Transcript
Presentations and critical decision points is built on being a strong interaction with the audience.
You're in the decision making process.
So as we go through here, through this presentation, you'll you'll be asked to present sign in to do your get your phone out.
And as a screen progresses, you'll see questions pop up.
Doctor Harper will walk you through that process, but the goal is a decision making process.
And in this one, we have 2 unique cases their initial presentation of abdominal pain in the first one.
And then we all I think about that this case point where it looks like.
So This is where we're gonna get into these questions about where we do things along the process.
And without further ado, I'm gonna give it over to Doctor.
Harper.
I'm excited to hear this presentation again, but this always gets a good thought provoking process and interaction with the audience.
And as with any of our present notations.
If you have a question, we encourage you to raise your hand just like this, not like this, but there's the the on the on the chat area.
That way, you can ask the question directly or just type that question in will prompt you periodically.
So the first thing if you would do is to just let us know where you're from in your job upsetting in the chat.
It helps us to get a better perspective and can address your situation or at least if a question predicts itself during a high school setting or college or professional sport or other setting in youth sports, etcetera.
So without further ado, I'm gonna give it over to you.
Harper.
Alright.
Thank you, Ray.
We will get started promptly, and we've decided to share these 2 case studies with you today and get your input.
So as you share in the chat where you're from, I'd appreciate it.
So, co founder, Moskor Stautistic, co owner of vaccine medical consultants.
There are some images in here that might show up in the prehospital emergency care.
So we're gonna take a look at the patient assessment process, Oliver, specifically dial in, and we're seeing size up and primary assessment.
And we'll take a look at 22 case studies that I think you will find some familiar hours you're with.
So here we go.
Case study number 1 is a twenty five year old male athlete reports to the athletic training room.
It just says, I don't feel very good at all.
And so as it comes into the hourly training room and you get an athlete that reports not feeling well, We're gonna stop just a moment, and every case study, we're going to present our framework of our decision making.
So step 1, a minimum equipment check.
This is your preparation.
Right?
Do you have equipment?
Is there medical time out?
Have you been trained?
And then we get into step 2, which is your primary assessment.
So as we make these decisions, keep in mind we we were gonna follow this progression.
This is saying safe.
How can we position a patient in the right place?
What's the nature of illness?
Is there any severe bleeding?
Any spinal precautions?
Do we need to call for help immediately?
Then the primary assessment, CAB.
Right?
Let's take a look at what it is that could be life threatening, and let's address it immediately.
And all of those come with potential interventions along that pathway.
So that's our framework.
So here goes our general impression upon walking in So this patient upon the perception of you is conscious, alert, responsive, meaning he's talking to you.
He's grabbing his side.
He's in significant abdominal pain, and he's holding his upper right quadrant.
He is pale cool in clammy.
I was like, he's seen a ghost.
He's sweating and says, man, I think I'm about to throw up.
Right?
So you got the genuine pressure that is athlete coming in, not doing well at all, and you have to respond to him.
So your assessment begins.
First thing you do is you get him into a little bit more private area, and and then you began to laying down in a comfortable position.
Now remember, we're still in the same size up.
We're still trying to measure up what it is that we're up against.
Right?
That's where we're at.
What positioning?
What's the general nature of illness?
What about this upper right quadrant?
What's in that upper right quadrant?
What does pale cooling clammy have to do with anything, and why does this guy nausea?
Alright?
So in this seen size up.
Again, we're in a broader picture of things before we dive into the direct patient assessment.
What's your first step you would take in this assessment.
Right?
So we're gonna, like, a Newcastle state and we're gonna get your phone out, and you're going to help us make this decision.
Okay?
So get your phone and scan the QR code, and we're gonna do this problem four or five times with this case study as we walk through and discuss.
So here's your options.
You admittedly transport the patient to a medical facility?
Like, you've got enough information to say, hey.
Let's go.
Do you take BSI or PPE precautions?
To protect the athlete?
Do you ask the athlete to stand or walk to assist mobility?
Do you provide some pain medication?
Give him some time now, give him some lead, start start trying to relieve some of his pain.
And so Let's go ahead.
I take a few minutes for you to dial this up, but keep your phone open because we're going to continuously talk our way through.
That said, and Doctor Cassel, you're going to come in and possibly join us in this conversation and ask him follow-up questions here.
Doctor Harper, if
you would, just you have the cohost to check on the chat to allow everyone to those change their settings.
We don't have I don't have access to do that.
So that Okay.
What someone responds they can ask.
They can they're responding to everybody.
All they can see the audience.
I have the questions.
It's done.
Okay.
Alright.
Excellent.
So I see some responses coming in.
We have eight people responding.
This is good enough.
So we got this thing down to BSI, and I immediately transport them to a medical facility.
So You know, this scene, Sausa, is an important step that we do not wanna forget, and it involves the prospect of this patient being nauseated, which can get really messy and a hurry.
So I am with you now whenever we ask these questions, there was a place for me to allow people to choose more than one response because lot of times in emergency medicine, you simultaneously do task.
But what we're trying to do today is lean into the mindset of what's next, what's next, what's next.
And we do respect the ideal that you can do multiple tasks at one time, but we wanna think our way through there.
7.
I'm thinking that I'm with I'm with y'all with this BSI.
