'This is 911. What is your emergency?' How prepared are you for a medical emergency?

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The Chairman

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I just don't log dives
Caveat. While not specifically about Scuba, this is a true experience I had to deal with today and it applies to your diving. Also, even though I go by 'NetDoc', I am not a medical doctor. I fix sick Networks, not people.

It's a gorgeous day here in the Keys. It's mid eighties, the sky is blue, I've been working on my van, sussing out a brake light issue and needed to get some exercise. I hadn't been to Pigeon Key and done the walk on the old seven mile bridge in like forever, so I decide to take the now fixed truck on an hour's drive to just south of Marathon. It's the middle of the afternoon, and did I mention that the Keys are gorgeous this time of year? Considering traffic on this weekday, I'm not the only one who feels that way. Oh, it's not too bad and since I'm already in paradise, there's really no rush.

I found a parking spot, almost the last one, and got my tunes going and hat on. There's a bit of a breeze that will keep me from sweating too badly, but I'm ready for the challenge. It's only 2.2 miles from Marathon to Pigeon Key, and with walking around the Key a bit, I might get five miles in. Perfect. I have been here before, but always with others. Sometimes that keeps you from noticing the details. I was surprised that the hand rails are reclaimed train tracks. Man, that's a lot of steel! 'Maryland 1911' is cast into the tracks which fits with the time Flagler was building his railroad. How cool is that to see steel that's over a hundred years old?!? Yeah, there's some rust, but it looks great. There's a few people out on the bridge and a few boats fishing under us. The current is swift and the water has a lot of sediment in the outgoing tide. A nice German couple is trying to take a selfie and I offer to take a picture for them. Eight pelicans fly by in formation and the gentleman tries to get that on his GoPro. What could possibly go wrong today?

Then it happens. I'm just about half way, and I run into a couple that's obviously in distress. He's speaking a language I've never heard or it's gibberish. It's pretty slurred and I can't make out a single word. I know a little of a lot of languages but this is really weird. The lady is frantic trying to talk to him and her English is perfect. He's sitting awkwardly on the pavement and the railing is supporting him. I approach and ask the lady if something is the matter and she tells me that her husband collapsed, tried to get up and now she can't understand anything he's saying. I ask for his native language and she tells me it's 'American'. They're down visiting from Kentucky.

That's when I realize that this poor guy is suffering some sort of stroke: a brain attack! Part of his brain has just shut down. I tell her to call 911 and what followed wasn't pretty. It's obvious she has no clue where she is and is totally confused by the situation. I gently take the phone from her and talk to the operator. I tell her where we are at, give her the symptoms and that I think it's a stroke. She seemed to know where I was (GPS???), asks me to stay with them and tells me that help is on the way. I give her my phone number just in case this one craps out. Fred (the husband) is trying desperately to get up at this point. I think he has been all along, and that's what he was probably trying to tell us. I crouch down, put my arm under him and pull him up. I doubt if he weighs more than 160. He's reasonably fit and looks to be about 40. He points with his right hand to the end of the bridge and tries to walk. Whoa, he's got no coordination or balance. I'm not sure this is the thing to do, so I humor him and help him to walk. We stagger from time to time, his wife is now crying about his condition, but I'm not going to let him fall. In the next ten to fifteen minutes, we make 50 feet or so. I am drenched in sweat and am glad to see the paramedics. They're off with Fred and Mary and I try to keep pace. We can't. We're too exhausted to even try. The ambulance is gone by the time we make the parking lot and she has calmed down quite a bit. She elects to drive to the Hospital against my judgement. I followed her to be sure she didn't get lost and went with her inside.

That was about four hours ago and my heart is still racing. Whoa! However, there are a number of things that really struck me about the incident.

