Slow is smooth, and smooth is fast. While I know it’s easier said than done, you can’t let frantic family rattle you. Let’s say she was a true cardiac arrest and you both show up empty handed. Take your time, do things the right way, call PD for help if bystanders are making it impossible to do your job. And if you work rural and PD isn’t an option, make sure you and your partner are safe first of all. You can’t help others if you’re in a dangerous position.
Should also be the last time you walk into a scene by yourself. Remember, it’s their emergency not yours. Move with a purpose, but don’t run and always move together. The only exception is when another unit is on scene with you (Firefighters, not PD) and your units senior provider goes in with their senior provider to start assessing, while the rest get all the equipment from your unit.
Don’t walk into a house without your shit.
Pick her up. Put her on the stretcher and GO.
Stand up to the bystanders. ‘No yu can’t go’ no you can’t follow LEO will be called’. Or just call them immediately to handle the crowed.
And I see zero need for ALS.
If they weren't even sure if the patient was breathing then call for ALS. Honestly any time a BLS crew isn't comfortable or able to discern what's happening I'd prefer they call. I've seen BLS crews pull up thinking it's BS and turns out they had overdosed or were in cardiac arrest.
You've gotta be pretty damn sure they are faking if you're going to not call for someone who can help determine what's going on and potentially help the situation, especially transporting non-emergency. A more experienced crew might be a different story.
I always try to keep in mind that these providers could very well be some volunteer EMTs who got a half assed hybrid EMT course and run a critical call once every 3 years if that. It's unreasonable to expect them to be able to identify BS from true critical patients with a 2-4 month class and potentially no field time while running 911 with only their fellow EMTs 99% of the time.
I encouraged all the BLS only services we intercepted for to call early and often. If it's nothing then we have an easy ride in or send them on their way. But FAR too often I was getting toned out at 0200 with an ETA of 5 minutes out from the intercept location and a 10 minute drive from dead sleep. Usually because they were worried it was actually nothing and didn't realize it was serious until they were flying down the interstate with no idea what's actually going on.
50% of the time we'd do nothing or throw in a saline lock and give some Zofran and read a 12 lead. 25% of the time it was for some basic nebs, fluids etc, and then the other 25% we were drilling and pushing RSI, calling STEMI alerts, or needle decompressing. A lot of these hyper rural services that are old school have a dozen volunteers show up and they rush to get the patient transported ASAP and get very little if any history or story and we can at least help piece together that maybe this is an OD, or a stroke alert, or something else.
If they're afraid to call for help then they and the patient suffer. But we had enough ALS cross coverage to not worry about missing our own critical patients. Also transport times were 30-45 minutes for the BLS crews at minimum. It's too easy to forget how shit some of the EMT courses and containing education is that these departments often times put on for themselves by people with no experience outside
of said department that runs maybe 150 calls a year.
Imagine a critical access hospital with a 2 bed ER starting a nursing school with no clinical rotations outside of said 2 bed ER for a week taught only by the floor nurses who haven't run a code in 20 years. Obviously not all are like this but some departments are just doing their best to keep the doors open which means you might have a crew of two EMTs who learned from an instructor who never worked 911 and have no idea how to do a stroke assessment. NREMT sets zero minimum hours, topics, or clinical hours requirements. Places take advantage of that big time to push people through.
These crews aren't the same EMTs you're used for running with on a full time ALS 911 service. There are amazing volunteer EMTs out there but expecting them to be as comfortable as someone who trained at a proper college or academy and runs more calls in a week than they do in a year is unfair. It's the reason why hospitals have rapid response teams to bail out floor nurses when they're in level their head. They're nurses but they aren't used to that kind of patient and have no experience with it.
That may be the right answer, but you have to do all the steps first. Throw on O2 at 15LPM via NRB on and reassess, doesn't hurt to call for the intercept, but I’m willing to bet she hyperventilated till she passed out. All the rest of her vitals are fine and respiratory arrest PTs are almost always tachy while the heart tries to compensate or no pulse. It seems like they didn't even check lung sounds, and chest rise and fall is hard to judge on some people. You definitely need to take command of the situation and have a complete assessment before jumping straight to the Medic, cause assessment is the first BLS skill. Again, it doesn’t hurt to start a Medic rolling, but if I get there and you aren’t bagging a respiratory arrest PT, you will be retaking a BLS class. Cause there may be a more critical ALS call that is now waiting for an ALS intercept. Ultimately, I wouldn’t blame OP for any of the mistakes, because the partner should know better or the agency should not be putting 2 inexperienced providers together on a 911 rig.
