Medical Director Northern California EMS, Inc. Presents:

Transcription

1 on February 10,

2 Eric M. Rudnick, MD, FACEP, FAAEM Medical Director Northern California EMS, Inc. Presents: on February 10,

3 Case #1 Chief complaint: Chest pain in a 75 year old male. At scene: 15:09 and depart 15:21 Dispatched code 3 to residence for CP along with Fire. On arrival to private residence to be greeted by Fire rescue who provided a brief report and escorted personnel to patient located in living room. On arrival to patient s side to find a 75 year old male laying supine on the living room couch in company of fire rescue. Patient found on O2 via NC Fire reported patient c/o chest pain and patient presenting what appeared to be anxious on their arrival. on February 10,

4 Case #1 Fire reported patient taking 1 of his own NTG with decrease in CP and patient was assisted with 2 nd NTG on their arrival with pain going from 9/10 to 7/10. Patient fond A&OX4, GCS 15, PWD, speaking softly which is baseline for patient, per patient. Patient C/O sudden onset of sharp chest pain while cracking walnuts. Patient reported pain starting at his epigastric area and radiating up his chest. Patient reported increase in pain with cough and palpation/deep inspiration. on February 10,

5 Case #1 Patient denied any recent trauma, denied any N/V, or SOB. Patient reports onset of a recent cough with green sputum production. Patient denied any recent illness, fever, or chills. Patient to being transported for further evaluation. on February 10,

6 Case #1 Assessment and VS as noted, EKG with NSR obtained with no ST changes but with RBBB, 12 lead transmitted to ED. Patient to LSU with no changes. Patient transported code 2 to hospital. ASA 324 mg PO with no change, NTG 0.4 mg SL Spray with decrease from 7/10 to 6/10 but shortly after returning to 7/10. IV16 g L AC successful X1. BG 298 mg/dl which patient noted history of DM. List medications/allergies provided and transported with patient. on February 10,

7 Case #1 Patient t presented in position of comfort. Patient en route to hospital who reported to attempt of another NTG and no further orders or questions. NTG 0.4 mg SL Spray with decrease in pain to a 6/10 but occasionally returning to a 7/10. Patient en route continued to be PWD, calm in position of comfort with off and on increase of sharp pain to his chest. Patient on arrival to ED reported pain being a 4/10 and denied any other changes. on February 10,

8 Case #1 Medications: Alprazolam, l ASA, Atorvastatin, Corvediol, Cyanocobalamin, Ergocalciferol, Glipizide, Metformin, Omprazole, Sertaline PMH:Stroke, Behavioral,Hypertension, Cardiac stent, Depression, PE: Mental status for patient normal, Neuro: Eyes reactive, Lungs: Chest pain/pressure (reproducible), Clear breath sounds, Abdomen:normal, Extremities: normal on February 10,

9 Case #1 15: /82, 74, 16, SpO2 97%, negative stroke scale 15:27 124/71, 70, 16 15:37 120/70, 69, 16 15:47 114/66, 67, 16 15:55 105/67, 64, 16 15:12 12 lead EKG 15:10 ALS assessment 15:26 Venous access 15:27 Blood glucose analysis on February 10,

10 Case #1 15:20 ASA, unchanged 15:25 NTG, improved 15:38 NTG, unchanged on February 10,

11 Case #1 on February 10,

12 Case #1 Documentation? Quality of care delivered? Other issues and concerns? Care appropriate? Overall impression? Protocol changes required? Teaching/Take home points on February 10,

13 Case #2 Chief complaint 55 year old female with CP and Difficulty breathing En route 21:24 At patient 21:32 Depart: 21:45 Code 3 for cardiac. Arrived to find pt lying in bed attended to by husband. Pt is on home O2 at 2 LPM. Pt is speaking in full sentences but appears pale, warm, and dry. on February 10,

14 Case #2 Pt reports she was walking in home approximately 30 minutes ago when she began to have midsternal chest pain. Pain is described as gouging type, initially 10 of 10 which radiates to armpit. Pain is increased with palp and 6 of 10 upon arrival of EMS. Pt reports with initial onset she had difficulty breathing, nausea, and sweating. Pt reports she has had difficulty prior to onset of chest pain but does not report duration. on February 10,

15 Case #2 Pt also reports was seen at hospital last week for similar episode but is unsure of her diagnosis. Pt is transferred to gurney and placed on 6 lpm O2 via NC which improves SpO2 and color. Pt is transferred to LSU. VS assessed and patient is found to be hypotensive. Pt placed on cardiac monitor which shows sinus tach 112BPM. 12 lead EKG performed which shows sinus tach with RBBB. EKG is transmitted to hospital. on February 10,

