Pucker Up: Case Reviews

[FL_Medic]

Drug use increases the risk of AMI at any age, this was a real eye opener for me as a medic student to ALWAYS thorouly assess my patients, no matter how clear cut the case may be.

Although it was not a real "Holy $hit someone died because I missed a sign" call, it had a real impact on the type of medic I am becoming so I thought I would share in hopes it may help mold (mould) someone else.

I'm sorry man, I really wasn't trying to judge you. I was kind of reassuring you. I didn't think you really did anything wrong. Missing something like that isn't like a huge mistake, but you're right, it is an eye opener. It can provide a better outcome for future patients.

I recommend that we have a separate forum for this called "Morbidity and Mortality Conference" where each case can have its own thread.

'zilla

I would be up for that. I think there are a lot of stories out there, and it's a really humbling experience to share these stories. Much different than these normal, "I'm smarter than you" threads. I learn more from my mistakes, and other peoples mistakes than I do from some "look how good I did" story. I'm hoping to see better case presentations, and maybe a little more of a fallow up. Learning as much as we can from each of these would be cool.

[fiznat]

Heh, had one of these this week. I'll play!

Dispatch Notes:

28 y/o male involved in a MVA, significant damage

Upon Arrival:

28 y/o male found seated in driver's seat of a motor vehicle that apparently veered off of the road at a high rate of speed, drove across the front yard of a house and struck another car sitting in the driveway. Very significant damage to the front of the patient's car although no intrusion into the passenger compartment. Bilat airbag deployment, patient was wearing a seatbelt on our arrival and was reported to not have moved.

Patient presents crying, not answering questions. GCS 14. Unable to obtain any history of the event from the patient (due to mental status) or witnesses (none available). Patient was extricated from the car with c-spine precautions. During extrication and assessment in the ambulance the GCS drops to 3. Lung sounds are clear bilat, no JVD, no distal edema. Skin warm/pink/dry. PEARRL and normal size, no neuro deficits noted at this time or when patient was more conscious. The trauma assessment is without any findings of deformities, the ABD is soft non tender without masses although there is a positive seatbelt sign. VS: BP 100/80 HR 120 RR 16 SpO2 95%. BGL is 82 mg/dL. Sinus tach on the monitor.

Patient received an OPA (no gag), 15lpm O2 NRB, 2 X IV access, transport to the trauma center. Reassessed enroute without any changes, patient remained GCS 3.

No past medical history/meds/allergies available. Didn't even know the dude's name.

Arrival at the ED:

After assessing and verifying the GCS, someone says "well, wanna try narcan?" 0.8mg wakes the guy right up, he's moving about on the board and now a GCS 15. Crying again. Apparently took too many of his Rx oxycodone "by mistake."

Shit.

Review:

Due to the significant mechanism and the witnessed acute change in mental status with this patient I was pretty much thinking about head injuries the whole time. I did a very detailed trauma assessment and didn't find anything though, checked the sugar and didn't see too much standing out with the vital signs. I thought there was a good respiratory effort and the sat was decent considering cold fingers.

What I didn't think about as much was "why the hell did this guy drive off of the road." The scene gave me a clue that I pretty much completely ignored, which was that there was apparently an event that preceded the crash. I was stuck on head injury, but I should have noticed that there was probably something wrong before the impact even took place. That little bit of information may have lead me down the right path, even if there wasn't much in the physical presentation to point me in that direction.

[FL_Medic]

I'm thinking this thread was a good idea. You can learn a lot from other people's mistakes. The oh $hit factor is a pretty good motivator. Keep 'em coming.

[Arizonaffcep]

One of mine was within the first few weeks of being a medic. I was pulling a reserve shift with a neighboring FD, and dispatched to a "sick person, difficulty breathing," Pt being around 16 yrs old, female. Enroute, my experienced and fulltime EMT-B partner (FT with this department), we got turned around and zigged when we should have zagged. By this point, dispatch came back and told us they were dispatching a second unit and giving CPR instructions.

U/A, found pt supine and unc./unresp. Nice sinus rhythm, maybe SLIGHTLY tachy (it's been awhile), and basically everything "within-normal-limits." Then...Pt wakes up, starts to talk, and goes out again! She does this repeatedly several more times, and I finally said we need a helicopter (C-3 transport to nearest hospital about 25 min away). I called for the helicopter within 5 minutes of getting o/s.

So...QBing this with the more seasoned medic (and one I HIGHLY respect), we figured out she was hyperventilating, and it was the lack of CO2 that was causing her to black out.

My justification for the helicopter was that she was 16(ish) and I couldn't figure out what was going on...so err on the side of the patient for the quick transport time.

I'd have hated to be in her house when she got the bill and the cycle repeated itself!

Now...I took what I learned from this and have not made this "mistake" again!

[FL_Medic]

Had a patient exactly like that a couple months ago. Luckily she was awake when I got there so I could witness the anxiety. She fainted once or twice, so I gave her some IN Versed. Her anxiety relieved for a short period and I received orders for Ativan. I was able to get her calmed down. Of coarse I tried talking her down, but it was useless... I have never seen hyperventilation that bad before. Good call, I once called for a helicopter; As the ship was landing my patient proved she was having a TIA, not a stroke. I know it was nearly impossible for me to know that was going to happen, but it just sucked giving the flight medics an asymptomatic patient that I called a stroke alert.

