Scenario

 

Dispatched priority one for a 78-year-old female at the local nursing home with complaint of fever and lethargy.

 

Upon arrival to the scene you are met by the RN who directs you to the patient’s room.  She also hands you paperwork and gives a brief history.  The patient spiked a fever of 102.3 this morning.  She was given Tylenol, but the fever has returned, and she has become increasingly lethargic.  She was doing well in the days prior except for two days ago when she fell out of her bed.  There were no injuries, so an ambulance was not called at that time.

 

Vital signs are as follows:  HR 126 with regular but weak radial pulses, RR 28 with shallow diminished lung sounds in all fields, BP 78/42, SpO2 93% on oxygen at 2 lpm via nasal cannula, and skin is pale/hot/dry.

 

Patient has a history of Dementia, Diabetes, COPD, Atrial Fibrillation, Hypertension, and Hypothyroid.

 

She takes Humalog, Lantus, Albuterol, Spiriva, Prednisone, Cardizem, Aspirin, Lisinopril, Spironolactone, and Levothyroxine.

 

She is a full code per RN and is stated so in the paperwork.

 

Answer - Sepsis

 

Patient is septic.  Due to the fall a few days prior she became bed ridden and rarely go up to move around due to her soreness.  Therefore, she has developed two sources of infection – UTI and pneumonia.

 

Sepsis is fast approaching the same Time Critical Diagnosis (TCD) as stroke and STEMIs.

 

Sepsis screening of you patient is simple and can be done within a matter of minutes.  It includes the following:

 

Prerequisite of infection suspected or documented; EtCO2 less than or equal to 25 mmHg; and lactate level of less than 4 mmol/L.  (Side note: as lactate levels rise as the EtCO2 drops).  Obviously, you would need capnography capability to do this.

 

If capnography is not available, you can still screen using the following assessments.

 

Quick Sepsis Organ Failure assessment includes systolic blood pressure of less than or equal to 100; respiratory rate of greater than or equal to 22; and GCS less than 15.

           

Systemic Inflammatory Response Syndrome (SIRS) assessment includes a temperature of less than 98.6F (36C) or greater than 100.4F (38C); heart rate greater than 90; respiratory rate greater than 20; and WBC less than 4000 or greater than 12,000.

 

Treatment is per your local protocols, but typically include tow large bore IVs to fluid bolus the patient up to 3 liters.  LR is the choice over NS since NS can worsen acidosis.  If patient remains hypotensive after fluid bolus a vasopressor may be given.  Maintain airway and intervene as appropriate with CPAP, biPAP, or intubation.

 

Scenario

 

Dispatched priority one for a 90-year-old male in respiratory distress.

 

Upon arrival to the scene found the patient sitting up in his bed.  Patient is in severe respiratory distress.  Patient was fine all day until he suddenly became short of breath and his SPO2 saturations dropped to the low 60s.  Patient is currently on oxygen via nasal cannula at 4 lpm. 

 

Vital signs are as follows:  HR 107 with regular but weak radial pulses; RR 32 with rales noted bilaterally; BP 187/102; SPO2 initially 65% on oxygen via nasal cannula at 4 lpm; and skin is pale, cool, and clammy.

 

Patient has a history of atrial fibrillation, previous heart attack with 3 stents placed, congestive heart failure, hypertension, and hypothyroidism.

 

Patient has no known allergies.

 

Patient takes Allopurinol, Alprazolam, Aspirin, Bumex, Finasteride, Folic Acid, Lovastatin, Omeprazole, Prednisone, Synthroid, Tramadol, and Warfarin.

 

Patient does have an active DNR and is refusing intubation.

 

Answer – Exacerbation of CHF

 

Patient is suffering from exacerbation of his congestive heart failure.  His symptoms started rapidly with an increase in pulmonary edema as noted by the crackles throughout his lung fields.

 

Congestive heart failure is one of the most common reasons for hospital admissions and rebound admissions in those patients over 65 years of age.  It is estimated that 5.8 million individuals in the US live with CHF.

 

Treatment is per your local protocol, but typically includes supporting the airway.  Obviously switching the patient from a nasal cannula to a non-rebreather in the short term is the appropriate course of action to raise his oxygen saturations.  Placing the patient on capnography cannula; if available, will assist in your diagnosis.  Obtain a 12 lead EKG.