16 Case #2 Pt is transported t code 2 per hospital request. Although pt has poor SPO2 pt does not appear to be having any respiratory distress. Head is atraumatic, Neck is stable with no JVD or deviation noted. Back appears normal, Chest is stable with equal rise and fall. Pt lung sound are diminished bilat with very slight expiratory wheeze. Abdomen is soft, Pelvis and extremities appear normal. on February 10,

17 Case #2 IV 20 left hand which h appears successful but late is found to be infiltrated. ASA 324 mg PO Albuterol 2.5 mg HHN with improved SpO2. IV 20 gauge left hand removed. Pt report to hospital and advised of patient tachycardia and with placing patient supine for nebulized treatment profound hypotensive. Pt currently has BP 106/79 but advised per hospital to hold further NTG. on February 10,

18 Case #2 Pt reports she is still having 6 of 10 pin but difficulty breathing has decreased. IV 22 right hand saline lock successful. No further changes in pt condition en route. on February 10,

19 Case #2 21:32 BP 80/55, 117, 18, 90 SpO2 low O2 21:32 BP 106/79, 106, 18, 98 SpO2 medium O2 21:40 BP 96/70, 117, 18, 91, 91 SpO2 low O2 21:46 BP 81/41, 121, 18, 92 SpO2 low O2 21:51 BP 61/32, 114, 18, 96 SpO2 med O2 21:56 BP 112/67, 112, 18, 98 SpO2 medium O2 22:02 BP 112/67, 112, 18, 98 SpO2 low O2 22:13 BP 117/58, 113, 18, 98 SpO2 low O2 on February 10,

20 Case #2 21:32 12 Lead EKG 21:39 EKG monitor 21:50 IV access 22:10 IV access saline lock 21:40 O2 by nasal cannula 21:50 Albuterol HHN 21:57 ASA on February 10,

21 Case #2 on February 10,

22 Case #2 Documentation? Quality of care delivered? Other issues and concerns? Care appropriate? Overall impression? Protocol changes required? Teaching/Take home points on February 10,

23 Case #3 Chi f l i t f ll i 78 ld l Chief complaint fall in 78 year old male En route 12:18 At patient: 12:26 In service 12:44 EMS dispatched to bank for a fall. Arrived to find a 78 year old male A&OX4 patient sitting in a chair in the lobby with bank worker and patient s friend at his side. Per staff at the bank they stated that patient suffered a fall. on February 10,

24 Case #3 S: Per bank at scene they stated that patient was waiting in line at the bank when he just all of the sudden fell backwards striking his head on the floor. Staff states that the patient didn t have any LOC prior to or post fall and that they assisted him from the ground and to a chair. Then they called 911. Upon making patient contact patient stated that he did not know why EMS were there and that he told them not to call EMS. Patient states that he has no complaints what so ever. Patient denies any associated head, neck, or back pain, chest pain, and or discomfort, shortness of breath, head ache, blurred vision, dizziness, N/V, or any other complaint what so ever. on February 10,

25 Case #3 Patient states that he feels fine and that he does not wish to go to the hospital, nor will he go to the hospital. Patient states that he has had this happen to him in the past when he just falls to the ground for no reason. Patient states that he can recall the entire incident id and that t he never had any type of LOC. on February 10,

26 Case #3 O: CAOX4, HEENT neg with the exception of a small abrasion to the back of his head, PERRL, S/S= PWD Trachea midline, No JVD, Chest wall intact without any visible signs of trauma noted. LS = CAEB, ABD soft non-tender, Pelvis stable Lower ext full ROM with good distal CSMs noted, Back and neck neg without any visible signs of trauma Upper ext full ROM with good CSMs noted. I did note that the patient s heart rate initially was approximately 60 BPM then changed to a very rapid rate at which time I asked patient if I could put him on the cardiac monitor which he agreed to. on February 10,

27 Case #3 TX: Vitals assessment, SAO2, Cardiac monitor= ST then went into a V-Tach at a rate of approximately 230. Patient states several times that there is no way he was going to the hospital, no matter what. I asked patient if I could do a 12 lead EKG on him and he stated that is fine but I am not going anywhere with you. I obtained a 12 lead which h showed elevation in several leads, 12 lead was transmitted to hospital. Both my partner and I urged him to go to the hospital with us told him that he was having some problems with his heart and left untreated that we were afraid that he could have serious complications up to and including death. At which time he stated that is fine if I am going to diei want to die at home and not at the damn hospital. on February 10,

