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Case #36 The Inadequacy Of The Requesting Description Can Kill.


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#1 Mike MacKinnon

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Posted 02 February 2008 - 12:07 AM

1) The Story.

You are kicked out 20 minutes after the SuperBowl for a suspected code to a rural area. The quick report given to dispatch is a 200 lb man having chest pains when his favorite team lost and then became confused and lethargic. Damn anyone whe beats The Pack. (had to slip that in there!)

2) On your arrival

You arrive at a single wide trailer in a rural area with little else around but other trailers. There are easily 15 cars in the driveway/lawn of which 50% are on blocks in varying degrees of disrepair. On short final you notice a to your 4 oclock horses are getting extremely spooked and one gets loose. Run free Black Stallion, our company will be paying big for this one.

Once inside the trailer you see about 10 people surrounding a rather large individual in a modified lazyboy which looks somewhat like a nascar. Odd, but true. He is gurgling but moving air (you can tell by the bubbles).

You estimate, just by looking, that this man is easily 350 lbs maybe more. You are flying in an AStar. Good times right there.

You see various types of spicy mexican food, beer, pizza, chips etc all over the room. Certainly you have entered a superbowl party with champions of the pot luck.


3) History

The wife is there to ask questions of, she appears distraught.

4) Obvious Pertinent Physical findings

Vitals: BP: 220/115 HR: 105 Sat: 94% RR: 24

Patient appears lethargic and is slurring his words
He smells of beer.... alot of beer.
Patient is diaphoretic & has a hand over his chest.
His wife says he has the "shootin chest pains in his chest" (you cant make this stuff up seriously)

There are no medics on scene just a volunteer FD who are EMTs. They didnt ask much but just called you. They did place N/C on the pt at 2 l.

Please start by commenting on the short final and the horses, then progress to what you want from the people around and further assessment. Ill add diagnostics as they are asked for.
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Mike MacKinnon MSN CRNA
WWW.NURSE-ANESTHESIA.ORG

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It's what we know for sure that just ain't so" - Mark Twain

#2 Sacmedic

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Posted 02 February 2008 - 03:19 AM

Here goes first...

1. On final get VFD personnel to resolve horse issue or find alternative LZ away from horse hazard. (Who would think that would be a problem?)

2. Determine from pilot the available weight for transport.

3. From bystanders- Amount of ETOH ingested by patient, other drug use (Rx and illicit), patient complaints/behavior before calling 911.

4. Assessment- ABC's, lung sounds, ECG, glucose check and neuro exam if oriented enough to follow directions.

5. If pt. supine, sit-up as tolerated. From indications of bubbling and obvious HTN it sounds like he might be full. Switch to NRB mask or BVM if he'll tolerate.

6. From wife- medical history, medications ( and compliance with same) and allergies. Any recent illness. Input/output? DNR? (Hehe!)
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Clayton Thomas, EMT-P

#3 MisterT

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Posted 02 February 2008 - 03:25 AM

I'll kick it off...
Well, they say ABC's first. Sounds like dude might need a little suctioning. Might need more O2 via NRB. Get living room cleared out, give yourself some room to work. Work on good hx(OPQRST). Secure IV access. Finger stick glucose. 12 ld.

there.
that should get us started in the right direction.
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#4 Speed

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Posted 02 February 2008 - 04:51 AM

Mr. T and Sac Med have started it off right. High awareness on this scene for safety(PD/SO). I'd add a 12 lead, start trying to rule out foreign body airway obstruction/choking/aspirate, PE, AMI, GI, TOX, and aneurysm. If we got to a point that we felt it wasn't surgical start working on flash edema, AMI, LV failure/valve defect, and evolving HTN crisis protocols. I'd be ready to intubate, pace/defib, and transport. Alternate LZ sounds great. Ground ambulance on scene? Closest time for cath and chest cutter destination?
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Mike Williams CCEMT-P/FP-C

#5 Speed

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Posted 02 February 2008 - 04:57 AM

Forgot stroke scale.
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Mike Williams CCEMT-P/FP-C

#6 MSDeltaFlt

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Posted 02 February 2008 - 05:50 PM

Mike, this presentation already sounds like over half the citizens in my county; NASCAR Lazy Boy included, but here we go:

Have the pilot lift back off to:
1) burn fuel
2) get far enough away from the horses to calm them down enough so that bystanders can get that damn thing back in the pin.

You do need some LEO's and EMS. The more strong backs you have the better. Tow motor (fork lift) would be great.

