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A man attempted to kill himself by opening a propane tank in his car, causing a fire. He suffered severe burns. It is important to be cautious around chemicals and be aware of the signs and symptoms of exposure. Emergency treatment involves removing the substance from the patient as quickly as possible and rinsing them off. It is also important to contact poison control or medical control for guidance on treatment. Ingested poisons are common, especially in children, and should be treated based on the specific chemical ingested. a car fire in the Walmart, in Office 68 there in Gardner. And so we arrived on scene, and there's this guy, he's kind of standing outside the car and he's smoldering, so we kind of put him out and everything. And we get him in the vehicle, we start treating him, and the fire department shows up. The car's still burning, so they're putting the fire out. It turns out this guy wanted to kill himself with propane. So he put a propane tank in his car and opened it. And so it started spraying out propane and he figured he'd commit suicide. Well, propane knocks oxygen off of the brain and it causes altered mental status. And while he was sitting there, he figured he'd have a cigarette. Boom! So the whole car went up. And so he had very significant burns. Burns to his airway, burns to his skin, burns to his face. Pretty bad burns. So be careful, because when the fire department put the flames out and they opened the trunk, there was another 20-pound propane tank in the back. Can you imagine if that had what they call blevied, if that had swollen up and exploded? We would all have been dead. So just be aware when you, just be careful when you walk up to cars. Make sure you keep your eyes and wits about you. Okay. Absorbed in surface contact poisons can affect this patient in many ways. Skin, mucosal membranes and eye damage. This would obviously be contact burns. Chemical burns would be contact burns. Rashes or lesions and then systemic effects. This is what's going to kill the patient. The systemic effects. It's important to distinguish between contact burns and contact absorption. You can have both. I can get surface burns and surface irritation and I can also, it can enter my body systemically and cause life-threatening conditions. So signs and symptoms can include a history of the exposure. So I was on scene and I got exposed. You know, the story is, person, within a 30-mile radius of this building, every chemical compound known to mankind exists. So you could come across any kind of chemical. As a matter of fact, recently, we just, there's a company in Millbury, I forgot the name of the company, but they work with plastics and electroplating and they use cyanide. Because cyanide is used in metal electroplating. And so there's a cyanide antidote kit. It's very expensive. It's hydroxycobalamin, which is vitamin B12, but it's huge doses it's given IV. And so you can come across cyanide, which cyanide is one of the most potent toxins you can come across. So liquids or powders on the patient's skin, you're going to see that. What are they going to tell you? You're going to go to a manufacturing company and they're going to say, hey, this person was exposed. All companies that have any chemicals are supposed to have an exposure control officer, whose job it would be to mitigate that. Burns, itching, irritation, redness of the skin, typical odors of the substance. If you walk into a room and something doesn't smell like Brut or Polo cologne, you know, something smells odd, just be aware that that could be a chemical. And it doesn't have to be a bad smell. Almonds. Almonds is cyanide. If you walk into a room and it smells like almonds, that can be cyanide. Emergency treatment. Avoid contaminating yourself and others. Remove the substance from the patient as rapidly as possible. Now, it's very important to remember there are certain metals and certain powders or substances that react violently with water. Elemental sodium and potassium. If you get that, or elemental potassium and sodium. If you get that mix, if you pour water on that, it will explode. It will ignite and the patient will get burned. So, if you have substances on it, if it's a liquid, rinse it right off right away. Liquids don't react. But if you have a powder, make sure you dry the brush as much powder off as you can before applying water because, again, you don't want it to react. And if I have a patient here that has powder on them, I'm not going to do this. Because what did I just do? Just aerosolize it. I'm going to put a mask on that patient, a mask on me, an N95 on me, surgical mask on them, and I'm going to gently brush it off. And then I'm going to hose them down. If you have a patient that exposed and has clothes on, I don't want the patient taking their clothes off. Because as they take their clothes off, they expose the outside of the body, the outside of the clothing that has the chemical