unconscious person

[AJemt]

fictional scenario (address and unit numbers are not real!). have fun....you are BLS so is your partner, and class 2 is BLS Lights & Sirens.


It's a beautiful day out, not too hot, not too cold, sunny but not too bright....and you are taking every advantage of that fact by taking a break from the TV in the station and eating your lunch outside at the picnic table. You've just opened your lunch when the tones go off....

*Ambulance 38-10, respond to 150 North Duke Street, at the library, for an unconscious person. Ambulance 38-10, respond to 150 North Duke Street, at the library, for an unconscious person, class 2. Time out, 1217.*

So much for that sandwich.... You put your lunch away and meet your partner in the truck; then go responding. *Ambulance 38-10 at 1219. 38-10, your patient is a 17 y/o/f who is dizzy and feels like she's going to pass out.*

ATF: a female who is sitting on the steps outside of the library. As you approach the pt you observe that she is very pale and has her eyes closed. She opens her eyes when you speak to her.


What do you want to know?

 

[mdtaylor]

I would want to know her ABC's, then lay her down and give O2 while checking her blood sugar. Partner is getting Hx.

ABC's? Blood Sugar? Pupils? Vitals? SAMPLE History? Diabetes? Is or could be prego? Last ate?

 

[AJemt]

Your findings:

S: pale/cool/clammy skin; lightheadedness, dizziness, H/A, nausea

A: PCN; bees

M: Epi-pen PRN

P: anaphylactic shock after bee sting 16 months ago; no other med problems; pt denies pregnancy (LMP 2-3 wks prior, no BF for 4 mos no relations since prior)

L: about four saltine's at suppertime yesterday; a few sips of water from the water fountain about 20 minutes ago

E: pt states that she didn't feel good yesterday so she only ate a couple of crackers for supper and didn't eat anything today bc she had no appetite. she was walking downtown and got very dizzy and felt like she was going to pass out (did NOT actually pass out though); a passerby helped her to the steps and called for an ambulance (caller is not available for questions).

Vitals: P170 regular but weak and thready radial, R32, BP 86/44, PEARRL



What do you think is going on?

What do you do for treatment?

What if the pt wants to sign off?
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what flow rate/method of delivery for O2? pt is conscious, and answering all questions appropriately.
also (going with state protocols) BGL is not a BLS skill so you do not have a glucometer on the truck.

 

[Flight-LP]

How is her skin turgor? How has her urinary output been? Color? Odor? Frequency?

Get ALS, as something as simplistic as obtaining a BGL isn't possible at the BLS level.........

A BGL is essential on this patient.......................

 

[mdtaylor]

Your patient (yours because BGL is a BLS skill and every BLS truck should have a glucometer) is on the threshold of non-compensated shock. She needs high flow O2 and either coaching with her breathing or BVM to increase the depth and return her to adequate breathing.

Rapid transport in trendelenburg position and rendezvous with ALS. BGL is a must, I agree with flight. She cannot refuse treatment or transport, sorry. She is not stable.

 

[fma08]

did she sleep last night? has she been drinking a lot of caffeine? BGL too? and if she's A&O x3 she has the right to refuse, but i'd be urging her as much as possible to go in.

 

[AJemt]

"How is her skin turgor? How has her urinary output been? Color? Odor? Frequency?"

skin turgor is good, she states she is peeing normally, not excessively dark and no odor.


" Your patient (yours because BGL is a BLS skill and every BLS truck should have a glucometer) is on the threshold of non-compensated shock. She needs high flow O2 and either coaching with her breathing or BVM to increase the depth and return her to adequate breathing.

Rapid transport in trendelenburg position and rendezvous with ALS. BGL is a must, I agree with flight. She cannot refuse treatment or transport, sorry. She is not stable."

BGL in PA is not a BLS skill (at least last i knew, though i believe there is something in the works to allow it). but regardless....

"did she sleep last night? has she been drinking a lot of caffeine? BGL too? and if she's A&O x3 she has the right to refuse, but i'd be urging her as much as possible to go in. "

slept okay, some gingerale last night. good point about the signoff, however.....


some more info:
~pt did vomit last night x5, but not since 2100.

You place the pt on O2 (whatever your protocol calls for)

ALS responds to your call for assistance. Their findings include:

Monitor: ST at 164
BGL: 56 mg/dl

after giving the pt some oral glucose, and rechecking sugar (now at 138), the pt is reassessed:

She is a little more alert, but still very pale, cool and clammy. repeat vitals are P156, R24, BP88/56
keeping in mind all that you've gathered about this pt, what are your next moves and what (if anything) else is going on? (i know someone touched on shock but why is she there?) also is there anything else you would like to know?

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interestingly enough no one has picked up on the one factor that is key to whether or not she can sign off......

 

[KEVD18]

interestingly enough no one has picked up on the one factor that is key to whether or not she can sign off......

thats a real brain buster. she's 17

 

[CFRBryan347768]

ABC's,Blood,Sugar,Pupils,Vitals,SAMPLE History,is she pregnant? Any alcohol/drugs(remember i wont tell your parents;-))

 

[AJemt]

HA someone caught it.....now for the twist (can't just be simple now can it?) yes she is 17 but parents are out of the country and pt lives in her own apt. now can she sign off?

alcohol/drugs.....no alcohol, pt denies drug use (no track marks etc.) and states she has never even tried them in her life; the only thing she's ever taken is a multi-vitamin she's taken every day for hte last two years, except the last day or so b/c of not feelign good.

anything else ya'lls want to know?

 

[Sapphyre]

Unless she's formally emancipated, no, she can't sign off.

 

[ffemt8978]

Unless she's formally emancipated, no, she can't sign off.

Unless she's had a kid or is married.

 

[enjoynz]

PM HX was allergic to bees.

