ERDoc

You are called to the house of a 43 y/o female by her husband. He has just returned from a family emergency out of state and found his wife unable to see and a bit confused. What else do you want to know?

Guess the doc isn't going to be able to get too much more info from the pt. I would first reasses ABCs, confirm tube placement, manual BP by my well seasoned RN. Completely expose if not done already. We need a full trauma workup including xrays (chest, pelvis, femur, hip, knee), CTs (pan scan at this point), labs (basics trauma labs plus cadiac enzymes (will be positive at this point), BNP, Dig level, ABG with K), blood and call trauma team, if we have one (no medical team would touch this pt due to the fall, his life depends on the surgeons (hope he's made his peace with whatever god he beleives in)). Need to drop in a cordis in the IJ for TVP and a femoral cordis for blood/pressors/etc. 12 lead would be nice. Would also be thinking about dropping in some digibind. Let's start there and see where it gets us.

I think that given the fact that he was dx with a URI, antibiotics, regardless of which one, is a poor choice. I'd like to know what the throat looked like. Was there any stridor?

I was working renal roundup with a relatively new EMT. We loaded the pt up after her treatment and as I jump in the driver's seat, I hear my partner ask the pt, in a very serious voice, "So, do you feel clean now?"

Hepatic encephalopathy, or at least close to it.

And why would a basic be sent on either one of these runs?

In some areas you don't get a choice. The county I am in is run by a volunteer system, with some companies having paid first responders (there is also a large number of volly ALS personel). There is no guarantee what you will get, it's a crap shoot. Pretty pathetic for one of the largest volly systems in the country/world. The call is dispatched to whoevers district the call is in and whoever shows up goes on the call. Most of the time there is some form of ALS on each call, but there is no guarantee. We even have a few companies in the area that are not ALS. It's a sad situation that does nothing to improve pt care, but the volunteer system has become such a part of the history here that it will take hell freezing over to change it. Sorry to run on so long, it is just s frustrating situation that will never improve.

While the seizure does sound like a typical seizure, I'm having trouble saying it is glucose related. It sounds to me like he has diabetes and a seizure disorder. People don't take dilantin for glucose related seizures. He also stopped seizing without intervention. A metabolic derangement that causes a seizure will generally continue to have a seizure until the derangement is corrected (although this is not 100% of the time).

Even when spell check is working.

I got one...

26 y/o female on her way to EMT-B class is chased down by a bunch of angry people from an online forum who begin to pelt her with various EMS related objects...

Just kidding. Welcome to the City. It can be a little rough in here.

Edited for Michael's approval (and to post pad )

It gives a new definition to tossing your salad! :twisted:

I got one...

26 y/o female on her way to EMT-B class is chased down by a bunch of angry people from an online forum who begin to pelt her with various EMS related objects...

Just kidding. Welcome to the City. I can be a little rough in here.

Each hemoglobin molecule is made up of 4 subunits, two of which are called the beta-globin subunits. The globin molecules are proteins (which are composed of amino acids). In someone with sickle cell, one of the amino acids in the Beta-globin subunit is switched. These modified beta-globins can cause the hemoglobin molecules to clump together within the RBC when they become deoxygenated. It is this clump of hemoglobin that causes a cell to sickle. They have the capacity to carry just as much oxygen as normal hemoglobin molecules. The problem with RBCs that are sickled is that they tend to lyse pretty easily, resulting in an anemia. Someone mentioned reticulocytes, which are precursors to mature RBCs. The body reacts to the anmeia by releasing immature RBCs, aka reticulocytes. In times of severe stress many RBCs being sickling and they start to clump together in the microvasculature casuing a vasoclusive crisis which is usually painful and one of the main reasons that people with SCD seek medical attention. The WBC and platelet counts are ususally mildly elevated, even during non crisis times due to the body's attempt to correct the anemia.

Hope this helps.

Has anyone ever used the paramedic textbook by Henry and Stapleton? It's an older book, so I will direct this at the veterans.