[MontvilleFire39]

Had one a little while back, humbling to say the least.

Dispatch Notes

Dispatched for male in 50s, assault victim wiht police on scene. No further information provided.

Upon Arrival

UA, found ambulatory male being interviewed by PD. Multiple bystanders around. Patient states he was involved in "encounter" with another male party and was struck in head with brick.

Patient Presentation

Patient has a small abrasion above right eye with slight non active bleeding. Patient and bystanders deny LOC, patient alert and oriented to person, place, time, and events. Patient obviously and admittedly intoxicated, drug use denied. Patient adamant about not being transported and intermittently beligerent. Patient vitals assesed, WNL. BP normal, HR normal, Resps normal, SPO2 99%. For whatever reason I was insistent on transporting patient to which he finally agreed. In unit, secured IV access. At the point of assesing lung sound, patient became increasingly beligerent. The quick listen I got sounded clear and equal. Patient has no other obvious signs of trauma, no visible bleeding. At this point I deemed patient stable and conceited to a hands off transport. Tranported without incident, patient ambulated to ED due to patients refusal of stretcher transport.

Hospital Course

Once inside ED, patient triaged by nurse without incident. After an apporx. 30 minute wait, patient was put in fast track room. Upon turning in trip ticket to nurse, I was informed by treating nurse that patient was now being moved to a major side room and was having a chest tube placed d/t pneumothorax. While placing patient in hospital gown (sp?), it was discovered that patient had a small puncture wound under his right breast. There was no bleeding. Upon furher interview patient recalled being stabbed with an awl.

Fortunately there was no negative outcome in this case. I was incredibly humbled and glad that for whatever reason I was insistent on transport. I learned to not be complacent, to better expose trauma patients, and attempt to uild a better raport with patients to allow for a more complete assesment. Truly a learning case for me...

[Camulos]

Funny one I had quite a few years ago that caused me some embarrassment to say the least.

C/T fifty something year old female with abdo pain. On arrival pt rolling around on the ground in distress. Reports sudden onset of abdominal pain which she described as “the worst pain I’ve ever had and it goes through to my back”. Pt looks terrible – pale, diaphoretic, short of breath etc. Obs were equally as bad – pulse around 130bpm and BP around 80 systolic. My partner and I are thinking AAA and pretty much load and go.

On starting up the truck the lady says she wants to go to the toilet to open her bowels. I remember being told once, from somewhere, that this can be an ominous sign in these sorts of cases. So I tell her to hold on – both because I don’t want her to bear down and rupture and also because I want to keep my truck clean. Obs don’t really improve en route and we rush her into the ED. Handover given and I tell them I’m thinking AAA. ED staff rush her onto a monitored bed and I go back to the truck to finish paper work and restock.

I go back into the ED to drop my paperwork off and am hit by the most offensive smell I have ever encountered to this day. Get back to where the pt is and one staff member is mopping something off the floor whilst others are cleaning the pt . Pt has just done one of the biggest bowel motions known to man and now is thanking me, of all people, because she feels “so much better”. I drop my paperwork off and run out the door whilst all the ED staff stare at me with utter contempt.

Check with a nurse the next day what the story was and ends up the pt just really needed to do a huge shit!!! She was discharged two hours later very happy that she had been “cured” by the kind ambulance man. Turns out she hadn’t opened her bowels in the past nine days and when she finally did certainly did it in fine fashion. In my haste to get this lady to hospital, and as I had my “diagnosis”, I had not even asked. I still can’t believe to this day that a need to crap caused such derangement of her observations to the point where I thought she had a AAA. These days I always check and I’m sure quite a few AAA pt’s have died hearing the last word’s “When did you last open your bowels?”

The partner I was working with that day has now retired however we still catch up occasionally. Every time, without fail, he manages to fit that story into the conversation. I guess you never live some things down.

Stay safe,

Curse

[AnthonyM83]

Fiz, looking back did he have any signs of opiate OD you might have picked up on even if you weren't thinking head trauma?

[FL_Medic]

I like the AAA poop scare call. We forget to ask that "last BM" question quite often. Important information for your DDx. LOL, treat for the worst right? If she was constipated at the time though, trying to make a BM could increase an aortic tear I guess. Poop in the back is worse than poop in the ER in my opinion anyhow. Good call.

Edited March 13, 2009 by FL_Medic

[fiznat]

Fiz, looking back did he have any signs of opiate OD you might have picked up on even if you weren't thinking head trauma?

Not really. I did look and I thought the pupils were normal. I didn't find any respiratory depression and there was no overt evidence of drug use (track marks, social cues, paraphernalia, etc). After the doc gave the narcan and it turned out to have worked, he said to me that he thought the patient was "maybe breathing a little shallow." I donno, the respiratory rate was okay (like 16), but it is really difficult to tell in the ambulance exactly how "deep" a patient's breathing is. Maybe if I had put her on the end tidal capinography I would have known. Next time.