As everyone else, ABC's, neuro check, VS's, and CHECK SUGAR (most pts this size who eat this much and drunk off their asses are usually diabetic). NRM, get some lines, CM, yadda, and get ready to tube him.

Bare in mind that 350# in an A-Star might have too much girth for the AC. Will he physically fit inside?
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Mike Hester, RRT/NRP/FP-C
Courage is resistance to fear, mastery of fear - not absence of fear -- Mark Twain

#7 chris

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Posted 02 February 2008 - 07:11 PM

Everyone has made a good start.
1st scene safety. Are the rest of the horses secure? Do you have comms with the LZ command? If so have someone perform (corral guard?). We sometimes have this problem where we are.
Once on ground 350 lbs. Can you take this dude? Will he fit?
Next assessment. Have your partner get hx from spouse. Get ETOH hx from buddies he is drinking with. What's his current GCS? Blood sugar?
Does his airway need to be secured? Looking at that b/p he's at high risk for a CVA. Needs a little labatalol for that. I would start with 10mg IVP, after you get a line going. You are going to have to monitor that and reduce it by a 1/3 to more reasonable level but not too low.
If he fits in a/c, I would load and get the heck out of there before Richard Petty comes over to see whats happening. If he doesn't fit. Ride with ground people to nearest appropriate facility.
Can't wait for the zebra to appear! :D
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#8 STPEMTP

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Posted 02 February 2008 - 09:17 PM

Well, here goes

1st: Secure the horses better. If unable to secure them, find another LZ, don't need anymore running free.
2nd: Can this guy even fit in the AStar? Is a ground ambulance on scene/en route? What is transport time air vs ground?

As for the patient:
Did the patient suddenly become confused? Any complaints of a headache prior to the confusion? What history does this patient have? Is there secretions in the patient's airway or is it the gurgling from the edema that is giving us the "bubbling" sound? How much ETOH? What medication does he take and is he compliant with the Rx?

As already mentioned: BGL, GCS, IV, EKG, 12-Lead, stroke scale, airway control, I'm going to go with NTG instead of Labetolol due to short half life and still able to reduce BP.

Well, may as well wait for the zebras to run me over.

Great case so far Mike
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#9 Medic36

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Posted 02 February 2008 - 11:48 PM

I'll give it a try before it gets too out of control...



1) As everyone has stated previouly we must control the horses and ensure no further incident with them. This may mean moving aircraft or moving the horses. Either way

2) Lets get a good idea of this man's mental status. When did it change, and to what extent?

3) While we are asking questions of the wife, lets try to establish a history. Heart, diabetes, CVA/TIA's, Surgery, recent injury or illness. How drunk is this guy?

4) This sounds like an everyone knows everyone community, maybe 1st resp. have some insight on this guy's history if the wife is too frantic

5) Assesment and treatment at this point would include the following:

* Further assesment of his mental status including Stroke scale
* Suctioning of his airway
* Lung assessment (Is he full of fluid?) If so I would consider CPAP (depending on level of lethargy) and pulmonary edema protocols
* Pedal edema present?
* 12 lead ECG
* Initiate IV (could be a lock at this time)
* Blood glucose check
* Physical exam to look for signs of trauma or infection
* Pupils

6) I wouldn't be too aggresive with his pressure until I was confident it wasn't a cerebral event.

7) Is this guy gonna fit? How far out is the ambulance?

8) With the vitals given it does really seem like severe respiratory distress unless he is on his way down already? SPO2 and RR don't seem to fit for a guy in pulmonary edema. That reminds me... what is his ETCO2

I am thinking the 12 lead is going to show us a little something but we never really know what Mike has up his sleeve!
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#10 sammedic

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Posted 03 February 2008 - 04:53 AM

If he doesn't fit IN the a-star ... slingload him.
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#11 LWTRF14

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Posted 04 February 2008 - 01:58 AM

I must be drinking...I am going to take a chance and add a post......

First, Can we narrow down EXACTLY what he had been eating? If it is "some who the hell knows who borught what type gathering", everybody is bringing something different and I saw Mexican food....maybe a reaction.

