A Nor Cal EMS Webcast Nor Cal EMS Medical Advisory Committee Run Review March Northern California EMS, Inc. All Rights Reserved Worldwide.
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1 By Engineer Bill Bogenreif 1
2 Eric M. Rudnick, MD, FACEP, FAAEM Medical Director for Northern California EMS By Engineer Bill Bogenreif 2
3 Dispatched code 3 to a local Vet clinic. On arrival to the Veterinary Clinic to find a 39 year female out the front door in company of co-workers. Pt. presented A&OX4, GCS 15, pale, warm, and dry. Patient is complaining of chest tightness secondary to SVT. Patient reported having extensive history of reoccurring SVT. Pt. reported taking Lopressor approximately 10 minutes ago and calling her cardiologist who advised her to be transported to ED. Patient reported attempting vaso-vagal maneuvers and carotid massage with no change. By Engineer Bill Bogenreif 3
4 Patient reported having a pulse oximeter and getting readings in the 200 s for her heart rate. Patient denies any C/P, SOB, or N/V. Patient did complain of dizziness. Patient reported onset at 12:48 today while sitting at rest. Patient reported last SVT episode required administration of Adenosine due to ineffective vagal maneuvers. Patient reported having her first SVT occurrence September of last year and having episodes reoccurring more frequently and lasting longer. By Engineer Bill Bogenreif 4
5 Patient reported being on a regular regimen of Lopressor 25 mg in the morning and 25 mg at night. Patient also reported being advised by her cardiologist to take additional 25 mg Lopressor when in SVT. By Engineer Bill Bogenreif 5
6 Assessment as noted and VS as noted. Vagal maneuvers attempted by having the patient blow into a syringe with no changes. IV 20g Left hand unsuccessful by paramedic intern, 12 lead EKG SVT with no ST elevation or depression. IV 20g unsuccessful Right hand. IV 18g Right wrist successful with 1000ml NS TKO. Patient transported code 2 ALS to Hospital. BG 134 mg/dl. By Engineer Bill Bogenreif 6
7 Just prior to administration of Adenosine patient self-converted. Patient reported chest tightness decreasing and dizziness subsiding. Patient continued to deny any other C/C. 12 lead obtained NSR with no ST segment changes. Both 12 leads transmitted to hospital successfully. Patient en route continued with VS wnl and NSR EKG. Patient report en route to hospital MICN via phone with no questions and reported to not follow chest pain protocol and not administer ASA or NTG for chest pressure. By Engineer Bill Bogenreif 7
8 Patient on arrival to ED presented PWD with very minimal chest pressure and VS/EKG WNL. Pt. on arrival to ED report given and transfer of patient care. Copies EKG print outs provided and left with RN. By Engineer Bill Bogenreif 8
9 Medication Allergies: sulfa Patient medications: Lopressor (Metoprolol), B12, Multivitamins By Engineer Bill Bogenreif 9
10 PE 13:18 Mental status: normal for patient Neuro: normal Eyes: reactive Skin: pale, warm, dry Head/Face: normal Neck: normal Chest/Lungs: normal chest assessment, clear and equal breath sounds By Engineer Bill Bogenreif 10
11 Abdomen: LUQ, LLQ, RUQ, RLQ soft, nontender GU: normal Cervical, thoracic, lumbar: normal, no deformities or pain Extremities: RU, RL, LU, LL: normal By Engineer Bill Bogenreif 11
12 Vital signs 13:21 BP 121/77, HR 184, RR 16, SaO2 99, GCS 15 13:31 BP 124/73, HR 189, RR 16, SaO :35 BP 112/74, HR 80, RR 16 13:42 BP 119/60, HR 78, RR 16 13:50 110/80, HR 82, RR 16 By Engineer Bill Bogenreif 12
13 13:21 ECG monitor SVT 13:24 ECG monitor SVT 13:33 ECG NSR 13:40 ECG NSR 13:18 Adult ALS assessment 13:22 Valsalva 2 attempts no change 13:24 IV access saline lock 13:26 Oxygen 2 LPM 13:29 IV access saline lock 13:30 Blood glucose 134 mg/dl By Engineer Bill Bogenreif 13
14 By Engineer Bill Bogenreif 14
15 By Engineer Bill Bogenreif 15
16 By Engineer Bill Bogenreif 16
17 By Engineer Bill Bogenreif 17
18 By Engineer Bill Bogenreif 18
19 By Engineer Bill Bogenreif 19
