Transcript
Today's session, wanna welcome you to our critical decision points 2.0 webinar, and I have doctor Ronnie Harper today presenting on navigating initial presentation of head pain and neck I mean, chest pain in athletes.
Sorry about that typo typo in the in the title.
No.
I did that, Ray.
We're gonna we have these 2 separated out for recording purposes.
So
Okay.
Alrighty.
Good.
Okay.
Sorry.
That's all.
We'll get that.
So, anyway, critical decision points.
2.0.
This is a series we started the last back in 23 where it's the focus is on really high level engagement with the audience and would go through a would go through scenarios and the presenter does and ask key questions.
And give us a thinking that in those terms of the actual scenario versus a typical presentation on a topic, a case study.
So in this first one we've got, we're gonna work in all Doctor Harper's gonna work in on a 2 part series to date.
First is going to be on navigating initial presentation of head pain in athletes.
So without further ado, I'm gonna give this over to Doctor.
Harper, welcome aboard.
Thank you, Ray.
And if you haven't met me yet.
Ronnie Harper just retired from the day to day rhino being an athletic trainer somewhat 30 odd years, 23 of that in the hospital setting.
And so became very interested in emergency medicine back in college, and I got my EMT in 1983 when that was way back in the day.
And then 4 years ago, decided, hey.
Let's do this again.
And while did it change over over those few decades.
And then really in the last 10 years, emergency medicine has changed dramatically.
And so That's what we're trying to do.
We're trying to provide educational opportunities in order to help the practicing athletic trainer just be better in Emergency Medicine.
So we get started here.
I am a cofounder of Moss Moores Audition, but also heavily involved in actually local consultants, so there'd be no brand or equipment display that endorse.
This is what we're gonna do is is gonna be very practical.
So get ready because we're going to ask you some questions along this pathway of trying to applaud what we are learning in the other sections and just using our own basic knowledge in emergency medicine to to try to make application as we look at these critical decision points.
So we're going to look at patient assessment and we're going to look specifically at 2 elements of this patient assessment.
1 is seen size up, and number 2 is primary assessment.
That's as far as we're going on this session.
So just to remind you, just seeing size up and primary assessment will be our focus today.
So here we go.
This call comes in.
This is our story.
A street quote calls you, and he says, hey.
I've got a female athlete with a with a severe headache.
And she don't wanna move.
Of course, the first inclination is, can you bring her to the authority?
Train your room.
I am busy.
He says no, and then that's the look on my face.
That's not me, but that's the best I could find a look on my face to go, like, are you kidding me?
Like, I gotta get up.
And I gotta go to the can you just bring her hair?
Like, what happened?
You just got a bad headache.
Please come and get her.
So she won't get up and move?
No.
She won't get up and move.
Okay.
I'll be right there.
So grab a small med kit.
Who knows, just in case, doesn't sound too bad.
And then I grab one of my student aids and say, hey, come with me.
You never know.
Right?
So we take off, and we head to the weight room, and it is a building over.
So we got we got about about a 2 or 3 minute track to get over there.
So before we get over there, let's just use our framework here.
Inpatient assessment.
So we always have the preparation, and we call it minimal equipment check.
Right?
That is like, do I have the right kit Is everything?
And the kit working?
Is everything that I would ever need in that kit?
Do I have other kits on standby?
Do we know where they're at?
Do we are they stocked?
Nothing is more frustrating, then not being prepared, and then using what you've been trained to be used on, nothing more, nothing less.
So which we get that done, then we are going to evaluate the seed.
Like, what are we up against?
What are the call came in as a headache of a female athlete in the weight room.
Okay?
That didn't sound too traumatic.
So but we gotta we gotta run across a checklist.
Is this scene safe?
What's the mechanism of injury and nature of illness?
Is there any severe bleeding?
I'm not gonna need any more help.
That's just the mental checklist.
Right?
Then as we prop and get closer, we're really taking a look at, like, the primary assessment, which includes severe bleeding, circulation, airway breathing.
Looking for light threats, and is this patient compensating Right?
And then what interventions do we have to do?
So that's as far as we're going today, later on in this year, where we'll bring in the secondary assessment the additional patient management, but this is what we're looking at today, is what interventions are needed in this primary assessment.
So here we go.
We're Rob.
Here's an eighteen year old female athlete.
She's sitting on a weight room bench.
Then she says or or gives indication.
This is an credibly severe.
She didn't even overlap.
She can't even open her.
It's like it just hurts so bad.
Right?
Of course, there are other athletes still actively lifting weight.
So put yourself in that weight room here, the sounds, the smells, the energy.
This girl just got through doing an intense workout.
She just finished.
And now she sits down and says, my head is killing me.
And so that that's what we got.
That's what we're up You came with your med kit, you came with your student aid, you went two buildings over, you walk in, and this is what you'd find.
So you start.
Right?
And when you start, she says, first thing I wanna do is get her out there, but she says, I gotta lay down.
Don't lay down.
Get up.
Get up.
Come on.
Nope.
I can't go.
I'm about to throw up.
I'm so dizzy.
And so she lays down on the floor.
She don't wanna get up or staying.
So she lays down, and there we are with my female athlete, with a severe headache that says, I don't wanna move.
I can't move.
My eyes are closed, and I'm about to throw it up.
