# ?Stroke/AMI/PE/Sepsis/I don't know.



## Melclin (Oct 21, 2010)

*15:34  56yrs Male: Doctor's request (<25mins) - ?Stroke. *

*O/A*: You arrive to find a community care nurse at the door of a run down house.

She provides the following handover:

 Alex G Bell is a 57 year old male with a newly placed stoma to whom the nurse has been sent to attend. On her arrival, the pt was complaining of tingling down his left arm and left leg. She called his doctor and he suggested she call the ambulance. She tried to get a blood pressure but had some considerable difficulty, saying she thinks it may be around 85 systolic with a pulse of about 80 but its very hard to palpate. He is a diabetic and his BSL is 5.6

*O/E: *You enter the house to find a slightly overweight and unkempt man in bed holding a colostomy bag against his stomach. He is alert and oriented and says that he has tingling in both legs and his left arm, and feels nauseated. Pt was discharged from hospital on the previous day after having had a portion of bowel removed due to cancer. He had gone to the toilet in the AM of this current day (~6am) and it, “felt like he was walking on blistered feet”, at which time his tingling sensation started. He had expressed these symptoms to the home care nurse who had activated the ambulance (slightly before the above time). The pt is mildly anxious.

*Vitals:*
SpO2: unrecordable. 
Monitored in Sinus Tach of ~200 (although it does appear that the machine is registering a T-wave as a QRS. Pulse matches the QRS rate).
BP:  90/P
Pulse: 98
Temp: 36.0 (both ears)
Resp rate: 22
BSL: 5.0

*Medical Hx:*
Type 2 diabetes, hypercholesterolaemia, bowel cancer, post-op bowel resection (14 days previous), pulmonary embolus (a “day or two”  before being discharged, they “didn’t give me any drugs or nothing” for the PE). No meds are listed in the PCR although I seem to remember Oxycodone being present. This is probably a hole in the scenario (I didn't run the job and am working from PCR and what I picked up from assisting) but I don’t think meds have anything to do with the outcome.
*
Physical:*
Breath sounds clear and equal bilaterally.
Lower arms, hands and finger are ice cold to touch and have a cap refill of about 4+ seconds, but are pink. Fingernails show mild clubbing.
There are a number of old superficial scars scattered around his chest and arms.

There is a recent surgical wound on his abdomen, slightly to the right of mid line, consistent with his colostomy. The wound appears quite healthy. It is surprisingly well healed,  undressed and well perfused. 

Both legs are extremely cold to touch and pale with very noticeable cyanosis in the toe nail beds. Very mild pitting oedema is also present in both legs.    

*After loading*:
Once in the ambulance the patient quite suddenly starts to sweat profusely (You could actually see the drips of sweat forming in seconds from nowhere) and states that he “feels like S**t” and is mildly short of breath (reports SOB after prompting for “any problems with your breathing”).


There are three parts to this scenario. This is the first; with the prehospital findings; the second will involve ED findings, firstly with 12-lead and then labs; and the third will involve something else...GO!


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## Aidey (Oct 21, 2010)

AAA

Why the heck won't it keep it capitalized?

Edit: Of course now it works.


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## Melclin (Oct 21, 2010)

I don't recall ever having considered AAA. He was, after all, in hospital for at least 14 days with, presumably, pretty close monitoring of his abdomen. Given the subsequent PE, one would expect multiple CxRs and/or CTs up to the day previous to this presentation. He was discharged the day previous to the day of presentation. I'm no expert on AAAs, but it seems like an unusual situation in which to sustain one...


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## Aidey (Oct 21, 2010)

It could also be a dissection of aorta, which if I was actually awake I probably would have said first. It is symptom based guess. 

Tachycardic, hypotensive, signs of shock, bilateral lower extremity swelling, hypoperfusion and an unusual sensation in his extremities.


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## jrm818 (Oct 21, 2010)

I'll take a whack at this one. 

I also hadn't thought of dissection/AAA, but now wish I had....I think the lack of pain is why they didn't leap out at me.  I guess that isn't the answer since Meclin was surprised, but without knowing that, the idea makes sense to me. 

The differentials in the title were my first thoughts, but the presentation doesn't seem quite right for any of them (and what fun is a scenario with the answer in the title).  I'd add non-AMI flavors of heart failure to the list.

Questions:

Does he have pedal pulses?

How do his lung sounds after his onset of SOB.  Vitals now?

Any chance of getting a look a the EKG?  12-lead?  I'm a bit confused about what you saw - Am I correct in thinking he had P's and QRS's each at a rate of 200 with only ~1/2 of the QRS's producing a palpable pulse?

How has his urine output been (are his kidney's intact)?  
Is is normal for him to have to wake up at 6AM? (If I were an unkempt overweight healing post-colostomy patient I think I'd consider that still nap-time.  In fact, I'm none of those things, and I still dislike being woken up that early....),

Other than the tingling, how is he neurologically?

When do we get to find out all the exciting ED findings?  I can't wait for the surprise....


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## Veneficus (Oct 21, 2010)

*OK, let's think about it.*



Melclin said:


> *15:34  56yrs Male: Doctor's request (<25mins) - ?Stroke. *
> 
> *O/A*: You arrive to find a community care nurse at the door of a run down house.
> 
> ...


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## Melclin (Oct 21, 2010)

jrm818 said:


> Does he have pedal pulses?
> 
> *He does. The are surprisingly strong.*
> 
> ...





			
				Veneficus;255524

[B said:
			
		

> How about mg/dl? (100.7) I really hate this mmol crap. [/B]
> 
> Then you're gonna hate it when the bloods come back
> 
> ...



When you load him into the ambulance and have a bit more of a play you notice the sudden, extensive diphoresis and he complains of SOB as mentioned.

BP : unrecordable
Pulse : 110 (weaker than before, barely palpable). 
Chest is still clear and equal bilaterally.
GCS : 15
Pt is significantly more anxious than he was. 
Denies chest pain or discomfort. 
Now feels nauseated.

You eventually get access - Meds? fluids? 
Transport decisions?
Ddx? 
Thoughts?

I'll post the ED findings in a day or so.


