S/P Hemodialysis Dyspnea

[BVESBC]

My second job presented me with a interesting situatation the evening/ morning what ever it was it went like this.

Disp, for scheduled transport for pt s/p hemodialysis, Pt presented A & O x 3 w/o complaint Pt HX, CRF, ESRD, NIDDM, + Hep C, two failed kidney transplants and Blind (bilat). Pt was moved to cot via sheet lift, covered w/ blankets & secured w/straps x 3. Pt was moved outside (cold air) to ambulance where pt spontaneously c/o I.........Cant..............Breath, I admin O2 @ 15 L do a quick set of vitals, BP 148/78 HR 104 Resp, shallow & labored & 24-26 per min. Lung sounds CTA sitting upright. This was obviously not a evanescent problem, the pt is obviously in a good deal of distress and not improving w/ our Tx. We go L & S to the other side of the block to go to the ER. O/A I give the charge RN a quick run down of the incident and my findings. Her response was, "So why didn't you take her back to the dialysis unit?" My partner heard her say this and realizing that I was completely stunned said " are you refusing to treat her?" She said "Bed 12" and we promptly transferred pt and left.

In retrospect we had very little info on pt, as the hemodialysis facility (in hospital) refuses to give out any info and pt was poor historian, the PMH was probably partial at best and when asked about medications she responded "lots" and denied any allergies.

1. Would anyone take her back to the dialysis dept?

2. Sudden onset dyspnea, my thought was either, asthma excerbated by cold air, or could their have been a acid/ base issue s/p hemodialysis, would it present itself suddenly or would it be slower onset. Is there any indicators that would be noted in the field as opposed to say labs?

3. Is there other etiology that you would consider?

Asthma is the obvious easy answer, I don't know the outcome of the pt (yet)

[Ridryder 911]

Dialysis patients are a train wreck. They have so many complex medical problems that majority of ER residents would bargain anything not to have to take care of.

Sure, weather induced asthma maybe a possibility but again remember what dialysis is for? To cleanse the body, because of kidney failure. With this there is of course excess fluid (possible pulmonary edema and probably what the nurse was thinking of, albeit she was poor on her action), major electrolyte imbalances and excess waste in the blood such as urea and nitrogen. All of the waste can become toxic as well again fluid overload.

Treat the patient accordingly and don't worry about the attitudes of the medical staff. They would probably be the first to criticize you if you did not take action.

R/r 911

[Scaramedic]

Hyperkalemia pops into my head first. What was her EKG? Did she have weakness, numbness in her extremities?

Did she actually get the Dialysis or did they decide to hold off that day for whatever reason? Sometimes for various reasons they do not always get their dialysis. She might have been hyperkalemic because her shunt was bad and they hadn't ran her that day. Though dyspnea is not a common Hyper K presentation it can happen.

Look for QRS widening, increased P-R interval, Peaked T's and arrhythmias in a R/O Hyper K, supposed post dialysis patient. Remember just because she went doesn't mean she got it that day.

[AnthonyM83]

Our company does not do dialysis runs, but if I were on one, I couldn't imagine why I would return her to the dialysis facility once they had transferred care (though, Rid helped explain why that hospital might want that)....but really would the dialysis facility have resources to care for her?

[VentMedic]

For this reason I can never understand why some EMTs and Paramedics consider dialysis pts "BS". Too many things go wrong quickly. These do occasionally get diverted to the ED before or after dialysis. Many times they have to be stabilized including intubation prior to going on the machine. Often the machine may have to come to their bedside in the ED or ICU.

Some EDs get a little concerned because their hospital may not have dialysis capability. That can be a nightmare reality for an RN and ER doc to be stuck caring for one of these patients and finding transport for them to an appropriate dialysis center.

The patient may have had a recent change or should have had a change in their dialysis "recipe". Electrolytes and fluid balances do many things. Many pts have on or post pump MIs.

Some dialysis centers will have a code cart but still rely on the code team from the hospital if attached. Others rely on 911.

As far as the dialysis center giving you very little info, you may have been one of the few that ever asked wearing an EMT or Paramedic patch unless it is a code at their facility. When these patients are diverted to our ED, the only info we can get from some ambulance crews is Diagnosis of dialysis or Renal Failure (luck guess). Code status is rarely known. The pt is known as the M-W-F 0700 dialysis run and that is all. Many crews have seen these patients several times as their regulars and know very little at all about who they are transporting. Rarely do we even get baseline vitals because it was just a "routine".

[CBEMT]

We go L & S to the other side of the block to go to the ER.

Ok, and how much time did that save you?

3. Is there other etiology that you would consider?

Yeah, the fact that they're ESRD and immediately post-dialysis. Translation: everything and anything is fair game.