  • I shouldn't have helped the guy walk. The paramedic was a bit distressed about that. I'm not sure why that is, but I'm going to try to find out.
  • I was the only one who tried to help. Wow. People passed us both ways and gave us a wide, wide berth. I don't think it's that they didn't care, but they had absolutely no clue that we needed help or how to give it. There were a lot of scared looking people on that bridge and I heard someone say 'I thought there was something wrong' when the medics showed up.
  • While I think this was a stroke, it didn't have the textbook symptoms. Yeah, the speech was a bit slurred, but it was more like a charismatic speaking in tongues. The face didn't look paralyzed on one side either. Still, I could tell this was something neurological and that he needed help.
  • The wife never thought to initiate EMS. When she did call she had no idea where she was or how to give symptoms. She was truly 'useless' and I think that's a function of shock and not intelligence. I found out later she's a science teacher at a middle school. It's not so much that she panicked but that she went catatonic: dear in the headlights.
  • The wife needed almost as much monitoring as the husband. I probably should have recruited someone from the people on the bridge to help me, but I was immersed in looking out for him and her.
  • When the caca hits the fan it can be devastatingly quick with no warnings. If this guy had been on scuba at thirty feet he would be dead now.
  • Nobody thinks about the rescuer. I had gotten EMS on the way, stayed with the couple, tried to help him walk, followed her to the hospital and into the emergency room. When they took her back, I gave her my card, said goodbye and left. I called Elena on the walk back and about ten minutes later I felt I was going to hurl. My body shook, I had to turn off the AC, and then had to turn it on high. Whatever adrenaline I had been running on ran out on me. I felt kind of fragile as I drove back home for at least twenty minutes or so.

I've taught a number of First Aid, CPR and even Emergency Wilderness First Aid classes. I've assisted in an accident or two here and there, but I think this was really the very first medical emergency where I was the First Responder. I know I didn't do everything right, but this was anything but a text book emergency. I was way over my head, but I think I'll give myself a passing grade if only because I took the initiative and never lost sight of that. I have no idea what will become of Fred and Mary. I do know that their Keys vacation went to hell in a handbasket and I feel badly for them. I have two friends, Brad Nolan and John Lewis who have suffered strokes and while I felt badly for them, I don't think I understood what happened to them. OK, I still don't have a clue about what they are going through, but I certainly gained a new perspective on it.

So, back to my original question: How prepared are you for a medical emergency? Do you have the training? The mentality? The focus? I'm sure there will be a lot of second guessing what I did and should have done. Some will see me as incompetent while others may see me as a hero. It doesn't matter. What does matter is how prepared you're going to be when something like this happens to you.
 
As you suggest, intervening at all was the most important thing you did. Kudos!

I know I didn't do everything right, but this was anything but a text book emergency. I was way over my head, but I think I'll give myself a passing grade if only because I took the initiative and never lost sight of that. I'm sure there will be a lot of second guessing what I did and should have done. Some will see me as incompetent while others may see me as a hero. It doesn't matter. What does matter is how prepared you're going to be when something like this happens to you.

As the EFR course teaches "Imperfect care rendered is better than perfect care withheld."

I shouldn't have helped the guy walk. The paramedic was a bit distressed about that. I'm not sure why that is, but I'm going to try to find out.
"

The reason to not move is that you don't know what the injury was - or whether moving him would worsen the situation. When there is no need to move a victim from where they are found from a safety standpoint, the proper course of action is to stabilize the victim in-place and await EMT.

Ray
 
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That's just it Ray: it wasn't an injury or an accident. He was trying hard to get up and walk. He was driven to do it. My initial instinct was to have him lie down but he would have none of that. I felt that I could either help him, making sure he didn't fall and get hurt or watch him continue to flail frantically. Moreover, I got the feeling that this was something specific to a stroke victim. Obviously, the paramedic was preoccupied with tending to Fred. He had no time to discuss this with me.

BTW, putting this all down was def cathartic. It really helped me to see it in perspective. I like that comment about imperfect care. I'll be stealing that.
 
That's just it Ray: it wasn't an injury or an accident.

By definition - it was either an injury or an illness. Or he was faking. Either way, when you don't know the cause - and there's no reason to move the victim - leave them in place.

Not second guessing. Just telling you why EMS wished you hadn't moved him.

As you suggested, if he was not going to stay put you did the right thing in staying with him.
 
Having been confronted with similar situations, I have always found it easier to take some specific action when the medical issue was something really obvious- any bleeding, traumatic amputation, gunshot, burns, etc. If it was obvious, I just reacted.

