adult_sns 2014 student

Developed and Authored by

Mike Helbock, M.I.C.P., NREMT-PMike Helbock, M.I.C.P., NREMT-PDirector - EMS AssociatesDirector - EMS AssociatesClinical Educator – Prehospital MedicineClinical Educator – Prehospital MedicineSeattle/King County EMS Seattle/King County EMS Division of Emergency MedicineDivision of Emergency [email protected]@me.comwww.facebook.com/mike.helbockwww.facebook.com/mike.helbock

2014

SICK…SICK… NOT SICKNOT SICK

DisclaimerDisclaimerMike HelbockMike Helbock

Developed and Co-Authored the Developed and Co-Authored the Adult and Pediatric Adult and Pediatric Sick/Not Sick Sick/Not Sick ProgramProgram

Acknowledgements: Acknowledgements: American Academy of Orthopaedic SurgeonsAmerican Academy of Orthopaedic Surgeons

American Academy of PediatricsAmerican Academy of PediatricsJones and Bartlett PublishersJones and Bartlett Publishers

John JerinJohn Jerin

SICK/NOT SICK…SICK/NOT SICK…

WhatWhat’’s it all s it all about?about?

SICKSICK NOT SICKNOT SICK

Make a Decision!Make a Decision!

EMS Providers EMS Providers mustmust do (2) things...do (2) things...

Make decisionsMake decisionsTreat patients Treat patients

(based on the decision)(based on the decision)

We must We must makemake a a Decision!Decision!

The DecisionThe Decision

SICKSICK

The SICK patient is one who The SICK patient is one who you believe is physiologically you believe is physiologically unstable based on key clinical unstable based on key clinical indicatorsindicators

WhoWho’’s SICKs SICK* Respiratory compromise* Respiratory compromise* Hemodynamic compromise* Hemodynamic compromise* Neurologically impaired* Neurologically impaired* Obvious trauma/MOI* Obvious trauma/MOI* Skins signs/color (skin vitals)* Skins signs/color (skin vitals)* Body position* Body position* Index of suspicion (IOS)…gut feel* Index of suspicion (IOS)…gut feel

SICKSICK

This patientThis patientcould die en route!could die en route!

NOT SICKNOT SICKThe The NOT SICKNOT SICK patient is one patient is one who you believe iswho you believe is physiologically stable based physiologically stable based on key clinical signs.on key clinical signs.

*Respiratory status is stable*Respiratory status is stable*Hemodynamically stable*Hemodynamically stable*Neurologically stable*Neurologically stable*Appropriate skin signs/color*Appropriate skin signs/color*Position of comfort*Position of comfort

WhoWho’’s NOT SICKs NOT SICK

NOT SICKNOT SICK

This patient will probably This patient will probably not die en route!not die en route!

The TreatmentThe Treatment

We We treattreat – based on our – based on our decision…!decision…!

The Clinical PictureThe Clinical Picture (Medical)(Medical)

Chief Complaint/N.O.I.RespirationsPulseMental StatusSkin Signs/ColorBody Position

The Clinical PictureThe Clinical Picture



DECIDEDECIDESICKSICK NOT SICKNOT SICK





Short Reportto ALS

Short Reportto ALS

100% O2NRM or BVM

History and Baseline Vitals

AppropriatePosition

Rapid Trans-port/ALS

Full Set VitalsFull Exam

Reassess


AppropriateTreatment

AppropriateTransport

Reassess


Low/ModerateFlow O2

*SAMPLE history*SAMPLE history*OPQRST*OPQRST*SAMPLE history*SAMPLE history

*Treat life-threatening*Treat life-threateningconditions immediatelyconditions immediately

*Care for obvious/additional*Care for obvious/additionalconditions as neededconditions as needed




Short Reportto ALS

Short Reportto ALS

100% O2NRM or BVM

History andBaseline Vitals

AppropriatePosition

Rapid Trans-Port/ALS


Reassess

*SAMPLE history*SAMPLE historyHistory and

Baseline Vitals



Reassess


Low/ModerateFlow O2

*SAMPLE history*SAMPLE history*OPQRST*OPQRST



The Clinical The Clinical PicturePicture

Form the clinical picture Form the clinical picture within 60 seconds!within 60 seconds!

