Part 1:

You are working in a tent set up to care for runners in a 10K race raising money for a local daycare center for handicapped children. Your team includes three paramedics, a physician's assistant, and another EMT. The outdoor temperature is 95ºF and it is very humid. There are about 100 runners of all ages in the race.

There are five patients currently in the tent being evaluated for various symptoms ranging from a twisted ankle to dehydration. The paramedics and the physician's assistant are all taking care of patients when another patient limps into the tent.  You bring the patient over to a cot to begin assessment. You notice that the patient is flushed and seems a bit confused.

1.         What kind of problems might you expect to find in your new patient?

2.         What should you do first to assess him?

Part 2:

The patient seems a bit tachypneic, but is moving air through his lungs with no abnormal sounds. You see no signs of bleeding, but notice that his skin is hot and dry, and he remains flushed. His respiratory rate is 28 breaths/min, with a pulse rate of 124 beat/min that seems to be a bit thready. His blood pressure is 94/60 mm Hg, and his temperature is 104ºF.

You try to obtain some history from your patient. He is able to tell you his first name is Robert, and he thinks he is 45 year old, but he is not able to give you any other information. He suddenly leans forward and vomits. Afterwards, he seems even more confused. 

3.         What should you do now?

Part 3:

You call over to one of the paramedics who is nearby and tell him you think your patient may be suffering from heat stroke.  He says that he will be there in a minute, but to start cooling the patient.  You place the patient supine and wet him down with water-soaked towels. You set one of the fans in the tent so that it is blowing on the patient. You also put some icepacks around the patient's neck, under his arms, and by his groin.

The paramedic comes over and asks you if you can set up an intravenous line for him. You spike a liter bag of normal saline, fill the drip chamber, and run the fluid through the tubing. You make sure that the air bubbles have all been bled from the tubing.  You also prepare some tape, which you hand to the paramedic to secure the IV catheter.

4.         What observations should you make related to the intravenous line?

Part 4:

The paramedic asks you to bring over a cardiac monitor, and you assist in placing the patches on the patient's lower limbs while he is placing the patches on the upper limbs. You also put an oxygen saturation probe from the monitor on the patient's finger; as the oxygen saturation level is 92% on room air, you apply a nonrebreathing mask at 15 L/min.

The paramedic asks you to call for a transport unit from the staging area. You radio the staging area, and while you are waiting, do another set of vital signs. The current vital signs are a respiratory rate of 20 breaths/min, pulse rate of 116 beats/min, and blood pressure of 98/62 mm Hg. The patient is still very confused.

5.         What do the current vital signs tell you about the patient's status?

Part 5:

Because the paramedic is busy with another patient that was just brought in, you meet the transporting crew, and proceed to give them a report about the patient.

6.         What should you include in your report?

Part 6:

You tell the responding crews that the patient was, and remains, confused with hot, flushed, dry skin.  You tell them the original and most recent set of vital signs. You report what cooling measures have been taken and the status of the intravenous line, including that about one-half the bag has been infused. The ALS crew takes over the care of the patient, and when they have gone, you begin to assist with other patients that are coming into the tent.

7.         What is one of the most important parts of working with an ALS crew?

Summary:

There are often times when providers of different levels, and some times from different agencies or disciplines, need to work together. Recognition of how those providers can work together is essential to a good outcome. Communication is an important element of the teamwork involved.    

Patients with more serious conditions may need a higher level of care. It is essential that BLS providers recognize when an ALS provider is needed, and what information is important to report to that provider. BLS providers may be able to provide additional assistance to the ALS provider by setting up intravenous lines, applying ECG monitoring electrodes, or helping with other procedures, depending on local protocols and training. 

1. What kind of problems might you expect to find in your new patient?

• Based on the signs and symptoms presented like flush and confusion, the patient is likely suffering from heat stroke.
• Heatstroke is a condition caused by your body overheating, usually as a result of prolonged exposure to or physical exertion in high temperatures. This most serious form of heat injury, heatstroke, can occur if your body temperature rises to 104 F (40 C) or higher. The condition is most common in the summer months.(citation)
• Heatstroke requires emergency treatment. Untreated heatstroke can quickly damage your brain, heart, kidneys and muscles. The damage worsens the longer treatment is delayed, increasing your risk of serious complications or death.(citation)
• Confusion, agitation, slurred speech, irritability, delirium, seizures and coma can all result from heatstroke. There is also an alteration in sweating. In heatstroke brought on by hot weather, your skin will feel hot and dry to the touch(citation)

