What would you have done?

[Fox800]

Here's the scenario:

Female patient 80+ years old, called out for a fall. Fire crew (4 EMT's) arrives 3-4 minutes ahead of the ambulance, finds pt. on her knees facing away from the toilet, pt. had defecated on herself. Fire crew lifts pt. off her knees into a wooden chair. We arrive and find pt. with altered mentation (GCS 14, slow to respond, repetitive questioning), diaphoretic. Pt. released from a small hospital yesterday for a UTI.

Hx: HTN, CAD, no hx of diabetes

Meds: Levaquin (for UTI)

NKDA

Initial VS: HR 66, VS 130/90, RR 30, SP02 90% on room air, lung sounds clear, temp 98.6 temporal, BGL 43.

2 or 3 unsuccessful IV attempts, pt. says she can't swallow anything so oral glucose is a no-go. 1mg Glucagon goes in IM. O2 via NRB @ 15lpm. Sinus rhythm on the monitor. Move pt. to stretcher, move to ambulance. Get pt. in the back of the ambulance, SPO2 is now 72% with an NRB @ 15lpm, RR of 40, ETC02 of 25, 2nd BGL (~10 minutes after 1st one) is 33. Fingers are now cyanotic. With better lighting in the ambulance, you can now see that the pt.'s abdomen looks mottled. Closest (appropriate) hospital is 8-10 minutes away.

What would be your next move? Go ahead and transport? Take some of the fire guys with you to help? Just wanted to hear some different thought processes.

[Dustdevil]

Take some of the fire guys with you to help?

Help what? Carry a little old lady?

Anyhow, it's too late for that. I gave the firemonkeys "the shove" as soon as I got to the scene.

[Fox800]

Help what? Carry a little old lady?

Anyhow, it's too late for that. I gave the firemonkeys "the shove" as soon as I got to the scene.

Somehow I figured that comment would come quickly I was kinda thinking about the difficulty of having to A) assist ventilations if this lady's sats and skin color are going to crap attempt more IVs/do an IO to get D50 on board vs. waiting to get to the hospital...with one set of hands.

[firedoc5]

I don't know if I'd do IO on her at her age due to osteoporosis, and I don't know how well D50 would push that route. Never tried it. Let me know DD of IO being utilized like that. If need be do a carotid vein stick if possible. Be nice and draw at least a red top tube of blood prior to IV being hooked up for hosp. lab.

But I'd say her prognosis isn't too possitive.

[ERDoc]

What's a carotid vein?

[crotchitymedic1986]

Many dont know this, but D50 can be given orally --- smells and tastes like sulphur, but it can be done. In the old days prior to IV's, D50 was mixed with a drink for diabetics who were in the hospital (prior to the EMS days). Most diabetics who can talk, can still swallow, even if you just get a little in her system, it can help.

This is not aimed at the OP, but rather, general advice for those who often find themselves in this situation:

And although, there are many patients who are difficult to stick, I could usually get IVs in the most difficult patients (even those who had ports due to poor venous access). Not because I am any better than anyone else, but because I did alot of phlebotomy and pediatric sticks at part-time jobs. A good tool to use to practice, is to blindfold yourself and find the veins in your partner's arms. just by the sense of feel.

Once you get used to finding veins by feel alone, you will be able to stick the patients that no one else has successfully.

[Kaisu]

Even in a non-responsive patient, you can turn them to a lateral recumbant and administer glucose in the dependent buchal.

[crotchitymedic1986]

Yes, you can always give it rectally via ETT to the tuckus --- which is all the motivation I needed to find a vein. LOL

[p3medic]

What's a carotid vein?

The opposite of the jugular artery. :oops:

[crotchitymedic1986]

Oh, and be nice and lubricate the tube before you give her anal D50, and try to get it out and get her dressed again before she regains consciousness.