Here in NY the law allows anyone that is declared brain dead to be declared legally dead and efforts to keep the body alive can be stopped without consent from the family. In my institution there is a lengthy process to declare someone brain dead. The person has to have an EEG and a perfusion MRI to show that the insult to the brain is catastrophic. The pt needs to undergo a full neurological exam by 2 seperate neurologists at least 24hrs apart. The pt needs to be off of all sedatives for 48 hours before these exams. The pt must be shown not to be able to breathe on their own (again, off of all sedating meds). It is a very thorough exam and leaves little room for debate. I saw it once when I was in the SICU. Most of our docs are not as harsh as the one in the story (even the surgeons, at least not in front of the family). It also allows the family time to get everyone together and have time to say goodbye. When looking at stories like this, we need to keep in mind that there is a difference between being in a coma, in a vegetative state and being brain dead.

Just out of curiosity, it is difficult to get an EMS job in other parts of the country? Here all you need is a pulse and a card (the ink doesn't even have to be dry) and the pulse is negotiable.

My respect. That and 39 cents will buy you a postage stamp.

From the hospital standpoint, the only confounding variable here is the EtOH. If she presented the same wihtout the EtOH, the collar would come off and she would go home (assuming no other injuries obviously). EtOH gets a collar and xrays, and likely a CT (depending on the xrays).

Holy heck batman

well with muffled heart tones I suspect that she has cancer around the heart and it's prohibiting her ability to pump. Or she could have a tamponade.

Any history of trauma after her syncopal episode??

We have a winner!!!! Yes, this woman has a malignant pericardial effusion causing tamponade. The previous syncopal episode was probably related to a pericardial effusion, but this time the effusion has become so severe as to cause tamponade physiology. Pts with cancer can get pericardial effusions. These effusions are usually chronic in nature, whereas in trauma they are acute. Tamponade in a trauma pt can be caused by as little as 100cc of fluid in the pericardium. With tamponade you can see what is called Beck's Triad which is a decreased pulse pressure, muffled heart sounds and JVD. What happens is that the fluid in the pericardium compresses the right ventricle to the point where it cannot fill up with blood.

In this woman's case, as her pressure is dropping, despite getting 4 liters of fluid and started on Dopa, we were at a loss to explain why she was crashing. When I first saw her I was thinking dehydration also. As a last ditch thing we put the ultrasound on her and found nothing in her belly, so we took a look at her heart and saw a huge effusion. Performed a pericardiocentesis and got about 500cc of fluid out :shock:. As the fluid was being drained, she starts telling us that she is feeling better. Her pressure starts coming up and stabilizes at 140/72. The cardiologists come by and do an echo on her and she still has a moderate effusion with some evidence of tamponade.

This was a tough case, even for us. Looking back on it, the diagnosis was staring us right in the face. When she presented she had a pulse pressure of about 12 with muffled heart sounds. When we put the EJ in she had huge EJs, not what you would expect in someone with dehydration. She had a classic Becks Triad but it wasn't picked up on. Obviously in the field there is no ultrasound, so it would be more difficult to make the dx. Like I said, tough case. You guys gave some really good answers.

We are crashing here big time, do we need to protect airway with a tube?

Agreed, "TFT" Time for tropes, but caution with that tacky rhytum just may see VT of VFib quik like.....but where are the labs ERdoc..?

Some Penta span or PRBCs may fill up the tank a bit looks low

Please explain?

EJs look like a CFR could hit them blind folded

are they flat or engorged? I suspect the pt supine by now, I am missing something here?

Flat fluid

JVD---- Chest sounds ie Lung again, not in failure if not bubbling!

any muffled heart sounds?

Treat the:

Fluid

Pump

Container

What if any urine being produced...I am looking to rule out Diabetes Insipitus...or am I way off base? :oops:

Pt is crashing, you're not going to get a CT. The EJ are engorged supine and upright. Pressors help bring the pressure up, but only momentarily. Her heart rate is now sky high. Pt is still conscious and maintaining her own airway, no need to tube. The labs will be of little use. Heart sounds are very muffled. Lung sounds are clear still. Pt does not report any problems with urination.

There was nothing impressive about the color of the vomit (no blood etc). What makes you think esophageal varcies? The 12 lead is unremarkable. All the labs previously requested were unimpressive. No fever. Your pts BP is now down to about 50/42 HR still in the 150s. Obviously at this point there will be no pedal pulses. You use your US again and there is still no AAA. Come on folks, your pt is crashing before you. As a hint, no matter how much fluid you dump in, the BP will not improve. Let's recap some of the pertinent findings:

Pt with cancer

Not feeling well

Hypotensive (look at the BP again) and getting worse

BP not responding to fluids

EJs look like a CFR could hit them blind folded

Lungs clear

EKG nl

Not septic or febrile

Any more thoughts?