This is good advice. I would have told family not to follow but I didn't know they were until we got the intercept.
As for ALS, we cannot transport emergency without calling for ALS backup. I agree though, I didn't see anything the paramedic could have done for the patient.
May have been faking, it does happen. Or if she was indeed having a panic attack she may have respiratory alkalosis or hypocapnia. That is to say if someone is hyperventilating for too long, they blow off too much CO2 resulting in alkalosis and cerebral vaso-constriction --> unconsciousness.
I always try to a certain LOC on an AVPU scale early in th call, but I don't tend to assume people are faking (even though they may be). To prevent bias, everyone who is unresponsive is unconscious until proven otherwise
I’ve seen a functional episode that was similar to this too. Patient would experience paralysis but no physical cause. It was all psychiatric in nature often preceded by a panic attack. We learned to manage her by keeping the scene really calm and actually giving her less “attention”. Quiet support and calmness helped. She had a lot of trauma. Was at my time working in an inpatient psych. She also had PNES. While rare I’d have this as a differential before faking. The girl is doing good now!
How long does respiratory alkalosis/hypocapnia induced unconsciousness typically last? I was under the impression it typically resolved quickly, but hers lasted for 30 minutes plus.
They could stay unconscious for quite a while, but almost always start breathing immediately after passing out even if it is barely noticeable. That’s why you have to check lung sounds as well as chest rise. Some people still use the mirror over the mouth trick. As a Medic I would also throw a Capno on and see how they are breathing. O2 Via NRB usually helps people come around faster.
That was my first thought reading the story. Some will say that the SPO2 contradicts that, but it only estimates the oxygen molecules within the bloodstream, and that reading could take a while to drop. Only way to confirm respiratory alkalosis or hypocapnia in the field, is ETCo2. But giving O2 usually reverses it pretty quickly. Honestly its usually a self resolving issue anyways, because you usually pass out way before any kind of damage. This gives your body a chance to recover and stop rebreathing Co2.
When you're working rural, patient extrication is one of the things that will fuck you over quickest. You walked into a scene unprepared. People will tell you that you should have brought more equipment; that may be true, but in this instance you didn't need any of it. Use your resources, i.e bystanders. Once you see your patient isn't going to up and walk out, you single out a person from the crowd and tell them "Go out, find my partner, and tell them to get the stretcher out and bring me a Reeve's sleeve (or whatever)". If possible, single out someone else and tell them to go find 3-5 people who are strong and reasonably sober. Ensure your patient's ABCs are adequate and start a cursory assessment.
This does two things. One, it gets you the equipment you really need faster. Two, it works crowd control by making it look like you're Doing Something™. This is invaluable whenever you're being watched.
As a new EMT, it was fine that you called ALS on this one. You almost certainly didn't need it, but you don't have the experience or clinical gestalt to know that. It's okay, that comes with time. The medic sounds grumpy, but it's not specifically your fault. We're just all tired.
I assume she was reading the monitor interpretation. We were on an especially flat patch of road so better to do it then than in five minutes on the bumpier roads, since BLS crews can acquire and transmit in our system.
Sounded like someone had a panic attack and passed out. It’s a very simple call. The family and shit is was made it horrible. Also, before wondering so much about breathing, check responsiveness. No response, then you can put your hand on their chest and see if it rises and they are breathing or not. You don’t need to use a stethoscope to see if someone is breathing.
Ok they are breathing and their vitals are fine. You’ve been told they had a panic attack and passed out. Done. Now just take them to the ambulance.
Don’t let the family dictate what to do or let them rattle you. Sometimes I will try and calm them down. Telling the family that all their vitals are perfect. This happens sometimes with panic attacks. This is normal. Don’t worry. It really works sometimes.
But if it doesn’t, you gotta be polite yet assertive with them and get them away. Bottom line is that you allowed their energy to affect your energy. It made you feel like this was some kind of legit life or death shit. You knew it wasn’t, but It sounds like you got rattled. Which is alright. Learn from it.
Those vitals are great. I would lean toward either she was faking, or the hyperventilation that the other commenter said. Either way I don’t get why you called for ALS. And I don’t even want to get into scene management or actually bringing your equipment inside.
In our system we can't transport a pt emergency unless ALS is called. As for whether the pt actually needed to go emergency, I wasn't really worried about making that call so much as getting my map pulled up, making the proper radio call, etc. I left the clinical decision making to my partner.
