Presented by Mike Helbock, M.I.C.P., NREMT-P Director - EMS Associates Clinical Educator – Prehospital Medicine Seattle/King County EMS Disclaimer Division of Emergency Medicine [email protected] Mike Helbock Developed and Co-Authored the SICK… Adult and Pediatric Sick/Not Sick Program Acknowledgements: NOT SICK American Academy of Orthopaedic Surgeons American Academy of Pediatrics Jones and Bartlett Publishers John Jerin 2013
SICK/NOT SICK…
What ’s it all about?
1 Make a Decision! EMS Providers must
SICK NOT SICK do (2) things...
Make decisions Treat patients (based on the decision)
The Decision
We must make a Decision!
2 SICK Who ’s SICK * Respiratory compromise The SICK patient is one who you * Hemodynamic compromise believe is physiologically unstable * Neurologically impaired based on key clinical indicators * Obvious trauma/MOI * Skins signs/color (skin vitals) * Body position * Index of suspicion (IOS)…gut feel
SICK
This patient could die en route!
NOT SICK Who ’s NOT SICK
The NOT SICK patient is one *Respiratory status is stable who you believe is physiologically *Hemodynamically stable stable based on key clinical signs. *Neurologically stable *Appropriate skin signs/color *Position of comfort
3 NOT SICK
This patient will probably not die en route! The Treatment
The Clinical Picture (Medical)
Chief Complaint/N.O.I. Respirations Pulse Mental Status Skin Signs/Color Body Position We treat – based on our The Clinical Picture decision…!
Chief Complaint/N.O.I. Respirations Make a Decision! Pulse Mental Status Skin Signs/Color Body Position The Clinical Picture Chief Complaint/N.O.I. Respirations SICK DECIDE NOT SICK Pulse Short Report *Care for obvious/additional to ALS Low/Moderate Mental Status Flow O2 conditions as needed *Treat life-threatening 100% O2 Skin Signs/Color conditions immediately NRM or BVM Body Position History and History and *SAMPLE history Baseline Vitals *SAMPLE history Baseline Vitals *OPQRST
Appropriate Full Set Vitals The Clinical Picture Position Full Exam
Rapid Trans- Short Report Appropriate port/ALS to ALS Treatment
SICK DECIDE NOT SICK Full Set Vitals Appropriate Full Exam Transport
Reassess Reassess
4 Chief Complaint/N.O.I. Respirations Pulse Mental Status Skin Signs/Color The Clinical Picture Body Position The Clinical Picture
SICK DECIDE NOT SICK
Short Report *Care for obvious/additional to ALS Low/Moderate Flow O2 conditions as needed Form the clinical picture within *Treat life-threatening 100% O2 conditions immediately NRM or BVM 60 seconds! History and History and *SAMPLE history Baseline Vitals *SAMPLE history Baseline Vitals *OPQRST
Appropriate Full Set Vitals Position Full Exam
Rapid Trans- Short Report Appropriate Port/ALS to ALS Treatment
Full Set Vitals Appropriate Full Exam Transport
Reassess Reassess
The Clinical Picture Make a Decision! (Trauma)
Chief Complaint/M.O.I. Chief Complaint/M.O.I. Respirations Respirations Pulse Mental Status Pulse Skin Signs/Color Mental Status Obvious Trauma Skin Signs/Color Obvious Trauma The Clinical Picture The Clinical Picture SICK DECIDE NOT SICK
Chief Complaint/M.O.I. Chief Complaint/M.O.I. Respirations Respirations Pulse Pulse Mental Status Mental Status Skin Signs/Color Skin Signs/Color Obvious Trauma Obvious Trauma The Clinical Picture The Clinical Picture
SICK DECIDE NOT SICK SICK DECIDE NOT SICK
Short Report Short Report to ALS to ALS
*Treat life-threatening Rapid 100% O2 Low/Moderate Spinal *Care for obvious/additional *Treat life-threatening Rapid 100% O2 Low/Moderate Spinal *Care for obvious/additional Extrication Extrication conditions immediately NRM or BVM Flow O2 Stabilization Injuries as needed Conditions immediately NRM or BVM Flow O2 Stabilization Injuries as needed
History and *Rapid trauma assessment History and *Focused trauma assessment History and *Rapid trauma assessment History and *Focused trauma assessment Baseline Vitals Baseline Vitals Baseline Vitals Baseline Vitals *SAMPLE history *SAMPLE history *SAMPLE history *SAMPLE history
Immobilize Extricate/ Immobilize Extricate/ Spine Immobilize Spine Immobilize
Rapid Trans- Short Report Full Set Vitals Rapid Trans- Short Report Full Set Vitals port/ALS to ALS Full Exam port/ALS to ALS Full Exam
Full Set Vitals Appropriate Full Set Vitals Appropriate Full Exam Transport Full Exam Transport
Reassess Reassess Reassess Reassess
5 Other Factors Affecting SICK/NOT SICK
*Nature of Illness (NOI) *Mechanism of Injury (MOI) *Index of Suspicion (IOS)
*Always include these concerns in your plan! Start your plan en route!