28 Case #3 I told patient s friend that drove him to hospital that we really felt like he needed to be treated by a doctor at the hospital and she said she will try to talk him into going to the hospital. Patient stated he would sign AMA form releasing the LSU crew of any and all liability Patient signed the form stating he understood all the possible risks. I also had his friend sign as a witness. I contacted the hospital and spoke to MICN advised her of the situation with the patient s heart rate in V-Tach and elevation. on February 10,

29 Case #3 No questions or orders. On last time prior to leaving I asked the patient to please come with us and he said no. Patient and friend were both advised to call 911 if anything got worse and or if patient changed his mind. They both agreed and patient got up and walked out the door on his own power and got into their vehicle and left. No further contact was made by EMS and advised was clear and available. on February 10,

30 Case #3 PMH: Hypertension Medications: a blood pressure medication unsure of what it was. Vitals: 12:27 BP 140/75, HR 112, RR 18, SpO2 96 room air on February 10,

31 Case #3 on February 10,

32 Case #3 on February 10,

33 Case #3 on February 10,

34 Case #3 on February 10,

35 Case #3 Documentation? Quality of care delivered? Other issues and concerns? Care appropriate? Overall impression? Protocol changes required? Teaching/Take home points on February 10,

36 Case #4 Chief complaint: Internal Defib Shocking At scene:20:29 Depart: 20:37 Dispatched code 3 to private residence for heart problems Arrived at scene to find a 44 year old female, semifowlers on her couch. Patient C/O internal defibrillator shocking her approximately 6 times PTA. Patient reports to recent placement of Internal Defibrillator in the last 2 weeks due to being in and out of V-Tach rhthym and having to be converted in the ED. on February 10,

37 Case #4 Exam: patient is pale, warm, dry, CA&OX4. HEENT: no trauma/deformities observed. PERRL Obvious facial droop Neck: trachea midline, NO JVD observed. Chest: equal rise and fall, no crepitus or bruising observed. L/S clear and equal in all fields with good tidal volume. Surgical scar in a healing stage observed in left upper chest where defibrillator was placed. Patient reports feeling being hot before she anticipates a delivered shock. on February 10,

38 Case #4 Patient t denies any CP or SOB and reports lying on couch for most of the day. CM attach showing initial NSR, before CM changes to Tordes DE Pointes and patient being shocked by her defibrillator. Patient was go lethargic, but not totally unconscious before becoming CA&OX4. Patient did C/O of blurry vision after each shock. Patient was shocked a total of 13 additional times during patient contact. on February 10,

39 Case #4 Patient t stayed conscious throughout h t patient contact. Abd: Soft and NT X4 no masses felt upon palpation. Back: unremarkable Pelvis: stable and intact, and no incontinence observed. Extremities: Good CSM X4, no trauma/ deformities observed, equal grips, push/pulls Dialysis shunt noted to left arm. on February 10,

40 Case #4 TX: Patient t lifted to stretcher t and loaded d to ambulance. En route to hospital. Treatment: patient exam, VS, CM, 12 lead, IV site access with poor vein access and difficulty accessing the IV site due the patient arms and legs flailing after each shock delivered. IV attempted X 1 without success. IO established with extended time due to patient flailing due to shocks delivered. O2 applied. on February 10,

41 Case #4 Hospital contacted upon leaving scene with no questions/orders received. Arrived at hospital without any change to condition. Magnesium sulfate was considered but no given. on February 10,

42 Case #4 Medications: Famotidine, Fluxetine, Carvediol, Prednisone, Sevelamer carbonate, Simvastatin, Warfarin, Mycophenolate Mofetil, Benazpril, Sotalol PMH: Stroke, Dysrhythmia, Lupus, AICD, Renal failure on February 10,

43 Case #4 20:32 BP 122/71, HR 73, RR 18, SpO2 97 low O2 20:37 BP 127/66, HR 79, RR 18 20:52: BP 133/100, HR 81, RR 18 20:30 NSR 20:33 Torsades De Ponts 20:39 NSR 20:42 Torsades De Points 20:45 NSR on February 10,

44 Case #4 20:45 Venous access 20:50 IO 20:27 Oxygen 20:50 Lidocaine i 40 mg on February 10,

45 Case #4 on February 10,

46 Case #4 on February 10,

47 Case #4 on February 10,

48 Case #4 on February 10,

49 Case #4 on February 10,

50 Case #4 on February 10,

51 Case #4 Documentation? Quality of care delivered? Other issues and concerns? Care appropriate? Overall impression? Protocol changes required? Teaching/Take home points on February 10,

52 Thank You for Attending! Any Questions? on February 10,

53 Thank You for Attending! Nor-Cal EMS Medical Advisory Committee Run Review February 2015 on February 10,