Unconcious Male At Bus Stop

[DFIB]

Local protocols are crap but I do a BGL anyway, so yes to BGL.

[AnthonyM83]

Holy crap, you guys jumped on this one. I like it! I had a hell of a 24 hour shift and slept all the next day. Back now.

Scene size-up:

Environment is an urban setting, evening, but still some light out. Appears safe. Regular looking people walking on sidewalk. Only patient found. Bus driver just found him slumped like that. Does not appear to need spinal immobilization. While we can't be sure, it looks like he passed out while sitting. Temperature is high 60's...normal for this area at this time of year.

Initial Impression:

Dressed in a dirty white button up short sleeve and jeans. Not quite homeless looking, but not well-kept either. Matches the part of town you're in. No smell of alcohol or urine readily evident. Appears in late 50's. 5'8, 190 lbs, slightly stout. No obvious injuries or immediate life threats as you approach.

AVPU:

No response to walking up and talking to him.

No response to loud verbal.

No response to tapping/pressure.

(Guess where this is going?)

No response to painful stimuli.

Unresponsive.

You start opening the airway, but your partner (we'll make her a hot blonde for you Kiwi) softly touches your arm and reminds you of the 2010 AHA Guidelines..... so instead you go straight to a carotid pulse check....one one thousand...two one thousands.........seven one thousand....No Pulse.

Have at it!

And yes, first guess around this area as soon as you hear the call dispatched "unconscious at a bus stop" you should be thinking either drunk...or the guy who calls daily for abdominal pain x2 years....but nope...those guys won't be calling until 3am...lucky you. You get this guy (Sorry...as much as LACoFD ship everything BLS, it's gonna be hard to "paint the picture" on your run sheet for this guy...)

You guys can be an ALS or BLS unit for this scenario, though...

[DFIB]

If running BLS.

Lay the patient flat on the floor and begin chest compressions at a rate of 100 per minute.

Compressions are fast and hard precisely to the beat of "Another one bites the Dust" Not sure if the music is playing somewhere in the background or my partner spontaneously began humming.

My partner breaks out the AED and attached it to the chest while I complete the round of chest compressions (30x5x2).

My partner also bags the patient and ventilates after every 30 compressions.

Since she can multitask like crazy she asks the people at the bus stop if anyone saw the incident and what happened.

After first round of CPR we stop compressions to let the AED work it's magic and take advantage of this time to Request ALS backup while gasping for air.

What does the AED analyze and recommend?

Edited May 9, 2012 by DFIB

[Kaisu]

ALS team - medic and emt. Unwitnessed arrest, unknown downtime, assuming no obvious signs of death (lividity, rigor, etc.) Is the guy warm? How's his skin? Be that as it may, my emt immediately begins chest compressions. I drop in an OPA, put on a NRB with high flow O2 and attach the cardiac monitor - paddles, remembering to plug in the patient cable. Quick femoral check to make sure compressions are producing pulse. I turn on the CPR feature on the LP 15 because EVERYBODY pushes too fast, even experienced providers. The metronome feature is much nicer than yelling at your partner to slow down. (It is helpful if the ventricles are actually filling during compressions.)

I have time to open my drug box, get my IV setup and EZIO. By this time, 2 minutes are generally up and it is time for a rhythm check. What is on the monitor?

[Just Plain Ruff]

Unwitnessed arrest, ALS, what's the monitor showing?

I'm gonna run through a round of acls and see what I get and if I don't get ROSC then this guys gonna be classified as DRT.

But I think ANT's got something under his sleeve, as I've already talked to him and he more than insinuated it was something good. I think he got bit by the love bug and it stopped his heart because she had to leave on he but to georgia. He coded because of a broken heart. What's his monitor show, are we sure he's not just profoundly bradycardic.

Edited May 9, 2012 by Captain Kickass

[Asysin2leads]

I would subtly and professionally remind my partner that it is entirely possible to look, listen, and feel for breath sounds while checking the carotid. Really, just move your ear a little closer. I'm ALS. Confirm cardiac arrest, call for back up. Lower patient to the floor, do quick reassessment of airway, breathing, pulse, instruct partner to start CPR. Attach quick look EKG. If it's asystole or PEA, move to two person CPR until backup arrives, ventilating with BVM hooked to high-flow o2, switching with partner in two minute intervals. . If its V-fib, do two minutes of CPR, then defibrillate once at 360 joules, resume CPR. When back up arrives, have them take over CPR, after reassessing rhythm. Have partner start IV 0.9% NS with as large a catheter as possible, perform ETI. Do a physical exam, check lungs for proper inflation, look for signs of trauma, look for medical alert bracelets, check BGL. Question witnesses, round up the usual suspects. Did anyone see what happened? PEA or asystole, start hunting for reversible causes.

