NOR-CAL EMS MEDICAL ADVISORY COMMITTEE RUN REVIEW, NOVEMBER 2014
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1 Eric M. Rudnick, MD, FACEP, FAAEM Medical Director Northern California EMS NOR-CAL EMS MEDICAL ADVISORY COMMITTEE RUN REVIEW, NOVEMBER meeting by Engineer Bill Bogenreif 1
2 CASE #1 Call Type : Fall in a 91 year old female PSAP: 19:38 Enroute: 19:38 At Scene: 19:43 At Patient: 19:45 Depart: 20:02 Arrive Destination: 20:08 Patient Released: 20:24 meeting by Engineer Bill Bogenreif 2
3 CASE #1 Primary Impression: Trauma Chief Complaint: Right hip pain x 2 hours NKDA Medications: Synthroid Hypothyroidism meeting by Engineer Bill Bogenreif 3
4 CASE #1 19:45 Mental Status: Normal for patient, confused, oriented person, oriented place, oriented events Neuro: Normal, speech normal Eyes: Reactive Chest/lungs: Normal assessment, clear and equal breath sounds Abdomen: normal, non-tender Cervical, Thoracic, Lumbar: Normal, no pain or deformities All extremities: Normal, positive C.M.S. meeting by Engineer Bill Bogenreif 4
5 CASE #1 19:45 Vital signs GCS 14 19:58 163/81 (right arm), HR 97, RR 18, SpO2 98% room air, pain 10 19:45 Stroke scale: Speech: normal, Arm drift: normal, Facial droop: normal meeting by Engineer Bill Bogenreif 5
6 CASE #1 19:45 ALS assessment 19:46 spinal assessment no deficits 19:58 cardiac monitor 20:03 Venous access extremity 18 guage meeting by Engineer Bill Bogenreif 6
7 CASE #1 20:03 Normal saline 20 gauge lock/flush 20:05 Morphine sulfate 5 mg IV meeting by Engineer Bill Bogenreif 7
8 CASE #1 Arrived to find an a/o x 3, GCS 14, 91 year old female sitting upright in a chair at home c/o right hip pain and right arm pain. Patient states she was walking through her house when she tripped and fell onto her right side and hit her head. Patient denies any LOC and is able to recall the entire event. Patient denies any chest pain, SOB, blurred vision, headache, dizziness, N/V, abdominal pain, or recent illness. Patient denies feeling weak. Patient is unable to recall the year or month. meeting by Engineer Bill Bogenreif 8
9 CASE #1 Per family, patient normally knows the year and month. Patient transported to closest trauma center due to possible head injury. Patient denies any change in pain after administration. meeting by Engineer Bill Bogenreif 9
10 CASE #1 REVIEW Care appropriate? What went well? What could have been improved? Recommended changes to protocols? meeting by Engineer Bill Bogenreif 10
11 CASE #2 Call type: Abdominal pain in a 6 year old male PSAP 18:52 Enroute: 18:53 At scene: 19:01 At patient 19:05 Depart: 19:15 Arrive destination: 19:36 Patient released: 19:50 meeting by Engineer Bill Bogenreif 11
12 CASE #2 Primary impression Behavioral/ Psychiatric Chief complaint: Chest discomfort X 10 minutes NKDA Medications: none PMH none meeting by Engineer Bill Bogenreif 12
13 CASE #2 20:20 Physical Examination Mental status: Normal for patient A X O 4 Neuro: Normal Chest/lungs: Normal assessment, Breath sounds clear and equal LUQ: Normal, non-tender LLQ: Normal, non-tender RUQ: Normal, non-tender, RLQ: Normal, non-tender Back: Normal meeting by Engineer Bill Bogenreif 13
14 CASE #2 19:05 GCS 15 19:12 temperature 37 C 19:13: 90/69 Right arm, HR 120, RR 24, SpO2 100% 19:18: HR :19 HR 131, RR 11 19:23 140/97, HR 125, SpO2 100% meeting by Engineer Bill Bogenreif 14
15 CASE #2 Responded code 2 for report of a male complaining of abdominal pain. First on scene and performed an assessment and obtained vital signs. Patient complains of chest discomfort and a funny feeling in his hands and fingers. Patient s family states that the patient has been yawning and that the patient states he can not yawn and get the air out. Patient was AXO4, GCS 15, skin signs pink, warm, and dry. Family denies that the patient has been ill recently. meeting by Engineer Bill Bogenreif 15
16 CASE #2 Patients Mother denies to her knowledge the patient consuming and alcohol or medications. Upon loading the patient into the ambulance an assessment was performed and vitals signs were monitored en route to the hospital. Patients lungs sounds were clear and equal bilaterally. Patients pupils were PERL. No signs of an allergic reaction on the patients body; no hives or discoloration of skin color. Patients Mother denies any similar episodes in the past. meeting by Engineer Bill Bogenreif 16
17 CASE #2 Care appropriate? What went well? What could have been improved? Recommended changes to protocols? meeting by Engineer Bill Bogenreif 17
18 CASE #3 Call type: unknown 20 year old female PSAP: 18:59 Enroute: 18:59 At scene: 19:06 Depart: 19:31 Arrive Destination: 19:44 Patient Released: 19:56 meeting by Engineer Bill Bogenreif 18
