RomeViking09

It is that fun time of the year for those of use who work with scouting to start planning camp. I am writing a new training scenario and though I would post it on here to get feedback and work out the flaws in advance. Scenario setting: Resident Overnight Scout Camp in the Blue Ridge Mountains in North GA Time: 1322 Local Time Call Info: A staff member calls into over the radio reporting a "problem" at the ropes course and telling to you to come quick. at 1325 you, your partners, and the camp ranger (with ability to transport 2 on backboards at a time to the camp health lodge) are on scene with a BLS Jump bag, ALS Airway Bag and 2 long spine boards (with Head blocks, and C-Collars of all sizes), the Ropes course has 1 additional Backboard with blocks and collars on scene already and there are 2 more additional backboard w/ blocks and collars on camp property (1 at the pool 3 mins from the scene and 1 at the lake 6 mins from scene). When you get on scene you find that a high ropes element failed with 3 campers on it, in addition 1 staff member and 1 adult leader have been injured by falling parts of the element. The camp ranger has called for local EMS and Fire and 911 gave him a estimated response time of 20 min for BLS Fire Engine Company, and 1hr for 1 ALS Ambulance, they request you advise if your going to need a 2nd EMS unit. Here are you patients after a quick triage: PT 1 (Johnny) - 15 y/o Male, c/c of fall from aprox 40 feet while in a harness and on belay, fall was broken at about 10 feet form the ground by belay device. Back shoulder, and neck pain, minor trauma to the right arm and bruising at harness site. You note damage to the harness from stopping the fall and damage to the climbing helmet. Vitals: HR 128 RR 28 BP 140/93 Pupils PERRL A&O x4 PT 2 (Billy) - 17 y/o Male, c/c of fall from aprox 40 feet while in a harness and on belay, fall was broken at about 15 feet form the ground by belay device. Back shoulder, and neck pain, minor trauma and brusing at harness site. You note damage to the harness from stopping the fall and damage to the climbing helmet. PT is altered and appear to have been hit in the head by a falling steel cable. Vitals: HR 96 RR 26 BP 128/60 Pupils Slow to react but equal Altered LOC but answer questions PT 3 (Bobby) - 14 y/o Male, c/c of fall from aprox 40 feet while in a harness and on belay, fall was broken at about 5 feet form the ground by belay device with strong impact, pt is unresponsive, airway is clear, no bleeding noted, PT's helmet is broken in 2. Vitals HR 52 RR 12/ not regular & Swallow BP 160/95 PT is unresponsive to Verbal or Pain PT 4 (Zack) - 24 y/o Male, c/c of back pain due to belay device and headache form falling objects. Pt was belaying Bobby when fall took place. PT was only wearing a half harness (think wist climbing harness). No trauma or bruising. Vitals HR 115 RR 26 BP 122/78 Pupils PERRL PT 5 (Andrew) - 39 y/o Male, c/c of back pain due to belay device and small lac above right eye from falling objects. Pt was belaying Johnny. PT was only wearing a half harness (think wist climbing harness). PT has a 3" long 1/8" wide cut above his right eye. Vitals HR 120 RR 28 BP 133/92 Pupils PERRL In addition to your listed patients you have 3 more adults and 8 more boys on the scene, none are injured. One of the boy was belaying billy but has no complaint of pain or injury. Tell how you would manage this scene and each patient. ALS can be on scene in 1 hour by ground, Air Evac Possible after fire arrives (total of 45min response time) The camp heath lodge is stocked with almost everything that would be on a BLS ambulance with access the the following Drugs: Acetaminophen Ibuprofen Naproxen Diphenhydramine HCL Pseudoephedrine HCL Epinephrine 1:1000 (5x 0.3ml EpiPen, 5x 0.15ml EpiPen) IV Normal Saline (4x 1 Liter Bags, 2x 250mL Bags) IV Lactated Ringers (4x 1 Liter Bags) D50 (2x 25g pre-packaged) You team is yourself (Paramedic), a 2 additional Medics (1 EMT-Intermediate/85, 1 EMT-Basic who is an Intermediate Student and authorized to do IVs under supervision), 4 First Responders (2 lifeguard w/ FR training, 2 Wilderness First Responders working in other part of the camp) are on camp and can come to assist (3 to 9 min out) with the addition equipment listed at the lake and pool and the Camp Ranger (who is a retired FF/Paramedic). You are operating under BLS Protocols (no Drugs unless listed above) with Limited ALS Authorized for Advanced Airway (Intubation, CombiTube, & Needle Cric are authorized) and IV Therapy (Saline & Lingers) Post how you would treat and when you would transport each patient (you have the ability to transport non-emergent in a camp van that can transport 1 patent on a backboard safely or up to 3 patients and 1 medic in addition to the drive in seats to a level 2 Trauma Center within 45 mins or Call for ALS Transport to the same Trauma Center, No Air Evac) This is going to be a training scenario that happens without the staff (minus the paramedic, ranger, ropes director, staffers playing patients and camp director) knowing in advance

You are called out to a 73 year old female patient for altered LOC, you get on scene and in your assessment you get a blood glucose reading of LLL. Your partner starts an IV, draws blood samples, and then you administer 25g D50, the patient comes around and is feeling much better. You recheck her BGL and it reads 290 now, the Patient says she feels better and thanks you for coming out. What do you do next?

