Unresponsive man from nursing home

[JoJoAZ]

I'm a EMT on an ALS ride. I just started with a private ambo and this was one of my calls my first day. It's been on my mind because of the treatment that was offered. Just wondering what ya'll would do.

Called to transport a man because of his tachycardia. Found old man completely unresponsive, NRB 10 lpm, o2 stat 89%, snoring resp at 36,lungs sounds absent on left, "junkie" on right, pulse 120, bp 96/low 50's (can't remember exact), pinpoint pupils, soiled pants. No one at nursing home seemed to know anything about him or have paperwork on meds, etc.

Again, just wondering what ya'll would do. I just started medic school, and was really confused by how my medic treated him.

 

[Shishkabob]

Initial treatment until more info:

Insert OPA while thinking about doing a more advanced airway. BVM doing overdrive respirations at 10-12 a min-- hows my sat now? Compliance with bagging?

What does my monitor say? Pulse match monitor?

Start IV, do a fluid challenge, about 250-500mls, reassess vitals.

BGL stick?

Make a nurse go get me his file, since they don't know anything on him, the paperwork will.

 

[DrParasite]

from a BLS point of view, OPA immediately, if he doesn't tolerate that, NPA. depending on condition, maybe even start bagging him. and try to obtain paperwork and any history/medications that he has (yes i know, you said no one knows anything, but still).

from an ALS point of view, check BGL, put patient on cardiac monitor, see what the results are, possibly intubate patient to secure airway (esp if OPA was administered prior).

either case, move patient to cot, attempt again to get paperwork on patient and transport to local ER

 

[Lifeguards For Life]

Sadly, there is a good possibility this is your patients "normal" mental status. Was the reason you were dispatched because of tachycardia only?

While the lung sounds may always be absent on the left side(left lung may of been removed),in the absence of trauma, a pneumothorax can also develop as a result of underlying lung diseases, including cystic fibrosis, chronic obstructive pulmonary disease, lung cancer, asthma, and infections of the lungs.

Did this patient have a fever?

Pin point pupils are generally indicative of Metabolic, or medical comas. While many conditions cause dilated pupils, there are only a handful conditions causing "pin point" pupils, one of them being a pontine infarct. Pontine lesions disrupt sympathetic pathways and cause "pinpoint pupils".

This patient is most likely suffering from a Lower Respiratory Infection. Pneumonia, bronchitis, and tracheobronchitis, are the leading causes of mortality and hospitalization in nursing home residents. Often, the signs and symptoms of pneumonia, in particular, are not apparent in elderly patients, making diagnosis more complicated.

For nursing home residents, many of whom are chronically ill, determining the severity of any illness(being a new illness or an exacerbation of a pre existing condition) is always challenging.

There was a study done by a group in Missouri, regarding predicting mortality in nursing home residents with Pneumonia. While the study itself, is outside the scope of this thread, the part that pertains to us as EMT's and Paramedics is that researchers developed a simple scoring system based on eight factors that independently predicted pneumonia without obtaining a chest x-ray. These factors were: Increased pulse, Increased respiratory rate (30 or higher), Temperature of 38 degrees C or higher, Somnolence or decreased alertness, Presence of acute confusion, Lung crackles on auscultation, Absence of wheezing and Elevated white blood cell count.

How many of the eight criteria listed above were present in your patient? While you can not know a WBC count, this patient has certain symptoms characteristic of leukocytosis secondary to an infection.

This patient needs to be evaluated and treated in the ER. Prehospital care for patients with pneumonia or possible pneumonia revolves around improving symptoms; treating hypoxia and hypotension.

For patients with clear symptoms of pneumonia and signs of dehydration, such as dry lips or mouth, a normal saline fluid bolus may be helpful in improving hemodynamic status. In patients with symptoms of wheezing and shortness of breath and suspected acute asthma exacerbation or COPD, albuterol by nebulization may be helpful.