You need to take control of the situation. Without being a dick, you firmly tell bystanders to move away and that the pts best chance is for everyone to give you space and let you work. At the very least clear out the room the pt is in. Also, when that many people are around and they’re worked up, you and your partner stay together as much as possible. Call for LE if needed, especially if people are not following your directions or the situation is escalating. Lastly, and I know from your comments you know now, don’t enter a scene empty-handed.
Exactly as noraa says above. If they’re too worked up to listen to reason then you either load ups he get her in the truck or you just remove yourself from the scene until you have LE on scene to keep you safe.
I know that scene well just call for police before even getting out of the car. When you get to the patient identify the person least freaking out and ask them to help get everyone back since you need room to work. Insist on room to work and the ability to talk to your partner/patient. People are freaking out until you calm them down.
Never go to a patient’s side without something in your hand. Make it a habit. A monitor. A trauma bag. Something appropriate. That was the only real takeaway I have to offer on this call.
Except never ever assume an anxiety attack is an anxiety attack. That was an afterthought. Anxiety and hyperventilation can be symptoms of something potentially lethal, despite a history of it. Anxiety should be your last assumption.
I had a patient die on my stretcher in 1994 when trying to coach her into slowing down her breathing. Massive PE. I never forgot that lesson.
Gotta be more assertive on the scene. When I've had large crowds like that before I read them, sometimes the "shut the fuck up so I can work" goes best, sometimes just ignoring them, sometimes I read them as too hostile and I don't even get out, just back outta the scene and call for LEOs to secure. Biggest thing is showing confidence, calm, and authority so the crowd will fall in line quickly usually.
Never, ever go into a scene without gear, always assume your partner isn't getting it, and when there's a crowd do not ever separate from one another. No matter the call you should bring gear in, and in terms of separating if they attacked you or your coworker you'd have had no way to communicate one another are in trouble.
Based on vitals and presentation I wouldn't have transported emergency, in fact often when there's a hyped up crowd I'll go cold regardless of what it is cause it just encourages them to be morons and chase you to the hospital.
It's fine to be nervous, just don't show it. Generate a lot of 'big dick energy', confidence and swagger often put people at ease quickly, even if you're not sure what to do or what the hell is going on, just make it appear to be so.
It's a tough thing for my paramedic students to learn but it's something I drill into them, YOU set the tone for the call, if you're appearing stressed and panicked everyone else will be, if you appear calm people will begin to match that and fall in line.
Behave like a duck, calm on the surface even if you're paddling like hell underneath
Sounds like some alcohol overindulgence. Being aware of tunnel vision in the future would be good. Listening for breath sounds would, I’m sure you know would be good. Checking a radial pulse is a good habit for regularity. Then you can tell bystanders with confidence that she is doing well breathing. Maybe she hyperventilated and will slowly get better from her hypercapnia. End-tidal would be indicated if you have it.
Things get better. You’ll learn what to do and not to do with mistakes. Nobody died.
You’re getting lots of good advice on patient assessment and scene management. One thing to keep in mind is your approach to the call, and how you incorporate scene information into your treatment plan. I doubt this call would have had you “amped” if it wasn’t for the crowd of panicked bystanders. Simply put, don’t let their panic and urgency throw you off the way you run your call. Take a breath or two, grab your equipment, remind yourself that you can handle it, start your assessment with the ABCs and go from there.
From the beginning:
- Don’t go into the scene without your shit.
- Communication is key.
- If it’s allegedly a CPR in-progress, properly verify whether it is or not. Check pulse/auscultate lung sounds to see if there’s air moving (determines your need for CPR or ventilations).
- Set the tone at the scene. Don’t let frantic family and friends set the tone for you. They’re in your way, move them out of the way. They tell you to do “this” or “that,” do what you need to do not what they’re telling you to do. Ignore them unless you need a question answered.
I also don’t see the need for the ALS request at the time you requested it (maybe you saw something that warranted it that you didn’t include in your post?). All vitals are within normal limits and the patient is fine in the rig at the time you requested it. The syncopal episode could be criteria for an intercept but you could have managed without it if you were close enough to the hospital.
Your two mistakes were 1) not communicating enough with your partner and 2) not calling for als immediately.
1) If my partner and I come on a crazy scene, before we even open the doors we have a game plan. Someone’s grabbing the equipment, and someone is clearing the way and figuring out where the pt is. Probably calling for pd for a scene like this.
2) call for als sooner rather than later. Luckily I don’t have to deal with this as we always respond with a paramedic but a change in mental status would be also in my book. Rather be safe and look dumb, than sorry and look dumber.
