April EMS Scenario

[N2DFire]

I was thinking - someone always post a scenario in the Firefighter forums every month - so why can't we have one here too ?

This is my first shot at doing one of these so please be kind.

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Dispatch Information
23:00 you are called to meet a Dept. of Game & Inland Fisheries boat @ dock XYZ the local lake (river, stream, fish pond, swimming pool, aquarium, etc. in reference to a hypothermic subject.

Upon arrival - you find a 30ish Male who was reported to have been kayaking on the lake all day - became disoriented/lost.

Weather Conditions
Air temp during the day was Mid 40's (F) - currently temp is hovering just above freezing.
Wind Advisory in effect from NWS. Recorded gusting to 20-25 MPH during this time. Intermittent snow showers throughout the day & night.

Pt. Presentation
Subject is wearing wet jeans, dry cotton T-shirt, cotton gloves (dry), a borrowed jacket & a fireman's nomex hood. Upon questioning - Pt. states he had changed clothes several times in an effort to stay dry.

Pt. is actively shivering and all extremities are bluish & cold to the touch. Pulse Movement & Sensation are present in all. Pt. is Oriented to Day, Date & Location, however he is sluggish and "sleepy"

BP: 132/118
Pulse: 110
Resp: 12 - 16
SpO2: 94% on "Room Air"
EKG: Sinus Tach (110) with Lots of artifact.

No Relevant Medical Hx.
No Allergies
No Medications

Last Oral intake uncertain, however (upon questioning) Pt states he had not eaten at all that day and had only drank water.

During transport/re-warming Pt. begins to complain of a tingling/burning sensation in his feet.
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Now - given your level of training & what ever equipment/resources you normally work with - describe how you would treat this Pt.

This was a real call I ran last night - after a few post I'll describe what I did, what I would have like to have done (and what I might do different next time).

Also - I know there will be things I might have missed so I'll monitor this the best I can to catch any questions you post.

Have fun with it and lets see if we can't share some ideas here.

Take Care - Stay Safe
Stephen
FF/Paramedic

[Lewiston2Capt]

I will start this off by stating that this response is from a BLS ambulance. I will put my personal intermediate take on it in parenthesis.
Upon arrival crank heat in pt compartment of ambulance prepare extra wool blankets and hot packs. Put on high flow O2. (Warmed IV solutions could be useful too.) Remove wet clothing and wrap in lightweight blanket followed by wool blankets. Place hot packs at back of neck, in armpits, at wrists and behind knees. EKG monitor for arrhythmia with warming. (Do a D-Stick, and start warmed IV). Transport.

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Shawn M. Cecula
Captain
Lewiston Fire Co. No. 2

[hagerff/emti]

Enroute warm IV fluids. After arrival, turn up the heat in pt compartment of ambulance. Get blanket ready and find the hot pack. Cut/get rid of all wet clothes. Then place the warm IV fluids and hot packs around the pt. in areas where they will be most helpful. Start a line with warm IV solutions. O2 High Flow, and cont. to monitor the pt. I think that I would also check his blood sugar to see what range it is in. Based on the fact that he is sluggish and "sleepy". I would also call ahead to our hosp and have them get the bear hugger started (its a warming machine that we have here, works like a charm) and warm up bath blankets. Wondering what you did for this pt.?

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D. Hager
FF/NREMT-I
REAL HEROES WEAR SCBA'S NOT CAPES

We are all slaves to the God "Motorola"!

[ALSfirefighter]

Pretty much the same here, have the patient get into patient compartment with heat on and remove all wet clothing. Wrap patient with lightweight blanket to help dry skin, and then have patient sit on stretcher with wool blankets, and new lightweight blankets against skin. Provide O2 via NRB (only because pulse ox's don't always read well in the cold), EKG Monitoring, IV fluid in warmer. Check glucose, treat prn with D50, and 2mg Narcan (hey you never know, where I'm at you don't find people often in the water when its that cold out) IVP, and I'd have my shock pads/Lidocaine nearby. Start out to hospital nice and easy, and while enroute, dry patients hair if need be with a towel best you can, and wrap blanket around head and shoulders. The Bear Hugger, and warming pad are in the ER, and the OR has a ton also so that's not a problem. Also in the event that a deli or something where warm water/soup broth is around, a cup or two of that doesn't hurt also.

[cfr3504]

This is a cool idea, lets try to keep it up. as far as the tx for the patient is concerned, I'm not sure I can add anything, I would have done pretty much was the others have said. I also had a similar call, except that the pt. turned over a 4 wheeler in a creek, and his disorientation was due more to being drunk and having a head injury than from hypothermia.

an after thought: I would have taken a body temp somewhere along the way, so see how much heat he had lost. I'm sure this would be useful info for the ER and just good to know.

[This message has been edited by cfr3504 (edited 04-18-2001).]

[N2DFire]

O.K. - I'm actually surprised that I got this many responses. I agree 100% with cfr3504 that we should keep this going so if any one else has some good ones to post - feel free to put them up here.

Now on to the scenario.
I intentionally left the Glucose reading off because I wanted to see how many people picked up on it. This particular Pt's was 101.

