chbare

Extrication takes about 8 minutes. You do your best to maintain C-spine and then perform a rapid extrication onto a board. (Note: the medics in the scenario that this situation is based on used a combi tube to initially manage the airway with success. The patient was completely unresponsive and had no gag reflex. This is not to say that other options are wrong however.) EDIT: Oh no, I am going to have a bunch of firefighters mad at me. Disentanglement takes about 8 minutes, then rapid extrication onto a board takes place. Take care, chbare.

I will try to answer all of the questions. You are 15 minutes from a level II trauma center. You do not have air evac assets due to the weather. (heavy wind and rain with poor visibility) You can operate at what ever level of care you would like for this scenario. The scene was secured by state police, there are no known hazards with the exception of sharp metal from the vehicle. BGL is 130 mg/dl. He actually appears very diaphoretic and pale. No medic alert tags are noted. Only one patient and you have all of the BLS and cool guy ALS supplies at your disposal. You ambulance is staffed with two people and the extrication crew will have 4 people trained at the first responder-EMT-B level. Due to a county wide mutual aid agreement one of the fire fighters can drive the ambulance or assist in the back if needed. Severe damage limits your ability to care for the patient. You cannot enter the cab and you are having extreme difficulty managing his airway through the window. Intubation will be difficult to impossible until the patient is extricated. Let me know if you need any more information. Take care, chbare.

PRPGfirerescuetech, your scene survey reveals the following; it looks like he was driving a F350 pickup truck. There is extensive damage to the front of the truck and it looks like the passenger compartment has been involved as well. The patient is trapped inside of the cab and it looks like the front of the vehicle was pushed inward causing the dash and steering wheel to trap the patient. You notice a few open beer cans within the vehicle and the state police officer reports that he smelled the scent of ETOH from the cab. No drug paraphernalia is noted. The patient is wearing a seat belt and it looks like he may have had the airbag disabled. (did not deploy) Your rapid trauma assessment reveals the following; the patient is unresponsive to any stimuli, he is breathing, but the rate is only about 8 per minute and shallow, the airway does not appear obstructed, but you do note several small abrasions and lacerations to the patients face and scalp. Fire is called and an extrication unit is 3 minutes out. Would you like to know anything else? EDIT: the resp pattern is irregular. Take care, chbare.

You are called to the scene of a MVC. Dispatch reports that a 22 year old male lost control of his vehicle on the highway and ran into a concrete barrier at a high rate of speed. State police have secured the scene and report that the patient appears unconscious. Would you like to know anything else? Take care, chbare.

EMS49393, thank you. Take care, chbare.

KatieC, I agree with EMS49393. It does indeed look like sinus dysrhythmia. The down and dirty things you need to ask when looking at a strip are, what is the rate and does it correspond to the pulse that I palpate, Is the rhythm regular or irregular, is there a normal P wave for every normal looking QRS, is the QRS normal, are there any T wave abnormalities (ST elevation, depressed T waves, etc), and what are my intervals. P waves are present for every QRS, so the underlying rhythm is sinus. The strip looks like lead II, so the upright morphology of the waves are normal for the lead. It does indeed look like you have 2 unifocal PVC's in strip number four. Unfortunately, a rhythm strip in lead II tells us as much about your general health as your user name and avatar. If you are concerned, get a complete exam performed by your PMD/PCP. Take care, chbare.

A word of caution to all parties involved in this situation. Hashing out the specific details of a bad situation with the potential for sequelae may not be the best thing to do on a public forum. Take care, chbare.

We have a rack in the nurses station where docs and nurses hang their scopes. I usually grab one of those scopes when I do an assessment. I save money and never have to worry about loosing a scope. On the ambulance I use the company supplied ambulance stock stethoscope. Take care, chbare.

Ridryder 911, thank you for the dose of reality. We as human beings cannot expect to alter the course of universal inevitability. People will die regardless of what we do to them. I go to great lengths to educate family members and friends about the reality of the patients condition. I cannot tell you how many people expect somebody to live just because we got the heart to start beating and I cannot tell you how many people actually believe that we can give them an actual number (%) on the patients chances of making it. I really believe we can be better health care providers by educating family/friends on the patients condition and help them accept the situation. Of course this should be accomplished with the greatest care and concern for both the patient and family. A little off topic but a good story. We got report from EMS that they were transporting a hospice DNR patient with end stage cancer. Everybody in the er groaned about getting a patient with this complaint. The patient and her family arrived and I took over the care of this patient. The er doc and I went in the room with the patient and the family. We talked to everybody and helped get them all on the same page. The family and patient knew that death was near, but wanted something to help with the pain. The patient was in severe pain and the family/patient wanted pain relief. I positioned the patient in the most comfortable position possible and the doctor assured everybody that we would do whatever it would take to alleviate the patients pain. I ended up giving allot of morphine that night. By the morning the patient was lying in bed sleeping soundly. Everybody told me this was the first time in a long while that the patient was not in severe pain. The patients breathing became shallow and the patient started to look pale and everybody knew the patients time was near. All of the family was with the patient and the patient ended up dying a peaceful death without pain. The family dealt with the patients death very well and everybody was happy that the patient did not die in pain. Even though the patient died I did not see this as a bad outcome. We helped somebody leave this world with dignity and comfort and helped a family through a stressful time. Take care, chbare.

