Case Study During your shift as an EMT, you are called to two different kinds of cases. The first…

Case Study

During your shift as an EMT, you are called
to two different kinds of cases. The first call is to a trauma patient. The
second is to a patient who is suffering from a medical problem.

Scene Size-up

You have been dispatched to an unresponsive
patient with an unknown problem. Upon arrival, you see an adult male supine at
the bottom of a two-story fire-escape ladder. A police officer approaches the
ambulance and tells you that they have been called for a reported domestic
incident and gunshots. The officer motions you to park a safe distance away
until the scene is secured.
»

Case Study

During your shift as an EMT, you are called
to two different kinds of cases. The first call is to a trauma patient. The
second is to a patient who is suffering from a medical problem.

Scene Size-up

You have been dispatched to an unresponsive
patient with an unknown problem. Upon arrival, you see an adult male supine at
the bottom of a two-story fire-escape ladder. A police officer approaches the
ambulance and tells you that they have been called for a reported domestic
incident and gunshots. The officer motions you to park a safe distance away
until the scene is secured. Moments later you see police leading a suspect from
the building. The officer motions you forward and tells you the scene is safe.
Anticipating that the patient may be bleeding, you already have on gloves,
mask, and eyewear with side shields as you jump from the ambulance and approach
the patient.

Primary Assessment

As you approach the patient, you notice
that the shirt front and left pants leg are soaked in blood, the skin is
extremely pale, and the right lower leg is severelydeformed. This is obviously
a trauma patient with a significant mechanism of injury—a probable fall from
the fire escape and a possible gunshot wound. Your partner immediately
establishes in-line stabilization of the head and neck and performs a jaw
thrust to open the airway. The patient does not respond to verbal commands;
however, he moans and makes a facial grimace as you pinch the trapezius muscle.
You assess the breathing status and determine that the patient’s chest is
barely rising and falling and only minimal air movement can be felt or heard.
You immediately instruct your partner to insert an oropharyngeal airway and
begin bag-valve-mask ventilation at a rate of 10/minute with supplemental
oxygen while maintaining in-line stabilization. A radial pulse is not palpable
and the carotid pulse is extremely weak, fast, and thready. The skin is pale,
cool, and clammy. As you continue with your assessment, you quickly cut the
shirt off and find a gunshot wound to the left anterior chest. You immediately
place your gloved hand over the wound. You then tape the plastic package from
an oxygen mask over the wound on three sides and continue to scan the anterior
and lateral aspects of the chest for any other wounds. Next, you expose the
area around the left thigh and find a wound with dark red bleeding at a steady
flow. You apply direct pressure to control the bleeding and then immediately
apply a pressure dressing. You indicate to your partner that this is going to
be a rapid patient transport.

Secondary Assessment

Now that immediate life threats are under
control, you begin the rapid secondary assessment. You quickly assess the head
and neck and apply a cervical spinal immobilization collar. Your partner
continues in-line stabilization. As you continue with your assessment, you find
decreased breath sounds on the left side of the chest. You find no
abnormalities in the abdominal or pelvic region, but the right lower extremity
is swollen and deformed and the patient moans when you palpate the angulated
area. With assistance from police First Responders, spinal stabilization is
maintained as the patient is log rolled and the posterior thorax and lumbar
region and buttocks are exposed. No additional injuries are revealed. While the
patient is still on his side, a police First Responder slides the backboard
next to the patient and the patient is rolled onto it and secured with straps.
A head immobilization device is applied. The right lower extremity is also
carefully secured to the board for stabilization. The blood pressure is
measured at a low 70/50 mmHg; skin remains pale, cool, and clammy; pupils are
normal in size, equal, and sluggish to respond to light; the heart rate is
rapid at 136 per minute; and the spontaneous respiratory rate is only 6 per
minute. You continue positive pressure ventilation with supplemental oxygen at
a rate of 10 per minute. No one at the scene knows the patient, so the only
portion of the history you are able to gather is information about events
leading to the injury. A neighbour reports hearing gunshots, seeing the patient
stagger out onto the second-story fire escape clutching his chest, then
watching in horror as the patient pitched over the railing and fell to the
pavement. The patient is promptly loaded into the ambulance for transport with
lights and siren. En route to the hospital, you apply a vacuum splint to the
right lower leg for better immobilization. You apply a sterile dressing and
bandage to a small laceration at the left temporal region of the patient’s
head.

Reassessment

Because this is a patient with critical
injuries, you continuously reassess the mental status, airway, breathing,
oxygenation, and circulation, and you take and record vital signs every 5
minutes while en route to the emergency department. You reassess the patient’s
injuries and check the effectiveness of interventions, making sure that
positive pressure ventilation is adequate, the dressing on the chest wound is
permitting escape of air on the unsecured side, the bleeding at the chest and
thigh is under control, and the immobilization to the backboard and splints is
secure. You radio the hospital emergency department to report patient
information and to alert them to your estimated time of arrival. No change in
the patient’s condition has occurred and you arrive at the hospital without
further incident. You give the hospital staff your oral report on the patient,
complete the written documentation, and prepare the ambulance for the next
call.