If someone has a low blood sugar due to other causes the ER can do blood work we can't do, ER docs can adjust their medications, the ER can admit them if they need to be monitored b/c of the result of the blood work. I am not saying you take in a paper cut, or someone not hurt in an MVA where someone else called 9-1-1 b/c they saw a MVA happen. I am saying that we don't need to keep brushing off low blood sugar as a waste of our time to take them to the ER. Unless you have some magic way of doing full blood work on them in the field that the rest of us do not have, how do you know what caused their sugar to drop and how do you know all they need is a quick fix? Lets look at a short list of causes of low blod sugar that will not be fixed by D50 and a refusal shall we.... Overmedication with insulin or antidiabetic pills (for example, sulfonylurea drugs) Use of medications such as beta blockers, pentamidine, and sulfamethoxazole and trimethoprim (Bactrim, Septra) Use of alcohol Missed meals Reactive hypoglycemia is the result of the delayed insulin release after a meal has been absorbed and occurs 4-6 hours after eating. Severe infection Cancer causing poor oral intake or cancer involving the liver Adrenal insufficiency Kidney failure (Acute or Chronic) Liver failure (Acute or Chronic) Congenital, genetic defects in the regulation of insulin release (congenital hyperinsulinism) Congenital conditions associated with increased insulin release (infant born to a diabetic mother, birth trauma, reduced oxygen delivery during birth, major birth stress, Beckwith-Wiedemann syndrome, and rarer genetic conditions) Insulinoma or insulin-producing tumor Other tumors like hepatoma, mesothelioma, and fibrosarcoma, which may produce insulin-like factors Now if you can rule all of those out in the field then just let them go, but since 90% of those can be checked with basic labs at the ER I would say take them into the ER. (Starting new topic on this one in patient care section)

I am looking at patient recovery, risk vs reward, and stress on the patient. An EJ has far more risk then a peripheral IV (an EJ is not a peripheral line pre many textbooks b/c of it's flow to the heart, many textbooks put EJ just below central lines as far as vascular access and time to action i.e. Transdermal->Oral->Sublingual->SQ->IM->IO->Peripheral IV->External Jugular IV->Central Line->Interacardiac) EJs are more invasive b/c of the risk to the patient and the after care required. If you give someone an IV or IO you can take it out and send them home, EJ you need to monitor them for 12-24 hours after removal b/c of the additional risk of an EJ.

Another point on D50, how many patients do we push a full amp (25g) of D50 and get a refusal for transport when we should be talking our patient into going to the ER to be checked out. The number of times I have heard a medic say "well your sugar was just a little low, you don't need to go to the hospital just sign here" when dealing with a patient they found altered or unresponsive makes me sick. If the patient is to altered to eat something then they need to be checked by a doctor even if the only reason their sugar is low is something as simple as they did not eat dinner last night. I work under the you call we haul theroy, I would much rather get called in to a supervisor's office to explain someone calling to complain about me trying to talk them into going to the ER then having to go back and work a full arrest on a patient I talked out of going to the hospital. Just my two cents on D50 in EMS

I agree that an IV is invasive in the the EMS setting but compaired to the use of the EZ- IO, the B.I.G., or even a hand driven IO needle an EJ is much more invasive. The risk to a patient and recovery time from an IO is almost excalty the same as that of a patient who gets an IV (having had a bone marrow sample taken from myself with a hand driven adult IO needle) the only additional risk to the patient from an IO is a fracture in the bone where the IO is placed, the additional risks to a patient getting an EJ are much more serious. I do not see a need for EMS provider who are trained, authorized, and have access to the needed equpment to do an IO to concider an EJ before starting an IO. The only time I would see the need to do an EJ when an IO is an option is after an IO has been estblished and it has failed to provide the needed flow rate for a patient in need of fluids to support their BP.

if they can't tell me not to do the IO then they go in the back of the truck an give the D50 En route to the ER, they can take up the IO with the ER staff, then need to go anyway

As a rule of thumb if you can't aspirate the line then the line is not patent, now then again most rules have their limits. Like you said what if the end of the catheter is on a valve. What is the patient like? LOC, D-Stick? If the patient is only slightly altered I think IM glucagon is the best bet, if the patient's D-Stick is LLL (Low Low Low) I am going to hunt for a better IV or even go IO if needed. just my view on the topic.