 

Upon further inspection of the patient, it was noted that the patient had edema in all four extremities; therefore, only a saline lock was placed for medication administration.  Patient was given SL nitro.  His systolic pressure was greater than 100, so he was given 25 mg of Captopril (ACE inhibitor).  The patient agreed to the placement of CPAP and tolerated it quite well.  SL nitro was continued every 5 minutes, as well as placing 1” of nitro past to the patient’s chest.  Blood pressure was monitored every 5 minutes to ensure the patient did not become hypotensive.  Obstruction was noted on the waveform capnography, so an albuterol treatment was nebulized through the CPAP mask.  Since the patient is currently on a diuretic he was also given 80 mg of Lasix for the increased edema.

 

Patient improved greatly during the 40-minute transport to the hospital.  Upon arrival to the hospital patient was taken off CPAP with respiratory standing by.  Patient was able to maintain his SPO2 in the mid-90s and was placed on a nasal cannula.

 

Is was later found out the patient had been celebrating his 90th birthday with family earlier with food he does not normally eat.  It is possible the cause of his exacerbation was due to a higher than normal ingestion of salt.

 

Scenario

 

Dispatched priority one for a 61-year-old male.  9-1-1 call is from a third party who was on the phone with the patient when he sounded like he was having difficulty breathing.

 

Upon arrival to the scene patient is found sitting on his back porch.  Patient has audible wheezing and appears to be in respiratory distress.  Patient is unable to speak in complete sentences and is difficult to understand.

 

Vital signs are as follows:  HR 113 with regular bounding radial pulses; RR 28 with wheezing and stridor noted upon auscultation; BP 151/77; SPO2 93% on room air; and skin is pale, warm, and diaphoretic.

 

Patient has a history of hypertension, hyperlipidemia, and cerebral palsy.

 

Patient takes lisinopril and vytorin.

 

Answer – Anaphylaxis

Patient is suffering from anaphylaxis due to running over a bee hive as he was mowing his lawn.  Patient has several bee stings to his face that are red and swollen.

 

Anaphylaxis is a severe life threating allergic reaction with a reported 200,000 cases per year.

 

Treatment is per your local protocol, but typically includes:  IMMEDIATE IM injection of 0.5 mg of 1:1000 Epinephrine; administer oxygen and closely monitor the patient’s airway in preparation for possible intubation; nebulize Albuterol and/or Duoneb; 50 mg of Benadryl; and 125 mg of Solumedrol.

 

Patient was transported to the local hospital 15 minutes away.  Patient was given additional breathing treatments as well as Vistaril (H1 antihistamine) and Zantac (H2 antagonist).  Patient was discharged later that day with a script for Prednisone and an EpiPen.

Scenario

 

Dispatched priority one for a 59-year-old female with difficulty breathing.  Upon arrival to the scene, found the patient sitting on a chair in the tripod position.  She can speak, but with some difficulty.  Patient states she had been getting Christmas decorations out of the attic and became short of breath a couple of hours ago.  She used her inhaler with no relief, so she called 9-1-1.

 

Patient was loaded on the stretcher and taken to the ambulance.  It is bitter cold at about 29 degrees.  Once in the ambulance, the patient begins to have increased breathing difficulty with anxiety and cyanosis.

 

Vital signs are as follows:  HR 124 with regular bounding radial pulses; RR 30 with rhonchi in the lower lobes; BP 135/86; SPO2 89% on room air; and skin is pink/cool/dry.

 

Patient has a history of COPD, Atrial Fibrillation, Mitral Valve Prolapse, and Hyperlipidemia.

 

Patient takes Albuterol, Proair, Warfarin, Atenolol, and Simvastatin.

 

Answer – COPD

Patient is suffering from exacerbation of her COPD after being exposed to dust and mold in the attic.  Patient attempted to get control of her difficulty breathing with her inhaler without success.

 

There are approximately 3 million cases of Chronic Obstructive Pulmonary Disease in the US per year.  Tobacco smoking is the number one cause of COPD.

 

Treatment is per your local protocol, but typical treatment involves; oxygen delivery via nasal/capnography cannula or NRB, 12 lead EKG, 2.5 mg Albuterol nebulized every 5 to 15 minutes as needed for relief, Duoneb (0.5 mg Ipratropium and 2.5 mg Albuterol) nebulized once, 125 mg Solu-Medrol IVP, and finally 16 mg Decadron nebulized.

 

There are studies that indicate treatment with CPAP, however the patient must be mentally alert.  This patient was beyond being able to tolerate the mask and was deteriorating rapidly.    

