WADAO with N/V/ HA

[Ace844]

[marq=up:f1dd79318d]*** PLEASE FOLLOW THE GUIDELINES AT THE BOTTOM OF THE POST WHEN YOU PARTICIPATE, I AM DOING THINGS AND ASKING YOU TO DO THIS WAY FOR A REASON, THANK YOU!!!!!*****[/marq:f1dd79318d]

You are working in a combo half urban half suburban dual response EMS system ( which is quite progressive and gives you all the toys you wish you could have). You have just sat down with your coworkers to enjoy a nice mid-morning "viewing" of Lucky # Sleven. you are enjoying your post sit down breakfast high with a coffee when shortly after the first 5 minutes of the movie you get toned and dispatched for a call..Theres a surprise..... :?: :!: :?:

[marq=left:f1dd79318d]"This is ******* FD brocasting a still alarm for E-1, A-52, P-26, to 5222 River ST on the 2nd for a 22yo F not feeling well."[/marq:f1dd79318d]

You arrive in a nice suburban neighborhood to at the same time as the PD, and fire. Mom meets you just inside the door and says

My daughter is really sick. She's weak and dizzy all over, shes in her room and has been getting worse over the last 36 hrs...we want her to go to ______ General

You bring all of your equipment to the second floor where you find your patient lying supine on her bed. Her mom tells your partner the followign info.; your pt has a hx of ectopic pregnancy (5 mos ago), HPV, migraines, and she smokes. She takes birth control pills and imitrex for the migraines, and has no known allergies.

Upon patient contact you find an obese 22yo patient with pale, hot dry skin, writing on the bed holding her head, and her eyes are tightly shut. You initally gather the following information. She started feeling weak and dizzy about a day and a half ago. This was followed by consistent migraines which she has been unable to relieve with tylenol, alieve and imitrex. Last night she states she started vomiting ( has vomited 4x total large amounts)and noticed that she was having trouble seeing, as well as occasionall loud pounding in her ears. When she tries to stand she states she feels very dizzy.

What is going on here?

Why do you think that?

What else would you like to know?

What are your assessment ?'s.

Whats your clinical impression?

If your an ALS provider; how would-do you utilize your BLS?

Do you triage down, and clear, or ALS the patient, and why?

What do you do for this patient and why? I want to not only know the treatments you would do, but why you chose those options over any other. YOU ARE WRONG (EVEN IF YOU ARE RIGHT) IF YOU DON'T EXPLAIN YOUR ACTIONS. The purpose of this is to make sure not just the "this is what we do" but the "this is why we do what we do" of EMS. Also list any questions and their relevace to your assessment. What's your DDX? IF your BLS what's you Rx, ALS, list yours as well...

Let the scenario begin.....Good luck,

ACE844

[whit72]

Does she have distorted vision or sensitivity to light?

[Ace844]

Does she have distorted vision or sensitivity to light?

Kindly reference the points below...

What is going on here?

Why do you think that?

What else would you like to know?

What are your assessment ?'s.

Whats your clinical impression?

If your an ALS provider; how would-do you utilize your BLS?

Do you triage down, and clear, or ALS the patient, and why?

What do you do for this patient and why? I want to not only know the treatments you would do, but why you chose those options over any other. YOU ARE WRONG (EVEN IF YOU ARE RIGHT) IF YOU DON'T EXPLAIN YOUR ACTIONS. The purpose of this is to make sure not just the "this is what we do" but the "this is why we do what we do" of EMS. Also list any questions and their relevace to your assessment. What's your DDX? IF your BLS what's you Rx, ALS, list yours as well...

To answer your question she has transient scatoma, and occasional diplopia

[tinman694]

Look at the combination of past hx, meds and smoking---

assess neurological---Symptomatic of PE or poss CVA?

Pt. would be ALS--Utilize BLS for initial care, assistance with assesment and pt.movement--

IV, o2, Monitor and transport---I mean really...why would you want to stay and play?