This Patients sonorous respirations, may easily be remedies with a simple BLS maneuver(thinking of the BLS as an afterthought thread), the head tilt chin lift.

While obtaining a definitive airway through intubation may be neccesary, I would try to avoid it(though this patient will likely require intubation long in the long term)

 

[Lifeguards For Life]

and was really confused by how my medic treated him.

which was?

 

[Akulahawk]

I'm a EMT on an ALS ride. I just started with a private ambo and this was one of my calls my first day. It's been on my mind because of the treatment that was offered. Just wondering what ya'll would do.

Called to transport a man because of his tachycardia. Found old man completely unresponsive, NRB 10 lpm, o2 stat 89%, snoring resp at 36,lungs sounds absent on left, "junkie" on right, pulse 120, bp 96/low 50's (can't remember exact), pinpoint pupils, soiled pants. No one at nursing home seemed to know anything about him or have paperwork on meds, etc.

Again, just wondering what ya'll would do. I just started medic school, and was really confused by how my medic treated him.

What was that? How I'd treat this patient would be partially driven by his DNR status. The rest would depend upon the results of the evaluation of this patient. I have some ideas... and I've seen this type of patient probably more than a few times.

 

[firecoins]

I'm a EMT on an ALS ride. I just started with a private ambo and this was one of my calls my first day. It's been on my mind because of the treatment that was offered. Just wondering what ya'll would do.

Called to transport a man because of his tachycardia. Found old man completely unresponsive, NRB 10 lpm, o2 stat 89%, snoring resp at 36,lungs sounds absent on left, "junkie" on right, pulse 120, bp 96/low 50's (can't remember exact), pinpoint pupils, soiled pants. No one at nursing home seemed to know anything about him or have paperwork on meds, etc.

Again, just wondering what ya'll would do. I just started medic school, and was really confused by how my medic treated him.

umm how did the medic treat him? What confused you? This type of pt and the staff's reaction are pretty standard.

 

[redcrossemt]

I'm a EMT on an ALS ride. I just started with a private ambo and this was one of my calls my first day. It's been on my mind because of the treatment that was offered. Just wondering what ya'll would do.

Called to transport a man because of his tachycardia. Found old man completely unresponsive, NRB 10 lpm, o2 stat 89%, snoring resp at 36,lungs sounds absent on left, "junkie" on right, pulse 120, bp 96/low 50's (can't remember exact), pinpoint pupils, soiled pants. No one at nursing home seemed to know anything about him or have paperwork on meds, etc.

Again, just wondering what ya'll would do. I just started medic school, and was really confused by how my medic treated him.

This guy is SICK!

A history would be really important. I think others have hit on the important things well... Airway, oxygen, possibly assist ventilations, give lots of fluid, and start antibiotics if you do that kind of thing.

What was his skin color and temperature? Were his extremities cool, mottled, or anything like that? Did he have a fever?

If his mental status is decreased from his normal, I would call this r/o septic shock pending the lactate.

Also interested in what your medic did...

 

[JoJoAZ]

Hey ya'll, I apologize for the delay. I've been away from my computer for the last few days. Thank you all for your responses. Lifeguard for life, appreciate the info on that study that will be helpful in the future.

Ok, so my medic wanted to move him to the ambo right way. While in the ambo, i said we needed to do something about his airway/breathing and he said to leave the nc on him at 4lpm. I got my pt's confused, he was not on a nrb, but a nc, sorry about that misinformation. I said are you sure, repeated the resp rate to him and he said yes. He said that the guy had overdosed and that that was the reason for his pinpoint pupils. NO basis for that thought though because no history of meds, etc. He only put the bp cuff on him, and started an iv and gave him narcan. He mixed the narcan with saline and gave it iv push. he said he likes to mix all his meds. He then told me to get in the front and drive. We get to the hospital bring him in, and the hospital staff didn't seem to care much but rather spent alot of time making fun of the guy because he crapped his pants. I was pretty disgusted so I went back to the ambo to clean up.