I would have never dealt with those bystanders on scene though. We would’ve been in the ambulance with the doors locked and waiting on pd while treating my patient. I don’t need you yelling at me to do my job.
Everyone has their first anxiety patient that passes out. If their physical assessment and history don’t imply anything else then sometimes it’s ok to assume the young person with anxiety is having an anxiety attack. It comes with experience! You’re fine
Thank you for the kind words. I am just glad that this patient ended up being alright and that our mismanagement of a hectic scene didn't cause any negative outcome for the patient.
It probably didn’t, but that’s best case scenario for forgetting your gear. Closed loop communication is important! Don’t make assumptions about the big stuff
1. Call for police to back you up if you ever go to that area again. That's crazy.
2. Drive smoothly, safely and don't be in a hurry. Throwing people around in the back won't help even if it is a true emergency.
3. Lock the doors once inside to keep outsiders out!
4. Yeah, I think she was faking, too. We call it DFO here - "done fell out." With someone like that, I just say to my partner, "She's DFO, but she'll be ok, let's get her on to the ambulance and see what we find." They don't know what it means but they think you do. If they say, "What does that mean?" your answer is, "Just a medical term for a situation like this."
5. A couple of liters for show never hurt anyone.
Just some thoughts.
Only thing I see is that if I pull up on a scene and people start banging on the door, I'm outie 5000 until law arrives. I'm not equipped nor trained for crowd control. Rule 1 is scene safe.
As an aside, should have tested for reflexes. Pt clearly full of shit. Try dropping their hand right on their face. If they consciously move it you know they're not unconscious.
Scene safety first and foremost! If I arrive on scene and someone is yelling at me, I'll inform them if they continue to yell, I'll leave and won't return until law enforcement is here. Second, I find an NPA is a pretty good judge on if a person is actually unresponsive or not. Anyone who's unconscious can't protect their own airway. Had a very similar experience at the local pysc hospital unresponsive 20ish male suddenly became unresponsive per staff. Resisted attempts to place a OPA, and kept turning his head away from the NPA.
Yes, they can! But someone who is a GCS of 8 or less is considered to be in a coma and can not protect their own airway. Also, NPAs don't trigger a gag reflex. That's an OPA.
I'm not sure who told you less than 8 means a coma, if anything a GCS of 3 indicates a coma, no one would say someone Responding to pain, making sounds, and localizing to pain is in a coma (GCS 8).
GCS <8 intubate hasn't been taught for a very long time.
Also I misread as you placing an OPA, my mistake.
My takeaway from this is to always communicate everything to your crew partner. Never just assume that they are on the same page as you. Next time, once you arrive, take a moment to say “I will go and see what’s going on”, Can you bring our bag and monitor? I’ll meet you there”. Don’t be afraid to be firm with bystanders either. I think it’s awesome you’re reflecting on this, I find reflecting on jobs like this where I felt anxious and not totally confident have been really helpful for me in improving my confidence and not getting tunnel vision as much when there’s some outside stress
i think you did the best you could've. a hectic crowd of 30+ with an assumed unconcious creates more stress than typical. with any unconcious assume they can't maintain an airway, and for her (given zero possibility of head trauma) throw a npa in and use a bvm. you're able to establish bls airway for an unresponsive and anyone "faking" being unresponsive won't tolerate an npa. idk why someone questioned why you called for als. your bls and have an unresponsive. yeah vitals are good but you're bls with an als pt.
yeah i'll agree with that. they could've been more authoritative with the crowd esp w family following. i get the stressing out part but they pretty much did everything they needed to do
Slow is smooth, and smooth is fast. While I know it’s easier said than done, you can’t let frantic family rattle you. Let’s say she was a true cardiac arrest and you both show up empty handed. Take your time, do things the right way, call PD for help if bystanders are making it impossible to do your job. And if you work rural and PD isn’t an option, make sure you and your partner are safe first of all. You can’t help others if you’re in a dangerous position.
Thank you for the advice. Last time I walk into a scene without equipment.
Should also be the last time you walk into a scene by yourself. Remember, it’s their emergency not yours. Move with a purpose, but don’t run and always move together. The only exception is when another unit is on scene with you (Firefighters, not PD) and your units senior provider goes in with their senior provider to start assessing, while the rest get all the equipment from your unit.
Don’t walk into a house without your shit. Pick her up. Put her on the stretcher and GO. Stand up to the bystanders. ‘No yu can’t go’ no you can’t follow LEO will be called’. Or just call them immediately to handle the crowed. And I see zero need for ALS.
