Welcome to Scenarioville!

Scenarios are just great.

We’ve posted a number of scenarios here over the past couple years as part of our Live from Prospect St. series. These are usually nuanced cases requiring a critical diagnostic approach, and we love to dive deep and discuss all the nitty-gritty angles and considerations. It’s a nice way to learn.

There’s another benefit of scenarios, however, which I don’t think we’ve been able to achieve. The simple fact is that when you first graduate from EMT class and enter the field, there’s a great deal of stuff you need to learn. Not the textbook stuff, but the street stuff. How to manage the flow of a call, approach a scene, identify people with useful information. What kinds of diseases are common and their typical presentation (versus the uncommon, atypical stuff that textbooks love). How to monitor a radio, find an address on the map, and coordinate with other responding resources. Clinical judgment and how to apply it. That sort of thing.

It’s what you learn over time as you develop experience. And while one of the goals of a good education is to shorten that learning curve, there are some aspects you just can’t teach; you have to live it.

But scenarios can help. Because they resemble real life, they can help you understand what real life “looks like,” before you’ve spent enough years on the road that you’ve learned it the hard way. A handful of interesting scenarios isn’t enough; you need to see all the other stuff, the sheer volume of humping routine, typical patients through routine, typical situations.

So while we plan to continue the Live from Prospect St. series, we’re kicking off a new project as well: Scenarioville!

Scenarioville is an imaginary city in a parallel universe, and you work there — so to speak. Unlike our previous scenarios, this will be a consistent environment that you can learn your way around. There’s a fixed map with specific destination hospitals, an emergency system and resources you can get to know, and an equipment list that won’t change on you.

Just like in real life, this means you can “get the hang” of working in a real EMS system. You’ll be dispatched with an audio clip (a transcript is provided if you’re playing via smartphone or other device without audio capability, but if possible, try to use the recording for realism), locate the address in the “mapbook,” respond to the scene, make the decisions, and later learn the outcome. We’ll be posting at least one scenario per week — broken into segments as we usually do, but to minimize clutter, updates to each scenario will simply be added on to the existing story rather than posted as separate chapters.

These cases won’t all be interesting or emergent or in any way unusual; many will simply be standard EMS fare. They’re based on reality, but they’re fiction, and debriefing discussions will be short and to-the-point. Over time, as you play our little game and slog through call after call, you’ll hopefully start to develop something suspiciously like experience. It won’t be the same as really working out there… but it’ll be closer than the textbook.

Make no mistake, this is intended for new folks. The truly green EMT fresh out of class without any experience needs this type of drilling, and it’ll bring him much closer to functional competence prior to the day he puts on his first uniform. Experienced providers may find this suspiciously like, well, work, but they’re still encouraged to play along and lend a grizzled voice.

The first scenario is up now. Take a look, let us know what you think, bear with any initial rough edges, and stay tuned for more!

Live from Prospect St: The Big Crunch (conclusion)

Continued from part 1 and part 2

 

In the end, all three patients receive spinal immobilization. You transport both pediatric patients to Bullitt Medical Center; the P12 assumes care of the mother and transports her to the same destination. No significant injuries are found upon follow-up assessments; however, when the P12 checks Samantha’s blood glucose, they find it to be 32 mg/dL. They administer D50, normalizing her sugar, which improves her level of consciousness; however, she remains confused and becomes somewhat combative. She does endorse substantial alcohol ingestion, is somewhat unclear on drug use, and continues to deny a history of diabetes.

After transferring care, both crews fill out state-mandated documentation to report child abuse, with regard to the mother driving two young children while under the influence and without appropriate car seats or other restraints. You write your documentation with extra caution, aware that it may eventually be used in a court of law.

 

Discussion

This was a case where no patient was highly acute, but operational issues required some attention and medical confounders obscured the assessment.