When my medic came back I asked if our pt had improved any and he said he never checked just had the nurse sign the paper. I asked him why he didn't do anything about the breathing. This was the first time I had seen someone unresponsive and I know regardless that abc are first. He said thats fine and dandy but we do things different in the field. I wish I would have stood up to him and did something about the airway, but it was my first shift and assumed my medic knew best.

My next shift I started to become more aware of his neglect towards pt's and how he talked to them or lack there of. We had one pt that was bleeding around his feeding tube. And when I asked him what the bleeding was like, how much etc. he told me that he never checked. I asked why? And he said why should he? He asked me why I was so critical of his pt care.

I told him that I was not being critical, but I was interested. I know this is what I want to do, so I'm gonna be curious and ask questions and what to see everything I can, and know what I should and shouldn't do. He told me he hates his job and that he's burned out and that he will do the bare minimum. I should have known when he told me at the beginning of our shift that he never uses the monitor and prefers to start only one iv a shift if he can help it. I though he was kidding. I'll told him that puts me in a bad situation ethically and that I'm gonna have to say something. And his reply was that he was not gonna hurt anyone.

I know I have gotten slightly off track, but what do I do? We had a similar call the other day right when we were supposed to be getting off. Again, the lady should have had had hiflo, but he insisted on keeping her on a canula. He couldn't get an iv and he poke her three times with the same needle. I asked what the stats were and he said the battery died. I went to get a glucose and there were no strips. I saw him check the truck off...grrr. When we get to the hospital they immediatley put her on hiflo and her stats went to 100% and she actually started talking.

I'm so embarrassed to have him as a partner, it's almost like guilty by association. I know something bad is going to happen if it hasn't already, and I don't want to be involved with this.

Any advice?

 

[redcrossemt]

Ok, so my medic wanted to move him to the ambo right way.

From a nursing home? Why? You have tons of room and light to do stuff in the room!

While in the ambo, i said we needed to do something about his airway/breathing and he said to leave the nc on him at 4lpm.

Probably was going down the overdose plan and thinking that reversing narcotics would fix the patient's breathing. Always start with A and B, as you suggested! You don't even really need to reverse the narcotics (if there were any) if you do good at A and B.

He said that the guy had overdosed and that that was the reason for his pinpoint pupils. NO basis for that thought though because no history of meds, etc.

This pt had no history suggestive of such, was tachycardic, and tachypneic... Probably not a narcotic overdose.

He only put the bp cuff on him, and started an iv and gave him narcan. He mixed the narcan with saline and gave it iv push. he said he likes to mix all his meds. He then told me to get in the front and drive.

It's a good idea to dilute a lot of meds. I'm not sure that narcan needs to be diluted. It may not be necessary, but it didn't hurt either.

I know I have gotten slightly off track, but what do I do? We had a similar call the other day right when we were supposed to be getting off. Again, the lady should have had had hiflo, but he insisted on keeping her on a canula. He couldn't get an iv and he poke her three times with the same needle. I asked what the stats were and he said the battery died. I went to get a glucose and there were no strips. I saw him check the truck off...grrr. When we get to the hospital they immediatley put her on hiflo and her stats went to 100% and she actually started talking.

I'm so embarrassed to have him as a partner, it's almost like guilty by association. I know something bad is going to happen if it hasn't already, and I don't want to be involved with this.

This guy sounds dangerous and like he's a liability to you, your patients, and your company. He told you that he's burned out and that he's only going to do the bare minimum - which is not what your patients need nor deserve.

Start by talking to him about your concerns. If he isn't responsive, take your concerns to your supervisor. If things still aren't cleared up, go to your medical control authority or director. You can make a difference here. If you go to the medical control authority about concerns not addressed by management, be prepared to be harassed or lose your job. I know it's not right, but it can happen and it will take more to fight it then you have.