And So we're in a pickle now.
She's laying there, and we gotta continuously do our assessment.
So just a reminder, As a reminder, we're in the same size of mode.
We're not ready to dive just yet into total patient primary assessment.
We're still trying to process this scene that we entered in and you remember there are athletes who are still actively lifting weights around her as we began to try to manage this particular scene.
So this is your turn now.
This is your turn to to chime in in the chat as we before we dive into primary assessment and deal with the patient, we gotta process the same.
In the chat, what are your thoughts on major issues that you may encounter with managing this athlete in this weight room where other athletes are still actively lifting, is this scene safe?
And do we have the big picture?
So Chime in with me on this on this chat.
I'm gonna see if you're thinking like, oh, thank you.
Come on.
Put it in the chat.
What what other issues we have against.
Daniel, I like that injury to yourself.
Checkouts for broken blood vessels like that, but I was trying to clear out the weight room.
I Steven, now you're on the path I'm thinking is we gotta deal with this scene before we deal with the patient.
Right?
Like, we get all excited about dealing with the patient, but Steven indicates that, hey.
We got to clear out this this weight room.
So first of all, the danger is somebody is lifting around her, and you know bad things can happen in wait room, and it can turn really bad in a hurry.
So immediately before we lock in on this patient, we have to clear that weight room.
How much fun will that be?
Right?
How much fun will it be to clear out a weight room?
So you gotta find the adult in the room and say, I need this wait room cleared now.
And so it's gonna take a little bit of time, but at least you know, or you can designate somebody to stand over her are between her and the person that's about to do a £500 squat, right, or trying to do some some power clean and some some weight comes off and hits her in the head.
And then all of a sudden, we're we're we're in a we're in a bigger mess.
So so you have to get somebody to protect her and guard guard her while the adult in the room clears the room and not everybody wants to adhere, so he's gotta raise his boys.
And and clear them out.
And then do we want them walking by her?
No.
We want them going out another door.
So we got some logistics to do, and that's the point.
That's the point is we gotta we gotta manage the scene before we manage the patient.
So, Doctor.
Harper, I have a couple of questions, I guess, that may grow into this that we, you know, start to look at.
So, first off, this is is looking through this scenario, this from not to go off track on this, but actually had a case like this years ago, you know, about 8 or 10 years ago where high school track meet athlete.
The only problem was it hurt when they got the set up.
And just to go through the assessment, which I know you're the primary side, but I did the initial assessment.
Vinyls were normal, but there's a problem end up being shit at aneurysm.
So it was something that was kinda unique.
But anyway, going out of that.
So what are some some couple of questions I have or what are what are some basic assumptions do you are you making as you go like, you're moving from where you were into that way?
And what are some basic assumptions that you have or the audience may take into consideration next time they are in this situation.
I said, get a call, have a girl with a headache, and a wait room.
So the coach doesn't provide a lot.
Do she get hit in the head?
That's a possibility in a way running.
Was it does she have proper concussion.
I'm running through my head.
Does this girl or do we have a name?
Do do we have any kind of medical foul either in my head or on a piece of paper that I can bring with me.
But what are the typical injuries in a weight run?
I mean, they don't usually involve the head.
Specifically with an eighteen year old female.
So I'm thinking more trauma than I am medical when I first inner in the weight room.
So I'm preparing.
I got gloves on, you know, and I'm preparing for bleeding.
I'm preparing for some kind of contact That's my assumptions.
Okay.
What as you I guess, so in this scenario, you're envisioning this, what are what's your joint impression?
So you've you've assumed that without even knowing that.
But what's the like, once you walk in there, what are some of the what's your impression of what's going on.
So of the scene, talking about the scene, not the patient yet, because we're only processing the scene.
Right.
Let me clarify.
Of the of the scene.
Yes.
Of the scene is I see active weight lifting still going on.
They haven't stopped.
This girl is sitting on a bench.
I ask, for the coach to bring her to the athletic trainer room or have somebody bring her, and he refused because she didn't wanna move.
So therefore, that must be pretty significant because most people just wanna get up and leave that noisy crowded environment, but she couldn't do that.
So my impression on the scene was this must be only moderate to severe side this girl didn't wanna physically get assistance out of there.
And so once I ruled out any significant trauma, from her getting hit on the head, and it's all about medical now, what is going on in this girl's head.
Okay.
But
So so you brought you mentioned you said you're coming in, you have gloves automatically, and that's probably not a normal thought process to have that.
Is it would instead of that, would what equipment would you bring?
I mean, or what's the alternative to not bringing equipment?
Because, like, as far as based on it's a weight room, would you already have that preset in that area?
Like, essentially
This is probably my biggest mistake in my profession, and I get these calls, and I forget to grab stuff.
Right?
And then I get there, and then I go, like, oh, crap.
I need a stethoscope I need I need stuff.
I need be aside my my, you know, my bio hazards.
And so Then I began to move all my equipment right at the front of the door so I'd have to go get it in another room so so that I could just grab it and go because I was making that error a lot.
And so in this case, I grab a general med kit, right, basic wound care, basic vital signs, diagnostics, and I brought that with me as the standard practice that should be coming The AD was in the weight room, so I didn't have to bring an AD, but I did have a general bed kit with basic bios diagnostics and and base supplies to manage a basic fracture all the way up to, you know, doing CPR.
