Maybe there is some sufficiently short transport time when you could just say, bugger it, I'm going. But just something to keep in mind.



That's just my point.  In our area, about 90% of the time, by the time the ALS crew arrives, the patient could have already been in the ED.  Also, the BLS crews around here all have AED's - nowhere near as good as a fully-stocked ALS crew pushing meds and manually defibbing,, but makes a big difference nonetheless.

I agree that squad-based CPR is much more difficult and far less-effective than stationary CPR.  But I still argue that with such a short transit time - running hot, we're talking less than 2 minutes - it makes a lot more sense to transport.

As an aside, I checked my notes on this, and the patient did NOT feel lightheaded before losing consciousness.  Her head did turn slightly to the left after loss of consciousness, and her legs did not collapse - they simply stopped supporting her weight, and she kind of fell over.  Also, while pupils were PERL upon ALS arrival, they were unknown post-episode.

I still lean towards seizures;  thoughts?


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## Vizior (Nov 19, 2009)

spinnakr said:


> I think in this particular case I would argue that a BLS squad would be an acceptable transport.  THAT IS NOT TO SAY THAT ALS WOULD NOT BE HELPFUL!
> 
> The reason I say that BLS would be acceptable:  this happened within a 3-minute flow-of-traffic transport to two different hospitals.  The response time (from call to contact) of Cleveland EMS to our campus is usually on the order of 10-12 minutes, whereas the response time of the on-campus BLS crew (when in-service) is usually about 4-6 minutes.  By the time CEMS arrived, the patient could have already been in the ED.
> 
> ...



How often do you have crews with an on-scene time to hospital time of less than 6 minutes?  Next time you think you are cutting down your on-scene time, take a look at what dispatch records and re-evaluate.


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## Seaglass (Nov 19, 2009)

reaper said:


> More then likely this was a pain response to hitting finger with a hammer!



That's what I would suspect, too. Some people react to pain in pretty strange ways, and fainting at the sight of blood is pretty common.


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## spinnakr (Nov 19, 2009)

Vizior said:


> How often do you have crews with an on-scene time to hospital time of less than 6 minutes?  Next time you think you are cutting down your on-scene time, take a look at what dispatch records and re-evaluate.



That's literally my job with our campus EMS group.
Our average response time, from call received to patient contact, for the past 2 years has been 4-6 minutes.


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## mycrofft (Nov 19, 2009)

*Vaso-vagal equals funky-chicken*

People who fall out due to a vasovagal response to pain or fear or both will often twitch, shake or even exhibit minor seizureform activity.
EEG???


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## spinnakr (Nov 19, 2009)

mycrofft said:


> People who fall out due to a vasovagal response to pain or fear or both will often twitch, shake or even exhibit minor seizureform activity.
> EEG???



I was under the impression that eyes rolling back (up) was a reliable indication of seizure in healthy adults.  Perhaps this was a misguided perception, but seizures certainly don't always present tonic-clonic activity, and are often misdiagnosed as syncope (of course the inverse is also true).  Also, seizure disorders be triggered by stressors - like pain.

The fact that she wasn't shaking was precisely the reason that I suspected seizure.  She showed what seemed to be tonic behavior - although admittedly I observed no clonic phase, seizures can most definitely vary in severity, presentation, and duration.  She displayed a prominent post-ictal state (extreme confusion and drowsiness).  Were she simply twitching... I wouldn't necessarily be so quick to think seizure.  

As for an EEG:  therein lies the problem.  I would like to say that there is some kind of definitive answer as to what even happened with this patient, but Cleveland EMS made no effort to convince the patient to go to the hospital, and she subsequently refused transport.  She was escorted home by a police officer, where (eventually) her friends convinced her to go to the campus clinic, which is notoriously lazy and at any rate does not have the equipment to make an adequate diagnosis of any neurological problems.

This brings up the second question that I posed in the OP.  From a legal standpoint, you are theoretically free of any liability once an EMS provider arrives on-scene; in the even that the patient refuses, any liability rests on the patient (or in the case of an inadequate refusal, the EMS provider).  Would that be sufficient from a CYA standpoint, or would you do anything more?

For the record, we ended up emailing her and suggesting she go get checked out - which is how I know that she eventually went to the clinic.  They were "unable to find anything" - although I'm sure it didn't help that she waited several hours to go.  We didn't do it out of a CYA standpoint (I was the only one with an *** to cover, anyways), but purely out of concern for the patient.  She was, after all, our student.


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## Vizior (Nov 26, 2009)

spinnakr said:


> That's literally my job with our campus EMS group.
> Our average response time, from call received to patient contact, for the past 2 years has been 4-6 minutes.



You misunderstood me.  

