DwayneEMTP Posted February 15, 2012 Posted February 15, 2012 I'm going to try and get better at posting scenarios, and maybe others can too? They're so valuable... 22 year old male Papua New Guinea native. Coworkers call to say that he's been acting strangely since lunch. He's fidgety, turning the ceiling fan off and on, he seems to be making strange expressions with his face. Four or five times/min he reaches across with his left hand and seems to be grabbing his right ribs. Today he was working in the 'gold' room. I'm unclear exactly what that is other than it's super secure and because of that his coworkers complain that 'the air is sick there.' It also requires him to stand on hard concrete with very little movement for nearly all of 12hrs, which they also believe causes this type of sickness. They said that they were going to bring him to the clinic themselves but when they tried he claimed that he couldn't walk. U/A pt is seated in his office chair in the accounting office. He's a 27 year old male, well groomed, appears in good shape and well nourished. He focuses on me when I enter the room with a good humored, though distracted affect. He has no trouble understanding me nor responding in clear, appropriate speech. Sitting in his chair he's unable to sit still. There are two water bottles on his desk that he keeps arranging in different places, switching their places, standing up and putting in his pockets, then back on the desk and sitting down. When he stands to put the bottles in his pocket his balance seems intact and the next time I ask him to sit in another chair across the room and his gait is even and confident. Skin is P/W/D/Afebrile, pulse 62/full/regular, b/p 156/106, resps 16/full/clear all fields, pt appears, and reports, being atraumatic globally. No daily meds, no traditional treatments, no significant history other than being in the clinic 10 days past with difficulty breathing. He was sent out to a local hospital where they found nothing conclusive, no allergies. What do you think is going on? Dwayne
Kaisu Posted February 15, 2012 Posted February 15, 2012 neurological symptoms.. I would guess heavy metal poisoning...
DwayneEMTP Posted February 15, 2012 Author Posted February 15, 2012 I'd considered that too....But how to know? Next level of care is the Lae hospital, about 4hrs drive from here. No chance of getting a helicopter for this patient. Think of the least sophisticated rural bandaid station hospital, and then go below that about 30% and you'll have an idea of the level of care there. Not trying to be facetious, or disrespectful to them, but accurate.
ERDoc Posted February 15, 2012 Posted February 15, 2012 What kind of work facility is this? What sort of testing can be done (labs, imagining, etc)?
Eydawn Posted February 15, 2012 Posted February 15, 2012 What was he treated with for the SOB? He's not the first one to develop these symptoms, I'm gathering, as his coworkers say the working environment "causes these symptoms"? My first thought was potentially a stress reaction manifesting as anxiety which he is self-soothing with repetitive behavior. However, my hubs, who has the degree in psych (and is also an EMT- *ALSO* immediately said "heavy metals!" So I'm betting he's right. Check at cuticle bases... take scrapings/hair samples, see if you can get it tested... also if there's others who have had/do have these symptoms, be interesting to see their presentation and if they started to resolve or not without treatment... Wendy CO EMT-B
DwayneEMTP Posted February 15, 2012 Author Posted February 15, 2012 What kind of work facility is this? What sort of testing can be done (labs, imagining, etc)? This is an open pit gold and copper mine in PNG. No testing on site that can't be found in an ambulance. I don't believe there is any thing more than that at the hospital with the addition of xrays. Treatment would have to be done in Port of Morsby, but that's not going to happen for this patient. The patient is in finance, so should realistically have no direct contact with the metals. Water standards are monitored fanatically, not only for camp safety but as part of the contract for the local tribes to assure their water is not being damaged by the mining. What was he treated with for the SOB?... Valium. Yeah, I'm not sure why unless they suspected anxiety. Which was at the top of my differential originally. That treatment was 10 days past. ...He's not the first one to develop these symptoms, I'm gathering, as his coworkers say the working environment "causes these