Medical problems not to miss that might appear to be a mental health/psych/behavioural issue

[fakingpatience]

High ammonia levels

[BEorP]

Thank you all for the replies. The list here largely lines up with what I planned on focusing on. A couple points of discussion:

Has anyone other than Ruff had any anecdotal experience with strokes presenting with behavioural symptoms? This was suggested to me by someone else who I had spoken with prior to posting but I haven't seen it myself and a quick (but by no means complete) search on the topic didn't reveal much.

Secondly, we have a great list here of important things that should not be missed in the patient's overall emergency care. How many of them do you think prehospital providers should actually be identifying specifically rather than just noticing that there is a serious underlying problem and it isn't "just a psych patient"? For example, there might be a hyponatraemic patient presenting with delirium/agitation/anxiety/perception disturbances. We might be able to suspect an electrolyte issue depending on the history, but since we won't have the bloods to confirm that it seems like it would be sufficient for us to simply identify that there is something going on that isn't a strict mental health issue.

Hypoglycaemia is obviously the other end of the spectrum where there is a clear treatment that can be provided prehospitally and that should not be delayed.

I've rambled a bit, but again my ultimate question now is:

Which of these conditions do you think prehospital providers should actually be identifying specifically rather than just noticing that there is a serious underlying problem?

[Just Plain Ruff]

Hey, the stroke was small in size but it struck in just the place where his behaviour was affected. The stroke team had a difficult decision to make as to either let it reabsorb or evacuate it and in the end the decision was to burr hole a small hole just above the stroke site and remove the blood. That was done, the guy was at the center for about a week and then discharged.

He doesn't remember his violent outbursts but I and my partner sure do.

[paramedicmike]

Had the prednisone psychosis been identified earlier the patient wouldn't have woken up under lock down in the violent patient section of the local emergency psychiatric hospital.

I'm not saying this is the fault (or even the sole fault) of the local EMS-ers. Obtaining a better history from family members who were present would have revealed the medication list and recent steroid treatments this patient had received. As she wound up involuntarily committed it could have also potentially saved a mess of a legal proceeding to get her released.

To be fair, I don't know if the medics even knew about steroid induced psychosis. It wouldn't have been on my differential until I encountered this particular patient.

So, to answer your question, I don't know that prehospital providers should actually be identifying this. However, a thorough history should at least keep it on the differential to avoid wrongly categorizing the patient for delivery to lock up vs the ER.

[Kaisu]

You asked for anecdotes... There was the nun that had localized seizures that manifested with the most foul mouthed expletives emerging from her sweet elderly face that I have ever heard... and I've heard a lot.

Episodes lasted 4 to 5 minutes and the lady had no recollection of her actions afterwards. It had been diagnosed as epilepsy.

[triemal04]

I've rambled a bit, but again my ultimate question now is:

Which of these conditions do you think prehospital providers should actually be identifying specifically rather than just noticing that there is a serious underlying problem?

I think most of them. While it may be hard to say for certain that some are the specific problem (and most will require extra tests that are not commonly available prehospital to be certain) with a good history and physical a competent provider should be know enough, and be able to figure out enough based on the questioning/exam to have them in their differential.

While it leaves out a lot, if you're teaching paramedic students the mnemonic AEIOU-TIPSS is pretty easy to remember, and covers a lot of issues that can cause changes in mental status.

Alcohol

Epilepsy (or seizure disorder, though that ruins the mnemonic)

Insulin

Overdose (very broad, but should start people thinking)

Uremia

Trauma

Infection

Psychosis

Stroke

Sepsis

[Happiness]

My friend had a brain stem stroke. When I first saw him, he was sitting on the stairs crying. His wife said they were just having a normal conversation and he all of a sudden burst into an emotional wreck and said he felt weak.

I did an assessment and it was very weird as every test on both sides were equal, for example grips, eyes, smile. He had no complaints of neck or head pain. At the time I knew that the ambulance was busy with a cardiac case, so I told the wife to take him to the hospital in their car but that they may have to wait.

They did an assessment and sent him home that night.

The next day I was doing a call and the wife came to the nurses station say her husband while in the shower had right sided weakness and couldn't raise his arm to get the shampoo out. He was in the waiting room.

They sent him for a CT scan and when he returned home they said they didn't find any signs of a stroke. I was the attendant that day and as we were unloading him, he saw his mother and burst into tears. I was very shocked because if you knew his mother, you would know this was very abnormal behavior.

The doc was going to release him as the tests didn't show a stroke. I asked to talk to the Dr. in private and she agreed. I let her know that I have known this man for 25 years and I couldn't put my finger on what was wrong, but he was not acting normal. She took me seriously and made arrangements for a MRI.

We then discovered that most times when CT scans are done for strokes they do not scan the brain stem. The MRI is the test that discovered that he did indeed have a stroke.

He is a very luck man as there is a very high mortality rate and the chances are very high to have another one. It has been about 4 years since it happened and the only lasting effects have been he has a slight right arm weakness and is always cold. He use to suffer from bi-polar type of symptoms but has been put on happy pills and it seems to have done the trick.

[DwayneEMTP]

One of my more proud "kind of" catches was a 60ish year old woman who's daughter had called in regards to her difficulty breathing. Before arrival the issues seemed to have resolved. I found no evidence of breathing/lung issues, but during my exam she would sometimes use the word 'dog' inappropriately. "Really, I'm feeling fine now, I was just dog for a few minutes." She didn't seem to notice it. Her diction was crystal clear, balance fine, perfect grammar with the one exception, educated vocabulary, middle/upper income. No obvious physical issues, stroke scale negative. The only other symptom was that she was unusually 'cuddly.' When I held her hand while talking to her she leaned in and gave me a chaste/motherly hug.

When I asked her daughter if either of these things was usual her reply was, "I don't think so..but I'm not sure." I convinced her to be transported for observation, a tickle in my brain that it might be a stroke, but far from confident. Stroke was her ultimate diagnosis.

It's a silly point maybe, but one that's important to me...which is that I think catching such cases has as much to do with your attitude going into a call as with your level of education. In the lady above I'm confident that none of my coworkers at that time would have transported her, in fact, it's likely even noticed the issues. Not because I'm so much better and smarter than they are, but because listening, noticing movements, types of speech, patterns of speech, inappropriate anxiety levels, both decreased and elevated from the expected, etc have just always interested me. But more importantly that I went into the call intending to help instead of clear the scene.

Provider attitude, it seems to me, is a very much overlooked aspect of competent clinical evaluation and diagnosis.

[BEorP]

Great point, Dwayne. Thanks for sharing! Along with that, the other thing we need to consider is how important it is that if the junior crew member has concerns, they need to speak up. All too often it seems that we respect seniority so much that if our more senior partner says it is "just a psych patient" or isn't anything to be concerned about that the senior gets their way even if the junior has a genuine and legitimate concern.

[Just Plain Ruff]

BEorP, I have been "schooled" by a junior partner several times.

One in particular was on a patient who I thought was one thing and he thought was another. He was adamant that we transport to a stroke center when I was sure we needed to just transport to a tertiary facility.

I asked why he was so adamant as to why we go to the stroke center and he said that his uncle presented with a stroke this way. I asked why he didn't say anything to that affect rather than just say "you need to take him to a stroke center" and he said he was afraid to speak up further.

Turns out the guy was having a stroke.

So all of us OLD dudes/dudettes need to listen to our younger partners. Not only might they be treating us one day, but they sometimes have some good things to say. My partners insistence likely saved this guy some persistent issues.