That's gonna be my first.
Impressions.
I gotta be ready for this dude to throw up all over me and wherever I'm taking him.
So I've gotta prepare for that.
So I am with you now.
So, Quisha, I I a couple quick questions with this I see.
Just if you don't mind.
And if and, again, audience, if you have a question, please send those in.
Or raise your hand and we can stop during this process as free because we wanna address those as we move along.
The couple quick questions to come to mind is one is what if this is a minor and if it's an opposite gender?
How do you would you approach this differently?
And then also Is there any concern what how do you manage the patient privacy?
If it's a minor, y'all should have facility new protocols that you're not to go into a private area without a number 1, a a somebody can see in.
The door is open.
You bring in another adult.
You bring in another responsible individual.
Into that room with you and you don't go in there by yourself.
So that's a facility predetermined protocol that you would follow, and we would like to ensure that that's there all the time.
Sometimes it's not, and you have to then make sure that you take all precautions as much as possible to protect you and your patient in that aspect.
If it's a minor, you should already have the parents permission.
If it was one of your athletes and the parents have signed off, that they have given you permission to treat if you're working in a facility that that you don't know the parent name, you would like to have their medical records on file to ensure that that breed is giving you permission to treat there.
Okay.
Real quick, Doctor Harper.
If you would check your screen to make sure you're at a 100% doing on the on your presentation.
I think there was a couple of questions from the audience that were having issues doing the doing it.
Gotcha.
Gotcha.
I think I shared it to the wrong location.
So let's try to see here.
How about that?
It should be yeah.
That should do it.
Let us know if it's if that works now for everyone.
Right.
Okay.
Go ahead and we'll move forward.
Alright.
Next question is after you've ensured BSI, which most of us chose that, what's your next critical step?
Is it a?
Evaluate the environment for safety hazards that could impact, determine the nature of illness to design potential spinal precautions, assess the need for additional resources.
Our emergency service is based on the severity.
Like, do we need to call for ALS at this time?
Do we just need to secure the perimeter for more privacy and space for assessment, potential emergency intervention?
So I know these are these are not as urgent, immediate, clear in a case where somebody has a potential illness like this, but we still are following basic rules, and we still have to think this way.
Is my sin secure?
In all areas.
So let's see what we got here.
Actually,
Doctor Harper, one of the things that I would I think would be worth seeing or at least you can discuss whether it's do whatever you on the how the this decision goes is on that first one, that number on c is You mentioned When when is it appropriate or when you make that decision to go ahead and call for resources or their key indicators.
Looking at that.
That predicate that.
Like, if this person looks like this, you go ahead and if they were unconscious or they have an ultimate status, do you go ahead and call for services or wait till they get better?
So the same size of the nature of illness is I have an athlete that's That's pale cooling clammy.
He walked in.
He's talking to me.
He has the beginning of an altered mental status, but he's still declared, alert, and responsive.
And so he's able to walk to a private room by himself with no assistance.
And so at any point in time, as this scene starts to unfold, haven't touched the patient, haven't asked any questions, I'm still in scene size up.
The moment that is altered mental status takes a die and begins to change, that is time to call for ALS.
We don't need to get it vital.
We don't need to ask Question, altered mental status in his level of consciousness is the sole indicator of immediate ALS.
Calling.
So, yeah, I think we're all on the same page here.
Sesame for additional resources based on severity that kinda wraps up kind of what we're talking about.
Yes, safety hazards could impact the care of this athlete.
In this case, the room is secure, but we would have to make sure we got into a secure room that was safe from any other potential elements that could possibly harm that particular athlete.
So let's keep going with how long I wanna go through.
Now we're jumping from the scene size up, which we did VSI, and we accounted for his ultimate status, which is his nature of illness.
It is the upper right quadrant.
Now we're trying to assess is he decompensating or his cells getting everything that he needs.
So upon assessing now, now we're testing a patient, now we're asking questions, now we're directly focused on the the athlete.
And we're assessing the CAB circulation airway breathing, which are the following fun.
Is with indicated need for immediate intervention.
So here we go.
See what you think.
So we're assessing the patient.
We're looking at skin color and temperature maybe.
We might be looking at life threats.
We're bleeding.
We might be checking our pulse.
We might be evaluating airway.
We got a lot to do in this CAB and quite often they get blended together, but we're focused on the athlete's circulation.
Yeah.
I think we're all on the point here that that under his circulation, it's not going very good.
His body is decompensating and that means it's pulling its resources into his vital organs and something is going on and driving that.
Now we gotta figure out what that is and what does this upper right quadrant have to do with anything.
Because that has already given us an indication of the reasoning behind this decompensation.
So, Doctor.
Harper, what would I guess, in looking at this scenario, how do you choose I know this is a common question we get, and I'm and I always like to ask this question is because I'd like to hear that, you know, going through protocols and processes, but for for the immediate intervention, in this case, how what do you prioritize as the most critical intervention?
Or or interventions and what what's what plays a part in that cross your decision process or in the in the decision process in this case.
So when you look at a person decompensating, the cell is not getting what it needs.
Is it water?
Is it glucose?
Is it electrolytes?
Is it pressure?
Like, why is this cells not getting what it needs in this person's body?
And so you have to try to begin to pull that apart.
