EMS Zoological Emergencies - When Scorpions Sting & Spiders Bite

Last year, the Bronx Zoo hosted an educational program titled "Bite Me!" designed to train EMS and search and rescue personnel on managing venomous creature attacks, despite the absence of scorpions and spiders in the zoo's collection.

The event featured presentations from experts, including Dr. Joshua Silverberg, who discussed snakebite treatment, and Stephen P. Wood, a former EMS provider, who covered bee, ant, and mosquito stings.

Leading the program was wilderness physician Dr. Sanjey Gupta, an experienced instructor in wilderness medicine. 

Dr. Gupta serves as the Chair of Emergency Medicine at South Shore University Hospital and as a professor at the Zucker School of Medicine.

His presentation focused on venomous spiders and scorpions, detailing their habitats, the physiological effects of their venom, and appropriate EMS response protocols.

For more information, access the article via this link via the Journal of Emergency Medical Services.

EMS Environmental Emergencies - Lightning Related Incidents

Each year, lightning-related fatalities surpass those caused by tornadoes, hurricanes, and earthquakes combined, highlighting the frequency and severity of these incidents. 

However, lightning strike injuries are often an underestimated component of environmental emergencies that EMS Providers must be prepared to handle. 

Lightning strikes not only present unique mechanisms of trauma but can also lead to high morbidity and sudden fatalities. These incidents demand rapid, informed, and skillful response due to their sudden and unpredictable nature.

EMS Providers play a crucial role as the first line of care in such emergencies, especially given that lightning strikes often occur in remote or outdoor areas where specialized medical assistance is not immediately available. 

Recognizing lightning as the second most common storm-related cause of death - surpassed only by flash floods - emphasizes the need for comprehensive training and awareness.

Mechanisms of Lightning Injury

The mechanisms of injury (MOI) are multifaceted, ranging from direct strikes to complex indirect effects like ground current and blast injuries. 

These factors make understanding the nature of lightning-related incidents vital for effective prehospital management and prevention of complications.

EMS providers must understand the primary mechanisms of injury associated with lightning strikes to properly assess and manage patients:

Direct Hit: Occurs when a person is directly struck by lightning, most often in open spaces such as fields or meadows.

Splash Lightning: Lightning can strike an object and "splash" or jump to another nearby object or person, following the path of least resistance.

Ground Current: The most frequent cause of injury, where lightning hits the ground nearby, and the electrical current radiates outward. If someone is within this radius, the current can pass through or over the body.

Blast Injury: The rapid expansion of air from a lightning strike can create an explosive force, causing secondary trauma.

Contact Injury: Occurs when a person is touching an object that conducts electricity, such as a wire fence or a corded phone.

Signs and Symptoms of Lightning Injury

Lightning strikes can present with a range of symptoms, including:

Cardiac / Respiratory Arrest: Immediate life-threatening emergencies.

Neurological Impacts: Loss of consciousness, seizures, paralysis, and balance issues.

Burns: Typically minor due to the "flashover" effect where current passes over the body.

Sensory Disturbances: Temporary blindness or deafness.

Trauma: Injuries resulting from being thrown by the force of a strike.

Key Treatment Principles

Scene Safety: Ensure the scene is safe, as lightning can strike the same area more than once.

Basic Life Support (BLS): Be prepared for prolonged rescue breathing and CPR as needed.

Comprehensive Examination: Conduct a thorough assessment of the patient and treat injuries accordingly.

Continuous Monitoring: Keep a close watch for any changes in the patient's condition.

Evacuation: Transport any individual struck by lightning for further evaluation and care.

Prevention Tips for Lightening Safety

EMS Providers should be aware of preventive strategies to minimize lightning injuries:

Seek Shelter: In urban areas, take refuge in buildings (avoid small sheds) or vehicles. The motto “When thunder roars, go indoors” underscores the urgency.

In outdoor areas, select locations surrounded by a uniform stand of trees or low, rolling terrain.

