Digest

This episode of EMS 2020 features a special edition focusing on patient scenarios from the \"Master Your Medics 100 Patient Scenario Books.\" The hosts present a challenging case of a 64-year-old female with altered mental status, found to be severely hypotensive and lethargic. The scenario emphasizes the difficulties of patient extrication from a challenging environment, particularly with a bariatric patient. Initial assessment reveals significant hypotension, requiring aggressive fluid resuscitation and the placement of an intraosseous (IO) line due to difficult IV access. The patient is suspected to be septic, necessitating further treatment including vasopressors. The extrication process is fraught with complications, including patient falls and equipment dislodgement, underscoring the critical role of logistics in pre-hospital care. Despite setbacks, the team works to stabilize the patient, establish definitive access, and prepare for transport. The discussion highlights the importance of rapid assessment, decisive treatment, and the practical challenges faced in real-world EMS scenarios. The episode concludes with a debrief, reflecting on the learning points related to patient handling, decision-making under pressure, and the critical interplay between medical treatment and logistical execution.

Outlines

00:00:00

Scheduling Clarity and EMS Scenario Introduction

The episode begins with a brief discussion on the ambiguity of scheduling using days of the week versus the clarity of specific dates. It then transitions into a special edition of EMS 2020, focusing on patient scenarios from the \"Master Your Medics 100 Patient Scenario Books.\" A new format is introduced where hosts challenge each other with realistic EMS scenarios, with listener participation via Instagram voting on performance.

00:07:41

Scenario Setup: Rural Patient with Altered Mental Status

The scenario involves a private ambulance company in a suburban area with ALS fire mutual aid, responding to a rural town with a BLS volunteer fire department. The dispatch is for a 64-year-old female with altered mental status, found alert but confused and lethargic.

00:16:13

Patient Encounter and Initial Assessment

Upon arrival, the crew finds Patricia, a 450lb, 64-year-old female, in an easy chair. Her friend reports increasing weakness and lethargy. Initial assessment reveals disorientation, abdominal pain, and vital signs indicating severe hypotension (BP 70 palp), shallow respirations, and borderline SpO2.

00:32:09

Treatment and Access Challenges

Initial treatment includes oxygen, a fluid bolus, and attempts at IV access. The patient has a significant medical history including morbid obesity, diabetes, and hypertension. Multiple IV attempts fail, leading to the decision to place an intraosseous (IO) line in the humeral head.

00:45:27

Suspected Sepsis and IO Line Success

Sepsis is suspected due to the patient's presentation. Pupils are assessed, and while temperature isn't immediately taken, the IO line is successfully placed. Administration of a fluid bolus and push-dose epinephrine leads to improved heart rate and blood pressure.

00:48:20

EKG, Transport Decision, and Extrication Challenges

A 12-lead EKG shows normal sinus rhythm, ruling out STEMI. Due to the patient's critical condition and the difficult egress from the worn house with a hazardous porch, the priority shifts to moving her to the ambulance.

00:51:15

Extrication Difficulties and Patient Movement

The team devises a plan to move the patient using a mega mover and gurney, facing challenges with the porch and terrain. Arriving firefighters assist in carefully maneuvering the patient.

01:04:26

Complications During Extrication and Access Issues

During movement, an IO line becomes dislodged, and the patient becomes more agitated. The fluid bolus is re-established. Further complications arise with slipping and the patient falling into water, highlighting the unpredictable nature of patient extraction.

01:11:17

Ambulance Loading and Access Reassessment

The patient is loaded into the ambulance via a power gurney. A critical re-check reveals the IO line is loose and potentially not patent, necessitating the establishment of new access.

01:12:08

Establishing New IV and IO Access in Ambulance

Faced with a lost IO, the team opts for bilateral tibial IOs and works on a new IV. A 20-gauge EJ is successfully established, while an attempt at a blue IO fails.