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## Aidey (Oct 21, 2010)

I have to admit some confusion, hyperkalemia causes bradycardia, not tachycardia. Or is the tachycardia from something unrelated, like A-fib?


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## jrm818 (Oct 21, 2010)

I feel totally outgunned here. I'm taking a shot more as a learning experience for me than anything.

Assuming there is actually hyperkalemia, I'd put stroke rather farther down the ddx list, and tend to be comfortable explaining the parathesia with the electrolyte issues for now.  Makes me think a lot more about renal failure - that's why i was wondering about urine output (once we get into the ED - labs will be muchos helpful).  

The circulatory/respiratory issue seems like the most acute issue at the moment.  His history and assessment are pretty convincing for another PE, but with the apparent renal/electrolyte/cardiac issues, I'm at a loss as to how to create a more unified ddx list, (though I'm sure he has multiple ongoing pathologies, so maybe it isn't possible).  

Obviously I'm thinking PE, Renal failure, he clearly has some cardiac issues and I'm not convinced they're all K+ related with only some peaked T-waves as the evidence, not sure AMI has been ruled out, bleed somewhere is possible, infection is possible but I"d say low probability guess, stroke is still possible, but again low prob. guess, I'm sure there's more but that's all that occurs to me.

With such uncertainty I'd be inclined towards rather conservative supportive treatment until we have some more information.  Unfortunately, he seems to be heading in the direction of forcing some more aggressive treatment I'm not sure what that should be.

Very uncertain, If I were dumped in the field today with this patient I'd be a bit..uh...puckered at the moment...


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## Veneficus (Oct 22, 2010)

Aidey said:


> I have to admit some confusion, hyperkalemia causes bradycardia, not tachycardia.



usually.

I wasn't clear on what the rate was without the t wave or if large peaked twaves were being counted as QRS, which would articilly increase the rate on the monitor.


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## Melclin (Oct 22, 2010)

No one else wants to have a shot at an alert and oriented bloke, tachycardic with no blood pressure and some neuro deficits, sweating like a stockbroker?


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## Veneficus (Oct 23, 2010)

Melclin said:


> No one else wants to have a shot at an alert and oriented bloke, tachycardic with no blood pressure and some neuro deficits, sweating like a stockbroker?



sounds like his body is desperately trying to compensate from his lack of cardiac output.


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## Mobey (Oct 23, 2010)

Soo what does the 12 lead show?

I am confused on this HR thing. When you count the qrs's, is it 200/min? If so, cardiovert.

If not, lets correct his pressure to start with. 
Bolus 1lt of fluid and start Dopamine 5mcg/kg/min increasing as necissary.

need another 12 lead.

Prolly a silent MI. 

The extremeties are not perfused, that is why they feel tingly/ funny etc. Tingly is not a neuro deficit, it is a perfusion problem.

Also, would like a ETCo2.


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## Aidey (Oct 23, 2010)

Mobey said:


> Soo what does the 12 lead show?
> 
> I am confused on this HR thing. When you count the qrs's, is it 200/min? If so, cardiovert.
> 
> ...



Ok, there is a difference between the rate of the QRS on the EKG and the perfusing pulse. In this guy his perfusing pulse is a perfectly acceptable 80bpm, not something that calls for an urgent cardioversion. 

Paresthesia can be a sign of a developing neuro deficit.


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## Mobey (Oct 23, 2010)

Aidey said:


> Ok, there is a difference between the rate of the QRS on the EKG and the perfusing pulse. In this guy his perfusing pulse is a perfectly acceptable 80bpm, not something that calls for an urgent cardioversion.
> 
> Paresthesia can be a sign of a developing neuro deficit.




Think about what your saying here.
It is perfectly acceptible to have a hr of 200, as long as only 80bpm are perfusing??
Is it OK to be in V-tach @ 180 as long as only every 2nd beat is perfusing?

Cardiac output is dependant partly on preload. With a heart rate this fast, the LV does not have enought time to fill, and supply blood with all 200 contractions to the body, so you can feel a pulse. Are you really telling me that is OK with you?

Step back for a minute and look at the clinical picture:
HR 200, anxious, nausea, hypotensive, impared perfusion to the extremeties.


Paresthesia is a sign of a developing neuro deficit in the traumatic injury pt, or a DD of accesory nerve disorder/injury. This guy has a perfusion problem, not a neuro problem.


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## rescue99 (Oct 23, 2010)

Melclin said:


> No one else wants to have a shot at an alert and oriented bloke, tachycardic with no blood pressure and some neuro deficits, sweating like a stockbroker?



Effusion?? Seems reasonable to put it on the list.


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## Melclin (Oct 23, 2010)

*ED findings*

Sigh, Okay so in the original set of vital signs:

The HR counter on the monitor reads about 200.

However, you can clearly see from the distance between the QRS complexs displayed that it would have to be about half that. 

When you print a strip and count the QRS complexes, it reads about half that.

What I'm saying is that the monitor is misinterpreting the information it has collected. Its registering a T-wave as being an additional QRS complex. Usually I would gloss over machines making mistakes, but this is relevant to the case. As vene correctly deduced (I though it would take a little longer :wacko: ), peaked T-waves would cause this and yes it was due to hyper-K.

So,

*O/A at the ED *

NIBP: 98/50
Manual Pulse: 120
ECG: SR, T-waves peaked in V2, V3 & II 
SpO2: varying between 65 and 90 with an utterly dodgy pleth waveform, on 8LPM by simple face mask.
GCS:15

Nurse notes that his blood is clotting extremely quickly when she draws for labs. The middle three toes on each foot are now extremely pale, while the other two are relatively well perfused. The pt has stopped sweating. His face and chest are far more pale than when he presented.  

When you follow up after an hour, bloods are back and an arterial line has been inserted. He has had a total:  

-4L  normal saline 
-1L of gelofusine
-1mg of metaraminol 

Art line BP is averaging around 80/40 and seems dependant on the manual rapid infusion of gelofusine by a trusty ICU registrar who is accompanying the array of various important looking doctors now bustling about.