Understand Risk Areas: Recognize that while some outdoor locations are safer than others, no place outside is completely safe during a lightning storm.

Monitor Weather: Be aware of local weather patterns and avoid exposure to known risk zones during storms.

Avoid High-Risk Locations:

• Elevated areas such as peaks, ridges, and hills
• Isolated tall objects (e.g., single trees)
• Open fields or meadows
• Large bodies of water and shorelines
• Shallow cave entrances or overhangs
• Previously struck areas
• Long conductors like wire fences, pipes, or wet ropes

Insulate and Disperse: When moving to a safer location is impractical:

Insulate yourself from ground current by crouching in the lightning position (heels together, minimizing contact with the ground).

Encourage group members to spread out to minimize the risk of multiple casualties.

In Conclusion

EMS Providers should be equipped with the knowledge to recognize the broad spectrum of signs and symptoms that can accompany lightning injuries, from cardiac arrest and neurological damage to less apparent conditions like temporary blindness or minor burns. 

The potential for cardiac and respiratory arrest underscores the necessity of timely and proficient Basic Life Support (BLS). Additionally, ensuring scene safety is paramount, as lightning can strike the same location more than once, posing a continued threat to both the patient and the responder.

Given the unpredictable nature of storms, EMS teams must be adept at prevention, risk assessment, and patient education to minimize exposure and injury rates. 

By understanding these principles and preventive measures, EMS Providers can effectively manage and mitigate the risks associated with lightning injuries during environmental emergencies.

Further Reading:

Alexander, M. & Belle, R. (2017) Advanced EMT: A Clinical Reasoning Approach (2nd Ed). Hoboken, New Jersey: Pearson Education

Bledsoe, B. E., Cherry, R. A. & Porter, R. S (2023) Paramedic Care: Principles and Practice (6th Ed) Boston, Massachusetts: Pearson

Gookin, J. (2011) Backcountry Lightning Risk Management. NOLS. Accessed October 24, 2024

Grayson, S. & Gandy, W. (2011) Environmental Emergencies. EMS World Online. Accessed November 8, 2024.

Limmer, D., O'Keefe, M. F., & Dickinson, E. T. (2020) Emergency Care (13th Ed) - Chapter 31: Environmental Emergencies. Accessed November 8, 2024

Mistovich, J. J. & Karren, K. J. (2014) Prehospital Emergency Care (11th Ed). Hoboken, New Jersey: Pearson Education

Oglesbee, S. (2014) Considerations When Assessing & Treating Patients with Lightning Injuries. Journal of Emergency Medical Services. Accessed October 26, 2024

Osmosis (ND) Environmental Emergencies. Elsevier. Accessed October 8, 2024

Peate, I. & Sawyer, S (2024) Fundamentals of Applied Pathophysiology for Paramedics. Hoboken, New Jersey: Wiley Blackwell

Schimelpfenig, T. (2021) NOLS Wilderness Medicine (7th Ed). Mechanicsburg, Pennsylvania: Stackpole Books

EMS Environmental Emergencies - Water Rescue Principles

Understanding and following the “Talk, Reach, Throw, Row, Go Tow” approach ensures that EMS Providers prioritize safety and efficiency during water rescues. 

Each step is designed to minimize risk while maximizing the chances of a successful rescue. Here is a overview of these principles:

1. Talk

Overview: The first step in any water rescue is to establish verbal contact with the victim. This is a crucial initial approach as it avoids placing the rescuer in danger while offering immediate assistance.

Purpose: Engaging with the victim verbally can calm them down, offer reassurance, and direct them on what to do until further help arrives. It’s especially effective if the victim is conscious and within earshot.

Implementation:

Calm the Victim: Use a confident and reassuring voice to reduce panic. Simple commands like “Stay calm,” “Float on your back,” or “Kick your legs toward me” can make a significant difference.

