Two Medical Call Reviews

[rat115]

Ok....this was an interesting couple of calls.

1st call.....

0220.....82 yr old female.... hx of diabetes and c/o choking.....

Arrived on scene to find 2 PD officers standing in the room with the pt. Husband very frustrated trying to get her glucometer set up and take her BGL. Pt laying on the bed alternating between (1) laying still and speaking either with non word babbling and unable to correctly answer any questions beside her name and (2) writhing around and screaming as if in pain. Poor perfusions of extrimities a normal thing on the pt so unable to get BGL with pt monitor and had to wait for my partners to arrive with our stuff. (We're a volly service and I responded straight from my home since it was only 2 blocks from home and I'd have to pass the residence to get to the shed.) After amb arrives, we get a BP of 230/100, pulse 100 regular and strong, BGL of 175 mg/dL and unalbe to get a SAO2. Started O2 at 15 lpm NC and tried to assist pt to the cot since she was calm as we started to move her but had her start screaming and collapse when we moved her so we ended up carrying her to the cot. No weakness in grips or deviation in eyes. We got her loaded, and the hubby told the EMT driving that she'd been dx with some form of dementia while we were en route. Unable to get any complaints from the pt beyond the abnormal behavior. This pt has been picked up going into diabetic coma but no one on the crew had seen her like this before.

2nd call.....

1105......dispatched to a local resturant for unknown medical which dispatch changed to a party choking........

Arrived on scene to find the same 82 y/o Fe laying on the floor with her head in her daughter's lap. Daughter stated that the ER had just released her mom about an hour before. No Dx from the earlier tranport given to us by the daughter. She stated that they were sitting at the table eating and "Mom suddenly clutched at her chest and started screaming and talking in babbles". Daughter stated that she had her mom in her arms and prevented her from falling onto the floor by lowering her. Pt calm enough that we were able to place ECG leads and print a strip for the ER (no ALS provider so no one authorized to read on the amb), pulse 68 regular and strong, SAO2 96% on RA. Went ahead and started O2 at 15 LPM NRB due to s/s, moved pt from the floor to the cot, loaded and transported. BGL not checked due to trying to get her out of the resturant and the EMT in the back didn't get it done once we were rolling. Pt did start having frothy spit as we arrived at the ER and started gaging on that, but it was the first we'd seen of anything like that.

No dehydration noted either time. Family noted that this behavior had never been so bad before and that she'd recently been to the doctor for med changes. Both times, the husband was worried and feeling way out of his depth in caring for his wife. Wish I had a copy of the strip to show, but I don't.

From a BLS stand point, I didn't see much else we could do. Comments? Questions? I'm trying to review this mentally myself incase we have similar with this gal again.

[akroeze]

Ok....this was an interesting couple of calls.

1st call.....

0220.....82 yr old female.... hx of diabetes and c/o choking.....

Arrived on scene to find 2 PD officers standing in the room with the pt. Husband very frustrated trying to get her glucometer set up and take her BGL. Pt laying on the bed alternating between (1) laying still and speaking either with non word babbling and unable to correctly answer any questions beside her name and (2) writhing around and screaming as if in pain. Poor perfusions of extrimities a normal thing on the pt so unable to get BGL with pt monitor and had to wait for my partners to arrive with our stuff. (We're a volly service and I responded straight from my home since it was only 2 blocks from home and I'd have to pass the residence to get to the shed.) After amb arrives, we get a BP of 230/100, pulse 100 regular and strong, BGL of 175 mg/dL and unalbe to get a SAO2. Started O2 at 15 lpm NC and tried to assist pt to the cot since she was calm as we started to move her but had her start screaming and collapse when we moved her so we ended up carrying her to the cot. No weakness in grips or deviation in eyes. We got her loaded, and the hubby told the EMT driving that she'd been dx with some form of dementia while we were en route. Unable to get any complaints from the pt beyond the abnormal behavior. This pt has been picked up going into diabetic coma but no one on the crew had seen her like this before.

I hope not!!

And for patient number one one thing that should be in your mind is possibly hypertensive emergency

Edited April 14, 2009 by akroeze

[emsboy_2000]

First of all, allow me to commend you for your volunteer work. My hat goes off to all who do this for no pay.

Some important questions I would ask are: does she have a history of high blood pressure? Does this episode look like an episode of dementia? Has this happened before, and if so, what caused it? And I understand there was history of diabetic coma.