Pt. could have variety of problems beyond what we need to worry about--we treat...but we do not Diagnose

And what is up with the equipment? Not gonna drag the truck up 2 flights on a Gen Med....

[TechMedic05]

What is going on here?

- Well, after a few questions and assessments I'd hope to put my finger on it. Right now, I'm leaning towards SAH

Why do you think that?

- Only cool things get posted on scenarios? just kidding --> Onset is questionable [detailed questions below] - however the 'migraine' without relief is not exactly a good sign, as well as the assumed weakness, dizziness and nausea she is experiencing.

What else would you like to know?

- Oh, lets see: What were you doing when it happened? What did the patient do yesterday? How did this start [Gradually or suddenly]? 0/10 pain at onset, and presently. Has their been any relief? Anything making it worse? Any association of movement with nausea? Photo-phobia? Any syncope? Any urine output? Any other past medical history? Specifically HTN, DM, SZ?

What are your assessment ?'s.

- Airway, RR, pattern, depth, LS, Pulse, Skin color, temp, turgor, lesions? Vital Signs - HR, BP [and orthostatic if patient is tolerant/ able to - partially dependent upon answers from previous questions] Monitor- fsbs, pain in calves?

Stroke scale [to local preference] We use Cincinnati around here - Facial Droop, Arm drift, Slurred speech. Pupils, able to track equally?

Whats your clinical impression?

- Depends upon some assessment findings. DDX below

If your an ALS provider; how would-do you utilize your BLS?

- Hate to be picky - but depends. If they were on scene first, Take report, and help them to continue to assess, and involve them in further assessment. And depend ant upon the system you work in, direct them to assist with monitor lead placement and/ or IV preparation [setting equipment]

Do you triage down, and clear, or ALS the patient, and why?

- sounds awfully ALS to me. As stated, a lot depends on assessment findings, however: This patient's differentials include CVA, SAH, viral infection/ meningitis, dehydration, or heat illness [being heat stroke or exhaustion], on top of migraine cluster headache, just to name a few. Not being able to completely rule out [as of yet] many of those, and have several [3, right off the bat] risk factors [Obesity, smoking, BCP use] for CVA, is enough to 'work it up', for potential degradation of patient condition.

What do you do for this patient and why? I want to not only know the treatments you would do, but why you chose those options over any other. YOU ARE WRONG (EVEN IF YOU ARE RIGHT) IF YOU DON'T EXPLAIN YOUR ACTIONS. The purpose of this is to make sure not just the "this is what we do" but the "this is why we do what we do" of EMS. Also list any questions and their relevance to your assessment.

- Currently, assessment as stated - to find what we have. Establish IV access - Depends on what we have - Currently, an IV lock until the necessity of IV fluid is known. Provides access. Again, this is if assessment warrants ALS Tx. If so, an IV gauge that your receiving ED prefers - understanding a possibility of contrast CT. Oxygen - Nasal cannula - Just some supplemental O2 - depending on my diagnosis - reasons could be increasing Oxygen, lowering C02, providing a minimal amount of cerebral vasoconstriction to hopefully lessen a bleed, or damage. Increasing oxygenation to all tissues. If Hypovolemic in nature, to help correct a likely metabolic acidosis through increasing O2 and decreasing C02. Again, lots of reasons - depends upon diagnosis.

Yes, we do diagnose. If we do not diagnose a problem, how can we treat it?

Regarding the mother's hospital choice - If this is where I think it may be - If ___________ General hospital happens to only be a few more minutes to the west, and have 24 hour Neuro available, on the Statewide Stroke Point of Entry list, I'd think it's a good idea. especially if the hospital in town is a smaller community hospital.

What's your DDX? IF your BLS what's you Rx, ALS, list yours as well...

All as stated above.

just taking a stab.