Nothing else matters until you get them out of the state.
And that state is the decompensation.
Process.
So we're under a path to try to figure out what is the immediate intervention now.
The body has a good reserve of water.
The body has a good reserve of glucose.
The body has usually adequate pressure in somebody like this, so we kinda can rule them out for the most part.
What the body struggles to maintain is adequate oxygenization.
So we do not have a reserve of that.
So we need to be thinking how can we evaluate that and then begin to supply more oxygen to the athlete.
So that's what I'm thinking.
Thanks.
Alright.
You notice his breathing is slightly elevated.
What that means is he's probably clipping a little over 30.
So a slight a slight, you know, that's faster than what we care to have.
He reports a stabbing pain in the upper right quadrant.
See, I know what everybody is doing right now.
I know what everybody is doing is your diagnose you're already having your head what this is.
Right?
Yeah.
Everybody's already nailed this down to 1 or 2 things, and that's natural.
As a matter of fact, it's fun.
It's a game to me in a lot of cases to see if I can be accurate quick and fast so that I can find the problem so I can solve it.
And so that's what we're trying not to do.
At this point in time.
We're trying to slow down and get the bigger picture and keep it at a very fundamental level And so he reports stabbing pain versus when he's lying down and what is next in your primary assessment.
So we're slowing down and making sure that we don't button jump, for a whole jump, lead jump over this primary assessment before we start diving in.
So let's Let's not rush it.
Let's take a look here, stabbing pain.
What's your next step?
You go to a focused exam.
Do you give him some oxygen?
Do you elevate?
Evaluate the circulation and continue to check for signs of shock or hemorrhage?
That can be related.
Proceed with OPQST, start describing the pain, where we start getting into the secondary assessment.
And try to dial out a little bit more.
This is definitely one of those, like, if I can multitask at this time, I'm definitely multitasking.
But again, I'm just trying to drive home the point not to jump over that this person has something physiologically going on to where his cells are not getting what they need and we have to address that first.
Understanding also that we can multitask.
We can do multiple things at one time.
So Now, me personally, me personally, I can do DMV at the same time.
Like you can too.
And, yes, I'm evaluating his signs and symptoms related to shopping with hemorrhage.
I'm I'm with you on that one.
But if during this primary survey, you get somebody pale cool and clamoring, you get someone indulging Resources are shifting, and that's a dangerous step for anybody.
I know we haven't isolated this, but it is now appropriate to start administering oxygen to try to fill that potential gap.
Remember, he's breathing.
He's breathing is elevated.
Therefore, he's blowing off some CO2, and he potentially is accelerating his decompensation.
If we don't address this oxygen CO2 imbalance at the fundamental root now.
I, like you, could continue to ask OPQRT questions.
Students like, let's drill down this plane, and let's start let's start getting into the secondary assessment while I'm administering an oxygen.
Doctor Harpreet, I know one of the one of the things that I that I know that us I have struggled with and as always, you know, as the for my athlete training mindset.
Is to make the we do that diagnosis.
We do it a lot, especially for the nontramatic cases.
But when I'm having to put my when I put my, as a dual provider, been as a EMT, right, but then it's trying to merge those 2.
You you alluded to that, we're doing the same thing.
It's just a different process of how we get to that intervention is is the Just think of it as the impression is we're making an impression of what it possibly is.
And if you can do that and you kinda forget about making a diagnosis, I've kinda learned that diagnoses are for the most part.
They're if you're making definitive diagnosis, we can see that sometimes, but it's at the end of the day, it's more of a it's kind of being overrated.
Like, we wanna get the impression and treat the impression based on what they're presenting, not necessarily because the diagnosis may be very different from what would indicate will be indicated for the for the interventions.
Is that a pretty good way of putting that, I guess, or that makes sense?
Yep.
That makes perfect sense.
And that's what we're trying to teach in these series is as an athlete trainer, sometimes we get we're we're we're conditioned in a good way, but it's also a bad way.
And that you have to slow down Look at the physiological needs of the cell.
They're not getting what they need.
Yes.
You have time to go digging to find out more information, but let's get these cells happen first.
Then we can worry about what's on the back end of what's causing this.
But let's we can we can start an intervention now.
That is the presence of oxygen.
So here we go.
When completing the CAB circulation airway breathing, you find the athlete that's weak and traded pulse.
What could that be?
We can thread it.
That means the stroke volume is not very strong that we would anticipate, and it's not it's not pushing out.
So that would tell us potentially that we have a volume problem or it could be a pump problem or it could be a container problem.
Is the pump not pushing hard enough?
Do we not have enough volume or is the container, so we can readily tell us something is happening with one of those.
Sorry.
We're not sure yet.
He's pale cool and clammy.
All of his airway is open.
In these breeding race slightly elevated.
So based on this, we're starting to we got some oxygen going.
Let's take a look at what we might be thinking next.
Monitor without doing anything.
Give us some oxygen.
Wait for further symptoms to develop before we give them oxygen.
Advise the athlete to adjust their position.
So let's see if we can't get some this getting in a more comfortable position.
Again, I do respect multitasking in this capacity.
I do respect that you would be multitasking.
I do respect that some people don't have oxygen ready available within that room at that moment at that time.
I do respect that.
Most people don't.