With a pocket mask?
So other than, like, if you get somebody so if
you forget something, you have requested, you would you still go through that process?
Or even if you didn't, you just need to know where it's I guess, to to help alleviate that is where to tell them if they know where if they're not familiar with your equipment, I'm assuming you'd have that labeled or or set type of a kit or are there standard kits you have or you would put in place?
Well, this is what I this is what I typically do when I get a call like that.
I grab my kid.
I look around the room.
And I try to find the next most competent person that can be freed up in that room that I truly trust that they know where things are at.
I just don't grab anybody.
Somebody that can operate under stress.
Somebody that can operate with with me.
And but bringing a human being with you on any case, any case, minor major, whatever is always a good practice as a it's like bringing a kit by bringing a person, and that's as important in this process, if possible.
If you can find that that person that can also go get additional supplies and know exactly where they're at.
Yeah.
That that becomes kind of I guess, hopefully, they're gonna tell you what's going on other than, like, I had a and you're aware of this.
We were told I had an event recently.
I was covering and, oh, I need you to go to this bank.
There's none as an athlete, but a none, it was past an event.
They're in, like, a festival area.
And nobody was there.
I'm like, hey.
You need to come to the venue, and I'm like, okay.
What's that?
They didn't tell me.
So I I went ahead and grab my kit.
Had about a 100 a fifty yard walk or so, and I'm glad I did bring it because now I don't know what I'm walking into.
But this person's laying on a bench.
It's outside.
It's cold.
You know, I can clearly see there's vomit vomitas on the ground.
They look into stress.
So, you know, kind of the same thing because you're bringing I had to I had my junk kit or a BLS kit.
That I'm only or we we already have stock, but making sure that's in place as well.
So I see Carrie has a comment on here, and, I mean, if you wanna if you can see that.
But
I saw it.
I saw it.
Lancing all my others.
Screen, and we'll get to that carrier when it comes to the actual what's the differential diagnosis and what can be done.
So keep that keep that thought in mind when we come to the primary assessment because right now, it's just processing the scene and making sure that the equipment is there, the resources are there, the anticipation of what you're up against that you're prepared, Everything's working.
And that when you enter the scene, you control the scene first and foremost before you get all tied up into this patient.
Because you can get tunnel vision.
Once you lock into the patient, you you can have bad things come back and bite you if you if you don't manage that scene.
So the last two questions I have for you on this would be is 1 is what did you do or what would you do to make that scene safer in the weight room?
And this is this is not this is a thing of real time.
Not scenario, but real time Everything's working around, etcetera.
And, basically, everybody else is kind of oblivious to what's going on.
Yeah.
That that that scenario.
The major error that you can do is you try to clear the room.
There has to be another competent adult in that room.
You have to make sure they are clearing the room because it fits you trying to clear the room as an athletic trainer.
A lot of the athletes don't listen to me.
But the coach starts barking and blowing a whistle.
They seem to move a lot faster than what they were doing for me as they should.
So I gotta find a competent adult to secure the scene and get it cleared ASAP because this athlete is not doing good at all.
Alright.
So yeah.
So with that being said, now that you're thinking about, was there a need to call an ambulance on on the initial same size up?
That's a tough one.
That's a tough one.
But because right now, no on the scene, as far as the seniors, no, but the verdict is still out when we get down to a patient assessment.
But as far as just, does this seem bad enough?
Now what could have made this seem bad enough to where we would have called an ambulance on on before we did any patient assessment is if there was obvious trauma, significant mechanism of injury trauma upon initial encounter then we would have called 911 and had them coming before we did any kind of patient assess.
Asked me.
So the coach would have called in and said, look, I had a girl that had a £45 weight come down and hit her on the head.
And there's bleeding everywhere, then that says my scene is bad enough to where we would call 911 as I would have been going.
To that to that athlete.
But in this case, I haven't had indications yet to call.
Alright.
Let's keep going here.
So just a reminder, we're now through the scene size up.
Now we'll get to actually touch the patient.
That's so hard to do sometimes.
The seat size up comes at, like, the light speed at you, but you cannot neglect seat size up in your assess process.
So so so here we go.
Primary assessment, let's dive in.
So, Carrie, keep your keep your thoughts in mind.
So initial impression and chief complaint, so she is conscious alert and responsive, right, with a rapid breathing rate.
So she has rapid rapid means 30 or greater with shallow breaths.
She complains of a a generalized headache Rachel headache on a scale of 1 to 10, 10, the worst you've ever had.
She says it's a 10 out of a 10 that tells me this girl is she's got it pretty bad.
How come you can't get up?
I'm too dizzy.
I can't.
My my head is spinning and I'm about to throw up and I don't wanna be moving anywhere when I'm throwing up.
I just gotta lay here.
Just let me lay here.
I'll be fine.
I'll be fine.
Leave me alone.
Like like like she's trying to ignore, you know, Trying to overcome it if she can.
It's getting worse and worse and worse.
So that primary assessment, she's responding, she's breathing, and I'm beginning to look for any other life threats as well as to see if she's decompensating, and I'm having indication through dizzy and nauseated that that something physiologically in her body is shifting resources, blood glucose, water volume.
Yeah.
She's decompensating.
There's a move going on in her body for resources, and we're starting to get evidence of that.