Nussy, good call. I would bet the inferior wall of his heart was thanking you all the way to the cath lab. Take care, chbare.

Itku2er, I am not really trying to prove if someone can "die from a broken heart." I just wanted to help explain some of the physiological responses to stress. Take care, chbare.

If we look at psychological stress from a physiological stand-point, it is quite easy to understand how people can develop medical problems as a result of this stress. What occurs at a physiological level when you endure a very stressful event? First, we have a release of sympathetic hormones. This leads to increased heart rate, increased contractility, increased oxygen demand, and increased blood pressure. While this response was good when that cave bear was chasing our ancestors out of their homes and their bodies needed to perfuse vital organs and utilize that extra cardiac out put to fight for their lives, you can imagine the potential problems that could develop if this continued for an extended period of time. In addition, our bodies release steroids in response to stress. On of the long term side effects of high levels of steroids may be immunosupperssion and increased risk of infection. The physiology behind steroid regulation is actually quite fascinating. It all starts in the brain. A little part of the brain called the hypothalamus releases a hormone called corticotropin-releasing hormone (CRH) in response to all kinds of stressors. Normally CRH is released on a cycle. Levels usually peak in the morning after waking up. CRH acts on the anterior pituitary gland and triggers the release of adrenocorticotropic hormone (ACTH). ACTH acts on the adrenal gland (cortex) and triggers the release of glucocorticoids. Normally rising levels of glucocorticoids will feed back and block the release of CRH. However, I would think that continued severe stress would trigger continued release of CRH. CRH is not only a hormone in this system, but it is also acts as a neurotransmitter. Some people believe that CRH plays a vital role in how the body responds to stress. Forgive me if I got a little long, however, the physiology behind the disease is most interesting. Take care, chbare.

Ace844, resourceful. Take care, chbare.

TechMedic05, I have given both fluids and lasix to people in rhabdo and to people who present with conditions that may cause rhabdo. (trauma, crush injuries, etc) We do not want those kidneys shutting down. I can think of a few other situations where fluids and diuretics may be given. Take care, chbare.

The hospital that I work at uses BNP testing on CHF patients. It is nice to have a number in addition to the patients assessment findings. Take care, chbare.

Richard, this is what I had been hearing before my ETS date a couple months ago. In our CLS classes we were emphasizing the use of NPA's. We also taught a modified CAB survey over the ABC survey to emphasize hemorrhage control in combat casualties. I have a buddy that was a medic with an MP unit who just got back from an 18 month deployment. I do not recall him emphasizing airway management in combat. He said all they did was stop the bleeding and EVAC. (that is truly all he had time for) He was in Baghdad, so EVAC times were pretty fast. Your techniques may change a little in the remote mountains of Afghanistan. You are right about the TQ thing, everybody is issued the CAT. Take care, chbare.

I always thought that cardiac arrest was like pregnancy. Either you are in arrest or you are not in arrest. Take care, chbare.

Ace844, good post. Just more proof that labs like anything should not be blindly used to guide treatment. Take care, chbare.

Dgmedic, I do not have an initial etC02, I think they used an easy cap. The temp was normal. The chest x ray did not indicate pulmonary edema nor were any wet lung sounds noted. As soon as the HR came down, the patients vital signs stabilized. CK was not elevated, kind of a surprise to me! I agree with ERDoc that they could have considered adenosine. (I was not there, so it is just Monday morning quarterbacking.) I think most of this patients problems were rate related. I also like etomidate, but most of our er docs do not have allot of experience using it and tend to go for versed, unless they are on with a nurse that is very familiar with using etomidate. I also like to use fentanyl for sedation. Thank you for your input. Take care, chbare.

Samson722, I use a small blackhawk range bag as a crash kit when I do EMS transfers. I can post pictures if you would like. Take care, chbare.

I did not intend to fan the flames. Whit72, easy, he clarified he position. I would not have been hurt in the least if somebody were to tell me that my education did not teach me good assessment techniques. (for all we know I am 10 years old and have good google fu kata techniques) We all have opinions and sometimes you have to say, I see what you are saying, but I disagree, and we can both agree to disagree. We do not need to get bent out of shape over some discussion on a public forum. I think there has been some good discussion and points that we can all take home and consider, but it looks like there will be some disagreement at the end of the day. I have my thoughts regarding what skills and procedures EMT's should perform, and I will continue to push for improved education for EMT's and paramedics and improved access to ALS care, (paramedic care) and you can push for your future vision of EMS. In any event it's time for me to get my butt to work. Take care, chbare.

PRPGfirerescuetech, I see, more of a general everybody needs better training & education in assessment statement. Take care, chbare.

PRPGfirerescuetech, I am not quite tracking on the "Neither are trained adequately" part of your post. I would be curious to hear your rationale. Not picking a fight just curious. Take care, chbare.

ERDoc, thank you for the input. I will pass this on. I was a little curious regarding the treatment as well. Take care, chbare.

AZCEP, he told me there was allot of pucker related to using cardizem, band he was shocked that cardioversion did nothing to slow the rate. He said as soon as the cardizem hit the rate slowed and the pressure went up. He just wanted to know how other people would have responded to this scenario and what other options could have been explored. Take care, chbare.