# Ask me about emergency medicine, EMT basic, some Paramedic and ALS



## ascanius (Apr 11, 2012)

Ok I am studying to be and EMT basic, and hopefully will be fully licensed, state and national, by June, knock on wood.  So I thought I would contribute what I am learning.  Please keep in mind though that this encompasses only prehospital medicine, and not hospital medicine such as surgery, or advanced diagnostics.  Also your going to have to think of the technology differences.  I can explain the steps I would take for a certain emergency, how I would do them, why, and what, if any treatments are possible along with the chemistry, pathophysiology, and biology behind them.  Almost forgot medical emergencies, COPD, AMI, and others.  I may be able to help with technological concerns, and give ideas if this becomes a problem. 

 I WILL NOT TALK ABOUT PATIENTS so don't ask.  ALSO don't think that because you read something online that you know what to do in an emergency, or how to diagnose, *ALWAYS CALL* 911.  I trust that everyone reading this to be mature but I do not want to be responsible for someone dieing because of this post.  I cannot stress this enough.  I just want to make this clear ok.  Please use this information for your stories only.  You may think I'm paranoid but I feel this is a just paranoia especially in this day and age.


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## SeverinR (Apr 13, 2012)

Basic Emt would be a Dr in alot of Middle ages settings, except they would also have herbals and tonics. There was no qualifier to who could be a "healer" or Dr.

Also an EMT can provide some description of trauma. (There are EMT sites that will show graphic trauma, I don't recommend it unless you are prepared.) And secondary effects of that trauma. 
I was a volunteer EMT-B for two years(quit because being on call limited family plans and provided few calls) and am an orthopedic nurse. I still respond to all codes on the first floor of the hospital I work at. (which means simple falls to full arrest.)

"All bleeding stops...eventually."

(I have a family that thinks nothing of talking about drainage, secretions, other gross conditions over a holiday meal. 6 nurses, 2 EMTs, 3 lab techs, 2 Medical assistance and an old school orderly.)

If ascanius doesn't know I might. (you lose alot if you don't use it regularly, so he probably knows more then I remember. I guess thats why they recert so much.)
I will offer my experiences also. (No two calls are completely the same.)
Most annoying call: Level 3 snow emergency(against the law to be on the road) just lifted after a long night, woman called ambulance for constipation, standing on what would have been the sidewalk with bags in hand, didn't want to wait for daughter to get off work in an hour.
Previous night, most agonizing call, level 3 emergency, call in for flank pain (Kidney stones), ambulance arrived 3 hours later, and arrived at hospital 2 hours later, following a snow plow all the way. (I believe there was a paramedic called to meet them in route for pain medicine.)


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## Devor (Apr 13, 2012)

I don't mean to sound morbid, but it would be great if you could talk about the kind of wounds we're likely to see writing about medieval combat, like those caused by blades or clubbings.


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## ascanius (Apr 14, 2012)

The possibilities are endless.  Most likely you are going to see lacerations, and blunt force trauma along with penetrating injuries like arrows and blade tips.  I know it doesn't really help, but so much is possible.  I'll briefly go over some of these injuries and what they look like.

Evisceration.  This is when there is an open abdominal wound like from a sword.  Depending on the severity of the wound the abdominal organs can spill out, or the intestine will come out looking like sausages being squeezed from the wound, not to mention blood.
Avulsion is a wound characterized by a flap/piece of tissue that has been partially or completely removed.  The picture I have in the book shows an avulsion of the scalp.  It shows the patients head, the bone of the skull is visible, and at flap of skin hanging off to the right.
Laceration.  Can range from a small jagged cut to deep lacerations leaving the bone visible or resulting in amputation of a limb. 

With bladed weapons I would think avulsions, lacerations and evisceration are going to be most common.  People having to carry their intestines in their arms.  pieces of skin hanging from arms or legs, or anywhere, leaving the bone visible and so on.

Blunt force trauma from an club or war hammer would be just as bad if not worse.  Lacerations caused by blunt force trauma would be really bad.  Imagine a war hammer slamming into someones leg leaving it nothing but pulp.  Bone fragments sticking out and blood pouring from the wound like a crushed melon.  The muscle looking like jelly while bright red blood spurted from an artery.

Then you get to penetrating wounds like from an arrow or blade tip.  An arrow to the chest and the hero simply breaks off the tip and continues.  However blood pools in the pleural space, space between lungs and chest wall, pushing against the lung.  The trachea begins to shift to the opposite side as more and more blood pushes the lug further and further to the opposite side.  Breathing become harder and harder because there is less and less space for the lungs to expand.