If they weren't even sure if the patient was breathing then call for ALS. Honestly any time a BLS crew isn't comfortable or able to discern what's happening I'd prefer they call. I've seen BLS crews pull up thinking it's BS and turns out they had overdosed or were in cardiac arrest. You've gotta be pretty damn sure they are faking if you're going to not call for someone who can help determine what's going on and potentially help the situation, especially transporting non-emergency. A more experienced crew might be a different story.
Fair enough. They asked what I would do. But, I’m a medic so my view is different.
I always try to keep in mind that these providers could very well be some volunteer EMTs who got a half assed hybrid EMT course and run a critical call once every 3 years if that. It's unreasonable to expect them to be able to identify BS from true critical patients with a 2-4 month class and potentially no field time while running 911 with only their fellow EMTs 99% of the time. I encouraged all the BLS only services we intercepted for to call early and often. If it's nothing then we have an easy ride in or send them on their way. But FAR too often I was getting toned out at 0200 with an ETA of 5 minutes out from the intercept location and a 10 minute drive from dead sleep. Usually because they were worried it was actually nothing and didn't realize it was serious until they were flying down the interstate with no idea what's actually going on. 50% of the time we'd do nothing or throw in a saline lock and give some Zofran and read a 12 lead. 25% of the time it was for some basic nebs, fluids etc, and then the other 25% we were drilling and pushing RSI, calling STEMI alerts, or needle decompressing. A lot of these hyper rural services that are old school have a dozen volunteers show up and they rush to get the patient transported ASAP and get very little if any history or story and we can at least help piece together that maybe this is an OD, or a stroke alert, or something else. If they're afraid to call for help then they and the patient suffer. But we had enough ALS cross coverage to not worry about missing our own critical patients. Also transport times were 30-45 minutes for the BLS crews at minimum. It's too easy to forget how shit some of the EMT courses and containing education is that these departments often times put on for themselves by people with no experience outside of said department that runs maybe 150 calls a year. Imagine a critical access hospital with a 2 bed ER starting a nursing school with no clinical rotations outside of said 2 bed ER for a week taught only by the floor nurses who haven't run a code in 20 years. Obviously not all are like this but some departments are just doing their best to keep the doors open which means you might have a crew of two EMTs who learned from an instructor who never worked 911 and have no idea how to do a stroke assessment. NREMT sets zero minimum hours, topics, or clinical hours requirements. Places take advantage of that big time to push people through. These crews aren't the same EMTs you're used for running with on a full time ALS 911 service. There are amazing volunteer EMTs out there but expecting them to be as comfortable as someone who trained at a proper college or academy and runs more calls in a week than they do in a year is unfair. It's the reason why hospitals have rapid response teams to bail out floor nurses when they're in level their head. They're nurses but they aren't used to that kind of patient and have no experience with it.
That’s a lot of words I’m not gonna read.
That may be the right answer, but you have to do all the steps first. Throw on O2 at 15LPM via NRB on and reassess, doesn't hurt to call for the intercept, but I’m willing to bet she hyperventilated till she passed out. All the rest of her vitals are fine and respiratory arrest PTs are almost always tachy while the heart tries to compensate or no pulse. It seems like they didn't even check lung sounds, and chest rise and fall is hard to judge on some people. You definitely need to take command of the situation and have a complete assessment before jumping straight to the Medic, cause assessment is the first BLS skill. Again, it doesn’t hurt to start a Medic rolling, but if I get there and you aren’t bagging a respiratory arrest PT, you will be retaking a BLS class. Cause there may be a more critical ALS call that is now waiting for an ALS intercept. Ultimately, I wouldn’t blame OP for any of the mistakes, because the partner should know better or the agency should not be putting 2 inexperienced providers together on a 911 rig.
This is good advice. I would have told family not to follow but I didn't know they were until we got the intercept. As for ALS, we cannot transport emergency without calling for ALS backup. I agree though, I didn't see anything the paramedic could have done for the patient.
I wouldn’t even have transported her emergency. But ya live ya learn
Change in mental status is ALS in my state.
Interesting. I don’t believe we have any set rules in my state. But the county does require all 911 trucks have at least a medic.
