"Routine Transfer"

[BushyFromOz]

Unknown if last bowel movement reduced pain, uknown escessive thirst but she has had a lot to drink today

You start transporting to the recieving facility which is 50 odd minutes away. Backup is probably 25 minutes away if you want them in a hurry. Once you load her onto your stretcher, you place her R lateral again with her legs drawn up, facial grimace stops. You do another assessment and nil has changed. You look for a vein to stick a line in and note someone has already had three attempts in the only 3 veins you can find, her skin and veins are terribly fragile and has a shiny lustre, you wonder if she is on prednisone.

You and your partner each have an unsuccessful attempt and decide that the patient is reasonably comfortable and you should start heading towards the recieving hospital. You let the back up crew know that they may be needed for some IM fentynal. (bear in mind, the patient has had no pain relief for several hours and is generally comfortable) you and your partner think better be closer to backup then keep stuffing around so far from it, 02 goes on and you head out of town.

half way to the recieving facility, your pt has a lucid moment, and has a frank conversation with you. She says that her tummy hurts (cant rate it, cant localise it) and that she feels like she needs to wee before she goes back to talking dribble. Another set of obs reveals no change from the intial assessment.

What would you guys have done in regards to treatment???

[Don1977]

I would say there is no such thing as a "Routine" call, either for EMS, Fire, or PD, as there are always going to be variables that can change the direction of a call, implementing themselves into that call, with no warning. You'll never see it coming.

Thats what she said Richard, even teh "3 days a week" dialysis transfer/transport was not routine.

I nver used it in my PCR but others did and she gave them he ll for saying that.

[brock8024]

Does she have a DNR? That would have been my first question. LOL

[zzyzx]

If she has abd pain and is jaundiced but no Hx of liver problems, then I would consider that she may have gallstones.

The most dangerous issues are AAA or acute MI. What does the 12 lead show?

Is she a DNR?

[firedoc5]

I would attempt an IV one more time, possibly by someone with your back up. If only "uncomfortable" and difficulty with an IV, then pain management may not be necessary, but would be nice.

What did she have to drink? Juice, water, tea, etc.

Keep comfortable as possible. Continue O2. Transport. Notice any gas passing or small amount of any BM or discharge such as mucus.

Keep up the good work.

[BushyFromOz]

No DNR

No 12 lead available

No movements since you have had her, and because i am a n00b i chose to head for the recieving hospital rather than try number 3 cannulation

About 10 minutes form the recieving hospital, the patient becomes very agitated, moaning and crying, abdo guarding returns with a pretty intense facial grimace. Vitals are

HR 130, Sinus tach on the monitor with both single and coupled VEB's

GCS 12 (E3, V3, M6)

B/P 110/P

RR28

Temp 37.1

Lungs still clear

Abdo has gone from being soft to rock hard on the R upper and lower quadrants over 3-5 minutes with increased pain on palpation judging by facial grimace.

You start swearing like Gordon Ramsay (on the inside) and ou wish you had have had another crack at a line, and ske for that IC car who are ironically at the station watching Hells Kitchen

[ERDoc]

Is this hard abd voluntary or involuntary guarding? Are you able to say in this pt? Other than trying to get a line I don't think there is much you are going to be able to do for this pt in the field. Let's continuously reassess vitals and check neuro status. I don't think this is an obstruction, but would need more information to be sure.

[zzyzx]

Is her abd distended?

Since we don't know when she last voided and she's been drinking a lot, I would consider acute urinary retention. She needs a Foley when she gets to the ER.

There are many other things that couuld be going on here, an AAA being the most serious thing to consider. But really, without a CT how could you diagnose what's going on, and what could you really do for her even if you did?

[firedoc5]

Sounds like you have done all you can do, just keep doing it and transport. I doubt you carry Demerol to be used IM. With permission you could do MS IM, but I'm not sure how your resource hospital works.

[BushyFromOz]

Well, might as well give the rest of the story...

About this point, you, being a n00b, finally exercise a bit of lateral thinking (half an our too late) and take the pts b/p on both arms and find it to be 110/90 non the right and 90/70 on the left. A bit more lateral thinking and you finally remember that cannula's are not for arms only and quite easily slot an 18g in her right ankle and give her 2 doses of 2.5mg of morph and she settles down quite well.

This is, as some of you have mentioned, a AAA. The theory is that the abdo pain for 2 weeks is from the AAA, with the paracetmol being used for her "tummy ache" and also causing the jaundice such as itku2er suggested. Interesting note that after arrival at A&E, she passed a bowel movement, her abdoman went soft again revealing a nice pulsing mass. And just to cap it off she had ST elevation in V3 and V4 and troponins of .16 :?

Im glad some of you guys have suggested that there is not much you can do with this in the field, i have beating myself up a bit over this - especially with the pain control, anything else you guys would have done assessment wise??