to their skin. What you do is you start hosing them off, soak them, 20 minutes, completely soaked. And then you cut the clothes off and you let them fall to the ground. You cut right down to the underwear and just let them fall off. That way you don't expose the skin to the exterior of the clothing. Okay? And you wrap the patient in a blanket and go. And we rinse until there's no burning. We don't know if there's chemical. The only way we know if a chemical is left is if the chemical is burning and I rinse and the burning stops. So I'm going to rinse for 20 minutes and I'm going to stop. I'm going to say, okay, do you feel any burning? If the patient says, yeah, it's starting to burn again, okay, another 20 minutes. These are one of the few times where I will stay on scene as opposed to transporting patients because I want to get the chemical off. Right? So we'll stay on scene. Unless the patient is in the airway issue or unresponsive. I still don't want to put them in my ambulance. I'm in a closed, sealed ambulance and I've got a patient who may be off-gassing chemical because I didn't rinse them off properly. So you want them decontaminated before they get in your ambulance. Well, because you would hope that you would be at a location that would have water. Any manufacturing facility that has any kind of chemicals has to have a wash station or a sink. Something. They have to have the ability to wash. If it's a residential, if you've got a hose, you've got a garden hose, you've got a shower, I take them in and put them in the house in the shower. If you don't have access to anything, you do have water. We carry about the equivalent of about two gallons of water in our anvils between saline and sterile water. You can use that, but that's not going to do very much. So you really have to. In a situation like that where I didn't have any way of decontaminating, I would call the fire department. You'd want them there anyway and they would be able to. They have the whole thing and they take the truck water and put you at the end of the hose, blow you across the street. If dry powder has been spilled, brush off the powder, flood the air with water for at least 15 to 20 minutes. If liquid has been spilled, again, 15 to 20 minutes. And remember, things like acids have surface, they burn the skin, they rot the skin from the surface. Things like alkalis, like lye and bleach and things, they do what they call liquefaction necrosis. They actually liquefy the tissues. So you want to really rinse those off well. We've seen this before, chemicalation in the eyes. This is the nasal cannula with a 60cc syringe of sterile water. And we just shoot the syringe, the water, into the nasal cannula and it comes right out through the eyes. It's a great way to rinse. Metachemical burns occur in industrial settings. Safety showers and specific protocols for handling surface burns may be available. They have to have, any manufacturer, any company that has any kind of chemicals, has to have some form of a wash station. So when you get to the patient, you're going to say, hey, who's the spill control officer or the exposure control officer? Because you're going to need two things. Where's your wash station and your eye station? And where is the MSDS for what the patient was exposed to? MSDS stands for material safety data sheet. And that is a sheet that tells what the chemical is, what it reacts to, what its health hazards are, and what you can do to mitigate it. So you want the MSDS. If they don't have it, if they have one, have them make a copy. I'll give you the sheet. If they don't have it, the hospital can look it up. Know what the chemical is. All right? Very important. So ingested poisons, about 80% of poisoning is by mouth. Things like liquids, household cleaners, contaminated foods, plants, and drugs. The 80% of poisonings happen by mouth. And what is the number one age group for oral ingestion poisonings? One to six, right? Children one to six years old, because everything is about the pie hole, right? Everything goes in the mouth. That's how they test things, how they look at things, right? Usually accidental in children and deliberate in adults by misusing drugs or misusing chemicals. Signs and symptoms include burns around the mouth, GI pain, vomiting, cardiac dysrhythmias, seizure coma death. The signs and symptoms have to do with what the chemical was that was ingested. Ingested poisons treat signs and symptoms and notify poison centers and medical control of the patient's condition. Do not call poison control. This is what happens. I come across you, you have a toxic ingestion. I know what the chemical is, but I'm not sure what to do. I call poison control. I'm online, I have to wait for poison control to come on. Then they ask me a series of questions and they have an algorithm. I've got to go through the algorithm. Then they're going to tell me to do something. Whether it be copious amounts of water or milk or whatever. Then I have to call