Let’s face it, there are a whole bunch of street drugs out there that we as EMS caregivers should understand. While we can’t always be expected to identify the exact drug a patient has ingested. We do need to be able to predict a given drugs effect on the body. We should also be able to take a fair guess at
the identity of an ingested drug based on our evaluation of the patient’s physical presentation. GHB is one of those drugs that can be hard to nail down based on the physical signs. But it does leave some clues – if you know what your look for.
What Is It? : A Multi-Receptor Stimulant
GHB is short for gamma-Hydroxybutyric Acid, a naturally occurring substance produced by the central nervous system and found in small quantities in beef, wine and citrus fruits. It was first synthesized in a laboratory in 1874 but it wasn’t used in humans until 1960 when it was used in GABA receptor research and found to have a wide range of effects. In that year, scientists began testing GHB as an anesthetic and in the treatment of insomnia and depression.
The drug acts on both GABA and GHB receptors in the brain. Stimulation of GABA receptors has a sedative and analgesic effect. Stimulation of GHB receptors is primarily stimulatory. GHB also produces a biphasic release of Dopamine which produces euphoria. Understanding this multi-function aspect of GHB is key to recognizing the wide range of physical symptoms that are produced from a single GHB ingestion.
The Hallmark of GHB Overdose: Wave-like Altered Mentation
A patient experiencing a GHB high will have many symptoms similar to other drugs. But they’ll also have a unique progression of symptoms unlike any other single street drug. This becomes confusing for the emergency caregiver. GHB overdoses don’t follow a linear progression of symptoms They ride waves of symptoms. … Let me explain.
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I first heard the BCAPBTLS acronym sometime around 1998 while helping a group of EMT’s practice their skills. I hadn’t been involved in EMT education for several years and I had missed the whole inception of the DCAPBTLS acronym. Dutifully, each aspiring EMT moved from the head to the neck, shoulders, chest and abdomen. Each student verbalized their assessments as they went along and sounded off the acronym in turn.
“I’m exposing the chest and looking for DCAPBTLS.” “I’m checking the abdomen for DCAPBTLS.” On 
and on it went until I finally interjected, “What is this word you all keep using?”
“What word?”
“That word. The Dee Cap something.”
“Oh yeah.” They chimed in and began explaining the purpose of the DCAPBTLS acronym. If I remember correctly, there may also have been a “TIC” component added on to the end as well. If there was, the TIC part has been lost to education history. The students explained that DCAPBTLS was an acronym that was designed to help them remember the various abnormalities that they were looking for during the assessment. Then the funny part happened.
Collectively the students tried to recall all the elements of the acronym. “Deformity, contusions … uh … abrasions.” The room fell silent. “Uh … the T is tenderness.”
“Don’t forget bruising.” Another student chimed in. “Oh, yeah. Bruising.”
By the time the students collectively produced all eight elements of the acronym, several things were clear. The eight elements of DCAPBTLS was not one of them. Before we get in to that, let’s set the record strait. DCAPBTLS stands for:
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Most EMT level providers are square on the primary function of the stomach. We can name several things our liver is doing for us and we get the whole kidney concept as well. But when we start drifting beyond the basics, the 
conversation can turn fuzzy.
OK … It’s been a little while since I studied this. What was the spleen doing again?
Something about the immune system right?
Oh, the Pancreas that produces Insulin doesn’t it?
Or was that the gallbladder?
Fear not. I put together a handy reference for you. Here’s a list of all those abdominal organs for your review. Now you can sort your large intestine from your small and your kidney from you appendix. Let’s get started.
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Sometimes, when we get on that outer boundary of established medical practices we start running in to 
controversy. As an author, and a bit of a non-conformist, I love controversy. One area that falls in the gray realm of medical assessment is testing for unconsciousness. This is a concept familiar to all who work in emergency services and rarely considered by the lay public. I’ll explain.
When we encounter a person who is not responding to us there are several possibilities.
1.) They may be unconscious
2.) They may be semi-conscious
3.) The person may be sleeping
4.) They may be fully conscious and feigning unconsciousness (for various reasons)
We treat all patieint who refuse or are unable to respond to us with a high index of suspicion for injury or illness, but it’s helpful to try to get an idea where the patient actually is mentally. Are they here and not responding to us, or are they just not here?
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When we think of testing for nystagmus, medical personnel and lay people alike, we tend to think 
of the horizontal gaze nystagmus test performed by police officers as part of the standard field sobriety test (SFST). It’s true that the police have taken this useful neurological exam and put it to good use to identify folks who may have had to much to drink. There are other good uses for the nystagmus test as well.
I use the horizontal gaze nystagmus test as a part of the basic neurological exam that I do any time I’m uncertain of how well a patients brain is talking with their body. Head injuries, altered mentation, syncope, dizziness and headaches are some of the common complaints that make me want to check out how well the patients brain is doing its job. So this test gets pulled out of the tool box frequently. But what is nystagmus anyway? How do you really test for it and what does it tell you when you find it?
What is nystagmus?
Imagine that I took a large drum and I painted it white with black stripes running evenly down it. Then I set the drum on an axis and spun it slowly in one direction. As you watched the drum your eyes would focus on a black stripe and follow it across the surface of the drum until the stripe moved out of visual range. Then your eyes would jump backward to acquire a new stripe and follow it. This repetitive cycle of smooth eye pursuit interrupted by fast twitches (saccadic movement) is what we call nystagmus.
