# Whats going on here?



## Longo118 (Sep 16, 2010)

Hello everyone, Just recently I went on a call. Came over dispatch as abdominal pain, I arrived on scene with a 59 y/o male complaining of a "groin pain". Got one emt to do vitals while I questioned the pt. Said he was working all day in his yard and building a shed, went into his garage and dropped something out of his hands and when he bent over to pick it up he felt a sharp "snapping" pain in his groin and went inside and called 911. He said he pulled his groin before and had a hernia but  it didn't feel like those types of pains. The pt was cool, pale and  clammy with a BP of 170/90 and a pulse of 98. Pt also stated he was dizzy and his head felt "loopy" and "out of whack". No allergies or past cardiac hx. 

Off of this knowledge how would you guys treat this? And what the hell is wrong with this guy?

I ended up transporting with cold pak on his groin, was going to take second set of vitals but he lived 5 blocks away from hospital so couldn't get that.  

I'm a new EMT and I was all alone with this guy so I'm looking just for some insight from you guys, if I missed any other important info to tell you guys let me know.


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## medic417 (Sep 16, 2010)

Did you expose him and see if anything was swelled, discolored etc?  Did you palpate groin for temperature of region, pulsating masses, etc? 

Did you consider that something may have torn, ruptured internally and he was bleeding out and vitals were high from compensating?


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## Longo118 (Sep 16, 2010)

medic417 said:


> Did you expose him and see if anything was swelled, discolored etc?  Did you palpate groin for temperature of region, pulsating masses, etc?
> 
> Did you consider that something may have torn, ruptured internally and he was bleeding out and vitals were high from compensating?



I took a look, no discoloration or swelling but I did not palpate, he told me it was not sore to the touch so I figured it was more internal. One of the EMTs did bring up the possible idea of an MI, due to his skin condition and blood pressure etc. Plus an MI being a referred pain, but for an MI can they have pain in leg? I know they can in other extremities but I never head of it in the leg


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## jjesusfreak01 (Sep 16, 2010)

Longo118 said:


> I took a look, no discoloration or swelling but I did not palpate, he told me it was not sore to the touch so I figured it was more internal. One of the EMTs did bring up the possible idea of an MI, due to his skin condition and blood pressure etc. Plus an MI being a referred pain, but for an MI can they have pain in leg? I know they can in other extremities but I never head of it in the leg



MI pain can be ANYWHERE, but if the patient described the original incident as a tearing pain in the groin, that probably wasn't from an MI. Its entirely possible he could have been having an MI when you got to him, but the original pain was almost certainly from something else.


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## Akulahawk (Sep 16, 2010)

If by groin, you're referring to the upper, inner thigh region... I'd likely have palpated the region and checked for distal CSM. Why? I'd be looking for swelling/discoloration (possibly not likely visible in the short time from occurrence to your arrival) and feeling for deformities in the musculature, specifically no tendon or muscle where there should be or possibly for pulsatile masses. The other thing is if he's got an aneurysm in that leg, it could very well decrease blood flow distally. There may not be much room for blood to collect, depending upon the location. If it's NOT that particular area, I'd be more worried about the possibility of a rupturing aneurysm. Sounds like you did right, and got him to an ED for them to begin to evaluate his problem.

Hopefully, it's nothing serious.


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## Veneficus (Sep 16, 2010)

*Rant*

Please, 

For all the people who post this kind of stuff it really helps to have a history and physical exam, otherwise the possibilities can be absolutely endless unless by some chance you happen to accidentally post a key finding that narrows the list down to a handful or so pathologies.

This started out so well with a description of the scene findings.

Positive or negative, or any for that matter, physical exam findings are not listed. Was he standing? Sitting? weaker on one side than the other? Did he have difficulty walking to the phone to call 911? Can he ambulate? Orthostatic? Equal pulses? Equal range of motion? Tumors?

Medical history incomplete without key details like did the guy have a history of HTN? Past surgeries? Normal level of activity? was he taking medications? what? Had he been hydrating?


From the description alone, he could have had a tendon or muscle rupture, which being rather vascular will cause some hypovolemia, which could have been exacerbated by a previous dehydration.


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## Medicus (Sep 16, 2010)

Veneficus said:


> Please,
> 
> For all the people who post this kind of stuff it really helps to have a history and physical exam, otherwise the possibilities can be absolutely endless unless by some chance you happen to accidentally post a key finding that narrows the list down to a handful or so pathologies.
> 
> ...