 

General considerations for MVAs

With any significant MVA (or MVC for “motor vehicle collision,” since the DoT takes the position that nothing is truly accidental), there are several factors we should consider:

  • Scene safety. Wherever the scene may be, it’s generally at or near a roadway, and it’s a location that’s already proven itself accident-prone. In this case, we were situated in a truck yard somewhat off the main road. If it were a busier area, and we were first to arrive, we would want to park the ambulance to shield the scene from traffic, and request fire apparatus (for more blocking) and police (for traffic control). We should also consider the presence of chemicals or other hazardous material in an industrial area, which was not a problem here.
  • Extrication. The time to request additional resources is early. Heavy extrication, where vehicle frames need to be bent or cut, is usually performed by fire department ladder trucks or dedicated rescue apparatus; in this case, the driver’s door was dented and needed to be popped open (technically “confinement” rather than “entrapment”), and it was handled prior to our arrival.
  • Cause. Some accidents happen for obvious reasons, such as inattention. Sometimes they’re due to conditions, such as weather or visibility, which is a good clue that such conditions probably persist and might endanger you as well; protect the scene and be cautious during extrication and transport. Sometimes, accidents have a medical cause, which was the case here.
  • Damage. We are clinicians, not mechanics, but vehicle damage can provide clues to injury type and severity. Modern vehicles often develop horrific-looking body damage while yielding minor personal injury; automotive safety science has become quite advanced, and a large part of a car’s protection comes from intentionally crumpling to absorb impact. If occupants are restrained, the vehicle can easily eat up a large amount of shock without anyone suffering significant harm. In this case, we saw a front-left impact at seemingly moderate speed, so we anticipate a head-on type injury pattern with some lateral energy. Damage to the driver’s-side lower dashboard area, plus minor knee injury, suggested a “down and under” rather than “up and over” direction of movement, which is typical for a restrained driver; the windshield was also missing any apparent point-of-impact, which supports this. With the seatbelt and airbag, we were not too suspicious of frontal head injury, but we did look for evidence of lateral head impact against the window or side-wall; we found no obvious head trauma or internal vehicle damage. There was likewise no signs of internal impact from the children in the rear, although we remain suspicious of pelvic or abdominal trauma, since they were wearing lap belts without any torso restraints.
  • Number of patients. Life was made easier by the truck driver, who was obviously unharmed and decided to elope from the scene prior to our arrival. Samantha was making vague reference to her brother, but it seemed that he was coming to meet her and was not an occupant. It is somewhat bad form to forget about people, so it’s good to try and confirm these things, and the first-in responders (the fire department in this case) can help.

 

Assessment

Just like in most cases, the majority of essential information was communicated in the first few seconds on scene.

Our eyeball exam from twenty feet was enough for an initial assessment on the kids. The Pediatric Assessment Triangle is a model for identifying pediatric life threats that focuses on obvious, big-payoff findings rather than details (like specific vital signs) which can be tough to measure. The three components are:

  • General appearance. This is overall impression and rough neurological status. Are they conscious? If so, sluggish, alert, groggy, engaged with their surroundings, tracking with their eyes? Is there any muscle tone or are they limp? Are they crying? If so, are they consolable? Do they look sick or well?
  • Work of breathing. This is respiratory assessment. Is the child struggling to breathe? Are they tripoding or assuming a sniffing position to maintain an airway? Is there accessory muscle use, pursed-lip breathing, nasal flaring, chest retractions? Are grossly adventitious breath sounds audible (i.e. wheezing, stridor, grunting, snoring)?
  • Circulation. This is general circulatory status. Is skin pink and warm? Is there clear cyanosis, pallor, mottling? Obvious bleeding?

From the first moments on scene, we were able to observe that the pediatric patients were: conscious, crying loudly (therefore with a patent airway and adequate breathing), generally unhappy but not acutely distressed, without obvious bleeding or other trauma, and with normal skin signs. That’s plenty for the initial triage — a more full assessment will come later, but it’s unlikely that we’ll uncover any true life threats.

How about mom? We initially notice no obvious issues except for an altered mental status, which may be masking other problems (such as pain or neurological deficits). We also don’t know the cause of the AMS. Is there alcohol involved? Probably: she directly endorsed this. Drugs? Perhaps: vehemently denying drug use is not uncommon in drug users, and there were purpura consistent with needle “track marks” on her arm. But even if present, neither of those precludes a concomitant traumatic head injury; drunk and high people can bump their head too. And we were reminded of the first rule of EMS: everybody is diabetic. Although the circumstances didn’t necessarily suggest hypoglycemia as the most likely cause, it fit the presentation, and all drunk patients are somewhat at risk for this complication. If she’d stayed in our care, glucometry would have been wise during transport.