*Blood work:*

Na+: 132mmol/L, K+:  6.7mmol/L, Ca+: 2.31 mmol/L, Albumin: 43 g/L, Lipase: 13.5, Ck: 47ng/dl, Troponin T: 0.01ng/dl?, Creatinine: 158 micromol/L Urea: 10.2 mmol/L, Haemoglobin: 16.5mg/dl, Glucose: 9 mmol/L, C-reactive protein: 4.9mg/L. 

(Some of the units of measurement might be wrong, the lab results came without units which would be fine if it wasn't for the frustrating differences in the use of various units of measurement between the US and Aus).

With Glucose + Insulin is ordered. 

A further 500mls of gelofusine is hung. BP, 5 minutely during the infusion of the third 500mls:  110/43, 110/49, 120/51. Pulse is consistently 110-120. 

1L has been removed from his colostomy. 

He is ready to go off to CT. What are you thinking now?


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## Aidey (Oct 23, 2010)

Mobey said:


> Think about what your saying here.
> It is perfectly acceptible to have a hr of 200, as long as only 80bpm are perfusing??
> Is it OK to be in V-tach @ 180 as long as only every 2nd beat is perfusing?
> 
> ...



But the heart rate isnt 200, it is 80. As annoying as this saying is, treat the pt, not the monitor. If the pt has a "normal" pulse rate the other symptoms aren't likely to be caused by poor cardiac output from tachycardia, because the pts pulse isn't tachycardic.


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## Aidey (Oct 24, 2010)

Ok, to quote Vene, I really hate this mmol/l crap. 

From what I can find it looks like mEq/l and mmol/l have the same normal ranges. 

Ok, so labs are what I would expect in acuute kidney failure. Low Na, high K+, high creatanine, high urea. I wonder what his PT/INR is.


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## Melclin (Oct 24, 2010)

Aidey said:


> I wonder what his PT/INR is.



I had it written down. But its been obscured all the other hurried writing. I was just jotting these into a note pad as the nurse read them out. :wacko:

It wasn't abnormal and they weren't worried about it. 



> Effusion?? Seems reasonable to put it on the list.



I don't quite follow. Care to elaborate?


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## jrm818 (Oct 24, 2010)

So the renal system is in the spotlight now.  Also, I take it we're supposed to assume that he's hypercoaguable, which certianly supports a PE hypothesis.  My ddx list hasn't changed much, I'm wondering if he's throwing clots all over - into his lungs, kidneys,(can you throw a clot into the arterioles feeding specific toes?  That's the only explanation I could come up with for that interesting perfusion issue).

Has his SOB resolved?  If the SpO2 is at all reliable (which I doubt), I'd guess not.

I assume they are CT'ing his lungs?

I'm still not quite sure what would be causing his BP issues...with a BP dependent rather heavily on colloid and alpha agents it sounds like he's likely hypovolemic...at least intravascularly.  Is he third spacing?  Any signs of ascites?  If not, it must have gone interstitial, and he has the edema to prove it.

MI looks pretty unlikely at this point.




Also I'm throwing Lupus out there.  It's gotta be right once in a while


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## MrBrown (Oct 24, 2010)

Buggered if Brown knows, where is the Consultant when you need him?


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## Melclin (Oct 24, 2010)

jrm818 said:


> Also, I take it we're supposed to assume that he's hypercoaguable, which certianly supports a PE hypothesis.



You're not really supposed to assume anything, Im just relaying as much of the information as I have written down/remember. The PT was normal. 



jrm818 said:


> That's the only explanation I could come up with for that interesting perfusion issue.



It did occur to me. LOL. But what is the likelihood of throwing two clots to two different arteries at the same time affecting the same three toes on each foot (the effect was bilateral). My thought was more neuro. The middle three toes are innervated by different spinal nerves to the outside two. So I thought that might have something to do with it. Getting different levels of sympathetic tone for some reason?



jrm818 said:


> Has his SOB resolved?  If the SpO2 is at all reliable (which I doubt), I'd guess not.



It has. To be honest it was never severe in the first place (I should have mentioned that) and it was pretty much gone when we got to ED with 8LPM. Blood gas was ordered, I never saw it, but he had been taken off supplemental O2 when we got back. 



jrm818 said:


> I assume they are CT'ing his lungs?



Yep PE was highest on the list at that time. There was some commotion from the imaging people about V/Q versus CT and the ED nurses were b**tching about them. The registrar I was talking to, who was most helpful, was quite sure it was a PE. Evidently the consultant wasn't as sure given we weren't in the cath lab. 



jrm818 said:


> Any signs of ascites?  If not, it must have gone interstitial, and he has the edema to prove it.



No ascites. No remarkable odema other than the very mild kind I mentioned at the start. 



> Also I'm throwing Lupus out there.  It's gotta be right once in a while



Its not lupus. And I measured his neighbour's cat urine for uranium, dead end there too. Maybe paraneoplastic syndrome? 

[/QUOTE]

10char


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## Aidey (Oct 24, 2010)

Both hyperkalemia and a PE can cause hypotension. Although his K+ isnt that astronomical, I've seen pts with higher that have a normal BP. He may also be dehydrated and/or have an infection, and it is just a combination of things.


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## firetender (Oct 24, 2010)

*Patient Care?*

Okay, here's what I see. Here are the OP's comments, in the whole thread about the actual patient as if he were a human being:




> *slightly overweight and unkempt man in bed holding a colostomy bag against his stomach. He is alert and oriented and says that he has tingling in both legs and his left arm, and feels nauseated.
> 
> *He had gone to the toilet in the AM of this current day (~6am) and it, “felt like he was walking on blistered feet”, at which time his tingling sensation started.
> 
> ...


 
________________________________________

And now, picture five more medics, standing around talking with Melclin, and in a total of 23 posts, here's what any of them have to say about the human being whom they are discussing



> VENEFICUS : I am going to have to say there is not enough info yet to make any definitive decisions.


 
That actually surprised me! Oh, wait a minute, that wasn't about the patient, it was about the "decision" Sorry!



> JRM818: With such uncertainty I'd be inclined towards rather conservative supportive treatment until we have some more information


 
"Supportive" that's kind of a nice, human word



> AIDEY: As annoying as this saying is, treat the pt, not the monitor


 
*Everybody is so damned concerned about what's going on, nobody is paying attention to what's happening, except AIDEY, but he treats the issue apologetically as a cliche!*

It's not a cliche it's a real patient. To his credit, Melclin asks people, "Hey, what would you actually DO?" But, well, no one bites.

