The phone rings and you are off. You are dispatched to a farmhouse about 45 minutes from the hospital. The call was initiated by a neighbour of the patient. The neighbour reports he has found the 50-year-old farmer in the barn, not responding. The neighbour phoned from a cell phone and the signal cut out before any pre-arrival instructions could be given.

Almost an hour later, due to treacherous roads, you arrive on scene. An angry looking German shepherd comes to greet you, barking ferociously. The farmhouse appears run down. No lights are on even though it is still dark at 08:00 hours. No smoke is coming from the chimney and the scene looks deserted except for a running vehicle in the driveway. The barn door is open and the neighbour appears to be waving you in. He appears anxious but under control. The dog responds to the neighbor’s commands.

You find a 50-year-old male lying on his right side on the floor of a cow stall. The neighbour has moved the cow. He reports he was worried about Frank and came to check on him about an hour prior to your arrival. He states Frank is rather eccentric and lives alone with no electricity, phone, or running water. He reports Frank was worried about his cow calving and was probably sleeping in the barn to ensure the cow was okay. The neighbour states he found Frank lying supine, breathing and mumbling incoherently. He moved him to a recovery position and phoned 911. He states Frank stopped making any noises approximately 15 minutes ago.

Primary survey reveals the patient to be unresponsive to verbal stimulus, withdrawing and mumbling only to pain. His skin is pale, cold and dry. His airway is open and he is breathing. A pulse is present at the carotid but absent at the radial. The carotid pulse is slow. The patient’s face, ears and hands appear waxy, cold and bluish. There are no signs of trauma to the head, neck, chest, abdomen, extremities or back. No medical alerts are found. Lung sounds are present and equal bilaterally.

The neighbour report Frank does not drink alcohol and takes no medications as he does not “believe in them”. He reports Frank is “healthy as a horse”. He is unaware of any allergy history

Pulse	84/minute
Blood pressure	70/40
Respiration	13/minute
Skin	cold, dry, pale
Level Of Consciousness	painful stimuli only (withdraws)
Chemstrip (Glucose)	6 mmol/L
Pulse Oximetry	Inconclusive
E.C.G.

1. Your first action should be: A. hazard check and control of dog B. mace the dog C. phone for police backup D. phone animal control officers    

2. Oxygen therapy for this patient: A. should be withheld B. may cause cardiac dysrhythmias C. should be supplied via a non-rebreathing mask at high flow D. should be supplied via positive pressure ventilations E. A and B are correct    

3. This patient is likely a victim of: A. alcohol intoxication B. hypothermia C. stroke/CVA D. hypoglycemia    

4. Hypothermia is defined as a core temperature below: A. 39 degrees Celsius B. 37 degrees Celsius C. 34 degrees Celsius D. none of the above    

5. Re-warming efforts for this patient should be avoided. A. True B. False   

6. A frostbitten tissue area should be re-warmed: A. with hot water B. by rubbing gently C. with warm water D. with heat from a hot pack, fire or stove 

7. The first stage of hypothermia involves: A. hypotension B. mental confusion C. muscle cramping D. shivering    

8. The hypothermic patient should be handled gently to avoid: A. CNS depression B. cardiac dysrhythmias C. tetany D. muscle spasms    

9. The most serious category of localized cold exposure is: A. frostbite B. frostnip C. hypothermia D. none of the above    

10. People under the influence of alcohol may be affected more rapidly and severely by exposure to cold. A. True B. False    

11. Infants and young children are more susceptible to hypothermia because of their: A. smaller muscle mass B. inability to shiver C. large skin surface areas D. all of the above E. none of the above    

12. An extreme wind chill causes a person to lose heat by: A. Conduction B. Radiation C. Evaporation D. Convection    

13. In the early stages of cold exposure the skin is most likely to appear: A. pale B. blue/cyanotic C. red D. hardened    

14. If blisters are present on a frostbitten extremity, they should be: A. punctured prior to bandaging B. covered with sterile dressings C. squeezed gently to release the fluid D. rapidly re-warmed with hot packs    

15. Pulse oximetry will not produce an adequate reading on this patient due to: A.  vasoconstriction B. cold skin temperatures C. hypoxia D. none of the above    

16. The ECG is:

17. The rhythm should be treated with atropine immediately. A. True B. False 

18. An intravenous for this patient: A. is contraindicated B. should be initiated C. should be initiated as a D5W preparation D. B and C are correct    

19. This patient should be intubated immediately. A. True B. False    

20. En route the patient’s rhythm changes to the rhythm at the top of this page. There is no pulse. This rhythm is: A. ventricular fibrillation B. ventricular tachycardia C. idioventricular rhythm D. pulseless electrical activity or PEA    

21. This rhythm should be treated with: A. CPR B. cardioversion x 3 C. defibrillation x 1 D. defibrillation x 3    

22. The rhythm remains despite your treatment. You should now: A. repeat defibrillation B. administer epinephrine C. administer calcium chloride D. start CPR    

23. The patient deteriorates to asystole en route. You should: A. administer high dose epinephrine B. defibrillate C. continue CPR D. stop resuscitation efforts    

24. Epinephrine should be administered in hypothermic arrests: A. in high dose regimes B. as subcutaneous injections C. via the endotracheal tube D. none of the above    

25. Your service could work to increase community PR and prevent environmental tragedies by: A. promoting neighbour community watch programs B. providing school pre­sentations on seasonal concerns C. providing media presentations on environmental exposure D. all of the above 

References

American Heart Foundation; Advanced Cardiac Life Support, 1994.

Canadian Red Cross First Responder; Mosby Lifeline, 1997

Grant, Harvey D. Et. Al.; Emergency Care Seventh Edition; Brady: 1995.

Sanders, Mick J.; Mosby ‘s Paramedic Textbook; Mosby Lifeline 1995.

The answers to these questions are to industry standards and may not necessarily be correct according to local protocol. If there is any discrepancy between these answers and local protocol, please follow the protocol for your area as set out by your Medical Director.

Heather MacKenzie-Carey is a paramedic with over 17 years EMS experience in Nova Scotia and Alberta. She has a Bachelor of Science Degree in Health Education from Dalhousie University, a diploma in Paramedicine from the Northern Alberta Institute of Technology, and a Certificate in Social Work from the University of Waterloo. Heather is an instructor for the Paramedic Program at the Southern Alberta Institute of Technology. She can be reached at geomac@cadvision.com or www.turningpointgroup.com.

Canadian Emergency News and the author of this quiz grant permis­sion for readers to copy it for personal and departmental educational purposes. All other reproduction and re-publication without written consent is prohibited.

This Article is reprinted by permission from the author (Heather MacKenzie-Carey) and the Canadian Emergency News. It originally appeared in the February - March 1998 issue (volume 21, number 1).