# How would you treat this patient?  ALS or BLS?



## nymedic9999 (Nov 12, 2013)

Patient was found seated in chair next to kitchen sink. Patient was CAOX3 and interacting with EMS. Patient was diaphoretic and pale. Patient was vomiting into kitchen sink. Patient stated that he had been seated reading the newspaper when suddenly he felt weak and dizzy and became diaphoretic. Patient stated that early on in the day he had gone to church and had not eaten a meal since the previous evening. Patient denied any chest pain, SOB, LOC, and recent illness. Patient also denied any recent surgery and traumatic injuries. 

BP-160/70
HR- 80 Regular
Respirations- 14
Spo2-93
GCS-4.5.6


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## Rialaigh (Nov 12, 2013)

How old is this patient?


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## medicdan (Nov 12, 2013)

Depending on my transport time to the hospital, and the fact i'm a new medic, I'd very likely work them up ALS. The patient can benefit from a BGL, IV, and a little fluid (given poor PO intake/Dextrose as necessary), some Zofran for the ongoing nausea. Given the rapid onset (and ?unknown age/gender), I'd put them on the monitor, and likely get a 12-lead or three. Lastly, perhaps 2L O2, but I'm not very generous with oxygen these days... so will troubleshoot the SpO2 of 93%, although there is some "comfort" afforded. 

I'd like to try to interrogate the causes of nausea, and perhaps offer relief in the time i'm with the patient. You don't give us much in the way of history or physical exam, and that's critical for developing a treatment plan for this patient. 

I'm also a new medic, so a relatively low threshold for working someone up ALS...


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## NBFFD2433 (Nov 12, 2013)

medicdan said:


> Depending on my transport time to the hospital, and the fact i'm a new medic, I'd very likely work them up ALS. The patient can benefit from a BGL, IV, and a little fluid (given poor PO intake/Dextrose as necessary), some Zofran for the ongoing nausea. Given the rapid onset (and ?unknown age/gender), I'd put them on the monitor, and likely get a 12-lead or three. Lastly, perhaps 2L O2, but I'm not very generous with oxygen these days... so will troubleshoot the SpO2 of 93%, although there is some "comfort" afforded.
> 
> I'd like to try to interrogate the causes of nausea, and perhaps offer relief in the time i'm with the patient. You don't give us much in the way of history or physical exam, and that's critical for developing a treatment plan for this patient.
> 
> I'm also a new medic, so a relatively low threshold for working someone up ALS...


I agree.


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## Akulahawk (Nov 12, 2013)

I'd do a 12-lead, check BGL. I'd change sites used for the SpO2. This patient may be pretty well peripherally vasoconstricted and that can affect the reading... if it's still < 94% and >92%, I might consider 2L Oxygen. What I want to know is what meds/drugs the patient is taking, in particular, any drugs for ED? Do a physical exam. Any dependent edema? Lung sounds? Heart sounds? Does the patient feel like he's OK to lie down? At some point, obtain vascular access, considering line vs lock.

As details are provided, I certainly may change any of the above at any time simply because there's very little info available so far.


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## nymedic9999 (Nov 12, 2013)

55 yo male


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## NJEMT95 (Nov 12, 2013)

Although there's a chance the pt would benefit from ALS treatment, since my transport times are 10-15 minutes (ALS would take 5-10 to arrive), I would administer O2 via NC and transport BLS. If BLS scope in your area allows it, I would check BGL.


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## EMT B (Nov 12, 2013)

BGL,12-lead, saline lock, labs, 4mg ODT Zofran. This call can be managed at the ILS level


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## TransportJockey (Nov 12, 2013)

Twelve lead, CBG check, iv and small bolus, iv antiemetics.


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## Wheel (Nov 13, 2013)

12 lead, iv, bgl, a little fluid, and zofran. Depending on assessment, maybe O2. That age with pale, diaphoretic skin would have me at least considering something semi serious.


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## medicdan (Nov 13, 2013)

nymedic9999 said:


> Patient was found seated in chair next to kitchen sink. Patient was CAOX3 and interacting with EMS. Patient was diaphoretic and pale. Patient was vomiting into kitchen sink. Patient stated that he had been seated reading the newspaper when suddenly he felt weak and dizzy and became diaphoretic. Patient stated that early on in the day he had gone to church and had not eaten a meal since the previous evening. Patient denied any chest pain, SOB, LOC, and recent illness. Patient also denied any recent surgery and traumatic injuries.
> 
> BP-160/70
> HR- 80 Regular
> ...