Assess Victim's State: While talking, gauge the victim's physical and mental status, identifying signs of distress or fatigue.

Instructions: If safe, guide them toward a nearby safe zone or floating device. Sometimes, victims can self-rescue if given clear, step-by-step instructions.

2. Reach

Overview: This involves using an extended object such as a pole, branch, or specialized rescue tool to reach the victim while the rescuer remains on solid ground or a stable surface.

Advantages: Keeps the rescuer out of the water, minimizing risk.

Techniques:

Secure Position: Ensure a stable footing or a firm hold on a structure before extending an object to the victim.

Encourage Victim to Hold: Guide them to grasp the object securely before pulling them to safety.

3. Throw

Overview: If the victim is beyond reach, throwing a buoyant object (such as a life ring, rope with a float, or even a makeshift floatation device) is the next option.

Key Points:

Accurate Throw: Aim for the throw to land close to the victim without hitting them.

Communication: Maintain eye contact and provide clear instructions, like “Grab the rope and hold on tight.”

Steady Retrieval: Once the victim has secured the object, slowly pull them to safety, avoiding jerky movements that could cause them to let go.

4. Row

Overview: When a victim is too far for a reach or throw, using a boat or flotation device to approach them is the safest option before entering the water.

Execution:

Boat Handling: EMS providers should be familiar with operating small boats, kayaks, or other flotation devices and should always wear personal flotation devices (PFDs).

Maintain Safety: Keep an eye on currents, waves, and potential obstacles. Approach the victim from downstream or downwind to avoid drifting into them uncontrolled.

Steady Approach: Row steadily and communicate with the victim, preparing them to grab the edge of the boat or flotation device.

5. Go

Overview: This is the most hazardous option and involves entering the water to rescue the victim directly. EMS Providers should only attempt this step if they are properly trained in water rescue techniques and have necessary safety equipment.

Preparation and Equipment:

Wear a PFD: Ensuring the rescuer’s safety is paramount. A PFD reduces the risk of the rescuer becoming another victim.

Rescue Aids: Bring a floatation device or rescue tube to aid in keeping the victim buoyant.

Techniques:

Approach Cautiously: Swim with strong, controlled strokes and avoid sudden movements that might startle the victim.

Contact Rescue: If the victim is panicking, use techniques to maintain distance until they calm down. Only make physical contact when safe, positioning yourself behind the victim to avoid being grabbed and pulled under.

Backup and Teamwork: Always have another team member on standby, either on land or in a secondary boat, to assist if needed.

6. Go Tow (Advanced Step)

Overview: This refinement of the “Go” principle emphasizes the use of towing techniques where the rescuer enters the water but minimizes direct contact by using a floatation device or rope to tow the victim to safety.

When to Use: The “Go Tow” method is ideal when entering the water is necessary, but maintaining distance from the victim is critical for safety.

Execution:

Secure Towing Equipment: Ensure a floatation device is connected to a rope or line that can be held or attached to the rescuer.

Approach and Transfer: Swim to a safe distance from the victim and pass them the floatation device, maintaining communication to keep them calm.

Tow Position: Once the victim has a firm hold on the device, use a strong swim stroke to pull them back to shore or the boat.

Safety Precautions: Regularly practice towing techniques and ensure proper training to avoid potential risks such as being overwhelmed by the victim’s movements.

Key Points for EMS Providers

Personal and Team Safety: Always assess the scene for hazards like strong currents, underwater debris, or dangerous weather conditions.

Call for Backup: Notify specialized water rescue teams when necessary; collaboration enhances the overall safety and efficiency of the operation.

Training: Continuous training in water rescue techniques, such as swift-water rescue, is vital. Familiarity with tools like throw bags, rescue tubes, and PFDs can significantly enhance rescue capability.

By following these structured principles, EMS Providers can effectively respond to water emergencies while ensuring their safety and the safety of their team.