Can't record an SPO2
Monitor registers false beats
BP by palpation (why?) 

In the unit, sweats (does it stop and when?)
says feels like S***
and then...
NOTHING

Sorry folks, the scenario looks like swiss cheese; especially when Melclin retracks any urgency to the breathing situation. At that point I said; he's really not helping us here.

Okay, sure it's nice to know why. But here I see a neglected patient because nobody's asking questions having to do with what would be determining urgency; taking measures to stabilize; and moving. Each and every one of those things would be reflected in "How is the patient?"

Even an "I'd treat as if... and roll" would be reassuring.

Does anyone do anything as a medic anymore or is everyone wanting to be MDs??


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## SanDiegoEmt7 (Oct 24, 2010)

I think the common supportive measures and general patient care were implied.  When a case study is posed, generally it is discussed with the goal of finding a definitive diagnosis and its definitive treatment, so that when similar signs and symptoms are seen in the field it adds a different differential to the toolbox (or a different way of looking at the same differential).  

If everyone had said, fluid bolus, O2/ventilations prn, comfort the patient to the ED, and left it at that it wouldn't have been a very interesting discussion.  I'm assuming that most people leave out the details of patient care you are discussing because they are a given.  If every response had included them, this thread would be twice as bulky and still not contain a definitive answer.

Buuuuuut, Firetender I do love you point of view on this and previous topics, I just think that most people are skipping the givens in search of an answer.  (At least I hope so, eeek)


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## Aidey (Oct 24, 2010)

<-------- she!


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## Melclin (Oct 24, 2010)

firetender said:


> Okay, here's what I see. Here are the OP's comments, in the whole thread about the actual patient as if he were a human being:
> ________________________________________
> 
> And now, picture five more medics, standing around talking with Melclin, and in a total of 23 posts, here's what any of them have to say about the human being whom they are discussing
> ...



What do you want mate? Someone to post an extensive list of ways in which we'd rub his tummy and tell him he's special? I went and got a towel and wiped drops of sweat off his brow because it was dripping in his eyes. I spoke to his family because no one else was and his daughter was crying. I helped him empty his colostomy bag. But who gives a toss? So would everyone else. Its just basic humanity. I don't need to post that and nor does anyone else need to suggest it in their posts. 

Its a given.

I'm not interested in other peoples versions of their human touch. I'm good with people and I'll get better in time with experience and personal reflection. What I need from the forum is suggestions about this case that would help me to make treatment, triage and transport decisions in the future. 

Thanks to this discussion, I've already realized I really should have considered bleeding. I didn't consider electrolytes until I saw the blood work. To big gaffs with early signs I could have noticed that I now know about. I've noticed other little things as well that would help me in future. Which is exactly what I hope for when I post jobs like this. 



> Sorry folks, the scenario looks like swiss cheese; especially when Melclin retracks any urgency to the breathing situation. At that point I said; he's really not helping us here.



That's because the job was swiss chesse. It was a very dynamic case. It was very complex in terms of the changing nature of his physical assessment. It was also a job that was sandwiched in-between 6 other jobs that day. All told its not that easy to communicate it all. 

Also I didn't retract any urgency. It was never there to begin with, I said he was _mildly_ short of breath after being _prompted_. What I did is recognize that I didn't really provide much detail in my resp assessment. 

I do, however, wish more people had weighed in with treatment and transport opinions but I didn't see yours there either firetender. 

You already have too much information (my bad, I'm rushing to the end with a thirst for the wisdom of the board), but based on my first post...

*Fluids?
Inotropes/Pressors?
Antibiotics? 
Oxygen?
Working diagnosis?
Tx decisions?*


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## Aidey (Oct 24, 2010)

Working dx of kyperkalemia, possible PE, possible sepsis. Had this been my pt he would have gotten a 12 lead, IV, O2 with EtCO2, Calcium, fluids if the calcium didnt fix the BP, albuterol (part of the hyperK protocol) and follow up treatment depending on what changes happened. No inotropes or pressors, unless for some reason his BP continued to tank after the calcium.

For me, forming a tx plan difficult in a case like this when I don't have the EKG and EtCO2, because those 2 things could confirm or refute my dxs rather quickly.


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## Melclin (Oct 24, 2010)

Aidey said:


> Working dx of kyperkalemia, possible PE, possible sepsis.
> 
> For me, forming a tx plan difficult in a case like this when I don't have the EKG and EtCO2, because those 2 things could confirm or refute my dxs rather quickly.



For my own benefit (not to be argumentative), how would EtCO2 effect your decisions in this case? (Are we talking nasal prong EtCO2? Those things would be awesome to have).


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## Aidey (Oct 24, 2010)

Melclin said:


> For my own benefit (not to be argumentative), how would EtCO2 effect your decisions in this case? (Are we talking nasal prong EtCO2? Those things would be awesome to have).



It wouldn't necessarily change what I would or wouldn't do, but it helps me figure out if there is more than one thing going on. If I throw the pt on the EtCO2 and its 38 mm/hg with normal waveform my suspicion for PE just dropped a bunch. There isn't a lot I can do for a PE, but if it is something mimicking a PE there may be something I can do. The catch in this case is that it is possible he is in metabolic acidosis from his kidney problems, so even if he doesn't have a PE his CO2 may be low. 

It is really just part of drawing a complete picture, and it helps me see how sick the patient is overall. If I started giving this patient medications like calcium and bicarb for the kidney issues I absolutely want to monitor his EtCO2 because that, his EKG and his BP are going to be the 3 places I would see the biggest changes if the medications were having a positive effect.

And yes, they are nasal prong EtCO2 readers. We have EtCO2 cannulas, where we can use them to give O2, or just to monitor their CO2.