The Clinical PictureThe Clinical Picture (Trauma)(Trauma)

Chief Complaint/M.O.I.RespirationsPulseMental StatusSkin Signs/ColorObvious Trauma





Short Reportto ALS

Short Reportto ALS

RapidExtrication


ImmobilizeSpine



Reassess




Reassess

Extricate/Immobilize

Low/ModerateFlow O2

*Focused trauma assessment*Focused trauma assessment*SAMPLE history*SAMPLE history

100% O2NRM or BVM

SpinalStabilization

*Rapid trauma assessment*Rapid trauma assessment*SAMPLE history*SAMPLE history

*Care for obvious/additional*Care for obvious/additionalInjuries as neededInjuries as needed





Short Reportto ALS

Short Reportto ALS

Rapid Extrication


ImmobilizeSpine



Reassess





Reassess


Low/ModerateFlow O2


100% O2NRM or BVM

SpinalStabilization

*Treat life-threatening*Treat life-threateningConditions immediatelyConditions immediately


Other Factors Affecting Other Factors Affecting SICK/NOT SICKSICK/NOT SICK

*Nature of Illness (NOI)*Nature of Illness (NOI)*Mechanism of Injury (MOI)*Mechanism of Injury (MOI)*Index of Suspicion (IOS)*Index of Suspicion (IOS)

*Always include these concerns in your plan!*Always include these concerns in your plan!

Start your plan en route!Start your plan en route!

* Entrapment…* Entrapment…* Head injuries …* Head injuries …* Airway considerations …* Airway considerations …* Multi-system trauma …* Multi-system trauma …

Consider (3) probable Consider (3) probable scenarios…scenarios…

……which generate which generate solutionssolutions

SICK!SICK!

NOT SICK!NOT SICK!

Make em Make em ““earnearn”” their keep!their keep!

Patient Status WorsensPatient Status Worsens* Vitals change* Vitals change* Cardiac symptoms appear* Cardiac symptoms appear* Acute respiratory distress* Acute respiratory distress* Seizures reappear* Seizures reappear* Neurologic status changes* Neurologic status changes

NOT SICKNOT SICK

You can move the patient You can move the patient to the to the SICKSICK category at category at

anytime!anytime!

Common MistakesCommon Mistakes* Delaying the initial decision* Delaying the initial decision* Failing to respond to new * Failing to respond to new

infoinfo* Tunnel vision* Tunnel vision

When All Else FailsWhen All Else FailsTreat what you know you have…Treat what you know you have…

for sure!for sure!

DonDon’’t forget the ABCt forget the ABC’’ss

SICK/NOT SICKSICK/NOT SICKCase StudiesCase Studies

Case Study 1Case Study 132-year-old female complaining of abdominal 32-year-old female complaining of abdominal pain and near syncope.pain and near syncope.

En route you and your partner discuss three En route you and your partner discuss three probable injuries or scenarios:probable injuries or scenarios:

*ectopic pregnancy*ectopic pregnancy

*flu *flu

*appendicitis*appendicitis

##

-- You knock on the apartment door but no one You knock on the apartment door but no one answers. After knocking again a female voice yells answers. After knocking again a female voice yells from the back bedroom to let yourself in...you do so.from the back bedroom to let yourself in...you do so.

-- You approach the patient who is lying supine in bed. You approach the patient who is lying supine in bed. You observe no obvious breathing difficulty. Her You observe no obvious breathing difficulty. Her respiratory rate is 16 and non-labored. She has a respiratory rate is 16 and non-labored. She has a strong radial pulse of 90.strong radial pulse of 90.

-- The patient appears conscious and alert, yet The patient appears conscious and alert, yet concerned. Her skin is slightly flushed, warm and dry.concerned. Her skin is slightly flushed, warm and dry.

