Hypothetical Scenario

[ny10570 745]

30 y/o male found 15' below grade at a construction site. You are in what will be the basement off a building with access via scaffold or narrow wheelbarrow ramp. Pt suffered a witnessed tonic clonic seizure lasting "at least 10 minutes". Pt alert and extremely combative. PERRL. Patent airway. L/S clear & equal. Skin warm, moist, normal color. Urinary incontinence. No obvious injuries. Assessment difficult and vitals impossible due to pt's combative state. Co-worker reports he has a seizure history and is on unknown medications that he takes every day. Unknown other medical problems. Unknown allergies. Unknown events leading up to. Pt is on O2 @15lpm via NRB(sort of) and tied to the long board but not very effectively.

What region are you from and what would you do?

I'm in NYC. He got Glucagon 1mg IM with no improvement. Midazolam 10mg IM was approved through med control and administered. Once the pt became sedated the pt received D50 25g IV. The pt was then further restrained and transported without further incident.

[NWFDMedic 58]

Well, I think you made a good choice to immobilize because of the unknown incidence of trauma (ie. how did he get there?). Otherwise, airway, breathing (O2 via NRB), circulation. Considering the patient is initially combative, your treatment could be limited. I see no indication for Glucagon. If you can stick someone with an IM injection, there's no reason you can't obtain glucometry to potentially rule out hypoglycemia, especially in the presence of a potential head injury.

My course of action would have been as follows after the c-spine and oxygen: First, I'd call for help. Get enough people to hold him down to safely immobilize him and get an IV started. If the help is unavailable, skip the IV and some IM ativan would probably be my choice. Even in the event of hypoglycemia or a head injury from a fall, it won't have a detrimental effect. Then get your IV started, check blood sugar, have the PD check his person for possible drugs or paraphanelia (?sp), and have an officer find out who on the construction site might know him and a little bit more. From there, if his vital signs seem to be indicative of an opiod OD, I'd give some Narcan and obviously if it's indicative of hypoglycemia, I'd give Dextrose.

It sounds like a simple seizure, but with unknown trauma, you'd obviously be immobilizing. I'd keep a close eye on respiratory status, mental status, and of course vital signs to look for signs of a closed head injury. If I thought any of those were compromised or about to be, I'd be ready with a BVM, Lidocaine, Atropine, Etomidate and Succhinycholine because I'd rather get the patient intubated while I can and before he's seizing again or dead.

I'm from the Hudson Valley Region and I'm honestly impressed that you got orders for 10 mg of Versed IM right off the bat.

[Oswegowind 17]

2 quick questions...

1) Is this a medical call or an injury? (In other words did he suffer a fall?)

2) What type of restraint did you use in order to get him to stop moving/fighting enough to admin the glucagon shot?

[pjm1733 22]

I think you have all the ems done. What would i do?

enter the call as a construction accident,that will generate a fire/police/ems call .

units that would respond from that

1 ladder, the rescue, police esu, patrol,als ambulance

if more needed special request, that dispatch will put at least 4 emts on scene not including the ambulance, also put all the necessary tools on the job from the get go.ladders,stokes,ropes.

from that i see notifications to

building dept

osha

Edited August 12, 2008 by pjm1733

[ny10570 745]

It was a medical call. Witnessed by co-worker who reported he was sitting on a spackle bucket and fell over sideways. Collar and head bed were tried just to hold him down, but c-spine was not a concern. He was just tied to the board for ease of transport. No glucometry in NYC yet. IM access isn't really so hard. One person on the legs, one on his chest and one the arm was enough control for the moment but not nearly enough to establish a line and secure it in this particular case.

Some times its better to be lucky than good. I expected the call for Versed to be an exercise in futility, but I got lucky and the doc was up for it.

Thats a nice response. First came across as BLS for a seizure. They called for ALS for a postictal pt. I got an engine for the carry. Since the pt was now sedated engine boss felt they could handle the carry up the wheelbarrow ramp. They dragged him out using a sked.

