Just encountered another BLS abdominal pain...NOT

Elderly female 24 hours status post lap cholecystectomy having abdominal pain from the surgery. Not so much! Don't let the elusive MI slip by you.

RSI Part 1...Rapid Dosing for RSI...S,M,L,XL

I have been performing RSI in the field for ten years now.  I have developed systems for each phase of the incident to make this low-frequency high-risk call go smoothly with positive outcomes for both the patients, as well as, the providers. 

I will be covering each aspect of this process over several blog posts.  Today, I am going to explain my system for dosing adult patients in need of rapid sequence intubation.  This procedure can be stressful for prehospital providers. Anything we can do to keep it simple so the provider can focus on the big picture is helpful. 

Weight based dosing in the prehospital arena is guesswork at best.  Unless you were a carnival worker in a previous life your weight estimates will be anything but accurate.  With this in mind I have observed many a paramedic give their absolute best effort in estimating a patient's weight.  We are mostly type-A perfectionists.  Of course we will do everything we possibly can to determine the patient's weight and drug dosing so it will be absolutely accurate.  I've watched providers look at a patient and say 150lbs or 175lbs, and then they begin the calculations to kilograms, consulting complex dosing charts that are in five pound increments.  Using this method wastes valuable time and effort. If you are currently doing this type of calculation I submit you are simply wasting brain cells.  Brain cells that could be used to figure out more important things such as the underlying cause of the patient's condition.  Use those brain cells not to miss the potentially hyperkalemic patient (new onset kidney failure, rhabdomyolysis in an elderly patient laying on the floor of their house for two days, etc.) It is these types of patients that your succinylcholine will most certainly be the kiss of death.  

When I am faced with an adult patient needing RSI the first thing I do is classify them as either a small adult (60 kg), a medium adult (80 kg), a large adult (100 kg), or an extra-large adult (120 kg).  If you are off by 10 or so kilograms; if they are a little smaller or even a bit larger, trust me, it won't matter.  They will still drop like a rock and you will still be able to control their airway without issue of drug effectiveness.  The drugs used to induce anesthesia in patients for RSI have a wide margin of error in dosing.  Use this to your advantage and estimate their weight in a simple even number of kilograms so your calculations will be easy to perform and easy to confirm.  

Take the dosages and drugs you use for RSI and write out a chart for all the sizes given above.  You will notice a pattern that forms, as each size increment is exactly 20 kilograms.  Once you commit this to memory you will be able to remove this stressor from the incident and be able to concentrate on other aspects of the call such as: safety, airway size-up, delegation of responsibilities, overall scene management, assuring each team member is able to perform their respective functions, and backing-up each team member to assure success!

Once you become accustomed to this type of dosing you will be able to quickly and easily draw up medications for the majority of the population without a second thought.  You will be able to determine dosages in your sleep, which may be helpful for that 3:00 AM call of your life.

Another tip for drawing up medications for RSI is to use different size syringes for different types of drugs.  I always use a 20 cc syringe for Etomidate, a 10 cc syringe for the paralytic (either Succinylcholine or Norcuron), a 5 cc syringe for Versed, and a 3cc syringe for Fentanyl.  An addded bonus for where I work is the order of administration is largest syringe to smallest syringe.  This way when the drugs are laid out beside each other they are clearly visible as to their function, order of administration, and should not be confused.  I have watched paramedics use several syringes of the same size and place labels on each syringe.  This is asking for confusion and just another waste of time.

Just a few thoughts on how to make this type of call go more smoothly for you.  Hope it was helpful!  Be safe out there!             

When to Put on Your Fireman Suit

Over the years I have noticed that persons assigned to an EMS unit have a habit of wandering around dangerous environments in half of their PPE or even worse no PPE.  When we are assigned to a suppression piece and the tones drop everyone is very clear as to when we dress and when we don't.  So why is there such a wide variance of PPE from EMS personnel?  Regardless of the reasoning I am going to attempt to remove some of the fog from this issue.

There are three distinct incidents that I feel personnel assigned to the EMS unit need to arrive in PPE and ready to perform.