Sometimes when we see varying or confusing symptoms presented that require differential diagnosis, it is so very easy for us to go into freeze mode. Trained professionals have the decision making tree printed in their brain. Is that person stoned, overdosed, drunk or a stroke victim? Do they have some prior diminished mental capacity or are the having their speech center affected by hidden blood flow issues? How they do it: Differential diagnosis - Wikipedia, the free encyclopedia

Hard enough for an EMT type. Worse for others... this is especially evidenced in the current teaching of awareness in Law Enforcement when confronted with a mentally disturbed person who is demonstrating aggression.

NetDoc: You are a Sheepdog. Know that.

Hooyah!
 
. It really helped me to see it in perspective. I like that comment about imperfect care. I'll be [-]stealing [/-] plagiarizing that.

It's written in the copyrighted Emergency First ResponseTM instructor and student materials several dozen times.

---------- Post added March 24th, 2015 at 11:20 PM ----------

Trained professionals have the decision making tree printed in their brain.

Having professional training is one thing, but professionals also have the advantage of something most lay people (hopefully) never get: experience.

No lay person - no matter how well trained they might be - has any idea how they'll handle a real situation until they are actually dropped feet-first into one. No matter how good the training, no matter how realistic the scenarios, there's just no way to make them "real" from a psychological standpoint.

Interestingly, the day after I completed my EFR Instructor course last year I was driving on a back road here in town when I came across a very serious accident scene. It was more "an accident in progress" actually; as it came into view as I rounded a curve there were still parts of three different cars sliding down the road.

The freshness of the training helped for sure. (So unrealistically and miraculously fresh that I was almost able to treat it like "a scenario" rather than "an incident." I was actually able to grab the gloves from my EFR Instructor crew pack since it was still on my passenger seat.) But frankly, the thing that helped me the most in this situation was having had the experience of responding to several significant dive accidents over the past decade.

As I was getting out of my car I took a deep breath and heard that voice in my head say - and I may have actually said outloud - something to the effect of "You know what to do... and you know you can do it."
 
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NetDoc: You are a Sheepdog. Know that.
I think I understand what you're saying with that. Yes, I felt very needed by them, though I'm not sure they felt they needed me. The calm that hit me made me aware of every thing I said or did. I didn't downplay any of the symptoms, but I sure didn't get hysterical either. She was doing enough of that for both of us. I tried to be encouraging and decisive as to what we were doing.
No lay person - no matter how well trained they might be - has any idea how they'll handle a real situation until they are actually dropped feet-first into one. No matter how good the training, no matter how realistic the scenarios, there's just no way to make them "real" from a psychological standpoint.
That's the real issue to me. I see people training on how to handle situations under water and wonder how they will react if/when something actually happens. Taking a deep breath, or even several deep breaths is always a good starting point.

BTW, one of the first SB trips was called "Wreckmania". I was wearing the t-shirt when the people in front of me had a fender bender. I pulled off to the median and went to check to be sure no one was hurt. The lady who rear ended the other was a bit dazed from the air bag and was further confused when she read my shirt. "You help people in wrecks for a living?" was her question. Too funny, but it helped break the ice. I kept her in the car until the bus arrived. I'm sure she had a number of injuries to her head, neck and back that she wasn't aware of yet. They boarded her and took her to the hospital, but it was nothing life threatening.
 
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Caveat. While not specifically about Scuba, this is a true experience I had to deal with today and it applies to your diving. Also, even though I go by 'NetDoc', I am not a medical doctor. I fix sick Networks, not people.

It's a gorgeous day here in the Keys. It's mid eighties, the sky is blue, I've been working on my van, sussing out a brake light issue and needed to get some exercise. I hadn't been to Pigeon Key and done the walk on the old seven mile bridge in like forever, so I decide to take the now fixed truck on an hour's drive to just south of Marathon. It's the middle of the afternoon, and did I mention that the Keys are gorgeous this time of year? Considering traffic on this weekday, I'm not the only one who feels that way. Oh, it's not too bad and since I'm already in paradise, there's really no rush.

