Medical emergencies at protests

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Facilitator:
Time: 65 mins; 0915-1020
Actual time:
Learning Objectives:
Materials:

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Intro

Facilitator says

We are going to run through 8 potential medical emergencies in the next hour. If you want to see us act out assessment and response to any of these, just holler, "Stop!"

Facilitator says

The focus of this section: add common medical emergencies to your index of suspicion so you can recognize, get help, and stabilize while you wait.

Let the patient teach you

Facilitator says

Most people who are having a medical emergency have had one before. People with serious medical conditions often have made an emergency action plan with their doctor, and carry medications and emergency contacts.

Facilitator says

Always take a SAMPLE history, with the focus on the P ("Past pertinent medical conditions").

Facilitator says

If someone already has a lowered level of responsiveness (LOR) when you arrive

• Scene/comms buddy: interview friends (about MOI/NOI).
• Patient buddy: after checking ABCs, look for medic alert bracelets and medications.

Chest Pain

Facilitator describes chest pain

Persistent chest pain or discomfort (which can range from discomfort to an unbearable crushing sensation in the chest) that lasts longer than 3 to 5 minutes or is not relieved by resting, changing position, or goes away and then comes back.

Common causes

Fractured rib, heart attack, pulled muscle, other causes.

Facilitator asks

What are some assessment questions you could ask? Good answers:

• Required: a "trauma or medical?" question (E from SAMPLE: "What happened to you?" from STOP 12345 or "Were you hit in your chest?" -- P from SAMPLE: "Do you have a heart condition?" or "Do you have a medical condition that could cause this?" or "Has this ever happened to you before?")

• Optional: Any other relevant assessent questions (SAMPLE/OPQRST) or physical assessment of the chest (for DCAPBTLS).

What you can do

Facilitator says

• Get help -- call for back-up.

• Do initial assessment and focused assessment.

• Calm, ground, help person find most comfortable position (sitting tripod, lying propped up at 45 degree angle, laying down) while waiting for further care to arrive.

• Splint suspected broken rib.

Heart attack

Facilitator says

Anybody can have a heart attack anytime, anywhere. Chest pain is the most common symptom of heart attack in men, but sometimes there is no chest pain. Other common symptoms of heart attack:

• Discomfort, pain, or pressure in either arm; or that spreads to shoulder, arm, neck, or jaw.

• Breathing difficulty, which may cause dizziness.

• Nausea.

• Skin may appear pale or bluish in color. The face may be moist or may sweat profusely.

• Lowered LOR (level of responsiveness).

What you can do

Facilitator says

• Call 911 for help.

• Patient may have a heart attack plan, and just need help carrying it out.

• Convince and help patient to stop activity and rest comfortably.

• Try to obtain additional information about patient's condition.

• Ask if patient has medicine for her condition; help find it (it's probably nitroglycerine, which causes a headache).

• Wait for ambulance with patient and watch for changes in condition.

• Be prepared for heart to stop beating before the ambulance arrives: find someone who can do CPR and find the nearest AED.¹

Shortness Of Breath

Facilitator says

Yesterday morning you learned to recognize and respond to life threatening airway and breathing problems during initial assessment. What do you do for shortness of breath that is not an immediate emergency?

Common causes

Facilitator says

Lots of conditions cause shortness of breath: asthma attack, heart attack and other heart problems, anaphylaxis, burn to airway, panic, choking, COPD flare-up, blood clot to lung, lower respiratory infection (bronchitis/pneumonia).

What you can do

Facilitator says

• Do initial assessment and focused assessment. Ask "Medical or Trauma" questions like you did for chest pain. It could be both. Ask if patient has medicine for her condition; help find it (asthma inhaler, nitroglycerine, epi pen).

• It can be difficult to get more than "yes and no" answers when a person is short of breath.

• Calm, ground, help person find most comfortable position (sitting tripod, lying propped up at 45 degree angle, laying down) while waiting for further care to arrive.

• Get the person to fresh air if she are near anything that may be triggering shortness of breath.

• "Breathe with me."²

• Apply acupressure to Ding Chuan (EX 17) or Vital Diaphragm (B 38).

• Offer warm green tea or warm black tea for very minor breathing difficulties that are mostly under control.³

Red flags

Facilitator says

call 911 if the mechanism of injury (MOI) or assessment reveals any red flags. Get help if the person doesn't get better within 5 minutes, or gets worse.

Anaphylaxis

Facilitator says

You learned to recognize and respond to life threatening anaphylaxis during initial assessment yesterday morning. Now we're taking a closer look.

What Is It?

Facilitator asks

Who can define anaphylaxis? Good answer: Severe, life-threatening allergic reaction.

Facilitator says

Anybody can have a dangerous allergy to anything, anytime, anywhere, even if she's never had a bad reaction to the allergen before.

Cause

Facilitator says

The most common causes of anaphylaxis are drugs such as penicillin, foods such as nuts and shellfish, and stinging insects such as bees.

Facilitator says

This is why you ask the A question during SAMPLE history ("Are you allergic to any drugs, foods, or stinging insects?")

