EMS and ER Response for an Unconscious Female Trauma Patient

Ginger Asks:

I have a 23-year-old woman with an obvious head wound (she got hit with the butt of a gun, but the first responders don’t know that) who’s been outside in 20’ish degree weather without a coat for an undetermined amount of time. She’s unconscious. Obviously an IV is started, but what else will paramedics do to treat her? Warming blankets? What would happen when she got to the ER?

Jordyn Says:

Thanks for sending me your question.
 

EMS Response:

For an unconscious patient with an obvious head wound, but is unable to tell how her injury happened should be placed in C-spine precautions. That means C-collar and backboard. IV-- yes. And warming. They'd get a set of vital signs, put her on a monitor and then do a full assessment to look for other injuries.

Checking her blood sugar is warranted because why is she unconscious? Did the injury to her head happen because she passed out from low blood sugar? Or is it too high? Looking for medical alert bracelets as well. They'd probably key in on a good neuro exam like are her pupils equal and reactive to light? What type of stimulation does she respond to (voice, touch or pain?) They might even give a dose of Narcan to rule out opiate overdose (like heroin.)  

In the ER:

Full assessment as above and we'll look for other injures. We'll maintain C-spine precautions. She would be completely undressed (again-- looking for other injuries.) We have a better ability to monitor temperature so we'll know exactly where she's at and work to rewarm her. This could range from warm blankets to warming lights and heated IV fluids. Full set of vital signs. We'd place her on the monitor as well to watch her HR, breathing and oxygen levels continuously.
 

As far as testing and procedures go, if she remains unconscious, I would say the following:

1. Spine X-rays. 

2. CT of the head (to look for bleeding, stroke, tumor.)

3. Labs: Full metabolic panel (this will check blood sugar again), complete blood counts, alcohol level, aspirin level, Tylenol level. Tylenol and aspirin are drugs people will overdose on that can be very serious.

4. Urine toxicology panel (this would pick up on major substances of abuse but not everything.) Also urine pregnancy test. 

5. ECG. To see if a heart arrhythmia or heart attack could be an explanation for her passing out.
 

Unless we know the exact mechanism of the injury we have to consider both inflicted wounds from another person but also that she might have just passed out and hit her head and what the reason for that might be.

If she's truly unconscious and doesn't respond to pain-- she'd likely get a tube in every orifice as they say and they'd have to consider whether or not to intubate her (put a breathing tube in) to protect her airway. If that happens, then NG tube (placed probably through the mouth into the stomach) and a Foley catheter which drains your urine into a bag.

If she's somewhat responsive but immediately drifts off-- they could hold off on tube placements, check the tests I've listed, and give her some time to see if she wakes up on her own if she's breathing well on her own.

Allergic Reaction: Dianna Benson

I always love it when friend and author Dianna Benson stops by! Dianna is a talented writer and has two treats for you today-- a new novel, Persephone's Fugitive, is releasing. I was blessed to have the opportunity to read and endorse this novel. Two, she is giving a factually based fictional account of an EMS call dealing with a severe allergic reaction called anaphylaxis.

Welcome back, Dianna!

“EMS 6, allergic reaction, at 123 Main Street.”

At 7:40 Christmas night, my partner and I flip on the lights and sirens and race our ambulance toward 123 Main Street. En route, my partner reads off details of our dispatched call on our dashboard laptop.

“Twenty-year-old female. Respiratory arrest.”

I grab the radio. “This is EMS 6, requesting assistance on our anaphylaxis call. Copy?”

“Copy EMS 6. FD 14 is en route.”
    

Once we roll up on scene, several people wave us into the two-story home, their faces contorted in panic. As we hear sirens from an approaching fire truck, we rush our loaded stretcher inside the front door and toward the young lifeless body lying on the tiled kitchen floor, cyanosis around her lips.

I notice our patient’s chest is motionless, and I don’t feel or hear any air moving out of her mouth or nose.

“What is her name?” I ask no one in particular in the crowd of about a dozen surrounding us.

“Ally,” several voices answer.

“Ally?” I rub my knuckles over her sternum.

“Unresponsive,” I inform my partner, who’s yanking out a BVM (bag-valve mask), other airway equipment, and the med box.

I feel for a carotid pulse on her flushed neck. “Rapid and weak,” I say to my partner. We share a look of understanding—our patient is headed for cardiac arrest. Our interventions must be quick and efficient.

“What happened here?” I again ask the room full of people as I press the mask over my patient’s mouth and nose with my left hand in the E/C formation. With my right, I squeeze the football-sized bag every five seconds to oxygenate the young woman’s system. Her chest rises and falls with every squeeze, indicating her airway isn’t blocked by swelling or any foreign object.