I think were pretty much all in agreement with the assessment and treatment for this patient, was there a curve ball here? Op, did you have a question about management or experience an unexpected reaction? For many medics this is straightforward, what are we missing here? 

I'd argue that even in systems with short transport times, its valuable to at least get a Lin, EKG and zofran, they don't take long, can provide almost immediate relief and change disposition. In the systems where I work, id have to justify why I didn't do an EKG, and short transport times aren't an excuse.


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## mycrofft (Nov 14, 2013)

What is transport time? Level of measures and and speed of drive to the receiver must rely on drive time versus pt condition and protocols/measures you can use measurement. Stalling to take data you can't use and which the hospital will derive as you leave the pt there is a waste. Stalling to start measures you don't need to is a waste. BUT, I also say trust your intuition.

Pt seems in no crisis if simply sitting helped. If it is a long drive (say 20 min) or if your spider sense says "not going to hold together", go ALS. IF it's short to the hospital, just go. Antiemetic sounds good. At the hospital if labs permit they will likely hang a banana bag and observe, take EKG etc. 

I hope this isn't a family member or a disputed run we are siding on.:unsure:


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## Rialaigh (Nov 14, 2013)

If BLS shows up first BLS, if ALS shows up first ALS, I don't see any long term benefit of going ALS for 25 minutes instead of BLS


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## Giobobo1 (Nov 15, 2013)

If i had the option, ALS for sure but if transport time is shorter than ALS, 02 Via NC and transport.


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## PFDEMT (Nov 15, 2013)

CHECK BGL!!!!!!!! 
EMT says: '' Are you diabetic Sir''

PT says: '' Yes sir''

EMT: well you havn't ate in a long time and now your BGL is 40.

Per your protocall ALS for eval most likely gets a sandwitch and no tranported is needed.



This would be exactly what i would do and ask before any interventions were done. 

But if BGL was normal i would still say due to vitals he is stable. BP high due to onset vommiting but bottom number is fine.
Pt does not seem to be severly dehydrated due to PR is normal and stable.
Resperations are fine and pt is AOx3/3 in no obvious signs of distress.

Spo2 is retarted and means nothing. ( in this case)

After medic eval and 12lead, I still think pt goes BLS.


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## triemal04 (Nov 15, 2013)

PFDEMT said:


> CHECK BGL!!!!!!!!
> EMT says: '' Are you diabetic Sir''
> 
> PT says: '' Yes sir''
> ...


Oh.  So you're one of those things.  Ok.  I'll play.

You have to decide whether or not to request ALS for an "eval."  Do you?  If so, why?  What are you concerned for?  If not, why?  What are you not concerned with?

What further information, if any, that you can determine for yourself and understand do you think would help with your decision making process?

Edit:  And don't just say "I'd do what my protocols tell me."


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## Handsome Robb (Nov 15, 2013)

We don't run a tiered system so yes, this patient would go as an ALS patient. This is the spitting image of my last STEMI. 

59 year old male, no history, allergies or medications, acute onset of dizziness, weakness, nausea and vomiting. Ended up with 3 stents. 

Even if the first 12-lead doesn't show something I'd be doing at least one during transport and upon arrival to the hospital. 

If you're BLS only and your transport time is shorter than it would be to have ALS intercept just take them but if it's a Medic/Basic truck the medic needs to be attending this call.

I guess I'll list out what I'd do so people don't put words in my mouth. 12-lead, IV, antiemetics PRN, beyond that I'd need more information to determine a treatment pathway. Could be run of the mill flu all the way up to a life/quality of life threatening cardiac or neurological emergency.


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## teedubbyaw (Nov 16, 2013)

PFDEMT said:


> CHECK BGL!!!!!!!!
> EMT says: '' Are you diabetic Sir''
> 
> PT says: '' Yes sir''
> ...



I would not be so quick to say that patient is stable. You might want to re-evaluate how you do things. Your know it all attitude may lead to a patient of yours dying.


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## abckidsmom (Nov 16, 2013)

All people who are vomiting with weak and dizzy have Sick in their potential.  Especially 55 yo men.  

If BLS was the first to get there, 12 lead, maybe 2 L o2, and transport.  I agree completely with the previously stated ALS treatment, and I don't think it's a "new medic" thing at all to give this guy the treatment he needs.

Is he going to survive the transport?  Yeah, probably.  Can he be more comfortably?  Definitely.


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## fma08 (Nov 16, 2013)

I'd treat him per assessment. Heard several vitals and a mental status yet not really any physical exam. Some more history too. Get a history, an exam, the tests (BGL, XII lead, etc) then I'll tell ya how I'd treat him. Per "protocol", would probably be defined as an ALS call to answer the original question.


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