symptoms"? Though I see where you're going, that can't really be assumed. Many of the places that I've been the locals have believed that a cool breeze, from the air conditioner or a fan causes untold numbers of seemingly unrelated pathologies. This patients said, 'I thought that if I could just poop, or fart, that I could get rid of the toxins and I'd be ok." Pooping and passing gas had no effect on symptoms. The point being that their diagnosis likely has more to do with their opinion of 'bad air' than the patient symptoms. The same diagnosis would likely have been offered for hair loss, runny nose, acne, and pregnancy. Oh, probably not pregnancy. ...My first thought was potentially a stress reaction manifesting as anxiety which he is self-soothing with repetitive behavior... Mine too.... ...However, my hubs, who has the degree in psych (and is also an EMT- *ALSO* immediately said "heavy metals!" So I'm betting he's right. Check at cuticle bases... take scrapings/hair samples, see if you can get it tested... also if there's others who have had/do have these symptoms, be interesting to see their presentation and if they started to resolve or not without treatment... No symptoms of the nails. No chance to get this patient tested for it, as mentioned above. But, I'll tell you this, that if you don't figure this out that this patient will almost certainly die. Dwayne Edit: In case you're thinking that this is some sort of freakish Nigerian Butt Slug answer or something..it's not. Though it made me a little batshit for a bit. I did ultimately figure this out on my own. Just so's you know I'm not cheating.
Eydawn Posted February 15, 2012 Posted February 15, 2012 Well, shit. You don't die from anxiety, so that's not the major problem. Can you give us the hint of how LONG we have to figure this out before the patient dies? Days? Weeks? Or tonight, if we don't get our shit in gear? Full physical exam. Abdominal exam, what's his poop look like, bowel sounds? Aortic turbulence? Vomiting/abd pain? Heart sounds? Discoloration anywhere on his body? Vision/cognition changes that he's aware of? Can he explain why he's fidgeting/moving stuff around? Change in food? Eat anything strange, by chance? Misidentified mushrooms, perhaps (or other local flora)? Wendy CO EMT-B
DwayneEMTP Posted February 16, 2012 Author Posted February 16, 2012 Well, shit. You don't die from anxiety, so that's not the major problem. Can you give us the hint of how LONG we have to figure this out before the patient dies? Days? Weeks? Or tonight, if we don't get our shit in gear?... It varies between patients, but I've been told by a doc I contacted after between 5-15 days. ...Full physical exam. Abdominal exam, what's his poop look like, bowel sounds? Aortic turbulence? Vomiting/abd pain? Heart sounds? Discoloration anywhere on his body? Vision/cognition changes that he's aware of?... All unremarkable. ...Can he explain why he's fidgeting/moving stuff around?.. He at once claims that he's not fidgeting, and then next says that he can't stop and doesn't know why. Though he really doesn't seem to notice that he's doing it. I believe he started answering "I don't know" because I kept asking him and he was tired of saying, "I'm not." Pt states that his skin, muslces, joints, have no discomfort, no headache, dizziness, loose stools. No discomfort of any time other than his chest/insides feeling muddy. And he keeps wrapping his left arm around to his right upper ribcage, but again, claims he's not doing it when asked. Facial expressions are strange...think tweeker. ...Change in food? Eat anything strange, by chance? Misidentified mushrooms, perhaps (or other local flora)?... Excellent questions, as I've run into people chewing beetle nut here and it can present wierd. But it also stains the teeth and lips bright red. None of that here. I truly explored this exhaustively, to the best of my ability, as i didn't have a friggin' clue where to go, and couldn't find anything out of the ordinary. He at the mess hall food same as the rest of us. I even gave him a drug screen. Negative.
ERDoc Posted February 16, 2012 Posted February 16, 2012 Has he been eating with any of the local tribes?
DwayneEMTP Posted February 16, 2012 Author Posted February 16, 2012 Has he been eating with any of the local tribes? It's unlikely. But if so, the tribes actually have a very low incidence of food born issues, if that's what you mean. They've lived as they do for so long that most of the nasty stuff can't sneak past their immune systems.
Recommended Posts