“She was eating and started coughing, and said her chest is all tight,” a hysterical woman answered, suddenly kneeling next to me. “She was itchy all over, had trouble breathing, hives on her back.” 

I face the middle-aged woman, tears flowing out of her eyes and down her cheeks. “Are you her mother?”    

“Yes. She was severely allergic to peanuts when she was little but out grew it or whatever.”

As I continue bagging, my partner pushes epinephrine IM (intermuscular) then inserts an IV into our patient’s left arm for med access and fluid replacement. A fire crew of four men darts into the house.

Without an exchange of words, I hand one of the firefighters the BVM, and two of them take over bagging. One presses a tight seal over the mouth and nose, the other squeezes the bag.
   

“Hand me our monitor,” I ask the firefighter closest to our cardiac monitor. He and the fourth guy assist me in hooking up a twelve led ECG to our patient’s four limbs and chest.

I study the monitor for our patient’s vital signs, looking for indications of imminent anaphylactic shock and cardiac arrest. “BP 80/52. Pulse 134. SPO2 86%. Normal sinus heart rhythm.”

“Uh-huh,” my partner says, letting me know he heard my report of the grave vital signs.

I hand him diphenhydramine and methylprednisolone to administer into the IV line.

“Does Ally have any medical conditions or take any medications for anything?” I ask the mother.

“No. Nothing.” 

We add Benadryl to the line then attach a little bag of Pepcid to the IV set up. Following up with those meds, we add Solu-medrol.

In scanning the kitchen, I spot several whole pies ready to be served, remnants of T-Bone steaks and empty lobster tails on multiple dirty plates. “Did she eat any nuts tonight?” I ask the mother to keep her occupied.  

“Nothing any of us ate tonight contains nuts.” The mother points over her shoulder. “We haven’t eaten any pie yet, but none of them has nuts.”
     

“Has she ever eaten lobster before tonight?” I ask while digging into our airway bag.
 

“Once. Couple of months ago and loved it.”

“It was probably the lobster. The second encounter with an allergen is when an allergic reaction occurs.” I turn to my partner. “Let’s intubate.”

“Uh-huh.”

I’m readying the intubation equipment when Ally jerks to a conscious state, coughing and rolling on to her side, shoving the mask away from her face.

“Guess she didn’t want to be intubated,” one firefighter whispers near my ear, not out of humor but relief, a feeling I share. 

“Ally? Hi.” I grab a non-rebreather mask. “You suffered a severe allergic reaction. You need oxygen.”

She nods, rolling to lie on her back again. Her mother squeezes her hand, pats her forearm.

“Bummer, I know, but we gotta take you to the hospital to be monitored overnight.” After turning the portable O2 tank on to 15 liters per minute, I strap the non-rebreather to Ally’s face. “Just breathe normally and relax. You’re doing fine. We’ve got you, Ally.” I smile at her.

The firefighters lift her weak body onto our stretcher; I study the monitor. “BP 96/60. Pulse 118. SPO2 92%,” I say to my partner.

“That’s what I want to hear,” he responds in a relief matching my wide smile.

You can read more posts done on allergic reactions/anaphylaxis here, here, and here.

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Dianna T. Benson is the award-winning and international bestselling author of The Hidden Son and Final Trimester. Persephone’s Fugitive is her third release. An EMT and a HazMat and FEMA Operative since 2005, Dianna authentically implements her medical and rescue experience and knowledge into all her suspense novels. She lives in North Carolina with her husband and their three children. www.diannatbenson.com

Trauma Call/Domestic Violence: Dianna T. Benson, EMT

I am pleased to welcome back award-winning novelist Dianna T. Benson. I love how she writes these scenes fictionally but conveys a host of medical details along with it. 

Welcome back, Dianna!

“EMS 6, Stabbing, TAC Channel 12”

     Responding to a domestic disturbance call, my partner and I park our ambulance in front of an upscale home over a million dollars. Not atypical – EMS is too often called out to the rich on domestic violence.

     “Did you know the power company turns off this zip code for lack of pay more than any other in the state?” I ask my new partner.

     “Yep. Idiots living beyond their means. No wonder they’re so stressed out and hurt each other.”

     At the front door, we join a fire crew, as three cops enter the house, all three with weapons drawn.

     “Scene isn’t safe?” I ask.

     “Not sure,” the last cop answers then trails his two buddies.

     The fire crew of four hangs back with me and my partner.  

     “Was the door unlocked?”

     “Yup,” one of the firefighters answers me.

