FireEMT2009

Not sure man, but I used to get them that appeared spontaneous.

What is her BGL?

DDX at this time for me in order of index of suspicion.

MI

PE

Bronchospasm

Anxiety secondary to argument with husband.

At this point she's relatively stable. But what would be your treatment options if you were remote and help was at least a few hours away? I wonder if it would make sense to trial Glucagon?...But I think some of these questions would likely be answered by SPO2.

Dwayne

Her BGL is 120.

We do not have a ETCO2 at this time.

She was not arguing with the husband and stated by her and her husband they were just watching TV and eating breakfast. Patient does not look scared or nervous. Upon impression and inspection you find no evidence of physical abuse or psychological/mental abuse.

You are about 10 minutes outside of the nearest hospital.

Why would you want ot trial glucagon for a patient having SOB?

You have given 324mg ASA.

She states that her SOB is slightly reduced with the application of oxygen.

What other treatments would you like. Are you ready to start hitting the road?

I didn't see the mitral valve replacement in the history.

Could the valve have malfunctioned or thrown it's own clot?

It might just be me and my recollection but shouldn't she be on a blood thinner based on the heart valve replacement?

My thought might be that the valve developed plaque on it/or an issue on it and it finally broke off going to her lung.

I think she might have been on a ASA regimine actually. Sorry about the red herring, I am having to run this based soley off recollection.

Well actually clots form over a period of time. Depending on her level of high cholesterol and her diet they can form over periods of months. My close friend many years ago had a huge clot in his left calf that they had to go in and put some type of clot busting drug directly on it which of course didn't work so they went in and stripped his vein in his calf. He said it hurt like a bitch having that happen.

So she doesn't have a clot, what else could it be?

You said chest pain, what is it's strength, is it off and on or is it constant? Is it tearing or just constant?

We could have a musculoskeletal event that was triggered by her getting up and turning wrong.

She states that it is hard to describe. She said its constant and it isnt musculoskeletal. It cannot be reproduced by palpation.

Well first what makes me think blood clot is that she was sitting in a chair and she stood up and within moments she had the soa.

The other would be her age.

Do an exam on her legs, see if her calves are red or inflamed. Ask her if she has or has had any type of calf pain in the past week or recently.

Does she sit for extended periods of time in that chair or any chair for extended periods of time.

Does she have a family history of high cholesterol?

Exam shows no reddened or inflammed areas. She has not and any type of pain recently except the shortness of breath. She says she sits for about an hour but gets up and does other stuff,. so no, not long enough to cause clots to form. and family history is unavailable.

How long was she in the chair for? Did she sit there for a long period of time - 4-6 hours without getting up?

Does she take blood thinners or has she ever had a PE or blood clot in the leg?

I'm leaning towards a blood clot in her leg, breaking off and travelling to her lungs. That would explain most of the scenario. But maybe you have a different thing happening.

Good scenario so far.

No history of PE or blood clots. She takes no blood thinners. She was only in the chair for about 20-40 minutes while eating breakfast with her husband while watching tv.

That is a good field impression. What are some other DDX for this patient?

Clear lung sounds and pretty decent O2 sats? I'm thinking there's more to this picture than meets the eye, especially considering she's an older woman and a diabetic. Let's get her moved into the truck ASAP and get a 12-lead EKG. Tell me about this chest tightness, where is it exactly? Does it feel deep or close to the surface? Is it going anywhere? Is it constant/intermittent? Has it been getting better/worse since it started or staying the same? Anything she's done to try and make it better or worse?

Any other history, meds, or allergies? Has this ever happened to her before?

HEENT: Any perioral cyanosis or nasal flaring?

Neck: JVD, retractions, tracheal deviation, subcutaneous emphysema?

Chest: Depth of respiration? Equality of chest rise? CABG scar or palpable implanted defibrillator/pacemaker?

Abdomen: Soft/rigid, any bruising, distention, pain/tenderness?

Pelvis: I presume it's stable since she is able to bear weight.

Posterior: Anything significant?

Extremities: Neurovascular function? Cap refill? Numbness/tingling?

As for vitals, I'd also like:

Pain rating.

BGL.