But I just want your mindset to be thinking that, right, that the cell needs something.
It usually they're depleted in oxygen, and we can assist with that.
And we might not be doing that immediately, but it's you should be trying to Put that in play if you have access to it.
If you don't have access to it, you have to move on down the chart at trying to figure out what to do next.
And so we have option c a and b on top of this.
I think so, Doctor Hope, I think we as we look through this, and I think that's just I know we've we've discussed periodically, I know with other and even amongst other colleagues is what is the like, for the audience, if you would just say if you yes.
If you have a if you have permission or within your protocols, you have oxygen available on-site or know is you don't have oxygen on-site and it's not in your protocols.
To use.
I think that that may help a little bit some of the context just for we understand that, but there is a you know, we have we can We have ability to do that, but it may be based or restricted based on state laws or position direction.
So if you would just everyone just put an an audience.
If you have an on-site oxygen with your facility and what you have, just put a yes or What I know is that you do not
attend the chat.
In the chat.
Sorry.
I guess as we're doing this, what is there, if you wouldn't mind, I think a good question would be is, at least I'm thinking of this, is how do you balance the need for oxygen?
Therapy.
And if you don't have it available, what's the next what's the next best thing?
Like, I know some of the do not have access to it.
But I don't have oxygen.
So what do they do?
What's the what's the next step that they would do as the next closest AdZone to accommodate when they know this is a problem.
There are 2 more things left on your to do list in this element of trying to Make sure cells are happy and they get what they need is start adjusting the position of the patient into the most comfortable It could be he's laying flat.
We need to put him in a foul words.
It could be that we're laying beside the cost of negotiating.
So we just gotta get him, and it could just be on comfortable with you.
He might feel better with his knees being laying flat.
Whatever.
Take the stress off his body because right now, his heart is weakened.
We in threading.
Stroke volume is not good.
So let's take the stress and let's try to put him in a better position.
Number 2, you have to began to deal with the emotional elements of that athlete and dial into how anxious they are about this moment.
You have to remain com.
You have to make sure that nobody else comes into that room to exacerbate his emotional state, which can derail this whole cell demand of oxygen.
So pay attention to the psychological parameters of your patient and yourself, the people around you, and make sure that he's seen in the right position.
And then the last one is temperature.
Is it hot?
Is it cold?
Can you manipulate his body temperature in any way so his body doesn't have to be fighting with a temperature issue.
So those are the next three things you address if you don't have oxygen to make sales happen.
Alright.
We're almost through with this one.
After completing CAB, initiating some oxygen or alternative therapy, not alternative.
They're poor therapies like physicians, psychological, as well as body temperature.
What should be the immediate next step?
Like, what are you focusing on next?
Conducted detailed OPQST about pain.
Trying to get more details.
Start your vital signs.
Start a sample history.
Perform a detailed head to toe assessment.
Now we're now we're giving ourselves permission.
To to either dive in on his chief complaint or do me and we we ready to jump and start focusing on collecting additional information under the under the secondary assessment section.
Once again, highly respect multitasking and highly respect the ideal that You can accomplish more than one thing at a time, but we're slowing down this process and thinking through what would be the next step and why.
And so I know y'all are hungry for information like I am by by putting me, like, tell me physiologically what's happening to this athlete's body.
Give me his blood pressure.
Give me a pulse rate.
Give me an oxygen saturation.
Give me a CVT.
I need you need a blood glucose.
Give me numbers, numbers, numbers, so I can figure out the severity physologically what's happening in this decompensation state.
You could have assigned that task to somebody else, while you dive into the OPQST and then sample history to try to figure out exactly what is the culprit here because if we can find out the culprit or potentially other call or then we're getting closer to an intervention stage, reading closer to a transportation phase because he can't stay here forever.
He's gonna leave this around one one way or the other.
He's going somewhere at some point in time.
So we're constantly thinking what the endgame is.
Oh, man.
There we go.
Alright.
We wanna I think this is our last one in this series.
The follow-up question grade would be ready to start our second one to wrap this one up.
No.
I think this was this was a great first one to get started.
I think the one thing I guess, I will have a if you don't mind, I'm gonna ask if you can jump online for a second.
Brad, do you mind if we unmute you and just wanna have a Like, you mentioned that that you're not locked in, but going through that process, maybe share your experience with call with with that point is if you don't mind doing that, just raise your hand.
Or you can give me a thumbs up or say yes, go ahead, and we'll activate, if you don't mind, just to
Hello?
Okay.
Hey.
Hey, Brad.
How are you doing?
I'm good.
How are you?
Great.
Oh, great.
So thanks again for joining.
So Sorry.
I guess the question, you know, you mentioned that you're making the call So you don't have oxygen on-site.
How soon what's your thought process of when you're making that that call in what you're telling the, like, EMS right there at that point.
Well, as the discussion has unfolded, we obviously know that that the 2 delivery is imperative at this point because we've continued you have continued to say, you know, that's what we need to support what's going on at the cellular level.
When we don't have that, that patient needs that.
So that that to me says, right now, EMS is being called because they they need that drug therapy.
And we've gotta understand that that that oxygen is a drug.
I mean, and they need it.
And I would much rather call EMS get them on scene and then not need them because everything else panned out to okay in that process.