[JPINFV]

Lets start with the basics here. LOC, V/S (temp, BP, pul, resp rate [rate and quality where appropriate], rythum), recent sexual activity (patch doesn't rule out pregnancy), family hx of cancer, any other family history, drug use, try any new foods recently, blood in the vomit? [need information before developing a list of DDX].

DDX: Cancer (HPV), infection (skin signs, headache, nausea/vomiting). There isn't much to go on yet, but that would change.

Tx: NRB 10LPM, bilateral axillary ice packs, forehead ice packs (hot, dry skin is never a good sign), IV with a large bag of NS (possible dehydration, plus relatively cold).

BLS utilization would be as an organic blood pressure machine, this is a sick girl who needs ALS.

To answer your question she has transient scatoma, and occasional diplopia

Sure it's scatoma and not scotoma? I'm more then a little curious on how you know it's scatoma from checking her pupils (are the pupils a little bit more brown then normal?).

Pt. could have variety of problems beyond what we need to worry about--we treat...but we do not Diagnose

And what is up with the equipment? Not gonna drag the truck up 2 flights on a Gen Med....

1. Its fun to work the patient like this. In real life, the patient probably needs more rx, studies, and tx then even the most progressive system can provide. This is happy land, though, with a complete lab and radiology department in your ambulance (unless I'm misreading the "every toy you could ever want" phrase).

2. You carry nothing. That's what the PD and basics are for

3. Everyone makes a differential dx, unless you're playing monkey see, monkey do. It might be as simple as, "the pt is hot, slightly confused, and pale, she might have an infection, so..." but it is still a DDX. The "but but but, we don't diagnose" needs to go in the same bin as "basics save paramedics" and "diesel bolus".

[MedicRN]

What is going on here?

Could be about anything from a horrible migraine to a cerebral aneurysm to brain masses.

Why do you think that?

Given her hx of smoking and taking BCPs, she's at high risk for blood clots. HPV can cause brains and encephalopathy. She's showing severe migraine-like symptoms (which appear to be refractory to her prescribed meds) which incidentally are also general s/s of increased ICP.

What else would you like to know?

Is the BCPs and Imitrex the only meds she takes? Any antivirals? Illicit drug use? Pregnant again?

What are your assessment ?'s.

Onset? Symptom progression? Thorough neuro exam - any deficits? (other than the scatoma (shit for brains)?? - or is it scotoma (diminished vision)?), Anisocoria? Gaze deviation? Sided weakness? CPSS or LAPSS score (if applicable)? Vitals (especially BP and HR)?

Whats your clinical impression?

See above

Do you triage down, and clear, or ALS the patient, and why?

Unless the hospital was a 5 minute transport, I feel I'd have to make this an ALS call. Something about this girl just doesn't feel right. Call it gut instinct.

What do you do for this patient and why?

I would make her as comfortable as possible (duh!) and do what I can to relieve the pain and nausea. However, I doubt med control would approve of morphine (or nubain) or phenergan due to the potential of skewing the neuro exam. If she were to become obtunded, obviously assess her ability to maintain her airway and intervene as necessary. These are in addition to IV with NS TKO (or better yet, locked) and O2. Transport to a facility with neuro/stroke care (neurologist staffed as well as CT and MRI available in-house) capabilities is extremely preferred.

[Arachne]

It's "scotoma", not "scatoma". A "scatoma" is an accumulation of feces that appears to be a tumor (http://www.fasthealth.com/affiliates/h_ths_nm/dictionary/s/scatoma.php).

To save others the trouble of looking those words up: Scotoma is a blind spot, and diplopia is double vision (from www.thefreedictionary.com)

As to the patient:

Vital signs? (Do I need to explain why I want to know those?)

Equal grip strength? How are her pupils? Confusion? Any other signs of CVA/TIA?

What was happening before all this started? Was she sick? Was there any trauma? (just ruling things out)

Is she orthostatic?

