Emergency Medical Care - Medical Overview

Medical Overview

Introduction

• Patients generally require EMS assistance due to:
  • Medical emergency (illness/condition caused by disease).
  • Trauma emergency (injuries from physical forces).
  • Both.

Types of Medical Emergencies:

• Respiratory emergencies: Breathing difficulty or inadequate oxygen to tissues.
• Cardiovascular emergencies: Affecting the circulatory system.
• Neurologic emergencies: Involving the brain; seizures, stroke, syncope (fainting).
• Gastrointestinal conditions: Appendicitis, diverticulitis, pancreatitis.
• Urologic emergencies: Kidney stones.
• Endocrine emergencies: Commonly from diabetes mellitus complications.
• Hematologic emergencies: Sickle cell disease or clotting disorders.
• Immunologic emergencies: Body’s response to foreign substances.
• Toxicologic emergencies: Poisoning and substance abuse.
• Psychological/behavioral problems.
• Gynecologic emergencies: Female reproductive organs.

Patient Assessment

• Similar to trauma patient assessment, but with different focus:
  • Nature of illness (NOI).
  • Symptoms.
  • Chief complaint.
• Establish accurate medical history.
• Use dispatch information to guide initial response, but avoid being locked into a preconceived idea.
• Assessment can be difficult with uncooperative/hostile patients; maintain professionalism, calm demeanor, and avoid labeling.
• A frequent caller may have a new, different complaint.

Scene Size-Up

• Scene safety: Ensure the scene is safe and use standard precautions.
• Determine number of patients and need for additional help.
• Nature of illness (NOI).
• Index of suspicion: Awareness of potentially serious underlying injuries or illness.

Primary Assessment

• Develop a general impression.
• Perform a rapid patient examination.
• Quickly determine the patient’s level of consciousness.
• Airway and breathing:
  • Conscious patients: Ensure open airway and adequate breathing; check respiratory rate, depth, and quality. Consider oxygen if breathing is affected.
  • Unconscious patients: Open airway using proper technique.
• Oxygen administration:
  • Patients in shock.
  • Difficulty breathing.
  • Low oxygen saturations.
  • Unconscious patients may need airway adjuncts and bag-mask ventilation.
• Circulation:
  • Conscious: Check radial pulse, skin color, temperature, and condition.
  • Unconscious: Assess carotid pulse.
• Transport decision:
  • Rapid transport needed for:
    • Unconsciousness or altered mental status.
    • Airway or breathing problems.
    • Obvious circulation problems (severe bleeding, signs of shock).

History Taking

• Determine the problem and its cause.
• Gather thorough history.
• Unconscious patients: Survey scene for medications or medical devices.
• Obtain a SAMPLE history and use the OPQRST mnemonic.
• Record allergies, medical conditions, and medications. Take medications to the hospital.

Secondary Assessment

• May occur on scene or en route to ED; may not always have time.
• Physical examination:
  • Conscious patients: Limited or detailed physical exam.
  • Unconscious patients: Secondary assessment of entire body (head-to-toe).
  • Examine head, scalp, face, and neck closely.
  • Assess chest and abdomen.
  • Palpate legs and arms.
  • Examine the patient’s back.
• Vital signs:
  • Assess pulse for rate, quality, and regularity.
  • Identify respiration rate, quality, and regularity.
  • Obtain initial blood pressure, blood glucose level, and pulse oximetry reading.

Reassessment

• Performed after assessment and treatment, continuing throughout transport.
• Consider need for ALS backup.
• Reassess interventions and document any changes.

Management: Transport and Destination

• Most medical emergencies require treatment beyond the prehospital setting.
• May need advanced hospital testing or medications beyond EMT scope.
• EMTs can use the AED.
• Scene time:
  • May be longer for medical patients than trauma patients.
  • Gather information to transmit to the ED.
  • Critical patients need rapid transport.
• Type of transport:
  • Life-threatening: lights and siren.
  • Non-life-threatening: Consider nonemergency transport.
  • Modes: Ground or air.
• Ground transport: EMS units staffed by EMTs and paramedics.
• Air transport: EMS units staffed by critical care transport professionals and paramedics.
• Destination selection:
  • Generally, the closest hospital is the destination.
  • Sometimes a specialized hospital is more appropriate.

Infectious Diseases

• General assessment principles:
  • Approach like any other medical patient.
  • Scene size-up, standard precautions, primary assessment.
  • Gather patient history using OPQRST.
  • Obtain SAMPLE history and baseline vital signs.
  • Ask about recent travel or contact with travelers.
• General management principles:
  • Focus on life-threatening conditions from primary assessment.
  • Be empathetic.
  • Position patient comfortably and keep them warm.
  • Use standard precautions.

Epidemic and Pandemic Considerations

• Epidemic: New cases of a disease substantially exceed expectations in a human population.
• Pandemic: A disease outbreak on a global scale.