-- She complains of 2 to 3 days of abdominal pain with She complains of 2 to 3 days of abdominal pain with intermittent vomiting and normal fluid intake.intermittent vomiting and normal fluid intake.

No difficulty, No difficulty, rate 16rate 16

Strong pulse Strong pulse 9090Conscious and Conscious and alertalert

Flushed, warm Flushed, warm and dryand dry

SupinSupinee

Abdominal pain and vomiting, Abdominal pain and vomiting, normal fluid intakenormal fluid intake







Short Reportto ALS

Short Reportto ALS

100% O2NRM or BVM


AppropriatePosition

Rapid Trans-Port/ALS


Reassess

*SAMPLE history*SAMPLE historyHistory and

Baseline Vitals



Reassess


Low/ModerateFlow O2

*SAMPLE history*SAMPLE history*OPQRST*OPQRST



Case Study 2Case Study 228-year-old female...apparent overdose28-year-old female...apparent overdose

While en route you and your partner discuss While en route you and your partner discuss three probable scenarios:three probable scenarios:

*decreased respiratory drive/arrest*decreased respiratory drive/arrest

*decreased LOC*decreased LOC

*presence of weapons*presence of weapons

##

-- The patient is lying on a couch at her boyfriend The patient is lying on a couch at her boyfriend’’s s house. The scene is secured by law enforcement house. The scene is secured by law enforcement when you arrive.when you arrive.

-- You see a lethargic female whose skin is pale, You see a lethargic female whose skin is pale, cool and dry. Her respiratory rate is approximately cool and dry. Her respiratory rate is approximately 20 - 24 BPM. You hear no abnormal breath 20 - 24 BPM. You hear no abnormal breath sounds and see no signs of respiratory distress. sounds and see no signs of respiratory distress.

-- Her radial pulse is weak at 150. Her radial pulse is weak at 150.




Rate 20-24 Rate 20-24 w/o distressw/o distress

Weak radial Weak radial pulse of 150pulse of 150

LethargicLethargic

Skin is pale, Skin is pale, cool and drycool and dry

Supine on Supine on couchcouch

OverdoseOverdose




Short Reportto ALS

Short Reportto ALS

100% O2NRM or BVM


AppropriatePosition



Reassess




Reassess


Low/ModerateFlow O2

*SAMPLE history*SAMPLE history*OPQRST*OPQRST*SAMPLE history*SAMPLE history



Mechanism of InjuryMechanism of Injury

* Height of fall* Height of fall* Type and size of vehicle* Type and size of vehicle* Damage sustained* Damage sustained* Type and direction of forces* Type and direction of forces* Type of weapon* Type of weapon

* Rapid* Rapid assessmentassessment* Rapid* Rapid treatmenttreatment* Rapid* Rapid transport to a trauma transport to a trauma

centercenter

Saving Lives in TraumaSaving Lives in Trauma

*Rapid*Rapid assessmentassessment

*Rapid*Rapid treatmenttreatment

*Rapid*Rapid transport transport to a trauma centerto a trauma center

Case Study 3Case Study 3

The alarms sounds for a two-car MVI at the inter-The alarms sounds for a two-car MVI at the inter-section of 1st and Mainsection of 1st and Main..

You and your partner discuss three probable You and your partner discuss three probable injuries or scenarios:injuries or scenarios:

*multiple patients*multiple patients *extrication, backboarding/c-spine *extrication, backboarding/c-spine *potential need for additional help*potential need for additional help

##

-- You approach the scene and see a two-car You approach the scene and see a two-car ““T-boneT-bone”” in the in the intersection. The driver of car #1 is out and uninjured...in intersection. The driver of car #1 is out and uninjured...in fact, he refuses care! The driver of car #2 is a 42-year-old fact, he refuses care! The driver of car #2 is a 42-year-old male, still belted in….minor mechanism of injury, little male, still belted in….minor mechanism of injury, little damage to either vehicle.damage to either vehicle.