As far as the dialysis center giving you very little info, you may have been one of the few that ever asked wearing an EMT or Paramedic patch unless it is a code at their facility. When these patients are diverted to our ED, the only info we can get from some ambulance crews is Diagnosis of dialysis or Renal Failure (luck guess). Code status is rarely known. The pt is known as the M-W-F 0700 dialysis run and that is all. Many crews have seen these patients several times as their regulars and know very little at all about who they are transporting.

I don't understand this. I used to transport dialysis patients whose history and at least part of the med lists I could recite from memory because we had to write out everything for every trip the patient made. One of my coworkers used to have some people's SSNs memorized.

[VentMedic]

I don't understand this. I used to transport dialysis patients whose history and at least part of the med lists I could recite from memory because we had to write out everything for every trip the patient made. One of my coworkers used to have some people's SSNs memorized.

While it is nice to have the SSN and meds memorized, how many times have you asked how did the dialysis go? Was the BP stable? Were they able to get off the amount they expected? These are questions the ED staff will usually ask if you divert. Many treat dialysis pts and other "routine" calls very lightly and don't actually look at the patient they are transporting but just go about doing their paperwork. That is, until something happens. The various forums have had dozens if not hundreds of threads started by people complaining about doing dialysis transports. Most don't understand dialysis or the disease processes of these patients enough to even construct a worthy argument.

[CBEMT]

The pre-treatment weight and vitals, along with the post-treatment weight and vitals, were always written by staff on the face sheet of the patient's paperwork that we'd get- which is how we always had med/history/allergies, etc.

We were expected to weight most of the patients we picked up, so that information was something we always had.

[BVESBC]

Well it is a week later and I don't know the outcome of the pt so I suspect that either she was admitted or she expired.

Scaramedic,

No EKG, I was on a BLS truck, all of our dialysis pt's are transported BLS on the premise that any pt needing higher level of care will be admitted to hosp. Weakness / numbness not able to assess fully, pt was in to much distress to communicate effectively. I had not yet considered hyperkalemia.

AnthonyM83,

I had not even considered returning the pt to the dialysis facility. Even though the dialysis facility is in part of the hosp. The pt care had been transferred to me and I believe that they would have said not our problem take her to the ER. Although was it a proper pt transfer of care? Without proper documentation and facility with held pertinent pt information That is another issue all together.

VentMedic Wrote,

"Rarely do we even get baseline vitals because it was just a "routine".

OMG.. the family is on the phone with Dewey Cheatem and Howe, can you say complete failure to assess?

CBEMT,

L & S saved us about 10 min in this urban mecca of non driving morons! Yes one block! As for remembering all of the DX, RX, Alg, it is a perdiem job in three years I MIGHT have seen this pt once before. I don't think that any providers memory should be substituted for a proper pt transfer of care. This facility has a long history of refusing pt info even on obviously altered pt that can not provide any HX or RX info. The service provider has informed us not to even try to get info from anyone but the pt. I just document that they refused to provide info and have the nurse initial next to it when they sign our run sheet.

[Asysin2leads]

I commend you on recognizing a critical patient, and hope that the nurse got out of her haze and realized the same thing and the patient received the proper care after you left.

A few things. As Rid said, a dialysis patient is synonymous with "A heck load of serious medical problems."

You mentioned asthma, however, from your presentation you stated the lungs were clear, so asthma is ruled out. In addition, typically, cold air can cause an asthmatic to have reach for their inhaler for relief, but it won't usually cause a true exacerbation.

We could try to look for some sort of exotic acid/base, fluid imbalance, but I prefer cheating and going for the more obvious answers.

Okay, so as we said before, a hemodialysis patient has a lot of medical problems. ESRD is commonly associated with renal artery stenosis and hypertension, and if your renal artery is errr.... stenotic, then there is a good chance some of your other vessels are stenotic as well, which is usually because of arteriosclerosis, and if they are really unlucky, its because of atherosclerois caused by plaque in the arteries. You also said he was NIDDM, which means that there is a possibility that they have neuropathy, in other words, they may not feel pain that others do, though this is more common in someone with full blown IDDM.

Now lets put it all together, you have a patient who probably has hypertension, hardening of the arteries, with a good possibility there is some plaque involvement, and also, possibly some neuropathy due to the NIDDM which means they may not feel some pain. So, elderly patient + hardened arteries + plaque + sudden onset of difficulty breathing = stat EKG, IV, ASA, NTG, and tell the cath lab to get off their butts and stop watching Jerry Springer.

In short, any hemodialysis patient who presents with sudden onset of difficulty breathing should be considered to be having a cardiac event until proven otherwise. Particularly when a cardiac event is one of the few things in the field we can kinda sorta treat.