Treatment wise, let's go ahead and put her on 15 lpm via NC. I'm hesitant to give her high flow O2 if this is a potential cardiac event, especially if she has clear lungs and good sats, but at the same time I want to give her some relief as well. If we need to adjust that later we will. Let's also get an IV of NS TKO.

Bieber,

12 lead comes back completely normal. The pain is in the her chest she really cant describe where it is or anything. Oxygen made it little better. The pain has stayed the same. Insulin is her only medication and no known allergies. This has never happened to her before. She also states that she had a mitral valve replacement about 8-10 years ago.

HEENT: Nothing remarkable.

Neck: Nothing remarkable.

Abdomen: soft nontender.

Pelvis: stable.

Posterior: nothing noted.

Extremities: Nothing remarkable.

Pain level- 4-5

BGL-130

15 lpm NC? Do you mean 5 lpm?

You now have an IV running TKO.

What was she doing prior to the event?

Any pain on inspiration in any particular area of the chest?

Sitting in a chair watching tv. She stood up and the pain started.

Ngetative on pain. and she has stated that it pretty much stays the same.

Scene size up: What does the house look like? Does the yard appear clear of debris, etc? Is the scene safe?

Patient assessment from a distance. You stated obvious trouble breathing. How is it obvious? Do we hear wheezing or obvious pulmonary edema from across the room? Anything coming out of her mouth (sputum, etc) ? Skin condition?

PPE - gloves, face masks if indicated due to severe CHF.

The stairs thing - I'm assuming you mean she's standing in the doorway of her residence with a couple stairs out the front door. Let's get her seated on the stretcher as quickly as possible, I don't like to let respiratory patients stand / walk for a long time.

Upon approaching pt - is she alert and oriented? Any complaints other than shortness of breath? Breath sounds? Medical history, especially anything that would cause a respiratory problem (CHF, COPD, etc)? When did this start? If it's been a while, what made it worse right now that made her call 911?

Have my partner obtain vitals, including RA SpO2, BP, pulse, 3-lead ECG for now, respiratory rate, and probably EtCO2.

Nice house, yard cut, clean, spotless. Scene is safe as possible. Extreme trouble breathing, really working on breathing. No audious breath sounds heard upon meeting the patient. Nothing coming out of her mouth. Skin is normal.

PPE- gloves are on, face masks are standing by just in case.

She was standing but you had her sit down on the steps of the stairs to do your assessment. She had to walk down a flight or two of steps to get to the door.

She is alert and orientedX4, tightness in her chest, clear breath sounds, IDDM and HTN, Started earlier when she stood up out of a chair. It started 10-15 minutes prior to your arrival.

BP- 146/94

SpO2- 95% on Room Air

HR- 100 regular strong in radial.

RR- 26 deep, labored.

EtCO2- unavalable.

3 lead EKG- Shows sinus tachycardia at a rate of 100.

You are dispatched to a house for a patient having trouble breathing,her husband and her have meet you at the door. She is having obvious difficuluty breathing. You get her to stand on the stairs behind her.

Treat her!

FireEMT2009

FireEMT, great scenario! Thanks for sharing it!

Dwayne, 90 seems to be the magic number people are liking nowadays--mostly in trauma, but from what I've heard that seems to extend to all patients as well. Ultimately, what I want to obtain is good perfusion to the patient's brain and vital organs, though since he's actually lost fluids, perhaps I should aim that number a little higher.

Hmm...

Thanks! I will definately be sharing another one here shortly!

That's a good point. I don't see anything so far that would lead me to believe that I'm going to have to intubate. We do need to reassess and clearly define the need for pain management, as it may already exist but has not been the priority, but so far I think we're on a decent path.

Dwayne

That is what I was thinking. We have the IVs in already, im saying be ready because his pressure could start to bottom any minute since be is bleeding like hell. The thing that I would say I dont agree with you on with your treatment plan is trying to pack the wound in his mouth. We need to try and stop the wound but being in the mouth it endangers the airway by trying to pack the wound. If I have misunderstood what you meant by packing it please correct me. Hopefully this patient doesn't crash till we can get to the hospital.

FireEMT2009

Yeah, and stopping for the insurance information at this point will likely get you fired faster than starting an I/O on a possible stroke/hypoglycemic. I'm getting paid either way my friend...