01:15:07

Transport Plan and Critical Interventions

The fire department is cleared to drive the ambulance. Crew assignments are discussed, and a code three response is planned. Fluid resuscitation via the EJ and initiation of a norepinephrine infusion begin due to suspected sepsis and ongoing hypotension.

01:17:23

Patient Vitals, Respiratory Monitoring, and Intubation Preparedness

Current vitals show improving but still low blood pressure. An N-tidal cannula is applied, showing an ETCO2 of 18 with an irregular waveform. Intubation equipment is prepared, and medication dosages are planned based on weight.

01:21:07

Pre-Hospital Report and Diagnosis

A pre-hospital report is given to the receiving hospital, detailing the patient's septic and hypotensive condition. Differential diagnoses include MI and medication effects. The limited acute value of temperature monitoring in sepsis is discussed.

01:26:54

Operational Challenges and Logistics in EMS

The main challenge of the scenario was the difficulty in extricating a sick patient from a challenging home environment, emphasizing logistics over complex medical treatment. The importance of logistics in patient care, especially for bariatric patients, is highlighted.

01:31:13

Scenario Reflection and Learning Points

The scenario serves as a debriefing opportunity to reflect on ignored safety plans and the impact of unforeseen events. Participants consider changes, such as earlier IV access for hypotension, and the benefit of early N-tidal monitoring. The episode concludes with sponsor acknowledgment.

Keywords

Q&A

• What are the primary challenges in scheduling using days of the week versus specific dates?

  Scheduling with days of the week like "next Monday" is subjective and can lead to confusion, as there are multiple Mondays in a month. Specific dates (e.g., "the 28th") offer objective clarity, reducing the risk of misinterpretation and making scheduling more efficient.

• What is the scoring system used in EMS 2020's special edition episodes?

  The scoring system ranges from 0 to 2. A '0' signifies a failure to manage the patient appropriately. A '1' represents a perfect, by-the-book run. A '2' is awarded for going above and beyond, demonstrating exceptional skill or handling challenging circumstances.

• What were the initial vital signs and primary concerns for the patient?

  The patient presented with a heart rate of 70, blood pressure of 70 by palpation, respirations of 26 and shallow, and SpO2 of 93% on room air. The most critical concern was severe hypotension.

• Why is intraosseous (IO) access often used in emergency medicine?

  IO access is crucial when peripheral IV access is difficult or impossible, such as in patients with severe hypotension, edema, or collapsed veins. It allows for rapid and reliable administration of fluids and medications directly into the bone marrow.

• What were the main challenges encountered during the patient's extrication?

  The primary challenges included the patient's significant weight (450 lbs), the dilapidated porch with rotten wood and plywood, and the need for a safe and efficient method to move her from the house to the ambulance.

• What interventions were initiated to stabilize the patient's condition?

  Interventions included a non-rebreather mask for oxygen, a fluid bolus, push-dose epinephrine to improve blood pressure, and successful placement of an intraosseous (IO) line for medication and fluid administration.

• Why was establishing IV/IO access difficult, and what alternative was used?

  Initial IO attempts were problematic. An EJ (Emegency Jugular) vein was successfully cannulated, providing an alternative IV access route when IO placement proved difficult or the needle was too short.

• What was the patient's likely medical condition, and what were the key interventions?

  The patient was likely septic and dehydrated. Key interventions included fluid resuscitation, norepinephrine infusion to manage hypotension, oxygen therapy, and establishing IV/IO access.

• What is the significance of N-Tidal CO2 monitoring in this scenario?

  N-Tidal CO2 monitoring provided an objective measure of ventilation and perfusion. While the waveform was initially irregular, it offered continuous data and could alert the team to changes in the patient's respiratory status.

• What was the main takeaway or learning point from this simulation scenario?

  The primary lesson was the significant challenge posed by the logistics of extricating a sick patient from a difficult environment, often overshadowing the complexity of the medical treatment itself.

Show Notes