2. What should you do first to assess him?

• The actual body temperature needs to be monitored at the core. Usually the thermometer is placed within the mouth, in the groin folds or armpits to detect the core temperature. A temperature of 40°C (104°F) or above is often a major sign of heatstroke(Citation)

Check for Heatstroke signs and symptoms such as:

• High body temperature. A core body temperature of 104 F (40 C) or higher, obtained with a rectal thermometer, is the main sign of heatstroke.
• Altered mental state or behavior. Confusion, agitation, slurred speech, irritability, delirium, seizures and coma can all result from heatstroke.
• Alteration in sweating. In heatstroke brought on by hot weather, your skin will feel hot and dry to the touch. However, in heatstroke brought on by strenuous exercise, your skin may feel dry or slightly moist.
• Nausea and vomiting. You may feel sick to your stomach or vomit.
• Flushed skin. Your skin may turn red as your body temperature increases.
• Rapid breathing. Your breathing may become rapid and shallow.
• Racing heart rate. Your pulse may significantly increase because heat stress places a tremendous burden on your heart to help cool your body.
• Headache. Your head may throb.(citation)mayoclinic.org

3. What should you do now?

• Remove excess clothing, and cool him or her by whatever means available, for example: Place in a tub of cool water or a cool shower or fan the person to immediately cool down the body temperature which is 104ºF(citation)
• Watch for signs of rapidly progressing heatstroke, such as seizure, unconsciousness for longer than a few seconds, and moderate to severe difficulty breathing.(Citation)
• Offer the patient fluids like water or sports drink to take to prevent further dehydration.
• The nurse should also refer the patient to the physician for possible intravenous fluid therapy for low blood pressure and to prevent severe dehydration.

4. What observations should you make related to the intravenous line?

• The nurse should check the catheter position, patency/occlusion, limb symmetry, any signs of phlebitis (erythema or redness of the skin or mucous membranes, swelling and pain), infiltration/extravasation. Intravenous infiltrations and extravasations occur when fluid leaks out of the vein into surrounding soft tissue.(citation)
• Observations of the IV site, type of fluid and volume infused, accurate rate of infusion for patient is also needed.(citation)

5. What do the current vital signs tell you about the patient's status?

• The body increases its respiration and heart rate in a person with heat stroke as a compensation to lower down the temperature. The patient's respiratory rate decreased from 28 to 20 breaths/minute and pulse rate decreased from 124 to 116 beat/min which means that the body is starting to cool down. The oxygen therapy via nonrebreathing mask at 15 L/min also helps in stabilizing the respiration of the patient.
• Heat causes an increase in blood flow to the skin and pooling of blood in the legs, which can lead to a sudden drop in blood pressure. There can be a feeling of light-headedness before fainting occurs. (Citation)betterhealth.vic.gov.au
• In the case of the patient, the initial blood pressure is 94/60 mm Hg but increased to 98/62 mm Hg. It is a good indicator that the patient is starting to cool down.

6. What should you include in your report?

• The patient's name is Robert and thinks he is 45 years old.

Initial Assessment:

• He was brought to the tent flushed and seems a bit confused upon assessment.
• The patient seems a bit tachypneic, but is moving air through his lungs with no abnormal sounds.
• With no signs of bleeding, but notice that his skin is hot and dry, and he remains flushed. His respiratory rate is 28 breaths/min, with a pulse rate of 124 beat/min that seems to be a bit thready. His blood pressure is 94/60 mm Hg, and his temperature is 104ºF. The patient also vomits.

Interventions performed:

• The patient was placed in a supine position and wet him down with water-soaked towels. Set one of the fans in the tent so that it is blowing on the patient. Icepacks are also put around the patient's neck, under his arms, and by his groin.
• Intravenous fluid was also started immediately. The patency and rate was also checked.
• The patient was also hooked to cardiac monitor, and oxygen saturation probe. The oxygen saturation level is 92% on room air so nonrebreathing mask at 15 L/min is applied.

Current Assessment:

• The current vital signs are a respiratory rate of 20 breaths/min, pulse rate of 116 beats/min, and blood pressure of 98/62 mm Hg. The patient is still very confused.

7. What is one of the most important parts of working with an ALS crew?

• Advanced Life Support (ALS) is a set of life-saving protocols and skills that extend beyond Basic Life Support (BLS). It is used to provide urgent treatment to cardiac emergencies such as cardiac arrest, stroke, myocardial infarction, and other conditions. (Citation)www.zoll.com
• It is important to work with an ALS crew because when there is an Emergency Medical Situation that needs an urgent and more complicated treatment, the ALS crew can act accordingly which can increase the chance of survival of the patient.