What caused you to choose this blood pressure?

Dwayne

Dwayne,

Our paramedic school and the standards themselves state now that 90 is where we should aim our BPs to be at in patients that are hypovolemic and need fluids. That is the rationale I'm guessing he used when he chose that number.

FireEMT2009

Let's go ahead and titrate our NS to try and get and maintain a pressure of around 90 systolic. Any changes in LOC?

We'll call the hospital back for insurance information later!

You drop another 750 mL, and he starts to groan. His blood pressure is now 89/60. You administer another 250 mL and he comes around and starts to wonder what happened and who you are. You are now at the hosptial and the ER docs and nurses have been handed care.

The doctor comes in later and stated that your patient stated that he had been working in the factory and he got sprayed with the dispenser accidenty. He said he wiped off as much as he could.but still had it all over him. He went home that night and started having horrible diarrhea and vomiting. He just thought he was haivng a horrible stomach flu. The doctor stated that he had suffered severe dehydration along with the organophosphate poisoning. Doctor shakes your hand and congraduates you on your save.

Congrats Beiber for working all the way thorugh the scenario! Thank you Dwayne and everyone else who commented.

This is one of those weird things that seems like a no brainer to me but seems like I'm the only one I know that does it, and that is that I want his clothes off before he's strapped to the board. It takes time and sometimes manipulation to get good visualization when trying to cut the clothes off after the straps are on.

So I have Fire Ccollar him and hold manual Cspine, his clothes are cut off down to his tighty whities, and I peek into those in front and back for missing or damaged or bleeding parts. I have FE09 supervise the Cspine taping and continue suctioning as I have little faith in my unknown help not to suffocate him with the suction or possibly increase bleeding by being too aggressive, or perhaps not aggressive enough.

Are we able to determine where the bleeding is coming from? Is there any way to pack it in the inside of the mouth? Does he respond to being disrobed, or manipulated with any type of pain/indignation response? I'm going with Warfarin as his med based on his statement and the difficulty with managing the bleeding. To me this means that we have to be very judicious with our fluids and do what we can to pack/bandage any wounds with significant bleeding as a 20 minute transport can make a significant difference to this guy. (Yeah, see, here we go again. Likely your protocols say that you can bandage his wounds, but not pack them, so what are you going to do with those that you can't bandage? Let them continue to bleed?)

After he is strapped to the board I'm going to load him on the cot with a couple of blankets stuffed behind the right underside of the board so that his airway will drain. (Right underside is only relevant so that he will be tilted facing me, instead of away, when I'm on the bench seat.)

Does he struggle on the board? If so trying to clean him up at this point enough to get a decent set of electrodes placed to see if a cardiac issue may be occurring is likely a waste of time. His resistance is going to queer any of my results as well as take up a lot of time for very little benefit at this time.

Two 14s preferable both on the right arm, one a blood Y, where they will hang out of my way as I'm confident that we have abd bleeding already as evidenced by the distention/guarding and possibly falling B/P. (Not sure as of yet, as two readings does not make a trend, but combined with his overall assessment it seems likely.) We may also be managing a pneumo/hemo before transfer of care and it leaves me less obstructed access. It also helps avoid any of our 'helpers' from pulling them accidentally.

I need to get really, really good vitals, and really, really good breath sounds at this point, monitor his mental status and I'll certainly intubate him if/when be becomes unresponsive. I know many might believe that I should be focused on his head injury, but as long as he can keep his airway clear, other than stopping the leaks, there is little that I can do for anything in his head that might be going to kill him, so I will prepare for the things that I believe are going to go wrong before transfer of care that I may be able to influence.

IVs TKO, constant monitoring of his airway, PMS x 4 regularly, lights and sirens and best safest speed (Which means we ask a fireman to follow in the police car and have cop drive us) while I call the hospital and tell them to wake up all of the expensive people.

Dwayne

Dwayne,

If you go intubation route you might want to try and premedicate the patient with lidocaine first. It is thought to help decrease ICP. which could be a major issue with him.

