?Stroke/AMI/PE/Sepsis/I don't know.

[firetender]

* I went and got a towel and wiped drops of sweat off his brow because it was dripping in his eyes. I spoke to his family because no one else was and his daughter was crying. I helped him empty his colostomy bag. But who gives a toss? So would everyone else. Its just basic humanity. I don't need to post that and nor does anyone else need to suggest it in their posts.

Its a given.

I'd like to say that's the truth that it's a given, but, unfortunately, it really isn't now and never was. If you "helped" him empty his colostomy bag that tells me there was no urgency to the call. That characterization alone tells me how I'd handle it. I would NOT treat or even worry about every little symptom unless it PERSISTED!

What I need from the forum is suggestions about this case that would help me to make treatment, triage and transport decisions in the future.

There's what is going on at the scene, choices made prior to loading, changes to consider en-route. In this case, those are quite simple. Unfortunately, they were not simply communicated.

Technically, as far as communicatineg here goes, you tripped yourself up by "leading us in" but the picture you painted was incomplete.

I'm back in the Stone Age thinking "radio report"! What would I have had to say to the Doctor to get the orders I needed to get the patient to the hospital quickly and simply and without further trauma? In this case (at the point at which I chimed in) the picture was incredibly muddled by everyone worrying about disease entities.

Look, here's what I'm saying; there's info to be considered AT the scene. That's a whole different ballpark than what is actually going on with the Pts greater problems.

GOOD! figure that stuff out, but if someone is presenting a case here, I'd sure like to hear -- AT FIRST -- this is what we saw, this is what we did, this is what happened, followed by what could have been done to make the call go more smoothly and LAST, what was REALLY going on, or what did we miss.

Thanks to this discussion, I've already realized I really should have considered bleeding. I didn't consider electrolytes until I saw the blood work. To big gaffs with early signs I could have noticed that I now know about. I've noticed other little things as well that would help me in future. Which is exactly what I hope for when I post jobs like this.

One of the things that didn't come out was you did have a handle on the immediate situation, responded effectively and, true to your profession, the patient got taken care of (and IMHO you took the EXTRA steps of being responsive to him as a human being BRAVO!). Give yourself a little credit. Understanding usually comes later, and you're seeking it, so let me give you credit for that, as well.

That's because the job was swiss chesse. It was a very dynamic case. It was very complex in terms of the changing nature of his physical assessment.

EXACTLY; he was exhibiting TRANSIENT symptoms (mild SOB upon being questioned, sweating). One of the skills you'll be learning is to not get thrown by every adjustment the body is making to get through an assault.

It was also a job that was sandwiched in-between 6 other jobs that day. All told its not that easy to communicate it all.

I don't care if you ran 20 calls that day. If you're going to communicate with me about this call; communicate as simply as you can; break things down into what is most "Now!" and do them. This forum is good practice.

I "got" that you were leading us into the scenario so you could sort of test yourself and what you DID do, but you worded it in a way that everyone said "Doctor time!" and jumped at the bait. As a result, no one really gave you what you asked for.

Also I didn't retract any urgency. It was never there to begin with, I said he was mildly short of breath after being prompted. What I did is recognize that I didn't really provide much detail in my resp assessment.

Good catch!

I do, however, wish more people had weighed in with treatment and transport opinions but I didn't see yours there either firetender.

According to what you presented, IV TKO, monitor, transport, of course, how could I make that call without knowing how far away you were from the Hospital.

AND that's where the ESSENTIAL information you began with this post really comes into play. You had plenty of time to be a responsive human being with the guy which probably did MORE for the guy's being able to enter a healing path than any drug or intervention bandied about here.

I'm here to tell you basics first and there's nothing more basic than observation, discernment of urgency, and communication. If you're going to work on anything, that comes first!

I appreciate your consistency in seeking more knowledge and experience through this forum, and hope what I offer is more encouragement than criticism.

Love the time you've been given!

 

[Melclin]

So why was the blood "clotting quickly"? I don't know any other reasons that would happen, but that's likely just ignorance on my part.

No idea. It was just the observation of the triage nurse. I suspect the subjective measure of blood clotting time is probably fairly useless, but I thought I'd throw it in for people to take or leave.