[Guest]

Dont ever over look the danger of cave ins from unstable earth. I think that's important that it be taught to EMT students the dangers of construction sites. Many times due to language barriers the initial response in my experience is grossly misguided, but not to any fault of the call taker.

[Oswegowind 17]

It was a medical call. Witnessed by co-worker who reported he was sitting on a spackle bucket and fell over sideways. Collar and head bed were tried just to hold him down, but c-spine was not a concern. He was just tied to the board for ease of transport. No glucometry in NYC yet. IM access isn't really so hard. One person on the legs, one on his chest and one the arm was enough control for the moment but not nearly enough to establish a line and secure it in this particular case.

Some times its better to be lucky than good. I expected the call for Versed to be an exercise in futility, but I got lucky and the doc was up for it.

Thats a nice response. First came across as BLS for a seizure. They called for ALS for a postictal pt. I got an engine for the carry. Since the pt was now sedated engine boss felt they could handle the carry up the wheelbarrow ramp. They dragged him out using a sked.

Thanks...that is what I was thinking if it were medical in nature...ease of removal. A fall would definitely get c-spine but a routine seizure on occasion gets to walk themselves to the bus...ahem. It looks like you made the right call since he was coming out of his post-ictal state, obviously this wasn't a simple epileptic seizure and there were other factors involved. And it is always nice to have a medical control doctor that trusts your judgment, no?

Also removal of the victim could've been tricky. This is one of those calls that I referred to in the discussion about the "new" New Rochelle Rescue and the part of the specs about a crane boom on the rig. Possibly could be used with a Stokes to remove the victim to ground level from below!

[x635 4,066]

Haldol's a wonderful tool in the drugbox.

[ny10570 745]

Haldol is a great drug, but is it indicated here? He's not schizophrenic and not experiencing an acute psychotic break.

[mfkap 0]

Haldol is a great drug, but is it indicated here? He's not schizophrenic and not experiencing an acute psychotic break.

Haldol can be used off-label to control acute agitation (per ePocrates). I myself would have thought some ativan would be a good thing to throw in there, especially since another seizure could be coming.

How can an agency carry Glucagon and D50 and not carry a blood glucometer? Isn't that like giving an anti-arrhythmic without having a cardiac monitor?

[Guest]

Thanks...that is what I was thinking if it were medical in nature...ease of removal. A fall would definitely get c-spine but a routine seizure on occasion gets to walk themselves to the bus...ahem. It looks like you made the right call since he was coming out of his post-ictal state, obviously this wasn't a simple epileptic seizure and there were other factors involved. And it is always nice to have a medical control doctor that trusts your judgment, no?

Also removal of the victim could've been tricky. This is one of those calls that I referred to in the discussion about the "new" New Rochelle Rescue and the part of the specs about a crane boom on the rig. Possibly could be used with a Stokes to remove the victim to ground level from below!

You would never remove a patient with anything hydraulic, to do it would run the risk of extreme injury to the patient.

[ny10570 745]

If D50 or glucagon were anywhere near as dangerous as anti-dysrythmics then yeah that would be negligent. If your glucometer were to fail you'd still be fully capable of treating hyoglycemia, however without a cardiac monitor there is no way to tell which rhythm you are trying to treat. Whats the down side to miss treating with 25g of D50 or 1 mg of Glucagon? Maybe a 200 mg/dL spike in blood sugar. Even in an acute CVA, a population shown to be extremely sensitive to hyperglycemia pre-hospital dextrose administration showed no affect.

[helicopper 1,050]

You would never remove a patient with anything hydraulic, to do it would run the risk of extreme injury to the patient.

Nothing hydraulic? Really? What then would you use?

I ask with sincere curiosity and no sarcasm! I point this out because it is so easy to miss the tone of a typed message.

[smwells 7]

I may have missed something in the prevoius posts, but the patient is located in a would be (basement), is there any issues that could have triggered the episode?

Airborne issues related to the construction that could effect rescue personel? The EMS and removal steps looked good above, but was the scene safe to enter?

[Guest]

Nothing hydraulic? Really? What then would you use?