I found a parking spot, almost the last one, and got my tunes going and hat on. There's a bit of a breeze that will keep me from sweating too badly, but I'm ready for the challenge. It's only 2.2 miles from Marathon to Pigeon Key, and with walking around the Key a bit, I might get five miles in. Perfect. I have been here before, but always with others. Sometimes that keeps you from noticing the details. I was surprised that the hand rails are reclaimed train tracks. Man, that's a lot of steel! 'Maryland 1911' is cast into the tracks which fits with the time Flagler was building his railroad. How cool is that to see steel that's over a hundred years old?!? Yeah, there's some rust, but it looks great. There's a few people out on the bridge and a few boats fishing under us. The current is swift and the water has a lot of sediment in the outgoing tide. A nice German couple is trying to take a selfie and I offer to take a picture for them. Eight pelicans fly by in formation and the gentleman tries to get that on his GoPro. What could possibly go wrong today?

Then it happens. I'm just about half way, and I run into a couple that's obviously in distress. He's speaking a language I've never heard or it's gibberish. It's pretty slurred and I can't make out a single word. I know a little of a lot of languages but this is really weird. The lady is frantic trying to talk to him and her English is perfect. He's sitting awkwardly on the pavement and the railing is supporting him. I approach and ask the lady if something is the matter and she tells me that her husband collapsed, tried to get up and now she can't understand anything he's saying. I ask for his native language and she tells me it's 'American'. They're down visiting from Kentucky.

That's when I realize that this poor guy is suffering some sort of stroke: a brain attack! Part of his brain has just shut down. I tell her to call 911 and what followed wasn't pretty. It's obvious she has no clue where she is and is totally confused by the situation. I gently take the phone from her and talk to the operator. I tell her where we are at, give her the symptoms and that I think it's a stroke. She seemed to know where I was (GPS???), asks me to stay with them and tells me that help is on the way. I give her my phone number just in case this one craps out. Fred (the husband) is trying desperately to get up at this point. I think he has been all along, and that's what he was probably trying to tell us. I crouch down, put my arm under him and pull him up. I doubt if he weighs more than 160. He's reasonably fit and looks to be about 40. He points with his right hand to the end of the bridge and tries to walk. Whoa, he's got no coordination or balance. I'm not sure this is the thing to do, so I humor him and help him to walk. We stagger from time to time, his wife is now crying about his condition, but I'm not going to let him fall. In the next ten to fifteen minutes, we make 50 feet or so. I am drenched in sweat and am glad to see the paramedics. They're off with Fred and Mary and I try to keep pace. We can't. We're too exhausted to even try. The ambulance is gone by the time we make the parking lot and she has calmed down quite a bit. She elects to drive to the Hospital against my judgement. I followed her to be sure she didn't get lost and went with her inside.

That was about four hours ago and my heart is still racing. Whoa! However, there are a number of things that really struck me about the incident.

  • I shouldn't have helped the guy walk. The paramedic was a bit distressed about that. I'm not sure why that is, but I'm going to try to find out.
  • I was the only one who tried to help. Wow. People passed us both ways and gave us a wide, wide berth. I don't think it's that they didn't care, but they had absolutely no clue that we needed help or how to give it. There were a lot of scared looking people on that bridge and I heard someone say 'I thought there was something wrong' when the medics showed up.
  • While I think this was a stroke, it didn't have the textbook symptoms. Yeah, the speech was a bit slurred, but it was more like a charismatic speaking in tongues. The face didn't look paralyzed on one side either. Still, I could tell this was something neurological and that he needed help.
  • The wife never thought to initiate EMS. When she did call she had no idea where she was or how to give symptoms. She was truly 'useless' and I think that's a function of shock and not intelligence. I found out later she's a science teacher at a middle school. It's not so much that she panicked but that she went catatonic: dear in the headlights.
  • The wife needed almost as much monitoring as the husband. I probably should have recruited someone from the people on the bridge to help me, but I was immersed in looking out for him and her.
  • When the caca hits the fan it can be devastatingly quick with no warnings. If this guy had been on scuba at thirty feet he would be dead now.
  • Nobody thinks about the rescuer. I had gotten EMS on the way, stayed with the couple, tried to help him walk, followed her to the hospital and into the emergency room. When they took her back, I gave her my card, said goodbye and left. I called Elena on the walk back and about ten minutes later I felt I was going to hurl. My body shook, I had to turn off the AC, and then had to turn it on high. Whatever adrenaline I had been running on ran out on me. I felt kind of fragile as I drove back home for at least twenty minutes or so.