medical control and get authorization to do that because what they tell me is not part of my protocol. I would rather call medical control. If you've got a doctor that's got any years of experience in an ER, he's seen it. If you know what the chemical is and you tell him, he's like, yep, I know exactly what that is. This is what I want you to do. If he tells you to do something, that's fine. Different from poison control. I don't even waste time with poison control. If you're home, your child ingests something, you want to call poison control absolutely all day. But when I show up, I'm not listening to poison control. I will call medical control and talk to the doctor because he's the one that's going to allow me to do things. Does that make sense? So don't worry about poison control. Consider whether there is an undissolved poison remaining in the GI tract and whether you can safely and effectively prevent absorption. How would we do that? How could we get rid of a chemical in the GI system? Do you remember? Charcoal. We don't use it en masse, but it is national skill and you have to know it. It's one gram per kilogram up to 50 grams. And it is a binding agent. Charcoal is a binding agent. It binds with chemicals. And then it's mixed with a cathartic agent, most commonly sorbitol or mannitol, which are basically sugars. And it literally makes you poop it out. So you eat it and then you poop it out. And what it does is it binds with whatever chemicals are left in your body and you excrete it. And that's what that is. Instachar, Axidose. This is the one we most commonly carried. It was in a tube or is in this. They used to have them in a powder. And what you do is take the powder, mix it in water and mix it into a slurry and have the person drink it. It tastes horrible. And it makes your mouth all black. And many people would vomit. And if you vomit drinking it, you've got to drink more. Because it's not an emetic. It's not meant to make you throw up. You have to swallow it. So what was happening is patients were aspirating. They were getting charcoal in their lungs. And so the doctors were like, well, don't bother with it. We'll give it to you at the hospital. You've got to show transport documents. And we were never using it. So that's why we took our own. Injected poisons. Includes intravenous drug abuse and venomation by insects, arachnids, reptiles. Now, in the United States, we really don't have anything that will inject you and kill you. Like arachnids, reptiles or even like rattlesnakes when they bite you. Can they kill you? Yes. But more often than not, it's a reaction to the venom than the venom itself. It can produce a serious bite and some serious tissue necrosis. Probably not going to kill you. Even black willow will not kill you. They'll be painful for about 48 hours, but they won't kill you. Out in Australia, everything kills you. So that's the difference. When out in Australia, thank God, we don't have to deal with that. But usually most of your insects, arachnids or reptiles kill because of anaphylaxis. Or your body's reaction to that. I think between insects, arachnids or reptiles, I think probably 300 or 400 people a year die from bites. Usually absorbed quickly in the body. It can cause intense local tissue destruction. And then once it becomes systemic, it causes a lot of the other problems. That's one of the reasons why when you get bit by a snake, they used to tell you put on a tourniquet, cut the wound and suck the blood out. I actually had an EMT book that did that and said that. Talk about BSI scene safety. Let me suck your blood out, right? I'm not a freaking vampire. But you don't even put constricting bands anymore because we want that toxin to slowly circulate through the body and let the body metabolize it. The solution to pollution is dilution. So I don't want to stop the flow of the toxin. I just don't want it to go quickly. So that's why I keep you calm, have you lie down, keep your respirations low. You don't walk. We'll carry you out. And that will allow the toxin to spread slowly and the body will be able to absorb it. There's no way to get the venom out because it's in the blood system. As soon as the animal bites you, that venom goes into the vascular system. It gets in the capillary bed. So God forbid it bites you through a vein, it gets right in the vascular system. You'll never be able to get it out. So any kind of a tourniquet makes that toxin stay there. Now granted, by doing that, the toxin doesn't spread through the body. But what it does is it keeps it there and it causes massive tissue destruction because that's what it does. It kills the animal from the inside. So you don't want it. You want to spread it so it doesn't cause that much damage. You cannot dilute or remove any injected poison from the body. So the best bet is to allow it to circulate. So signs and symptoms may include dizziness, weakness, fever, chills, unresponsiveness, or excitability. I get bitten by a snake. I might