19 CASE #3 Primary Impression: pain Chief complaint: Neck pain secondary to vehicle accident x 44 minutes. Allergies: Sulfa Medications: none PMH: none Vehicular injury indicator: space intrusion greater 1 foot Estimated speed: 55 + mph meeting by Engineer Bill Bogenreif 19
20 CASE #3 19:07 Physical examination Mental status: normal mental status for patient, AxO4 Neuro: normal Eyes: reactive Neck: normal Chest/lungs: normal assessment, Clear and Equal bilaterally LUQ, LLQ, RUQ, RLQ normal, soft and non-tender Thoracic: normal, no pain or deformities meeting by Engineer Bill Bogenreif 20
21 CASE #3 19:07 Extremities: normal Head/Face: Pain/Tenderness Cervical: Pain Lumbar: Pain meeting by Engineer Bill Bogenreif 21
22 CASE #3 19:07 GCS 15 19:26 152/91 right arm, HR 93, RR 18, SpO2 98 % room air 19:33 Blood glucose :40 163/75, HR 75, RR 18 19:26 Monitor: normal sinus rhythm 19:32 Venous access Saline lock 18 gauge 19:33 glucose Analysis meeting by Engineer Bill Bogenreif 22
23 CASE #3 Dispatched to a vehicle and found 20 year old female, in the third row of the vehicle she was in, on freeway, with Fire assessing her, who was involved in a motor vehicle accident. The patient is the restrained passenger, in the third row on the right side, of SUV, with air bag deployment, with 1 foot intrusion into the passenger compartment from the rear of the SUV, that was stopped on the freeway, and rear ended by a vehicle going 50 to 70 mph. Patient placed in a c-collar and placed in manual spinal precautions. Patient extracted out of the SUV and placed in spinal precautions. meeting by Engineer Bill Bogenreif 23
24 CASE #3 Patient carried onto stretcher via backboard and loaded into the ambulance. Patient complains of midline neck pain, lower back pain, and right face pain. Patient denies dizziness, headache, nausea, vomiting, numbness, and tingling. Patient transported to Trauma Center code 2 trauma. En route patient vital signs monitored, 18 gauge IV saline lock given right AC, and blood sugar checked 135. meeting by Engineer Bill Bogenreif 24
25 CASE #3 Patient denies chest pain, shortness of breath, dizziness, and headache. meeting by Engineer Bill Bogenreif 25
26 CASE # 3 Care appropriate? What went well? What could have been improved? Recommended changes to protocols? meeting by Engineer Bill Bogenreif 26
27 CASE #4 Call Type: Seizure/Convulsions 2 year old male PSAP: 09:38 Enroute: 09:39 At scene: 09:49 At patient: 09:51 Depart: 10:01 Arrive destination: 10:12 Patient released: 10:24 meeting by Engineer Bill Bogenreif 27
28 CASE #4 Chief complaint: seizure x 2 minutes NKDA Medications: none PMH: Seizure disorder, fetal alcohol syndrome, SZ (first time last week without dx) meeting by Engineer Bill Bogenreif 28
29 CASE #4 Mental status: normal for patient, Oriented person, Oriented- place, Oriented- time, Orientedevents Neuro:normal Eyes: reactive Skin: normal Head/face: normal Neck: normal Chest/lungs: normal chest assessment, Clear and equal bilaterally meeting by Engineer Bill Bogenreif 29
30 CASE #4 10:00 LUQ, LLQ, RUQ, RLQ: normal, soft, non-tender Cervical: normal, non-tender Thoracic: normal, non-tender Lumbar: normal, non-tender Extremities: RU, LU, RL, LL: all normal 10:05 Chest/Lungs: normal chest assessment, clear and equal breath sounds meeting by Engineer Bill Bogenreif 30
31 CASE #4 09:51 GCS 15 09:58: blood sugar: :00 temperature: 37 C 10:02: 99/75 left arm, HR 142, RR 28 SpO2 100 % room air 10:09 115/84 HR 118, RR 26, SpO2 100 % room air Monitor: sinus tachycardia 00:00 Fire Responder, prior to arrival: oxygen by mask 15 lpm meeting by Engineer Bill Bogenreif 31
32 CASE #4 Arrived on scene private residence, to find 2 year old male sitting in foster mother s lap, in no apparent distress, with Fire at side. Patient AxO to baseline. Per guardian, he was sitting on the couch, and was about to fall asleep, when he was witnessed to have a full body tonic-clonic seizure lasting approximately 1 minute, followed by focal bilateral arm activity x 1 minute. He had a straight stare the entire time and remained pink, warm and dry the entire time. meeting by Engineer Bill Bogenreif 32
33 CASE #4 Per foster Mother, this was his second seizure in two weeks. Last week, he had his first known seizure, and was at hospital X. He did not receive a dx at that time. He had not had any accidents, injuries, or medical procedures. He had not been suffering from fever, cough, cold, nausea, vomiting, or diarrhea in the past several weeks. Patient was afebrile, BGL WNL. Transported to hospital X code 2. meeting by Engineer Bill Bogenreif 33
34 CASE #4 Care appropriate? What went well? What could have been improved? Recommended changes to protocols? meeting by Engineer Bill Bogenreif 34
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