     After five long and boring minutes of standing around on the lawn in the dark of night, I radio in to dispatch. “EMS 6. Standing by outside residence. Any updates from PD on scene?”

     “Yes. Scene is secure. PD is with victim.”

     “Copy that.” I roll the front of our loaded stretcher into the house.

     In the family room, I find one officer bent over a body, the other two talking with an agitated man.

     I kneel at the woman’s other side. She’s supine on the carpet, her lapped hands pressed to her lower abdomen and covered in blood.

     “Ma’am?” I touch her shoulder in comfort.

     My patient blinks at me then flutters her eyes closed.

     “Can you tell me your name?”

     “Judy,” she whispered in a pained voice.

     I brush my hand over hers. “Judy, are you hurt anywhere other than here?”

     “Don’t know,” she mumbles.

     “Judy?” I stare into her eyes, mascara smudged underneath them. “Can you move your arms down at your sides?”

     She does.

     My partner hands me trauma scissors, a stack of 5X9 sterile gauze pads, and an occlusive dressing. As I rip open the gauze packages, my partner hooks up the patient to our cardiac monitor and focuses on assessing and monitoring vital signs.  

     “How can I help?” one of the firefighters asks me.

     “Perform a rapid trauma assessment.”

     “You got it.” He starts at the head.

     With the trauma scissors, I cut Judy’s shirt, exposing the wound. Noting no debris other than blood, I cover the gushing horizontal wound—thin but long—with one sterile gauze pad after another, and apply direct pressure with my palms. “Did a knife do this, Judy?”

     “He did.”

     “With a knife?”

     “Steak knife.”

     “I see nothing else,” the firefighter informs me at the patient’s feet.

     I nod. “Thanks.”

     I glance at the monitor screen for Judy’s vital signs. Her heart rhythm is normal, but her blood pressure is too low, pulse too high, indicating she’s headed to shock due to blood loss. My guess is she’s bleeding internally, the knife blade sliced an organ or two, maybe the abdominal aorta. Regardless of what’s injury, she needs a surgical team.

     I look at my partner. “We gotta go. Now.” 

       

     “Give me the switchblade,” one of the cops says, alarm in his tone. “Sir, you’re just making things worse for yourself.”  

     “Past time to go,” I whisper to my partner, a rush of panic clogging my throat.

     “No kidding,” he whispers back, wide-eyed.

     “Get out of here,” one of the cops says to us.

     “What’d you say to them?” the agitated man shouts.

     “You don’t want a murder charge, do you? The EMS crew needs to get her to the hospital.”

     The cops deal with the perpetrator, as my partner readies the stretcher. I blanket the dozen or so bloody gauze pads with a towel.

     Inside the moving ambulance, I raise the foot of the stretcher to treat for shock. I cover Judy’s mouth and nose with a non-rebreather oxygen mask and turn on the O2 to 15 lpm. Since none of her organs eviscerated, I do not apply an occlusive dressing. Instead, I add additional 5X9s and a fresh towel and instruct the one firefighter who joined us en route to press his hands over it for direct pressure. I insert an IV saline bolus and consider administering morphine or fentanyl for pain.

  

     “More cops dispatched to scene,” my partner yells back from the driver’s seat. “Guy stabbed one of the cops and fled the scene on foot.”

     I look down at my patient. She doesn’t indicate she heard those disturbing words.

  

     “We’re ten minutes out,” my partner yells back at me.

     I pick up the radio. “Wake Med ED, this is EMS 6.”

     “Go ahead EMS 6.”

     “We are enroute with a thirty-eight year old female. Left lower quadrant adnominal stab wound. No evisceration. BP 82 over 56. Heart rate 173. Non-rebreather at 15 liters per minute. Legs elevated for shock treatment. Place OR on stand by. ETA 10 minutes.”

     “See you in 10. Wake Med out.”

     “EMS 6 out.”  

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Dianna Torscher Benson is a 2014 Selah Award Winner, a 2011 Genesis Winner, a 2011 Genesis double Semi-Finalist, a 2010 Daphne de Maurier Finalist, and a 2007 Golden Palm Finalist. In 2012, she signed a nine-book contract with Ellechor Publishing House. She’s the author of The Hidden Son, her debut novel. Final Trimester is her second release. After majoring in communications and a ten-year career as a travel agent, Dianna left the travel industry to earn her EMS degree. An EMT and a Haz-Mat and FEMA Operative since 2005, she loves the adrenaline rush of responding to medical emergencies and helping people in need. Dianna lives in North Carolina with her husband and their three children. You can connect with Dianna via her website.