20 Documentation? Quality of care delivered? Other issues and concerns? Care appropriate? Overall impression? Protocol changes required? Teaching/Take home points By Engineer Bill Bogenreif 20
21 Responded code 2 for a female with a possible stroke. At scene to Board and Care to be greeted by caregivers. The caregiver went to the kitchen and returned to find the patient slumping to the right drooling, slurred speech, and right facial droop and the right hand contracted up. Patient was last seen normal at 16:20 hours. Patient was found sitting in a chair in her bedroom with the caregiver and neighbor in attendance. Patient had positive stroke assessment. By Engineer Bill Bogenreif 21
22 Patient denies CP, SOB,, or N/V. The caregiver provided the DNR and current medication list. POA could not be reached due to the caregiver not having the POA s phone number. Patient was able to speak however the words were slurred. By Engineer Bill Bogenreif 22
23 Patient was A&OX1 to person only. GCS 14 with reduction due to confusion. Patient s skin signs were pale, warm, and dry. HEENT was clear with right sided gaze and dilated pupil on the right with sluggish reaction. Trachea midline without JVD. Equal chest rise and fall with clear LS. Abdomen SNT. Pelvis intact and stable. By Engineer Bill Bogenreif 23
24 Good CSM on the left with flaccid motor function on the right. Patient was loaded onto stretcher and into the ambulance. Patient was transported code 2 to hospital. In the ambulance vitals and pulse ox were obtained. Patient was placed on the cardiac monitor with A-fib showing. A 12 lead EKG was obtained. Phone report was given to the hospital with orders to upgrade to code 3 and the was a stroke alert. Bilateral IVs were started in the wrists. By Engineer Bill Bogenreif 24
25 Blood sugar levels were obtained with a reading of 103mg/dl. Patient given oxygen via nasal cannula at 4 LPM. The patient vomited and the oral pharynx was cleared with a hand towel. Arrived at hospital ER without further complications. While wheeling the patient into the hospital patient vomited again. Patient was turned on the left lateral position. By Engineer Bill Bogenreif 25
26 16:28 PE: Mental status: confused, oriented-person Neuro: normal Eyes: R: sluggish L:Reactive Skin: normal Head/Face: Asymmetric smile or droop Neck: normal Chest/lungs: normal chest assessment, clear and equal BS By Engineer Bill Bogenreif 26
27 Heart: normal Abdomen: LUQ, LLQ, RUQ, RLQ: soft, nontender GU: normal Cervical, Thoracic, Lumbar: non-tender, no pain Extremities: RU weakness abnormal CSM, LU normal, RL weakness, abnormal CSM, LL normal By Engineer Bill Bogenreif 27
28 16:30 BP 200/105, HR 78, RR 16, SaO :35 BP 210/108, HR 68, RR 16, SaO :40 BP 201/101, HR 75, RR 16 16:45 BP 217/107, HR 88, RR 16 16:50 BP 214/109, HR 68, RR 16 16:55 BP 209/110, HR 78, RR 16 17:00 BP 215/106, HR 65, RR 16 By Engineer Bill Bogenreif 28
29 16:30 Blood pressure 16:30 Pulse oximetry 16:35 Cardiac monitor 16:39 Venous access 16:45 Blood glucose 16:45 Venous access 16:50 Oxygen nasal cannula 4 PLM By Engineer Bill Bogenreif 29
30 By Engineer Bill Bogenreif 30
31 By Engineer Bill Bogenreif 31
32 Documentation? Quality of care delivered? Other issues and concerns? Care appropriate? Overall impression? Protocol changes required? Teaching/Take home points By Engineer Bill Bogenreif 32
33 Chief Complaint: N/V/Back pain in a 55 female Dispatched for a female with abdominal pain. Responded code 3. On arrival finds patient walking down stairs to her front room with fire and her husband in attendance. Patient states that at approximately 12:30 today she began to have abdominal pain. Patient states that her pain is in her right quadrant and in her thoracic area. By Engineer Bill Bogenreif 33
34 Patient states that it has been increasingly getting worse and approximately 13:30 she began to have nausea. Patient states that she has not vomited, nor had a bowel movement today. Patient states that she no longer has her appendix or gallbladder. Patient denies any chest pain, shortness of breath, headache, or dizziness. Patient has a port-a-cath in upper right chest, she states that she is extremely hard to get an IV established and wishes to wait to have the port accessed. By Engineer Bill Bogenreif 34