be a little bit excited. Monitor the airway. Provide high flow oxygen and be alert for nausea and vomiting. Remove rings. This is very important. Rings, watches, bracelets. I've seen people lose fingers because they had an injury and they didn't remove the ring. And the finger swelled up and blood flow was occluded by the ring and they lost the finger. So we have ring cutters in the ambulance which will cut everything but those friggin' titanium rings. I hate those. But everything else we can cut through. So use your ring cutter if you have an injury. Remove all jewelry. So seeing signs, take standard precautions and look for clues. Is there an odor in the room? Is the scene safe? If you walk in a room and you smell something and your patient is altered, get them out of there or you get out of there and wait for hazmat. If you're already in there, get the hell out. Are there medication bottles lying around? Is there medication missing that might indicate an overdose? We can count back. They call it counting back a prescription. So I look at the prescription. It says two BIDs. That means two pills twice a day. And then I look at the total number of the prescription. The prescription will have the dose and the total pill count and the date. So I know the prescription was yesterday. It says two pills a day for 30 days. So it's 60 pills in the bottle and there's only 10 pills left. Which means that person took 50 pills as opposed to two or four. See? So we can count that back. If you're not going to spend time counting it, bring the bottle with you. The hospital can count it back. The nurses will do that. At least when they do what they call the Chem 7 and the toxicology blood work, they'll at least know what to look for. Are alcohol beverages containers present? Alcohol is a common chaser with all drugs. I'll be honest with you. I have been known in the past taking antibiotics for some various type of infection over the years. And I forget to take my pill and I'm drinking a beer. Oh, let me pop that pill and chug a beer and swallow it. Not a smart thing to do, but I was never very smart anyway. Drug alcohol is common with drugs. Oh, let's go smoke some dope. Yeah, I'll bring a six pack. I mean, it's common. So just be aware of that. When you're dealing with overdoses or drugs, there could be alcohol involved. The number one phrase that keeps us in business, hold my beer and watch this. Are there syringes or other drug paraphernalia? Things like syringes, needles, scales, lighters, pipes, you know, things like that. Are there suspicious odors that may indicate the presence of a drug lab? A few years ago in Boston, in Dorchester, I think I told you the story. There was the call for unresponsive child. So Boston EMS shows up, knock on the door, EMS here, they open the door. They immediately smell what they shouldn't be smelling and they left and they called the police and hazmat. So hazmat showed up at the SCBA and entered the building. Well, what happened was the front was a daycare center of the apartment. The back of the apartment was a meth lab. And so, I don't know if you know anything about crystal meth, but crystal meth is three times more explosive than gasoline and it's highly toxic. When you cook it, you have to wear a respirator. And what happens is it seeps into the walls and the walls will off-gas it for up to six months afterwards. So they ended up, one child died, another child had severe exposure to the fumes. So be careful. If you smell something, be very careful. Step back. Cell phones, radios can set explosions off. So just be very careful. And that's another thing where crystal meth, you can cook it and you can make a lot of money by cooking it. So it's not uncommon for a drug dealer to move into a depressed neighborhood, buy a house on auction, just gut it and cook a million dollars' worth of meth and then just leave the house. So when somebody comes in, a family comes in and says, oh, we'll buy that house, we'll do the work together and we'll fill the house up. And you go to the house the next day because you have four unresponsive people because they were gutting the house that was off-gassing these fumes. Determine the severity of the patient's condition. Obtain a general impression. That's your overview of the patient. These patients may be short of breath, semi-altered, the pinpoint or dilated pupils. They may be uptundation or unresponsive. They might be seizing. They might be hypothermic. Assess their level of consciousness. Determine any life threats for you and for them. Do not assume that a conscious, alert, and oriented person is in stable condition. I had a patient one time that we went for the psych eval. And we arrived, this was at the Shaw's in Western Square in Worcester. So I show up with my partner and we go up, we talk to the person, the police are there, and the girl says that she took like 50, I don't know, pills, right, these orange pills. And she explained to me they were the orange tablets. I