Is spinal immobilization needed? Local protocol comes into play. The children are probably low risk. The mechanism as a whole is potentially risky, due to the possibility of side-on energy transfer and head injury, but generally is not too alarming and the assessment findings are fairly reassuring. In the case of the mother, she is the classic example of a poor reporter who cannot reliably describe neck or back pain or participate in a neurological exam; most selective immobilization protocols (such as NEXUS or the Canadian C-spine rule) would advise immobilization in such cases. In this instance, due to equipment shortcomings, one child was immobilized via KED and the other two patients immobilized to long boards, with towel rolls used liberally. The children were liberated almost immediately after arrival at the ED, after a clinical exam by the pediatric emergency physician. The mother began fighting her board after she was roused with D50.

 

Transport and documentation

This case highlighted the need for intelligent patient assessment to guide transport destinations. Although low-acuity pediatric patients can sometimes be assessed in an adult ED, it depends on the receiving physician’s level of comfort, so in many cases they’ll prefer to transfer them to a specialty center (and any time a patient has to be transferred from where we brought them, we’ve failed them somewhat).

In a similar vein, acute patients needing surgical intervention should always be delivered to trauma centers. Does mom need a trauma center? Since we’re unable to rule out a traumatic cause for her mental status, it’s probably wise, although perhaps not essential. Do the kids need a pediatric trauma center? Probably not; they are, by all appearances, doing fine. Finally, although we could transport parent and kids to different hospitals, it would be distressing to everyone and create logistical headaches (involving consent, billing, and other concerns), so Bullitt Medical Center (an adult trauma center as well as a pediatric ED, although not a pediatric trauma center) is a sensible destination. (Since it’s a larger hospital, it’s also more capable of sustaining the “hit” of receiving three patients simultaneously than a small community ED.) Since the mother is a more challenging patient, it makes sense for the paramedics to take her while our BLS unit acts as a bus for the kids.

As for documentation, depending on state law we may be required to report all instances of child abuse to protective agencies. (In this particular region, reporting is mandated for any child or elder abuse.) If so, local procedures should be followed; although the hospital will most likely perform such reporting as well, in many states this does not absolve EMS of its own responsibilities.

When documenting the call, be aware that charges may be pursued against the mother for neglect, driving under the influence, or other offenses. These may hinge upon your documented findings, such as altered mental status, lack of appropriate child restraints, or statements about substance use. Depending on local laws for mandated reporters, you may be required to report these findings directly to police, or you may actually be prohibited from doing so by HIPAA laws; in either case, however, they should be noted in your report.

Live from Prospect St: The Big Crunch (part 2)

Continued from Part 1

Since the two children appear generally intact, you ask your partner to evaluate them more fully while you head for the sedan to find the driver. Anticipating three transports, two stable and one potentially critical, you ask your dispatch to continue the P12, and also to ensure that police are en route (they are).

Arriving at the sedan, you find a middle-aged woman in the driver’s seat, alert. She is pink and warm, perhaps more diaphoretic than you’d expect for the ambient temperature, and does not initially notice as you kneel beside her. A firefighter is holding C-spine immobilization from the back seat.

When you greet her and pat her on the shoulder, she gives no response, but with more vigorous stimulation she looks over and acknowledges you distractedly. With multiple attempts and some yelling, you’re able to get answers to a few questions, but she is slow, tangential, and often ignores you outright. She gives her name as Samantha, but cannot or will not provide her last name; she is unable to describe the events that led to the collision; and she gives no medical history or current medications. She does state several times that she’s fine and would like to leave. When asked about her passengers, she mumbles “my kids” and mentions her brother several times. She endorses pain when asked explicitly, but does not specify where. She agrees that she drank “a little” alcohol; when asked about any drug use, she denies it vehemently.

Physically, she appears generally unremarkable. She is breathing somewhat shallowly but effectively, and her radial pulse is around 100 and slightly weak. Her seatbelt is not in place, but it’s unclear whether it was removed at some point. No gross trauma is apparent upon her head, face, or neck, and she does not complain or grimace upon palpation. She is uncooperative with a neurological exam, but demonstrates spontaneous movement of all four extremities. Her pupils are equal and seem appropriately small on this moderately bright day. Chest rise is generally equal and her abdomen is supple; no bruising consistent with seatbelt injury is visible. Her left knee is abraded and somewhat swollen. A sprinkling of dark blotches and streaks are noted on her left ventral arm in the antecubital region. Both frontal airbags are deployed; the windshield is cracked, but lacks a “starred” point of impact; and the plastic dashboard in the driver’s knee area is damaged and cracked. No blood or other damage is visible in the interior compartment. There are no child seats.

Your partner comes over. “The kids seem fine, just upset. One’s complaining of some abdominal pain, but it looks okay. They’re little troopers. Fire says they were wearing regular lap belts with the shoulder strap tucked behind them.”