35 Patient assisted to gurney and to the ambulance. C/C abdominal pain TX: patient placed on cardiac monitor and vitals obtained as noted. 12 Lead EKG obtained as noted. O2 placed as noted. Zofran administered as noted with no relief. PE: HEENT: clear PERRL Skin: pale, warm, clammy By Engineer Bill Bogenreif 35
36 Neck: intact Lungs: clear with equal chest rise bilaterally. Abdomen: soft, non-tender in all four quadrants, non-distended, active bowel sounds in all four quadrants. Pelvis: intact CSM intact in all extremities During transport no acute changes. By Engineer Bill Bogenreif 36
37 Allergies: Toradol Medications: Alprazolam, ASA, Carvediolol, Estradiol, Famotidine, HCTZ, Losartan, Progesterone, Omeprazole, Paroxetine, Prednisone, Promethazine, trazadone PMH: HTN, Cardiac Stent, GI/GU conditions, Psychological/Depression, Anxiety By Engineer Bill Bogenreif 37
38 Vitals: 15:45 BP 112/73, HR 68, RR 18, SpO :53 BP 115/86, HR 80, RR 20 By Engineer Bill Bogenreif 38
39 By Engineer Bill Bogenreif 39
40 By Engineer Bill Bogenreif 40
41 Documentation? Quality of care delivered? Other issues and concerns? Care appropriate? Overall impression? Protocol changes required? Teaching/Take home points By Engineer Bill Bogenreif 41
42 Dispatched code 2 to a private residence for chest discomfort and elevated heart rate. On arrival to rural residence, personnel unable to gain access into residence. Med Com advised patient will be opening door. Upon patient contact to be greeted by a 78 year old male who was just requesting a BP evaluation. Patient presented A&OX4, GCS 15, PWD, speaking full sentences without difficulty and no slurred speech. By Engineer Bill Bogenreif 42
43 Patient provided documentation of 6 blood pressures he had obtained with his home automatic cuff and was concerned by his high blood pressure results and so he reportedly called 911. Patient denied any C/C, patient denied CP, SOB, HA, blurred vision, or N/V. Patient reported not taking his blood pressure medications as prescribed and only taking it occasionally. Patient reported taking his metoprolol approximately 30 minutes PTA of EMS. By Engineer Bill Bogenreif 43
44 Assessment as noted and unremarkable, negative stroke scale, + CSMX4, no pedal edema noted. Vital as noted with an initial manual BP of 280/140 mm Hg, HR 92 irregular, RR 16, SpO2 97% on RA. CM SR with occasional PVCs. Patient was advised of the need to be transported and the rik of complications associated with HTN. Patient agreed to be transported. After extended time securing patient s residence as requested by patient, patient to LSU without changes and or incident. By Engineer Bill Bogenreif 44
45 Patient transported code 2 to hospital. 12 Lead obtained with no ST segment, SR with PVCs as noted, O2 via NC with no changes, IV left FA successful X1, BG 197 mg/dl VS en route as noted with continuous HTN. Patient report via phone with no questions or orders. Patient en route continued to deny any C/C. By Engineer Bill Bogenreif 45
46 PE: Mental status: normal for patient Neuro: normal Eyes: reactive Skin: normal Head/Face: normal Neck: normal Chest/lungs: normal chest assessment, clear and equal BS By Engineer Bill Bogenreif 46
47 Abdomen LUQ, RUQ, LLQ, RLQ: soft and nontender GU: normal Cervical, Thoracic, Lumbar: normal, no pain or deformities Extremities: RU, LU, RL, LL: normal By Engineer Bill Bogenreif 47
48 23:50 BP 280/140, HR 92, RR 16, SpO2 98% 00:18 BP 198/106, HR 78, RR 16 00:30 250/110, HR 88, RR 16 23:45 Assessment- adult 00:15 Venous access- saline lock 00:16 BG 197 mg/dl 00:10 Oxygen per NC 4LPM By Engineer Bill Bogenreif 48
49 By Engineer Bill Bogenreif 49
50 By Engineer Bill Bogenreif 50
51 Documentation? Quality of care delivered? Other issues and concerns? Care appropriate? Overall impression? Protocol changes required? Teaching/Take home points By Engineer Bill Bogenreif 51