 

[JoJoAZ]

Thanks for the encouragement redcrossemt. I know I have a duty to say something, I'm just concerned that he will know it will come with me, and that I'll become a black sheep and no one will want to work with me. But on the flip side, I would rather that, knowing I stood up for an obvious wrong.

So drugs can be diluted even in a standard push/bolus even if it doesn't state so in the drug profile? Just curious..

 

[redcrossemt]

Thanks for the encouragement redcrossemt. I know I have a duty to say something, I'm just concerned that he will know it will come with me, and that I'll become a black sheep and no one will want to work with me. But on the flip side, I would rather that, knowing I stood up for an obvious wrong.

If you let things go now, you will probably always let them go. I vote for integrity and standing up for the good patient care you believe in. He will know it's you - you've already confronted him. He knows that you expect him to shape up and that if he doesn't you'll report him. So see how things go, and report him if need be.

So drugs can be diluted even in a standard push/bolus even if it doesn't state so in the drug profile? Just curious..

You have to be careful about what you dilute in what; as well as how concentrated or fast you need to give it (adenosine comes to mind). But in the case here, nalaxone is compatible with normal saline and the speed of push doesn't matter, so yes... I personally haven't, and I'm not sure there's a need to, but yes, it can be done.

 

[Melclin]

To suggest that this was a narcotic overdose full stop, no other considerations, is pretty absurd.

A ddx for miosis includes:

-Horner's syndrome (Clinical syndrome consisting of Miosis, ipsilateral ptosis [slight drooping of one eye lid), and anhydrosis [lack of sweating]) that are caused by a disruption of the sympathetic nerve pathway somewhere between the spinal cord and the eye). Typically only causes mild miosis, so probably not the cause of true "pin point pupils". Although it can be caused by certain apical lung tumours and iatrogenically during their removal (damage to the sympathetic nervous system) which is a possibility considering he may have had a lung removed (you mentioned no breath sounds).
-Argyll-Robertson's (Prostitutes Pupils: sign of syphilis, pupils that are constricted by focusing on something close but not in response to light). Again, miosis is only situational and mild. Probably not the culprit.
-Pontiene Haemorrhage (already been mentioned and explained).
-Cholinergic drugs used to treat Alzheimers can sometimes cause Miosis as can antipyschotics, and some varieties of antidepressants and topical drops for glaucoma (pilocarpine, etc). Certainly a possibility, but they don't tend to cause true "pin point" pupils; at least, this is my understanding.
-Opiates
-Iridocyclitis (condition involving irritation of the eye, you'll see redness and watering plus blurred vision in conscious pts. There is a long list of diseases that cause this as well as chemical irritants, but again my understanding is that it tends to cause more mild miosis).
-Organophosphates. Not this time, not with the tachycardia and tachypnea, you wouldn't think, plus no other symptoms of parasympathetic discharge.

There might be something I forgot to mention; maybe some metabolic thing. It's too complicated to be applying in the field perhaps, but just good food for thought. I think its good for any EMS practitioner to realise that pip point pupils does not a narcotic overdose make.

What was his GCS? What was his temperature?

REDCROSSEMT: I'm curious how the miosis would be part of septic shock? Is that something that you see in septic patients?

 

[Aidey]

There is also the possibility that the pt has had eye surgery and his pupils are fixed at that size from that.

On the drug thing, all drugs end up diluted to some degree. Because you push them in the IV line and not directly into the IV catheter they will automatically mix with the saline before being flushed into the body by more saline.

That being said, there are some drugs that are incompatible with each other and/or they need to be administered via D5W,or some other fliud and not NS. So those you don't want to dilute with saline. There aren't many of those I can think of off hand that are commonly carried. You start running into those drugs more on critical care transport ambulances and with flight teams.

 

[JoJoAZ]

Thanks for the info on the miosis! That will definitely be helpful in the future.

The pt's gcs: 4 and temp was cool, no official temp was taken.

 

[usalsfyre]

Sepsis...