Consider (3) probable scenarios… …which generate solutions SICK!
* Entrapment… * Head injuries … * Airway considerations … * Multi-system trauma …
6 NOT SICK!
Make em Patient Status Worsens “earn ” their keep! * Vitals change * Cardiac symptoms appear * Acute respiratory distress * Seizures reappear * Neurologic status changes
NOT SICK
You can move the patient to the SICK category at anytime!
7 Common Mistakes
* Delaying the initial decision * Failing to respond to new info * Tunnel vision
8 When All Else Fails ????? Treat what you know you have… for sure!
Don ’t forget the ABC ’s
Case Study # 1
32-year-old female complaining of abdominal SICK/NOT SICK pain and near syncope. En route you and your partner discuss three probable injuries or scenarios: Case Studies *ectopic pregnancy *flu *appendicitis
- You knock on the apartment door but no one Abdominal pain and vomiting, normal fluid intake answers. After knocking again a female voice yells from the back bedroom to let yourself in...you do so. Chief Complaint/N.O.I. No difficulty, - You approach the patient who is lying supine in bed. Respirations rate 16 You observe no obvious breathing difficulty. Her Pulse Flushed, warm Strong pulse 90 respiratory rate is 16 and non-labored. She has a and dry Mental Status strong radial pulse of 90. Skin Signs/Color Supine Body Position Conscious and alert - The patient appears conscious and alert, yet The Clinical Picture concerned. Her skin is slightly flushed, warm and dry.
- She complains of 2 to 3 days of abdominal pain with SICK DECIDE NOT SICK intermittent vomiting and normal fluid intake.
9 # Chief Complaint/N.O.I. Respirations Pulse Case Study 2 Mental Status Skin Signs/Color Body Position The Clinical Picture 28-year-old female...apparent overdose
SICK DECIDE NOT SICK While en route you and your partner discuss
Short Report *Care for obvious/additional to ALS Low/Moderate three probable scenarios: Flow O2 conditions as needed
*Treat life-threatening 100% O2 conditions immediately NRM or BVM *decreased respiratory drive/arrest
History and History and Baseline Vitals *SAMPLE history Baseline Vitals *SAMPLE history *OPQRST *decreased LOC
Appropriate Full Set Vitals Position Full Exam *presence of weapons Rapid Trans- Short Report Appropriate Port/ALS to ALS Treatment
Full Set Vitals Appropriate Full Exam Transport
Reassess Reassess
Overdose - The patient is lying on a couch at her boyfriend ’s house. The scene is secured by law enforcement Rate 20-24 Chief Complaint/N.O.I. w/o distress when you arrive. Respirations Pulse Weak radial - You see a lethargic female whose skin is pale, Skin is pale, Mental Status pulse of 150 cool and dry. Her respiratory rate is approximately cool and dry Skin Signs/Color Body Position Lethargic 20 - 24 BPM. You hear no abnormal breath Supine on couch sounds and see no signs of respiratory distress. The Clinical Picture
- Her radial pulse is weak at 150. SICK DECIDE NOT SICK
Chief Complaint/N.O.I. Respirations Pulse Mental Status Mechanism of Injury Skin Signs/Color Body Position The Clinical Picture SICK DECIDE NOT SICK * Height of fall
Short Report *Care for obvious/additional to ALS Low/Moderate Flow O2 conditions as needed * Type and size of vehicle *Treat life-threatening 100% O2 conditions immediately NRM or BVM * Damage sustained History and History and *SAMPLE history Baseline Vitals Baseline Vitals *SAMPLE history *OPQRST * Type and direction of forces Appropriate Full Set Vitals Full Exam Position * Type of weapon Rapid Trans- Short Report Appropriate port/ALS to ALS Treatment
Full Set Vitals Appropriate Full Exam Transport
Reassess Reassess
10 Saving Lives in Trauma
* Rapid assessment * Rapid treatment * Rapid transport to a trauma center
*Rapid *Rapid assessment treatment
*Rapid transport Make a Decision! to a trauma center SICK NOT SICK
11 # Case Study 3 - You approach the scene and see a two-car “T-bone ” in the intersection. The driver of car #1 is out and The alarms sounds for a two-car MVI at the inter- uninjured...in fact, he refuses care! The driver of car #2 is a section of 1st and Main . 42-year-old male, still belted in….minor mechanism of injury, little damage to either vehicle. You and your partner discuss three probable injuries or scenarios: - The patient complains of jaw and neck pain. He has a laceration on his forehead that is bleeding moderately over *multiple patients his face. He is alert and oriented. *extrication, backboarding/c-spine *potential need for additional help - His skin is slightly flushed, warm and dry. You see no obvious breathing difficulty. A strong radial pulse is present.
