Patients Define Their Emergencies (Part 2)

True Story…

The dispatch information was updated before we had even rolled our rig out onto the pad. Eye injury, no serious symptoms. Jodie shut down the lights and I informed dispatch that we’d be responding non-emergent.

Up stairs and inside the small two bedroom apartment, Samantha, our patient, was waiting on the couch, holding a hot compress to her swollen right eyelid. Mom worked calmly in the kitchen finishing diner for her other two children. Alan, Samantha’s father sat on the edge of his seat next to his daughter in a state of barely containable anxiety.

He had recently arrived home from work and his wife had informed him of the apparent infection in Samantha’s right eye. One look and he was on the phone to us. Now he breathed rapidly as he fumbled through a list of questions. What caused it? Could it damage her vision? Could she lose her eye? Could she go blind?

I cleared the engine to go back in service and sat down next to him. Over the next ten minutes we both explained what pink-eye was and how to take care of it. We talked about hot-compresses and how contagious the bacteria was going to be. We reviewed the typical course for such and infection. How to prevent it in the other kids. How likely it was that one of them already had it. And we discussed his plan for morning. (It involved asking a neighbor to drive them to a near-by clinic.)

Alan called 911 for pink-eye. And…(This part is bound to be controversial, depending on what kind of system you work in.) I never offered to take him to the emergency room. And he never asked.

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Responding to Hypothermia

Part 2 of a 2 part series. (Part one is here.)

In our last post we looked at some of the causes of hypothermia, both typical and atypical. Then we talked a bit about the recognition of the hypothermia progression and what patients might look, feel and act like as they progress through their hypothermic condition.

Now let’s look at some of the guidelines for treating our hypothermia victims.

On the surface, treating hypothermia might seem deceptively simple. The treatment of mild hypothermia often is simple. Bring them in, stop the cooling and rewarm them. But as we progress into moderate and severe hypothermia, things get more complicated. Here are 12 guidelines to consider when the patient is more than just a little chilled.

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Wrong Medicine

Some of the stacks of trip reports were nearing four feet high and they filled the musty closet. Dividing them up, we started sorting through them in earnest. The dates indicated that the calls had been run between 1972 and 1978. Most of the narratives were as brief as the treatment lists.

Hall Ambulance’s station one was an older house in an early residential area of Bakersfield, California. It had been, at one time, the residence of the company’s owner, Harvey Hall. In the early days of the ambulance service, Harvey had both lived in the home and run his fledgling ambulance service out of it. 

One of the crews stationed at the home had gone digging in the dusty storage closets and struck EMS history gold. Stacks and stacks of old trip reports from the Mother, Jugs and Speed days of EMS. That’s where we found it. A call run by our medical director back in his days as a paramedic for the service. A cardiac arrest, no less. The total list of treatments given; CPR, BVM, Epinephrine 1mg, Sodium Bicarbonate 2 amps.

The year was 1991. We found this hilarious. We were still in our ACLS infancy. There was no CPR first or AEDs or Amiodarone. Nobody had heard of capnography and there was nothing therapeutic about hypothermia. Yet we felt very advanced looking at our medical directors run report. The massive Sodium Bicarbonate doses of the seventies had long since gone away. 

More than happy to reminisce about the call, our doc read the report with a bemused sort of faraway look and announced, “I remember this guy.” He told us the story of the overweight, mid-sixties male who had collapsed in the parking lot across from the hospital. And then he made an observation that has stuck with me my whole career.

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What Is GHB Anyway?

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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Treatment of Head Injury

Part three of a three part series

In our last two installments we looked at the way heads get injured and the various ways the brain tends to bleed. In this, our last installment in the head injury series, let’s take a look at basic treatment and management of the head injury patient.

There are a lot of variables that need to be considered when managing a head injury patient in the prehospital environment. Your treatment will be guided by considerations like the mechanism and severity of the head injury, other associated injuries, the patients mental status and their basic stability. 

These are some guidelines when sizing up and prioritizing your care.

Airway Management:

Head trauma management begins with the airway. The brain is sensitive to hypoxia and a poorly managed airway can turn a significant but recoverable head injury into a devastating head injury. Our brain injured patients can present some unique airway challenges. Seizures and posturing can produce trismus and spinal precautions prohibit proper tilting of the head.

In these cases, oral and nasal airway adjuncts are helpful in ensuring proper ventilation while keeping the head midline and neutral. If the Glasgow is less than eight, consider an advanced airway like a king tube, combi-tube or ET tube. All of these should be protected from the possibility of a clenched jaw with some sort of bite block type protection.