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## jrm818 (Oct 24, 2010)

Aidey said:


> Working dx of kyperkalemia, possible PE, possible sepsis. Had this been my pt he would have gotten a 12 lead, IV, O2 with EtCO2, Calcium, fluids if the calcium didnt fix the BP, albuterol (part of the hyperK protocol) and follow up treatment depending on what changes happened. No inotropes or pressors, unless for some reason his BP continued to tank after the calcium.
> 
> For me, forming a tx plan difficult in a case like this when I don't have the EKG and EtCO2, because those 2 things could confirm or refute my dxs rather quickly.



Learning point for me: Would you be at all concerned about the possibility of heart failure not related to the hyper-K state?  When I was thinking about supporting BP chemically I was worried about increasing the demand on what may be an already failing heart (and so I didn't really propose any specific treatment, thus part of firetenders objection I suppose).  I'd have the same concerns about albuterol, although it's not being given for quite the same reason.  The pressors the hospital gave don't seem to have killed this pt., so I suppose that's part of the answer, but I'm interested in the decision calculus that goes into the decision from your perspective.




Melclin said:


> You're not really supposed to assume anything, Im just relaying as much of the information as I have written down/remember. The PT was normal.



So why was the blood "clotting quickly"?  I don't know any other reasons that would happen, but that's likely just ignorance on my part.




> It did occur to me. LOL. But what is the likelihood of throwing two clots to two different arteries at the same time affecting the same three toes on each foot (the effect was bilateral). My thought was more neuro.



It was a bit of an outlandish guess.  I bet you could have written a paper about it if it had turned out to be right.



> The middle three toes are innervated by different spinal nerves to the outside two. So I thought that might have something to do with it. Getting different levels of sympathetic tone for some reason?



I'd never seen the innervation described like that.  I flipped back through some old notes, and they have the toes all in the same dermatome.  Dermatomes are sensory of course, but I can't find a good description of the sympathetic innervation of the toes, and if anything I'd expect the distribution to be more overlapping than the sensory distribution -  not well segregated enough to see differences between toes.  That said, if you could point me in the direction of some better information, I'd be appreciative.

This does actually make me think a bit more about a neuro pathology.  I thought about a spinal cord/nerve root issue when you first described the extent of the pale cold skin, but again since the distribution wasn't really dermatomal, I decidyed that the issue was more likely that the more distal structures were poorly perfused.  

I don't know that I would consider this really plausible, but I can imagine a scenario where [nerve root compression, partial SCI, degeneraiton of some sort] would cause in effect a partial sympathectomy - which could cause the tachycardia and hypotension corrected with alpha agents and fluid, could cause the pale skin due to reflex vasoconstriction wherever sympathetic innervation persists, sweating due to reflex sympathetic overdrive wherever innervation persists (was he sweating all over or just his pink bits?), 

A bit too hypothetical to have anything to do with the care of this patient at the moment, so apologies to firetender for that mental diversion...



> It has. To be honest it was never severe in the first place (I should have mentioned that) and it was pretty much gone when we got to ED with 8LPM. Blood gas was ordered, I never saw it, but he had been taken off supplemental O2 when we got back.



That leas me to believe that the ABG didn't show much of an oxygenation issue.  That might knock PE down the list a tad?

I'll play along with the decisions:



> Fluids?


yes, but I have the benefit of seeing the ED treatment now so the decision is easier.


> Inotropes/Pressors?


Initially I said no, now I say yes, again thanks to seeing the ED response



> Antibiotics?


Not yet



> Oxygen?


yes, for presumptive PE with an unreliable SpO2, discontinue if the ABG shows he's oxygenated appropriately.



> Working diagnosis?


working dx of renal failure with PE until PE is ruled out, but I'm starting to feel like we're going to find that PE isn't the primary issue.

ddx:
PE, renal, neuro , infection isn't off the list yet, bleed, cardiac failure (due to...)




> Its not lupus. And I measured his neighbour's cat urine for uranium, dead end there too. Maybe paraneoplastic syndrome?



I'll buy a beer for anyone who guesses paraneoplastic and is right...but this is your scenario, so I'm not sure you can cash in this time....


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## Veneficus (Oct 24, 2010)

Melclin said:


> As vene correctly deduced (I though it would take a little longer :wacko: ), peaked T-waves would cause this and yes it was due to hyper-K.



I see that at least once a day, it is why i take a manual pulse, which also helps during heart tones.

So,

*O/A at the ED *

NIBP: 98/50
Manual Pulse: 120
ECG: SR, T-waves peaked in V2, V3 & II 
SpO2: varying between 65 and 90 with an utterly dodgy pleth waveform, on 8LPM by simple face mask.
GCS:15



Melclin said:


> Nurse notes that his blood is clotting extremely quickly when she draws for labs.



Nothing like a WAG clotting time.




Melclin said:


> The middle three toes on each foot are now extremely pale, while the other two are relatively well perfused. The pt has stopped sweating.



before or after treatment?

Before would be really bad. After not as bad.



Melclin said:


> His face and chest are far more pale than when he presented.



because he is busy trying to die.




Melclin said:


> -4L  normal saline
> -1L of gelofusine
> -1mg of metaraminol
> 
> ...



While his K is not at 7 yet, I might be seriously thinking about some emergent dialysis.

We really really need to know what his coag values are. To determine if he is in or at risk for DIC in addition to the local clotting.



Melclin said:


> (Some of the units of measurement might be wrong, the lab results came without units which would be fine if it wasn't for the frustrating differences in the use of various units of measurement between the US and Aus).



Well you guys are upside down



Melclin said:


> With Glucose + Insulin is ordered.



Tight regulation of hormonal control is a normal ICU event. The insulin shold help lower his K+ also.



Melclin said:


> A further 500mls of gelofusine is hung. BP, 5 minutely during the infusion of the third 500mls:  110/43, 110/49, 120/51. Pulse is consistently 110-120.



because he is losing protein, possibly from liver complications and/or a nephrotic syndrome. 




Melclin said:


> 1L has been removed from his colostomy.



Not surprising. 



Melclin said:


> He is ready to go off to CT. What are you thinking now?



He is CTD. 

This dude has some major issues. Let's make a summary.

Recent surgery.

Most likely an adenocarcinoma. Hopefully only invasive and not metastatic. If it was the likely locations of spread and destruction are: lymph, liver, lung, and bone.

FE deficiency is a high likelyhood.

