Quick decision at a MVC

[mobey]

We can run this out as a scenario if you guys want, but I am just looking to see who chooses which patient.

After your choice, give me your initial stabilizaton treatments and level of cert, I am interested in all level's opinions.

Scene: Single vehicle rollover... car unrecognizable. Vollie fire on scene. 3 patients, all ejected

No helo out here. Fixed wing 1hr away

There is 2 crews responding. 1 ALS, 1 BLS. You can be whichever crew fits your cert level. No more backup (love rural EMS)

Patients:

Patient #1 21 y/o male, lying approx 10ft from car, UnCx snoring resps. Accepts OPA. Possible Fx left wrist. Vitals normal. Sp02 99, EtC02 33 (sidestream)

No other injuries to report

Patient #2 19 y/o male lying directly beside Patient #1 (nearly spooning). A&O x4 though lethergic. Complain of parastesia from waist down and severe mid-back pain. No loss conciousness, no resp difficulties.

Vitals BP 84/42 HR70

Negative babinski reflex, No pain responce at any level in his legs.

Patient #3 DOA

So the question is: who goes ALS, who goes BLS?

[RaceMedic]

First i want to know ... Is the ALS truck dual medic or mixed crew ?

[mobey]

First i want to know ... Is the ALS truck dual medic or mixed crew ?

Sorry, left out a few details there...

Mixed crew, there is only 1 Paramedic on the scene. Fire is not trained medical.

Transport time is 30min to a small town clinic. Trauma centre 3+ hrs out.

Helo is out of service. (ya... we only have a few here, and sometimes.... well often, they are not avail)

Edited October 31, 2011 by mobey

[RaceMedic]

We can run this out as a scenario if you guys want, but I am just looking to see who chooses which patient.

After your choice, give me your initial stabilizaton treatments and level of cert, I am interested in all level's opinions.

Scene: Single vehicle rollover... car unrecognizable. Vollie fire on scene. 3 patients, all ejected

No helo out here. Fixed wing 1hr away

There is 2 crews responding. 1 ALS, 1 BLS. You can be whichever crew fits your cert level. No more backup (love rural EMS)

Patients:

Patient #1 21 y/o male, lying approx 10ft from car, UnCx snoring resps. Accepts OPA. Possible Fx left wrist. Vitals normal. Sp02 99, EtC02 33 (sidestream)

No other injuries to report

Patient #2 19 y/o male lying directly beside Patient #1 (nearly spooning). A&O x4 though lethergic. Complain of parastesia from waist down and severe mid-back pain. No loss conciousness, no resp difficulties.

Vitals BP 84/42 HR70

Negative babinski reflex, No pain responce at any level in his legs.

Patient #3 DOA

So the question is: who goes ALS, who goes BLS?

Never mind, If it is a dual medic truck they get split and then both units are ALS...

However i do not believe that that will be the case.

PT one is most definitely ALS, although they will both be receiving ALS treatments prior to transported

Both will be boarded and collared. IV's, One should be tubed and Bag assisted. obvious Fx's splinted.

PT two will also need ALS as he is a neurologically compromised he is not compensating as evident by the hypotension and "normal" pulse rate.

PT one could be a vegetable with a herniated brain stem already ... hmmmmmm

im rambling ... whats next Mobey

Race

Sorry, left out a few details there...

Mixed crew, there is only 1 Paramedic on the scene. Fire is not trained medical.

Transport time is 30min to a small town clinic. Trauma centre 3+ hrs out.

Helo is out of service. (ya... we only have a few here, and sometimes.... well often, they are not avail)

sounds like home

[mobey]

Are you suggesting we tube Patient #1 and send it BLS?

Or hang some sort of ALS "drip" on patient #2 and send it BLS?

BTW: We can call NaCl I.V.'s a BLS intervention for this scenario... just to keep it comprehensable

[BEorP]

I would hope that since we're talking about rural EMS, that your ambulances are capable of taking two stretcher patients? If so, would certainly consider sending both in the ALS ambulance with the ALS provider and one of the providers from the BLS ambulance.