Than continuing to wait, continuing to wait, and all of a sudden, we're so deep in that hole.
It it it may be too late.
For EMS to even do anything.
So I'd rather have them there and not need them than need them there, and they're not there.
Well, I think it's a great I mean, that's the thing.
What what you said about calling calling earlier, you can always tell them no.
But if it if but it's hard to tell them no when they're not even there.
And I that's one thing.
I've always tried that, you know, when working as a bench, when you say we're gonna call it ambulance, obviously, it's parent.
They're thinking of cost.
And they're like, no.
We don't wanna do that.
Like, look.
This is an option.
We you can still refuse them, whatever it does.
But, you know, that and I think the one thing that we're we're doing a lot more of a note for Doctor.
Harmana, we do our education in our in our live court doing live courses is really emphasizing the grid between if you don't you don't have oxygen because of state law restrictions.
Otherwise, you just use monitoring the vital signs And if they are hyperventilating, you could still put you can still you you can still do a a beep or or low below 8.
You can put a VVM on them and still control give them some or control that breathing process.
So that's the and we didn't talk touch on that.
That's a great That's something we'll hit down the line of when when and when not to use a BBM.
We think of it as when the CPR, but there are so many other cases that can be used or, you know, to help with hyperventilation and stuff like that.
But Thank you, Sharon.
There's so much.
I wish I could show you a video.
Wish I could we we would have more rich information about his alternative status, that's so critical in this because if there's any inclination of him decelerating his alertness and his speech in this then.
As changes as seen dramatically.
I think the point we just try to get across here is, yeah, we're ready to dive in and start collecting a buff load of information, for example, PQLST and vital signs, but Peloton clammy skin, nausea, That's enough to say that the cell is struggling.
We gotta support the cell.
Oxygen is an alternative positioning, body temperature, and psychological don't overestimate those being just as impactful or more impactful sometimes than what oxygen can do.
So we still have plenty to do in that section.
So now if you notice this These 2 case studies today are not going to get into the secondary assessment.
We've talked about doing it, but we will come back with this case study probably in a few months, and we will finish this story out through all the way through it.
Right now, we're just getting through these first three categories with these case studies.
So stay tuned on that when we walk through these steps.
K?
Alright.
Trying to get us out of here in the right time.
Don't wanna rush it, but at the same time, any bound thoughts from anybody on this one?
Alright.
Didn't take long to find plenty of medical condition cases of abdominal pain of athletes.
You notice we haven't even done a differential diagnosis or we haven't even tried to guesstimate what this is, again, that's coming later.
We're just getting through the scene size up and in time of your sense.
Great.
Thank you, Doctor Harper.
So on this next case, we're going to or in this case today, the for the critical decision points, we're going Doctor Harper is going to go through a simulated case again These these are intended to be highly interactive audience participatory.
So though if you haven't had chance to, have another chance to log in again, and or log in and to use your phone, or you can use a computer, you can share a screen, and type in that code.
But today, this one on this one is gonna be on what happens when we someone presents on the entrepreneurial status in those first couple of minutes, how we're gonna handle that.
So with that, Doctor.
Harper, great to have you on here again for this one.
I'll give it over to you.
Right.
So continuing to own down this path, seeing disclosures that we had before And so we're going to once again look at effective patient assessment in regards to seeing size up and primary assessment.
That's kind of the the the place we're stopping, and we will get into the and we'll get into the process of evaluating the patient.
So here we go.
16 year old female athlete not responding.
You took a 2 hour bus trip, soccer barrel soccer bus trip.
When you pull back up, where everybody snooze and everybody's sleeping and everybody's exhausted.
And when they pull back up, as they're pulling back up, One of the teammates is not responding to their prompts to get off the bus.
And then they say, come back here and check her out.
So that's what we got.
So do we have our kids with us, or are they somewhere else?
Right?
Do we have our equipment?
Is it is it stopped?
Is it ready?
Right?
What is we're kinda seeing where we're at.
We're on the back of the bus.
We got questions to address in regards to a a a back of a bus and what could be our issues.
We're going to ensure that we don't skip the primary assessment.
We seemingly do have a girl that is unconscious, so does does require an in-depth primary assessment, and then we is there anything we can do to get a or here.
Again, number 4 and 5 will come later in the year, but we're just getting through these first sections.
Alright.
So here's what you see upon approaching this athlete.
So we're right here in this category.
Same size.
Let's don't jump.
To primary assessment.
Let's make sure we address the scene first.
What's the first action you should take when approaching this scene?
Here we go.
Let's see what you got.
We got 4 choices immediately rushed to the patient to assess their condition.
That means let's bypass sin size up and get straight to the patient.
Figure out what this failed because I can't make the ants.
Off additional resources.
Began moving a patient before you assess the scene.
I I got it.
Man, it's so tempting.
So tempting to bypass this morning.
So tempting to bypass this one.
And, you know, that's where I have over the course of my career.
Yes.
I have blogs and I have certain PPEs that I have on my kits, but so many of my jackets at home, I still do this day have gloves in them.
You know, even traveling down the road and not taking anything from Granite and making an assumption that that especially, I think, post COVID may be more aware of carrying PPEs on a more consistent basis.
So tempting to skip over that, but I'm with y'all going to ensure my BSI and not skip over these other sections.