-- The patient complains of jaw and neck pain. He has a The patient complains of jaw and neck pain. He has a laceration on his forehead that is bleeding moderately over laceration on his forehead that is bleeding moderately over his face. He is alert and oriented.his face. He is alert and oriented.

- - His skin is slightly flushed, warm and dry. You see no His skin is slightly flushed, warm and dry. You see no obvious breathing difficulty. A strong radial pulse is present.obvious breathing difficulty. A strong radial pulse is present.




No distressNo distress

Strong radial Strong radial pulsepulse

AlertAlert

Flushed, Flushed, warm and warm and drydry

Laceration to Laceration to foreheadforehead

Jaw and neck painJaw and neck painminor MOIminor MOI




Short Reportto ALS

Short Reportto ALS

Rapid Extrication


ImmobilizeSpine



Reassess





Reassess


Low/ModerateFlow O2


100% O2NRM or BVM

SpinalStabilization

*Treat life-threatening*Treat life-threateningConditions immediatelyConditions immediately


Case Study 4Case Study 4You are dispatched to the home of a man who You are dispatched to the home of a man who was said to have fallen off a roof.was said to have fallen off a roof.

You discuss the call with your partner en route You discuss the call with your partner en route and come up with four probable scenarios:and come up with four probable scenarios:

*C-spine/head injury*C-spine/head injury *impaled objects*impaled objects *multiple fractures*multiple fractures *underlying medical problems*underlying medical problems

##

- - You arrive to find a 47-year-old male on the back patio You arrive to find a 47-year-old male on the back patio attended by his wife. He is being propped up in a sitting attended by his wife. He is being propped up in a sitting position.position.

-- You see a man in respiratory distress with a rate of about You see a man in respiratory distress with a rate of about 30. He appears conscious, but tired. His skin is pale. 30. He appears conscious, but tired. His skin is pale. There is a small laceration on his head. His hand is There is a small laceration on his head. His hand is clutching the left anterior area of his chest. Blood is clutching the left anterior area of his chest. Blood is apparent from under his fingers.apparent from under his fingers.

-- His radial pulse is rapid and weak. He complains of His radial pulse is rapid and weak. He complains of shortness of breath. The fall was confirmed to be about 15 shortness of breath. The fall was confirmed to be about 15 feet. feet.




15 foot fall onto patio15 foot fall onto patioObvious Obvious distress, rate of distress, rate of 3030Weak radial Weak radial pulsepulse

Conscious Conscious but but appears appears tiredtired

PalePale

Minor head lac, Minor head lac, chest injurychest injury




Short Reportto ALS

Short Reportto ALS

RapidExtrication


ImmobilizeSpine



Reassess




Reassess


Low/ModerateFlow O2


100% O2NRM or BVM

SpinalStabilization




Your patient Your patient will not diewill not die just just because you canbecause you can’’t diagnose the t diagnose the

problem!problem!

He or she He or she will diewill die if you donif you don’’t t provide provide

……ABCABC’’ss

SICKSICK!!

NOT SICK!NOT SICK!


You make the You make the Decision!Decision!

SICK!SICK!

NOT NOT SICKSICK!!

NOT NOT SICK!SICK!

SICK!SICK!

NOT NOT SICK!SICK!

SICK!SICK!

Sick/Not Sick

can be found @Jones & Bartlett

Publishers…jblearning.com

www.emsassociates.com

Follow us on Facebook** www.facebook.com/emsassociates** www.facebook.com/The SummitCDA** Twitter @emsassociates** Twitter @The SummitCDA

Related websites of Related websites of Interest… Interest…

Developed and Authored byMike Helbock, M.I.C.P., NREMT-PMike Helbock, M.I.C.P., NREMT-PDirector - EMS AssociatesDirector - EMS AssociatesClinical Educator – Prehospital MedicineClinical Educator – Prehospital MedicineSeattle/King County EMS Seattle/King County EMS Division of Emergency MedicineDivision of Emergency [email protected]@me.comwww.facebook.com/mike.helbockwww.facebook.com/mike.helbock

2014

SICK…SICK… NOT SICKNOT SICK

adult_sns 2014 student

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