2-4 mg IF THE BP WILL SUPPORT IT is the "recommended" dose of morphine for any MI. For an inferior you would want to get the BP up first, give the NTG and ASA, and then Morphine (if the BP is still above 90 to 110 depending on your protocol) The patient needs to reduce the oxygen demand on the heart and morphine will do that.

With the better education do we need to limit those who are not educated to the "new" standard from performing skills they have been doing for some time now?

OK so why are we still doing EJs when we have devices like the EZ-IO?

Let's say you can't get an IV even after you get him out of the SUV. (in my area only anterior medial tibia site IO is authorized for EMS with the EZ-IO and B.I.G. the FAST-1 can be used in the Sternal Site)

As a current paramedic student who just finished airway and is about to start clinicals I would like to drop my two cents into this "topic". We spent 2 weeks learning about the anatomy, physiology, and pathophysiology of the airway, when to take control of that airway, what methods we have to take control of the airway. Our instructor focused more on management of the airway as a whole and did not focus on just one way to control a patient's airway. Intubation is best used for total airway control in a patient who can not protect their own airway and is going to be given positive pressure ventilation. Just like there are problems with intubation there are also problems with CombiTubes and King Airways. The King Airway does not provide the same back up method as the CombiTube. If you place a King into the trachea you can not ventilate the patient and you must remove the airway device and re insert, this can be a problem with patients with short airways and lots of inflammation of the GI tract. With the CombiTube and King you can not protect a closing airway such as a patient having an allergic reaction and may have to result to in surgical airway methods. If we don't want to be performing more needle and/or surgical cricothyrotomy airways we need something better than blind devices such as king and combitubes. Now what only a few people have pointed out is improve our training in assisting with intubation with devices such as the lighted stylet, retrograde intubation, bougies, and field fiber-optic scopes. We are lucky to have a hospital that will allow our paramedic students to manage airways on patients undergoing scheduled elective surgery as part of our clinical rotations. We have to get 5 intubations but we also have to perform alternative airways including LMAs, CombiTubes, King Airways, and even good old fashion BVMs with OPA or NPA. It seems to me that more people focus on just intubation as the only form of airway management, intubation is one of many options we should have. From a textbook only point of view a good paramedic should be able to not only intubate but also use blind airways, and perform needle and surgical cricothyrotomy airways. Just because your patient is in cardiac arrest does not mean they need to be intubated, a king is all they need. We also need to remember that we do not have the "right" to do anything as paramedics. We are working under the license of a medical director and he or she gives us permission to perform medical care under his/ her supervision. If the powers that be say no intubation then no intubation and if you want to tube go back to school and become a CRNA or PA or CNP or MD. We should strive to provide the best patient care and give our medical directors reason to let us do more, but we must never get the idea that we have the "right" to do anything we do in EMS. "Skill authorized to the paramedic in their scope of practice are not a right but a privilege given by the medical director." Nancy Caroline's Emergency Care in the Street 6th Edition page 1.15

You respond to a high speed MVC, you find a patient entrapped in a SUV with signs and symptoms of shock, abdominal tenderness, and a broken left femur. Your standing orders and protocols call for vascular access on all trauma patients with signs and symptoms of shock but you and your partner can't gain IV access on his arms. What method of access do you think is best: IO access in the right anterior medial tibia with the EZ-IO or start a External Jugular IV. Give you reasons for your chosen method.

SOLO, WMI of NOLS, and WMA all use the Wilderness Medical Socity as the standard for Wilderness Medicine. So any of the 3 would be fine. I did my EMT-Basic and Wilderness EMT at Landmark and they do an amazing job. I would recomend them. If your already a Paramedic you can just take a Wilderness First Responder if you can't find a Wilderness Upgrade class and you still get Wilderness EMT. The WFR will cover more basics (PT Assessment and BLS skills) than the WEMT but the wilderness content is all the same. Good Luck.

It looks odd but medical kinda works. I still would maybe push for early use of transport vent after inserting a combitube or ET Tube to control the rate and volume before removing any real airway support and oxygenation. I guess if they are gasping the airway is open (while not patient) and that high flow O2 could provide them the needed oxygen if they are getting good compressions.