I'd never seen the innervation described like that. I flipped back through some old notes, and they have the toes all in the same dermatome. Dermatomes are sensory of course, but I can't find a good description of the sympathetic innervation of the toes, and if anything I'd expect the distribution to be more overlapping than the sensory distribution - not well segregated enough to see differences between toes. That said, if you could point me in the direction of some better information, I'd be appreciative.


Yeah I was just thinking dermatones. Tintenallis has toes in three divisions, some others in two. Google it, you'll see a few subtle variations. Anyway as you point out its a sensory affair. I don't know what it means for sympathetic innervation.


I'll buy a beer for anyone who guesses paraneoplastic and is right...but this is your scenario, so I'm not sure you can cash in this time....

Maybe I misunderstood. I thought you were referencing House as a joke when you said Lupus. Paraneoplastic syndrome was the follow on in that line of humour.

before or after treatment?

Before would be really bad. After not as bad.

Before treatment.

Tight regulation of hormonal control is a normal ICU event. The insulin shold help lower his K+ also.

The insulin/glucose was specifically for the potassium.


Let's not even get into paraneoplastic syndromes.

I was joking. Its a reference to House.

Couldn't hurt, but I don't see it making a difference.He has a reasonable suspicion to be septic, so some vanc would be good prophylactically.

Ceftriaxone is all we carry. Appropriate?

I'd like to say that's the truth that it's a given, but, unfortunately, it really isn't now and never was. If you "helped" him empty his colostomy bag that tells me there was no urgency to the call. That characterization alone tells me how I'd handle it. I would NOT treat or even worry about every little symptom unless it PERSISTED!


The colostomy bag was at hospital. With the exception of that, I would expect any medic here to do all of those things.

Technically, as far as communicatineg here goes, you tripped yourself up by "leading us in" but the picture you painted was incomplete.

Leading you in with what? I don't see how it changes the discussion of possible pathologies and what the means for treatments.

I'm back in the Stone Age thinking "radio report"! What would I have had to say to the Doctor to get the orders I needed to get the patient to the hospital quickly and simply and without further trauma? In this case (at the point at which I chimed in) the picture was incredibly muddled by everyone worrying about disease entities.

In the absence of medical control, I don't really see how you treat patients without having some idea of what might be going on.

Look, here's what I'm saying; there's info to be considered AT the scene. That's a whole different ballpark than what is actually going on with the Pts greater problems.

I don't know that they're that different. How do you treat a person without a working diagnosis? If he's having a PE, then seems to me I should haul arse to a hospital capable of dealing with it. Is he septic? Enough for some ceftriaxone? I've perhaps, got more time to arse about with an IV if he's septic. I didn't consider haemorrhage. Maybe we don't wanna pour fluids into him if he's haemorrhaging. Are these not important considerations?


GOOD! figure that stuff out, but if someone is presenting a case here, I'd sure like to hear -- AT FIRST -- this is what we saw, this is what we did, this is what happened, followed by what could have been done to make the call go more smoothly and LAST, what was REALLY going on, or what did we miss.

I wanted to present it as job people could work themselves. It warps things if I go and tell them what we did and were thinking.

One of the things that didn't come out was you did have a handle on the immediate situation, responded effectively and, true to your profession, the patient got taken care of (and IMHO you took the EXTRA steps of being responsive to him as a human being BRAVO!). Give yourself a little credit. Understanding usually comes later, and you're seeking it, so let me give you credit for that, as well.

Well thank you, but I think we have different ideas about what presenting this scenario is about. I'm not looking to tell people what I did, or be evaluated on it. I'm more interested in what other people would do. I'm not down on myself for the way this job went. Firstly, it wasn't my job and secondly, the medics involved did well I thought.




I don't care if you ran 20 calls that day. If you're going to communicate with me about this call; communicate as simply as you can; break things down into what is most "Now!" and do them. This forum is good practice.

I "got" that you were leading us into the scenario so you could sort of test yourself and what you DID do, but you worded it in a way that everyone said "Doctor time!" and jumped at the bait. As a result, no one really gave you what you asked for.

No, as I said, "I" didn't make any decisions about this job. I will eventually post what did happen, but not to be evaluated on it. I'm more interested in the other peoples interpretations of what was going on, so that I may, in the future, be more informed to be making the good decisions made by the actual medics on the day. And I got exactly what I wanted. I did have to push people for treatments, but whether they'd give 1L or 2L is a bit beside the point. I'm more interested in what they thought was going on and what points about the case lead them there.