[DFIB]

Patient one: what is his respiratory rate? Is he in a decorticate or decerebrate position?

Patient two: What is his capilary refill? Is he bleeding and how much?

Can the medic administer ALS meds and sent the patient via BLS?

What is the ETA to the hospital?

Edited October 31, 2011 by DFIB

[mobey]

Patient one: what is his respiratory rate? Is he in a decorticate or decerebrate position?

Resp rate 30. Decorticate

Patient two: What is his capilary refill? Is he bleeding and how much?

Not gonna lie, I did not do a Cap refill, I never do on adults.... half because I forget, and half because I am not certain it is scientific. Abd is soft, no obvious bleeding.

EDIT to add:

As I suspected:

http://www.ncbi.nlm.nih.gov/pubmed/2039096

MAIN RESULTS:

For the blood donor group, mean capillary refill time before donation was 1.4 seconds and after donation was 1.1 seconds. Mean capillary refill time for the orthostatic group was 1.9 seconds and for the hypotensive group was 2.8 seconds. When scored with age-sex specific upper limits of normal, the sensitivity of capillary refill in identifying hypovolemic patients was 6% for the 450-mL blood loss group, 26% for the orthostatic group, and 46% for the hypotensive group. The accuracy of capillary refill in a patient with a 50% prior probability of hypovolemia is 64%. Orthostatic vital signs were found to be more sensitive and specific than capillary refill in detecting the 450-mL blood loss.

CONCLUSION:

Capillary refill does not appear to be a useful test for detecting mild-to-moderate hypovolemia in adults.

Edited October 31, 2011 by mobey

[DFIB]

I am an EMT-B. I just finished school in August. No cert. I will take NREMT in Dec.

Considering that both patients would be packaged with full spinal inmobilization.

Scenario one: If the ALS unit can carry two patients. I ride with ALS and the two patients. My ambulance follows.

Scenario Two: If ALS can only take one patient and cannot administer meds prior to BLS transport, ALS would take Patient 2 and BLS Patient one.

Scenario three: If ALS can administer meds to the BLS transport I would request a IV with a hypertonic solution (D5NSS?) on patient one, an osmotic diuretic (Manitol), Dexamethazone, and whatever else the medic recommends (Zofran or Ativan?) and transport him BLS. Patient two .would be transported by ALS. The Ambulances would travel in caravan and maintain communication.

I only mention capillary refill because it is a primary component of the start triage. Since patient one is in a decorticate position the scenario becomes simpler for me.

Moby – Please critique my rational as I consider this a learning experience.

Edited October 31, 2011 by DFIB

[Bernhard]

Pat#1: 2 i.v.'s cristalloides, e.t. intubation and O2, c-collar (after intubation), fast splint fracture of left wrist, scoop stretcher to vacuum matress, monitoring, transport with BLS unit to trauma department.

Pat#2: c-collar, 2 i.v.'s cristalloides mixed with colloides (2:1, we have HES here), O2, analgetic pain control (esketamine here), scoop stretcher to vacuum matress, monitoring, transport with ALS unit to trauma department.

The transport decision is based upon the following: Both of them would earn an ALS ambulance, but this is restricted by scenario. My solution would include to transport in both ambulances driving close after another, so the single medic could switch if needed. If number one is stable and could be manually bagged easy, it would be perfectly OK if he goes by BLS - maybe we even could give the ALS unit's automatic respirator to the BLS unit if they don't have one. The second patient at the moment is more likely to get unstable going into severe shock, considering the lethargic appearance and low blood pressure. So I would take him in the ALS ambulance, providing more space for possible further actions, which patient #1 doesn't need because already done. Here, all units have vacuum matresses and even BLS has basic ECG monitoring (3-lead) plus EMTs usually know how to operate automatic respirators in "normal" conditions.

Patient #3: document, hand over to the cops, no transport.