If his liver is involved it cold account for a lack of albumin, but I think his greatest loss is from his Kidney.

Clotting can be caused from a myriad of things, no way to pinpoint. 

If there is bone spread anemia is almost a promise. Furhter increasing his hypoxic problems.

Let's not even get into paraneoplastic syndromes.

He already had a PE, so he is at risk of basically infarct everywhere.

Kidney complications from surgery and likely acute kidney failure, is going to really be a problem in managing his hemodynamics. 

Urine protein would help.

If he has some sort of post surgical infection, there could be not only DIC but all kinds of organ damage, particularly to the Heart and adrenals would complicate the matter in a large way.

If he is lucky, clotting is restricted to the pulmonary system and his toes. If not, he probably already has several micro infarcts. If he is really unlucky, in his coronaries, kidney, and adrenals as well.

For treatment, this is going to be one tough customer. But let's look at just prehospital:



Melclin said:


> Fluids?




yes for sure, NS, LR, and colloid if you have it.
This has to be weighed against overloading the heart's ability to pump and putting him into cardiogenic shock, but I would start with at least 1L or isotonic and 250 of colloid if available. At hospital some Plasma and RBCs. Stay away from Platelets.



Melclin said:


> Inotropes/Pressors?



If he stopped sweating prior to treatment or his HR decreased, Yes, if not I would hold off.



Melclin said:


> Antibiotics?



Couldn't hurt, but I don't see it making a difference.He has a *reasonable suspicion* to be septic, so some vanc would be good prophylactically.



Melclin said:


> Oxygen?



If you must, but he probably would only get about 4L of cannula from me. His o2 carrying ability is likely diminished from things o2 will not really make a huge difference with.



Melclin said:


> Working diagnosis?



Renal and clotting complications from surgery.



Melclin said:


> Tx decisions?



The hospital that did his surgery or a really great surgical intensivist for transport. Prehospital treatment already discussed.

Firetender: 

I see the point you are getting at, but I really wasn't inclined to try and type out a bedside manner. It is very important to be calm and kind to this guy and his family. His discharge may well be to the ECU. 

I think one of the most important questions are: 

Can medicine help this patient? (some may be surprised that while we can most expertly build Frankenstein's monster out of just about anyone, that doesn't equate to helping.) There comes a point when palliative care is the best we can do.

What is the endgame of that treatment?
(home? with deficits? SNF? ICU to the end? See where we are in a few days?) 

These are not really decisions for medics in the field though.

As of this reply, I don't think we can answer those questions. More data is needed. Part of that data is asking the pt what he wants.


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## Veneficus (Oct 24, 2010)

jrm818 said:


> *Learning point for me: Would you be at all concerned about the possibility of heart failure not related to the hyper-K state?*  When I was thinking about supporting BP chemically I was worried about increasing the demand on what may be an already failing heart (and so I didn't really propose any specific treatment, thus part of firetenders objection I suppose).  I'd have the same concerns about albuterol, although it's not being given for quite the same reason.  The pressors the hospital gave don't seem to have killed this pt., so I suppose that's part of the answer, but I'm interested in the decision calculus that goes into the decision from your perspective.....




*No, if the guy found a surgeon and anesthesiologist who would put him under and cut him open, he couldn't have heart failre that badly, and would have been extensively screened prior to surgery.*




jrm818 said:


> When I was thinking about supporting BP chemically I was worried about increasing the demand on what may be an already failing heart (and so I didn't really propose any specific treatment, thus part of firetenders objection I suppose).




I would also tread cautiously here, but I detailed it in my response.



jrm818 said:


> I'd have the same concerns about albuterol, although it's not being given for quite the same reason.




Not something I'd be concerned about. The problem is just like in trauma, and there very well could be a bleed somewhere still. (though with the hyper coag state I doubt it, because in a massive bleed I would expect hypocoag)

It is a simple case of prefil and hypotension. However, if it has progressed to progressive shock state, it could have damaged the myocardium, but at that point it is damned if you do and damned if you don't.

 I am not eager to chemically treat the hyper K+ because he is still neuro intact. In my opinion what he needs is renal support not back of the truck chemistry. 

He made it this far, unless there is a change in mental status, he can wait a bit longer.



jrm818 said:


> The pressors the hospital gave don't seem to have killed this pt., so I suppose that's part of the answer, but I'm interested in the decision calculus that goes into the decision from your perspective.




If the fluid and colloid don't bring up the pressure to reasonably perfuse heart, brain, and kidneys, treatment must be escalated. 

In the back of the truck I would escalate a step at a time, however, if he stopped sweating prior to at least 500ml of fluid, I would be concerned he no longer had the catecholamine reserve to continue compensation. (for a variety of reasons) That can be managed by most EMS systems using pressors.


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## jrm818 (Oct 24, 2010)

Veneficus, as always I learn a lot from your perspectives, but I'm left with a few questions this time, if you don't mind.



Veneficus said:


> before or after treatment?
> 
> Before would be really bad. After not as bad.



What is the thinking here?  You mention clots in the extremities in your post, is that it?




> We really really need to know what his coag values are. To determine if he is in or at risk for DIC in addition to the local clotting.



This has always confused me a bit.  Are you looking at INR, PT, or PTT for DIC determination?





> For treatment, this is going to be one tough customer. But let's look at just prehospital:
> 
> 
> 
> ...


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## Veneficus (Oct 24, 2010)

jrm818 said:


> What is the thinking here?  You mention clots in the extremities in your post, is that it?



He has a host of conditions that could cause microvascular clotting, I want to know how extensive it is to determine if some of the clotting is from chronic predisposition or if it is systemic acute clotting.

If he stops sweating prior to treatment, he could be out of catecholamine.




jrm818 said:


> This has always confused me a bit.  Are you looking at INR, PT, or PTT for DIC determination?



Yes, I want to know all there is about his blood.

All the coags and all the hematology.

Everything gives you a piece of the puzzle, in this case it is indicated, and at the very least a base to look for potential changes in all aspects of infection, oxygen carrying capability, pro and anti coag factors.




jrm818 said:


> I've been keeping this on my list, but I'm not sure I can articulate why.  What s/s specifically point to a septic etiology?  What would make or break this diagnosis?