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EMS Response To Sexual Assault

A Guest Post By: Jimmy Futrelle

The EMT Spot would like to welcome Jimmy Futrelle to our guest post roster. Jimmy s a Paramedic hailing from Scurry County Texas. Jimmy has been responding on calls long enough to remember the Lifepack 5 and using D50 as a diagnostic tool. His unique background working for private and public EMS as well as for local law enforcement makes him uniquely qualified to teach on the subject of sexual assault.

This detailed guide to responding to these challenging calls is well worth reading. I sincerely thank him for this contribution.   

Responding To Sexual Assault

Introduction

Sexual assault is possibly the most devastating form of assault perpetrated on another human being.  The legal definition of sexual assault is “any genital, anal or oral penetration by a part of the accused’s body or by an object, using force or without the victim’s consent.”

The U.S. Department of Justice’s National Crime Victimization Survey reports that over 500,000 women and approximately 49,000 men report being sexually assaulted each year. It is estimated that 1 in 5 women will victims of rape by the time they are 21 years of age.  61% of reported rape victims are less than 18 years old. 1 in 7 women will be raped by their partners. Only 16% of rapes are ever reported to the police.

Let us not confuse sexual assault with sexual abuse. Sexual abuse is repeated instances of sexual assault occurring over a period of time, generally by a person familiar to the victim. Whereas this crime is no less devastating, we are going to focus on the act of sexual assault.

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The EMT Guide To Swine Flu

By now, you’ve most likely heard the reports of a possible swine flu pandemic and maybe you’ve even fielded a few questions from concerned friends and neighbors. As always, The EMT Spot aims to keep you updated on what you need to know to do your job safely.

The latest strain of swine flu is an influenza type A virus. (H1N1) These viruses emerge from the shared pool of influenza viruses that occasionally transfer from birds (avian flu), to humans (common flu), to pigs (swine flu). Each time we trade these viruses back and forth between humans and animals, the viruses have an opportunity to mutate. The new strains may be more contagious than the last and may respond differently to antivirals. (But not necessarily.) Currenty the CDC is recomending Oseltamivir and Zanamivir for this strain of virus.

As of today the virus has killed 68 people in Mexico and sickened over one thousand more. Now the illness has jumped the boarder and appears to be spreading fairly rapidly across the U.S. At the time of this writing 20 cases have been confirmed by the CDC within the U.S. starting in California and moving to Texas. The list of confirmed cases now includes New York, Kansas and Ohio.

What to look for in your patients

Swine flu presents like a common respiratory influenza. Patients will present with common flu symptoms that can vary significantly in severity from one person to the next. Look for productive or dry cough, fever, chills, body aches, sore throat and fatigue. There have been some reports of GI symptoms like vomiting and diarrhea.

Swine flu may precipitate significant respiratory distress, especially in patients with underlying respiratory conditions or those with compromised immune systems like HIV patients and patients receiving chemotherapy.

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Understanding Combative Head Injuries

Big biker dude strained against the double layers on tape across his forehead and it occurred to me that the act of c-spine seemed pointless if the patient insisted on fighting violently against the tape and straps. Three firefighters were still holding big biker dude (BBD) down and the firefighter closest to his head was yelling, “calm down. … CALM DOWN!” This wasn’t working, but I understood. Sometimes the urge is irrisistible. For his part, big biker yelled back in disorganized consonants and vowels, “uaaaaghhh”.

BBD had laid his Harley down just before an intersection at the corner of our district. Medic units from threedifferent providers would be responding to the intersection to establish who’s patient he really was. This was often a recipe for conflict, but not tonight. The second medic on scene was happy to assist me with setting up IV’s and the third drove by without stopping. From his position in the road, BBD clearly wasn’t in my response area, none-the-less, big biker dude was all mine.

Maybe it was all the leather, or perhaps it was the Harley, or the time of night, but I assume from their demeanor that most folks on scene thought that big biker dude was really drunk or really mean or both. In reality he was neither. Big biker dude had a closed head injury and he was in his combative phase. Combative closed head injuries can be easily mistaken for aggressive patients by emergency responders and, if we’re not careful, the confusion can lead to incidents like this one and profoundly inappropriate care.

So what makes closed head injury patients fight us?

I found surprisingly little information addressing this specific question. While there is plenty of information to be found regarding the debate over how to treat these challenging patients, exactly why they fight is left unexamined. The reasons for combativeness are primarily theoretical. They are likely a combination of the following:

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