Jaw and neck pain Chief Complaint/M.O.I. Respirations minor MOI Pulse Mental Status Skin Signs/Color Obvious Trauma No distress Chief Complaint/M.O.I. The Clinical Picture Respirations Pulse Strong radial SICK DECIDE NOT SICK Flushed, pulse Mental Status Short Report warm and dry to ALS Skin Signs/Color Aler *Treat life-threatening Rapid 100% O2 Low/Moderate Spinal *Care for obvious/additional Extrication Obvious Trauma t Conditions immediately NRM or BVM Flow O2 Stabilization Injuries as needed Laceration to History and *Rapid trauma assessment History and *Focused trauma assessment Baseline Vitals Baseline Vitals forehead The Clinical Picture *SAMPLE history *SAMPLE history Immobilize Extricate/ Spine Immobilize
Rapid Trans- Short Report Full Set Vitals SICK DECIDE NOT SICK port/ALS to ALS Full Exam
Full Set Vitals Appropriate Full Exam Transport
Reassess Reassess
# Case Study 4 - You arrive to find a 47-year-old male on the back patio attended by his wife. He is being propped up in a sitting You are dispatched to the home of a man who position. was said to have fallen off a roof. - You see a man in respiratory distress with a rate of about You discuss the call with your partner en route 30. He appears conscious, but tired. His skin is pale. and come up with four probable scenarios: There is a small laceration on his head. His hand is clutching the left anterior area of his chest. Blood is *C-spine/head injury apparent from under his fingers. *impaled objects - His radial pulse is rapid and weak. He complains of *multiple fractures shortness of breath. The fall was confirmed to be about 15 *underlying medical problems feet.
12 Chief Complaint/M.O.I. Respirations 15 foot fall onto patio Pulse Mental Status Skin Signs/Color Obvious distress, Obvious Trauma Chief Complaint/M.O.I. rate of 30 The Clinical Picture Respirations SICK NOT SICK Pulse Weak radial DECIDE
Pale Mental Status pulse Short Report to ALS Skin Signs/Color *Treat life-threatening Rapid 100% O2 Low/Moderate Spinal *Care for obvious/additional Obvious Trauma Conscious conditions immediately Extrication NRM or BVM Flow O2 Stabilization Injuries as needed Minor head lac, but appears History and *Rapid trauma assessment History and *Focused trauma assessment Baseline Vitals Baseline Vitals chest injury The Clinical Picture tired *SAMPLE history *SAMPLE history Immobilize Extricate/ Spine Immobilize
Rapid Trans- Short Report Full Set Vitals SICK DECIDE NOT SICK port/ALS to ALS Full Exam
Full Set Vitals Appropriate Full Exam Transport
Reassess Reassess
Your patient will not die just because you can ’t diagnose the problem! SICK! He or she will die if you don ’t provide
…ABC ’’’s
You make the Decision!
NOT SICK! SICK NOT SICK
13 NOT SICK!
SICK!
NOT SICK!
SICK!
NOT SICK!
14 SICK!
SICK! SICK!
Related websites of Sick/Not Sick Interest… (www.sicknotsickcasestudies.com can be found @ (Sick/Not Sick Case Studies) Jones & Bartlett Publishers… (www.facebook.com/sicknotsick) (facebook – Sick/Not Sick) jblearning.com
15 Presented by Mike Helbock, M.I.C.P., NREMT-P Director - EMS Associates Clinical Educator – Prehospital Medicine Seattle/King County EMS Division of Emergency Medicine [email protected] SICK… NOT SICK
2013
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