So After ensuring your own safety with BSI, like, diagnostic and glove zone, I don't know what I'm walking into here.
What's next in this thing?
So let's take a look at it.
What's next?
How many patients?
Are there any more athletes in this condition?
Did we miss any by is somebody sitting and laying down?
Is this is are we dealing with more than 1?
Start providing care to the one that we see is the the one that is the most affected, and we ensure the buses parts and not in the incoming traffic and the engine has turned off, meaning Are we bouncing around and still, you know, is there has that been taken care of?
Sure the buses parked not coming in any traffic, and I ain't got that.
Yep.
Cool.
Once again, I respect the ability to multitask.
That's true.
And things like this, you can do lots of things at one time.
But we're just sort of methodically thinking through what you have to do in a whole same size up arena and not jump this step.
Right?
So I'm I'm with you.
I'm going to make a sweep.
Make sure that I'm not missing anything.
Or somebody hiding back in the back seat that's not breathing or whatever.
Like like, what's the cough?
One is down, maybe it affects more than 1, whatever that might be.
It might be carbon oxide poisoning.
Right?
It could be something that they ate or some kind of drugs that got passed around or how many people am I dealing with?
And then you got that old bus.
Is it parked?
We don't I don't show you a video.
I don't show you you can't tell if it's moving, but you do have to respect that you're in still in a precarious position because you're in a vehicle, and that vehicle needs to be secured at some degree.
Doctor Harper, what would like, really, there's a scene size up.
When you're assessing, if you're walking in, what are some of the if you were doing this in real time and, you know, first off, I'll say, when I'm reading the initial scenario, it just kind of you know, like, this could be probably one of the worst things you could imagine, you know, a really bad situation and you're having to, like, what's going on here.
And they're just not just asleep.
It is what are some of the things you think of off the top of additional resources based on as you're walking, you mentioned a couple of examples that may be going on, but how do you how do you differentiate when you're telling, you know, EMS if it's or calling 911, hey, I need this versus this.
So it's so hard.
I wanna comment on what's next, that's primary assessment and what you would do.
But at this point in time, all we know is is all we've seen is one girl unconscious.
We got call to the back of a bus.
We really didn't say if it's moving, if it's cut off, but we need to address that, and then we need to address the ideal that how many are we dealing with.
And then the nature of illness is that this girl is not responding or it's been declared that she's not responding.
So We're picking up information at light speed right now, and we're in the back of our mind have to ask ourselves, do I need an additional effort resources at this point in time.
I haven't even tried to rouse the barrier myself.
So at this point in time, I don't need any of us.
I don't need them.
Alaska.
So I need to go see if I can get her away through some kind of stimulation.
I need to do an evaluation of her error.
I need to get into primary assessment.
A little bit deeper before I declare for ALS.
So we get a a very quick scope of the same size up, and Alice Dob in the primary assessment.
Right?
So now we got this girl and we where the bus is secure, there's only one girl.
We we now have ensured that that we have isolated down that we're dealing with a individual that has not responded.
So let's take a look at this first step in the primary assessment.
You check first quaternists, but shall end you on tapping.
We start giving our option at 15 liters a minute.
If you had it, You really start chest impressions.
Do you check your blood pressure?
I think this is an easy one right here.
Absolutely.
Yes.
Hey.
Hey.
You're okay.
Try to get her to respond.
Somebody else has already tried her.
They were to come and got you.
Now you get a chance to try to see if you can stimulate her and get any kind of response now.
What kind of response are we working for?
So we're looking for does she respond to pain?
And do we get any kind of verbal inclination out of her at any level?
When we try to communicate a mumbling or groan.
Are there any kind of verbs or words coming out of her mouth when we steam you make her?
Because we gotta classify her level of consciousness, alert verbal, painful, unresponsive, and that's the test that we do.
Right.
So what I would do is I would pincher somewhere.
I would try to elicit a little bit of pain in the trap.
If I if I just tap and just gently shake her and I didn't get in response, I'm gonna try to when I say pay, I'm gonna try to make her uncomfortable.
To see if that might elicit a response in this case.
I had a student I responded to in a counselor's office.
It's always a high school athletic trainer to call me a counselor's office.
Girl unconscious, similar to this.
Why is she unconscious?
Come to find out later on, she was faking.
She didn't wanna address the issues in front of her, and she just wouldn't respond until And then I saw the paramedic do this, and it stuck with me.
I can't visually show you very easily, but they put her hand right above her face and droplet.
Like like so that if she was faking it of any kind of incidents and she removed it and didn't allow it to hit her face, that would tell them that she really just kinda minimally checked out.
If it allowed it to hit her face, she truly is unconscious.
And I was like, that's genius.
And I've always remembered that in that case.
So That's kind of the trick of the trade here.
So moving around along after establishing that the patient's arms possible.
What's your next step?
Hey.
Hey.
Are you okay?
You're okay.
We tried to stimulate anything.
We didn't get verbal, and we didn't get painful.
Now we're now we're what do we do next?
What do you think?
You
Okay.
Alright, Rani.
Trying to next step, like, after, hey.
Hey.
Are you okay?
Let's see if the girl's breathing.
Absolutely.
Checkup pulse and carotid artery.
Okay.