Hypoxia: Check SPO2 and ETCO2

Hypoglycemia: BGL, look for medic alert bracelets

Hydrogen Ion (acidosis): Maintain appropriate ETCO2 reading, bicarb if really necessary

Hypothermia: It's LA. Unless he was found on the LA King's practice area this probably isn't a problem

Hyper/Hypokalema: If there is a regular rhythm, check for peaked or flattened T's, look for evidence of recent dialysis, consider calcium chloride if hyperkalemia is suspected.

Hypovolemia: If it's a PEA and you suspect hypovolemia, rapid infusion of NS 0.9%

Thrombosis: If you get a regular rhythm or hopefully ROSC, do a 12 lead immediately

Toxins/Tablets: Look for signs of OD or ingestion of a poison. Check pupils for sign of heroin OD. Check again. Then give him Narcan.

Trauma: If a traumatic cause is suspected, continue CPR and have second crew prep for transport

Tamponade: See above.

Tension Pneumothorax: Auscultate lung sounds after airway securement when BVM is compressed, look for distended neck veins or tracheal shift. Decompress as necessary

If it's V-fib, do CPR for 2 minutes and then defibrillate at 360 joules, immediately resume CPR. Keep an eye on ETCO2 for signs of ROSC. Administer amiodarone or lidocaine, Mag sulfate if it's torsades.

Edited May 9, 2012 by Asysin2leads

[AnthonyM83]

You ask the bystanders (who are staring at what's unfolding as if it were a TV show) if they saw anything...most of them startle when they realize you are addressing them and it's not a TV and you can actually see back at them...they mutter stuff in Spanish and quickly hustle off, pulling their kids away as if you were yelling at them. Typical.

AED says no shock advised. If BLS level...what would you guys do next in your area?

ALS:

EKG shows VTach. You confirm no pulse. Finish off two minutes CPR. Charge during compressions. Shock. Continue compressions.

Alright guys, gotta throw in order of interventions. Can't just say I'd intubate, start a line, physical exam and have it magically done all at once...not getting off that easy. You have an engine of 3 FF/EMTs also showing up. In addition to your EMT partner.

Edited May 9, 2012 by AnthonyM83

[craig]

If in local protocols, and in level of practice, are you going to do a blood sugar level finger stick test?

IF IN PROTOCOLS AND IN SKILL LEVEL??? WTF!!!! this is basic stuff people.........our bloody trainees can do this procedure. what backwood service would not allow their staff to carry out this minor skill....

[Asysin2leads]

Given that this is being done on the street, getting the patient loaded into a more stable environment is one of the priorities.

If I have V-tach on the monitor and we've already done one shock, this is how I would proceed. I would have two of the FF/EMTs take over CPR and ventilation and get the last one to arrange the stretcher and a scoop if necessary, and have it prepped for transport, and have him or her take the keys of the ambulance. His role will be to rotate in with the others after 2 minutes of CPR have passed.

I would have my partner initiate IV access and perform endotracheal intubation. By this time we should be ready to defibrillate again, which we would do. I'd resume CPR and administer 1.0 mg Epinephrine 1:10,000 as well as 300 mg of Amiodarone. We would finish out this round of defibrillation and CPR and then as best as possible without interrupting CPR and remove him to the stretcher and get in the back of the ambulance. We would do another round or two in the back, away from prying eyes. If we wanted to work this code on the way to the hospital, one FF/EMT would drive, I'd keep one in the back with me and my partner for chest compressions, and have the last one drive their vehicle, if necessary. Then we'd be off to the hospital, repeating epi-boluses and pulling over if necessary.

Edited May 9, 2012 by Asysin2leads

[Richard B the EMT]

IF IN PROTOCOLS AND IN SKILL LEVEL??? WTF!!!! this is basic stuff people.........our bloody trainees can do this procedure. what backwood service would not allow their staff to carry out this minor skill....

Please note that you're in NSW. We have established, in other strings, that outside of the US, BLS includes a bunch of good stuff that, if I were to do here in New York City, I'd get nailed to the wall for being outside of "Scope of Practice". Some examples are, as an EMT-Basic, I am not allowed to start an IV. I'm only allowed (under state protocols) to administer albuterol, 81 Mg chewable aspirins, glucose paste, and oxygen. BLS crews are not YET allowed to do finger sticks, as ALS only recently got the OK to do so, but my instructors foresee it coming.

Going back to IVs, we BLS providers in the state of New York used to be allowed to transport patients on an IV, as we got training on maintaining the flow, and orders to stop the IV (with notation of the time) if we found the line to be infiltrating. A few years ago, that was taken from us in favor of a placeholder IV started. I'm blanking on the name at the moment, but it is just an IV needle filled with saline, if memory serves.