What it looks like

Facilitator says

• Small allergic reaction can cause a rash where person was exposed.

• Larger allergic reaction: sudden appearance of skin rash all over. Rash (swelling) may include airway -- in addition to itchy welts on skin, person may have shallow, rapid breathing, wheezing, swelling of throat/face/lips/tongue; restlessness; fainting/shock/unconsciousness.

What you can do

Facilitator asks

What do you do when a person may be having anaphylaxis? Good answers:

• Ask "Are you having an allergic reaction?"

• Ask "Do you have an Epi-pen?" Help the person find it and self-administer it.

• Call 911.

• Calm, comfort, reassure, and help the person sit or lay in position of comfort.

Abdominal Pain

Cause

Facilitator says

There's no way to know for sure in the field.

• Abdominal pain could be some pretty bad things, but you can't find out if it's something like ectopic pregnancy, appendicitis, or another immediately life-threatening condition from just an exam.

• Abdominal pain is often from pretty mundane things: constipation, haven't been drinking enough water, have been eating a lot of powerbars, didn't get to say that thing you really needed to say at the meeting.

What you can do

Facilitator says

Ask, "Has this ever happened before?" It is beyond your scope to assess abdominal pain, but you can help a person remember her own history. If she has a history of diverticulitis, Crohn's disease, or epigastric pain, it's probably not the first time she has felt this pain.

Facilitator says

If it hasn't happened before:

• Do initial assessment and focused assessment. Ask "Medical or Trauma" questions like you did for chest pain. It could be both. Ask about MOI for abdominal trauma.⁴

• Calm, ground, help person find most comfortable position (sitting or laying, knees drawn up, propped up at 45 degree angle).

Red flags

Facilitator says

Call 911 for any of the "Bad Belly 8"

• Cold and clammy skin with rapid pulse; ashy skin (signs of shock).

• Blood in vomit, feces, or urine.

• Pain that lasts longer than 12 hours.

• Pain just in one spot -- especially with guarding, tenderness, or rigidity.

• Pain that gets worse during jarring movement (like footsteps).

• Loss of appetite, vomiting, or diarrhea for more than a day.

• Fever over 102 F.

• History and signs that indicate possibility of pregnancy.⁵

Facilitator says

If there are no red flags: this is a good time to find a more experienced health worker. Take abdominal pain seriously: the patient could get worse fast.

Diabetic Emergency

What Is It?

Facilitator says

Situation in which someone with diabetes has an acute change in their blood chemistry -- sugar too high, sugar too low, or other abnormality. In a street situation low sugar more immediately dangerous than high.

Cause

Facilitator says

• Not eating enough, stress, exercise.

• Too much insulin or other diabetes medication.

• Infection or other illness.

What you can do

Facilitator says

• Give the person something sweet: Icing, honey, juice, sugar tablets. If patient has lowered LOR, consider rubbing sweet substance on gums.

• Help the person sit or lay down.

• If the person doesn't get better within 5 minutes, call 911.

• Get the person to more substantial food soon.

Seizure

What Is It?

Facilitator says

A seizure is a disordered firing of nerves in brain. May be small local seizures or involve whole body.

• Person may know it is coming.

• Person may or may not lose consciousness.

• A seizure can be acutely embarrassing for a person.

• If there is loss of consciousness, person will be confused afterwards.

Model

Trainer may only demonstrate seizures of a type she has witnessed.⁶

Trainer models

tonic-clonic seizure:

1. Trainer cries out and loses consciousness (fall from sitting position).

2. Arms flex up then extend and remain rigid (the tonic phase) for a few seconds. A series of jerking movements take place (the clonic phase) as muscles contract and relax together.

3. The jerking slows and eventually stops.

Trainer buddy pair responds

• During seizure: clears the area around patient.

• After seizure: puts patient in recovery position to aid breathing and keep airway clear.

Trainer models (facilitator may narrate)

complex partial seizure:

• May have aura (or warning -- most typical is sensation in stomach).

• May have automatisms (such as lip smacking, picking at clothes, fumbling)

• Unaware of environment, may wander.

• Amnesia for seizure events, mild to moderate confusion during, sleepy after.

Trainer buddy pair responds

• Clears dangerous objects from person's path.

• Calmly directs person to sit down and guides him from dangerous situations.

• Remains with person until fully alert.

Cause

Facilitator says

Lots of things can cause seizures, including head trauma or underlying seizure disorder like epilepsy.

Facilitator says

Common triggers during protest: changes in diet (vegan diet can throw off nitrogen balance), dehydration, prolonged stress.

What You Can Do

Facilitator says

during a seizure:

• Get help, make space, protect privacy.

• Do not interfere with seizure.⁷

• Find person's friend if possible

• Stay with person until seizure ends.

Facilitator says

Following seizure, person will be lethargic, possibly confused and want to sleep. Headaches sometimes occur, with sensitivity to light and sound. Full recovery takes minutes to hours.

• Continue to protect privacy as person reorients.

• Introduce yourself, tell person where she is, that she's in a safe place, that she just had a seizure.

