Brazilian pepper, Schinus terebinthifolius,

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ISSN:1059-6518 Volume 29 Number 3

By Brandon Munsell NREMT-P , WEMT-P, SOLO Instructor

As the campfire kicks into high gear, a camper throws on boughs from a nearby tree. Although the tree limbs seem dead, the tree they were taken from is abloom with bright red berries and serrated toothed leaflets. As the now burning branch begins to spew smoke, a wind directs it towards gathered campers. Upon inhalation the members begin to experience irritation to their faces and throats, and they also begin to tear up as they assume tripoding positions to catch their breath. As they retreat from the offending fumes, many begin to wheeze and seek water for their now burning eyes. What has caused this unexpected reaction?

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By Frank Hubbell, DO

Illustrations by T.B.R. Walsh

In the June 2014 edition of the WMNL, the pathophysiology, recognition, and treatment of cardiovascular disease was discussed. With these various illnesses the source of the chest pain is a problem with the coronary circulation of the heart itself. In this issue of the WMNL, we will look at the sources of the non-cardiac chest pain.

Imagine you are working with a group of park rangers in the Rockies when the team gets a call for a hiker in distress. As it turns out, the hiker is reportedly on the same trail as you are, and they are an estimated 3 miles away, about a one-hour hike from you present location. According to dispatch, they were notified via cell phone from the hiking party that one of their members is complaining of chest pain and does not feel as if he can continue on.

Dispatch is able to give you some additional information: the hiker is a 46-year-old male, one of four in their hiking group. The group left the trailhead before sunrise and were taking the most direct route to the summit, in hopes that they would reach the summit before sunset and hike down in the dark with headlamps. They are not prepared to stay out overnight. The other three hikers are all men in their late 20’s.  They have known each other for years, as he was their outing club director and their math teacher in high school.

An hour later you catch up with the hiking group. They are sitting together under a large pine tree, sharing some gorp (trail mix) and water. You introduce yourself to the patient and explain that you are a paramedic working with the park rangers. The patient is very glad to see you and seems to be quite relieved.

He states that after hiking for several hours, the incline of the trail became quite steep, and he was having a hard time keeping up with his younger companions. As he pushed onward, he began to develop pain in the anterior of his chest, tingling in his hands and arms, shortness of breath, mild nausea, and began to feel weak, almost as if he was going to pass out. He states that he did recover completely after a five-minute rest, but when he would start hiking uphill again, the symptoms returned after about fifteen minutes. Currently, he feels much better, since they have been at rest for the past hour. He feels that he can walk out, as it is mostly downhill.

The real concern regarding this 46yo male, is whether the chest pain is cardiac or not. If cardiac, he deserves rapid evacuation. If non-cardiac chest pain, then he can most likely walk off the mountain.

You should always err on the side of caution and assume that all chest pain is cardiac until proven otherwise. To sort out cardiac chest pain from non-cardiac chest pain requires a good history, specifically looking for the cardiac risk factors and a good physical exam to try to accurately determine the source of the pain. As you read the descriptions of non-cardiac chest pain types, you will notice that some sources would require immediate evacuation.  When in doubt, as stated above, always err on the side of caution and assume all chest pain is cardiac until proven otherwise.

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The Challenges of Emergency Airway Management:

 By Frank Hubbell, DO

Illustrations by T.B.R. Walsh

First, let’s define the problem:


1.     When the need for emergency airway management arises, it is usually a scene that is already difficult, desperate, rapidly deteriorating. A scene that most likely requires critical care skills. One of those rare times where speed is of the essence.

2.     Your patient may be unruly, uncooperative, or even intoxicated.

3.     Your patient will most likely already be hypoxic with poor oxygenation and decreasing respiratory and ventilatory efforts. As a result they will not tolerate even short periods of apnea or hypoxia.

4.     Your patient may have recently eaten or drank, and these stomach contents dramatically increase the risk of vomiting and with the risk of aspiration.

5.     Their airway may already be compromised by blood, vomitus, secretions, or distorted anatomy from trauma.

6.     Your patient may be a cardiac arrest or a near-arrest situation.


OXYGEN: Let’s begin this discussion with oxygen.


When we talk about the importance of maintaining an open airway, what we are really talking about is the importance of a constant, uninterrupted flow of oxygen to every cell in the body. The cells with the greatest demand, and therefore the most sensitive tissues to oxygen supply, are the nerve cells that make up the brain. These neurological tissues can only survive intact for 4 – 6 minutes without oxygen; after 10 minutes without

O2 , irreversible brain damage occurs and most likely death.


The human brain makes up 2% of our total body weight, but it is hypermetabolic:

– it requires 15% of our cardiac output,

– 20% of total body oxygen consumption, and

– 25% of the total body utilization of glucose.

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Volume 26 Number 4

By Frank Hubbell, DO

Illustrations By T.B.R. Walsh


To be used on anyone who is exhibiting signs and symptoms of hypoxia:


Shortness of breath

Increase or decrease in respiratory rate

– Adult: respiratory rate less than 10 or greater than 30

– Child (1 year – 12 years old): respiratory rate less than 15 or greater than 30

– Infant (0 – 12 months old): respiratory rate less than 25 or greater than 50

Increase in heart rate.

Change in level of consciousness.

Change in skin color: pallor or cyanosis.


 Never, ever withhold oxygen from someone who appears to need it.

The following is needed to provide supplemental oxygen to a patient:

✔  O2 tank

✔  Regulator

✔  Delivery device – O2 mask


 Medical Oxygen Storage Tanks:

Come in various sizes.

Are identified by color– either the entire tank is green or the curved part of the tank, “the shoulder,” is green

Have an identifying yellow, diamond shaped label on the tank that is marked U.S.P. and Oxygen

Full tanks contain 2000 PSI of pressure and must be handled properly.


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