Medical emergencies

[SAR-EMT40]

I have discussed this post with both Jason and Marty and they understand and everyone else should understand that this is in no way a reflection on what they did in the very sad situation they found themselves in. I said before and I’ll say again that they did the best they could and probably nothing that could have been done would have changed that outcome.

I know that I have written several times about trauma and how to do patient assessments for trauma but I don't think that I have written anything about what to watch out for with possible medical problems. This is an attempt to correct that shortcoming on my part. This doesn’t cover every possible event but it is a start.

These are things that could be a medical emergency and may require an immediate evacuation:

None of these are walk outs, they are carry outs except where noted. Some of these people will absolutely not be able to walk out. Others may want to and should actively be dissuaded from doing it. It should be noted that in the backcountry there is always going to be second guessing about carry outs because they put rescuers at risk and just as importantly they delay evacuation for the person with the condition. In these following cases I would consider a carry out to be a necessity until proven otherwise or clearance from a doctor. Contacting a doctor through the SAR team or relay by cell phone if possible to reinforce that belief should be attempted if possible. Try to get a doctor from the ER to talk to about the situation. Give as complete a medical history as you can including a SAMPLE and OPQRST work up and as full a patient assessment including vitals as you can to help them make an evaluation. If you need to know what the SAMPLE and OPQRST mnemonics mean I will tell you but what that actually means is you need to take a First responder or first aid class.


Here is the probably incomplete list:

Prolonged intense pain anywhere in the body, intermittent or constant.

Someone complaining of pain, constriction, pressure or heartburn in the chest area behind the sternum. Chest pain that radiates into the jaw or left arm. Those are symptoms in both men and women. Men also, but in particular women with any severe abdominal or back pain especially if the women are of child bearing age. Especially if either sex are diaphoretic (heavy perspiration). Especially if they also have dizziness, feel like passing out or have passed out. In particular with defecation and/or urination if they do pass out. Especially if the pain doesn't stop after resting for 10 minutes or if it restarts on exertion.

Any difficulty in breathing the patient considers abnormal.

Any altered mental status including passing out. Check if they are a known diabetic by looking for medic alert brackets or check their medical history if they are coherent. Are they conscious? If so try giving them some food or place some sugar between their cheek and gum if you suspect a diabetic issue. Don’t put anything in their mouth unless they are conscious enough to be able to protect their airway to prevent aspiration of the food. Also, don’t put your fingers in the mouth of any person with altered mentation. This type of an emergency may be a walk out if you can get them to a stable mental state. Always approach altered people with caution. Don’t get yourself in a situation where you cannot retreat if you need to. Altered people, even friends, can be dangerous. Always protect yourself.

A patient with drooping or weakness on one side of the body. Learn the Cincinnati stroke index and how to do it.

Cincinnati stroke index

With strokes time is of the utmost importance. Depending on if it is a wet stroke or dry stroke that will determine how the hospital is going to proceed with treatment. You need to document to the best of your ability the time of onset. This is critical as they only have a relatively small window to use the drugs for a stroke caused by a clot.

Evacuation by helicopter for strokes in particular should be mentioned and strongly considered if possible.

In my first aid kit I always carry eight baby aspirin or two 325mg adult aspirin (minimum) for use on myself.

What I am going to say next I need to qualify with several caveats. Offering, giving, suggesting, etc. to anyone that they take any medicine, any medicine, always opens oneself up to serious legal problems. I, like any EMT operates under protocols that are designed by committees and doctors and backed by national protocols, state protocols, regional EMS council protocols and our sponsor hospital. Doing what the tell us to do while in their jurisdiction protects us (EMT’s) legally. What I can tell you is that anyone in my jurisdiction gets 325mg of aspirin as part of our protocol for chest pain suspected as heart related. PROVIDING they have no known aspirin allergy, they are over 13 years of age and they have no known active GI bleed. We are talking about 4 baby aspirin (81 mg) or one adult aspirin (325 mg) chewed. Other areas have different protocols that include 162mg and others have no protocol for aspirin at all. Even me doing this in a wilderness setting technically/legally can be a problem for me. Just a warning.


I will try to answer any questions there might be and remember I am not the final medical authority. While this is as accurate as I feel I can make it if you have other questions in particular about yourself ask your doctor. I am not giving medical advice, just mentioning protocols used in my jurisdiction that are considered acceptable. Other areas may have different protocols.

