New to the Forums---a scenario that gave me some problems.

[Juilin]

Hello,

I am relatively new to EMS and just discovered the forums here a few weeks ago. I've been scrounging around and finally thought it would be good of me to maybe contribute to a little discussion, ask a few questions, or at least make a nuisance of myself.

I would like to give you guys a little scenario and get some input on it. Me and my partner had some problems.

About a month ago we arrived on scene to a 65 year old male ALT LOC. The patient lived alone with hired help that would come and do his laundry, make food, etc. etc. The origin of the call was from his a niece who had been attempting to contact him for some time and were unable to get him to answer his home telephone. Concerned, she called 9-1-1.

Upon entering we find him aimlessly walking around in a soiled (food, urine, stool, whole 9 yards) robe. He would repeat the same routine: walk to the couch, sit, ask one of us to help him stand walk to another location of the house, sit, and once again ask one of us to help him stand. It was almost a ghost like trance. Alert only to name. Appeared to be breathing normally, had an incredible amount of edema about mid thoracic down to the feet which was secondary to what we gathered from the niece to chronic liver failure and being treated with meds and routine hospital visits for drainage. Other than that we were not able to get much information at all other than he was normally much more lucid and appeared to be in a significant amount of pain.

I work in a tiered response system, so I am normally BLS transport for a patient that has already had the Fire Department on scene for some time. I am still trying to work out the first responder "jitters" (for lack of better term) and would like to see how you guys handle this patient as a first on. Many thanks.

Juilin

[medic001918]

As a first responder/bls provider the best thing you can do for this patient is to try to get as detailed of a history as possible. What is this patients baseline mental status and health like? Where are his healthcare providers? If the patient won't really answer any questions for you, you'll have to do some searching in the house for any clues. Search for medications that might give you a hint as to what's going on. Take a complete set of vital signs and perform a thorough assessment. Does he have a head injury from a fall that is causing the mental status changes? You could try to put the patient on oxygen if he'll cooperate with you and is tolerant of it. It sounds as though he already has a complicated medical history.

As an ALS provider, this is a patient I'd work up to see if I can find anything wrong with him. Thorough assessment is vital once again. Vital signs, lung sounds, ekg, blood sugar, etc. Treat what I find (if anything). This patient could also have some infectious process working against him and is now going septic causing the altered mental status. Supportive care is probably going to be the best care provided prehospitally.

Shane

NREMT-P

[Ridryder 911]

First welcome to the City !

From the information you given sounds like the gentleman may have multiple medical problems. Definitely as you described liver/hepatic problems. He might have associated electrolyte and ammonia levels as well, causing other problems, or may even have onset of dementia.

These type of patients are getting to become more common as the mean population increases. We (EMS) will see more & more multiple medical scenarios. We usually call them "train wrecks" due to complexity of the case. I am sure he was treated for more than one diagnosis.

I truly believe that EMS needs to start focusing on medical emergencies (diversified) as the as run volume increases with these type of calls. As the population ages, these type of calls will be the norm.

Be safe,

R/R 911

[ERDoc]

Hepatic encephalopathy, or at least close to it.

[Ridryder 911]

LOL.. That was I was thinking too Doc.. but, the door is so open...

R/R 911

[Dustdevil]

Probably a little steroid psychosis on top of it all, just for good measure.

[WelshMedic]

Not forgetting:

Korsakoff's

Ascites due to end-stage liver failure

WM.

[als_medic_uk]

So I gather this person was an alcoholic, although no-one mentioned the odour of alcohol, never the less, one has to realise that many as people grow older [a large percent of the population] we have to change in order to prepare, we don't want manifestations, we want understanding.

Many people, have a care-less attitude when it comes to the elderly, especially the mentally impaired elderly, these people require individual care, otherwise you end up with a patient like the one described. These patients, need a care assistant to come 2-4 times a day, with this in act, the level of need/stress on the EMS structure will be reduced. People are left to rot, literally, with more and more cases ever so more present.

As for Korsakoff's syndrome, as someone mentioned, what gave you that diagnosis?, deficiency of thiamine, and encephalopathy rolled in one, lol, you must have just read your neuropathology book, and there is/was a contradiction.

Regards.

[Juilin]

Thanks for the replies.

I already learned some new terms I didnt know about, ie steroid pychosis, in fact I just had this incredibly anxious 21 year old who thought she couldnt breathe while putting together 120 word sentences. She was on Flonase and Prednisone. ^^

Anywho, for this last patient I gather the best thing I could have done was Assess baseline LOC, make sure the ABC's were in order with a quick glance (he was walking around and in no obvious distress) and gather the best history I could. The thing that was difficult was that he would literally not stop moving and would not tolerate VS, O2, an exam, or answer any questions.

The best part was he lived up four flights of stairs and everytime we tilted the stairchair back he would scream and flail around as if we were twisting his head off. Eventually we got him to walk down, albeit very very slowly. Thanks for the help!

Juilin

[WelshMedic]

ALS-Medic,

Do me a favour and read the last few posts that you've written since you've been here. You seem to have made it a sport of blinding people with your fantastic knowledge base and then kicking them in the teeth with some snide comment. Just remember we're all here to learn something from one another, whatever level of provider you are. Your attitude, frankly, stinks. I'm sure you are a very knowledgeable person, but as long as you keep the attitude then I'm afraid not many people are going to listen you.

I mentioned Korsakoff's only as a possibility, I didn't make a diagnosis, I can't do that from a PC 5,000 miles away from the patient. But I'm sure you already knew that, didn't you?

WM.