This peculiar tracking of the eye can be induced by spinning in a chair, riding on a roller coaster or observing a spinning object like in the example above (AKA Opticokinetic nystagmus). It can also be caused by a wide variety of medical and pharmocological conditions. Most causes of nystagmus point to an abnormal condition within the nervous system. It is a physical finding that calls us to pay attention and look deeper.
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Did you ever watch the old Star Trek TV show? No of course you didn’t, but this is just you and me talking 
here right? OK, remember when something would threaten the ship. The captain’s first response was to say, ”Go to red alert.” or “Set condition red.” and the lighting would change and a little alarm would sound. That funky shaped light on the front console would start pulsing red. Everyone knew to treat the situation with importance.
I don’t know about you, but I have a list in my head of assessment findings that cause me to shift mental gears into condition red. I don’t need to say anything overly dramatic, but everyone on who works with me can tell when I’ve switched gears to condition red.
For one thing, I start moving just a bit faster than my usual casual pace. I delegate tasks in a laundry list fashion. “I’m going to need an O2 mask. Lets get the pram to the door and bring a stair chair up here. Jesse strip me a line in the rig and check the status of Swedish ER.” The patient may not know the difference, but people who work with me can tell that I’ve set condition red.
Here are a few of the assessment findings that send off alarm bells is my head.
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Abnormally constricted or “pinpoint” pupils are a great finding for our rapid diagnosis series. There are many things that can cause the pupil to abnormally dilate. Very few things will make the pupil abnormally constrict. Constricted pupils are a doorway to a very short list of ailments and with a bit of background you should be able to hang your hat on one fairly quick.
How do we assess for “pinpoint” pupils?
Recall that the pupil should be mid-range and reactive under normal lighting conditions. When subjected to bright light, the pupil will constricted to reduce the volume of light entering the iris. In darkness the pupil will dilate to allow as much ambient light in as possible. Pupils smaller than 2mm in diameter under normal lighting conditions can be considered “pinpoint”. Any pupil that responds to changes in lighting conditions with 1mm of movement or less can be considered minimally reactive or nonreactive.
To assess for pinpoint pupils we need to subject the pupil to darkness by asking the patient to close their eyes or covering the patients eye. When we return the light source to the pupil we expect the pupil to be larger and rapidly return to its original size. If the pupils remain <2mm in diameter through the changing light conditions we have a “pinpoint pupils” finding. The fancy medical term for this phenomenon is abnormal miosis.
If the patient has bilateral pinpoint pupils consider the following possible etiologies:
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The dispatcher reports that the patient is vomiting blood. Hemataemesis if you want to be technical about it. It could be a whole bunch of things right? … Well yes it could. Before you e-mail me to say that you can’t believe I missed Bolivian Hemorrhagic Fever, here’s one web site that lists 113 possibilities.
But if you want to play the numbers, it’s going to be one of four things. And if you want to play “stump your partner” you can narrow it down quite a bit based on your patients age and disposition.
There are four things that tend to cause a person to vomit blood. Before you click on the little “read more” link, how many can you name?
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I hope you’re sitting down for this. I trust that a good number of my readers do indeed sit while surfing the internet so I’m just going to tell you this strait up. Sometimes … patients lie. They do. Occasionally they intentionally tell us bold, outright lies. And it gets worse. With even greater frequency they are just plain inaccurate. They may not be intentionally deceiving us, they may be confused, misinformed, exaggerating, in denial, overwhelmed or embarrassed. Regardless of the reason, we are frequently faced with subjective information that isn’t all together accurate.
What’s an EMT to do?
I don’t want to suggest that you should skip or disregard your subjective assessment. The things that your patient tells you are vital and important clinical findings. Even inaccurate information can give you vital clues regarding the patient’s mental status and physical condition. But I’d also suggest that you put a premium on physical findings that give you instant and accurate information about the patient’s physical condition. The longer I work in emergency service the more I find myself falling back on basic patient assessment truths like this one:
Pay attention to your patient’s skin.
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Treatment Guidelines For The Burn Patient
You’ve taken an educated guess on burn depth, calculated the burn area and classified the burns severity. With those priorities out of the way we can start treating the victim. (Yes, I’m taking some creative literary licence here, since assessment and treatment tend to occur in tandem.)
There are things we tend to do well and things we tend to do poorly in prehospital burn management. Here are some “do and don’t” type guidelines to direct your burn treatment.
Always consider the possibility of non - accidental trauma in pediatric burns.
Do:
Assess the heck out of the Airway.
- Inhalation burns are easy to miss if you’re not paying attention. Burn victims have a tendency to gasp when they are burned. You need to look really close at that airway. Shine a light on the patients facial hairs (yes women have them also) and look for singed or missing patches. Look up their nose and in their mouth for evidence of burns.
- Listen to the lungs and auscultate over the trachea. Reassess frequently. Only time will tell for certain if there is damage to the lower airway or lungs. Until then, you need to reassess frequently and don’t get caught behind the eight ball trying to manage an airway that goes down hill due to unrecognized burns.
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the identity of an ingested drug based on our evaluation of the patient’s physical presentation. GHB is one of those drugs that can be hard to nail down based on the physical signs. But it does leave some clues – if you know what your look for.