I I could I could do that, but really, really, we're gonna start saying, is this girl breathing adequately?
Yes or no.
Now listening for long sounds, we can do that with the stethoscope, but in this case, we just got our good old ears on to try to hear if we can identify any kind of abnormal sounds like wheezing or crackling or girdling or any kind of then what kind of rate do we have?
So so we're dialing down or breathing pattern.
Hey, you find out that she is breathing.
It's rapid and shallow.
That's not good.
And you hear this rackling sound and particularly in her right lung.
Now if you had your stethoscope, this is when you dial in and try to distinguish if you hear an abnormal sound, now we gotta figure out is that abnormal sound.
One lung, both lungs, upper lung, lower lung, that would be nice to know.
That helps part of the process of the severity of what we're up against.
See, you are doing the exact same thing again.
You're trying to diagnose and I do it as well.
You're trying to figure this out.
You already have ideas.
You already got your differential diagnosis add on.
And that's good, but don't pass the primary assessment.
Argus sells getting what they need.
And right now, she's rapid shallow breathing, crackling, lung sounds is decompensating.
And so what is your next step?
So number 1 is She doesn't respond, and she is breathing.
It's shallow.
We've got some crackling sounds.
That's what we know so far.
Alright?
What do what do we do next?
Right.
Once again, I'm gonna say it again, I respect multitasking.
I didn't allow you to select multiple ones maybe in the future and you can select, like, I would do these two things first understanding that.
We're not there yet, but there are multiple tasks that you could do in this case.
In order to move down the primary assessment.
We did get into an open airway We did get into some level of breathing.
Is it adequate or not?
That's still in question.
But it is one that we need to figure out like what is happening with their circulation.
So when we check a radial pulse or we check a carotid pulse, the answer is both.
I definitely wanna know a radio pulse because if I can't get a radio pulse, I already have an indication that her systolic blood pressure is probably not over a 100, which would be an important piece of information as I check her radio calls.
If I do get a radio calls, then that means that we have adequate circulation to our extremities, and then I need to look at the quality.
I'm not interested in a number yet.
Not interested in a number.
I just wanna feel for the the the the speed and the quality, and that would tell me her stroke volume.
We can't go wrong with oxygen because we already have signs.
It's it's do you have it with you?
And what are the things could you begin to do the supplement?
The cells and get her cells happy with with the resources that it needs.
Are we ready to immediately transport her?
And wouldn't restart immediate full body examination looking for other things or anything.
Right?
Yeah.
I just think, you know, the the things that kinda come through this is, you know, obviously, the you know, we have audience that and we've come we've been in the situation before where where we don't have oxygen available.
And the question is how about adequate breed, you know, we you hear this phrase of they have adequate respirations or adequate breathing.
In this case, is what is not adequate about this patient.
And if so, what's the next inter what's the intervention steps?
You would take if you didn't have oxygen.
You know, we're starting to show you a video.
If we could see it, we definitely could be more have a more intelligent response here.
But when I say rapid and shallow, if I say it's over 30 and it's shallow and crackling, that's in adequate.
Anything above 30 basically tells us that when we take in a normal breath, it's 500 milliliters of volume of air, and we start breathing shallow A lot of that air just goes to the dead space, which is one third of the of the airway never makes it to the Avila.
So one third.
So even though it's shallow and breathing fast, that means it's not going deep.
So we're really on a a slow path of of danger here when we when we have this breathing mechanism shallow and fast.
This crackling sound also, you know, I wouldn't mind to expect a wheezing sound or something, but now I got this.
This weird crackling going on, which tells me that what that I've got some fluid buildup somewhere.
What's causing this fluid buildup?
How Comashi can't get it processed.
So so we're we're processing a lot of things really quick.
I guess probably the easiest thing would be is, like, I I like to hold my hand.
I like to when I describe this or thinking about it, this is this is adequate.
This should be the low end of respiration.
This is the upper end of normal rest.
Like, like, for adobe 12 to 20.
And they're normal.
There's normal breathing in and out with note with normal sounds and to make it simple, I guess, for what you're saying is anything that does not fall in this window right here if it's above it or or below it.
Abnormal sounds otherwise, that no.
That's not adequate.
Correct?
Yeah.
Yeah.
The numbers I have in my head is below 8, and above 30, it requires an intervention.
Anything below 8 and above 30 requires an intervention, or I'm really enclosed in intervention, definitely below hey.
Above 30, you got a little wiggle room to figure things out.
They don't have much, but but you you you you you start to get me into dangerous territory because things aren't gonna stay that way for long.
Alright.
So here we go.
We we have discovered.
Hey.
Hey.
Are you okay?
She doesn't respond to anything.
Reject her pulse as we can thread it at the at the in the wrist, right, in the radio pulse.
She's in respiratory distress, a shallow and it is got some less crackling exam, and it's rapid.
So that's our that's what we know so far.
So let's let's take a look.
Okay.
Slide 8.
Oh, come on.
Alright.
Well, that one didn't work.
So let's move on.
Let's talk about it then.
Just talk about it.
What do you think, Ray?
What's what's the next step?
I got a breathing.
I mean, she's breathing.
It's it's it's it's weak.
Arthritis pulse, respiratory distress.
She's not responding.
What else is in the primary assessment we need to do?
You're on mute.
We're in the same room.