Specific Infectious Diseases

• Influenza:
  • Those with chronic conditions, compromised immune systems, and the very young/old are most susceptible to complications.
  • Transmitted by direct contact with nasal secretions and aerosolized droplets.
  • Wear PPE (gloves, eye protection, HEPA respirator/N95 mask).
  • Place a surgical mask on patients with suspected respiratory disease.
  • Annual immunization is essential for EMS personnel.
• Herpes Simplex:
  • Common virus strain; symptomatic infections cause vesicles on lips or genitals.
  • Can cause more serious illnesses in susceptible patients.
  • Primary mode of infection is close personal contact.
• HIV Infection:
  • EMTs face a risk of exposure; no vaccine exists.
  • AIDS can still be fatal, but treatment can provide a near-normal lifespan.
  • Not easily transmitted in the work setting (risk limited to exposure to infected blood/body fluids).
  • Many patients show no symptoms. Wear gloves, handle needles carefully, cover open wounds. Seek medical advice if exposed.
• Hepatitis:
  • Inflammation/infection of the liver caused by viruses and toxins.
  • No sure way to tell which patients are contagious. Vaccination with hepatitis B vaccine is highly recommended for EMTs.
  • Hepatitis A: Fecal-oral transmission, vaccine available, body clears infection.
  • Hepatitis B: Blood, sexual contact, vaccine available, treatment minimally effective; up to 30% of patients may become chronic carriers.
  • Hepatitis C: Blood, sexual contact, no vaccine, costly but effective treatment for many strains; cirrhosis develops in 50% of chronic cases.
  • Hepatitis D: Blood, sexual contact, no vaccine, no treatment, occurs only with active hepatitis B infection; fulminant disease in 20%.
  • Toxin-Induced Hepatitis: Inhalation, skin exposure, ingestion, or intravenous administration. Some chemicals may initiate an inflammatory response that continues to cause liver damage long after the chemical is out of the body. Occurs within hours to days, no vaccine, treatment is to stop exposure and some drugs may minimize liver injury if given early enough.
• Meningitis:
  • Inflammation of meningeal coverings of brain and spinal cord.
  • Most forms are not contagious; take standard precautions.
  • Treated at ED with antibiotics; contact employer health representative after treating a patient.
• Tuberculosis (TB):
  • Chronic mycobacterial disease usually affecting the lungs; most infected patients are well most of the time.
  • Highest risk patients have a cough; N95/HEPA mask is required.
  • Absolute protection does not exist; one-third of the world is infected. Get tuberculin skin tests regularly; preventive therapy is almost 100% effective.
• Whooping Cough (Pertussis):
  • Mostly affects children younger than 6 years; symptoms include fever and a "whoop" sound during inhalation after coughing.
  • Vaccination is the best prevention; mask patient and yourself.
• Methicillin-Resistant Staphylococcus aureus (MRSA):
  • Bacterium resistant to many antibiotics transmitted by unwashed hands.
  • Risk factors: antibiotic therapy, prolonged hospital stays, intensive care/burn unit stay, exposure to infected patient; results in soft-tissue infections.

Global Health Issues

• COVID-19:
  • Originated in Wuhan, China; spread globally.
  • Controlling Methods: Social distancing.
  • Symptoms: fever, cough, shortness of breath (2–14 days after exposure).
• MERS-CoV (Middle East Respiratory Syndrome Coronavirus):
  • First human case in 2012 in Saudi Arabia; no cure or vaccine.
  • Place a surgical mask on suspected patients.
• Ebola:
  • 2014 outbreak in West Africa.
  • Incubation period: 6-12 days, symptoms may appear up to 21 days post-infection.
  • Fatality rate up to 70% without prompt ICU treatment.

Travel Medicine

• Be aware of travel-acquired infections in patients recently outside the US.
• Patients can present with a variety of symptoms; mask the patient and gather information.
• Important questions:
  • Where did you recently travel?
  • Did you receive any vaccinations before your trip?
  • Were you exposed to any infectious diseases?
  • Is anyone else in your travel party sick?
  • What types of foods did you eat?
  • What was your source of drinking water?

Conclusion

• Assessment/treatment of medical patients can be challenging due to the nature of medical conditions.
• A medical patient’s condition may not be as apparent as in a trauma patient, and treatment may not be as straightforward.
• Patients sometimes have more than one isolated problem.

Review Questions and Answers

• Question: A seizure patient is having what kind of medical emergency?
  • Answer: Neurologic.
• Question: If an injury distracts an EMT from assessing a more serious underlying illness, the EMT has suffered from?
  • Answer: Tunnel vision.
• Question: If a “frequent flier” calls 9-1-1 because of a suspected head injury, you should NEVER:
  • Answer: Assume you know what the problem is; every case is different, and you don’t want to miss a potentially serious problem.
• Question: If your medical patient is not in critical condition, how long should you spend on scene?
  • Answer: However long it takes to gather as much information as possible.
• Question: Your patient is having respiratory difficulty and is not responding to your treatment. What is the best method of transport?
  • Answer: With lights and siren, to the closest hospital.
• Question: When assessing a patient with an infectious disease, what is the first action you should perform?
  • Answer: Size up the scene and take standard precautions.
• Question: Your patient believes he has hepatitis and is now exhibiting signs of cirrhosis of the liver. He most likely has:
  • Answer: Hepatitis C.
• Question: Your patient is complaining of fever, headache, stiffness of the neck, and red blotches on his skin. He most likely has:
  • Answer: Meningitis.
• Question: What should you do if you are exposed to a patient who is found to have pulmonary tuberculosis?
  • Answer: Get a tuberculin skin test.
• Question: All of the following are factors that increase the risk for developing MRSA, EXCEPT:
  • Answer: Close contact with wild birds.