Or someone takes a club to the gut and doubles over in extreme pain.  Blood pours unseen from the lacerated spleen, or pancreas, kidneys, liver.  The blood pools in the abdomen pushing it out feeling hard and stiff like a drum.  Cullen sing develops, bruising around the belly button.  Soon he feels cold and anxious as shock sets in.

Or a mace to the head leaving a jagged flap of skin hanging from the face where the mace pulled the skin away.  White bone sticking in jagged fragments sunken into the skull.  Blood began to pull in the cavity covering the exposed brain.

Or a club to the chest leaving multiple ribs broken in multiple places, flail chest.  This results in paradoxical chest movement where the area with the broken ribs will bulge out with each exhalation and sink in with each inhalation.  I find flail chest kinda disturbing because you know it shouldn't be moving like that.  


Really anything can happen and the wound will depend on the mechanism of the injury.  A club to the chest will be different from a club to the abdomen or face or arms.  Some with unseen consequences while others more evident.  All these injuries are going to cause many other things like increased respiratory rate, changes in skin color temperature, moisture, or increases in heart rate.  There is actually quite a lot that can happen and go one with any one injury.


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## ThinkerX (Apr 15, 2012)

Ok...quick and easy one for you - I think.

At different times I used to know a couple of EMT types who had to go on a great many OD runs. They became very weary of dealing with people who were both badly injured and stoned, and over time took to giving these sorts what they both called the 'Chaser' - which as I understood it basically 'killed the high' almost instantly.  What is the actual name of the 'Chaser'?


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## SeverinR (Apr 16, 2012)

ThinkerX said:


> Ok...quick and easy one for you - I think.
> 
> At different times I used to know a couple of EMT types who had to go on a great many OD runs. They became very weary of dealing with people who were both badly injured and stoned, and over time took to giving these sorts what they both called the 'Chaser' - which as I understood it basically 'killed the high' almost instantly.  What is the actual name of the 'Chaser'?


Are you talking about a drug that ends the high? Narcan by IV, primarily, counters narcotic affects very quickly. Almost as fast as a diabetic with low blood sugar getting a iv dextrose injection. (Like switching on a light.) Talwin has some effects of this too, but will add to the problem if the offending drug is not a narcotic. (Narcan is no harm no foul if not a narcotic.)



ascanius said:


> The possibilities are endless.  Most likely you are going to see lacerations, and blunt force trauma along with penetrating injuries like arrows and blade tips.  I know it doesn't really help, but so much is possible.  I'll briefly go over some of these injuries and what they look like.
> 
> Evisceration.  This is when there is an open abdominal wound like from a sword.  Depending on the severity of the wound the abdominal organs can spill out, or the intestine will come out looking like sausages being squeezed from the wound, not to mention blood.
> Avulsion is a wound characterized by a flap/piece of tissue that has been partially or completely removed.  The picture I have in the book shows an avulsion of the scalp.  It shows the patients head, the bone of the skull is visible, and at flap of skin hanging off to the right.
> ...



Very good short list.  Then post injury infection makes for more fun, if they survive.

Degloving avulsion are interesting. HArd to say what would happen in days of old when the skin is removed from the hand or fingers. Probably would result in amputation. Infection would set in if left open. 
I think the one I remember was the wedding ring on a finger got hooked on a cattle truck rail as the person jumped down. I was not a nurse or EMT then so being case specific isn't a problem.


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## ThinkerX (Apr 17, 2012)

> Are you talking about a drug that ends the high? Narcan by IV, primarily, counters narcotic affects very quickly. Almost as fast as a diabetic with low blood sugar getting a iv dextrose injection. (Like switching on a light.) Talwin has some effects of this too, but will add to the problem if the offending drug is not a narcotic. (Narcan is no harm no foul if not a narcotic.)



Yep, that is what I was talking about.  Thanx.


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## Penpilot (Apr 26, 2012)

Hi I'm not sure if this is the thread to ask this but I need a character injure both their arms so severely that they'll need 6 months to a year or so to recover at least basic use. What kind of basic damage could I expect the arms to suffer in order for that type of time line? Eg broken bones, broken elbow, broken ligaments, etc. I don't need anything too in depth. It just a bit of info I need to drop once to set something up.


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## Devor (Apr 28, 2012)

Okay, I've got a character who was stabbed in the lower back and dropped from a height of like 25 feet.  He lives.  What kind of permanent injuries could he have?


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## SeverinR (Apr 30, 2012)

Penpilot said:


> Hi I'm not sure if this is the thread to ask this but I need a character injure both their arms so severely that they'll need 6 months to a year or so to recover at least basic use. What kind of basic damage could I expect the arms to suffer in order for that type of time line? Eg broken bones, broken elbow, broken ligaments, etc. I don't need anything too in depth. It just a bit of info I need to drop once to set something up.