 

When this patient was taken outside into the bitter cold it caused her to bronchospasm.  Patient’s initial capnography reading was hypercapnia with a typical shark fin waveform presentation.  As the breathing treatment was administered the patient became anxious and hypoxic.  5mg of Versed was attempted to calm the patient.  This did not work, and patient progressed to respiratory failure.  Patient agreed to intubation.  RSI was performed using 30 mg of Etomidate and 100 mg of Succinylcholine.  7.0 tube was placed without difficulty.  There was no difficulty bagging the patient.  Continued sedation post intubation of 100 mcg of Fentanyl was administered every 10 to 15 minutes.

 

Patient was eventually extubated and discharged home.

 

Scenario

 

Dispatched priority one for a 39-year-old female roadside in active labor.  Her husband was driving her to the hospital when she advised him she felt the baby was coming out, so he pulled off the shoulder of the interstate and called 9-1-1.  When you arrive on scene you find the patient in the front seat having contractions and feeling the need to push.

 

What do you do first?  What information do you need right this moment?

 

Answer – Child Birth

 

As stated in the scenario upon inspection you notice the baby is crowning.  Your partner heads to the truck to obtain the OB kit.  Before he arrives back to the vehicle you have delivered the baby.  The baby’s airway is suctioned and is cleaned.  The cord was clamped and cut.  Luckily there were no complications.  The mother was loaded onto the cot and secured with 5-point harness straps.  Baby was wrapped in a blanket and carried to the ambulance.  Once the mother was loaded into the ambulance the baby was placed in her lap.  Mother started nursing the child on the short transport to the hospital without incident.

 

The point with this scenario was to get you to critically think in a high stress situation.  

 

It also has a secondary lesson...safe transport of pediatric patients.  There is a change of culture currently taking place to ensure research and testing are taking place to keep our youngest patients safely secured during transport.  So, if you hear about this initiative, please support it.

Scenario

 

Dispatched priority two for 7-year-old male who was playing on the playground at recess and fell off the monkey bars striking his head on the ground.  No loss of consciousness noted.

 

While enroute you are upgraded priority one as the child has started seizing.

 

Vital signs are as follows: HR 110 with regular strong radial pulses; RR 10 and shallow; no BP obtained; SPO2 95% on room air; skin is pale/cool/dry.

 

According to the school nurse the patient has no health history, takes no medications, and is not allergic to any medications.

 

Answer – Head Injury

 

Patient is suffering from a closed head injury.  The seizure activity witness is due to the fact the patient has a subdural hematoma.  

 

Subdural hematoma ranges from a fatal life threat to a minor insult on the brain.  Recently it was considered the number one cause of accidental death to patients under 45 years of age.  Head injuries tend to make the patient prone to seizure activity for years following the accident.

 

In this patient he did not lose consciousness but shortly thereafter began to seize.  After the seizure stopped the patient had unequal pupils and a deviated gaze.  HR started to drop.  BP was finally obtained with a reading of 140 palp.  Respirations are now 8 and irregular. (Cushing’s Triad)

 

IVs initiated.  Patient was intubated using Rapid Sequence Intubation.  

 

Transported priority one by ground to the closest level one trauma center where the patient was stabilized and then transferred to the closest children’s hospital for neurological care.

Scenario

 

Dispatched priority one for a 47-year-old female who was found unresponsive by her family.  Patient is reported to have shallow respirations.

 

Upon arrival to the scene you find the patient lying supine on the couch.  Her father and daughter are in attendance.  The daughter states she woke up and found her this way.

 

Vital signs are as follows:  HR 125 with regular bounding radial pulse; RR 12 and shallow; BP 97/67; SPO2 97% on room air; and skin is pale/warm/dry.

 

Patient has a history of an inoperable brain aneurism.  Patient only weighs 80 lbs.

 

According to family the patient is not allergic to any medications and only takes OxyContin for chronic pain.

 

Answer - Overdose

 

Patient was found to be suffering from an overdose.  

 

During transport the patient was given a dose of Narcan.  Shortly thereafter she became alert and combative.  Upon arrival to the emergency room the physician decided to RSI the patient as she was having periods of unresponsiveness combined with combativeness.  Drug screen showed the patient had Amphetamines, Benzodiazepines, and Opioids in her system.

 

One only needs to open their newsfeed every day to see that there is an opiate crisis. Narcan is a drug that EMS has had for quite some time. Due to the increase of heroin usage Narcan has become quite popular in mainstream media. Those of us in EMS know that Narcan does come with some side effects; therefore, we should not take its usage lightly.  As with anything, if you have your patient’s best interest in mind you will make the right choice.

Scenarios

 

Dispatched priority two to the local nursing home for an 84-year-old woman with abnormal labs.  Upon arrival to the scene you find the patient sitting in her recliner in no obvious distress.

