Stumped

[rdelisle]

This call we went on this morning has me stumped. We arrived to find a male early 70s only complaint is from the family stating patient was hard to rouse after drifting off for a nap while sitting on the couch. Vitals were Bp 150/80, pulse 56, respiration 12, BGl 4.9, pupils 4 and perl, temp read as low on our tympanic but patient's skin was normal and unremarkable, 3 lead showed NSR. I did a thirty second stroke (cincinatti) scale and found no deficits. Patient staggered slightly when trying to walk but otherwise unremarkable. Only meds are lasix, asprin, metoclopramide(?), and med for prostate cancer. Patient treated for Atrial fib five years ago with no relapse and no othe hx. Only other symptom was patient slept for 30 minute transport and woke when spoke to. I even asked about ETOH and recreational drugs with negative to both. Patient plays golf x2/week and works out in gym x3/week. Any guesses as to what might be up or if I missed anything.

[itku2er]

It looks like you had all the information and didnt miss anything. Could be a slight TIA or something like that. He hadnt had a recent infection of any kind did he?

[akflightmedic]

Hmmmmm.....

Sounds like a normal 70ish year old. Hell I am difficult to wake sometimes as well, dont we all have those times?

Why does there always have to be a medical problem? Why can't people just get old and be left alone as nature intended?

We do not always win despite our best efforts...

[itku2er]

Good point AK sometimes old people just need to nap. They do it all the time at the NH. when I get old and want to nap you bettter let me

[medic001918]

Hmmmmm.....

Sounds like a normal 70ish year old. Hell I am difficult to wake sometimes as well, dont we all have those times?

Why does there always have to be a medical problem? Why can't people just get old and be left alone as nature intended?

We do not always win despite our best efforts...

My thoughts exactly. I've been in a deep sleep and hard to wake up. And sometimes when I get up, I'm a little off balance or don't move that quick due to old injuries and such. Doesn't really sound like he had any problem...other than being tired. I don't think you missed anything. Not every patient that has 911 called for them has a problem.

Shane

NREMT-P

[Doczilla]

Metoclopramide is sold under the brand name Reglan. It's for nausea, gastroesophageal reflux, diabetic gastroparesis, migraines, or other problems.

AK, I'm assuming that some knucklehead got hold of your login information, and you are, as we speak, pummeling him with a brick. You too, Terri.

There are several potentially disastrous causes that have to be considered.

Infection. First on my list. All elderly people in my ER get a urinalysis no matter what they came in for.

Metabolic derangement. Sodium problems (hypo or hypernatremia) can present this way. You were correct to check the blood sugar. He's on lasix, so electrolyte disturbances are possible.

MI. Global weakness is not an uncommon presentation of MI in the elderly. Worsening CHF will also do this.

Hypoxia. Must be ruled out with a pulse ox, preferrably on room air and watched over time.

Renal failure from any number of causes. Azotemia will cause the symptoms you describe. You know he's at risk for this because he has hypertension.

Drug overdose. Elderly folks with questionable renal function can easily accumulate toxic doses of several medications, so it can be more of a chronic thing. Also, slight decline in neuro function can lead to a medication mix-up, either taking too few, too many, or the wrong ones.

Intracranial problem. Smouldering subdurals can present as your patient did.

Liver failure is somewhere on this list. Elevated ammonia level will cause somnolence and ataxia.

Anemia. A slow steady GI bleed from a cancer or ulcer could deplete the RBC count without notice. Anemia is common in the elderly also from poor dietary iron intake, stomach or intestinal problems, or poor RBC production in the bone marrow.

Bottom line: subtle signs and symptoms in the elderly can herald a potentially life-threatening problem. It should be worked up. I would NEVER encourage this patient to refuse transport, and would allow him to do so only if he flatly refuses while knowing all the risks. And if he's somnolent, I am invoking implied consent and transporting him against his will.

'zilla

[akflightmedic]

Nope, no knucklehead got my info. I will own up to this one and I still standby it.

Yes, I see your point with all the differentials and yes I agreee 100 percent not to overlook the subtle signs of a more serious underlying problem.

However, sometimes we just dig way too deep. It was the family that initiated the call, which is fine as your loved ones are sometimes more acutely aware of subtle changes before you are, but my point was I am tired of being called for every little bump, bruise, or variance in behavior.

Maybe I am just a wee bit jaded at the moment, life views changing, philospohies, who knows. It just seems like so much overkill and the biggest issue is we run to 911 for every unknown no matter how benign it is, when just a few decades ago it all would of been treated as "just life".

Sometimes there is NO cause or reason for what is occurring. In this case, it very simply could of been foghead. I have been that way many times.

The medic did a good job, checked everything he could prehospitally. I never recommended deferring transport, but he could have just as easily went with family instead of ambulance and maybe even called his personal doc to see if an appt was available.

Sorry if I am not full of vhim and vigor but man, let the guy be....lol.

Who wants to live forever???

[Just Plain Ruff]

Case in point guys, today I went to see my grandmother in the nursing home. She was asleep, I woke her. It took her a full three or four minutes to fully get to alert status.

I knew better but someone who didn't might say OMG, Call 911 shes having a stroke or something.

I agree that we read too much into things but Doc is right, differentials here.

so what happened to the old bird?

[rdelisle]

Hi all. I called the ER later on in the day for an update on the patient. He had remained drowsy while in the observation bed and it was discovered he had undergone home cardiac telemetry monitoring two weeks prior with nothing found. However, the ER Doc was just as stumped as myself and after running a 12 lead (negative findings) and blood work (again zip) patient was released. Thanks for all the info both pro and con to transport. Up until the patient stood up I had been contemplating leaving him at home as he was refusing transport. After I seen the stagger I "mentioned" that the patient was more serious than first suspected and "advised" transport.

[DwayneEMTP]

Actually this case brings to mind, (was it AZ?), that said something to the effect "you will find that stable patients can be much scarier than unstable patients"

If this gentleman had been in just a little worse shape (positive stroke scale, positive cardiac findings, less mentation, etc), many answers would have floated to the top, allowing you back into your comfort zone.

Being just slightly off seems to have made things much more difficult by cheating you out of a clear cut (or even fuzzy) set of differentials to hang your hat on...Pretty interesting...I hadn't thought along those lines before...thanks for your post!

Have a great day all.

Dwayne