Which is telling us that shock is now in the process.
We just don't know what kind and we don't know how severe.
This is taking place.
So I need you I need your comments again in the chat.
What are your initial steps to determine if the athlete has any immediate life threats or she's decompensated?
We'll get to interventions in a second, but What's your first thoughts on your assessment of life threats?
What are the potential life threats here?
And or What are the clues that she's decompensating?
In play?
Clues meaning signs and symptoms so far based on what you know.
Sensitive to light.
Yep.
Yep.
Kelly, we're not ready for a vital shit.
That will come up in secondary assessment, but that would definitely be an indication of another indication of of of decompensation for sugar, Kelly.
Right now, in our primary assessment, we're trying to figure out Do we have any major bleeding?
Do we have any major significant spinal issues we have to address?
Like, are there any live threats?
Is she breathing?
And then again, is she breathing adequately?
Because we might need to assist her and her breathing.
We might need to start some interventions along with that, like, supplemental auction, but So what are the primary clues?
Yeah.
There we go.
Kelly, skin color, sweating, consciousness.
Yep.
Yep.
Jason, we're gonna get to people's size and in the secondary assessment.
But yes, we're gonna do a rapid trauma assessment and look into your ears.
We're gonna feel her cervical pain, Jason.
We're gonna feel numbness and tingling in a rapid trauma assessment.
Yeah.
And and, Ben, we're gonna get in the numbness and teamling, we're gonna do that in a rapid trauma assessment.
However, rapid trauma assessment is just major lipids.
It's not the head, the toe.
Yes.
Rhine level of consciousness is skin color and temperature.
So is she looking me in the eyes with direct question of initial talk?
Yeah.
Chad, that is like That is, like, your your level of consciousness of a v p u or Glasgow, coma scale, like like, ishia, what the can she respond to person place time and event?
Like, do you know your name?
Do you know where you're at?
Do you know about what time it is?
That will help us with her level of consciousness.
Rapid trauma assessment is we have to go shopping throughout her entire body looking for clues that we don't have additional life threats.
Now a lot of her skin is exposed, so that makes it really easy to do, easier to do.
For us to scan her body, but we're still responsible for that.
And we can't neglect that step as we look.
It's not a detailed head to toe.
But it is a rapid Toronto assessment.
But the big ones that are standing out are skin color temperature and nausea and dizzy.
That's telling us that we are decompensating and that has to be addressed now.
We can't wait for later information like a pulse and vitals and blood glucose.
We don't need all the additional information The point is we have enough clues to say something is happening in her body.
She is in shock.
We need no more information.
That's enough.
To start an intervention.
Now, what intervention is in the primary assessment that we could get involved with.
Put that in a chat.
What do you think?
What what intervention in a primary assessment?
Not a turnkey.
It's not a chess band.
It's not anything to do with 3 or bleeding.
There's a couple of things that I would considering the intervention.
Now, Chad, what body position is going to be the best for her body to assisted in overcoming the circulation demand.
So do we want to elevate a body part?
And that's that's a golding question because we elevate the wrong body part.
We actually could be contributing to that.
So if she has an aneurysm, when we start elevating the feet, that's not good.
If we try to raise her up, she might throw up on this.
That's not good because her airway is compromised.
So right now, the most comfortable position trumps anything, and it seems to be she has naturally put herself in her most comfortable position.
So I'm good with where we're at right now.
If she's decompensating that her body is struggling with the delivery of oxygen, and we need to maximize that.
So I would send my assistant.
I did not bring my oxygen kit, but per protocol, I would go get and tell him, go get my oxygen kit, bring it back, and then I would put her on 2 liters of oxygen because it's a head trauma.
And I'm not sure exactly what I'm dealing with this yet.
Is it the priority of all priorities It's up there.
It's worthy to go get and start that process.
Plus, I need my suctioning device out of my our and kept because if she's nauseated, she throws up on me, then I wanna make sure I have every opportunity to make sure that airway is clear.
So go get my oxygen kit.
Get back here.
Probably should have brought it to begin with, and then let's start giving her 2 liters of oxygen with a nasal cannula.
They will measure we'll get more diagnostic with our pulse ox and our vitals later to see if we need to touch trade that up to 6 liters per minute.
But she's a candidate.
She qualifies.
She is decompensating.
So, Doctor Harper, what what are some things that you would like, you're looking at this from assessment.
But I think just there's at least from the comments, I think this has become it's kind of a common thought process is what at what point are you are you stopping the the information from the primary assessment?
And now you're getting information in that second that that that next level assessment of, like, getting checking vitals and things like that.
What are where's that it's more if you just kinda go into that a little bit.
And at that point in time, you're still finding what are what are the clues you see or the patient has decompensated.
C size up goes like the light speed.
Primary assessment goes like really fast.
You're doing it simultaneously.
So we teach it segmented quite often in real time, it gets integrated in people who had been doing this for a while, they get really good at integrating same size up.
They get really good at primary assessment.
And they get really good at at assigning somebody to get vitals and all that happens simultaneously.
We teach it like this to say, don't over don't jump steps.
Make sure you look at her and say, she is the compensating.
She needs auction.
She needs in the right position.
Now I can begin to collect more information.
I don't need more information to know if she needs we need to start that process.