I've taught a number of First Aid, CPR and even Emergency Wilderness First Aid classes. I've assisted in an accident or two here and there, but I think this was really the very first medical emergency where I was the First Responder. I know I didn't do everything right, but this was anything but a text book emergency. I was way over my head, but I think I'll give myself a passing grade if only because I took the initiative and never lost sight of that. I have no idea what will become of Fred and Mary. I do know that their Keys vacation went to hell in a handbasket and I feel badly for them. I have two friends, Brad Nolan and John Lewis who have suffered strokes and while I felt badly for them, I don't think I understood what happened to them. OK, I still don't have a clue about what they are going through, but I certainly gained a new perspective on it.

So, back to my original question: How prepared are you for a medical emergency? Do you have the training? The mentality? The focus? I'm sure there will be a lot of second guessing what I did and should have done. Some will see me as incompetent while others may see me as a hero. It doesn't matter. What does matter is how prepared you're going to be when something like this happens to you.

First off, Let me commend you for taking control of the situation presented to you and making decisions you are not often faced with. Your decision to call for assistance could have quite possibly saved this inviduals life or a lifetime of disability. Lay rescuers are often unprepared with faced with challenging events such as these and for you to keep your wits and provide accurate info was stellar.

I am an Advanced Care Paramedic, working in a large urban centre in Canada and based on the description you provided, I would certainly be leaning towards this individual having experienced a CVA, whether hemorragaic or ischemchic. Obviously there may be other things going on, intoxication, hypoglycemia, sepsis, acute psychosis, head injury, etc etc.

Your course of action to try to control things and ask for help and allow him access to advanced care may save him from a lifetime of debilitation. The first 210 minutes following onset of symptoms are critical to access care, obtain a head CT and begin therapy if the CVA is an ischemic event. YOUR action started that and is one of the greatest predictors of positive outcome. You would have got a slap on the back and an "atta boy" from me. Seriously.

There is a simple tool we use to measure whether an invidual is experiencing a stroke and it involves three simple tests:

1.Ask the patient to smile and show teeth. If one side of face droops or does not move, that is a positive sign.
2.Have the patient extend the arms and raise the arms to shoulder height, palms up, close their eyes and hold the arms in place for 5-10 secs. If one arm does not move or drops before the other, that is a positive sign.
3.Ask the patient to listen to a small sentence and repeat it back to you. I always use the standard "You can't teach an old dog new tricks" IF they have trouble either receiving and understanding instructions or expressing verbally, that is a positive sign.

The test is called the "Cinncinati Stroke Scale" and it is standard across North America in BLS and ACLS teaching.

Any one of the three, is approximately 75% sensitive for some kind of Neurological event, all three is in the range of 90-95% depending on the literature you read.

Based on what your description, I would assume he was receptive and descriptive aphasic, and with the balance issues, he probably had unilateral weakness but it was difficult to measure due to his reluctance to comply with instructions.

Based on your description, I would have had no issue running this man into a stroke centre, after ensuring it was not another condition that I could remedy such as hypoglycemia.

I have taken several patients to a stroke centre bypassing community hospitals that later turn out not to be a CVA. The neurologist do not want us to not transport them though and encourage us to continue because in 97% of the cases that were not CVA's, something neurologically was going on that we are unable to differentiate in the field. Short answer: they have fancier tools and get paid more :cool2: Let them sort it out. Give the patient benefit of the doubt

People often don't want to involve themselves for whatever reason, rather standing to the side and being an armchair qb. You did the right thing, you called for help and you STAYED WITH THEM!!!! Nothing pisses me off more than drive by callers that don't bother to stick around. I get if someone doesn't stick around if they don't fell safe but don't fly by in your car, drive home and then call 911 to report a man down that you noticed when you were leaving the office 45 mins ago. You took control and managed the scene to the best of your ability. Thank you.

