Lowered LOR emergency

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Facilitator: Grace + Becca
Medics: Charis + Greg
Patients: Lisa
Time: 25 mins; 0940-1005
Actual time:
Learning Objectives:
Materials: Gloves for trainers

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Return to Lisa: lowered level of responsiveness with threat to airway

Facilitator tells students

Remember "Lisa" from yesterday? Come crowd in close so you can see. The weather is nice, the day's action was calm, she's at an action in Oklahoma City on the Kerr Park steps.

Facilitator tells medics

Hey, Lisa fell asleep on the steps and we're trying to get her up so the cops won't arrest her for laying down, but she won't wake up!

Model

Buddies talk to each other, patient, and patient's friends, but not to classroom while they demonstrate:

• Grounding, put on gloves.

• Scene survey.

Patient care buddy

• Introduces pair, is nice, asks consent, explains every touch.

• Checks AVPU (not alert, doesn't respond to loud but nice "Open your eyes!" and doesn't respond to pressure on clavicle notch pressure point -- unresponsive).

• Tells standing buddy: "She's unresponsive. Call 911."

• Does head tilt/chin lift and looks, listens, and feels for breathing (it is present).

• Does bloodsweep.

• When buddy holds phone to ear, tells 911 operator "she is unresponsive but currently breathing" then nods that buddy can take the phone back.

• Rolls patient into recovery position.

• Re-checks LOR ("Open your eyes!" re-applies pressure to clavicle notch pressure point -- still unresponsive).

Scene control and comms buddy

• Continues scene survey

• Talks to her friends to investigate MOI: "Y'all been with her all day? And you're sure she didn't fall or get hit by something?" (Finds out she is diabetic and hasn't eaten all day and all last night. Doesn't know if she takes insulin.)

• Makes privacy circle, calls 911, gives location and history ("Her friends say she is diabetic and hasn't eaten for 24 hours") before holding phone to the ear of lead medic to transmit patient's condition.

Both buddies

calm, comfort, and reassure and maintain consent all the way.

Debrief

Facilitator asks students

What did we find out? Good answers:

• She probably has no involvement of physical trauma, the cause of her condition is probably blood-sugar related (MOI).

• She's unresponsive (AVPU+D+threat of A).

• She's breathing (A+B ok).

• She's not bleeding (C ok).

Facilitator asks students

What did the medics do? Good answers:

• Had a buddy and clear roles, grounded, BSI, scene survey (made the scene safer for themselves).

• Introduction to pt, calm, consent/explanation, privacy circle, talked to friends (controlled the scene and made it safer for pt).

• Investigated MOI, assessed AVPU, discovered emergency, activated EMS (stop and fix).

• Continued: assessed ABC, discovered ok.

• Rolled into recovery position to maintain airway and reassessed AVPU.

Practice lowered level of responsiveness management skills

Students

count off into groups of 3.

Practice clavicle notch pressure point

Students

find clavicle notch pressure point and apply painful stimulus. Hints:

• Directly behind clavicle bone in a depression approx halfway between shoulder joint and sternum.

• Apply downward pressure at a 45 degree angle towards the body center.

• Watch for pain response: flinching, grimace, vocalization, etc.

Facilitator explains

• Police pinch this nerve bundle for pain compliance; it can sometimes be used to help keep someone alert enough to keep breathing through heroin overdose.

• Applying pressure to the clavicle notch pressure point will cause pain without damaging anything. A person who can respond to pain will flinch or cry out.

• This is the only method we use to find out if a person who cannot respond to our voice can still respond to pain. There are many other methods used in emergency medicine for provoking pain, but most of them have more risks than the clavicle notch pressure point.¹

Assessing with AVPU lecture

Brain needs controlled environment to work well. Orientation to the world and alertness are compromised by factors like

• Disturbed oxygenation, nutrition, or waste management of brain tissue.

• Brain temperature fluctuation.

• Brain swelling from injury.

Common causes of altered mental status in emergency medicine (students don't need to memorize these; just tick off and move on) : AEIOUTIPS

A

for alcohol.

E

for epilepsy.

I

for insulin (actually low blood sugar but whatevs).

O

for overdose.

U

for under-medication (aka withdrawal).

T

for trauma & temp (temp as in hypothermia or fever).

I

for infection.

P

for psych & poisoning.

S

for stroke.

We revisit causes of altered mental status during focused assessment this afternoon.

Brain loses function in layers like an onion. It ditches optional shit in order to preserve most essential functions of survival. What you're about to learn is a rough measure of how much of the brain is shut down, so that you can pass that info on to advanced care workers who can interpret it.

An alert and oriented person becomes alert but disoriented as cortical hemispheres shut down. We'll learn how to assess disorientation this afternoon. Disorientation can present as drowsy stupor, altered perception, hallucination, loss of eye contact, irritability, and combativeness.

Then a person withdraws into the brain stem. With Lisa, we assessed how deep into the brainstem she has withdrawn.

1. Before we got there, she lost the ability to be alert and appeared to be passed out or asleep, but could still respond to her friend's loud voice: "Hi, I'm John. I know some first aid, what can I call you?" would have made her open her eyes, grimace, or say "Huuuhh??"

2. Then she lost the ability to respond to voice and could only respond to pain. That's what you assessed with the clavicle notch pressure point.

3. Finally she would have become unresponsive to pain.

Remember AVPU

(Alert, responds to Voice, responds to Pain, Unresponsive): you will have to use it during scenarios!

Anything below Alert is an emergency

Stop and fix by calling 911. Don't give anything by mouth, no mater how thirsty the patient is (risk of aspirated vomit).

Level of consciousness fluctuates. You might be able to bring someone who overdosed on opiates back to an alert state with repeated clavicle pinches and repeated commands to "open your eyes." A person who lost a lot of blood or has swelling in his brain could steadily head down the AVPU scale.

How a person's mental status changes over time is valuable information for advanced caregivers. Jot down changes with the time on the patient's skin or on tape on the patient's clothing.

Facilitator asks students

What can you learn about a person's mental status by firmly introducing yourself and asking "What can I call you?" Good answers: whether the patient is oriented, alert, or responsive to voice.

Facilitator asks students

What can you learn about a person's mental status by causing pain at the clavicle notch pressure point? Answer: whether the person can respond to pain or is unresponsive.

Practice head tilt/chin lift; look/listen/feel for breathing

Students practice

head tilt/chin lift; look, listen, feel for breathing for 10 seconds. 10 seconds feels like a long time -- count off all 10.

Facilitator explains

• Absence of breathing, gasping, gurgling, using extra muscles to breathe, fast or slow breathing are emergencies.

• Stop and fix by calling 911, repositioning head, looking for visible blockage in mouth, asking if anyone knows CPR.

• If someone is unresponsive, she is at risk for losing her airway to gravity's effect on the back of the tongue, position, or aspirated vomit.

• Head tilt/chin lift helps mechanically open the airway when it is threatened by gravity and position but doesn't help with vomit.

Practice recovery position roll

Students practice

recovery position: one-person roll and two-person roll.

Facilitator explains

• Recovery position mechanically keeps the airway open and allows vomit and other fluids like blood to drain from the mouth.

• Can save the life of someone who is passed out drunk.

• Stay with the patient and keep assessing breathing.

Practice all lowered LOR skills

Students practice

putting it together.

• Still in groups of 3, 1s and 2s are a buddy pair that approaches 3s (patient playing Lisa) and run through the whole shebang.

• Questions/problems/feedback from trainers?

• Stay in groups of 3.