EMSGeek

Hatzolah is a very special group of people. Very, very special. Some of our NYC providers already know about them.

Definitely need to know what the hospitals can take. Any hospitals in the area which are not trauma centers also need to be notified of the possible numbers which they might receive. Treat/package the patients. Stop the bleeding. Prevent shock as possible. Limit exposure to the elements. If an MCI trailer exists have it brought to the scene. The IC will be tracking where patients are going so now the only thing to do is to save as many lives as possible and get everyone to the hospitals which will best serve them.

Given the new information I will have the rescue trucks respond to the scene as well as getting the helicopters in the air. I am going to continue the ambulances to the scene. I feel the needs of these patients outweigh the possibility of a call in the surrounding area. I'm not sure if it is common practice but in my area the dispatchers will have begun tracking available resources and will stage ambulances from further areas in the areas which no longer have ambulances available. Request any available military helicopters with or without medical personnel but with the ability of transporting patients to be readied and I will pull medics from some of the ambulances as needed. Have the IC start relaying initial casualty numbers to receiving hospitals so they can prepare themselves. Once arriving on scene and seeing that this truly is a MCI I would "declare" a level 1 MCI which puts certain protocols into effect (this may be specific to my area). Request that the FD stabilize the bus enough to get those people inside out. I think we need to get them out before we can tend to those that may be under the bus. Ensure trauma centers in the area know they will be receiving multiple critical patients thereby giving them time to bring in extra hands.

Given the potential mechanism and chance for a large number of patients I would request all available ambulances from the surrounding area and get the helicopters in the air. IC would need to find out the receiving numbers for any hospitals in the area, especially trauma and burn centers. LEO would need to be present in force on scene to keep things under control. I'd be concerned about family going to the scene. Additionally put other rescue units on standby should we need multiple extrications. Perhaps get the Red Cross involved since there may be people who don't need a hospital but will have no where to go for a while. The Red Cross will also be able to provide grief counselors and folks of that sort.

I'll be interested to download that powerpoint when you get it.

If you get a difficult call, take it and do the best you can. Render the best quality care you can and deal with any mental ramifications after the fact. If you abandon a patient or deny them care you will have to deal with that on your conscience as well.

That's a good idea which I had forgotten. The 50/50 mixture is an effective and practical solution for keeping these guys hydrated. I've used that for standbys at athletic events such as marathons. Get a nice big Gatorade tank like the kinds contractors use and put that on the rig when going to a structure fire. You can get powdered Gatorade to be kept handy when needed. If local places like Sports Authority do not carry the power it is available off Amazon.com.

Fire monkeys can be very resentful to our actions as EMS providers when it comes to rehab. I believe, and its also the feeling of fellow providers I have spoken to, that a lot of the problems we have with FFs are because they don't respect us so my advice is to explain very clearly the medical reasons why you are not comfortable letting them go back in. Be respectful but firm and make it clear you are speaking to a fire fighting professional as an emergency medical professional. This is true even when the fire monkey you are talking to is some redneck smelling like beer (not true for all firefighters but for some). Patronizing is good, but make sure that no matter what the firefighters best interests are looked after.

The body is always working towards homeostasis but when it has become so taxed that it can no longer do so bad things happen. In the case of heat stroke we are talking about the bodies ability to regulate temperature. The bodies main methods of temperature detection is the skin (hence why burn patients have trouble regulating temp.) so when the skin is compromised the body can not detect temperature. The way the body actually adjusts its temp. is through sweating which requires water. If the skin is compromised or the body doesn't have enough water it needs time to redevelop those abilities so, yes, once you have had a heat related event you are predisposed to have another. The body needs time, usually a day or more, to get back to normal.

The patient's NIDDM is tied to Metabolic syndrome (syndrome has 4 key features: diabetes, hypertension, obesity/overweight, and high cholesterol). Suspect significant renal degradation leading to her current condition. Recommend a flat plate of the abdomen for kidney size, intravenous pyelogram, a 24-hr urine catecholamine, a serum cortisol, a plasma renin level, a 24-hr urine aldosterone determination, a cystoscopy, and retrograde pyelography. The patient is exhibiting some symptoms of later chronic renal failure. My "diagnosis" is renal distress with the need for immediate tertiary care.

Ok, what do those documents give us? Can I contact her primary care physician for a consult? Has she seen any specialists in the past? Any possibility of an autoimmune disorder such as lupus?

I'm definitely not tossing in a white flag. The medics and docs out there have too much fun anyway so there's no way I'm going to miss out. :wink: That was my definitive real world solution. I'm still abusing google trying to work out a few theories/possibilities.