So so just don't overskip primary assessment even if something is somewhat simple as this.
And what was your follow-up on that.
Right?
I think just the the from a decomp it, like, where at what point are you where where are you identifying decompensating the patient's decompensating.
What were some of the typical thing you've seen you said this already, and I just wanna I'm asking that just as a as a reaffirmation just from I've seen some of the comments as well.
Yeah.
So we
we haven't asked her about concussions.
We haven't asked her about a hangover.
We haven't we don't need to.
That's the point.
Because you don't even have to ask the sample history to get vitals to know that her body is shifting resources.
And so go ahead and instigate go ahead and investigate your interventions.
And, yeah, Ben, if if there's any way, if she's still acknowledged, I can get her on her side.
I I wouldn't like, if if I can convince her that I get her on her side to protect her airway, that's exactly what I'm talking about.
It's positioning.
And oxygen administration can instantly go in motion, and you don't even have to even know any more information just yet.
As long as you have accounted for, any kind of head trauma.
Did she hit her head when she came went to the ground, or or did she get hit hit in the head anywhere in this process?
And if we can rule that out and the same size out, then we're ready now to move into our secondary assessment.
So you mentioned, like far as a head injury or other not no head injury rolling that out, but is there how are you how are you determining what the in this scenario, how are you determining what mental status?
And then how do or how do you confirm the mental status?
Person place, town, event, is is the is the a and alert and responsive.
So maybe if you can ask a person place time in in event, then you are considered alert.
And if that's the case, then which I anticipated is the case here.
If she can't do that, then I gotta move them down the ABPU and say, do you respond to me at all verbally?
Do you respond to any pain that I inflict?
And if I can't get either one of those and she goes unconscious, then we move to the you and unconscious.
So that's the process.
So if the if the patient was presenting is being or appearance of being confused.
You know what normal is.
You value that.
You're seeing what happen you're identifying really rapidly what abnormal is, and and hitting those initial interventions without going further down the line.
But if the patient is was confused or the parents of being confused, what is that how do you take that information as far as the the intervention any interventions you would apply?
You just you just pull the rug out from under my feet because you took away the majority of the information and make the big decisions.
And when somebody you can't get valid information out, you're now you just escalated a lot of things.
Number 1, their mental status says decompensated even more, and you can't now ask the relevant questions to concussions and and hangovers and all the other, right, things like having eaten in, you know, 48 hours or whatever, you know, belts you're up against.
So This means you've escalated everything.
Yeah.
So one other question I have is that, you know, you're going through you're going through this this rapid process, and you're you're trying to determine very rapidly.
You got all this other stuff going on around.
You're trying to control everything.
How do you know at what point do you decide when you need additional assistance or additional so that, you know, after you complete that primary assessment, what What point do you do you wait?
Do you move forward with who you know that this is based on this scenario?
So when seeing signs up, we had to make that decision and I did not make that decision.
I didn't call.
The only help I did was get my student aid to come with me or somebody.
Now I'm digging into primary assessment.
She's decompensating.
So I always have this meter going in my head.
Right?
This this this this, like, scale, mild, moderate, severe.
So currently, she's in the moderate category.
And I need something to move me to severe.
And so level of consciousness is that marker that would move me to call in for ALS support and get her out of here because she's going to need to get going to a stretcher.
And move physically to a medical facility if I can't get her to be alert and respond anything less than alert and responsive.
Remember, I haven't done any vitals.
I haven't done any medical history.
All it is is alert and responsive.
Our AVPU scale and then make the decision.
Okay.
Thanks.
It's all I had.
Mhmm.
Yep.
Alright.
So in review, Check your equipment.
Don't forget seeing size up.
Make sure you do a thorough primary assessment and start your inner vent before you dig into the deeper, more qualitative information.
You have enough information to start your interventions and decide Do I need any more help at that point in time?
You don't need to do a secondary assessment.
That's enough information to make a decision.
I we have one more similar case study like this before we wrap this up.
Any comments or questions?
Y'all have done a great job of helping fill in the gaps through this case study.
Anybody wanna throw anything in here as we go to the next one?
Alright.
So this represents a second case study that we're looking at as deals with generalized chest pain in athletics.
I'm Ronnie Harper, and I have been doing this for quite some time.
And really enjoy emergency medicine.
And I am a co owner of action medical.
I have no other disclosures to make.
We're gonna take a look at steps of effective patient assessment, how to make a scene safe, intermediate threats, and then we'll talk about the primary and assessment as well as the same size up.
So here we go again.
You see that same look on my face.
Right?
It's kinda stuck on there.
That's not me, but I I wish I had a hair like, no.
Yeah.
Kinda always thought I had hair like that.
But, yeah, I really would have this look with this scene.
The track code says, hey.
1 of his athletes is not feeling well.
Okay?
She she complains.
She says that he complains as some tight this in his chest, but nothing more than that.
Okay?
Can you come and check on him soon?
And so my question is, can you bring into me?
And, of course, the stadium is a half a mile away.
It's not on campus.
Which I hate campuses like that where your athletes are a car right away, not a not a golf cart right away.
And so, no, I can't.
I'm responsible for all of my athletes, and I'm not gonna put him in a car.
With another athlete, you gotta come to him.
He's saying his chest is tight.
Oh my goodness.
What could that be?