All excellent questions for developing a DDx. Experience helps a lot, but unfortunately many times diagnostic aids such as a FAST ultrasound, CT, blood labs, or simple radiogram are needed to whittle down the differential diagnosis. Unavailable to you at this level, but an EKG would have been nice.

-Medicus


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## Veneficus (Sep 16, 2010)

Medicus said:


> All excellent questions for developing a DDx. Experience helps a lot, but unfortunately many times diagnostic aids such as a FAST ultrasound, CT, blood labs, or simple radiogram are needed to whittle down the differential diagnosis. Unavailable to you at this level, but an EKG would have been nice.
> 
> -Medicus



That is not the limit of my questions, just some examples from off the top of my head. 

Diagnostic aids help by providing extra data. They are not fail safe and have various limitations. The more data compiled the more accurate a dx can be. 

But it is not always the difference of determining the potenial invasiveness of a dysplastic cell. There are many conditions that can be easily diagnosed by a skilled clinician without spending thousands of dollars or running every diagnostic test known to man.

Of course when you come to rely too much on technology...


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## Medicus (Sep 16, 2010)

Veneficus said:


> That is not the limit of my questions, just some examples from off the top of my head.
> 
> Diagnostic aids help by providing extra data. They are not fail safe and have various limitations. The more data compiled the more accurate a dx can be.
> 
> ...



Agreed. We were taught in medical school something to the effect of 80% of diagnoses can be made by physical assessment and a good history and 20% would require a diagnostic aide. It works particularly well in an austere environment which is one of the reasons I have always admired EMS. 

That being said, those diagnostic aids really help and many times are required to eliminate possibilities on a differential diagnosis. For example, it would be a risk to take this patient, look at his EKG and dismiss it. I would still like to see a blood lab with CK-MB levels. I can look at a diabetic and where EMS stops there, we have to investigate the cause and blood batteries help for that.


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## Veneficus (Sep 16, 2010)

Medicus said:


> Agreed. We were taught in medical school something to the effect of 80% of diagnoses can be made by physical assessment and a good history and 20% would require a diagnostic aide. It works particularly well in an austere environment which is one of the reasons I have always admired EMS.
> 
> That being said, those diagnostic aids really help and many times are required to eliminate possibilities on a differential diagnosis. For example, it would be a risk to take this patient, look at his EKG and dismiss it. I would still like to see a blood lab with CK-MB levels. I can look at a diabetic and where EMS stops there, we have to investigate the cause and blood batteries help for that.



you like CK-MB over troponin?


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## Medicus (Sep 16, 2010)

Veneficus said:


> you like CK-MB over troponin?



They're generally ordered together and it really depends on how long ago you suspect the MI occurred. CK-MB returns to normal within two or three days so it can be used to diagnose reinfarction (troponin I hangs around for a week or week and a half and can't be used for it). You can actually use the two to give a rough estimate of infarct time (if any at all).

-Medicus


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## Veneficus (Sep 16, 2010)

Medicus said:


> They're generally ordered together and it really depends on how long ago you suspect the MI occurred. CK-MB returns to normal within two or three days *so it can be used to diagnose reinfarction *(troponin I hangs around for a week or week and a half and can't be used for it). You can actually use the two to give a rough estimate of infarct time (if any at all).
> 
> -Medicus



Thanks, good info, didn't think of that, was just considering the acute phase.


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## Medicus (Sep 16, 2010)

Veneficus said:


> Thanks, good info, didn't think of that, was just considering the acute phase.



I still do that. My background was EMS through high school and undergrad and med school. On the USMLE, the answer is always CK-MB (though I would agree with you, if it's a recent onset, troponin I is probably better). The world of the MD is the same as the world of EMS- there's what you put down on the paper, and there's what you do in real life.


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## medic417 (Sep 16, 2010)

Good information from the PA.


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## Veneficus (Sep 16, 2010)

Medicus said:


> I still do that. My background was EMS through high school and undergrad and med school. On the USMLE, the answer is always CK-MB (though I would agree with you, if it's a recent onset, troponin I is probably better). The world of the MD is the same as the world of EMS- there's what you put down on the paper, and there's what you do in real life.



Jason?


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## Medicus (Sep 16, 2010)

Veneficus said:


> Jason?



Who? Sorry, I don't understand the reference.


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## Medicus (Sep 16, 2010)

medic417 said:


> Good information from the PA.



I don't appreciate slander.


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## medic417 (Sep 16, 2010)

Medicus said:


> I don't appreciate slander.



Slander?  What slander?  What are you talking about?  Why did you presume I was talking of you?


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