Hopefully this will be of some use.

Regards,
Keith

EMS Instructor candidate
CT EMT-B
Wilderness EMT
NREMT-B
PHTLS
PEPPS

 

[Jason Berard]

Thank you for posting this, Keith. We always say on this board that we should learn from our experiences, and the experience of others. I hope people can learn from your post.

 

[RoySwkr]

What I can tell you is that anyone in my jurisdiction gets 325mg of aspirin as part of our protocol for chest pain suspected as heart related.

I carry 2 of the 325mg aspirin and will take them both if I feel chest pain which I haven't.

I also carry 2 Benadryl which I will take for bee stings if I need to.

These are normal adult doses and I am not allergic to either, while I will offer them to others I don't know their allergies and will let the take them themselves.

 

[SAR-EMT40]

These are normal adult doses and I am not allergic to either, while I will offer them to others I don't know their allergies and will let the take them themselves.

Hi Roy,

I am certainly not telling you what to do but some things to think about.


Those are adult doses (650mg) primarily for pain and fever control. There are two concerns with doses that high for use with cardiac patients. The first is that many agencies believe that 162mg is effective for cardiac distress. There is also evidence that 325mg is no better in treating cardiac problems in an anti-platelet role than 165mg and there is clear evidence that greater than 325mg is counter-productive. With the higher dosage there is also an increased risk of bleeding and some surgeons will not operate because they feel the bleeding risk is too great. Secondly, if I am in contact with a doc in the ER or on scene. I have strong concerns about the long transport times to get me or someone else out of the woods. I would like to be able to have at least one more dose, maybe more if I have a doc tell me that I can administer it over an amount of time. Problem is I don’t know when that time would be. I don’t know if there are any studies that tells when that is. Usually a medic would be on scene soon after the administration of the aspirin and he has hospital based protocols with very powerful anti-platelet medications that he can use.

Again, I am not telling you what to do but I personally would not take more than 325mg. I would not give more than 325mg to my mother if she was having a suspected cardiac problem. And no, no matter what the outcome I would not expect my mom to sue me or press charges.

I have mentioned things about Benadryl in other posts that I think is easy enough to find. If you don’t have an anaphylactic reaction Benadryl is probably going to be fine if you actually need it. If it is a true anaphylactic reaction then Benadryl is probably not going to work as a first defense but may be of use if taken immediately after taking an epi. Hopefully the Benadryl will be kicking in by the time the epi wears off. Two epis being available in addition to the Benadryl would be preferable so a second can be administered when the first epi wears off if needed.

Again, I am not the final word on any of this. If you have questions/suspicions about what I have written please talk to your doc.

Regards,
Keith

 

[Mohamed Ellozy]

Keith,

Thanks! I was about to ask Roy why two tablets. If one is good, two are better????

I have known that chewing is usually advocated, but until your post did not do any research. Here is one article I found: Aspirin for heart attack: Chew or swallow?.

 

[peakn]

Thanks for the post Keith. I always carry Benadryl, Acetaminophen and Ibuprofen but will now add Aspirin to the kit.

 

[Waumbek]

Do not assume that aspirin is a drug to be taken lightly and under any circumstances. It can be a life-saving drug for an ischemic stroke (clot), but it can also be a death-dealing or seriously disabling drug for a hemorrhagic stroke (brain bleed). Clots account for the large majority of strokes, but it's still a gamble when you self-medicate. Most people know the signs of ischemic stroke. Also learn the signs of hemorrhagic stroke. The severe, even crushing, headache that sometimes occurs is not to be treated with aspirin or any other blood-thinner. The nausea that also sometimes accompanies hemorrhagic stroke can be misinterpreted as cardiac related. I would not automatically toss aspirin down if I were within reach of qualified medical evaluation, that is, a hospital ER. If I were three miles up a trail, I might gamble on the aspirin for myself, but not for someone else.

 

[peakn]

Good point. In addition, they may have taken Ibuprofen earlier and that would add to the blood thinning effect. I saw an article recently (don't remember where) that mixing Ibu and Aspirin can increase the risk of stroke.

 

[SAR-EMT40]

Keith,

Thanks! I was about to ask Roy why two tablets. If one is good, two are better????

I have known that chewing is usually advocated, but until your post did not do any research. Here is one article I found: Aspirin for heart attack: Chew or swallow?.