Has she been to hospital at all in the past few months, or had any type of surgery,tatoo's etc done?

Enjoynz

 

[paramedix]

A lot of history have been covered and answered in the previous posts, but I would like to know more...

What is her social status, what did she do in the last couple of days, where did she hang out, anything done differently in the last few days...etc.

I have picked up something small by asking background and not always direct...maybe even the water fountain was contaminated, (maybe not in this case, because she had been ill before she drank from it), but anything could lead to a diagnostic question.

Regarding her signing... in SA, any child from the age of 14 years that has no mental dysfunction or deficiency is allowed to give or decline medical consent provided it is not life threatening to the patient or risk for public health.

 

[mdtaylor]

I'd have to ask you to be more specific with the AB part of the ABC's. How are the breath sounds, how are lung sounds?

Any insect stings, contact with grass, insecticides, herbicides, etc. in the past hour? (Just because of Hx.)

Although she should be dehydrated given your S/S your skin description really doesn't describe dehydration. With the BGL as it was, and past 24 hour Hx, we would have used D50 instead of oral glucose.That would have also provided for an IV injection site. Fluid loss from vomiting and not eating/drinking may even suggest the need for NS drip.

Color of mucosa, conjunctiva, etc?


Edited to add.... don't delay transport if things don't rapidly improve.

 

[Eydawn]

If her parents are out of the country and she's living in her own apartment, have they set up for her to be emancipated? Or does she have an appointed guardian stateside? If not, can we reach the parents, wherever they are?

What did she eat prior to becoming ill? I know she had crackers last night because she was feeling crappy (sounds all too familiar at this point...) but what did she have to eat earlier yesterday? Anything she wouldn't normally eat? The local shoddy food joint? Malt-O-Meal cereal, perhaps? (Been a huge recall of that due to possible salmonella contamination... mostly the puffed wheat stuff).

Has she been out of the country herself recently? Any bugs she could have picked up that way? Recent domestic travel? What does she do for a living? If she works with kids, then picking up a bug makes sense...

Has she had the craps, as well as the hurls? (pardon the language... I'm currently waiting for both ends of my OWN GI tract to quit exacting revenge for whatever karmic act I must have committed) Any blood in the vomit? Any history of anorexia? Does she look like she's been receiving adequate nutrition other than the last couple of days from being too ill to keep stuff down? Does she have a fever, or can she remember if she's had one since feeling icky?

Definitely obtain IV access and start the fluids... whether or not that means ALS is dependent on your area. For me, it's still BLS... but I would like to see a three lead EKG at the very least. Any funky rhythms?

Wendy
CO EMT-B

 

[AJemt]

wow. lets see if i can answer all the questions in one post without forgetting anything.


no recent hospitalizations, ER visits (not since being stung when discovered allergic to bees), no surgerys, tattoos, piercings, or recent immunizations.


social status - not quite sure what you mean by that. pt has not been anywhere out of the ordinary for her (friends house for dinner two nights prior, friend is fine; stopped by parents house to get their mail and feed the fish like she's been doing for the past month)


lungs are C&EtA x 6pt posterior and 4pt anterior, no wheezing rales rattles or other sounds noted. no stings, no contact with any chemicals other than lysol wipes (used to clean counter in her kitchen yest AM per her normal routine. mucosa color is pale but not white.


no breakfast, very small bowl of granola and yogurt for lunch (exp dates okay per pt and tasted fine). no travel, works retail PT at a local organic flower shop (2 yrs employed, no issues with anything, no chemicals from work). yes diarrhea, pt states was dark, no blood in the vomit, no hx of eating d/o. she is slim but does not appear undernourished (~5'3" 115lbs). pt states she felt like she had a fever last night, pt took 2 APAP.

you check her temp and find a slight fever at 101.6 (F). what sz angio, what fluid, what flow rate? EKG shows sinus tach, no 12 lead obtained.
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anything else anyone wants to check, investigate, question, etc.?
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the AMA was just a rabbit trail - pt is going to the hospital and agrees to transport, just was wondering how ya'lls would handle it if she said no.
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PS eydawn - hope you feel better soon!

 

[Eydawn]

Let's be nice and give her something small like a 20 gauge... and I'd be doing normal saline. As for flow rate, I kind of haven't gotten to that place in my IV course yet... let's not go wide open, but nice and slow... When's the last time she hurled? Has she ever had a history of syncopal episodes before?

I'm saying our next best course of treatment is to get her to the nice comfy ER bed and get lab work done... supportive treatment by us enroute. Not much more we can learn here or do for her at this point.

Wendy
CO EMT-B

 

[piranah]

any female is considered pregnant and in that cas eshe has the right to refuse although...is she balemic or anorexic...she is alergic to bees...so why not do an exam for a stinger....asses airway/lung sounds for wheezing and deal according to local protocol.....O2 via NRB 15 LPM..her BGL was low i would have given either oral glucose or glucagon 1mg via IM with med control orders......reassess....transport priority immediate......question..she could have either been sick and is now malnurioused from not eating and vomiting....

 

[AJemt]

eydawn - 2100 hrs last night, no hx of syncope. only thing for me is personally i'd go with an 18g - nothing wrong with a 20g but if i can get an 18 in this pt i would, just in case her bp doesn't come up or starts going down and she starts crashing; however you are correct in the flow rate, KVO or TKO (whichever ya'lls call it), about 1 drip every 3-6 seconds (depending on how you learn it), i'd prly personally go closer to about 5 or 6.

piranah - no anorexia or bulimia, not stung, not pregnant, lungs are clear no wheezing, pt is not malnourished only threw up yesterday and up till feeling sick she was eating normally (day before last, little food early on in the day yesterday before started throwing up).
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i will stop torturing ya'lls and post the answer in a few hours