back pain

[zzyzx]

Note that I just made an edit to my previous post about checking for orthostatic changes.

[vivibonita]

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?

Let me tell you a little story. We received a pt. in the ER about 3 months ago, with back pain and nothing else. The paramedics talked him into going to the hospital even though he refused. He only wanted some morphine to get rid of the pain, that was all! Well, to make a long story short, this guy had a AAA, no other signs of this were found on him. Unfortunately he had other conditions that kept the doctors from helping him, but we would've not known what he had, if he hadn't gone to the hospital (thanks to the medics :roll: ).

I don't think you should feel comfortable leaving a patient at home, even if s/he has a headache or something that you don't think is important. Sometimes you can miss something in your assessment, sometimes other signs won't show... you just never know. Here in this county, the protocols say that the last thing a paramedic/EMT sould do for a patient is (drumroll please), transport. It is your obligation to take the patient to a place where s/he can get better or a higher level of medical attention.

If you tell your patient what is going to be done to him/her in the hospital, s/he will have some expectations, if that isn't done... you will look like a liar... and how would you know if that's going to be done or not?

You can always do what mr. ERDoc said:

I won't answer any of these things, I would speak with the pt and discuss my concern, and tell him that if he doesn't come in there is a good chance he will die.

Don't dicuss diagnosis, the only person allowed to do that is a Dr. ... once again you (or the career) will lose credibility, think of the patient expectations.

Thanks for you attention :wink:

Vivi

[emt322632]

Is his bp really stable at 210/104? I really don't understand how you could say the patient is stable with that kind of a blood pressure.

The BP is of great concern to me, granted this guy is having severe back pain, but I've never really seen a BP get to be that high due to severe pain. I'm thinking he has some underlying pathology.

I would explain to the genteleman that his blood pressure is of great concern to me and that I would like to take him to get checked out. I would say in no certain terms that while at the ER you MAY receive an X-ray, CT, some blood work and another 12 lead ECG.

If he still refuses to go, I would call ERDoc and have him speak with the patient.

I would definitely not want to leave without this patient in my ambulance. There is definitely something fishy going on here.

[Quicksilver]

I agree the BP, which could be that way everyday for the last month, isn't stable. Though I was called here for the back pain, my other findings are, in some respect, of more concern.

Be honest with him about the ER trip, whether it is with us or his daughter.

If the BP was 130/85, no, I probably would let him sign the refusal, tell him to call if he changes his mind and wish him well.

I'm guessing here but I might think about doing the Miami Stroke Test

[zzyzx]

More great responses! You guys are right on it.

I also once had an elderly patient who was complaining of back pain from a previous injury who turned out have an abdominal aneurysm that hadn't been previously diagnosed. (His back pain, however, was unrelated to the aneurysm).

To answer the question about the Miami stroke test....I'm not familiar with that one, but here's what you find on the Riverside Stroke Test (:wink: )

He grips your hands with equal strength.

No facial droop.

No slurred speech.

[Dustdevil]

Is his bp really stable at 210/104? I really don't understand how you could say the patient is stable with that kind of a blood pressure.

I agree the BP, which could be that way everyday for the last month, isn't stable.

Okay, we're starting to degenerate into semantics here.

Nobody said the patient was stable. She said the BP was stable. I have heard nothing from the OP to indicate the BP was unstable. Elevated is not synonymous with unstable. Two completely different terms.

[zzyzx]

I anticipated a lot of discussion regarding this patient's BP, so that's great. I think there are misconceptions about hypertensive emergencies among us providers. I certainly have been misinformed about this subject in the past. For more info, check out these xlnt articles:

http://www.emedicine.com/emerg/TOPIC267.HTM

http://en.wikipedia.org/wiki/Hypertensive_crisis

[triemal04]

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?

Better late than never I guess.

1. No, I would definitely not be comfortable turfing this guy. No, someone with non-traumatic back shouldn't ALWAY'S go by ambulance. But sometimes yes. Same for the ER.

2. X-ray, CT, ultrasound, definitive diagnosis of what the root cause it.

3. Yes, if he was normotensive I'd be a bit more comfortable, though the numbness to the lower extremities is still bad. Yes, could be symptomatic of an aortic aneuryism. (think that's been covered already). If he was asymptomatic then why would I be there in the first place? Going to the ER because of the HTN...yeah. I'd guess he get a full workup and then probably get started on meds to lower it.

4. Maybe, maybe not. 2 PVC's aren't a big deal. If he was starting to bleed out then it's a bit more significant. I'll just say I'm not that worried about it right now.

5. Changes in back pn, other symptoms (dizzy, N/V, abd pn, abd masses, other pain, HA, how he feels normally and if he is able to function without a problem on a day to day basis), pedal pulses, cap refill in lower extremities, how long ago this started?

I'll call this a AAA until proven otherwise. IV TKO, O2, vitals, transport.

I had a patient several years ago who was pretty similar. Called for back pn. Turns out this guy had injured his back years ago (40+) and has chronic back pn, today it feels just like it always does when he has a bad episode, and he is unable to walk to his wife's car to get to his doc unaided. No other significant hx, vitals were all stable, physical was unremarkable. During the assessment his son arrived, offered to help him get to the car and into the hospital. Make a long story shorter, I turfed him, at the hospital he was dx'd with an abdominal aortic aneuryism and died on the operating table.

[zzyzx]

To answer the question about pedal pulses, you get the volunteer on the fire crew to take off the patient's shoes :x. Good pulses and cap refill.

Anything else you guys would like to check?

[SGVEMT]

You say the pt has numb legs and with the hypertension im thinking he should probably get checked out. I would try to at least get him to go by private auto bottom line. I wouldnt feel comfortable but at least he might go on his own. I've seen T.I.A.s that were similar to this. Was he at all lethargic since this happend?