I guess I should have given more "background" to the story as well. Seems there were actually 2 guys who had just bought kayaks and wanted to test their new toys. Unfortunately they we not experienced boaters nor were they familiar with the lake (Big lake - lots of little islands to wind around).

Based on this story & the response from the Pt. regarding oral intake for the day - we ruled out ETOH or other "bad stuff" - But ALSFirefighter's call on the Narcan was a good one - I didn't think about it at the time.

Also - the warm soup/broth idea is a great one, but as CFR3504 can tell you, we are WAY in the boonies here. (He's in the next county over from me - if anyone wondering)

No one mentioned the Pt. complaint about the tingling/burning sensation yet. Either you didn't catch that or didn't think it was important so I'll keep that one to myself for now.

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Now for those that asked, here's how I handled it.

First off - I am the only medic for our squad plus I live over 6 minutes from our station (in the opposite direction of this call unfortunately). We get dispatched out & the BLS crew on duty plus some extra people respond to the station. After some quick coordination over the radio - our first out truck leaves with a "heavy" BLS crew (Heavy means they took a bunch of people) and left a EMT/Driver behind for me to bring a second truck. (Good thing because we didn't know it was 2 people and not 1 till we got there - however the second guy wasn't nearly as bad as this one).

On my arrival - the BLS crew was just loading the Pt. into the truck, so I hoped on board, split the crew to cover the second Pt. & initiated transport (from where we were it was a good 30 to 45 minutes to the ER).

- From that point it was off with the wet jeans and wrapped lower body in a blanket (all we have are the thermal cotton blankets - no foil ones - yet)
- Removed coat, nomex hood & gloves to evaluate Pt. (opted to leave T-shirt in place since it was dry/warm)
- Placed hot packs under neck, in arm pits, and one on abdomen/chest & covered with blankets.
- Wrapped a (now warmed from the heater) blanked over Pt's head/shoulders similar to a horseshoe collar.
- Placed hot pack over groin area & added a second (warmed) blanket over lower half of body.
- Vital signs taken & monitor being connected by EMT & ride along during the above (Including the Glucose stick).
- Made 2 attempts to start an IV (Warmed Normal Saline), but no luck. Superficial veins were almost nonexistent and the flashback looked like brown Kayro Syrup.
- Further treatment consisted mainly of continual gentle warming, talking w/ the Pt. to maintain mental status, and transport.
Once we arrived @ the ER - they were overloaded and no beds open - so I continued to treat Pt. in the hall on my cot by adding blankets from the ER warming closet.

Now to the critique.
What things did I consider that night but didn't/couldn't do.
If I had an IV I would have liked to given a bolus of warm fluid to raise temp & treat possible dehydration. I would also liked to have given some D50 (although 100 is the magic number for us & I would have had to get orders for it)

What would I do different next time.
I would have considered (possibly just given even without orders) oral glucose (what's it going to hurt ?)
I would also have put O2 on the Pt as a precaution. Warmed & Humidified if possible. (Yupp - I never once put O2 on him - even after I commented to the R/A that placed the Pulse Ox that I didn't really trust it due to the poor circulation in the Pt's extremities - Doh !!)

I would also have liked to get a Core Temp reading but don't have "the stuff" on the trucks to do it.

Well - for better or worse that's how we did it. Please feel free to continue posting your treatment ideas and such.

Take Care - Stay Safe
Stephen
FF/Paramedic

[RWK]

Good thread.

Since we respond primarily on wilderness search & rescue ops we see lots of hypothermia and similar environmental injuries.

Gentle rewarming on someone that is responsive is going to be your best bet and everyone keyed on this. Getting the wet clothes off and the victim dry is important. Watch the hot packs - do not put them directly on the skin - especially sensitive areas. They can/will burn the pt. Warm/humidified O2 is nice if avail. If not avail. - the O2 will still be beneficial. The warm/tingling toes and the fact that the pt. is shivering is good - circulation is returning to the extremities. He is not into the more serious stages. Always good to monitor cardiac activity. Severely hypothermic victims can often arrest even when moved slightly - making evacuation difficult. Rectal readings are preferred for determining core temp. Prolonged shivering will wipe someone out so monitoring glucose is approp. Giving oral glucose will likely help quite a bit.

Good thing that you didn't have to search for the guy. You might have had to provide treatment well away from any vehicles, etc. if the location were remote. Sounds like the pt. did some things right that may have saved his life (changing clothes frequently to stay dry).

[N2DFire]

Well - looks like this is a dying thread so I'll just add a few closing type remarks.

1) RWK mentioned about placing hot packs agonst the skin - this I neglected to comment on (for reasons still unknown to me) but we always wrap hot packs ina towel (or in this case just used the first blanket as a "barrier"

2) RWK also mentioned that the tingling/burning sensation is from the circulation returning and is a good sign. When the Pt. first mentioned this it kinda concerned my EMT & R/A till I explained this to them (and the Pt).

Well - I hope all that participated in this thread enjoyed it. I also hope we all learned something new (or at least remembered something we forgot http://www.firehouse.com/forums/wink.gif )

If anyone else has any good calls to share as scenarios - please post them on here and let the rest of us have a crack at them.

Take Care - Stay Safe
Stephen
FF/Paramedic