Right?
Can you tell me any more information about this tightness?
Because I don't like tightness in the chest, and it could be a cold.
It could be a lot of things.
So once again, I gather my equipment, I grab my general med and oxygen kit with an AD, and I'm not bringing a student aid with me because technically in my place, I couldn't bring them in my personal vehicle.
So I'm on my own this one, but I've gotta make sure anybody I leave behind is supervised as well, which is always a trick.
So here we go.
When I'll put in my car, does it work?
Do I have enough on my train to use it?
Is it well stocked and do I have everything because I can't easily come back.
So I gotta, like, grab my oxygen kit this time.
Oh, that's a pain in the butt.
But I still gotta do it.
I gotta grab my general med kit.
And if there's not an AED at the track stadium, I gotta grab an AED.
And I can't make any assumptions here.
If you make assumptions, you will get embarrassed and you will never do it again.
So grab it what you need.
To take care of a scene.
I can't forget my scene size up, track stadium, male athlete, college setting, chest tightens.
Doesn't sound too bad.
When I get there, I've gotta get through my primary assessment, and then wonder if I gotta do any interventions before I get out on my primary assessment.
So I get there, and this is what I got.
I got a twenty three year old male athlete running on a track complaining of significant but generalized chest pain.
And this is what he looks like.
As I walk up to him.
I don't like this look.
This doesn't look like the the chest cold that I was a assuming was about to come into.
I don't like this.
He's grabbing his chest, and it has debilitating him.
He can't functionally move very far at this time.
Kinda wished I would have known that ahead of time, but this is what I got.
So we're gonna focus on seeing size up here.
So here we go.
Once again, it's your turn.
Initial thoughts on major issues you may encounter with managing an athlete where other athletes are still actively running.
C size up.
Help me fill in the gaps here.
Add it into the chat.
What what's what's going on in this scene that I have to account for.
Before we get into primary assessment.
We're in this seat.
How do I manage this seat?
He's out in the middle.
We don't see any athletes behind it now.
But what we gotta what we gotta be thinking about?
Yep.
Yep.
Jason.
Yep.
Man.
Yep.
Yeah.
But all y'all chomping in, y'all thinking the way I'm thinking is.
Number 1, this is not what I'm gonna do my assessment.
This is not where I wanna do any of my assessment because I got other people running and they are zoned in and doing exchanges with their with tons and you got you got people that are just in their own zone that pays no attention to the things that are going around now.
If you ever been on a track, you know that it is a catastrophe waiting for happen when people aren't paying attention to other people.
That are around them.
So do you somebody mentioned crowd control?
Yeah.
And you gotta you gotta address, you know, if it's there, this looks like a practice.
Yeah.
So you guys gotta protect yourself.
Right?
So here we go.
Now let's we're out of scene size up.
We're gonna move him out of that place, get him away from other track athletes, get him promising.
And so we we we we we we're not gonna put him in our car yet.
We're not ready to call 911 yet.
Get the golf cart, transit safe here.
There we go, Mara.
Yeah.
If I had my golf cart there or if I had one, I absolutely would get him into a room.
Versus Alvin open like this, but I didn't have my golf cart.
I only got my car, and I don't have a facility at the track.
If I did, I would go into it or maybe it's close.
I just walked him around the corner, got him under a stadium, and he's still grabbing his chest.
Right?
And so the athletic training rooms in another location, so that's not an option.
So the assessment begins.
Right?
Now I'm ready to move into the primary assessment.
Help me out of here.
Initial steps to determine if the athlete has light threats or is a decompensating.
What clues did we see any life threats as an easy?
No severe bleeding?
And we have to determine is he have adequate breathing, and he's struggling to breathe.
And so And he is let me see.
Yo.
I don't have it, but let me give you a little backstory in this.
There we go.
Van Airway sounds.
I wanna hear sounds.
Only here is rate.
Right now, his breathing rate is over 30.
It's shallow.
And his chief complaint is significant crushing chest pain.
Yeah.
That feels like somebody is standing on my chest, and that's his chief complaint.
He is pale.
He is nauseated.
He he isn't dizzy yet, and he has a very rapid and bounding heart rate.
Well, wait a minute.
He's twenty three years old, and he's breathing heavily, and he's chest hurts.
So that's what we know so far about this patient.
It is not lining up.
This is not making sense that a senior twenty three year old track athlete in a college setting should be having this kind of pain.
This is not making sense.
There's no trauma indicated.
Right?
Yeah.
Steven, great great question.
Those would be out of the chief complaint, which is a OP QST part of the chief complaint onset of provocation, quality, radiator, severity, and time type of questions that we would ask out of this, primary assessment.
And we would garner, no.
He doesn't have any radiating painting.
And he is breathing.
His breathing shallow.
His skin, his pale coat and clammy.
He does have a rapid bounding chest, and it's centered over his left chest long area.
Is where he is grabbing and where he's saying his chest is tight and is hurting like crazy.
So, Doctor Harper, what would be just to kind of just put wrap around on this briefly because we've covered a lot of information in the last 2 or 3 minutes.
What are the initial steps, this kind of as a summary point that do we need to take to that you're gonna complete this primary assessment?
This is
following your following your c c a b c.
Yep.
Did he have a rapid bounding?
Is he getting adequate, high to volume out of his heart?