12 lead shows a sinus tachycardia, no ST elevation/depression or T-wave inversion or any other appreciable abnormalities. The temperature outside is in the high 80's, low 90's. Cap refill is about 3 sec. Son says his father is allergic to penicillin, has an unknown cardiac history, doesn't know any other medications besides something that starts with "warf". He doesn't know anything else aside from the fact that the patient's been consuming copious amounts of ETOH tonight.

Well I am going to keep the blanket on him anyway because since he is bleeding in copious amounts and the rigidity in the stomach and the dropping BP means that he will become susceptable to hypovolemic shock and will become easily hypothermic. I am also gonna get another set of vitals.

FireEMT2009

Well, I think that's all I got. It sounds like organophosphate poisoning to me, though hopefully we can get some samples of that powder to the hospital for analysis. At this point, I'm gonna go ahead and open up that line since his pressure's staying pretty low and bolus in 250 cc of NS and reassess his pressure and vitals and we'll just take him in. If the patient's breathing spontaneously and adequately now we can stop assisting ventilations.

After initial bolus BP and pressure change, others stay the same.

BP- 72/48

HR- 120.

Well, I think that's all I got. It sounds like organophosphate poisoning to me, though hopefully we can get some samples of that powder to the hospital for analysis. At this point, I'm gonna go ahead and open up that line since his pressure's staying pretty low and bolus in 250 cc of NS and reassess his pressure and vitals and we'll just take him in. If the patient's breathing spontaneously and adequately now we can stop assisting ventilations.

After initial bolus BP and pressure change, others stay the same.

BP- 72/48

HR- 120.

Make sure you get the Insurance Information... If the Service doesn't get paid, you don't get paid...

Aflac pays you money!

Yeah, I'm afraid I occasionally suffer from a minor case of head-in-ass syndrome. There's no known cure, but with treatment I should be able to live to a ripe old age.

Let's just keep going with the 2 mg atropine until we either dry his secretions up completely or until signs of atropinization occur. It would have been nice to check his wallet and phone, but those are probably in the bag with the rest of his clothes. Oh! Why don't we send somebody to run inside real quick and look for any phone numbers for friends/family/work (especially work)? See if we can't get a hold of somebody and find out what he was exposed to.

Let's get a sugar on him as well, and reassess his LOC. After that, and unless we can get any more information out of his neighbors or contact his work, I'd say let's get him rolling. I'm still thinking this is some sort of organophosphate poisoning, but there's a lot of unanswered questions. He was in his pajamas, so he must not have been at work, but we didn't find anything in or around his house? Is he a smoker? Any other medical history, meds or allergies we were able to get out of the neighbors or anything we found on scene?

EDIT: Also, any recent history of illness? Travel outside of the country, even?

Beiber,

His secreations have officially stopped with the administration of the 2mg. His wallet and phone was found in his clothes. Your crew walks in with a biohazard bag and collects the clothes on the floor. They state his floor and bed were all covered in this white looking powder, the same looking powder that are on his uniforms that were in the pile. The neighbor has no further information. You call the plant he works for and they tell you that he has been out the past two days with a real bad stomach bug. They tell you that he works in the pesticide department pouring a powder pesticide into the bags. Remember beiber the time is 2200. You find no ashtrays or cigarettes/lighters.

His BGL is 130, and still unconscious.You find a number for a person named "Mom". You call and she tells you that he is only allergic to penicillin and milk. She also tells you that he has never been out of the state in his whole life. She also states that his age is 35 y/o. What other questions do you have?

New vitals are

HR- 140

RR 12 BVM

SpO2- 99

BP 62/38

EDIT; for grammer and more information that is needed to continue scenario.

FireEMT, you successfully suction out the patient's airway again, but I bet by now you know what's gonna keep happening, don't you?

Bystander states he is the patient's son and that the patient was consuming ETOH tonight (the smell of which is evident on his breath) when he drove down the street on his moped at sixty miles per hour and "wiped out". Oh, and he also mentions that the patient has a "heart history" and takes something that starts with "warf".

You note no battle signs, however the patient's face is still completely covered in blood. If you didn't know better, you'd almost say someone had torn off the epidermis on his face. You also successfully put on the NRB, and the patient is pretty much able to maintain his own airway, though he continuously turns his head to the side and spits or demands you suction him out. Once you get in the back of the truck, one of the fire guys offers to drive you in so you and Dwayne can dual medic it in the back. You are between fifteen and twenty minutes away from the nearest trauma center (closer to fifteen, thanks to the low traffic at night). HEMS is available.