Further Reading:

Alexander, M. & Belle, R. (2017) Advanced EMT: A Clinical Reasoning Approach (2nd Ed). Hoboken, New Jersey: Pearson Education

Bledsoe, B. E., Cherry, R. A. & Porter, R. S (2023) Paramedic Care: Principles and Practice (6th Ed) Boston, Massachusetts: Pearson

Ferrero, F. (2006) Whitewater Safety & Rescue (2nd Ed). Bangor, Gwynedd: Pesda Press

Grayson, S. & Gandy, W. (2011) Environmental Emergencies. EMS World Online. Accessed November 8, 2024.

Limmer, D., O'Keefe, M. F., & Dickinson, E. T. (2020) Emergency Care (13th Ed) - Chapter 31: Environmental Emergencies. Accessed November 8, 2024

Mistovich, J. J. & Karren, K. J. (2014) Prehospital Emergency Care (11th Ed). Hoboken, New Jersey: Pearson Education

Ostis, N. (2015) NOLS River Rescue Guide. Mechanicsburg, Pennsylvania: Stackpole Books

Peate, I. & Sawyer, S (2024) Fundamentals of Applied Pathophysiology for Paramedics. Hoboken, New Jersey: Wiley Blackwell

Schimelpfenig, T. (2021) NOLS Wilderness Medicine (7th Ed). Mechanicsburg, Pennsylvania: Stackpole Books

Ray, S. (2013) Swiftwater Rescue (2nd Ed). Asheville, North Carolina: CFS Press

EMS Environmental Emergencies - Mechanisms of Heat Loss

Understanding how heat is gained or lost by the body is important for EMS Providers to manage environmental emergencies effectively. 

Each mechanism of heat transfer plays a role in the development and management of temperature-related conditions. 

Here’s a look at how radiation, conduction, convection, evaporation, and respiration are relevant in prehospital care:

1. Radiation

Definition: The transfer of heat from the body to the surrounding environment through electromagnetic waves. It occurs without direct contact and is responsible for a significant amount of heat loss, especially when the ambient temperature is cooler than body temperature.

Relevance in Environmental Emergencies:

Hypothermia: When a patient is exposed to cold air or environments without sufficient insulation, heat loss by radiation increases. EMS providers should minimize this by covering the patient with blankets or heat-reflective materials.

Hyperthermia: In hot environments, the body gains heat through radiation, which can exacerbate heat-related illnesses.

Management Tips: Shield the patient from radiant heat sources in hot environments or use reflective blankets to retain heat in cold environments.

2. Conduction

Definition: The transfer of heat through direct contact with objects or surfaces. The body can either lose or gain heat depending on the temperature of the contacted surface.

Relevance in Environmental Emergencies:

Cold Exposure: If a patient is in contact with a cold surface (e.g., the ground), rapid heat loss can occur, worsening hypothermia.

Heat Transfer: In cases of hyperthermia, placing the patient on a cooler surface can help decrease core temperature.

Management Tips: Insulate patients from cold surfaces by placing barriers between them and the ground. For heat stroke, apply cool packs or cold water-soaked materials directly on the skin to facilitate conduction-based cooling.

3. Convection

Definition: The transfer of heat through the movement of air or liquid across the body. Heat is carried away as the air or fluid passes over the skin.

Relevance in Environmental Emergencies:

Wind Chill Effect: In cold weather, wind significantly increases heat loss through convection, increasing the risk of hypothermia.

Cooling Techniques: Fanning or using a cool breeze is an effective way to dissipate body heat in hyperthermia.

Management Tips: For hypothermic patients, minimize exposure to wind by providing shelter and using windproof barriers. For hyperthermic patients, promote cooling by increasing airflow, using fans, or positioning the patient in a breezy area.

4. Evaporation

Definition: The process where liquid on the body (e.g., sweat or water) absorbs heat as it changes into vapor, thereby cooling the body.

