EMS World

AUG 2011

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By James J. Augustine, MD, FACEP | CASE REVIEW Families to the Left An exposure to an unknown substance at a school brings out worried parents THE ATTACK ONE crew arrives at the junior high school and fi nds many of the students outside. The principal had set off the fi re alarm to evacuate the building after a group of about 20 students and teachers had suddenly started coughing and choking near the school’s cafeteria. It’s just before noon, and media trucks are on scene almost as quickly as the hazardous- materials team. The Attack One crew is assigned to perform triage. They report to the front of the school and begin work on those with symptoms. Three individuals are complaining of shortness of breath, coughing and burning eyes. All can speak in full sentences, and they report they were exposed to something near the school’s cafeteria that immediately caused irritation. One 12-year-old student has asthma, and she says she went to her locker and took several puffs on her inhaler, but it’s not relieving her symptoms. A teacher who stayed in the area to help move students away now complains of a persistent cough, and another student, 13, complains of coughing so hard “it made me throw up blood.” The Incident Commander suspects a release of pepper spray and has instructed crews to close off the building, but not disrobe the exposed or lay out a decontamination area. There are no obvious smells on the victims’ clothes, so the Attack One crew sticks with that plan. They assemble the rest of those having symptoms and do a quick check on each. With a lot of students and faculty milling around, they cordon off an area of the front lawn upwind from the school for those feeling ill. One crew member is assigned to establish a separate area in the warm zone for performing a pre-suit evaluation of members of the regional hazardous-materials team. Hazmat team members will then enter the building in protective suits Victim Assessments Many fi re and EMS organizations use triage systems that result in patients being numbered in sequential fashion. This box represents the results of that triage process here. The crews triaged 20 patients, categorizing them by compromise of the ABCDE body systems. FIGURE ONE ASSESSMENT PATIENTS 1–3 Airway Breathing Circulation Disability Exposure of Other Major Problems Special Issues Open In mild distress, with respiratory rate elevated at 24–28 and two with audible wheezes; pulse ox 98%. Good perfusion No defi cits Three females, all complaining of diffi culty breathing, coughing, eye irritation, sore throats; one reports vomiting blood. Not contaminated. The patient reporting the blood was noted by classmates to have put her fi ngers down her throat to try to induce vomiting. Triage Class 3 patients and analyze for hazardous substances. The Attack One crew continues the triage process, gathering information from victims about where they were when their symptoms started. They relay this information to command, and then to the hazmat team leader— it is vital to locating the source area and establishing the incident’s cause. The crew leader contacts the regional poison control center to report the incident, the likely source and the victims’ symptoms. In combination with medical control, the crew decides to send the most symptomatic patient— the student who’s wheezing—to the hospital. The poison control center will coordinate any information exchange with other hospitals, if needed, and also with the broader healthcare community. The transport ambulance will take the girl to the local children’s hospital, and PATIENTS 4–9 Open Coughing but no distress; pulse ox 98%. Good perfusion No defi cits Mild cough, no wheezing PATIENTS 10–20 Open No diffi culty Good perfusion No defi cits Mild eye and throat irritation; no skin problems. None None 6 patients 11 patients its paramedic leader will remain on the radio there to share information from the hospital and relay any questions between the scene and emergency department. The rest of the victims are not in distress, but the Attack One crew, medical control and Incident Command decide to keep them at the scene and provide symptomatic care until the nature of the exposure is identifi ed by the hazmat team. At this point, the triage area converts into the treatment area. The Attack One crew huddles with their counterparts from other ambulances assigned to the incident to organize a transport area and operation, should it be needed. The two victims complaining of diffi - culty breathing receive albuterol by nebulizer. The young victim who had been coughing and vomiting blood is carefully examined. There is no sign Copyright granted for this article for department use only up to 20 copies. EMSWORLD.com | AUGUST 2011 21

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