Is a rapid bounding strong pulse.
I assume then that's a strong enough blood pressure.
Then we go to airway.
Is it Is his airway open and is it adequate?
His breathing rate is above 30 and his breathing shell.
So therefore, he has his breathing in.
There's a lot of debt space going on.
He's not getting adequate, annualization.
He's not getting adequate oxygen to his loans.
Breathing rate, I hear upon just general oskitation.
I haven't got my stethoscope.
I do hear I do hear some crackling sounds from his breathing.
So I got my CABs done.
Right?
And then I got my general impression, my OPQR chief complaint, I'm ready to make a decision.
Alright.
So with that, what are the what are the the the key things that you're going to address with specific interventions.
Like, what are the things you're gonna to hit those issues you've seen, what are the intermediate interventions that we we see that he's compensating.
We know that he's been creating and definitely not getting better.
What are what are the rapid interventions to start addressing this problem before moving into that secondary and getting other vital signs, etcetera.
Alright.
3.
1 in psychology, I have to I have to remain calm, and I've gotta reflect calmness in him because he thinks he's about to die So I gotta I gotta work on his brain.
I gotta work on his head.
I gotta change the channel on his brain.
I gotta get him thinking of something else.
Number 2, I'd get him in a better position, starting with a Fowler's position, which is a sitting position.
I don't have anything to sit on right there, but I would try to find something but I couldn't, then I would get him to the sit down against one of those beams and and take the pressure off of his body and get him closer to the ground.
Number 3, I would get him hooked up to oxygen with the nasal can.
You got 2 liters per minute.
Those are the 3 interventions I would do.
Okay?
So you started those interventions.
You moved.
So what when do you determine if you need additional assistance?
Like so will this will this get better?
Are you waiting to see if it gets better, or you are kinda like, okay.
This is this person's having a problem no matter what.
I need to go ahead and call like, if you're gonna pull a option now, is that an automatic need to call EMS?
Yeah.
Or are you waiting to find out something later in that process?
Here we go back to the same thing, level of consciousness.
If person plays time and event, if he can answer that, I'm waiting.
I'm just waiting till I get more information before I activate EMS specifically with a twenty three year old.
But I've got him on a short leash, but calls it it it's it's in a thoracic region as his chief complaint.
If his complaint is in his thigh, his leg, his arm, anywhere else, I'll give him a long leash right now if he's got a short leash because he's grabbing his chest.
So I wouldn't call them at this time, but I need a little bit more information.
Great.
Thank you.
Yeah.
So here we go.
In review, should I have brought that equipment with me?
It's a pain in a butt, but, yes, you gotta bring whatever your scope of practice tells you to bring whatever your protocol.
Either you gotta have it at the at the track stadium or you gotta log it over there with you.
I couldn't bring a human being if it was not appropriate according to policy.
But I really would like to have had another competent person with me all the time.
Writing over there, I don't like chess tightness.
That's why I actually came.
If they said his hamstring was tight, I would say, no.
I'm not coming.
You gotta get him here.
So come and see me.
But chest tightness had trauma.
I'm coming no matter what I think it might or might not be.
And then once I get there, like like life threats, the compensating start manner events, I don't need any more information, put him in a position, deal with the psychological, and began to administer oxygen as I continuously decide on additional health that's needed.
What do you all think on this chest pain.
We did not go into secondary assessment.
Right?
We did that's another day.
We will actually bring this patient back, and we'll have time to dig down into the vital sample history head to toe.
And interventions that might calm if there's any kind of medications or any kind of other things that might be in our scope of practice to manage these cases, but and then how do we do a hand off report to EMS?
And what does that look like?
And what do we document?
But we just got through the first three and a half steps today to make sure that we don't overstell and and go blowing past, seesize a primary assessment and, oh, yeah, make sure we got the right equipment and resources to pull off what our scope of practice says that we should pull off.
As anybody else care may mention of an halfway similar to that, that was referenced to a hangover, and we won't go to differential diagnosis at this time.
But I'm hoping that these two cases where you can relate to both of those and how challenging they can be in in in sometimes we pass them off as simple to manage, and sometimes they are.
But I'm constantly and you will too if you stay in this profession and I know what to be all are attending today or like me and Ray, when you enter into your day, It's like it's a good day when nobody dies on me.
Right?
And so you cannot die on me.
I don't have a box on my form that says death.
And I always am the pessimistic person that always looks for worst case scenario and what could possibly go wrong on my day, and both of these are seemingly my chest hurts.
I'm a track athlete.
Hey.
You ever run the 800 before?
You feel like your body is about to die, like your chest will hurt if you run the 800 or a mile or or do anything past.
You know, your general, you know, stressful events.
But, yeah, everybody said hurts in a weight room.
If you're in there, say everybody's head hurts.
You you're discomfort.
The wayroom is not for comfort.
It's for discomfort.
And so, yeah, Those are two places that are common that people have aches and pains.
And sometimes people pull the trigger too quick.
But sometimes they should pull a trigger quick and get your attention to solve the potential problems.
What'd you think?
Right?
Yeah.
I just think after going through this, I think this is a you did a fantastic job of just wrapping up the first 2 to 3 minutes.
I mean, this is not this is very rapid.
I think the the importance of starting identifying what areas the patient is decompensating before and then really getting that rapid addressing the oxygen.