Relevance in Environmental Emergencies:

Hyperthermia: Evaporation is the body’s primary method of cooling during high temperatures, as sweating allows heat to dissipate. However, in high humidity, this process is less efficient, which can contribute to heat illnesses.

Hypothermia Risk: Wet clothing increases evaporative cooling, which can rapidly lower body temperature in cold conditions.

Management Tips: In hyperthermic patients, spray water on the skin and encourage fanning to enhance evaporative cooling. For hypothermic patients, remove wet clothing and dry the patient thoroughly to prevent further heat loss.

5. Respiration

Definition: The exchange of air through breathing, which involves both heat and moisture loss as warm air from the body is expelled and cooler air is inhaled.

Relevance in Environmental Emergencies:

Cold Exposure: In cold weather, significant heat can be lost through respiration. Rapid or deep breathing can further accelerate heat loss.

Hyperthermia: In hot environments, heavy breathing increases water loss through respiration, potentially leading to dehydration and worsening hyperthermia.

Management Tips: For hypothermic patients, ensure that the airway is protected and encourage calm, measured breathing to minimize heat loss. For hyperthermic patients, address dehydration as a part of the management strategy, since increased respiratory water loss may occur.

Prehospital Care

Preventive Measures: Understanding these principles helps EMS providers take immediate actions to prevent further heat loss or gain in patients. 

For instance, providing thermal insulation, shielding patients from wind, using wet towels, or facilitating airflow can make a significant difference in patient outcomes.

Integrated Treatment: Utilize combinations of these mechanisms for treatment. 

For instance, in cases of hyperthermia, evaporation (misting and fanning), conduction (cool packs), and convection (fan or breezy location) can be used together to cool a patient effectively.

By grasping how the body interacts with its environment through these mechanisms, EMS providers can better manage environmental emergencies and enhance patient care in prehospital settings. 

Further Reading:

Alexander, M. & Belle, R. (2017) Advanced EMT: A Clinical Reasoning Approach (2nd Ed). Hoboken, New Jersey: Pearson Education

Bledsoe, B. E., Cherry, R. A. & Porter, R. S (2023) Paramedic Care: Principles and Practice (6th Ed) Boston, Massachusetts: Pearson

Grayson, S. & Gandy, W. (2011) Environmental Emergencies. EMS World Online. Accessed November 8, 2024.

Limmer, D., O'Keefe, M. F., & Dickinson, E. T. (2020) Emergency Care (13th Ed) - Chapter 31: Environmental Emergencies. Accessed November 8, 2024

Mistovich, J. J. & Karren, K. J. (2014) Prehospital Emergency Care (11th Ed). Hoboken, New Jersey: Pearson Education

Osmosis (ND) Environmental Emergencies. Elsevier. Accessed October 8, 2024

Peate, I. & Sawyer, S (2024) Fundamentals of Applied Pathophysiology for Paramedics. Hoboken, New Jersey: Wiley Blackwell

Schimelpfenig, T. (2021) NOLS Wilderness Medicine (7th Ed). Mechanicsburg, Pennsylvania: Stackpole Books

EMS Environmental Emergencies - An Overview

EMS Providers must be equipped to handle a variety of environmental emergencies that can pose serious risks to patient health. 

These situations often require rapid assessment and intervention to prevent further deterioration. 

Here is an overview of common environmental emergencies EMS providers may encounter:

1. Submersion Injuries (Drowning and Near-Drowning)

Pathophysiology: Involves hypoxia due to water entering the airway, potentially causing laryngospasm and subsequent respiratory and cardiac arrest.

Management: Prioritize airway management, oxygenation, and ventilation. Consider spinal precautions if trauma is suspected. Initiate CPR if necessary and be prepared for potential complications such as hypothermia and aspiration pneumonia.

2. Temperature-Related Illnesses

Hypothermia:

Definition: Occurs when the body’s core temperature drops below 35°C (95°F). Severity ranges from mild (shivering, lethargy) to severe (loss of consciousness, arrhythmias).