Dwayne, GOOD PLAN! You get masked up and get your truck set up. The patient just lies there. He moves his head to turn it on the side to spit, and moves his hands around emphatically, even when you tell him to stop, but he's not combative--just uncooperative. When you try to tell him what happened and that you're there to help and take him into the hospital, he responds with a "F*** you!" and also rants about you and FireEMT being assholes, but otherwise refuses to answer any questions.

Once you get him in the back of the truck, you guys get him naked and note the following:

HEENT: Eyes are swollen shut, and you are unable to assess his pupils. The blood is making his eyelids too slippery to raise. Everything else is as before, and if not for the fact that you can see the rest of his body you would have no clue what color his skin was. Attempts at mopping up the blood seem futile, and his facial wounds continue to bleed slow but steady.

Neck: Same as before.

Chest: No soft tissue injuries or deformity of the chest wall noted. No subcutaneous emphysema.

Abdomen: Upper left and right quadrants are soft, with no bruising, distention or guarding. Upper and lower right quadrants are rigid, with bruising noted and guarding present.

Pelvis: Patient is incontinent of urine, no priapism or soft tissue injuries present. Pelvis is still stable.

Posterior: Same as before.

Extremities: Patient continues to demonstrate normal motor function with no gross deficits, vascular function is intact in all extremities. Significant bruising is noted to the right knee, and patient has multiple small abrasions on both lower extremities. Upper extremities are the same.

Also note patient's skin feels very cool to the touch and appears pale. You get your lines, and you're easily able to restrain the patient with the soft restraints. EKG shows a sinus tachycardia with no ectopy. With constant suctioning, you're able to maintain a patent airway.

Vital signs now:

HR: 100

RR: 24

BP: 108/76

Beiber,

Well I am definately gonnna start two 14 gauge IVs like you said. The patient seems to becoming more and more unstable and is gonna start decompensating soon due to the fact that is lower quadrants are rigid and his blood pressure has dropped over 10 points since we got the first set. I would set my lines TKO until his blood pressure really starts to fall faster. I will also do a 12 lead just to verify that he has not had a heart episode in another part of heart. I will also cover him up with a blanket to prevent hypothermia. What was the temperature outside? I would roll lights and sirens. How is my capillary refill? I would like a repeat of my vital signs every 5 minutes. Can the son give us anymore SAMPLE?

First I'm going to retreat and get PPEd for this guy. I don't know if he spit on me on purpose, but with continued bleeding in his mouth it's a fair bet that he is going to continue to spit all over the place. It's just what they do. No fire or volly or police are to approach this patient without a minimum of goggles, mask and gloves. No question that this will be reported later as an exposure so lets try and not have to look any dumber than necessary by having to report more than my partner and I. Also, I am going to report me and my partner for a failure to properly protect ourselves and suggest remediation with BBP (blood borne pathogen) education.

As you go back to your ambulance for PPE, what is the patient doing? How is he behaving? Is he trying to stand? Holding his head up or letting it droop? Trying to speak? Aware of the things going on around him?

What does the bystander say happened?

I want my partner to go ahead and set up the back of the ambulance for a trauma, which for me means meant two 14g IV set ups, one 10ggt, one blood Y, intubation kit set out but not opened, NRB mask attached and running, though it doesn't sound like we'll be using it on this fellow, stethoscope hanging on the grab bars, 3/12 lead ECG set out with patches applied.

While s/he does that I'm going to re approach the patient with the Fire guys with a C collar, long board, soft restraints, suction, and trauma sheers.

We need to get this guy naked, boarded/collared, (leaning on it's side to keep the airway clear) so that we can figure out how badly he's damaged and how we're going to manage it. From your above description is sounds as if we're dealing with mostly cranial trauma. It's possible other than O2, and lines that we may do little more than this depending on the answers to the above question regarding trauma centers. Either way, we need to be moving quickly, though intelligently, towards a higher level of care.

Dwayne

Who looked lke the dumba** that forgot the PPE and indangered all the crews around? THIS GUY!!!!! Thanks for commenting on the PPE Dwayne.