1) First Due Building Fire
When you are the first arriving medic unit to a building on fire you need to be fully dressed in your fireman suit and ready to work.  Your primary responsibility is not to make the nozzle, ladder the roof, or run around and try to prove what a great fireman you are.  You can do this when you are assigned to the engine, truck, or rescue.  Your number one responsibility is to locate, triage, and treat any civilian injuries.  In order to do this properly you need to be fully dressed so that you can safely approach and work in and around the scene.  Large crowds are often found all around a fire scene.  In these crowds you will find witnesses, homeowners, civilian rescuers, green linemen, and many of them may be walking wounded.  It is your job to figure out what happened, how many are injured, and relay to command all of this information along with any additional resources you will need to begin to develop the EMS branch of the incident.  Look for soot running out of nostrils or on clothing, torn or ripped clothing, citizens without shoes, cuts and scratches, or obvious burns.  Adrenaline will be running high with victims and they will be ignoring any and all pain or discomfort. As you are doing this by no means should you neglect the kink in a hose line, but do not expect to be fighting fire.  It is not a glorious job but a very important one.  Everyone on the incident has a specific job to do and the EMS unit is no exception.  If there are no civilian casualties your number two responsibility is to function as the initial RIT medic unit for any firefighter injuries or deaths that may suddenly occur.  It has been said that the word "MAYDAY" is the most frightening thing that can be heard over a fire ground radio.  It is your job to be prepared for and expect this event on every fire.  Be familiar with the egress points and make a plan to evacuate any civilian or firefighter casualties from each exit point.  Some tricks of the trade I have learned over the years are:

• Place your cot in the down position in an area easily accessed by all egress points
• Only bring essential EMS equipment away from the unit to perform the initial key functions in a cardiac arrest (airway, IV, defibrillation), everything else can be treated in the unit after the victim is evacuated from the scene.
• Use a reeves stretcher or a large soft stretcher such as a Shamu to evacuate victims.  They work much better over hose lines and around common obstructions found on a fire scene than trying to roll the cot everywhere. 
• Be diligent, be prepared, and expect the worst.  Everything else will be no problem  

2) Vehicle Fire
It is very important for the EMS crew to be dressed and ready to work on a vehicle fire. Not so they can smoke the engine with a dry chem, but to perform and/or assist in any victim rescue from the vehicle.  It is a rare occasion, but the reason an EMS unit is dispatched on a vehicle fire is for just this reason.  When you do roll up on an incident with a screaming victim hanging halfway out the drivers window with black smoke billowing all around them you better be ready.  If you are not already dressed and able to easily and quickly don your SCBA you will be way behind the eight ball.  Some tricks of the trade I have learned over the years are:

• Be ready to break glass and cut seat-belts.
• If you have an extra SCBA place it on the roof and give the victim air.  We carry three on our units in case we have an intern.
• Bring a dry chem to the car (to help extinguish the interior fire around the trapped victim). They will appreciate this even more if you have a mask on them so they don't suffocate from the dry chem as well as the smoke
• Be mentally prepared for "whatever it takes!" If you have ever run an incident like this you know that it can be one of the most trying and stressful incidents you will ever run. There is nothing quite like being face to face with another human being while they claw and scream at you because they are burning alive.  This image alone should be reminder enough for you to get dressed before you leave the house.
• You may need to enter the vehicle while it is on fire from the opposite side to remove the victim.  This is an impossibility without full PPE and SCBA.

3) MVA with Extrication
On an extrication it is the rescue's job to either remove the victim from the vehicle or remove the vehicle from the victim.  It is the job of the EMS crew to access and treat the victim during the rescue.  This cannot be done unless the EMS crew is in full PPE.  There should be no one in the action area around the vehicle without the proper PPE, but too many times you see a member of the EMS crew popping in and out wearing a station uniform and a traffic vest.  This is unacceptable and should never happen. Some tricks of the trade I have learned over the years are:

• Be ready to break glass and cut seatbelts
• Absolutely do not try to enter a vehicle that has not been stabilized
• Coordinate with the rescue officer
• Wear a low profile rescue helmet rather than a suppression helmet.  It allows you to move around the interior of the vehicle more easily. 
• Carry a small amount of essential EMS supplies with you when you are the interior EMS.  Be prepared to control an airway, start IVs, control bleeding, place tourniquets, etc. 

These three types of incidents are when EMS personnel need to arrive absolutely without question in full PPE and ready to perform.   

Prehospital Abdominal Assessment Part 4..MI?

For the upper right quadrant we are not going to concentrate on bleeding ulcers, any stomach disorders, or the spleen.  As I have said before paramedics are experts on what is going to kill you in the next 20 minutes, and the most devastating disorder we can encounter in the upper right, or any quadrant does not even originate from the abdominal cavity, it is a myocardial infarction.