Management: Remove the patient from the cold environment, use passive and active warming techniques (e.g., warm blankets, warm IV fluids), and monitor for rewarming shock.

Hyperthermia:

Definition: Elevated body temperature due to heat exposure, ranging from heat cramps and heat exhaustion to life-threatening heat stroke (core temperature >40°C or 104°F).

Management: Initiate rapid cooling methods such as ice packs, cool water immersion, or evaporative cooling. Provide hydration and monitor for signs of multi-organ dysfunction.

3. Cold Injuries

Frostbite and Frostnip:

Frostnip: A mild form of cold injury that does not involve tissue freezing, causing reversible skin blanching and tingling.

Frostbite: Involves actual freezing of tissues, potentially leading to permanent damage. Signs include white, hard, or waxy skin, and blisters after rewarming.

Management: Gradual rewarming, protection of the affected areas, pain control, and prevention of refreezing. Avoid friction or direct heat, which can cause further damage.

4. Bites and Envenomation

Animal Bites:

Includes domestic or wild animal bites that carry the risk of infection and soft tissue damage.

Management: Clean and debride the wound, control bleeding, and consider tetanus prophylaxis.

Snake and Insect Bites (Envenomation):

Involves venomous snakes or insects leading to local or systemic reactions (e.g., swelling, neurotoxicity, anaphylaxis).

Management: Immobilize the affected limb, avoid suction or incision, and administer antivenom if appropriate. For anaphylaxis, administer epinephrine and supportive measures.

5. High-Altitude Illness

Conditions:

Acute Mountain Sickness (AMS): Characterized by headache, nausea, and fatigue due to rapid ascent.

High-Altitude Pulmonary Edema (HAPE): Causes shortness of breath, cough, and potential cyanosis due to fluid accumulation in the lungs.

High-Altitude Cerebral Edema (HACE): A severe, life-threatening condition marked by confusion, ataxia, and coma due to brain swelling.

Management: Immediate descent to lower altitudes is crucial. Administer oxygen, medications like acetazolamide, and supportive care as needed.

General Considerations for EMS Providers

Assessment and Early Recognition: Rapidly identify symptoms and their severity to initiate appropriate care.

Transport Decisions: Understand when rapid transport is critical to access advanced care and when field stabilization suffices.

Environmental Precautions: Protect yourself and the patient from ongoing environmental exposure during care.

The goal in managing these emergencies is to minimize further harm while stabilizing the patient for transport to definitive care. 

Each condition has unique aspects to consider, but the key is to prioritize life threats, airway, breathing, circulation (XABCs), and prevent secondary injury.

Further Reading:

Alexander, M. & Belle, R. (2017) Advanced EMT: A Clinical Reasoning Approach (2nd Ed). Hoboken, New Jersey: Pearson Education

Bledsoe, B. E., Cherry, R. A. & Porter, R. S (2023) Paramedic Care: Principles and Practice (6th Ed) Boston, Massachusetts: Pearson

Grayson, S. & Gandy, W. (2011) Environmental Emergencies. EMS World Online. Accessed November 8, 2024.

Limmer, D., O'Keefe, M. F., & Dickinson, E. T. (2020) Emergency Care (13th Ed) - Chapter 31: Environmental Emergencies. Accessed November 8, 2024

Mistovich, J. J. & Karren, K. J. (2014) Prehospital Emergency Care (11th Ed). Hoboken, New Jersey: Pearson Education

Osmosis (ND) Environmental Emergencies. Elsevier. Accessed October 8, 2024

Peate, I. & Sawyer, S (2024) Fundamentals of Applied Pathophysiology for Paramedics. Hoboken, New Jersey:  Wiley Blackwell

Schimelpfenig, T. (2021) NOLS Wilderness Medicine (7th Ed). Mechanicsburg, Pennsylvania: Stackpole Books