Many of the more rural parts in southern Georgia will share 2 or 3 ambulances for 3-5 counties, so they had access to EMS just with response times of about 2 hours up to even 3 or 4 if there is not a truck in service in a nearby county. The service providing EMS to them now covers two counties and only has 4 Paramedics 1 Cardiac Tech (same as an EMT-I/99) and 9 EMTs (trained at the EMT-I/85 level). It is amazing that in the US any county does not have at least a volunteer service. I was in a camping accident in the same part of the state and had 2º burns to my chest, left leg, left arm, and neck. It was faster for my friends to drive me to a small local ER then call 911. When they got me to the ER (about 45 minutes after the accident) all the ER did was start IVs and tried to get a life flight to take me to the burn center, they ended up not flying me and taking me by ground 300 miles to the burn center in augusta. I am glad to see the larger services in Metro Atlanta trying to do something to help out the undeserved parts of the state I live in.

12-Lead should be redone, aVR should not be upright. I see Sinus with Pacer.

Based on your info here is what I would have done, take from it what you will: VS q 10 min (HR, BP, RR, SpO2, 3-Lead ECG), O2 @ 15 Lpm NRB, IV, 12-lead, Albuterol & Atrovent Breathing Treatment, maybe call for orders for Solu-Medrol or another respiratory steroid. I would not worry about the tachycardia with a clean 12-lead as the most likely cause is the DIB. I would be ready to treat the tachycardia if no improvement or the rate goes past 150. Our local protocol says to give the A&A if DIB and with those lung sounds unless HR is greater than 150. Did you treat the Tachycardia?

5 am Typo...sorry Here is the corrected data from my report for class (not counting additional post after I did the report for class) Data Source: 14 Online Responses 21 Local Responses 35 Total Responses of a Mix of EMTs and Paramedics PT #1 - 20 y/o Male A/Ox 4 HR 120, RR 22, BP 95/P Closed Fx to Left Arm, Open R Lower Leg Fx Red 10 (29%), Yellow 22 (63%), Green 3 (9%), Black 0 (0%) Based on START Triage this Patient is a Yellow PT # 2 - 25 y/o Female A/Ox4 HR 92 RR 20, BP 130/P, 7 Months OB, Minor Lac on right face above the eye, soreness in the left arm Red 1 (3%), Yellow 8 (23%), Green 26 (74%), Black 0 (0%) Based on START Triage this Patient is a Green (OB is not an Emergency in it's self and does not change triage) PT # 3 - 28 y/o Female Unresponsive HR (weak) 20, RR (labored) 8, BP 20/P, Injuries to the chest and abd, open right femur Fx Red 25 (71%), Yellow 0 (0%), Green 1 (3%), Black 9 (26%) Based on START Triage this Patient is a Red (The patient is still breathing and does still have a pulse, while it is weak and his outlook is not good there is no reason to place this patient as expected yet given your resources)

Ya my spelling at 6am without sleep is not the best... opps

Expected or Dead Patients should be placed in the same area, you would not want to place a patient who your think is going to die (given his vitals) with a bunch of walking wounded. Review the concept of Incident Command in keeping the scene as calm as possible (to a point) if you put a dead guy (or almost dead) with a bunch of living people then you are going to most likely cause someone to freak out.

The scenario comes from a book, I think in the field you would not find a pulse on this PT you need at least a 50/P BP (source: Wilderness First Responder 2nd Edition, Published by Morris Book Publishing 2004, Patient Assessment Page 23) to have a carotid pulse, now if you checked for heart tones with a stethoscope you could get a pulse but we use START. The book says Red, I said black the first time I read the scenario based on the BP (and additional training).

Well I have all the data I needed (internet combined with medics & EMTs where I live) Data Source: 14 Online Responses 21 Local Responses 35 Total Responses of a Mix of EMTs and Paramedics PT #1 - 20 y/o Male A/Ox 4 HR 120, RR 22, BP 95/P Closed Fx to Left Arm, Open R Lower Leg Fx Red 10 (29%), Yellow 22 (63%), Green 3 (9%), Black 0 (0%) Based on START Triage this Patient is a Yellow PT # 2 - 25 y/o Female A/Ox4 HR 92 RR 20, BP 130/P, 7 Months OB, Minor Lac on right face above the eye, soreness in the left arm Red 1 (3%), Yellow 8 (23%), Green 26 (74%), Black 0 (0%) Based on START Triage this Patient is a Green (OB is not an Emergency in it's self and does not change triage) PT # 3 - 28 y/o Female Unresponsive HR (weak) 20, RR (labored) 8, BP 20/P, Injuries to the chest and abd, open right femur Fx Red 25 (71%), Yellow 0 (0%), Green 0 (0%), Black 0 (0%) Based on START Triage this Patient is a Red (The patient is still breathing and does still have a pulse, while it is weak and his outlook is not good there is no reason to place this patient as expected yet given your resources) Thanks to everybody who responded and helped out

Posted them both at the same time in the same post (can't help the posting system)