I'm a BLS provider and assuming I'm on a BLS rig which has been requested to transport this patient I'm going to need to make a decision soon. I want to see what her vitals have been like for as long of a period as the hospital can give me. If the trend seems to be about stable I am going to request a paramedic to hop on board my rig in case the patient should have the nerve to croak but I'm going to take this transport. From a BLS point of view I may not be able to solve what is wrong with the patient and almost certainly I cannot fix it so the best thing I can do is to get the patient to a facility which can help her as quick as possible. Having the medic on board will allow better tracking of the patients condition, treatment of anything which may crop up, and a cushion should something bad happen. If I could not have gathered all the information which has been collected so far I would refuse the transport, give the hospital my EMT #, explain my reservations, and tell them to contact my supervisor. The initial report left way too many variables for me to even remotely comfortable taking the patient because at the end of the day I need to do what is best for the patient and keep the safety of my crew in mind. A patient with such a potentially serious condition needs more than my ambulance can provide during transport, suggest requesting a helicopter to take her out. Additionally with so little information I'd rather not take the slim chance that whatever she's got is contagious and expose my crew to it. I'm going to keep thinking regarding the scenario in terms of problem solving though.

ERDoc: Thanks for the clarification. Congrats on the 1000th post. Is the patient's WBC considered elevated? Here's a breakdown of what I've gathered so far organized into the AEIOU-TIPS grouping. A: No evidence for alcohol. Husband was with PT and did not report anything. Nor do any of the physical findings indicate ETOH involvement. E: Endocrine/electrolytes are still a possibility as far as I can tell...cannot eliminate but nothing leading towards it. I: Condition existed while the BG was fine so I'd be comfortable removing insulin from the list. O: Same as ETOH, no reason to think opiates. U: Although the neurological symptoms of uremia line up with the patient none of the physical symptoms do. T: No trauma so I'm ruling this one out. I: I'm not sure what could cause a change in ICP outside of trauma so I can't really rule this one out. P: Poisoning could be a possibility just because it is such a general grouping. More blood tests would need to be run for any toxicological findings. Speak with the husband to determine if an exposure to any harmful substances could be possible. S: Nothing to indicate the patient is post-ictal so I'm ruling out seizure. Sepsis is a good possibility depending on what some of the other information shows. Ask husband about the patients activity in the last couple of days. Any travel, exotic foods, etc? I may be way off but I'm trying here....don't kill me, please.

Could you interpret the WBC for me? A quick google search shows me that a normal reading is "4,500-10,000 white blood cells/mcL (cells per microliter)". How does the figure you gave relate? Sorry about the dumb question. What are her vitals? When answering questions is she searching for the answers? Why only one word answers? Any joint pain, rashes, or dizziness? Regarding the UA...has she not been asked to urinate? has she been unable/unwilling to urinate? does she have a decreased need to urinate?

Did the hospital do any tests? How about a blood glucose level? Run through the AEIOU-TIPS pneumonic to try and determine a cause for the AMS. How long has the pt been in the hospital? How did they get to the hospital? Has their level of AMS changed? What have their actions been while altered? (Is the scene safe?) Any medical history? What do I see when I see the patient? What is their posture, appearance, demeanor, etc?

The medics who support my counties Emergency Response Team are not armed but must undergo training to use the rifles and side arms that the officers carry.

Prior to attending college two years ago I had never been involved with EMS. I entered college pursuing a BA in Technical Theatre which is the degree program I am currently enrolled in. Since getting into EMS and becoming an EMT I have been struggling with the decision to seriously pursue EMS and the education which would go along with it. Now I am trying to figure out the best way for me to transfer schools and or get an associates in paramedicine. I've been looking at several colleges which offer degrees in emergency management or EMS management, etc which would allow me to get a BS which relates to EMS and become a paramedic. I'm going to start a new thread about some of those programs soon. Gosh you must know NYS pretty well. Hit that one on the head. I've learned this to be a sad but true fact and there's no reason for it. Going against my expectations knowing I would have to carry the patient out of her home she was surprisingly skinny. I'd guess 130lbs perhaps. She wasn't malnourished or sickly but rather in decent shape and with a slim frame. I would say that 98% of the time when ALS is needed they are available. This happened to be a really bizare evening in which multiple emergencies occurred within minutes of one another. A series of severe thunder storms were part of the problem, those same thunderstorms slowed down our transport. That's what she told me. We've all known patients to do dumber things, right? She seemed to go down hill rather rapidly once we were in the ambulance. The vitals I had were shortly after arriving on scene. I did not get another set until after we were pulling into the ER. She was speaking in approx. 2 word blocks due to her SOB. She understood the neb might help and was able to take it. I think it was within 10 seconds or so because I don't remember using the BVM for very long after. It seemed like a switch was turned on because she gasped and started gagging immediately. I'm going to keep an open mind and not rule anything out. I listened for lung sounds when I thought she stopped breathing and where I had heard sounds before there was nothing. I'm a big fan of on going education and I am certainly reviewing a lot of info about asthmatics.