This is not a "what if this guy is the 1 in a million weird presentation?" He has a host of realistic risk factors like:

Potential DIC, potential renal and/or cardiac failure from bacteria, hypotension, potential internal leakage from colostomy, possibly inadvertant fistula created in surgery. 

Nothing really concrete, but the possible benefit of helping outweighs the potential risks in this case.


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## Aidey (Oct 24, 2010)

Veneficus said:


> I am not eager to chemically treat the hyper K+ because he is still neuro intact. In my opinion what he needs is renal support not back of the truck chemistry.
> 
> He made it this far, unless there is a change in mental status, he can wait a bit longer.



So are neuro deficits your "flag" for chemically treating the hyper K+? Our protocol (and our med director) both have hypotension as the tipping point symptom for treatment.


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## Veneficus (Oct 24, 2010)

Aidey said:


> So are neuro deficits your "flag" for chemically treating the hyper K+? Our protocol (and our med director) both have hypotension as the tipping point symptom for treatment.



Neuro deficit is a sign of hypoperfusion. I like to treat the patient based on presentation. In the case of electrolyte balance, unless the patient is grossly unstable, in my mind discretion is the better part of valor.

If you look at the vitals throughout, at no point are there any listed that demonstrate severe hypotension. I know some protocols like to make 100systolic the magic number, sometimes 90 systolic, but systolic BP does not correlate with CVP and that makes using systolic bp as a sign of perfusion iffy at best. MAP or if you want to be quick and dirty, pulse pressure, will give you a better measurement. But even the kidneys can survive around 80 or less for a brief period. 

Also in order to determine lack of cardiac contractility over hypovolemia, you would need an ultrasound. If you start treating hypovolemia and it is not working it is easier to then go to Calcium than it is the reverse.

Perhaps seeing the QRS amplitude might make the case more compelling, but in absence of that, trying to balance labs without actual results on a patient compensating well is not what I would do in such a short transport. If the protocol demanded it, I would call med control and make a case for not doing it.

Aside from sympathetic response and a mild tachycardia, I can't say this patient disturbs me enough to warrent trying to acutely reverse K+ based on an EKG. 

From the lab perspective after getting to the ED, his albumin deficit coupled with his K+ would make me more inclined to fix him with an emergent dialysis which would serve him better in the long run while attempting to find out what caused the renal failure and if it is reversible.

At the very least, figure this guy is going to the ICU and when he gets there, he is going to be put on glucose/insulin control, and the insulin is going to drop his K as well. At that point he is going to have his PH evaluated as well.

Do you think this patient is unstable enough to crash in the next 1/2 hour to hour? 

I think it fair to say if you suspected that, more aggressive measures would be indicated. But it is a judgement call, not a right or wrong as I see it.


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## Aidey (Oct 24, 2010)

I'm off to work, so I can't reply in full right now, but with his possible clotting issues is he even a candidate for emergent dialysis? I'm pretty sure they have to get that sorted out first since clotting causes so many complications with treatment. I suppose they could hold off on the heparin, and instead use saline and just adjust the treatment to remove the extra fluid. In his case he needs the dialysis more for cleaning than fluid removal at this point, so he isn't as high a risk for fluid overload as some people would be. .


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## Veneficus (Oct 25, 2010)

Aidey said:


> I'm off to work, so I can't reply in full right now, but with his possible clotting issues is he even a candidate for emergent dialysis? I'm pretty sure they have to get that sorted out first since clotting causes so many complications with treatment. I suppose they could hold off on the heparin, and instead use saline and just adjust the treatment to remove the extra fluid. In his case he needs the dialysis more for cleaning than fluid removal at this point, so he isn't as high a risk for fluid overload as some people would be. .



I don't think he needs fluid removed, I think he needs renal support for managing the components of his blood.

The best way to fix clotting (especially DIC) is to find out what is causing it and get right to the point.


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## firetender (Oct 25, 2010)

Melclin said:


> * I went and got a towel and wiped drops of sweat off his brow because it was dripping in his eyes. I spoke to his family because no one else was and his daughter was crying. I helped him empty his colostomy bag. But who gives a toss? So would everyone else. Its just basic humanity. I don't need to post that and nor does anyone else need to suggest it in their posts.
> 
> Its a given.


 
I'd like to say that's the truth that it's a given, but, unfortunately, it really isn't now and never was. If you "helped" him empty his colostomy bag that tells me there was no urgency to the call. That characterization alone tells me how I'd handle it. I would NOT treat or even worry about every little symptom unless it PERSISTED!



Melclin said:


> What I need from the forum is suggestions about this case that would help me to make treatment, triage and transport decisions in the future.


 
There's what is going on at the scene, choices made prior to loading, changes to consider en-route. In this case, those are quite simple. Unfortunately, they were not simply communicated.

Technically, as far as communicatineg here goes, you tripped yourself up by "leading us in" but the picture you painted was incomplete.

I'm back in the Stone Age thinking "radio report"! What would I have had to say to the Doctor to get the orders I needed to get the patient to the hospital quickly and simply and without further trauma? In this case (at the point at which I chimed in) the picture was incredibly muddled by everyone worrying about disease entities. 

Look, here's what I'm saying; there's info to be considered AT the scene. That's a whole different ballpark than what is actually going on with the Pts greater problems. 

GOOD! figure that stuff out, but if someone is presenting a case here, I'd sure like to hear -- AT FIRST -- this is what we saw, this is what we did, this is what happened, followed by what could have been done to make the call go more smoothly and LAST, what was REALLY going on, or what did we miss.



Melclin said:


> Thanks to this discussion, I've already realized I really should have considered bleeding. I didn't consider electrolytes until I saw the blood work. To big gaffs with early signs I could have noticed that I now know about. I've noticed other little things as well that would help me in future. Which is exactly what I hope for when I post jobs like this.


 
One of the things that didn't come out was you did have a handle on the immediate situation, responded effectively and, true to your profession, the patient got taken care of (and IMHO you took the EXTRA steps of being responsive to him as a human being BRAVO!). Give yourself a little credit. Understanding usually comes later, and you're seeking it, so let me give you credit for that, as well.




