# RLS for internal bleeding?



## MMiz (Jun 26, 2005)

Dispatched P3 (non-emergent but going to hospital.  Standard non-scheduled  nursing home call) to a local nursing home.  ATF 70 y/o supine in bed with dark red / bluish skin.  I've never seen this before.  BP 120/56, P 46 irregular, R18.  Pt complains of pain in right leg/hip.

NH states patient has been bleeding since 5/25, and over the past two days he has been bleeding w/ significant blood loss through nose and mouse.  Black stools.

I noticed no other significant findings and he had no complaints.  He was on blood thinner, which was stopped 24 hrs prior, but he continued to bleed.

Now my question, do you take this to the hospital RLS?

I called for ALS, they weren't readily available, and I then went RLS to the hospital.  I now have my doubts.

My reasoning: Pulse was irregular and sometimes hard to find.  This guy was red/purple, and the family was shocked.  The NH kept passing this off from shift to shift until someone realized this.  When they did, they called us, and after talking to them they seemed to think he needed to go to the hospital urgently.

So?  What would you have done?


----------



## Ridryder911 (Jun 26, 2005)

Sounds like the patient may be anemic or have petchaie (bluish/reddish appearance to skin/conjutiva) , that can be related to the blood thinners. Thrombocytopenia may even be involved. Since this patient has been on blood thnners her PT/PTT/INR even platelets (Lab test for blood clotting time & viscosity) is probably off wack. 

The irregular pulse may be associated with the history of why the patient is on blood thinners ( recent Atrial Fib patients are on blood thinners) to prevent them from developing & throwing a clot. The patient does not appear to be hypotensive, & appears to be non-cpmpensating, since this has  occured over a period of some time. I would not classify as life threatning emergency; however, you did not hurt anything by doing so.

Be safe, 
Ridryder 911


----------



## MMiz (Jun 26, 2005)

Ridryder911,

Great catch, I forgot to include history.

Pt did have a history of Afib and anemia I believe.

It was a safe transport with nothing exciting, but I'm feeling a bit of guilty aftwards.   

I really wish I had the clinical and book knowledge to put all of this together like you did.  I feel at this point I'm treating symptoms, not understanding the entire puzzle.  Hm.


----------



## rescuecpt (Jun 26, 2005)

Matt, if you have that icky "this doesnt seem so good" feeling, and you can justify RLS to your superiors, do it.  Never underestimate the power of an EMTs gut.  I've done that many times, and while filling out paperwork had a doc or nurse tell me what was wrong with the patient - even though I didn't know what specifically was wrong, something told me get them there quick - and I was usually right.


----------



## TTLWHKR (Jun 26, 2005)

First of all, what does RLS mean?

Ringers Lactate Solution?

 :blink: 

I think however that you mean Red-Lights & Siren. So going on that assumption, and the fact that the man is on a blood thinner and bleeding from three out of five holes... I'd say that guy has a problem. Although, the blood in the stool may be explained as digested blood, etc. Maybe the bleeding is originating from the sinus region which would also explain blood from the nose and mouth. But if he's been doing this for nearly a month, and his skin is turning blue then he's clearly not profusing well enough. I'd look at it as a hypovolemic case, it is possible to lose a large amount of blood, and maintain regular vital signs as long as you're always supine. I doubt you could, or would even try to make him stand... but I'd have like to seen the hydrostatic BP. 

I'd have wanted to give him two tall drips; NS & LR (which acts byitself to replace the electrolytes and minerals that are found in the blood). He definitly needs blood, and surgical or endoscopic intervention to clot off that bleeding.

_Given you had no ALS, I'd say you made the right decision. _Depending on how close I was to an ER, that is how I decide need for L&S. Sometimes it's just not safe no matter how quick you need to get there, even with a full code. Ambulances make civilian drivers stupid, which put us in peril. 

But still, those damn nursing homes, I'd rather be shot that live in one of those. Chest pain, began two shifts ago, breathing stopped at 11pm (now 7am); all the codes - shift change.. All claim over worked and under staffed; but nonetheless worst care anywhere.  :blink:


----------



## rescuecpt (Jun 26, 2005)

Yesterday my partner and I were going lights and sirens to a firefighter's family for an unconscious.  Most people were pulling over quite nicely, but there was one guy who wouldn't... despite the lights, the wail, and the buzz.  So we hit the airhorn.  It took a 1-2 count, but he slammed on the brakes, swerved to the right, and left a little bit of his tire on the pavement.    There was smoke rising off his back tire...  we were hysterical - then we said "oh $hit, he's going to be our next call for a massive stress induced MI."   HEHEHE.