• Help her find a safe place to rest, tea (lemon balm and oatstraw is nice) or water to drink, clean underpants if she wet herself, food if she's hungry.

• Do focused assessment. Ask "Medical or Trauma" questions. Ask if patient has medicine for her condition and where it is.⁸

• If person fell and was injured, offer first aid.

Red flags

Facilitator says

Convulsive seizure is usually not a medical emergency unless:

• It lasts longer than five minutes or a second seizure occurs soon after the first.

• The person is pregnant, injured, diabetic or not breathing easily.

• The person has no history of seizures.

If person is not breathing after seizure, find someone who can start CPR and call 911.

Headache

Cause

Facilitator says

Common headache causes: dehydration, stress, lack of sleep.

What you can do

Facilitator says

Usually instead of saying he has a headache, person seeks Tylenol or Advil.

• Engage care: "I can't give over-the-counter meds because pharmacists own the right to do that. I have some non-medication strategies to deal with pain we could try. Do you mind if I ask why you want the Advil?"

• Take a SAMPLE history: Was it caused by allergies or medications (A&M in SAMPLE)? "Have you had a headache like this one before?" or "Do you have a medical condition that could be the cause of this headache?" (P in SAMPLE). Has the person been drinking water, eating food, and producing clear and copious urine (L in SAMPLE)? Is there a mechanism of injury for head trauma (E in SAMPLE)?

Facilitator says

Universal care is water, temple massage (esp. with white flower oil or tiger balm), rest.

• If person has a history of migraine diagnosis and doesn't have strategies for dealing with his migraines, recommend rest in a quiet, dark place and caffeine.⁹

• If person has low blood sugar, consider water, snacks, and rest.

Red Flags

Facilitator says

Call 911 for:

• MOI for head injury, especially if there was any vomiting or loss of consciousness after the injury.

• Severe, disabling headache of more than a day, or headache with light sensitivity and vomiting from pain.

• Stroke signs.¹⁰

Trainer demonstrates

FAST stroke exam: "If there was a stroke, you need to act FAST!"

F

for Facial weakness -- Ask person to smile. Does one side of the face droop?

A

for Arm weakness -- Ask person to raise both arms. Does one arm drift downward?

S

for Speech difficulty -- Ask person to repeat a simple phrase. Is their speech slurred or strange?

T

for Time to act. -- If you observe any of these signs, call 911 immediately.

Fainting

What Is It?

Facilitator says

Fainting is a temporary loss of consciousness with a spontaneous recovery. Onset is more gradual and recovery much more rapid than with seizures. People are generally awake and alert afterward, as opposed to dazed and drowsy after most seizures.

Cause

Facilitator says

• Earlier head injury.

• Other major trauma or medical: heart problems, lots of bleeding (internal or external), diabetic emergency, stroke.

• Dehydration, heat.

• Low blood sugar. Make sure to eat and drink enough at demos.

• Standing for long periods of time with little movement: muscle contraction in legs from any movement pumps blood back to the heart. Without movement, blood pools in legs and doesn't get up to the brain. Keep moving, even marching in place, in large crowds.

• Pain.

• The sight of blood.

• Extreme stress or emotional upset.

• Prolonged or severe coughing from chemical weapons exposure.

Symptoms

Facilitator says

Light-headedness, nausea, dizziness, weakness; pale, cool, clammy skin; seeing spots,

Red Flags

Facilitator says

Get help for all fainting. Help might include another street medic with more training, or a hospital visit.

Facilitator says

Call 911 if associated with:

• Head injury.

• Heavy exertion.

• Elderly person.

• Chest discomfort or palpitations (feeling like the heart is beating very fast or irregularly).

• Shortness of breath.

• Low/high pulse rate.

• Double vision/loss of vision or speech, one-sided numbness, FAST stroke signs.

• Sudden severe headache.

• Blood loss.

What You Can Do

Facilitator says

First aid:

• Put person in recovery position while passed out (to protect airway).

• Calm and engage friends.

• Get food and water after recovery.

• Take SAMPLE history after the person recovers and respond to cause of fainting as needed.

• Keep lying down for 10 minutes (to increase blood flow to the brain), then help person get up.

Facilitator says

Aftercare (for people who don't go to hospital):

• Recommend taking it easy for the rest of the day.

• Encourage eating and drinking enough.

• Discourage suspected causes of the fainting.

Harness pathology

Cause

Facilitator says

Compartment syndrome is a condition that can affect climbers who spend extended periods of time in their harnesses. It can lead to a condition called rhabdomyalsis. Here's what happens:

• lack of adequate bloodflow causes cellular panic

• cells start breaking down and releasing potassium

• lots of inflammation inside fascia

• big danger: when harness releases, surplus potassium floods the rest of the body, causing anything from discomfort to arrhythmias.

Red Flags

Facilitator says

• Muscles downstream from harness get rock-hard and painful (don't release, transport to EMS so they can administer medications before releasing harness)

• Signs of potassium flood after harness release (transport to EMS so their heart can be monitored)

What You Can Do

Facilitator says

Prevention: shift every 30 mins. Loosen strap for a few seconds to let blood move, then tighten back down.