I was waiting to see if someone was going to jump on your for considering the above separate steps separately. I can't tell you how much I respect that you consider your initial impression, separated from your more thorough exam. You can learn a lot in the minute or two that it takes your partner to get an 'official' set of vitals.

Also, man, you think that you have your head up your ass? OP poisoning and PPE didn't even enter my mind. Yikes...I was thinking of intubating so that I could quite screwing with his airway and wondering if I could remember how to mix dopamine at about the same time that you noted SLUDGE. That's cool as hell on your part, not so much on mine.

Outstanding scenario as well as assessment! Man, this thread is really strong...It's truly the best of what's good about the City.

Dwayne

Edited to make me look like an even bigger idiot that I did when I originally posted. No significant changes made.

Why dont you give me a treatment plan for what you are thinking mixed in with beibers that way we can get a double medic attack on this guys condition?

As you approach the patient, he spits blood in both you and your partner's faces and yells "Get that f'**in' light out of my face!" He speaks appropriately, though he has blood in his mouth, but refuses to respond to your questions. Though he is not cooperative, he is not combative. You and your partner (who had not been wearing face masks) are covered from the waist up in blood spray!

Vitals as noted at this time are:

HR: 88

RR: 22

BP: 110/78

Visible injuries:

HEENT: Massive swelling to the zygomatic processes bilaterally with crepitus felt beneath, lacerations to his mouth and scalp which are bleeding steadily, swelling around his eyes prevents the patient from opening them. No deformity to any other bones of the skull noted. Copious amounts of blood in the mouth, which he continues to spit out without regard for his aim.

Neck: No JVD, retractions, tracheal deviation, subcutaneous emphysema, deformity to the cervical spine (assessing for pain meets the response "F*** you!")

Chest: Patient is wearing an intact T-shirt at this time. No abnormal chest wall movement is noted through the shirt, however.

Abdomen: See above.

Pelvis: Patient is wearing jeans which are intact. Pelvis is stable.

Posterior: Upon log rolling the patient, you lift up his shirt and note no soft tissue injury or deformity to the back or the chest wall or spine.

Extremities: Intact with no deformity noted. You do see a couple of abrasions to the patient's forearms, and his hands are covered in blood. Vascular and motor function are in tact, patient refuses to answer you when questioned about his sensation.

You suction the patient's mouth out and manage to clear it, however you note that it is quickly filling with blood once again. Fire crews arrive and begin to assist you with immobilizing the patient.

EDIT: Also! A bystander is on scene if you'd like to ask him any questions. And as another note, the patient's age is currently indeterminate due to the blood covering his entire face; however he is obviously an adult male.

I will continually suction the mouth and once the BLS crew gets here get them to take over suctioning and get another set of vitals. I also want the bypasser to give me what he knows about what happened and if he knows this guy. I am suspecting a basal skull fracture. Do I note battle signs?

SInce the facial and mouth bleeding are the only ones noted I will get someone to control the bleeding on the head. Is the abdomen tender, nontender, rigid, or soft? I am going to also try and put on a nonrebreather on 15lpm if I can keep the airway open.

I will also get my partner to check on the other patient in the truck if he hasn't already. How far am I away from my nearest trauma center, and if its far off, is HEMS available?

Edit: I am also suspecting a spinal cord injury, possibly brown sequard syndrome. Do I note any ETOH on his breath? I will get one of my assistance to check a BGL as well. I will also get him in a C collar, backboard, and fully trauma packaged as well. How are my pupils?

Oh jeez, I suddenly realized my mistake. Sorry, guys, I haven't reviewed this stuff in a while--what was I thinking? Let me go ahead and get my head out of my ass for a second and then we'll go ahead and give this guy a man size dose of atropine. Let's go with 2 mg and keep suctioning those secretions, we can give another albuterol as well.

Beiber,

I was wondering why such a low dosage but I gotcha now. 2mg are now in and the secretions have dried up a little. Albuterol has been administered and wheezing is very very faint now. All vital signs are the same as before except for HR at SpO2 which are as follows:

HR- 140

SpO2-99.

What do you want next? Do you need more information? any other physical assessments you would like to do?

Oh jeez, you really want to make me work, don't you?