You must scrutinize any and all abdominal pain for the presence of an MI, regardless of what the patient is telling you, regardless of the quadrant, regardless of your gut instinct as to the origin of the pain or discomfort.  Not long ago a woman walked into a hospital complaining of gallstones.  She had a history of gallstones.  She told the triage nurse the pain was more to the upper left quadrant and she was sure it was her gallstones.  The patient stated she should of had her gall bladder removed years ago but did not and now she is paying for it.  The nurse and the patient had a very thorough conversation regarding the patient's history, all signs and symptoms pointed to the gallbladder.  After the patient was escorted to a room the doctor ordered a routine EKG and found the following:

 
This was no gall stone!  The only reason we perform 12 lead EKGs in prehospital medicine is to quickly identify the presence of an acute MI.  We cannot successfully do this unless we get in the habit of rapidly (within 5 minutes of patient contact) performing a 12 Lead EKG on all patients at risk of having an MI.  That means all chest pain, chest discomfort, dizziness, syncope, shortness of breath, nausea, and yes abdominal pain to name a few.  There are few medical patients that you can absolutely rule out the risk of an MI.  If you are going to perform a 12 lead EKG on a patient it should be done quickly and efficiently.  Train your partner and crew to make this part of their initial physical assessment and acquisition of vital signs.  A well trained paramedic should never say, "do you want to get a 12 lead now or wait till we get to the unit?"  My response to that question is, "exactly how long would you like to wait to determine the patient is having an MI? Would 10 more minutes suffice?"

Don't let an MI slip through your fingers just because the patient describes abdominal pain.  You do not want  to be THAT medic!

Prehospital Abdominal Assessment Part 3

In Prehospital Abdominal Assessment Part 3 we are going to take a good look at the lower left quadrant.  The two conditions we are going to look at in the lower left quadrant are worlds apart from each other, kidney stones and an abdominal aortic aneurysm.


Kidney stones can obviously occur on either the right or the left side as we have two kidneys, but we are going to discuss them here because we spent our time in the lower right quadrant focusing on appendicitis. Kidney stones are not life threatening but have been described as the most painful medical experience, including childbirth, one will ever encounter. One minute you are fine and the next minute it feels like you are being stabbed in the back or the groin.  Most kidney stones pass on their own but the ones that don't may require some sort of urological intervention that can range from supplemental medications to surgery.  Kidney stones do not cause symptoms until they try to pass through the urinary system.  Symptoms are extreme pain in the back or side that will not go away, nausea and vomiting, blood in the urine, and fever/chills.  The best prehosptital indicator that the pain your patient is experiencing is a kidney stone is a good history.  A history that predisposes a patient to kidney stones are, male gender, previous stones, family history of stones, diet heavy in animal protein and eggs.  There is no magic physical assessment tool  here that will point towards a kidney stone in the field.  The pain can be anywhere from the back to the groin, depending on where the stone has decided to get hung up, or radiating down to the groin.  The best prehospital treatment for a kidney stone is good pain management.  Pain medications are classically under dosed in the prehospital setting.  Give an initial dose of medication and continue to give additional doses as long as their pain is greater than a 5/10.  Your goal should be 0/10 pain management, but that is rarely possible with a kidney stone.  Left untreated a kidney stone can lead to infection and sepsis.  


The next emergency you should rule out is a big one and can definitely kill your patient faster then you can transport them to the nearest operating room.   An abdominal aortic aneurysm is a permanent localized dilation of the abdominal aorta greater than 3 cm and  is  one condition every near syncope and every syncope patient needs to be scrutinized for.  Symptoms can range from back pain to lower abdominal pain. it has been described as tearing, stabbing, or ripping pain.  A pulsitile mass can be an ominous sign and if you feel one then you need to be very gentle with the patient and very carefully transport to the nearest hospital with an operating room staffed and ready to go.   

Attached is a good YouTube video explaining the anatomy and the process of the surgical repair.

Prehospital Abdominal Assessment Part 2

     Continuing the prehospital obdominal assessment we will look at the right lower quadrant.  In this area we are going to talk about the obvious acute appendicitis.  In order to help us differentiate an appendicitis in the presence of RLQ abdominal pain I would like to add two more assessment tools to your repertoire: tenderness over McBurney's point and obturator sign.  Positive results from these tests point toward appendicial irritation and possibly an acute appendicitis. McBurney's point  is a site of extreme sensitivity in acute appendicitis, situated in the normal area of the appendix one third the distance between the umbilicus and the anterior iliac spine in the right lower quadrant of the abdomen.  Finger pressure over McBurney's point in the presence of an acute appendicitis brings immediate and intense pain.  Tenderness over McBurney's point is one indicator of an irritated appendix.  