Standard bone healing is six weeks(1.5 months). Complex fractures can require surgery or external fixation. Which is a metal frame that holds screws that go into the bone, sometimes external fixation healing is slow, you have pins going from open air to bone, good source of infection.
If you use the extremity, it could never heal. 
This is with modern medicine, old medicine would still immobilize the bone, but complications would not be easily handled.

Nerve damage can take a while to heal, and make for very painful times. Hit your "funny bone pain" that doesn't end for months type of thing. 
Ligaments; take longer to heal also. I'm thinking twice as long as a bone. We don't get alot of ligament damage that doesn't require surgery. Surgery was a life and death issue prior to modern medicine. No antibiotics(WWII), poor anethesia, So ligament rupture or severering was permanent injury.


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## SeverinR (Apr 30, 2012)

Devor said:


> Okay, I've got a character who was stabbed in the lower back and dropped from a height of like 25 feet.  He lives.  What kind of permanent injuries could he have?


A fall of 10' or more is an automatic helicopter ride/ life threatening injuries.
Organ rupture, organ bruising, broken bones that puncture organs, broken ribs that cause breathing abnormalities(Flail chest)
More then likely back injuries, which could be para or quadraplegia, or permanent back pain from crushed disc and pinched nerves.
Low back penetration; kidneys and bowels most likely injured. Both could cause bleeding to death, bowel would cause peritonitis. (massive infection of the abdomin) Also muslce of the back are damaged, so moving those muscles would be impossible or very painful. Twisting and bending motions use the back musles.

Infection; if not modern, infection can kill a person. Infection from the bowel contents or just an oinfeciton of the wound from outside, the hole goes from the surface to the organ that was damaged, that path allows bacteria direct access to the organ.
Infection of an organ can lead to sepsis systemic infection of the body.


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## ascanius (May 2, 2012)

Thank's severnR been busy with the EMT class, NREMT test is two weeks away so been studying.  Thanks again.


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## SeverinR (May 2, 2012)

They hit areas I knew fairly well.  
If you can add anything, feel free.


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## Devor (May 2, 2012)

SeverinR said:


> A fall of 10' or more is an automatic helicopter ride/ life threatening injuries.
> Organ rupture, organ bruising, broken bones that puncture organs, broken ribs that cause breathing abnormalities(Flail chest)
> More then likely back injuries, which could be para or quadraplegia, or permanent back pain from crushed disc and pinched nerves.
> Low back penetration; kidneys and bowels most likely injured. Both could cause bleeding to death, bowel would cause peritonitis. (massive infection of the abdomin) Also muslce of the back are damaged, so moving those muscles would be impossible or very painful. Twisting and bending motions use the back musles.
> ...



Thanks!  I should have mentioned that he lives, and time passes after the event.  So is it believable that he would survive with lingering back pains?  Are there other possible issues I could include for him without sidelining him completely?


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## Kit (May 3, 2012)

Back injuries- like head injuries, as we were discussing elsewhere- can be a real spin of the Wheel Of Chance as far as what hurts and how debilitating it is, and for how long. An endlessly wide and varied range of possibilities there.


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## SeverinR (May 3, 2012)

Devor said:


> Thanks!  I should have mentioned that he lives, and time passes after the event.  So is it believable that he would survive with lingering back pains?  Are there other possible issues I could include for him without sidelining him completely?



Long term pain is always a problem. Pinched nerves, pain anywhere from annoying little pain all the way to crippling pain(not crippling from the injury, but the pain is so bad you don't want to move.)
Like P.Manning, muscle strength and coordination can be affected. (blind sided by several large linebackers could be equal to a high fall.)
Lets look at what has been survived:
Person falls 7 floors and lives,
Here is some people saying airmen in WWII fell from the sky and survived.
What is the highest point from which someone has fallen and survived?

Other possible issues:
Any broken bone can improperly heal(commonly falls cause shattered bones, very hard to put back together.), or just cause unending pain.
Dislocations; once dislocated a joint is more likely to dislocate again.
Muscle or tendon damage; falling can injure or rupture muscles even if repaired might not function right. Rotator cuff damage would prevent the person from lifting their arm above thier shoulder height.
organs that have ruptured might not function as well. The spleen is commonly ruptured in high impact trauma, most commonly is removed, which means the person has greater chance of getting infections.
Phobia's; irrational fear of falling again, fear of heights. 
also The typical pain related to the weather.