As for the allowing the guy to walk and the Medic chewing you out a bit about, Meh. It happened. Not the end of the world. Is it preferable not to have the guy walking around? Absoloutly. But you are also the only guy and tackling a stranger that is experiencing an unknown neurological event, not advisable. We don't do it unless we have 4 cops, 2 medics, soft restraints and sedation ready.

Biggest reason to prevent him walking is obviously to prevent injury from a fall. A head injury can be a contraindication for thrombolytic therapy for ischemic CVA.


As for me being prepared for an emergency, that all depends what clothes I am wearing and what kind of vehicle I am in. My Mitsubishi and Jeans and T shirt, I would have been waiting for help like you, just with more understanding of pathophysiology. In my white bus with flashing lights, I hope I have everything I need:confused:

I'll wrap up by again commending you for your involvement and for providing care to BOTH patients, the husband and wife. You are a truly caring individual and that shows.

By reaching out and letting others know what happened to you today, you have begun a debriefing phase following the events. This will help you process your thoughts and promotes positive mental health.

Feel free to reach out to me via PM if you so wish or need. I would be happy to chat privately if you wish but you sound like you are well on your way to processing these emotions.

Take care.

Kevin
 
Thanks for the kind words, Kevin. So you know, this is the Keys. All of the fancy clinics are on the mainland. He was taken to Fisherman's Hospital. While it's a top notch facility for what it does, it's background is treating fishermen for the types of injuries they sustained.

As for the allowing the guy to walk and the Medic chewing you out a bit about, Meh. It happened. Not the end of the world. Is it preferable not to have the guy walking around? Absoloutly. But you are also the only guy and tackling a stranger that is experiencing an unknown neurological event, not advisable. We don't do it unless we have 4 cops, 2 medics, soft restraints and sedation ready.

Biggest reason to prevent him walking is obviously to prevent injury from a fall. A head injury can be a contraindication for thrombolytic therapy for ischemic CVA.

OK, I've slept now. The event is well behind me and something occurred to me. The paramedic that was upset was the youngest of the three and I doubt if he was in his mid twenties yet. I think he was a bit freaked by the show.

I've researched a bit on strokes this morning and was surprised to see others reference it as a brain attack. I have used it in my classes for years and have had MDs tell me what a unique way of explaining it that is. I guess I'm not as unique as I thought. :D Balance is a huge problem for stroke victims. I know it was for Fred as I was his balance and his strength. Here are the signs of stroke for those of you that don't know:

From Am I Having A Stroke?

Use FAST to remember the warning signs:

FACE: Ask the person to smile. Does one side of the face droop?
smiling.jpg


ARMS: Ask the person to raise both arms. Does one arm drift downward?
arm.jpg



SPEECH: Ask the person to repeat a simple phrase. Is their speech slurred or strange?
mouth.jpg



TIME: If you observe any of these signs, call 9-1-1 immediately.
stopwatch.jpg



icon-exclamation.png
It is important to recognize stroke symptoms and act quickly by CALLING 9-1-1.
 
It is important to [-]recognize stroke symptoms and[/-] act quickly by CALLING 9-1-1.

Stroke mnemonics and such are interesting fodder for discussion, but I think that another key thing for lay people to remember is that the role of Emergency First Response is pretty straightforward: activate professional emergency medical services and stabilize/protect the patient until EMS arrives.

EFR training includes simple situation/sign/symptom-dependent things that should be considered and actions that should be taken. However, beyond simple "don't move them if it might be a spinal injury" or "it might be shock, get a blanket" sort of things there is no reason for - or value in - a lay EFR spending valuable time on DDx.

  1. The training we receive is not sufficient to enable us to do so effectively
  2. We're not trained to - and shouldn't - do anything different based on whatever Dx we might come up with anyway

When time is of the essence - and you might not be qualified to even determine THAT accurately - don't delay care or try to determine who to call based on results of amateur field diagnostics. Call 911, stabilize the victim, and render primary/secondary care until EMS arrives.

Beyond the fact that it's the right thing to do medically, you're also better protected legally if you stay within the scope of your training/expertise.
 
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