All right, well, I don't want to move him into the back of the truck just yet. Let's get some masks and gowns on everyone and consider this a possibly contaminated patient. What do we see around the house? What kind of area are we in, anyway? Farming land, maybe? Send somebody out to look around the outside of the house (along with the garage and shed if there is one) for any pesticides or the like. Let's strip him down and bag his clothes, and rinse his skin off with copious amounts of sterile water!

After we rinse him off and dry him off, let's also put him on the monitor, get a quick 12-lead to make sure there's nothing going on in there, and if there isn't, let's go ahead and get a line on scene and pop 0.5 mg of atropine. While we're doing that, can we have somebody inspect the inside of his mouth, suction out any secretions, and maybe even start assisting ventilations to try and slow his respirations down with a BVM at 15 lpm and administer a dose of albuterol as well.

Now let's reassess our interventions! And maybe think about getting headed toward the truck once we have the patient thoroughly deconned.

Right now I'm strongly suspicious for organophosphate poisoning or some type of cholinergic poisoning. Oh hey! That reminds me. Mr. Neighbor, does the owner of this house keep any pesticides or the like around?

Beiber,

Luckly for you this patient is in pajamas, but decontamination should still be taken, the patient is deconned. He is in a suburban area, no farm land, plants or anything around the house is growing, neighbor says he works all the time. She says he works at a company that makes pesticides in small amounts but he doesn't know if it is in that department. You suction his mouth deliever the atropine. 12 lead only shows sinus bradycardia. Respirations are slowed and albuterol decreases wheezing but some is stll heard. His vitals are as follows:

HR -58

RR-12 BVM

SpO2- 98

BP 68/32

He is still has salivation and you have to continuously suction, The diaphoresis and lacrimation is still going on strong as well.

What next for this patient?

Any signs of trauma?

Usual alphabet soup dine in please we are in no hurry - BP, PR, RR, SPO2, ECG, BGL, temp, lung sounds

Secondary survey - pupils, broken bones, abdo exam

The patient was found unconscious after the neighbor heard a thud when taking out the trash and he has glass around him, thats all the information you have about trauma due to the scene.

Let's have somebody take C-spine and we'll role him onto his back after clearing any glass out of the way and make sure his airway's open. From there, why don't we...

Assess his LOC.

Assess his respirations (lung sounds, rate, depth).

Assess his perfusion status (radial pulse, rate and quality; skin condition).

Then let's have somebody get a set of vital signs (HR, BP, SpO2, BGL), I'll go ahead and do a quick head to toe. What do we have in terms of injuries?

Also, guys, please be careful of the glass if you're gonna be kneeling down!

Good Job Beiber, You clear the glass, C-Spine is taken, and airway is open.

LOC: Unconscious

Respirations: 24 Regular, normal depth, Lung sounds Wheezing.

No Radial Pulse, Carotid is at 46, regular, weak, pale cool diaphoretic.

HR: 46 Regular weak

BP 68/32

SpO2: 97

BGL: 127

Temperature: 98.5 degrees F.

Pupils: Constricted, Eyes are watery.

Physical Exam:

Tiny cuts are found in the skin, all bleeds are just oozing.

Head: Unremarkable.

Neck: No step-offs. Unremarkable.

Chest- Unremarkable

Abdomen: Soft, non-tender, unremarkable

Pelvis: stable, unremarkable

Legs: Unremarkable.

You note a large amount of saliva on the ground at the patient's mouth.

You also note the following things during the assessments: A strong smell of feces, diaphoresis, smell of urine, breath smells of vomit.

What else do ya'll want?

FireEMT2009

Neighbor is lying, they obviously knocked the patient out with something glass, robbed them; then called 911 to make it look like an accident. I'd assess and likely immobilize, since he can't say "X Hurts", and consider distance to the nearest hospital... and which is the quickest way to get there.

I would try to get more information before jumping on the neighbors a theif train, just saying.

You are dispatched to a call for a pt found unconscious on their floor. No further is given.

You arrive to find a male patient 35y/o laying prone on a hardwood floor. Neighbor states that they were taking out the trash when they heard a loud thud from inside the house. You see broken glass all around the patient. The time is 2200

Go!!

FireEMT2009