Fatal Abdominal Pain

[ibemt31]

Hey all, I had an interesting run that I would like to share with the EMTcity community, to see what they think may have ultimately lead to my pt`s death.

We were dispatched to a correctional facility with the initial dispatch of a BLS sick call.

Upon our arrival, however, we found our patient to be semi conscious and incapable of coherent speech. the frazzled doctor and nurse, who commanded me to get the pt to the hospital "NOW!!", disregarding the escort required by protocol, and informed me that our pt, who had a hx of gastric ulcers, had developed severe abd pain, before "deteriorating". i was told that his Spo2 was initially in the 50s but had come up to 81% with an NC. ( Why no hi flow? good question...) i was also informed that the pt had become bradycardic, his current radial pulse being 40 and weak.

i immediately went with some hi flow o2, based on the sats, and some severe visible distress, until i could determine what was going on. i recognized the need for rapid transport. pt was placed on my gurney and taken as fast as possible (with the escort, whom i hurried along) to my bus. it was during the movement to the ambulance that i realized that the pts respirations were at a rate of about 6-8 and were incredibly shallow, and i knew he would need assisted ventilations. as soon as i placed him in my nearby ambulance, i began ventilating and placed an oropharyngeal airway as transport was initiated.

ALS intercept requested but the only available unit was too far away, so we did not utilize them. i continued to ventilate, noticing some involuntary movement upon insertion of the airway, and an increased amount of involuntary movement the more i ventilated the pt. during transport the pulse rate was barely palpable. i was relying mostly on the fact that there was some involuntary movement and some respiratory effort, albeit poor, to assure myself my pt still had a pulse. spo2 during transport was 42% with the pulse oximeter providing a pulse rate of 30.

upon arrival at the ER, pt care was transferred. IV access established, pt RSI`ed etc. at one point during my chart writing i checked on the pt to find HR 70s, presumably after some atropine, bp 150/90, pt being bagged. a later check found the pt being worked in full arrest, from which he later recovered with v/s of palpable pulse of 200, and a b/p of 120/90. this was when i went back in service and left the ED. Some minor assessment details: pupils were dilated, and the ED staff found a fresh track mark on pt`s arm. Follow up with the ED today confirmed that the Pt did not pull through, although the doctor i asked about this pt had no further information other than that he did not make it.

I am just curious as to what others think. I was thinking AAA, but the BP of 150/90 in the ED does not correspond. The track mark could obviously be indicative of an Overdose, but i wonder if that is the only piece of the puzzle here. To those who usually criticize my grammar, i hope this post is a little easier on your eyes.

thanks

IBEMT31

[AZCEP]

We were dispatched to a correctional facility with the initial dispatch of a BLS sick call.

If your system designates this mess as BLS, that indicates a serious problem with the ability of those that called for your help.

[/quote=ibemt31]Upon our arrival, however, we found our patient to be semi conscious and incapable of coherent speech. the frazzled doctor and nurse, who commanded me to get the pt to the hospital "NOW!!", disregarding the escort required by protocol, and informed me that our pt, who had a hx of gastric ulcers, had developed severe abd pain, before "deteriorating".

[Just Plain Ruff]

my suspicions are leading to a perforated bowel due to the history of ulcers.

What drugs could this guy have gotten hold of that would exacerbate ulcers or cause them to rupture?

This could also be a ruptured appendix that went on wayyyyyyyyyy too long for my comfort. Could his demise have been due to a ruptured appendix with resulting infection and bowel problems?

The what-if's are extensive here.

I can imagine that you have not seen the end of this case. Expect to get a subpoena into court on this one. Any time a prisoner dies their loved ones will sue the state and whoever else they can sue, as it's the nature of the beast. So make sure your report was excellently written and I'd keep a copy if you can get one or make sure you have written down exactly what you did for that patient come time that you get subpoena'd because it's gonna happen.

[Doczilla]

There's a whole lot of questions here. On your differential of abd pain and shock, the list is extensive, but there are some possibilities off the top of my head:

AAA

perforated gastric or duodenal ulcer

pancreatitis

strangulated bowel

You also have to wonder if they meant epigastric pain, so also on your list:

acute MI

pulmonary embolus

Another question is how accurate the SaO2 waveform was. You didn't mention his vitals on scene. This is one reason I am a fan of pulse ox that gives a waveform, so you can judge how accurate it is with some precision.

'zilla

[DwayneEMTP]

To those who usually criticize my grammar, i hope this post is a little easier on your eyes.

As one of those that offered constructive criticism, I'd like to say this...

I'm proud of you for taking it to heart instead of crying about it. That post was much more mature and certainly easier to read!

Now just find your "Shift" key to correct your capitalization and your posts will be first rate.

I thought this was a great case study and am grateful that you hung around to post it, posted it as a professional, and showed the guts to do so again after a less than "warm and fuzzy" first attempt.

Good for you!

And just a quick note...Any case study or scenario that gets AZCEP and any of the Docs involved should make you feel pretty good...

Dwayne

[mediccjh]

What was his initial blood pressure at the Jail? One thing that could explain his slow heart rate and lack of respirations would be a head bleed, due to cocaine.

You said he had a fresh track mark; my guess would lie in that he did a speedball (Cocaine and heroin). I say that because I had one c/o massive headache Tuesday night after doing a speedball or two, and ended up with a subarachnoid hemorrhage.

Considering the facility that you picked the person up from, I'm not surprised. I hate doing jobs there.

[Happiness]

One thing I would like to know is about the fresh track mark. There is no mention whether this pt had an IV when they arrived, or if the Doc at the prison admisitered any pain drugs. I know that some don't like to give the drugs until the problem is diagnosed.

[ibemt31]

Whether the Doc administered anything prior to my arrival, unfortunately, is unknown, happiness. The pt did not have an IV when I arrived. The jail medical staff were far too frantic to provide any useful information such as this, and I too busy to ask.