Lets try some scenarios..shall we

lcbjr3000

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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
 

BossyCow

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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.....
 

reaper

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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.
 

lcbjr3000

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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.
 

BossyCow

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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.
 

reaper

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

BossyCow

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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.
 
OP
piranah

piranah

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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:p
 

AZFF/EMT

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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.
 
OP
piranah

piranah

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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..
 

certguy

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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 .
 

lcbjr3000

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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

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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].
 

certguy

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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 ?
 

certguy

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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 .
 

Outbac1

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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.
 

BossyCow

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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.
 

certguy

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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 !!!!
 

DesertRatetteEMT

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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....
 

BossyCow

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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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