Call Received: A
En Route: B
On Scene: C
Transporting: D
At Hospital: E

The time from B to C is your response time
The time from C to D is your on scene time

The point I was making is that it is pretty rare that your on scene time will be less than 6 minutes.


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## spinnakr (Nov 26, 2009)

Vizior said:


> The point I was making is that it is pretty rare that your on scene time will be less than 6 minutes.


It's also pretty rare that Cleveland gets there within 6 minutes of our call.  It's even rarer that we get a cardiac arrest.  Actually, we've *never* had one - and the nature of the call will absolutely influence on-scene time.  So while our average on-scene times are more like 20 minutes, roughly 80% of our calls are priority 3 patients.  And yes, we have had on-scene times of less than 6 minutes.  We've also had times where we've waited for Cleveland EMS to arrive for 12 minutes on a patient who was in severe respiratory distress.*

I don't think there's any reason a decent 3-man squad couldn't package and load a patient (while performing CPR and automated defib) in 5 minutes, which would leave 1 minute to get to the hospital for the best-case scenario from Cleveland's response time:

Arrive, BSI, scene safety                 <1 minute
Check ABC's                                  10 seconds
Begin CPR and apply AED                 30 seconds
AED                                             30 seconds
Logroll to backboard for rigidity         10 seconds
Backboard to cot                           10 seconds
Cot to squad                                 2 minutes tops

You could have the third crewmember conduct any bystander interviews necessary.  That's less than 6 minutes.  You can perform CPR through the entire process
My former instructor (with over 30 years of in-field experience and an 18-delta as a son) would argue that even a 2-man crew should never need to have an on-scene time of greater than 10 minutes for an arrest, AAA, etc.

Plus, 6 minutes for Cleveland is only the time it takes them to get there.  That doesn't include the amount of time it would take to brief them, for them to start their thing, etc etc.  Sure, that won't take very long - less than a minute - but "not very long" is important when you're talking a transport time of approximately a minute.

And yes, this is a very very specific case, and for our service (as our current transport protocols wouldn't allow us to transport this patient anyways) a purely hypothetical situation, but again, my point is simply that people should consider more than just the type of call when making transport decisions!  At any rate, once the patient is loaded in the squad, the wheels should be rolling and they shouldn't stop until you're at the ED, because stopping for an ALS intercept would be longer than the transport time.

So perhaps the scenario should be more like:  call for ALS backup, but load and go anyways.  If they're there before you leave, great, transfer care.  If not, just go, and update dispatch to pass the word on.

*I'm not trying to libel CEMS here.  I'm stating our experience with their service, and admittedly they are usually only called for Priority 2's, which our current transport protocols do not permit us to transport.  That said, we do get the occasional Priority 1, and there is plenty of information out there on the shortcomings of CEMS and their response time.  I have heard speculation (albeit undocumented) that their documented response times are actually those of the Cleveland Fire Department, which oftentimes gets called for mutual assist of high-priority EMS calls.  I can say, however, that CEMS was recently the subject of an investigation for inadequate response times to emergent calls.


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## Vizior (Nov 27, 2009)

It  looks good on paper to have a cardiac arrest en route to the hospital in 5 minutes BLS, it is still relying on things going smoothly.  The least of which is assuming that the patient is on the ground floor and bystanders are not in the way.  I'm not debating that there are a number of situations where load and go to the hospital is appropriate versus an intercept, but I am just trying to urge that our roles as pre-hospital providers be considered.  While we should move with a sense of urgency, we must do our jobs well.  Do good CPR and AED skills, move quickly while still gathering a good history and patient information.  If it takes you the extra couple of minutes and the medics are there, let it be there decision when transport is begun.  If they aren't there, get en route and use the radio.  

I believe that load and go is a situation that many providers take too literally.  Load and go does not necessarily mean throw the patient in the ambulance and hit the lights/sirens.  This holds more true when you are further than walking distance from the hospital, but if you have an actively seizing patient loaded with a 20 minute transport time while the medics are 10 minutes out...

P---->YOU------------>H

Let's reconsider what's in the best interest of the patient.  Running away from the medics at the same speed they are traveling is like a bad math problem, they will always stay 10 minutes away while the hospital gets closer and closer. 

Why does your service only allow you to transport BLS patients if you are so close to the hospital?


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## spinnakr (Nov 27, 2009)

Vizior said:


> Why does your service only allow you to transport BLS patients if you are so close to the hospital?



This is an extremely complicated question.  We can only transport ambulatory, stable patients - and largely this is because 1.) we don't have a full squad (yet) and 2.) our service is only 4-and-a-half years old.  Not to mention we operate on a budget of about $10k per year.  It's a mess, that's what it comes down to.


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