Dizziness, vomiting, visual disturbances and head pain are all indicators for some sort of problem in the brain. As mentioned above, the combination of smoking and BCP raises her risk for blood clots, which could occur or travel to the brain, so I would be considering that as a possibility, which is why I'd like to know about the grip and pupilary response. I'd want to know about recent trauma and what was happening when this all started because a head injury could also cause these symptoms.

I'm also wondering if this is some sort of hypovolemia issue (hence the question about orthostatics) - the vomiting, dizziness and visual and aural disturbances could be related to this. Perhaps not if she has those symptoms while lying down as well, but it's something I'd want to consider.

BTW - that service doesn't run dual response anymore. For a patient like this one, they'd probably just have send A52 for "the transport" - they'd be lucky if the dispatcher was motivated enough to give a CC.

EDIT: Apparently a bunch of us are writing at the same time - there are some entries that already cover some of this that weren't there when I started. My apologies for the redundancy of some of this.

[Ace844]

“Techmedic,”

Great response and I would expect nothing less from you, thank you for doing as asked.. Now to answer your questions.

What is going on here?

- Well, after a few questions and assessments I'd hope to put my finger on it. Right now, I'm leaning towards SAH

Excellent first thought, certainly in the top 5 of the DDX for this pt.

Why do you think that?

- Only cool things get posted on scenarios? just kidding -->

I wish I could know about those cool medical cunditiones, but we didn’t all go to the ‘tech’ hahaha..LOL, JK

Onset is questionable [detailed questions below] - however the 'migraine' without relief is not exactly a good sign' date= as well as the assumed weakness, dizziness and nausea she is experiencing.

Good point, care to carry that further?

She was walking with her boyfriend down the road smoking; she felt weak, and dizzy then got this loud rhythmic pounding in her ears. She had to sit down for 10 mins. Then, was able to continue. The sx’s resolved and later came back as mentioned in the first post while watching TV and drinking coffee and smoking cigarettes.

Discomfort initially was a 4, then the symptoms were transient through the first night. On day 2 they became constant and worsening. Now the discomfort is a 10.

Position, and exertion. When she tries to stand or sit up ‘things just get terrible’ The patient has not tried to do either of the preceding in the last 6 hrs because of perceived discomfort. Also when she tries to stand and move she has some vertigo type sx’s and occasionally the ‘rhythmic pounding’ returns.

No photophobia, but she does have transient scatoma, and occasional diplopia.

[Ace844]

“JpinVA”

Lets start with the basics here. LOC, V/S (temp, BP, pul, resp rate [rate and quality where appropriate], rythum),

L arm B/P: 190/100, HR: 116, RR 26, Normal TV breaths, and normal regular pattern.

recent sexual activity (patch doesn't rule out pregnancy), family hx of cancer, any other family history, drug use, try any new foods recently, blood in the vomit? [need information before developing a list of DDX].

Has been having sex with Bf regularly for last 4 mos, she started the birth control regimen after the ectopic in the hosp, family Hx of colon CA and breast CA, no new foods or detergent changes recently, no blood in vomit

DDX: Cancer (HPV), infection (skin signs, headache, nausea/vomiting). There isn't much to go on yet, but that would change.

Good first list.

Tx: NRB 10LPM, bilateral axillary ice packs, forehead ice packs (hot, dry skin is never a good sign), IV with a large bag of NS (possible dehydration, plus relatively cold).

BLS utilization would be as an organic blood pressure machine, this is a sick girl who needs ALS.

Ok, any other ALS Rx’s you think are necessary or would like to do?

Sure it's scatoma and not scotoma? I'm more then a little curious on how you know it's scatoma from checking her pupils (are the pupils a little bit more brown then normal?).

She realtes visual field defects and seeing spots, since this is a medical professional forum I used the term scatoma, but misspelled it, sorry…At that point no one had checked her pupils yet, but here’s your exam:: pupils track equally, are sluggishly reactive, at approx 6mm bilat, but pt notes she does have transient scotoma, and occasional diplopia.

Hope this helps,

ACE844