As far as airway adjuncts go I only have OPAs and NPAs. We're a little behind in the times. Combitubes and King LTs are relatively new for medics here in New York and not that widely used. The medics in my area don't even carry them. I know a few agencies in northern New York which do carry them but most of the medics are more comfortable with standard intubation. I agree completely with AZCEP...EMTs need better education not just more training. <rant> I see too many red neck fire monkeys who are unfortunately certified as EMTs who really don't give a damn about PT care other than the bare minimum. These are the guys who show up in sweat pants and have cars with 4 blue lights. I hate when I tell someone I'm an EMT and they have a look of surprise and explain that they think of someone with a large beer belly and a pickup as an EMT not a prehospital care provider as we should be. I want to see the day where there is much more education as well as training in the EMT and Paramedic program but unfortunately the public isn't willing to pay for quality care until they need it and then it's too late. </rant> Sorry about that. Thanks for the great feed back and discussion.

Thanks for the compliments chbare, but I have yet to leave school...unfortunately the college degree I'm pursuing doesn't do a lick of good in EMS. Paramedic is coming my way sooner than later.

You said gurgling respirations...is the airway clear, any fluid, if so what? Definitely interested in the meds (look at quantity of pills and compare to date issued as well as rate to be taken, try to determine if OD is a possibility). Make sure the pt is in the sniffing position. Any difference in pain response between left and right sides? Last time she was "normal" was when the son last saw her? How long ago? May not be much but it's something. Any ETOH around? Smell anything on her?

Thanks for the replies guys. I absolutely realized from the onset that the PT needed ALS but I was the best she had for the time being. I figured good BLS goes before ALS anyway so I might as well try to do that and hope for the best. I agree that I've over simplified the pharmacology of Epi but part of that is due to the depth which the EMT-B program covers Epi. I'm reading up on the pharmacology of epi now. I already plan on paramedic school. It's in my near future but between wishing a little more experience as a BLS provider and not having the time yet (already a full time student) it won't happen for about a year. Thanks again guys.

Before I get to my question let me explain the call and my EMS system. I volunteer in a suburban area on a BLS rig. Our county has a contract with a private ambulance service to provide paramedic response as needed however for my recent call the county had numerous calls going on at once and all the paramedics were unavailable. My dispatch was for a 35 F with severe difficulty breathing due to athsma. On scene about 12 minutes after the dispatch to find a 30s F kneeling on the floor of her bathroom dry heaving into a toilet with audible wheezes. Power was out and it was fairly dark. I ruled out trauma and got the patient moved out of the bathroom to the living room where there was some light coming in from the outside. Patient was cool, pale, diaphoretic, and in significant distress. Vitals were: BP of 140/70, HR of 100 strong and rapid, and RR of 20 and labored with wheezes. Patient stated she had been sick for about 16 hours and her Dr had diagnosed her with food poisoning. She had been vomiting for the entire time and in the last 8 hours she started having increasing difficulty breathing due to her athsma. She had a albuterol inhaler which she had taken twice in the last two hours without any relief. I started her on high flow O2 via NRB at 15lpm, got her in the rig, immediately started transport, and re-requested ALS but no luck. I got a quick medical hx from her with nothing that stood out. No problems other than athsma and the food poisoning, no cardiac problems, no other respiratory problems, etc. Lung sounds were still tight with bilateral wheezes. I gave her a nebulized albuterol treatment per protocol with no improvement. Our normally 10 minute transport time was increased to 20 going L+S due to severe thunderstorms which made the roads dangerous. 10 minutes into the transport (about 4-5 minutes after the neb treatment) the patient went into respiratory arrest. Patient's pulse was down to around 80 (my educated guess, I didn't count). I dropped an OPA and began bagging the patient while having my driver update the hospital and the medics. Approximately 2 minutes after the patient stopped breathing we got a medic to link up with. We were still almost 10 minutes out from the hospital at that point. I gave him a quick report but he already had some info from our radio transmission. He gave the patient an IM injection of Epi (not sure the dosage) and within seconds she took a gasp of air and I pulled the OPA which she started to gag on. Safe to say she started breathing again. Respirations were still labored with wheezes but at least she was breathing. Paramedic took over treatment and the patient made it to the hospital without any other changes. Now I can get to my question. I have friends who work in rural areas that have 40+ minute transport times without the possibility of ALS linkup in under 30 minutes. My call got me thinking about what I would have done if I had that call in one of my friend's districts. Should I just stick to my BLS protocol and keep bagging the patient or would it be acceptable to call medical control and request to give an Epi pen? I don't know how the dosages would compare between an auto injector and the dosage drawn up by my medic. Would the .3ml I could give actually hurt the patient? In terms of the biology I believe ALS uses it for Athsma because it is a broncodialator and BLS uses it for anaphylaxis because it counters the immune response. Let me make it clear I would not do this without the ok of a Doc so I would like some responses from some of the Docs in the community as well as other EMS providers. Thanks in advance.

I've got a co-worker who swears by the Big Shears. I handled his and they feel great in your hand. He has owned them for a year or so now and as a firefighter/EMT has gotten to use them to cut off a fair amount of fabric. His assessment was that they made short work of heavy fabrics like denim and had no trouble with leather or bunker gear either. The holster they come with seems to make them very easy to carry as well.

I'm going to take a guess at what the deal might be. Join USMC. Get deployed to Iraq. Get issued all sorts of gear in which may be a desert jacket. Get shot at. Ruin said jacket. Start all over. Am I right?