I ask with sincere curiosity and no sarcasm! I point this out because it is so easy to miss the tone of a typed message.

A 4:1 mechanical advantage attached to a high point, or just haul them out using two lines, one as a haul line and one as a safety with either a one way cam device or a munter hitch.

[Oswegowind 17]

Nothing hydraulic? Really? What then would you use?

I ask with sincere curiosity and no sarcasm! I point this out because it is so easy to miss the tone of a typed message.

A 4:1 mechanical advantage attached to a high point, or just haul them out using two lines, one as a haul line and one as a safety with either a one way cam device or a munter hitch.

As usual, scary, but Chris and I were on the same page when I read this. Roof, I mentioned the crane boom as an object being able to pull up the victim in a 4:1 mechanical by sticking out over the below grade scene and hoisting the victim up using the winch part of the crane apparatus. This could also be done with a Helo, or a TL if so equipped. This hole may have been way to large for a simple tri-pod winch setup, no? It was an idea, and maybe the idea behind specing such a device. Not only could it help in confined space (vertical) but in wide open below grade scenarios, i.e. over a cliff (Yonkers?). However, they have removed victims in a Stokes device from below and above grade situations in many areas using a TL and securing the basket. And the TL is hydraulic, no???? Sometimes there is no other way with time being a factor. Unfortunately I am unfamiliar with a "munter hitch" so I am going off to do some research.

[Guest Loud412]

How can an agency carry Glucagon and D50 and not carry a blood glucometer? Isn't that like giving an anti-arrhythmic without having a cardiac monitor?

The NYC REMAC ALS Protocol #511 AMS, States that the third step is to administer D50, belowthat it says "NOTE: A GLUCOMETER (IF AVAILABLE) MAY BE USED TO DOCUMENT BLOOD GLUCOSE LEVEL PRIOR TO DEXTROSE ADMINISTRATION."

Protocol #513 Seizures, the fourth step is to administer the D50. No where in this protocol is the use of blood glucose monitoring even mentioned.

Protocol #521 Head Inj. doesnt list the administration of dextrose anywhere, which mean that is wont be given unless directed by medical controle, and even that is a longshot.

Now I know that typicaly the cost of aquiring a BGM is usualy negligable due to most manufacturers simply donating them to ems agencies. However the cost of the testing strips can be quite considerable. And as long as the REMAC doesnt require blood glucose monitoring prior to administration of dextrose, FDNY and any other agency within NYC REMAC's controle is going to look at as an unnecessary cost.

[Goose 188]

I really don't think that the cost of strips is the issue. It probably has to do with keeping/ensuring that the meters are calibrated properly - having a program in place to keep all of those glucometers in service and properly calibrated and finding a doctor thats willing to sign off on the whole thing is probably the biggest hurdle.

Edited August 28, 2008 by Goose

[ny10570 745]

The biggest reason for not using glucometers was "why do you need them?" You can effectively treat your patients without causing harm and never know your patients blood glucose levels. If you don't issue glucometers you don't have to worry about people treating the device and letting a hypoglycemic pt get worse because the machine hasn't been calibrated in 3 months. That mindset is slowly changing and glucometers are coming to the field after the next round of core training. They are purchased along with the strips and sitting in warehouse awaiting distribution. At the same time Thiamine may disappear from the drug bag as its price continues to climb. We can't get IO needles or 100 cc syringes but we're getting glucometers.

[Guest Loud412]

I thought we got the E/Z IO's... One of the HAZ-TAC medics showed me the drill a few weeks ago.

[ny10570 745]

EZ I/O is only for adult pts in cardiac arrest.

Edited September 3, 2008 by ny10570

[Remember585 815]

Dare I ask - but is he stable enough and coherent enough to say, "I can walk out of here?"

If not, there's a couple options I am thinking of.

1. Basically what roofsopen said - put him in the Stokes and haul him out. (4:1 is nice, but I think a 3:1 would probably work).

2. Put him in the Stokes and carry him out on the wheelbarrel plank.

3. Put a ladder into the "basement," load patient in the stokes and slide-haul them up and out.