Scene Size-up

Shortly after the call to the man injured
in the domestic dispute, you are again dispatched to a patient with an unknown
problem. This time, you arrive at a well-kept home in a quiet neighborhood and
are met by a middle-aged woman who says she called EMS for her mother, who
cannot catch her breath. The woman, Mrs. Conlon, leads you into the house. As
you enter the living room, you see an elderly woman sitting up in a chair and
an oxygen tank in the corner. You conclude that your patient likely is
suffering from a medical problem rather than trauma.

Primary Assessment

Mrs. Conlon introduces you to her mother,
Mrs. Ortega, and tells you that her mother is 72 years old. Mrs. Ortega is
sitting up in a chair, leaning forward, with her hand on her chest. She says,
“I’m glad—you came. I feel like—I can’tbreathe.” Her remarks assure you that her
mental status is alert and her airway is open. You observe that she is
breathing in fast, short puffs, but with adequate rise and fall of the chest.
Your partner applies the pulse oximeter and obtains a reading of 89%. You apply
a nasal cannula at 2 lpm, explaining that this will help relieve her distress.
Because she has a home supply of oxygen that she has occasionally used, she
understands and welcomes the oxygen therapy. You are able to palpate a somewhat
rapid radial pulse, and you note that her skin is warm, pink, and dry

Secondary Assessment

You sit down on a chair next to Mrs. Ortega
and begin to take the history, starting with an elaboration of the chief
complaint. She is not experiencing pain, so most of the OPQRST questions do not
apply, but she does tell you that the onset of her symptoms was gradual over
this morning and afternoon and that she has been suffering from the breathing
difficulty for several hours. You determine that she chronically has a
difficult time breathing, but this episode was slightly worse than usual—a 5 on
a scale of 1 to 10. You continue with the assessment using the mnemonic as the
foundation for asking questions. She has no allergies that she knows of. The
medications she takes, including oxygen, are related to her history of
emphysema, a serious lung disease. Her last oral intake was lunch at around
noon. There were no unusual events leading to the onset of the symptom.
Meanwhile, your partner has been taking and recording Mrs. Ortega’s baseline
vital signs. Her respirations are puffy, somewhat labored, and at a rate of 28
per minute with adequate chest rise. Her pulse is rapid at 100 per minute
and irregular. Her skin color, temperature, and condition remain normal. Pupils
are normal, equal, and reactive. Her blood pressure is 120/90 mmHg. The
pulse oximeter reading has improved only slightly to 90% while on the nasal
cannula at 2 lpm so you increase the flow to 3 lpm and continue to monitor the
SpO2 reading. The physical exam you conduct is focused on Mrs.
Ortega’s complaint and related body systems. You assess her pupils and find
that they are midsize and sluggish to respond. Her oral mucosa and conjunctiva
are slightly cyanotic. Her neck veins are flat. You quickly inspect the chest
by lifting her shirt to look for any potential evidence of trauma. You
auscultate her chest with your stethoscope and detect wheezing noises that, in
fact, you can hear even without the stethoscope. The breathing sounds are
present and equal on both sides. Her abdomen is nontender and no distention is
noted. You inspect the lower extremities for redness and swelling, especially
to one calf. You quickly palpate trying to elicit a tenderness response. You
ask Mrs. Ortega to “Point your toes back toward your head” checking for
tenderness in either calf region. You then ask her to “Point your toes” again
checking for any tenderness. You inspect the ankles and feet for edema. You
place Mrs. Ortega on the wheeled stretcher and transfer her to the ambulance.
You raise the head of the stretcher so that she can ride to the hospital in a
sitting position, which she finds is more comfortable and helps her to breathe

Reassessment

You perform a reassessment by reassessing
her mental status, airway, breathing, oxygenation, and circulation, and
reassessing and recording her vital signs. You repeat an assessment focused on
her breathing problem by using your stethoscope to auscultate her chest and
reconfirm that breath sounds are present and equal with wheezing sounds on both
sides. You assess the SpO2 reading to ensure the nasal cannula at 3 lpm is
keeping the SpO2 at or above 94%. Because Mrs. Ortega is a stable patient, you
repeat the reassessment every 15 minutes en route. You radio the hospital
emergency department with patient information and your estimated time of
arrival. You arrive at the hospital with no further incident, give your oral
report to the receiving staff, complete the transfer of care, finish the
prehospital care report, and prepare the ambulance for the next call.

 

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