This was a very, very sick patient. Assuming full code status immediate needs were airway control, mechanical ventilation and fluids (4-5 liters if I can get it on board). Watch B/P carefully and consider levophed if he starts crapping out. Consider running an inline neb to help loosen secretions.

 

[usalsfyre]

Sepsis...

This was a very, very sick patient. Assuming full code status immediate needs were airway control, mechanical ventilation and fluids (4-5 liters if I can get it on board). Watch B/P carefully and consider levophed if he starts crapping out. Consider running an inline neb to help loosen secretions.

 

[MSDeltaFlt]

I'm a EMT on an ALS ride. I just started with a private ambo and this was one of my calls my first day. It's been on my mind because of the treatment that was offered. Just wondering what ya'll would do.

Called to transport a man because of his tachycardia. Found old man completely unresponsive, NRB 10 lpm, o2 stat 89%, snoring resp at 36,lungs sounds absent on left, "junkie" on right, pulse 120, bp 96/low 50's (can't remember exact), pinpoint pupils, soiled pants. No one at nursing home seemed to know anything about him or have paperwork on meds, etc.

Again, just wondering what ya'll would do. I just started medic school, and was really confused by how my medic treated him.

These are the calls that frustrate me because there are skills that I can do as a RT and not as a medic in my state. Frustrating.

Question. Does this man have a PEG tube?

Most unresponsive NH residents are septic. It sounds like pneumonia is the culprit; aspiration or otherwise. Regardless, I believe this man could really have benefited from NT suction.

My thoughts.

 

[MedicineMan975]

These are the calls that frustrate me because there are skills that I can do as a RT and not as a medic in my state. Frustrating.

Question. Does this man have a PEG tube?

Most unresponsive NH residents are septic. It sounds like pneumonia is the culprit; aspiration or otherwise. Regardless, I believe this man could really have benefited from NT suction.

My thoughts.

Gotta' love those "low sick" nursing home calls, eh Ta? lol

 

[Lifeguards For Life]

This was a very, very sick patient. Assuming full code status immediate needs were airway control, mechanical ventilation and fluids (4-5 liters if I can get it on board). Watch B/P carefully and consider levophed if he starts crapping out. Consider running an inline neb to help loosen secretions.

To be diagnosed with sepsis, you must exhibit at least two of the following symptoms:

Fever above 101.3 F (38.5 C) or below 95 F (35 C)
Heart rate higher than 90 beats a minute
Respiratory rate higher than 20 breaths a minute
Probable or confirmed infection

This patient is displaying 2 of the above symptoms, which could just as easily be explained by several other etiologies.(tachycardia and tachypneic)

Possible infection, and as the OP tells us , the patient felt cold, though a BCT was never obtained, this patient could be septic.

Sepsis is a potential complication of pneumonia, or many of the numerous nosocomial infections.

You would give the patient 4-5 liters of fluid?

Aggressive administration of crystalloid solutions can lead to volume overload, electrolyte disturbances, coagulopathy heart failure, pulmonary edema, interstitial edema, and acute respiratory distress syndrome.

Patients in shock typically require and tolerate infusion at the maximum rate. Adults are given 1 L of crystalloid (20 mL/kg in children) or, in hemorrhagic shock, 5 to 10 mL/kg of colloid or packed RBCs, and the patient is reassessed. An exception is a patient with cardiogenic shock who typically does not require large volume infusion.

Patients with intravascular volume depletion without shock can receive infusion at a controlled rate, typically 500 mL/h. Children should have fluid deficit calculated replacement given over 24 h (1⁄2 in the first 8 h).

Even in cases of severe sepsis, the literature states 20-30ml/kg as a good starting point.

If septic, this patient is not in severe sepsis or septic shock.

2L would be considered aggressive fluid managment in this patient, 5 liters could prove fatal.

http://rn.modernmedicine.com/rnweb/article/articleDetail.jsp?id=463604