Great reference Mo. Absolutely they should be chewed to speed absorption. Even if they aren't the baby aspirin. Also make sure what you carry doesn’t say enteric coated. As a side note the adult aspirin is going to taste like crap but its better than the alternative.

Just one other comment on how aspirin works and what it does. It does not reverse the heart attack. You are not likely to feel better. Hopefully you will not get worse. It is an anti-platelet which basically makes the clotting factors in your blood "greasy" so that they slide over one another instead of collecting and prevents the coronary vessel from getting more clogged. It does not reverse any of the clots that are causing the problem.

Keith

 

[Kevin Rooney]

Chewed vs. Swallowed vs. Under the Tongue?

Keith -

I've been told by medical personnel that the fastest absorption is to place the aspirin under the tongue. Do you have any comments on that?

Mohamed - thanks for the reference.

peakn - I've also read there are some risks to taking ibuprofen and aspirin, so I googled it recently and found that it has to do with timing. I don't recall the recommended minimum interval, but I was satisfied that if I take an aspirin in the morning at breakfast, then enough time will have elapsed if I take ibuprofen after a long hike.

 

[Paradox]

Great post Keith. Two questions 1) Is "baby aspirin" still available? and 2) Does SAR carry the new, smaller, Automated External Defibrillators (AED) or do you figure it is too late by the time you would get one to the patient?

 

[RoySwkr]

1) Is "baby aspirin" still available?

Yes, it is now called low-dose or somesuch and it costs more than the full dose.

> There is also evidence that 325mg is no better in treating cardiac
> problems in an anti-platelet role than 165mg and there is clear evidence
> that greater than 325mg is counter-productive.

Thank you for this information, I was of course just assuming "more is better" and taking the maximum labelled dose for headache since aspirin is not labelled for self-administration for cardiac use.

> I have strong concerns about the long transport times to get me or
> someone else out of the woods.

My greater concern is that since I usually hike alone, any treatment I get for a serious condition may be limited to what I do for myself before I pass out.

 

[SAR-EMT40]

Great post Keith. Two questions 1) Is "baby aspirin" still available? and 2) Does SAR carry the new, smaller, Automated External Defibrillators (AED) or do you figure it is too late by the time you would get one to the patient?

1) Absolutely. I carry baby aspirin with me. It tastes much better than the Adult stuff ? Make sure any aspirin you use is not enteric coated.

2) The new smaller AED's are still not that small and light. At least the ones I am familiar with. Since AED's treat a very limited set of abnormal heart rhythms I doubt that they would carry them and like you said. It is unlikely that all the events would come together at the right time to make it useful considering how long it takes a search team to get to a location. It could be done but there are probably many other things that would go in a pack first considering the weight, and volume that an AED would take up and considering the chances that it would be used.

Keith

 

[SAR-EMT40]

Keith -

I've been told by medical personnel that the fastest absorption is to place the aspirin under the tongue. Do you have any comments on that?

Our policy is to chew and swallow the aspirin for what that is worth. I would definitely chew it because I think the absorption is faster the smaller you make the aspirin because you produce more surface area. The smaller the aspirin pieces the greater the amount of surface area that can be covered and used to absorb it so I would expect absorption to go faster which seems to be borne out in the study that Mo listed.

Glucose is administered between the cheek and gum for faster absorption but that is different because glucose can be used directly by the body. It doesn’t need to be broken down into something else. I don’t know if aspirin is used in the same way by the body. Maybe someone with a chemistry/biology degree or a Doc knows the answer and could chime in.

Keith

 

[SAR-EMT40]

My greater concern is that since I usually hike alone, any treatment I get for a serious condition may be limited to what I do for myself before I pass out.

I hear you Roy. I also have concerns like that when soloing so I know what you are talking about.

In that situation you have to do what you think is right for yourself. I believe I will still use my training and stick to the protocols if it is me but I'll grant you I'm closer than usual to the person I’m treating. And I think very highly of this patient. I think I will behave the way I should.

Keith

 

[marty]

Thank you Keith and everyone who posted for sharing your vast wisdom on this difficult, but most important topic.

Best regards,
Marty

 

[Neil]

I say this in the friendliest and nicest possible way.

But,

When you treat yourself you have a fool for a patient.

That has to be factored into the solo self-help strategy, somehow.