You would you would think that after doing as we do, we would exit the muting of video on.
Yeah.
My initial thought is just, okay.
What else can I do?
There's, you know, you're not having other medicines, you're addressing the respiratory issue, other things coming down the pipeline, but I'm thinking of What's the skin color skin temp?
And Down cooling plant.
I'm I have some type of, like, a mildark, a small mildark sheet.
We're just trying to control body temperature.
Hopefully, that's gonna do it.
I'm also, you know, re just reassessing vitals if it's been within the 5 minute window or
And I haven't even seen that yet.
That's not right now.
Yep.
So do you need take
that on it, but but initially, I'm probably putting a blanket with the oxygen.
Okay.
That's the first thing.
Get them into a positional comfort.
That's coming.
That's an intervention of tree.
Comfort, she's in a good position of comfort, at least right now.
Here's my question I'm trying to get to is, at this point in time, has that enough information to say we need to call ALS?
Oh, definitely.
Okay.
I mean, I I wouldn't say anything.
Anything that's an airway a compromise in airway circulation or breathing are are those 3, this hits on potentially circulation cool clammy, the breathing issue, I'm calling I I think what what Brad said earlier I'm calling 911.
I'm gonna get them do an early intervention to get them there and then continue down the pathway.
So there's 2 stop points where we ask for help.
1 is a scene size up.
Do we know enough to know we need help now?
That after we finish our primary assessment, we have another stop point.
Do I need more help now?
And what does that help look like?
What level of help do I need, and it might come in ways through that process.
And so all we try to do today is present a couple case studies, try to bring you through a thought process of slowing down.
Don't jump the primary assessment and scene signs up.
As we continue to build this case out again in a few months, we'll cycle back through, and we will finish this story with a secondary assessment and with a reassessment and then talk about the pacing transfer, and we'll do a differential diagnosis, and we'll talk about the interventions that we can do.
And that's a that's another whole lecture by itself of additional information that we need.
All we know is that this girl reads ALS, and we need it coming now, and then we can continue on with the rest of our assessment.
But Hey.
Our Tom has has come and gone so quickly.
I think you're catching the idea of where we're going with this.
We're building our base first.
And then we're going to begin to add layers and layers to our case studies every single month.
And I hope you've enjoyed this format.
We'll send out an evaluation, and we'll be able to get some feedback.
But we really like what we're doing here, and hopefully, you find it valuable for sorta.
Great.
So we put in the chat or any questions, audience.
That was fantastic.
Doctor Harper, both both sessions were.
This afternoon that you presented as well.
So if there aren't any other or any we'll give a second for any questions that audience may have.
And if you're in a little typing, we can just raise your hand and go from there.
I have
one I have one question and need to put in the chat if you were doing this on your phone or if you were on the desktop phone or desktop because we had a question about Sladio and this tool with your own mobile phone and how it works.
We really like this interaction that we have.
It really plays well.
With this format.
If you could put in the chat, just bear with us.
Did you watch this on your mobile, or did you watch this on your desktop?
And the and the difference is is we were where we'll put the the these questions, we can put them on on the side.
So you seem just like a chat area versus embedded in the PowerPoint itself, which makes it limit a little bit.
So was trying to get a gauge of how many are you using on a phone.
We saw 1 or 2 who did that.
So
If you used a mobile phone, could you could you still vote on Could you still respond while you're watching another mobile phone?
I'm curious.
Do we know that answer, Ray?
I don't have an answer.
It's a great question.
It has tremendous merit, but have no answer, though.
Okay.
Here's one toggle button for it.
Minimize all screen and went to Claudia and Safari.
Still watch all screen while I'm slothier, yes, and respond.
Sarah, you're you're tech savvy.
And and if it's if it's Sarah Keating, I'm thinking of, she had a great teacher.
Well, what which was it?
I wanna choose something like that.
That's great.
We're just trying to figure out the best way and likewise, Sarah.
So great to see you on board here today.
I think the main thing is we're trying to streamline, make this more interactive, and easier for you also with that.
So I've taken there no other questions, and we've we've extended over about 5 minutes, and we value your time.
And, again, thank you all for attending.
Don't forget, we're gonna be hosting out this the the on demand version should be ready sometime tomorrow.
We'll send a message out.
Everyone who's in the the in the see you in lease platform.
She'll have that successful.
Doctor Harper, I thank you again for taking time to share your expertise in in this these scenarios.
Yeah.
Absolutely.
So as as in the last of 4 to next month, as we continue to roll out our case studies, we have quite a few coming.
Yep.
Great.
So thank you again for the audience.
This know that we're going to be you'll get a notification later on about the if you're not already a subscriber to see you at least, We're adding these 4.
We now have 44 courses in in that platform, all 100% emergency care, as well as we have some other exciting stuff coming on the pipe we have the connect forum that you can post questions and you have the entire audience as well as us to help you answer your questions and help we're all in the same boat together, solving problems and sports emergency care.
So with that, thank you all for attending, and hope you have a a fantastic remainder of the week and continuing forward.
Thank you again for attending.
Have a good day.
Thank you.
Critical Decision Points 2.0: Navigating Initial Presentations of Generalized Abdominal Pain and Altered Mental Status
General Course Information
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Updated Feb 21, 2024
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