This document provides an overview of responding to emergency medical calls as a paramedic. It discusses gathering key information from callers, developing a differential diagnosis based on symptoms, performing a focused physical exam, considering clinical scenarios and protocols for treatment. Specific examples covered include responding to calls for abdominal pain, chest pain, shortness of breath and headaches. Clinical decision making for emergency childbirth, seizures, allergic reactions and cardiac arrest are also reviewed. The document emphasizes developing an assessment and treatment plan tailored to the patient's condition.

1. WHAT’S BEHIND DOOR
NUMBER 2...?
Veronica Bonales, M.D.
CEPAmerica, Emergency Medicine
EMCC Paramedic Coordinator

2. 911, What’s your emergency?

3. Responding to a Call

4. Responding to a Call
Need the info

5. Responding to a Call
Need the info
Age

6. Responding to a Call
Need the info
Age
Sex

7. Responding to a Call
Need the info
Age
Sex
Chief Complaint

8. What are the possibilities?

9. What are the possibilities?
AKA the differential...

10. What are the possibilities?
AKA the differential...
What could cause chief complaint?

11. What are the possibilities?
AKA the differential...
What could cause chief complaint?
What are issues related to age?

12. What are the possibilities?
AKA the differential...
What could cause chief complaint?
What are issues related to age?
What are issues related to sex?

13. Headache

14. Headache

15. Headache

16. Headache
Migraine

17. Headache
Migraine CVA

18. Headache
Migraine CVA
Bleed

19. Headache
Migraine CVA
Trauma
Bleed

20. Headache
Migraine CVA
Trauma
Infection
Bleed

21. Headache
Migraine CVA
Tumor
Trauma
Infection
Bleed

22. Headache
Migraine CVA
Tumor
Trauma
Infection
Bleed

23. Headache
Migraine CVA
Tumor
Trauma
Infection
Bleed

24. Headache
Migraine CVA
Tumor
Trauma
Infection
X
Bleed

25. Headache
X
Migraine CVA
Tumor
Trauma
Infection
X
Bleed

26. Headache
X
Migraine
X
CVA
Tumor
Trauma
Infection
X
Bleed

27. Chest Pain

28. Chest Pain
AGE-related
CAUSES
- infant
SEX - Muscle/Skeletal
- child
- Male - Cardiac
- teen
- Female - Pulmonary
- adult
- GI
- elderly

29. Shortness of Breath

30. Shortness of Breath
CAUSES
- Muscle/Skeletal
- Cardiac
- Pulmonary
- GI

31. Abdominal Pain

32. Abdominal Pain

33. Primum Non Nocere

34. Arriving at the Scene

35. Arriving at the Scene
Survey the scene
A - Airway
B - Breathing
C - Circulation
D - Disability
E - Exposure

36. Vitals
Heart Rate
Respiratory Rate
Blood Pressure
Temperature
Pain Scale

37. Physical Exam
Focused but thorough

38. Clinical Scenarios

39. 911 Call
28 y.o. female c/o
abdominal pain and
vaginal bleeding.

40. 911 Call
28 y.o. female c/o
abdominal pain and
vaginal bleeding.

41. What is the differential...??

42. What is the differential...??
Ectopic pregnancy

43. What is the differential...??
Ectopic pregnancy
Ruptured ovarian cyst

44. What is the differential...??
Ectopic pregnancy
Ruptured ovarian cyst
Dysparunia

45. What is the differential...??
Ectopic pregnancy
Ruptured ovarian cyst
Dysparunia
Complicated UTI

46. What is the differential...??
Ectopic pregnancy
Ruptured ovarian cyst
Dysparunia
Complicated UTI
Trauma

47. Behind door #1...
Pain off and on
since last night
Now more intense
and more frequent
cramping pain
Noticed blood after
went to bathroom

48. Behind door #1...
Pain off and on
since last night
Now more intense
and more frequent
cramping pain
Noticed blood after
went to bathroom

49. Now what...??

50. Now what...??
Imminent delivery

51. Now what...??
Imminent delivery
Back-up

52. Now what...??
Imminent delivery
Back-up
Supplies

53. Now what...??
Imminent delivery
Back-up
Supplies
Position

54. Now what...??
Imminent delivery
Back-up
Supplies
Position
Slow and controlled

55. Now what...??

56. Now what...??
Not this.....

57. Now what...??

58. Now what...??
Place patient into position

59. Now what...??
Place patient into position
Gloves or clean hands

60. Now what...??
Place patient into position
Gloves or clean hands
Towel and control the head

61. Now what...??

62. Now what...??
Support head

63. Now what...??
Support head
Tell mother to stop pushing
when head is out

64. Now what...??
Support head
Tell mother to stop pushing
when head is out
Check for nucal cord

65. Now what...??
Support head
Tell mother to stop pushing
when head is out
Check for nucal cord
Remove if found

66. Now what...??

67. Now what...??
Support head

68. Now what...??
Support head
Pull down then pull up to
deliver each shoulder

69. Now what...??
Support head
Pull down then pull up to
deliver each shoulder
Hold baby firm as will slide
out easily

70. Now what...??

71. Now what...??
Protocols...

72. Now what...??
Protocols...
Lay baby on mother’s abdomen and transport

73. Now what...??
Protocols...
Lay baby on mother’s abdomen and transport
Cut umbilical cord and transport

74. Now what...??
Protocols...
Lay baby on mother’s abdomen and transport
Cut umbilical cord and transport
Deliver placenta and transport

75. Questions...?

76. 911 Call
40 something year
old male witnessed
fall at bus stop

77. 911 Call
40 something year
old male witnessed
fall at bus stop

78. What is the differential...??

79. What is the differential...??
Drunk

80. What is the differential...??
Drunk
Stoned

81. What is the differential...??
Drunk
Stoned
Drunk and stoned

82. 911 Call
Civilians standing
at bus stop say
patient sitting on
bench and “just fell
over.”