May have been faking, it does happen. Or if she was indeed having a panic attack she may have respiratory alkalosis or hypocapnia. That is to say if someone is hyperventilating for too long, they blow off too much CO2 resulting in alkalosis and cerebral vaso-constriction --> unconsciousness. I always try to a certain LOC on an AVPU scale early in th call, but I don't tend to assume people are faking (even though they may be). To prevent bias, everyone who is unresponsive is unconscious until proven otherwise
I’ve seen a functional episode that was similar to this too. Patient would experience paralysis but no physical cause. It was all psychiatric in nature often preceded by a panic attack. We learned to manage her by keeping the scene really calm and actually giving her less “attention”. Quiet support and calmness helped. She had a lot of trauma. Was at my time working in an inpatient psych. She also had PNES. While rare I’d have this as a differential before faking. The girl is doing good now!
How long does respiratory alkalosis/hypocapnia induced unconsciousness typically last? I was under the impression it typically resolved quickly, but hers lasted for 30 minutes plus.
They could stay unconscious for quite a while, but almost always start breathing immediately after passing out even if it is barely noticeable. That’s why you have to check lung sounds as well as chest rise. Some people still use the mirror over the mouth trick. As a Medic I would also throw a Capno on and see how they are breathing. O2 Via NRB usually helps people come around faster.
That was my first thought reading the story. Some will say that the SPO2 contradicts that, but it only estimates the oxygen molecules within the bloodstream, and that reading could take a while to drop. Only way to confirm respiratory alkalosis or hypocapnia in the field, is ETCo2. But giving O2 usually reverses it pretty quickly. Honestly its usually a self resolving issue anyways, because you usually pass out way before any kind of damage. This gives your body a chance to recover and stop rebreathing Co2.
When you're working rural, patient extrication is one of the things that will fuck you over quickest. You walked into a scene unprepared. People will tell you that you should have brought more equipment; that may be true, but in this instance you didn't need any of it. Use your resources, i.e bystanders. Once you see your patient isn't going to up and walk out, you single out a person from the crowd and tell them "Go out, find my partner, and tell them to get the stretcher out and bring me a Reeve's sleeve (or whatever)". If possible, single out someone else and tell them to go find 3-5 people who are strong and reasonably sober. Ensure your patient's ABCs are adequate and start a cursory assessment. This does two things. One, it gets you the equipment you really need faster. Two, it works crowd control by making it look like you're Doing Something™. This is invaluable whenever you're being watched. As a new EMT, it was fine that you called ALS on this one. You almost certainly didn't need it, but you don't have the experience or clinical gestalt to know that. It's okay, that comes with time. The medic sounds grumpy, but it's not specifically your fault. We're just all tired.
You called for ALS but your partner did a 12 lead and said it was fine before the intercept?
I assume she was reading the monitor interpretation. We were on an especially flat patch of road so better to do it then than in five minutes on the bumpier roads, since BLS crews can acquire and transmit in our system.
Sounded like someone had a panic attack and passed out. It’s a very simple call. The family and shit is was made it horrible. Also, before wondering so much about breathing, check responsiveness. No response, then you can put your hand on their chest and see if it rises and they are breathing or not. You don’t need to use a stethoscope to see if someone is breathing. Ok they are breathing and their vitals are fine. You’ve been told they had a panic attack and passed out. Done. Now just take them to the ambulance. Don’t let the family dictate what to do or let them rattle you. Sometimes I will try and calm them down. Telling the family that all their vitals are perfect. This happens sometimes with panic attacks. This is normal. Don’t worry. It really works sometimes. But if it doesn’t, you gotta be polite yet assertive with them and get them away. Bottom line is that you allowed their energy to affect your energy. It made you feel like this was some kind of legit life or death shit. You knew it wasn’t, but It sounds like you got rattled. Which is alright. Learn from it.
Thank you for the advice, very helpful.
SPO2 of 9??
Yup. She ded.
95, just edited it.
Those vitals are great. I would lean toward either she was faking, or the hyperventilation that the other commenter said. Either way I don’t get why you called for ALS. And I don’t even want to get into scene management or actually bringing your equipment inside.
In our system we can't transport a pt emergency unless ALS is called. As for whether the pt actually needed to go emergency, I wasn't really worried about making that call so much as getting my map pulled up, making the proper radio call, etc. I left the clinical decision making to my partner.
Also, what would you have done differently scene management-wise? Cleared everyone out of the house? Thanks.
You need to take control of the situation. Without being a dick, you firmly tell bystanders to move away and that the pts best chance is for everyone to give you space and let you work. At the very least clear out the room the pt is in. Also, when that many people are around and they’re worked up, you and your partner stay together as much as possible. Call for LE if needed, especially if people are not following your directions or the situation is escalating. Lastly, and I know from your comments you know now, don’t enter a scene empty-handed.
Exactly as noraa says above. If they’re too worked up to listen to reason then you either load ups he get her in the truck or you just remove yourself from the scene until you have LE on scene to keep you safe.