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## ascanius (May 5, 2012)

@ devor.  Just thought I would note with organ damage in particular the liver and spleen, patients can get what is called referred pain.  Like if the spleen is ruptured there will be pain in the left shoulder that has nothing to do with the injury to the spleen, liver is right shoulder pain (hope I didn't get those two mixed up).  But if the character fell the referred pain wouldn't really matter, just a FYI for you.

@SeverinR  Hey I have a question for you.  What would be treatment for a flail chest in a classical setting?  I cannot think of a way to treat it that does not involve surgery.  Wouldn't the ribs, even with bulky dressings, suck in with inhalation preventing them from healing the way they should?  I looked online for treatment options and surgery seemed the go to guy, along with meds to manage pain, and aggressive care of the pleural space and lungs.


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## SeverinR (May 9, 2012)

ascanius said:


> @ devor.  Just thought I would note with organ damage in particular the liver and spleen, patients can get what is called referred pain.  Like if the spleen is ruptured there will be pain in the left shoulder that has nothing to do with the injury to the spleen, liver is right shoulder pain (hope I didn't get those two mixed up).  But if the character fell the referred pain wouldn't really matter, just a FYI for you.
> 
> @SeverinR  Hey I have a question for you.  What would be treatment for a flail chest in a classical setting?  I cannot think of a way to treat it that does not involve surgery.  Wouldn't the ribs, even with bulky dressings, suck in with inhalation preventing them from healing the way they should?  I looked online for treatment options and surgery seemed the go to guy, along with meds to manage pain, and aggressive care of the pleural space and lungs.



Hadn't heard the pain in the shoulders for the mentioned organ damage, but the pain is on the correct side, so it is probably right.

Flail chest: without surgery, pain control and splinting the ribs.  As with any rib injury, people tend to limit their breathing, which will lead to pneumonia. Most of the treatments I read didn't mention healing difficulties, I think because they would just do surgery if it didn't heal properly. 
Some sites do say the ribs heal more often then not without surgery. Improperly healed ribs could make for a lifetime of problems. 
For the immediate: Signs of flail chest: obvious deviations in ribs, pain with breathing(even bruised ribs cause this), bruising, reverse movement of affected area(sucking in on inspiration, going ot on expiration), 
Complications: trouble breathing, severe pain when breathing, punctured lung(coughing up blood, probably fatal in times of old)
punctured organs(abdomin filling with blood, again fatal) pneumonia-caused by not breathing deeply, and stiffling cough response), difficulty breathing-possibly life long if not healed properly.
[Weird, I just completed a CE(continuing education) that included this]


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## ascanius (May 10, 2012)

The case I wanted for one of my characters was a right side flail chest due to blunt force trauma with a two inch laceration and contusion above the left eye and closed transverse humerus fracture a hands breath superior the elbow, Unconscious going for concussion, no hemopneumothorax, or pneumothorax, no airway problems.  Breathing is of course labored, shallow and rapid.  Cardio is good, no pericardial tamponade or other issues, with elevated BP, but strong rapid distal pulses, did i miss anything else in shock.  The character _is_ young but I'm not going to go for compensation or anything else.  (sorry you probably don't need to know all this but I'm trying to prepare for the test so have been studying non stop.  I have Obstetrics and pediatrics down but haven't reviewed chest trauma so am going completely off memory.)

It's the flail chest thats giving me treatment problems.  I don't get the treatment of the reverse movement of the affected area and splinting, if the ribs are constantly moving how can you splint the ribs.  On every inhalation the ribs in question will sink in the chest cavity, sure you can use a bulky dressing which is what were told to do.  I see how it will prevent the ribs from bulging out on exhalation but don't see how it can prevent them from sucking in on inhalation.  Unless you do circumferential bandages, tight bandages, to the point the ribs cannot move at all on ventilation.  Were told not to do that for obvious reasons.  Or is that what would end up happening? tight circumferential bandages/split to prevent any chest movement.  

Are tight circumferential chest bandages what you mean by splinting the ribs?

Not that readers will know which treatments are effective or what not, this is more for the sake of my sanity.


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## SeverinR (May 10, 2012)

ah...you forgot "scene safe", sorry maybe next time.  

I think the dressing is to minimize the movement of the flail part.  

The splinting I was talking about is mechanical. Using a pillow or cushion held against the painful part when coughing or taking a deep breath.

I think it would be treated like a normal broken rib in old times.
Broken Rib Treatment


I understand wanting to get the medical right. I wrote a scene with a person getting a broken jaw with concussion while flying on the back of a dragon. I read everything I could find on broken jaws and concussions.


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