Second (and this is the law enforcement side coming out of me...dumb cops)...alcohol is a CNS depressant. Could contribute to the slurred speech and bubbles as his level is high enough to effect motor function. Usually hits around a .12 - .14 g/100L of blood. On the flip side, if this guy is experiecing pain, alcohol would increase the thersold of it...usually at a .10 g/L of blood, pain tolerance increases about 30% (you know we have all done it...a few beers and we can conquer the world). So in addition to everything requested so far - I'd like a set of good lung sounds, try and get a better description of onset and intake, and does this guy have edema anywhere, like he has a pre-existing and un-diagnosised condition or is he just in need of a treadmill? Oh, and put a beer in the lower right pants cargo pocket of the suit...you know...for testing later.
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Earl F Bakke III, NR-EMT-P, CC-EMT-P, PNCCT

#12 highercare

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Posted 04 February 2008 - 09:12 AM

Okay..time to jump on board. I'm at work so time is short. Everybody pretty much has the assessment pegged so far, so I won't beat a dead horse (sorry for the pun!). I can tell you I lifted a 375 pound dude in a Astar(B2). It can be done, but but it's about like giving birth backwards! The Pilot will most likely need to lift to burn some fuel, but that may not be feasable depending on transport time. We only hade a 20 min. flight with our big boy, so we didn't need as much fuel.

It would by a VERY good time to decide if he is going to need a tube 'cause you ain't gonna be able to even think about it in the A/C. You will also need much more lifting help if you value your back, so time to call for LEO's or more hose jockeys (or is that horse jockeys?) Can't wait to hear more!
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#13 jay

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Posted 04 February 2008 - 09:49 AM

Alright, here I go...

I don't actually fly so the first part of my contribution may be way off (heck, the rest of it may be too...but at least I have an excuse for this part).

As for the free horse, I imagine that would add an extra hazard to the landing. Hopefully he would stay far away from a big, loud machine; but who knows what a terrified animal is gonna do? So I would want all eyes out during the landing. Actually, maybe a hot offload of the flight crew may be justified so the horse doesn't run out of no-where while powering down and get chopped up. But, then the bird has to put down somewhere else and come back or circle...both of which may create fuel issues, especially when flying a big dude who is gonna require more juice. On the topic of the big dude...I imagine that getting him onto a pram, out of the trailer, past the 15 cars (I'm assuming this probably isn't on pavement too) and into the 'copter is going to require a lot of time, ingenuity and manpower. Maybe a good use for some of the folks there would be prepping a path that was clear and smooth as possible from the trailer to the chopper. I'd also want to be thinking of a realistic time estimate for getting this guy from the chair to the chopper.

On to the patient care...First off, I'd get him on a NRB, throw a nasal air way in, if I had a portable sxn I'd like to clean out his oropharynx, and I'd get a line, also I'd want him on monitor as quick as possible and want a 12 lead cooking and d-stick in the works.

A) Seems like he is only barely managing his airway. Hopefully the sxn and trumpet help, but I'd want to be preparing to intubate this fellow.

B) how hard is he working to breathe? What do his lungs sound like? Are they full of fluid? Clear? (doubtful) Rhonchorous? (sure that isn't spelled right) If he has a sat of 94%, he must be perfusing ok, but again I want to be ready to tube him. Question about this at the end.

C) As mentioned above, line (preferably 2), monitor and what does his 12 lead look like? Color? JVD?

D) Neuro exam. how oriented? Will he follow commands? If so I'd want to see grip strength, check for arm drift, and grimace. Of course, that may be beyond his ability at the moment. Pupils? any facial droop?

Hx) I'd want to ask very specific questions to the wife to get the best possible answers...
How long has he been like this? What did he start complaining of? What medical problems does he have? Does he have high blood pressure? diabetes? heart problems (heart faliure, angina, prev MI, irreg heartbeat)? has he had a stroke? Does he take medications? Can you get me the bottles? Does he take them regularly? Any prev similar episodes? If so did he go to the hospital? If so, what did they tell him? How much did he drink today? Did he use any other drugs?

Diff DX: 1-hypertensive crisis
2-MI
3-stroke
4-too drunk to breathe c reflux and/or emesis and pos aspiration
5-combo platter

tx: I'll wait on a little more info before going too into tx, but I'm sensing intubation and a nitro gtt in this guy's future.

Issues: In the hospital this guy would probably get intubated, but that is with all the resources in the world at immediate disposal. I'm guessing a guy this big has strong potential to be a difficult tube. True? If so, I'd want to consider the possibility of bipap (is that even something available to most flight crews have avaliable?) and seeing if that seems feasible. I guess the other sign of the coin, is that if his mental status is deteriorating, he may not react well to being strapped to a pram and put in a chopper and a 350 lb angry dude in flight would be non-ideal. Second, with the potential difficulty of getting to the chopper it seems to add a lot to also be trying to bag him while moving. Thoughts on moving to the copter as quick as possible and delivering most of the care there?

thanks, looking forward to hearing the rest of the story and others thoughts.