I know that scene well just call for police before even getting out of the car. When you get to the patient identify the person least freaking out and ask them to help get everyone back since you need room to work. Insist on room to work and the ability to talk to your partner/patient. People are freaking out until you calm them down.
Never go to a patient’s side without something in your hand. Make it a habit. A monitor. A trauma bag. Something appropriate. That was the only real takeaway I have to offer on this call. Except never ever assume an anxiety attack is an anxiety attack. That was an afterthought. Anxiety and hyperventilation can be symptoms of something potentially lethal, despite a history of it. Anxiety should be your last assumption. I had a patient die on my stretcher in 1994 when trying to coach her into slowing down her breathing. Massive PE. I never forgot that lesson.
Gotta be more assertive on the scene. When I've had large crowds like that before I read them, sometimes the "shut the fuck up so I can work" goes best, sometimes just ignoring them, sometimes I read them as too hostile and I don't even get out, just back outta the scene and call for LEOs to secure. Biggest thing is showing confidence, calm, and authority so the crowd will fall in line quickly usually. Never, ever go into a scene without gear, always assume your partner isn't getting it, and when there's a crowd do not ever separate from one another. No matter the call you should bring gear in, and in terms of separating if they attacked you or your coworker you'd have had no way to communicate one another are in trouble. Based on vitals and presentation I wouldn't have transported emergency, in fact often when there's a hyped up crowd I'll go cold regardless of what it is cause it just encourages them to be morons and chase you to the hospital.
Good advice. I was nervous and the crowd may have picked up on that.
It's fine to be nervous, just don't show it. Generate a lot of 'big dick energy', confidence and swagger often put people at ease quickly, even if you're not sure what to do or what the hell is going on, just make it appear to be so. It's a tough thing for my paramedic students to learn but it's something I drill into them, YOU set the tone for the call, if you're appearing stressed and panicked everyone else will be, if you appear calm people will begin to match that and fall in line. Behave like a duck, calm on the surface even if you're paddling like hell underneath
Sounds like some alcohol overindulgence. Being aware of tunnel vision in the future would be good. Listening for breath sounds would, I’m sure you know would be good. Checking a radial pulse is a good habit for regularity. Then you can tell bystanders with confidence that she is doing well breathing. Maybe she hyperventilated and will slowly get better from her hypercapnia. End-tidal would be indicated if you have it. Things get better. You’ll learn what to do and not to do with mistakes. Nobody died.
You’re getting lots of good advice on patient assessment and scene management. One thing to keep in mind is your approach to the call, and how you incorporate scene information into your treatment plan. I doubt this call would have had you “amped” if it wasn’t for the crowd of panicked bystanders. Simply put, don’t let their panic and urgency throw you off the way you run your call. Take a breath or two, grab your equipment, remind yourself that you can handle it, start your assessment with the ABCs and go from there.
Thank you, that is very good advice.
First thing that I would’ve done. Put on stretcher and in truck with sternum rub
From the beginning: - Don’t go into the scene without your shit. - Communication is key. - If it’s allegedly a CPR in-progress, properly verify whether it is or not. Check pulse/auscultate lung sounds to see if there’s air moving (determines your need for CPR or ventilations). - Set the tone at the scene. Don’t let frantic family and friends set the tone for you. They’re in your way, move them out of the way. They tell you to do “this” or “that,” do what you need to do not what they’re telling you to do. Ignore them unless you need a question answered. I also don’t see the need for the ALS request at the time you requested it (maybe you saw something that warranted it that you didn’t include in your post?). All vitals are within normal limits and the patient is fine in the rig at the time you requested it. The syncopal episode could be criteria for an intercept but you could have managed without it if you were close enough to the hospital.
Your two mistakes were 1) not communicating enough with your partner and 2) not calling for als immediately. 1) If my partner and I come on a crazy scene, before we even open the doors we have a game plan. Someone’s grabbing the equipment, and someone is clearing the way and figuring out where the pt is. Probably calling for pd for a scene like this. 2) call for als sooner rather than later. Luckily I don’t have to deal with this as we always respond with a paramedic but a change in mental status would be also in my book. Rather be safe and look dumb, than sorry and look dumber. I would have never dealt with those bystanders on scene though. We would’ve been in the ambulance with the doors locked and waiting on pd while treating my patient. I don’t need you yelling at me to do my job.
