back pain

[zzyzx]

You are called to the home of a 55 y/o male who is having back pain. The home is well kept and you are greeted by the patient’s teenage daughter. She explains that her parents don’t speak English but that she'll translate.

The patient is covered with a blanket lying on a couch. With his daughter translating, he says that he was working in the yard when he threw his back out. He walked in and laid down on the couch. He has a bad back and he always feels better with a few days of rest. He says he doesn’t need any medical help. The family called 911 anyway because they know he’s stubborn and they didn’t want to see him suffer. They would like to know if there’s anything you can give him for his pain.

History: None. “He’s never seen a doctor in his life.”

Meds: none

Allergies: none that they know about.

His vitals:

GCS: 4/6/5

Skins: warm, slightly diaphoretic, pink

Pulse: 96 strong & regular

Clear bilateral breath sounds with a respiratory rate of 18

PO 98% on RA

BP: 210/104

[zzyzx]

Here's what you see on your monitor (3 lead): http://library.med.utah.edu/kw/ecg/mml/ecg_unifocal.html

[irme]

Any pain other than his back?

What type of pain is it? PQRST

Any other complaints? How often has this happened, what normally provokes it?

My thoughts,

He could be compensating, or as he has had no dr he could just be suffering from hypertension..

[Quicksilver]

Has he taken anything for it (ASA, etc.) does he have an ice/hot pack on it.

What part of his back hurts the worse and 1/10 pain scale.

Can he sit up (I want another BP when / if he does)

Pupils?

I just started to study EKG, so I don't know if a 12 lead is a good next step.

[emt322632]

12 Lead please?

Has he ever had this type of pain before. what exactly was he doing in the yard when he "threw his back out"?

Hx of alcoholism, drug use? Hx of back spasms or fractures?

Take any herbal supplements/remedies?

Does the pain radiate, and yeah what is it on a 0-10 scale? Any N&V? Hx of sickness recently?

[ERDoc]

Any recent trauma (ie MVAs)? Any numbness or tingling?

[zzyzx]

All great questions so far!

Orthostatic changes? It's too painful for him to sit up, so you are unable to check. No, he doesn't have any other pain, just the pain in his lower back which he describes as sharp, non-radiating, 10/10. He also has some numbness in both legs and they feel weak. He has a hot pack on it and says that's helping. Yes, he's taken some Tylenol. No history of drugs/alcoholism. He has had back pains like this before but has never had any traumatic injuries and has never seen a doctor. No recent illness. He does not take herbal remedies. He says he threw his back out when he was reaching down to pick up a bag of fertilizer.

Sorry, I don’t have a 12-lead for you, so I’ll just have to describe what you see. It shows a normal sinus rhythm with a few PVC's (less than 10 a minute). No T wave or ST changes.

[zzyzx]

Here are a few discussion points that I think may be interesting to consider. (These aren’t my opinions, just things that may help the discussion along.)

1) This patient doesn’t want to go to the ER. Would you feel comfortable not taking him? Should someone with non-traumatic back pain always be taken by ambulance to the ER? Should they go to the ER at all?

2) If a person with back pain were to ask you what the hospital is going to do for them besides give pain medication, what would you explain?

3) If his BP was lower, would you feel more comfortable not taking him to the hospital? Is his BP symptomatic of anything? If he had no back pain nor any other symptoms, would you try to talk him into going to the ER because you were concerned about his elevated BP? Will the ER do anything to lower his BP if he’s asymptomatic?

4) Is his ECG a concern?

5) What else would you like to know about this patient? What further assessments are needed?

[ERDoc]

Here are a few discussion points that I think may be interesting to consider. (These aren’t my opinions, just things that may help the discussion along.)

1) This patient doesn’t want to go to the ER. Would you feel comfortable not taking him? Should someone with non-traumatic back pain always be taken by ambulance to the ER? Should they go to the ER at all?

2) If a person with back pain were to ask you what the hospital is going to do for them besides give pain medication, what would you explain?

3) If his BP was lower, would you feel more comfortable not taking him to the hospital? Is his BP symptomatic of anything? If he had no back pain nor any other symptoms, would you try to talk him into going to the ER because you were concerned about his elevated BP? Will the ER do anything to lower his BP if he’s asymptomatic?

4) Is his ECG a concern?

5) What else would you like to know about this patient? What further assessments are needed?

I won't answer any of these things, I'll leave that to the field providers. If I were to get a call to RMA, I would speak with the pt and discuss my concerns (including diagnosis, but again, I'll leave that up to more debate) and tell him that if he doesn't come in there is a good chance he will die.

[darkangel]

If i was called to this situation i would feel comfortable leaving him at home if that is what he wants. He is showing no signs of respiratory or cardiac distress at this time. His vitals are all stable and continue to remain stable during the intial assessment of the pt. With the hx that the pt presents with i would advise him on going to the er and at least getting an x-ray done maybe rule out a compression fx or a buldged disc. If he still refuses to go to the er technically i cant force him to go since he is Aand Ox3. If he was to ask what the ER would do for him I would explain that the ER can order some blood tests to rule anything out and also order an x-ray or an MRI to rule out any kind of injury he might have.