jay
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#14 DHowerton

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Posted 04 February 2008 - 08:24 PM

What a mess as these things usually are. Everyone has things covered so far, but I am sure that it will all change shortly. Looking forward to it. Fly Safe
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Dwayne

When once you have tasted flight, you will forever walk the earth with your eyes turned skyward, for there you have been and there you will always long to return. LdV

#15 Speed

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Posted 05 February 2008 - 01:20 AM

No follow up from MacKinnon yet... I'll go ahead a give 'em narcan and thiamine. What do his pupils look like? If he doesn't respond to narcan or need D50%, and doesn't have a gag: tube him (looking for an FBAO) and an NG/OG if I don't see any blood or hx of varices. Need to know what the 12-lead looks like...? Signs of trauma? Check pedal pulses and for abd. mass. 200 lbs. sounded OK, but 350??? get a truck on the way fast, may need to intercept, if too far might meet a FW (or bigger RW) if required for appropriate destination. Check for an AD or DNR. Tell us more.
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Mike Williams CCEMT-P/FP-C

#16 EDMEDIC

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Posted 05 February 2008 - 02:32 PM

Hi all, well this starts off sounding more like a Jeff Foxworthy skit than an EMS call. Been there and done that. Really questionable that this pt will go into the AStar? Also relocating the aircraft to a safe ( horse-free) LZ is in order. Do the VFD/EMT's have transport capability? If not, let's get someone who can on their way! What is the ETA by air, and by ground? ( sounds like we need to weigh that one out pretty quickly) Obviously evaluating ABC's is the first step and I agree with Jay's Diff/Dx ( even the combo platter, lol) Questions. What is the blood sugar reading. How much did he REALLY have to drink. Any hematemesis? Adventitous breath sounds? Will he tolerate a NPA and /or oral suctioning( or is that going to make him vomit his airway?) Sounds like he has a minimally protected airway at this point, and ETI may be on the horizon. Just my few thoughts for now..waiting for the zebra Mike.....Brian EMT-P/CC
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Brian EMT-P/CC
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" you don't know what you don't know"

#17 fiznat

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Posted 06 February 2008 - 08:33 PM

I'm not in HEMS so I won't comment too much on the LZ/horse situation other than that the scene obviously needs to be safe and horses removed as much from the equation as possible.

It sounds from the scenario that this guy has a lot of factors that point towards acute CHF: obesity, recent large intake of salty foods, hypertension, gurgling, ?chest pains.

Evaluation of this ?AMS (assuming the slurring, lethargy etc are not baseline) is complicated by the ETOH, but at the moment I would wonder if this patient isn't lethargic due to respiratory effort, and slurring due to the beverages.

SAMPLE history from spouse if possible, and an "intake" history from his football buddies would be a good idea: food + beverage amount + type.

As far as Tx, I agree that a NPA and NRB would be a good start for now. Lung sounds would be a priority for a quick decision on whether to CPAP or not. Distal edema/JVD present? 3rd heart sound?

Also,

12 lead
BGL/Pupils/Stroke Scale
Large bore IV
Figure out what your transport capabilities are ASAP


I would hold off on the beta blockers, narcan, and thiamine for now until we get more information...
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#18 Speed

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Posted 06 February 2008 - 11:20 PM

I would hold off on the narcan and thiamine for now until we get more information...


What are your contraindications for withholding? Granted his BP isn't really indicative of a "classic" narcotic ingestion, and he wasn't said to have convulsions prior to collapse (Wernicke's/ETOH), but the historian doesn't sound too reliable. To me it's just something else to rule out easily on an unconscious person. FSBS and D50% (if indicated) included would be an intermediate protocol for an unresponsive person. Just friendly brain jogging... would like to know your thoughts.
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Mike Williams CCEMT-P/FP-C

#19 Mike MacKinnon

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Posted 07 February 2008 - 10:51 PM

Hey all

I havent forgotten about the case!!

Im having some "scanner issues" along with my CABG pt coding on the table today, good times :P


That will be another case later ;)
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Mike MacKinnon MSN CRNA
WWW.NURSE-ANESTHESIA.ORG

"What gets us into trouble is not what we don't know
It's what we know for sure that just ain't so" - Mark Twain

#20 Speed

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Posted 07 February 2008 - 11:35 PM

Hey all

I havent forgotten about the case!!

Im having some "scanner issues" along with my CABG pt coding on the table today, good times :P
That will be another case later ;)


Did you get to break out the spoons?
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Mike Williams CCEMT-P/FP-C