With the blood pressure that high, on a diabetic especially, a stroke would definitely be a possibility. Keep in mind that most diabetics suffer from complications such as heart attacks and stroke—the main killer of diabetics. Another important thing to remember is that not all strokes present with the classic symptoms we've all heard of: one-sided weakness, eye deviation, slurred speech and facial droop. Other symptoms include: altered mental status, which could translate into a patient “acting abnormally; inability to speak correctly; severe headache; loss of consciousness and blurry vision, to name a few.

With a sugar of 175, I highly doubt it was a diabetic related issue. A blood sugar of 175 rarely, if ever, causes any symptoms. And diabetic coma occurs with prolonged blood sugar extremes—blood sugar that's either too high or too low for too long, such as diabetic ketoacidosis (DKA) and diabetic hyperosmolar syndrome (a reading of 600 mm/dL); or hypoglycemia—a sugar level less than 80, but coma usually sets in with levels much lower than that.

Obviously, from what I understand, your patient did not suffer any of these since she was released without a diagnosis the second time; however, what I've mentioned are only some things to think about. For now, simply ensure that your ABC's are intact; if they're not, correct them to the extent of your training. And don't get too hung up on "diagnosing" the ailment. Although it's great if you can figure out the cause of the problem, it's not crucial at your level of training.

Well, I hope this helps out a little. Good luck.

Edited April 14, 2009 by emsboy_2000

[fiznat]

Honestly being that you've had this experience twice with the same patient following an ED examination, it seems more and more likely that the symptoms are probably psych related or connected to the progressing dementia. Still, the danger of course exists with these types of patients that THIS TIME it isn't psych but rather some other malignant problem.

Some things to keep in mind:

1. Hypertension like that and altered mental status should make you start thinking about CVAs. You should do a good look for focal neuro deficits, not just hand grasps if you can. Get serial blood pressure readings and verify that an outstanding reading like that is legitimate.

2. Acute altered mental status in diabetic patients should always prompt a BGL check. There is no excuse for not doing it. In fact, if it comes up normal and there are no other good explanations for the AMS, do it again. Sometimes you can get a bad read.

3. The most important feature to know about with AMS patients is BASELINE mental status. Spend some time learning from the family how this patient normally behaves so you can clearly articulate what is different *today.* Sometimes it takes multiple good questions to really pull the information you need from a family member. Along the same lines, ask about previous episodes or issues relating to the incident at hand.

4. Remember your AEIOU-TIPS, and go through it in your mind when you've exhausted the obvious stuff. Alcohol, Epilepsy, Insulin, Overdose, Uremia, Trauma, Infection, Psychosis, Stroke.

5. Forget about obtaining the 3 lead ECG. It is a complete waste of time if you can't read it, and even if you can you would know that a 3 lead tells us very little anyways. The hospital doesn't care about your strip. Your time can be better spent elsewhere.

6. Lastly, remember that you don't always need to "figure out what exactly is going on." Especially at the BLS level. Make sure you protect the c-spine if necessary, keep her airway open, give oxygen, understand the story, and monitor for changes in vital signs. That is pretty much your job. Make sure you at the minimum do that stuff well, and save the zebra hunting until after.

Edited April 14, 2009 by fiznat

[mobey]

First of all, allow me to commend you for your volunteer work. My hat goes off to all who do this for no pay.

Ya, I'll bet you feel all warm and fuzzy knowing somewhere some EMT is going to work at McDonalds since people are killing his career by doing it for free!

There is no nobility (sp?) in volley EMS.

Anywhoo..... Did the hospital draw labs?

I am thinking there is a big piece of the puzzle missing.

Could be neurological, behavioral, or something as simple as a improper perscription refill.

EDIT: Did you get a temp? Infection presents in many forms in the elderly.

Edited April 14, 2009 by mobey

[CBEMT]

Pt did start having frothy spit as we arrived at the ER and started gaging on that, but it was the first we'd seen of anything like that.

From a BLS stand point, I didn't see much else we could do.

Suctioning would be a start. And since at a BLS level there was nothing else to do enroute except more vitals, that BGL should have been done. Period. What did the tech spend the transport doing? Better not have been his paperwork.

[Katiebug]

You said the patient had recently been to the doc for med changes. Since the behavior is new, it's probably important that the doc knows about it. Any idea what the meds were?

[Just Plain Ruff]

First of all, allow me to commend you for your volunteer work. My hat goes off to all who do this for no pay.

Some important questions I would ask are: does she have a history of high blood pressure? Does this episode look like an episode of dementia? Has this happened before, and if so, what caused it? And I understand there was history of diabetic coma.