said, well, where's the box and everything? She didn't have it. So I'm thinking to myself, you know, maybe she's making it up because she was psyched, she wanted to go to the hospital. But I did my due diligence and I reported it to the hospital and we arrived. We get into St. V's, she went to St. V's. No sooner do we get her in the ED into the room, she starts vomiting. And what comes up, copious amounts of these orangey pills. She did really swallow like 50 pills. I don't know how she did it, 50 pills would make me throw up. But, and the thing with Tylenol is, when I talk about it, Tylenol kills the liver without any outward signs of damage. So I take 50 pills of vinegar, of Tylenol, or acetaminophen, not going to do anything to me. Well, that was a waste of time. I guess it didn't do anything. In the meantime, it's destroying my liver. I don't die now. I die 7 to 10 days later from liver failure. So that's the problem with Tylenol. It's very insidious. You don't realize it. There is actually an antidote to that. It's called N-acetylcysteine. It's an IV. And the skin, given within two hours of the overdose, two to three hours of the overdose, it can reverse the effects of liver damage. So don't assume, because the patient's conscious and alerted, that they're okay, because they may just not have gotten the full effect of the toxic exposure. Ensure the patient has an open airway and adequate ventilation. Don't be afraid to put these patients on oxygen, any kind of toxic exposure. If the patient has difficulty breathing or inhalation injury, begin oxygen therapy. Make sure you have suction available, because they could start vomiting at any time, as well as you might have to ventilate the patient. Assess the pulse and skin. Do all your vitals. And they will vary. Your pulse and circulation will vary based upon the substance. Transportation and decision, high priority. You're never going to go wrong. A person that's exposed to a chemical or toxic substance or an overdose, you're never going to go wrong. High priority. I'm going to say, why did you guys go like this? Because the patient was potentially unstable. I didn't know how the patient was going to react. Everybody who's exposed to a hazardous material of any kind must be thoroughly decontaminated before leaving the scene. I don't want them in the back of my enclosed ambulance with no ventilation, but I also don't want to go trips into the ED with them, because I'm going to get spanked for that one. So even after the patient's been decontaminated, I'm going to call the radio and say, Mr. C-Med, I'm going to say, UMass, this is MedStar 38 coming to you with a 38-year-old patient exposed to XYZ chemical. Patient was decontaminated by fire. Patient's vital signs are blah, blah, blah. Most likely they're going to say, meet the decon team outside of the ER, and they'll do a secondary decontamination before we walk in. Or they'll take you right into a specific sealed room. They don't want you traipsing through the ED, even if the patient's decontaminated, because they want to make sure they're decontaminated. So they might not do that. They might accept the fire department, but more than likely they probably will do a secondary decontamination. If your patient is responsive, do your sample history, because again, we need to know their history. Do they have COPD? Do they have cardiac issues, AFib? Do they have neurological conditions? Are there things that could be exacerbated by a toxic explosion? If your patient is unresponsive, you have to get the history from other sources. You may not be able to. You may not get any sample history. Patient's unresponsive, nobody knows him, we take him as is. In addition to the sample, you're going to ask, what substances involved? What was the chemical? Try and get the MSDS if you can. When did the patient become exposed to it, and how much did the patient ingest, and what was the level of exposure? You notice how they don't have why up there. Unless you're specific in thinking that the patient attempted to hurt themselves, why is important. Otherwise, why isn't important. Doesn't help me with treatment, doesn't do anything for me. So unless you're thinking suicidal attempt, don't even bother with why. Over what period did you take or get exposed to the substance? It might be days. Has the patient of IsAIDA performed any interventions, i.e., done any type of antidote? If they've taken an antidote of any kind, even if it's just syrup of epitaph or mustard to try and get you to vomit, we want to know. And how much does the patient weigh? Weight is very important. So focus on the area involved in poisoning and the route of exposure. Was it inhaled? Was it ingested? Was it injected? Or was it absorbed? Focus on the area that the exposure came into the body. A general review of all body systems may help to identify systemic problems. How do I do an overall general body system check? What wouldn't that entail? If I wanted to check overall the whole