Feeling QUEASY

We were dispatched for a 12-year-old male with a deep, six-inch gash to his left lateral thigh. When we arrived at the group camp site in the state forest, we found an awake and oriented patient. A paramedic--a member of the boy's camping party--had already controlled the bleeding and applied a large compression bandage around the wound. The patient had fallen on a piece of glass, had no other complaints, and his vital signs were normal. His group had no vehicle to transport him, so they requested ambulance transport.

Our patient was excited about his first ambulance ride and talked rapidly as we showed him different patient care equipment. It was a 30-minute drive along curving and undulating rural roads to the nearest hospital. A few minutes into the ride, the patient was asking fewer questions and staring out the rear window at the rapidly receding pine trees. Soon, his skin turned pale, his palms got sweaty and he began to swallow more frequently. Instinctively, I passed him an emesis bag and prepared for the inevitable stream of partially digested pancakes, bacon and orange juice he had reported as his last meal.

The final portion of our journey was on a straight, smooth state highway. The patient's color and mental status improved dramatically. His brief bout with motion sickness had passed, and he was eagerly anticipating stitches.

Many patients--with or without nausea--experience motion sickness while riding in the ambulance.¹ According to the American Academy of Otolaryngology, motion sickness occurs "when the central nervous system (CNS) receives conflicting messages" from the inner ears, eyes, skin pressure receptors, and muscle and joint sensory receptors. These systems control our sense of balance. The inner ear monitors body motion: forward or back, left or right, and up or down. Our eyes monitor where the body is in space--right side up or upside down--and directions of travel. Skin pressure receptors in the joints and spine communicate to the CNS which part of the body is down and touching another object, such as the ground. Muscle and joint receptors tell the CNS which parts of the body are moving. The CNS receives and analyzes all of this input to know which direction the body is pointing, where it is going and if it is moving.²

Signs and Symptoms
Motion sickness, sea sickness and air sickness are the same disorder and all relate to balance and equilibrium.² The symptoms you have experienced on a roller coaster, charter fishing boat or airplane are the same as what your patients might experience in the ambulance. Signs and symptoms of motion sickness include nausea, vomiting, dizziness, pale skin, sweaty skin and malaise.

Preventing/Reducing Motion Sickness
Some things you can do for low-priority transport patients to prevent or reduce motion sickness include:

• Drive slower
• Brake and accelerate more smoothly
• Take a route with fewer stops and turns, even if it might be a little longer.

During transport of all patients, use the following ideas to prevent or reduce motion sickness:

• Calm and reassure the patient.
• Help the patient find a position of comfort. Lying supine and focusing on a poster or sticker on the ceiling might be best.
• Advise the patient to not stare at cardiac monitor or pulse oximeter displays.
• Encourage the patient to not look out the window or at things that are swinging, like IV tubing. Instead, the patient should close his eyes or look at a fixed point on the ambulance wall.
• Place a cold cloth on the patient's forehead, and use a directional fan to blow fresh air on his face.
• Offer the patient supplemental oxygen by nasal cannula.
• For long transports, a pair of headphones and relaxing music are very helpful.
• Don't ask the patient to read and sign a "release of information" or billing information document during transport.

Upon arrival at the hospital, a patient with motion sickness should avoid sudden position changes.

• Move slowly and gently from the ambulance to the hospital room.
• If the patient is going to stand after lying supine in the ambulance, first assist him to a sitting position on the side of the cot for a few moments before standing.

Summary
Motion sickness can quickly become any patient's chief complaint. Rearward-facing transport, coupled with the stress and anxiety of injury or illness, can easily confuse the signals the body is sending to the CNS about equilibrium and balance. Any patient will appreciate your efforts to anticipate, prevent and minimize motion sickness.

References

1. Fleischhackl R, et al. Forum: Reduction of motion sickness in prehospital trauma care. Anesthesia 58(4):374, 2003.

2. American Academy of Otolaryngology-Head and Neck Surgery. Dizziness and Motion Sickness. www.entnet.org.

3. Beck RK. Pharmacology for the EMS Provider, 3rd Edition. Thomson Delmar Learning. Clifton Park, NY, 2003.

Greg Friese, MS, NREMT-P, is president of Emergency Preparedness Systems LLC, which helps clients rapidly deploy emergency education. Greg and EPS associates have authored and edited dozens of online education programs for first responders, EMTs and paramedics. Friese is a paramedic, Wilderness Medical Associates lead instructor and EMS author. Contact him at gfriese@eps411.com.

Online Resources
To learn more about causes, assessment and treatment of patients with nausea and vomiting, visit www.rapidce.com to complete a CECBEMS-approved lesson. RapidCE is presented by www.emsresponder.com and powered by CentreLearn.