EMS World Magazine is the most authoritative source in the world for clinical and educational material designed to improve the delivery of prehospital emergency medical care.
Issue link: https://emsworld.epubxp.com/i/516933
CASE REVIEW By James J. Augustine, MD, FACEP EMSWORLD.com | JUNE 2015 15 ABOUT THE AUTHOR James J. Augustine, MD, FACEP, is an emergency physician and the director of clinical operations at EMP in Canton, OH. He serves on the clinical faculty in the Department of Emergency Medicine at Wright State University; as an EMS medical director for fire-based systems in Atlanta, GA; Naples, FL; and Dayton, OH; and on the EMS World Editorial Advisory Board. Contact him at jaugustine@emp.com. THE ATTACK ONE CREW is called to stand by for a session at the department's training academy. The day started off like most spring days, with a cool morning and some fog, but about an hour before the training was to begin, the fog dissipated and temperatures warmed. The session is a multipurpose one: The depart- ment is training on new ladder trucks, a new train- ing tower and self-contained breathing apparatus recently purchased for the agency. The training will involve climbing evolutions and work inside the tower. Multiple crews will go through their paces at the same time, and fresh crews will arrive every two hours to complete the rotations. The senior members of the Attack One crew are to provide training to junior department colleagues during this session. The crew is responsible for any injuries that occur and for establishing and main- taining a formal incident rehabilitation program. The paramedic member of the Attack One crew is desig - nated as rehab command and will be responsible for the surveillance and rehabilitation functions. The rehab area is placed close to the training tower. It is initially set up in a sunny area of the train- ing grounds, but soon the crew notices that tem- peratures are climbing and higher than predicted for the day. They move the rehab area into some shade and ask for cooling equipment to be brought from the storage area where it spent the winter. The rehab area is initially pretty quiet; the injuries are mostly minor lacerations from the sharp edges of the new equipment. But then some of the firefight- ers begin to get very warm and come in for cooling and fluids. One of the trainees notes the screening process seems to rely on something other than traditional teaching on heat-related illnesses: "I've noticed our firefighters have all come in with cramping. Some have really red skin, some are pale, and some have normal-looking skin. That doesn't seem to predict who's the sickest." "That's correct, and you'll see this take place the rest of the afternoon," the paramedic responds. "Many of our members get really bright red skin as they work. Some get cramps. Mental status change is our key symptom. If someone isn't thinking clearly Severe Heat Illness What's the key to recognizing a patient in danger? Copyright granted for this ar ticle for depar tment use only up to 20 copies. Initial Assessment A 45-year-old male, confused and warm to the touch. He was initially reported to be unresponsive but has been speaking since he was removed from the training building. PRIMARY SURVEY ❯ AIRWAY: Open. ❯ BREATHING: Uncompromised. ❯ CIRCULATION: Poor capillary refill. ❯ DISABILITY: Speaking inappropriately, not oriented to time or place. ❯ EXPOSURE OF OTHER MAJOR PROBLEMS: Skin blotched, warm to touch on the head, but extremities cool. VITAL SIGNS TIME HR BP RR PULSE OX. 1240 130 100/palp. 28 94% 1246 136 104/palp. 28 95% 1253 142 96/palp. 24 92% SECONDARY ASSESSMENT, APPROPRIATE TO PRESENTING CONDITION ❯ HEAD: No trauma. ❯ NECK: No trauma or tenderness. ❯ CHEST: Breathing rate increased, clear breath sounds. ❯ ABDOMEN: Not tender. Patient is nauseated. ❯ EXTREMITIES: Moves all four, distal pulses palpable. Skin becomes more blotched. ❯ NEURO: No focal neurologic findings. Moves all four extremities. AMPLE ASSESSMENT ❯ ALLERGIES: None. ❯ MEDICATIONS: None known. ❯ PAST MEDICAL HISTORY: Negative. ❯ LAST INTAKE: Breakfast at 0700. ❯ EVENT: Altered mental status with likely severe heat illness.