When you wonder aloud whether there are more patients, he says, “There was nobody else in the car when fire arrived. The truck driver gave a statement to the police about how she was swerving across the road and plowed into him, but then he eloped.” He looks over your shoulder. “Oh, and the P12 is pulling up now.”

 

What is your treatment plan for these three patients? What are their respective priorities, any points of concern, and how could you shed additional light on their status?

Who will transport which patient, and to which destinations?

What special considerations should be made during documentation?

 

The conclusion is here

Live from Prospect St: The Big Crunch (part 1)

It’s 4:00 PM on a gloomy Friday in Chandlerville, and you’re the technician for the A2, a dual-EMT, transporting BLS unit dedicated to the city. Chandlerville is a small town, but densely populated, and its numerous industrial districts are frequent sources of work. 911 dispatch is directly through the fire department, which also sends a BLS fire apparatus to assist on all medical calls; your company’s ALS is also available by request. You are equipped with finger-stick glucometry, glucose, aspirin, and epinephrine.

After a “man down” call that ended in a patient refusal, you’re now returning to quarters. Just as you’re beginning to back into the garage, a tone sounds.

Engine 3 and Ambulance 2, respond to 2108 Coastal Rd, the Empire Shipping Company, for an MVA. That’s two-one-oh-eight Coastal Road, in front of Empire Shipping, for an MVA. Engine 3?

“Engine 3 is responding.”

Ambulance 2?

As your partner flips on the lights and pulls out to the street, he speaks into the radio: “Ambulance 2 has 2108 Coastal Rd.”

Time out 16:01.

Coastal Road is a long connector that wraps around the edge of town, and you glance at the map book to confirm that the 2000 block will be near the very end, about as far away as you can get in Chandlerville. Engine 3 is stationed in that district, however, so they arrive within minutes.

“Engine 3 to Firecom.”

Firecom answering.

“We’re off at 2108 Coastal Road. Two-car MVA, car versus truck. Multiple injured parties and entrapment. Start an ALS unit and a ladder for extrication.”

Engine 3, you have a car versus truck, multiple injuries with entrapment. Break. Ladder 3, respond to 2108 Coastal Rd for the MVA; Engine 3 is on scene and A2 is responding. Time out 16:04.

A few seconds later, your company radio dispatches Paramedic 12 to the same address, after Chandlerville Firecom contacts them via landline. The P12 starts responding, but they’re coming from two towns away, with an ETA of 10+ minutes. The field supervisor also starts rolling from an unknown location to assist. 30 seconds later, Engine 3 updates that they have an injured adult and several children.

Now very awake, you reflect that the nearest hospital will be Chandlerville Memorial, a 3–5 minute emergent transport (10 minutes otherwise). The nearest large tertiary center, Bullitt Medical Center — a Level I adult trauma center and a designated pediatric ED — is 15 minutes emergently (25 otherwise). The nearest Level I pediatric trauma center, however, is the Children’s Hospital, which is also 15 minutes but in the opposite direction; they do not receive adult patients.

Ladder 3 arrives on scene momentarily, and you pull up a few minutes later. As you park and call yourself out, you observe a Ford sedan with its front left corner smashed in, two feet of its fender and frame crumpled. This is evidently the result of driving almost headlong into the side of an 18-wheeler. It appears that the driver swerved right to avoid the truck, undercutting its rear wheels and “submarining” itself; the damage reaches the passenger compartment, but there does not appear to be significant intrusion. The truck itself seems minimally damaged.

As you jump out, a firefighter waves you down. “We’ve got three!” he announces. “Mom’s in the driver’s seat; she seems really loopy, probably drunk. Her door is just dented, we popped it open. But her kids are over there.”

Twenty feet away, you see two young girls, around 4 years old, each in the arms of a firefighter. They are crying loudly and clearly upset, with no visible injuries. The mother is hidden from sight in the sedan. The driver of the truck is nowhere to be seen.

 

What are your initial steps for addressing this scene?

Who appears to be the first priority for care?

What resources will you need? Which, if any, should you cancel?

 

Continued in part 2 and the conclusion

The “Big Picture” Diagnosis

Our topic for today: diagnosis using a broad constellation of indicators, not a single red flag.

To mix things up, rather than read about it, let’s talk about it.

Here’s the quote I mentioned, from TOTWTYTR at the CCC blog.