52 Dispatched code 3 to a MVA. scene to find a 41 year old male walking toward the ambulance. Patient C/O neck/back/lt arm pain positive rollover. Patient reports driving home to Redding from UC Davis Medical Center, when he fell asleep while driving. Patient reports to driving with cruise control set at 70 mph. Patient was driving full sized Dodge truck and was unsure how many times the truck rolled. By Engineer Bill Bogenreif 52
53 Patient s truck went through a wire fence coming to rest at the current location upside right. Patient reports to wearing shoulder and lap belt and was self extracted PTA. Patient s truck has major damage all over with right rear tire torn off, deformity to roof with intrusion into passengers compartment with approximately intrusion to passenger s side. Starring of windshield with partial ejection of windshield observed. No steering wheel or dashboard deformities observed. No airbags deployed. By Engineer Bill Bogenreif 53
54 Exam: Patient was pale, cool, and moist. CA&OX3, negative to time and unable to recall recent Thanksgiving Holiday. HEENT: Approximately 1 inch lac to LT side head, 1-2 mm wide and no active bleeding. No crepitus/deformity/depression noted. PERRL, no oral trauma noted. Neck: Trachea midline, No JVD observed no pain with palp but did c/o pain while being c-spine. Chest: Equal rise and fall, no crepitus or bruising observed. By Engineer Bill Bogenreif 54
55 No subcutaneous emphysema noted. L/S are clear and equal in all fields with good tidal volume. Swelling noted to left armpit area. Abdomen: S&NT X4, no masses felt upon palpation. Back: No trauma/deformities felt upon palpation. C/O of high back pain during c-spine. Pelvis: stable and intact, no incontinence observed. Extremities: Deformity noted to left shoulder joint with soft tissue swelling. No crepitus noted. By Engineer Bill Bogenreif 55
56 Capillary refill at 3 seconds and difficulty palpating radial pulse. Patient c/o unable to move arm and decreased sensation. Abrasion noted to left elbow, rt 2 nd and 3 rd metacarpals, abrasion to bilateral shins just above ankles, all with no active bleeding. By Engineer Bill Bogenreif 56
57 Treatment: Patient examined with TTA. Patient placed in full c-spine, placed on stretcher and load to ambulance. En route to hospital code 3. 4X4 placed on abrasion to left elbow. Left arm positioned to patient s thoracic area. IV X 2 started as noted. CM attached not due marked artifact unable to determine rhythm. By Engineer Bill Bogenreif 57
58 Skin prep done without any change to CM. O2 applied and BG obtained. Patient report given to hospital before drive to Sacramento and further denies any other recreational drug or prescription use. Patient denies ETOH with CHP reporting the patient blew zero on breathanalyzer machine. Base contact made with no further orders. Arrived hospital without incident. By Engineer Bill Bogenreif 58
59 NKDA Medications: Medical THC PHM: chronic knee pain By Engineer Bill Bogenreif 59
60 PE: Mental status: normal Neuro: normal Eyes: reactive Skin: cold, clammy, pale Head/Neck: normal Neck: normal Chest/lungs: normal chest assessment, clear and equal By Engineer Bill Bogenreif 60
61 Heart: normal Abdomen: LUQ, RUQ, LLQ, RLQ: soft, nontender GU: normal Cervical: normal Thoracic: normal Lumbar: normal Extremities: LU, LL, RU, RL: normal By Engineer Bill Bogenreif 61
62 03:31: BP 127/79, HR 61, RR 16, SpO2 99%, GCS 15 03:35: BP 131/89, HR 61, RR 16 03:50: BP 139/113, HR 55, RR 16 03:59: BP 134/85, HR 55, RR 16 03:23: spinal immobilization 03:36: Venous access 03:37: Blood glucose 204 mg/dl 03:40: bleeding/ hemorrhage control Arm left 03:46: Venous access By Engineer Bill Bogenreif 62
63 03:33 Oxygen by nasal cannula 6 LPM 03:36 Normal Saline at KVO By Engineer Bill Bogenreif 63
64 Documentation? Quality of care delivered? Other issues and concerns? Care appropriate? Overall impression? Protocol changes required? Teaching/Take home points By Engineer Bill Bogenreif 64
65 By Engineer Bill Bogenreif 65
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