With the blood pressure that high, on a diabetic especially, a stroke would definitely be a possibility. Keep in mind that most diabetics suffer from complications such as heart attacks and stroke—the main killer of diabetics. Another important thing to remember is that not all strokes present with the classic symptoms we've all heard of: one-sided weakness, eye deviation, slurred speech and facial droop. Other symptoms include: altered mental status, which could translate into a patient “acting abnormally; inability to speak correctly; severe headache; loss of consciousness and blurry vision, to name a few.

With a sugar of 175, I highly doubt it was a diabetic related issue. A blood sugar of 175 rarely, if ever, causes any symptoms. And diabetic coma occurs with prolonged blood sugar extremes—blood sugar that's either too high or too low for too long, such as diabetic ketoacidosis (DKA) and diabetic hyperosmolar syndrome (a reading of 600 mm/dL); or hypoglycemia—a sugar level less than 80, but coma usually sets in with levels much lower than that.

Obviously, from what I understand, your patient did not suffer any of these since she was released without a diagnosis the second time; however, what I've mentioned are only some things to think about. For now, simply ensure that your ABC's are intact; if they're not, correct them to the extent of your training. And don't get too hung up on "diagnosing" the ailment. Although it's great if you can figure out the cause of the problem, it's not crucial at your level of training.

Well, I hope this helps out a little. Good luck.

With a sugar of 175, I highly doubt it was a diabetic related issue. A blood sugar of 175 rarely, if ever, causes any symptoms. And diabetic coma occurs with prolonged blood sugar extremes—blood sugar that's either too high or too low for too long, such as diabetic ketoacidosis (DKA) and diabetic hyperosmolar syndrome (a reading of 600 mm/dL); or hypoglycemia—a sugar level less than 80, but coma usually sets in with levels much lower than that

I am a type II diabetic, when my sugar gets to 175 or so I begin to have a screamingly severe headache, sweat, nausea and some vomiting. I've not had to call EMS but when I get to that number I know that I have either forgotten to take my glucophage for the prescribed time or I ate something I'm not supposed to.

My sugars rarely if ever get above 125 and 90% of the time run from 75-110. So I do get symptoms with a sugar of 175.

[emsboy_2000]

With a sugar of 175, I highly doubt it was a diabetic related issue. A blood sugar of 175 rarely, if ever, causes any symptoms. And diabetic coma occurs with prolonged blood sugar extremes—blood sugar that's either too high or too low for too long, such as diabetic ketoacidosis (DKA) and diabetic hyperosmolar syndrome (a reading of 600 mm/dL); or hypoglycemia—a sugar level less than 80, but coma usually sets in with levels much lower than that

I am a type II diabetic, when my sugar gets to 175 or so I begin to have a screamingly severe headache, sweat, nausea and some vomiting. I've not had to call EMS but when I get to that number I know that I have either forgotten to take my glucophage for the prescribed time or I ate something I'm not supposed to.

My sugars rarely if ever get above 125 and 90% of the time run from 75-110. So I do get symptoms with a sugar of 175.

Okay, so you get symptoms with a sugar of 175; but I’m speaking in general terms. Let me clarify my point: A sugar of 175 does not generally produce the symptoms (or even considered to be a medical emergency, for that matter) described in this situation. Obviously, not every diabetic shares the same sugar level sensitivity. For example, I’ve known people with average blood sugar levels in the 200’s feeling perfectly fine, while others like yourself fall ill to lower levels. So there you go. Does that make more sense?

I appreciate the comment, ruffems.

[NYCEMS]

First I'd like to say that I also commend you on your volley work. Disregard people like that jerk who had the stupid comment. Now as far as your pt I have a few comments.

1- From what your saying I'm leaning more toward a psyc problem. At her age it could also be possibly altzheimers. Worst case senario a bleed causing the ams.

2- I'd really like to know if she was on any psyc meds. Sometime certian psyc meds taken together for the first time can cause a reaction called " a distonic episode". The pt is usually excited, yelling and drooling when this happens for the first time and there mouths seem to be always open ( cause of drooling).

Other then the elevated BP I see no other problems with her vidals.

Also never ever let anyone tell you not to try and diagnos your findings. I'm an EMT for 17 years with The New York City Fire Dept. Bureau Of EMS and in my job I'm required to give a diagnosis on my report. If you don't try you won't learn. If your wrong so what!! When you find out the answer you'll be ready for the next time a simular incident occures and become a better tech. I'm guessing a medic gave that comment.