body, what would I do? What would I check for an overall body system check? What would I do? How about your vitals? Vitals. Do a good set of vital signs. Listen to lung sounds. Assess the skin, right? That's what you want to do. Remember, vital signs tell me systemically what's going on with the body. Sometimes they're a late sign, but we want to review vital signs. Get early. Right away. Bam. I'm going to start by asking some questions. My partner's going to take vitals. Get your vitals right away. Get your baseline vitals right away. Reassess the adequacy of your ABCs. Maybe you need to kick up the oxygen. Maybe you need to put them on oxygen. Maybe you need suction available. You're going to do vital signs and evaluate your interventions every five minutes. I know it says 15 for stable patients, but remember, every toxic exposure or poisoning is potentially unstable. Yeah, they're stable now, but they might not be five minutes from now. Do vitals every five minutes. Any exposure, five minutes. You're only going to have the patient for 20 minutes anyway, so do them every five minutes. You need two sets to begin with, so you might as well do them every five minutes. Always assume that any exposure patient is potentially unstable. Supporting the ABCs for your treatment is the most important task. Keeping the airway open, having oxygenation, suction available. That's one of your top priorities. Contact medical control to discuss treatment options, not poison control. Manage airborne exposures with oxygen. Remove contact exposures with water. If it's powder, brush off the mane before you rinse off the breast. Consider activated charcoal. Well, you can consider it, but we won't do it. Or we can consider it. I'm thinking about it, but I'm not going to do it because I don't even have it. Report as much information as you have about the poison or the chemicals to the hospital. Get that MSDS. If it's a poisoning at a home or residence, you're probably not going to have an MSDS. Bring a container with you. If it's a bottle of bleach or something like that, bring it with you, right? Or bring the MSDS with you if it's in a work setting or a business setting. Yes? If it's an illegal drug, do you need to report it to law enforcement? No, your job is not to report, but don't worry. It'll get there. The information will get there. I'll be honest with you. I've done overdoses up the wazoo, and most of the time the cops don't even care. They're like, alright, whatever. You're going to transport to the hospital? Okay. They don't even do anything anymore. Because the laws for possession are so low now that it's not even worth it for them. Most of the time they'll just let it go. Maybe a small town might be different, but in a big city... We wake up, sir, here's your ticket. We're going to jail. Sometimes. Sometimes. Sometimes they don't. Most of the time they don't. Ensure scene safety. Remove tablets or fragments from the patient's mouth. This is very important. I told you about the patient that I caught chewing on a fentanyl patch, right? He was chewing on a fentanyl patch. So if they're chewing or have any fragments in their mouth, remove them. Take them to the hospital again. Wash or brush the poison from the patient's skin. Brush it off before you rinse it if it's in powder. Assess and maintain the ABCs. Provide oxygen and perform assisted ventilation if necessary. Treat for shock and transport to the nearest hospital. Closest appropriate facility. There are no specialized poison sensors. Any hospital can handle it. Some EMS systems allow the EMT to give activated charcoal by mouth. Ours does not, but it is still a natural skill. Activated charcoal binds with specific toxins and it's carried out in the body, in the stool, through a cathartic agent. So the cathartic agent is like a sugar. And the binding agent is the activated charcoal. That's one of the reasons why all of your filters, pretty much all filters, whether it be water filters or whatever, they all have charcoal in them. That's what does the filtration. Activated charcoal is contraindicated in patients who have ingested alkali poisonings. It won't neutralize the alkali, but it may cause the patient to vomit, bringing up the alkali and burning the airway again. So you double whammy. That's why we don't give it. Cyanide, cyanide is metabolically processed, so it's not going to do anything with that. Ethanol, it doesn't do anything with that. Iron or any heavy metal, iron, lithium, that's not going to work on that because it doesn't remove heavy metals or organic solvents. So again, anything like that, we do not give activated charcoal. So if you ever see a question on that, that's the answer. Decreased level of consciousness or a patient cannot protect their airway. They've got to be able to swallow it. If this patient wouldn't take oral glucose, they couldn't give them aspirin, then you can't give them activated charcoal. They've got to be able to process it, eat it, and swallow it.