It was bullshit. I wish I had a fake plastic Oscar in my tech bag to give to people when they were doing their routine. Look at his vitals. Right on point for someone who was agitated and upset but physiologically ok.

I mean, sure maybe he was having some sort of weird off the wall House M.D. episode TIA where he had a sudden onset of hemiparesis, but I really doubt it, more like he was some schmuck looking for attention.

I really hope his parents were well insured, its always heart breaking when you see someone like that sattle their poor family with hospital bills because they need a little attention. I've noticed in my career that people of lower economic class tend to have a lower incidence of paroxysmal idiopathic syncope, with one notable exception.

In certain parts of the city, there is a certain ethnic group who shall remain nameless, who are occasionally stricken with a related syncopal disorder known colloquially as the "Ai-yai-yais." This usually occurs when a young woman and a young man get into a heated discussion following some Coronas, words get exchanged back and forth and back and forth until, finally, the man has enough and CRACK! smacks her across the face. In our culture, this is spousal abuse. In their culture, apparently, it is legitimate means to end an arguement. After that, its all over, suddenly the woman is on the floor, passed out, not moving, and the family is around her DESPERATELY trying to wake her up (hence the term, 'ai-yai-yais') and throw water on her and pray and light candles (I'm not exaggerating, this is really what happens) and call 911, for the ambulance to come and revive her. This leads the poor, inexperienced, bewildered EMS crew dispatched to an unconscious secondary to trauma, and given the chaotic scene, can really look very bad, after all, you really can get very hurt if someone hits you hard enough in the face. But usually, almost always, its not neurogenic shock secondary to cervical trauma, its just a case of the ai-yai-yais. Arouse her gently, start making like you're about to start an IV, and you'll get a miraculous recovery and even walk away with an RMA, plus a few new friends. Really, you could probably go back later off duty and have a few Coronas at the party, you'll be the star of the scene, and let me tell ya, being a hero in front of a few of the girls from Telemundo is not the worst place you can find yourself. Yes, that was sexist and innappropriate and I don't care. Suck it up.

Note: The comorbidity of the families presentation, charactized by hypertension, tachycardia and tachypnea, is known collectively as 'status hispanicus'.

Not to be politically incorrect either, but in some circles the syndrome you have referred to is called Aye-tach, very unsimilar to v-tach (which is life threatening). My guess in this case is conversion disorder vs. malingering. What feild of work is the pt in?

Is she on any diuretics? Does she have a fever or anything. What are her lung sounds like. I am thinking maybe cardiogenic or septic shock.

Patrick

Indiana EMT-B

Paramedic Student

No diuretics. Afebrile. Lungs are clear.

Got Priest ? .............

Hmm... Sounds like an omnious triple A .. of with other things.. mets might have went systemic into arteral walls.. notify the Doc.. go ahead with some fluid and monitor the pressure..If it is a AAA, want to keep her pressure down. Hopefully, you can get a larger line after some fluids, but you take what you can get at times. Expedite since she is a full code, I really would prefer not to be working on her if she does arrest with term. Ca...

Good scenario as usual Doc!

R/R 911

Abd is soft, not distended, nontender. Your state of the art dept has an ultrasound machine and you look at the aorta and it looks normal. You cannot find anything in the arms or legs, but the EJs are like pipes and you have no problem dropping in an 18. You give her 2 more liters and the pressure stays the same. What else are you thinking?

She is full code. Last chemo was 3 weeks ago, no radiation yet. Labs were normal when she was d/c last week. The only access you are able to get is a 22 in the back of the right arm. Fluids are going and after 2L her pressure is 90/80 with a HR of 140s (STach). You put her supine and she is now complaining of some very mild pain in the epigastric area going to her back and lower chest. She also gets that gray look to her face (the more seasoned know that gray around the gills, I'm going to die soon look). She is still conscious, but more somnolent.

A 59 y/o woman with a history of lung ca with mets to the brain calls you because of a near syncopal episode. One week ago she was admitted to the hospital for 2 days secondary to a syncopal episode. For the last two days she has not been feeling well, has had a few episodes of vomitting and some diarrhea. She is not complaining of any pain at the moment. Her VS are: 118 86/77 18 97% on RA. What else do you want to know and what do you want to do for her?

Heard a hospital presentation where the pt was complaining of general malasia. I guess her Cambodia was acting up again.