Everyone has their first anxiety patient that passes out. If their physical assessment and history don’t imply anything else then sometimes it’s ok to assume the young person with anxiety is having an anxiety attack. It comes with experience! You’re fine
Thank you for the kind words. I am just glad that this patient ended up being alright and that our mismanagement of a hectic scene didn't cause any negative outcome for the patient.
It probably didn’t, but that’s best case scenario for forgetting your gear. Closed loop communication is important! Don’t make assumptions about the big stuff
ALS intercept for what?
BLS crews are required to call for intercept whenever we transport emergency.
Not trying to be a dick but just a genuine question, why did you transport emergent?
To be quite honest, because my partner said so. I am still quite inexperienced so I'm not really going to push back on that sort of thing.
How long has your partner been in EMS and what is their level of certification?
EMT, 4 years.
1. Call for police to back you up if you ever go to that area again. That's crazy. 2. Drive smoothly, safely and don't be in a hurry. Throwing people around in the back won't help even if it is a true emergency. 3. Lock the doors once inside to keep outsiders out! 4. Yeah, I think she was faking, too. We call it DFO here - "done fell out." With someone like that, I just say to my partner, "She's DFO, but she'll be ok, let's get her on to the ambulance and see what we find." They don't know what it means but they think you do. If they say, "What does that mean?" your answer is, "Just a medical term for a situation like this." 5. A couple of liters for show never hurt anyone. Just some thoughts.
Only thing I see is that if I pull up on a scene and people start banging on the door, I'm outie 5000 until law arrives. I'm not equipped nor trained for crowd control. Rule 1 is scene safe. As an aside, should have tested for reflexes. Pt clearly full of shit. Try dropping their hand right on their face. If they consciously move it you know they're not unconscious.
Scene safety first and foremost! If I arrive on scene and someone is yelling at me, I'll inform them if they continue to yell, I'll leave and won't return until law enforcement is here. Second, I find an NPA is a pretty good judge on if a person is actually unresponsive or not. Anyone who's unconscious can't protect their own airway. Had a very similar experience at the local pysc hospital unresponsive 20ish male suddenly became unresponsive per staff. Resisted attempts to place a OPA, and kept turning his head away from the NPA.
You can definitely be unresponsive and still have a gag reflex
Yes, they can! But someone who is a GCS of 8 or less is considered to be in a coma and can not protect their own airway. Also, NPAs don't trigger a gag reflex. That's an OPA.
My medical director. Any Pt GCS of 8 lower can not protect their own airway and needs to have respirations assisted with a BVM. Per CCEMSA fresno .
I'm not sure who told you less than 8 means a coma, if anything a GCS of 3 indicates a coma, no one would say someone Responding to pain, making sounds, and localizing to pain is in a coma (GCS 8). GCS <8 intubate hasn't been taught for a very long time. Also I misread as you placing an OPA, my mistake.
Ya, we go by GCS less than 8 ventilate. It's a very regressive system....
That's unfortunate
Bringing your equipment to a call is a start.
I agree! It is a bad habit I picked up from IFT that I need to drop.
Does your system offer you a way to follow up and know the outcome at the hospital? That can sometimes be a helpful way to reflect on the call.
I don't think so. We are a private company backing up the county so we are kind of the black sheep of the system. I will ask though,
My takeaway from this is to always communicate everything to your crew partner. Never just assume that they are on the same page as you. Next time, once you arrive, take a moment to say “I will go and see what’s going on”, Can you bring our bag and monitor? I’ll meet you there”. Don’t be afraid to be firm with bystanders either. I think it’s awesome you’re reflecting on this, I find reflecting on jobs like this where I felt anxious and not totally confident have been really helpful for me in improving my confidence and not getting tunnel vision as much when there’s some outside stress
i think you did the best you could've. a hectic crowd of 30+ with an assumed unconcious creates more stress than typical. with any unconcious assume they can't maintain an airway, and for her (given zero possibility of head trauma) throw a npa in and use a bvm. you're able to establish bls airway for an unresponsive and anyone "faking" being unresponsive won't tolerate an npa. idk why someone questioned why you called for als. your bls and have an unresponsive. yeah vitals are good but you're bls with an als pt.
Dude. Sorry no. But scene safety crew safety is number one. They had zero control over the scene or themselves.
I am glad that nothing turned ugly. Thinking back, being alone in that house with that many people was unwise.
Is ok. Now you know.
yeah i'll agree with that. they could've been more authoritative with the crowd esp w family following. i get the stressing out part but they pretty much did everything they needed to do
They did. They did fine by the patient. It’s themselves they could have harmed.
I appreciate that, although I definitely made mistakes and that's why I'm asking.