83. Behind door #2...

84. Behind door #2...
Pt. does not respond
to painful stimuli,
smells of alcohol,
no obvious trauma
found, put on
gurney and carry
into rig and start
transport

85. Behind door #2...
Pt. does not respond En route, patient
to painful stimuli, starts to have
smells of alcohol, seizures...
no obvious trauma
found, put on
gurney and carry
into rig and start
transport

86. Behind door #2...
Pt. does not respond En route, patient
to painful stimuli, starts to have
smells of alcohol, seizures...
no obvious trauma
found, put on
gurney and carry
into rig and start
transport

87. What do you do...?

88. What do you do...?
Benzo’s
Airway support
Establish iv
Get to E.D.

89. What do you do...?
Benzo’s
Airway support
Establish iv
Get to E.D.

90. EMS History

91. EMS History

92. EMS History
David Rosenbaum, 2006
Journalist living in D.C.
Found by F.D. and thought to be intoxicated
EMS took 20 minutes to arrive & bypassed closest
hospital
Waited in E.D. For an hour before RN noted
patient vomiting
Died of trauma to head after assault

93. Questions...?

94. 911 Call
35 year old male
with chest pain

95. 911 Call
35 year old male
with chest pain

96. What is the differential...??

97. What is the differential...??
Musculoskeletal

98. What is the differential...??
Musculoskeletal
Pulmonary

99. What is the differential...??
Musculoskeletal
Pulmonary
Anxiety

100. What is the differential...??
Musculoskeletal
Pulmonary
Anxiety
Cardiac

101. Behind door #3...
States was going to
gym when felt
pressure in middle of
chest
Girlfriend made him
call
He thinks it’s just a
pulled muscle

102. 911 Call

103. 911 Call

104. Now what...?
Morphine
Oxygen
Nitroglycerin
ASA
Call to activate cath
lab!!

107. Normal Sinus

110. Atrial Fibrillation

113. Atrial Flutter

116. Torsades de Pointes

119. Ventricular Tachycardia

122. Ventricular Fibrillation

123. Medical Scenarios:
Trauma Scenarios:
Wrist Laceration Asthma Attack, Emphysema, Chronic Bronchitis,
Burns CHF/Pulmonary Edema, Pneumonia, Pulmonary
Skull Fracture Embolism
Motor Vehicle Accident Myocardial Infarction (MI), Silent MI, Cardiogenic
Diving Accident Shock, Abdominal Aortic Aneurysm, Syncopal
Blunt Chest Trauma Episode
Cardiac Tamponade Stroke, Transient Ischemic Attack, Grand Mal Seizure
Penetrating Abdominal Trauma Hypoglycemia, Diabetic Ketoacidosis, Hyperosmolar
Upper Extremity Fracture Hyperglycemic Nonketotic Coma (HHNC)
Femoral Shaft Fracture Bee Allergy
Joint Injury Upper Gastrointestinal Bleed, Lower Gastrointestinal
Vehicle vs. Pedestrian Accident Bleed, Appendicitis
Overdose
Heat Exhaustion
Ectopic Pregnancy, Placenta Abruptio, Placenta Previa,
Normal Delivery, Nuchal Cord, Meconium Stain
Pediatrics—Croup, Pediatrics—Epiglottitis, Pediatrics
—Asthma, Pediatrics—Bronchiolitis
Pediatrics—Hypovolemic Shock

124. 911 Called - 58 yo female with allergic
reaction

125. On arrival, female complaining of
swelling of tongue
States has been getting worse all
afternoon
Now feels more difficulty speaking

126. PMHx: HTN, Hyperlipidemia
PSxHx: Hysterectomy
Meds: Lipitor, Niacin, Lisinopril
Allergies: food allergies

127. Went to Church this morning, attended a
Church picnic afterward, went home and
took a nap, awoke with swollen tongue
Vitals: HR 85, B/P 135/85, RR 16,
Pulse Ox 96%

128. Physical exam: well-nourished female
in NAD, PERRL, large tongue, no stridor,
RRR, CTA bilat, soft/NT/+BS, no edema,
MAE

129. You suspect an allergic reaction. Name
three drugs that you would give
immediately.

130. Patient feels minimal improvement after
you give the medication.

131. You place on monitor in the ambulance
and pulse ox is now 91%. RR is 16.
You would:
A. do nothing
B. start nasal cannula at 3L
C. start face mask at 15L

132. After applying oxygen, patient feels
slightly better but then begins to
complain of chest pain. You look at the
monitor and see sinus tachycardia. HR
110.
Why would she have this?

133. You hang a bag of normal saline and
start to secure the patient when she
says, “I don’t feel so good” in a very
scratchy voice. She then stops
breathing.

134. For RSI
name a drug that is an induction
agent
name a drug that is a paralytic

135. Put these in order
A. induction agent
B. visualize vocal cords
C. preoxygenate
D. paralytic agent
E. intubate

136. Name 4 things that confirm ETT
placement

137. Patient is successfully intubated

138. You go to revital patient and see this on
the monitor, B/P 120/ 45
Name a drug you can give for this
rhythm

139. While you are deciding which drug to
give, you start to see this on the
monitor; there is no pulse

140. What do you do now?

141. If rhythm continues what do you do
next?

142. You get back a rhythm but then lose
pulses and see asystole on the monitor.
What is the first thing you do?
Name two drugs you would use

143. You have return of spontaneous
circulation. Depending on protocol,
what might you initiate?

144. The patient is stable, HR 75, B/P
130/50, intubated, 100% on pulse ox.
Transport to E.D.

145. Questions...??