----------



## ma2va92 (Jun 26, 2005)

> _Originally posted by MMiz_@Jun 25 2005, 11:39 PM
> *
> 
> 
> ...


 Really no need to give a reason....you were with the pt. .. and it was your call.. you felt .. that you need to get the pt... to the hospital faster then the every day norm.....to me .. you did what you felt was right for the pt...... you called for  ALS ... but no was home.... you felt the pt. needed more than you could do for him/her..... I'm glad you made the call.. and stuck to it.....u did good.... 

have a few in our squad that i wish would make calls like this



request has been sent for one AT-A-BOY PATCH


----------



## PArescueEMT (Jun 26, 2005)

Great choice matt... i give you my kudos... I am also seconding the request for the AT-A-BOY patch...


Alex... i was under the assumption that you never completed your medic school... was I wrong in this assumption?


----------



## TTLWHKR (Jun 26, 2005)

> _Originally posted by PArescueEMT_@Jun 26 2005, 08:04 PM
> * Great choice matt... i give you my kudos... I am also seconding the request for the AT-A-BOY patch...
> 
> 
> Alex... i was under the assumption that you never completed your medic school... was I wrong in this assumption? *


 I never took the National Registry exams... I've had my PA DOH EMT-P Cert since I was 21. 

But since I worked in Ohio for the most part, it was useless.


----------



## Jon (Jul 1, 2005)

> _Originally posted by TTLWHKR+Jun 26 2005, 10:05 PM--></div><table border='0' align='center' width='95%' cellpadding='3' cellspacing='1'><tr><td>*QUOTE* (TTLWHKR @ Jun 26 2005, 10:05 PM)</td></tr><tr><td id='QUOTE'> <!--QuoteBegin-PArescueEMT_@Jun 26 2005, 08:04 PM
> * Great choice matt... i give you my kudos... I am also seconding the request for the AT-A-BOY patch...
> 
> 
> Alex... i was under the assumption that you never completed your medic school... was I wrong in this assumption? *


I never took the National Registry exams... I've had my PA DOH EMT-P Cert since I was 21. 

But since I worked in Ohio for the most part, it was useless. [/b][/quote]
 Ahh....


I agree with Ridyrider, and also with Alex.

Something ain't right, and I got the feeling that you felt something was WAYYYY out of whack, you called for ALS, ALS wasn't availible.... this is the biggest reason that ALL BLS rigs should have emergency warning devices, and also one of the few times you can almost always justify Class I / II transport as a BLS rig.... ALS level care indicated, without ALS level care being availible.


Jon


----------



## SafetyPro2 (Jul 2, 2005)

I'd rather err on the side of flipping the lights on and getting to the ER a couple minutes faster than taking the extra time and having a PT code in the back of the rig. Yes, non-emergency transport is safer, but if you drive with care and don't push it too hard, I don't think its that much greater of a risk.

I'll admit, I've transported Code 3 a couple times where on reflection, it probably wasn't necessary, but I don't regret having done so because I've had the other calls where I wasn't sure I should go Code 3 and am glad I did.

Good example happened a couple weeks ago. Elderly female PT found supine at the base of a set of stairs outside an apartment. PT had moderate facial trauma and was somewhat confused (didn't remember falling or any events prior, but was other than that A&O). No significant complaints beyond the facial trauma and some neck pain. Vitals were not too bad for an elderly PT. We C-spined and controlled the bleeding, and I went as the PT care person in the back. Even though she was stable, my gut told me "go Code", so I told the driver to light it up.

Later that night, was back at the ER with another PT (an elderly male this time found supine at the TOP of a set of stairs with similar facial trauma...go figure). We didn't go code on him 'cause it was 2 AM and no traffic to worry about anyway. We brought him in, and the nurse (same one from earlier) looks at him and you can tell she's thinking "Not another one!". She looks at me and says, somewhat jokingly, "If this one has a bleed too, you guys can't come back again." I ask her what that means, and she proceeds to tell me that the previous PT had an intercranial bleed and was in the ICU. 

So, don't sweat it. Like high-flow O2, high-flow diesel usually won't make the situation any worse, but can definitely make it better in some cases.


----------



## KEVD18 (Jul 4, 2005)

i would conservitively estimate that i have the most priority transpots of anybody in my agency with comparable street time. this is because i never second guess my self. if for one second i think the pt needs to get there that fast, i hit the switches and never look back. and its paid off for me.

your a professional. go with your gut. maybe your wrong and the pt would have been just as good with a normal t/p. but, assuming nobody got hurt as a result of you coding through the city, then alls well that ends well.


----------