  

The next test you can do is called obturator sign.  The internal obturator muscle lies close to the appendix and flexation of this muscle in the presence of an acute appendicitis will cause an increase in pain in the lower right quadrant.  A picture is worth a thousand words so this test is best explained by watching the following video:
  
http://youtu.be/jV80jcnhNtA

This brings us to the topic of rebound tenderness.  We have all learned that the presence of rebound tenderness in the LRQ could mean an appendicitis. Rebound tenderness is not an isolated test for an appendicitis.  Anytime the peritoneum is inflamed you will find rebound tenderness.  An inflamed and infected appendix will irritate the peritoneum thereby causing rebound tenderness in the area of the appendix.  Rebound tenderness can also be an early sign of abdominal bleeding even before rigidity as blood in the abdomen will cause peritoneal irritation as well.  So rebound tenderness in itself is not conclusive of an inflamed appendix.  Using the assessment tools I have described above is much more specific and useful.  When confronted with a patient with LRQ abdominal pain it is very important to determine the likelihood of an acute appendicitis as it is an emergent surgical case and a ruptured appendix can cause profound septicemia.

The most common signs and symptoms of an appendicitis are abdominal pain, loss of appetite, nausea, vomiting, and fever.  When you have this presentation along with tenderness over McBurney's point and a positive oburator sign...think acute appendicitis

Coo Coo Bird? A Practical Prehospital Psychiatric Assessment

Psychiatric emergencies can be one of the most dangerous and challenging emergencies that prehospital providers can encounter. Our training in these situations is scant at best and these patients present a myriad of challenges. If you are presented with a patient in the midst of psychiatric emergency emotions will be at an all-time high for the patient, as well as, you and your crew.  If you follow these four simple guidelines you will increase your confidence and improve the patient's outcome in these very challenging emergencies.

1) They are having a medical emergency until proven otherwise.

     This is extremely important as there are several medical conditions that can affect a patient's behavior: hypoglycemia, thyroid disorders, toxins, and stroke to just name a few. In the prehospital setting we can rarely rule out all the causes of behavioral changes so never pigeon hole a patient as a coo coo bird. This is a classic mistake and will only lead to poor treatment decisions and a horrible experience for the patient and their family who has summoned you to save them from a seemingly impossible situation. 

2)  Safety first: The safety of the patient and the emergency responders is paramount.  One of the first determinations you need to make is whether the patient is dangerous to themselves or others.  Always include law enforcement and never allow the patient to be alone at any time once you have made contact.  Truly suicidal patients who are being cornered will make any excuse to get away from you and finish the task.  It is not unusual for a patient to simply ask to go to the bathroom and then jump off of their balcony.  Remember, once you make contact don't let them out of your sight and make sure you always have enough help to fully restrain and immobilize them in case the situation warrants immediate control.

3) Simple assessment questions:  Ascertain the patient’s suicide scale and homicide scale.  On a scale of 0-10 where zero is no thoughts whatsoever and 10 means they want to commit suicide right now; what number would they give themselves? If they give you any number above zero for the suicide scale the next question you want to ask is do they have a plan? A truly suicidal patient spends 24/7 thinking about and planning on how they are going to get the job done. If they give you a plan then add a few points to the scale because they are serious. If they give you any number above zero for the homicide scale the next question you should ask is to whom their aggression is directed. If they are having feelings of anger and aggression you need to know who the target is. Is it one person or a group of people? Is the person in the room? Are you the person? These are all very important pieces of information that will assist you in diffusing the situation. Ask the patient if they hear voices. If they say yes then you want to know what they are saying. If the voices are telling them to kill the paramedic then that is a very important piece of information. Ask if they are seeing things and what they are. If you ask every suspected psychiatric patient these few questions it will give you a very good snapshot of their mental stability. So remember to ask these questions:

• Suicide Scale
• Homicide Scale
• Voices
• Hallucinations

4) Diffuse the situation: The next step in mitigating these types of emergencies is to diffuse the situation and transport the patient to the nearest hospital with psychiatric facilities. If their suicide scale is anything above a zero then they warrant an emergency custody order and immediate transport regardless of their feelings about the situation.  Consult your state laws regarding ECPs and TDOs. Never humor their delusions or lie to them about anything that is happening or going to happen. The best road to successfully diffusing the situation is honesty and professionalism. Remain tactical and aware of scene safety. Psychiatric scenes are very dynamic and can change rapidly from a pleasant conversation to a life threatening MAYDAY in a matter of seconds.