 

NH staff state the patient had blood drawn earlier today and they just received word that the INR was high, so the physician would like the patient transferred to the hospital.

 

Patients vital signs are as follows:  HR 88 with regular weak radial pulses; RR 20 and regular; BP 110/64; SPO2 94% on room air; and skin is pale/warm/dry.

 

Patient has a history of atrial fibrillation, hypothyroidism, hypertension, hyperlipidemia, CHF, GERD, and dementia.

 

Patient is allergic to penicillin.  She currently takes Warfarin, Levothyroxine, Metoprolol, Simvastatin, Lasix, Prilosec, Celexa, and Ibuprofen.

 

Answer – Abnormal Labs

 

While this patient did have abnormal labs with an elevated INR; she was stable and did not require any intervention.

 

Sometimes the best thing we can do in the back of the ambulance is to hold a hand.  Compassion is key to everything we do in this field.  Sometimes it is easy to lose sight of this when the patient is critical or a frequent patient.  

 

I have had many a transport where I held hands, offered more blankets, talked about kids and grandkids, gardening, cars, military service, etc.  

 

Therapeutic is not always about the monitor, IV, oxygen or meds.  Sometimes the most therapeutic thing you can do is a gentle reassuring touch and a smile to show the patient they are the most important thing to you at that very moment.

 

Scenario

 

Dispatched priority two to the local nursing home for an 84-year-old male who suffering from hypotension.

 

Upon arrival to the scene you are met by the RN who directs you to the patient’s room where you find the patient curled up in the fetal position on his left side.  Patient is altered, but staff states this is normal for the patient.

 

Patient’s vitals are as follows:  HR 72 with regular weak radial pulses; RR 16 regular with clear and equal breath sounds; BP 87/55; SPO2 94% on room air; and skin is pale/cool/dry.

 

Patient has a history of Alzheimer’s, Dementia, GERD, Hypertension, Bipolar Disorder, Seizures, and Chronic Pain.

 

Patient’s medications include Acetaminophen, Aspirin, Citalopram, Dilantin, Fentanyl Patches, Hydrocodone, Losartan, Metoprolol, and Tramadol.

 

Answer – Failure to Thrive

 

Patient was given a fluid bolus of 600 ml which did increase his BP to just over 100 systolic.

 

It was determined by the physician in the emergency room that the patient had been over medicated and was suffering from a urinary tract infection.  It was also determined that the patient’s Alzheimer’s has advanced to the point where he is becoming a failure to thrive.  

Scenario

 

Dispatched priority two stage in the area for a 47-year-old male who is behaving erratic and threatening his wife.

 

Once the scene is cleared by law enforcement you are advised to proceed.  Upon entry to the residence you find the patient sitting naked on the floor unresponsive.

 

Patients vitals are as follows: HR 107 with regular bounding pulses; RR 24 and shallow; BP 144/74; SPO2 97% on room air; skin is cold, jaundice, and mottled in the lower extremities.

 

Patient has a history of cirrhosis of the liver, diabetes, hypertension, and previous stroke with no lasting deficits 5 years ago.

 

Patient’s current medications are Furosemide, Invokana, Januvia, Lactulose, Metoprolol, Omeprazole, and Spironolactone.

 

Answer – Elevated Ammonia Levels

 

Patient was found to have elevated ammonia levels due to his advanced liver failure.

 

Hyperammonemia is a metabolic condition whose symptoms can mimic a stroke.  Symptoms usually include lethargy, irritability, difficulty word finding, and hyperventilation.

 

If not treated properly the amount of ammonia built up in the brain can lead to damage and even death.

 

Scenario

 

Dispatched priority one for a 20-year-old female who is actively seizing.

 

Upon arrival to the scene you find the patient lying on the floor of the living room.  The house is empty except for a few bags.  The house smells of fresh paint.  The patient is postictal.  There is a small amount of blood coming from her mouth.

 

Vital signs are as follows:  HR 93 regular and strong radial pulses; RR 12 regular and shallow; BP 105/76; SPO2 99% on room air; skin is pink, warm, and dry.

 

After vitals are obtained the patient starts to actively seize again.

 

Answer – Pseudo Seizures

 

Patient suffered four seizures enroute to the hospital.  Patient was given a total of 15 mg of Versed that failed to stop the seizures.

 

Patient’s toxicology came back clean.

 

Patient was transferred to a higher level of care.  It was determined the patient was suffering from pseudo seizures brought on by stress.  She was placed in psychiatric care for 96 hours and eventually released.