Disagreement on a scenario

[TKO]

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

What would you do in this situation?

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

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

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


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

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

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

 

[TKO]

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

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

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

Gotta go! Gotta call!

 

[EMTMandy]

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

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

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

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

 

[JPINFV]

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

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

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

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

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

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

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

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

This is all based on the national registry,

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

and i understand that different areas may not have trendelenburg in their protocols. my particular area does have it tho, as do many others i am sure.

i'll rephrase my question: lets say there is no als available. lets say you dont put this pt in TP, but you package, give him O2, control bleeding and transport/reassess. well, on the way to the ED the pt goes hypotensive and eventually dies.

Trendelenburg would not have stopped this anyways.

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

-Jeff

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

 

[TKO]

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

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

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

 

[EMTMandy]

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

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

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

 

[TKO]

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

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