Melclin said:


> That's because the job was swiss chesse. It was a very dynamic case. It was very complex in terms of the changing nature of his physical assessment.


 
EXACTLY; he was exhibiting TRANSIENT symptoms (mild SOB upon being questioned, sweating). One of the skills you'll be learning is to not get thrown by every adjustment the body is making to get through an assault.




Melclin said:


> It was also a job that was sandwiched in-between 6 other jobs that day. All told its not that easy to communicate it all.


 
I don't care if you ran 20 calls that day. If you're going to communicate with me about this call; communicate as simply as you can; break things down into what is most "Now!" and do them. This forum is good practice. 

I "got" that you were leading us into the scenario so you could sort of test yourself and what you DID do, but you worded it in a way that everyone said "Doctor time!" and jumped at the bait. As a result, no one really gave you what you asked for.



Melclin said:


> Also I didn't retract any urgency. It was never there to begin with, I said he was _mildly_ short of breath after being _prompted_. What I did is recognize that I didn't really provide much detail in my resp assessment.


 
Good catch!



Melclin said:


> I do, however, wish more people had weighed in with treatment and transport opinions but I didn't see yours there either firetender.


 
According to what you presented, IV TKO, monitor, transport, of course, how could I make that call without knowing how far away you were from the Hospital. 

AND that's where the ESSENTIAL information you began with this post really comes into play. You had plenty of time to be a responsive human being with the guy which probably did MORE for the guy's being able to enter a healing path than any drug or intervention bandied about here.

I'm here to tell you basics first and there's nothing more basic than observation, discernment of urgency, and communication. If you're going to work on anything, that comes first!

I appreciate your consistency in seeking more knowledge and experience through this forum, and hope what I offer is more encouragement than criticism.

Love the time you've been given!


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## Melclin (Oct 25, 2010)

jrm818 said:


> So why was the blood "clotting quickly"?  I don't know any other reasons that would happen, but that's likely just ignorance on my part.
> 
> *No idea. It was just the observation of the triage nurse. I suspect the subjective measure of blood clotting time is probably fairly useless,  but I thought I'd throw it in for people to take or leave.*
> 
> ...





Veneficus said:


> before or after treatment?
> 
> Before would be really bad. After not as bad.
> 
> ...





firetender said:


> I'd like to say that's the truth that it's a given, but, unfortunately, it really isn't now and never was. If you "helped" him empty his colostomy bag that tells me there was no urgency to the call. That characterization alone tells me how I'd handle it. I would NOT treat or even worry about every little symptom unless it PERSISTED!
> 
> 
> *The colostomy bag was at hospital. With the exception of that, I would expect any medic here to do all of those things. *
> ...



The highly unsatisfying answer (for me anyway) to this scenario is that he was dehydrated. They could find nothing wrong in the ED or the ICU other than that. He bounced back well and went to the ward a day later. I don't know what happened after that. No PE, no AMI, he wasn't septic as far as they could tell. The electrolytes and kidney function were thought to be secondary to the poor perfusion from his dehydration. I feel that something else was probably going on that they would figure out down the track a little, but I wasn't around long enough to find out and I don't know much more than that.

Out of interest: he got ~1L of rapid infused saline from us + metoclopramide for nausea. I wasn't privy to the the ddx because I was bringing some gear in from the house, but they were thinking hypovolaemia [what their theory about the origin was, I'm not sure] or sepsis. One of the medics was a little less keen on fluids than the other, I think he was leaning more towards PE, but the other was MICA so he won. Transported non-emergently to the hospital that did his operation.


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## jrm818 (Oct 26, 2010)

Melclin said:


> The highly unsatisfying answer (for me anyway) to this scenario is that he was dehydrated. They could find nothing wrong in the ED or the ICU other than that. He bounced back well and went to the ward a day later. I don't know what happened after that. No PE, no AMI, he wasn't septic as far as they could tell. The electrolytes and kidney function were thought to be secondary to the poor perfusion from his dehydration. I feel that something else was probably going on that they would figure out down the track a little, but I wasn't around long enough to find out and I don't know much more than that.



I agree...not a particularly satisfying answer about a patient who appeared very sick (at least to me, and I'm glad I'm not the only one). If I were the patient, of course, I'd be very satisfied indeed.

Don't have too much more to add at this point (other than an "oh well") Thanks for posting the scenario though - it was a fun mental exercise and a great learning experience for me as well; much appreciated.  For what it's worth, I agree with the rationale for why you posted the scenario the way you did.  Telling us the answer at the beginning shades all the responses and doesn't give you an accurate idea of what other people would actually do or think in a similar situation.

Aside: 

Sorry, I don't really see "monitor IV transport" as actual treatment, or even really "care" at all.  "Monitor" just allows you to start to form a working diagnosis (or not, if you can't tell the difference between an EKG and those funny earthquake recordings), but is rather useless if you're not going to use the information to develop a treatment plan based on what you interpret.

"IV" is preparation for some sort of treatment that might go into the tube, but without anything going in, jamming a plastic straw into a vein is rather non-theraputic.  To decide what goes in (no, sorry "TKO" doesn't count), if anything, you have to have some idea what would be most beneficial for your patient....thus discussions like this.

"Transport" well, if you're not treating your patient because they'll be at the hospital soon enough, well we might as well throw the patient in a rickshaw and run them over to the medicine man.  Transport may be the only treatment for some patients, but if your priority is just to get to the "move the patient" bit on every patient encounter...well, I'd say piano-moving probably pays better.

I don't think our goal should be to have no clue what is going on with our patient, rely on the authoritative voice at the other end of the phone to tell us what monkey skill to perform, and mindlessly move the body of your patient from A to MD.  Yes yes, care of the spirit etc....but at some point care of the body has to be part of the equation for many patients, and I think EMS should aspire to provide meaningful treatment for sick and injured bodies.




> Maybe I misunderstood. I thought you were referencing House as a joke when you said Lupus. Paraneoplastic syndrome was the follow on in that line of humour.



No worries, Lupus was a joke, and I knew you were joking too.  I just meant that eventually the joking diagnosis of Lupus or paraneoplastic is bound to actually be the right answer....and when that happens, I think it deserves some recognition


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