I think, you know, even I'm looking at some of the comments here seeing what, you know, whether or not, like, Jason mentioned, would you know, early, would you put a AED on the person automatically?
That's another decision point of whether or not you, you know, you put them all in their standing or the seating do you you know, what what's going on with that patient?
What you actually shock them?
I think it goes back to well, you're gonna wait till they go unconscious before you shock them.
They're You can do that if it's indicated, but that needs to be in a hospital setting where they're doing some different controls, doing a control shock.
That's very different process versus infield.
And then, Carrie, you mentioned about you know, that situation where you the difficulty breathing you apply oxygen early, but realize it may be hyperventility.
And Then at that point in time, it's not an oxygen issue.
It's a it's a carbon dioxide issue.
So it's a what and what that looks like and and whether it looks like or they may be having a coronary spasm, which that's gonna if they're again, it goes back to assessing I think you've you've really really good job of, like, we we gotta get down into the heavy assessment, the more the secondary assessment vital signs, like, what's s p o 2?
And if they're above 96 and they're having chest pain, that may be the contraindication to where
you like that point.
Carrie, you make a good point.
And so if they're hyperventilating, I'm not, like Ray said, I'm not getting excited about oxygen even though I can't give it.
It's not my highest priority.
I would try to coach him down and and be focused on my secondary assessment.
But At the same time though, here's how I've used oxygen.
I don't know.
Right?
Tell me if this is unethical, but I when I have somebody like this that I feel like they would benefit from oxygen, when I give it to him, I need them taking deep breaths because I need that dead space filled up.
I need I need air to get down deep, and I'm trying to coach him to breach slow down your breathing.
When I put the oxygen home, I really oversell the benefit of oxygen and they psychologically begin to think, this is the magic juice that's gonna solve all their problems.
And I use that to my advantage when I put it on him and say, look, take a deep breath and breathe in as oxygen.
Right?
It's 2 liters per minute.
Right?
It's it's it's like a trickle.
And they put it on to go, Oh, yeah.
Yeah.
That's wonderful.
That's wonderful.
And I go like, oh my gosh.
Like like, that actually worked.
It it it didn't solve the problem, but I used it.
Is that unethical way?
I don't think he's unethical.
I mean, I think he was trying to and, again, if a person's hyperventilating, your goal is you've gotta get them into controlled breathing.
You've gotta The idea is you want to get them to manually lower hold their breath or you like the bag.
You're just trying to stabilize your CO2 levels down to a better level.
It's not necessarily a lack of oxygen.
They have too much CO2.
They're trying to blow off or, you know, from that.
So trying to get them stabilized so that then they can do it themselves.
Otherwise, you're gonna have to put press positive pressure ventilation if they start to get, you know, if they start to get unconscious and they're still hyperventilating, you're gonna actually go into control use a VVM to control that greeting.
That can be done as well.
But, again, you need to have that part of your protocol You've gotta work on those product have some establish these scenarios get into that you can address.
So Here's something that you know, I'll let you tackle the question that
Yeah.
Needs to put in there.
It's Hello.
Hello.
Y'all can re how y'all can relate to this stuff that will track coach collapse during practice girls community work on Huddl's name, coach, and jump through Rambling.
Left him there for 5 minutes before he couldn't find anyone.
He was awake, able to answer questions, chest tightness, pressure jaw pain, radiating, and down, having active wildcard infarction.
Yeah.
Wow.
Yeah.
Very interesting.
Jason, I think I heard you maybe tell that before.
But if you live in this profession long enough, you will have plenty of stories in emergency medicine.
And I had an athlete trainer just a few weeks ago as I was telling him how excited I was about retiring and working with Ray on trying to educate athletic trainers more about immersing medicine and his general response was, like, yeah, that's okay.
But, man, I rarely ever see, you know, apply a lot about Mercy Medical skills, and I just went like, dude, you're just too young.
You're just too young.
You just ain't tight, baby.
It is coming at you, and you will get your attention that you will find yourself up against the wall, you were wished you were better in emergency medicine, and you would wished you had protocols in place and your equipment checked, and you're just too young to respect until you get scared out of your mind a few times.
And are get burned because batteries didn't work or you didn't have the equipment or you were too lazy to grab it and bring it with you.
And then you will wake up and start paying attention to this kind of stuff.
Yeah.
I think that's a this is a example that Jason gives and everyone can see on there as well.
This is a is something you can't make, you know, just you can't make it up.
I mean, it's just we can talk about scenarios, but to have it actually happening, you know, this is like a these are like books in itself or chapters in a book.
But yeah.
I mean, you did that on you know, recently, you had the same thing having you know, you can make make sure you're having equipment checks and do things as well.
Again, having those little things and are are so critical, even if you're trying just to not a crisp like even for a glucometer, you're not trying you know, it's not the most it's not the the incoming the world if you don't measure it, but when you need it and if it doesn't work or something is missing, why having those those you know, we you emphasize at the very beginning, this is equipment.
Having equipment checks, make sure things are in there and operational when someone grabs it, you know it's there and have those mechanisms for that.
So
We are going to do this every month.
Critical Decision Points 2.0: Navigating Initial Presentations of Head Pain and Chest Pain in Athletes
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Updated Jan 22, 2024
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