According to what you presented, IV TKO, monitor, transport, of course, how could I make that call without knowing how far away you were from the Hospital.

Well I don't actually need to you name a hospital. I just need you to discuss the factors that influence you decisions. You could just as easily say, I'd go to the closest reasonable hospital, one with an ICU; or well depending on where I am, I'd go to the hospital that did his surgery or somewhere with a cath lab.

I just wanted an educative discussion (and I got it). The exact details I don't really care about. Same for the hospital. I just want your thoughts, not a complete and 100% accurate specific plan of management.


I'm here to tell you basics first and there's nothing more basic than observation, discernment of urgency, and communication. If you're going to work on anything, that comes first!

I agree.

The highly unsatisfying answer (for me anyway) to this scenario is that he was dehydrated. They could find nothing wrong in the ED or the ICU other than that. He bounced back well and went to the ward a day later. I don't know what happened after that. No PE, no AMI, he wasn't septic as far as they could tell. The electrolytes and kidney function were thought to be secondary to the poor perfusion from his dehydration. I feel that something else was probably going on that they would figure out down the track a little, but I wasn't around long enough to find out and I don't know much more than that.

Out of interest: he got ~1L of rapid infused saline from us + metoclopramide for nausea. I wasn't privy to the the ddx because I was bringing some gear in from the house, but they were thinking hypovolaemia [what their theory about the origin was, I'm not sure] or sepsis. One of the medics was a little less keen on fluids than the other, I think he was leaning more towards PE, but the other was MICA so he won. Transported non-emergently to the hospital that did his operation.

 

[jrm818]

The highly unsatisfying answer (for me anyway) to this scenario is that he was dehydrated. They could find nothing wrong in the ED or the ICU other than that. He bounced back well and went to the ward a day later. I don't know what happened after that. No PE, no AMI, he wasn't septic as far as they could tell. The electrolytes and kidney function were thought to be secondary to the poor perfusion from his dehydration. I feel that something else was probably going on that they would figure out down the track a little, but I wasn't around long enough to find out and I don't know much more than that.

I agree...not a particularly satisfying answer about a patient who appeared very sick (at least to me, and I'm glad I'm not the only one). If I were the patient, of course, I'd be very satisfied indeed.

Don't have too much more to add at this point (other than an "oh well") Thanks for posting the scenario though - it was a fun mental exercise and a great learning experience for me as well; much appreciated. For what it's worth, I agree with the rationale for why you posted the scenario the way you did. Telling us the answer at the beginning shades all the responses and doesn't give you an accurate idea of what other people would actually do or think in a similar situation.

Aside:

Sorry, I don't really see "monitor IV transport" as actual treatment, or even really "care" at all. "Monitor" just allows you to start to form a working diagnosis (or not, if you can't tell the difference between an EKG and those funny earthquake recordings), but is rather useless if you're not going to use the information to develop a treatment plan based on what you interpret.

"IV" is preparation for some sort of treatment that might go into the tube, but without anything going in, jamming a plastic straw into a vein is rather non-theraputic. To decide what goes in (no, sorry "TKO" doesn't count), if anything, you have to have some idea what would be most beneficial for your patient....thus discussions like this.

"Transport" well, if you're not treating your patient because they'll be at the hospital soon enough, well we might as well throw the patient in a rickshaw and run them over to the medicine man. Transport may be the only treatment for some patients, but if your priority is just to get to the "move the patient" bit on every patient encounter...well, I'd say piano-moving probably pays better.

I don't think our goal should be to have no clue what is going on with our patient, rely on the authoritative voice at the other end of the phone to tell us what monkey skill to perform, and mindlessly move the body of your patient from A to MD. Yes yes, care of the spirit etc....but at some point care of the body has to be part of the equation for many patients, and I think EMS should aspire to provide meaningful treatment for sick and injured bodies.

Maybe I misunderstood. I thought you were referencing House as a joke when you said Lupus. Paraneoplastic syndrome was the follow on in that line of humour.

No worries, Lupus was a joke, and I knew you were joking too. I just meant that eventually the joking diagnosis of Lupus or paraneoplastic is bound to actually be the right answer....and when that happens, I think it deserves some recognition