# 64 yo M fall, not dangerous (per dispatch)



## Burritomedic1127 (Aug 13, 2014)

At 0200 your ALS rig gets dispatched to one of the city MBTA stops for the fall, not dangerous. OA you find a 64 yo M local drunk who you know has frequent episodes of Rapid Afib with RVR and very poor vascular access, pt is walking back and forth near train platform, sits down crosses his legs and complains of SOB.

Get her done..


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## PotatoMedic (Aug 13, 2014)

Taxi voucher?  Just kidding.

Vitals, skin signs, EKG, onset of SOB, lung sounds, meds pt takes, and have they been drinking.


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## STXmedic (Aug 13, 2014)

1) Why is this in the Health and Fitness section?

2) You basically just gave us the answer... (Eta: disregard this bullet. Misread the initial post)

3) To play the game, how about vitals?

4) It was dispatched as a Fall, so I will definitely _not_ be bringing in my O2 bottle.


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## DesertMedic66 (Aug 13, 2014)

STXmedic said:


> 1) Why is this in the Health and Fitness section?
> 
> 2) You basically just gave us the answer...
> 
> ...



But you'll be bringing in a backboard and C-collar right?


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## Burritomedic1127 (Aug 13, 2014)

Pt was AOx4 and has not been drinking (shocker). Stated he fell yesterday morning off of the platform, about 5 feet, onto the tracks just missing the 3rd rail. No LOC and no one witnessed the fall. HR 70 RR 22 non labored with clear LS in all fields, pt refused manual BP just demanded he goes to the hospital

Hx Afib, COPD, ETOH abuse, hyperlipidemia
Meds Metoprolol, Albuterol, Simvastatin


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## Burritomedic1127 (Aug 13, 2014)

Taxi voucher for the win ha


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## DesertMedic66 (Aug 13, 2014)

Burritomedic1127 said:


> Pt was AOx4 and has not been drinking (shocker). Stated he fell yesterday morning off of the platform, about 5 feet, onto the tracks just missing the 3rd rail. No LOC and no one witnessed the fall. HR 70 RR 22 non labored with clear LS in all fields, pt refused manual BP just demanded he goes to the hospital
> 
> Hx Afib, COPD, ETOH abuse, hyperlipidemia
> Meds Metoprolol, Albuterol, Simvastatin



Skin signs? 12-lead? SpO2? Any neuro deficits? Pupils? Any injuries on his head, chest, abd? Pain? Can he take a deep breath?


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## STXmedic (Aug 13, 2014)

Is the patient actually taking said medications?


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## PotatoMedic (Aug 13, 2014)

So... why did he call ems today?  Because he fell yesterday?

And my taxi idea is coming back.  (one agency I worked for we had taxi vouchers for, what so far appears to be, this reason.)


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## samiam (Aug 13, 2014)

Monitor and transport. $300 taxi service. If he consented I would probably board and cspine to cover my butt O wait NO etoh? Then just load and go if he clears nexus!.  I dont really see what you want us to solve here? Is there some strange underlying thing we are missing? I will go with Neurally Mediated Syncope brought on by urination? Hows that?


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## PotatoMedic (Aug 13, 2014)

He did fall... Rectal Tone Test?


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## chaz90 (Aug 13, 2014)

samiam said:


> Monitor and transport. $300 taxi service. If he consented I would probably board and cspine to cover my butt O wait NO etoh? Then just load and go if he clears nexus!.  I dont really see what you want us to solve here? Is there some strange underlying thing we are missing? I will go with Neurally Mediated Syncope brought on by urination? Hows that?



Even if he was wasted drunk and walking around complaining of SOB as described I wouldn't backboard him. Agreed with the rest of your post.


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## DesertMedic66 (Aug 13, 2014)

FireWA1 said:


> He did fall... Rectal Tone Test?


Gotta buy him dinner before you do that


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## STXmedic (Aug 13, 2014)

Previous call looking for validation?


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## DrParasite (Aug 13, 2014)

Burritomedic1127 said:


> Pt was AOx4 and has not been drinking (shocker). Stated he fell yesterday morning off of the platform, about 5 feet, onto the tracks just missing the 3rd rail. No LOC and no one witnessed the fall. HR 70 RR 22 non labored with clear LS in all fields, pt refused manual BP just demanded he goes to the hospital


So take him to the damn hospital.  He wants to go, he is relatively asymptomatic, I'm assuming he either doesn't want a 12 lead or it is normal.

Sir, please walk to the ambulance, sit on the bench, we are going to take a nice slow ride to the ER.  

we all go home happy at the end of the day


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## samiam (Aug 13, 2014)

chaz90 said:


> Even if he was wasted drunk and walking around complaining of SOB as described I wouldn't backboard him. Agreed with the rest of your post.



I changed my mind once i read it again and saw no etoh and was too lazy to erase it so i just added on


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## PotatoMedic (Aug 13, 2014)

OK so in reality I would tell the guy if he wants to go to the ER then he needs to sign the accept treatment and transport line.  Then document he refused all care and take him to the ER. And bill him.


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## Burritomedic1127 (Aug 14, 2014)

My bad slow response here

Pt walked to truck, no obvious signs of trauma, skin color WPD, no signs of respiratory distress. Pt started complaining of non radiating back pain between the shoulder blades. No head neck or back pain on palpation. Pt refused backboard because it makes his breathing worse but allowed for BP once in the truck. Pt was hypotensive in the 80s. Afib on the monitor in the 70s, 12 lead unremarkable, 98 on RA, NIBP 60/40

Local hosp 2 mins away
Trauma center 15 mins away


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## Burritomedic1127 (Aug 14, 2014)

Unknown if pt has been taking medications, no neuro deficits noted, PEARLA, both legs have old wounds that have been treated at the hospital recently, no dinner date or check of rectal tone. IV access is a 22 in pts Thumbs that blows with fluid, humeral IO access obtained. Blood sugar 104 Lactate 0.2 Pt was afebrile 

Transport to local hospital (2 mins away) or trauma/everything hospital (15 min away)? and would you trauma alert?


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## STXmedic (Aug 14, 2014)

Did you seriously start a humeral IO on this guy?


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## chaz90 (Aug 14, 2014)

If I were actually on scene with this patient, no way would my index of suspicion of dissecting AAA be high enough to start an IO or call a trauma alert. Isn't he still basically asymptomatic with back pain and hypotension in the 80s? 

Since you posted it on here, I'm assuming the right answer is "Trauma Alert and expeditous transport to the trauma center."


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## Burritomedic1127 (Aug 14, 2014)

with a dropping BP in the 60s i see no problem. Another attempt was made by my partner but no luck. He is well know to EMS and surround hospitals for terrible access.


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## Burritomedic1127 (Aug 14, 2014)

Brought him to the local hospital with fluid running through the IO and his pressure back up to 100s. Come to find out he had a small bilateral hemos with a T5 T6 shift. Our med control battled that this was a trauma pt and should have went to the trauma center and my company felt different. The case went to Rounds with good discussions but no resolution. So my question with this scenario is there a time limit on "traumatic events" and going to trauma centers? Example if a fall happened lets say 10 hours before would you still go to a trauma center?


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## Burritomedic1127 (Aug 14, 2014)

Also where i work, if i were to not start an IO in this situation and just bring the pt to the hospital hypotensive, i would get a new one ripped reall quick


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## DesertMedic66 (Aug 14, 2014)

Burritomedic1127 said:


> Brought him to the local hospital with fluid running through the IO and his pressure back up to 100s. Come to find out he had a small bilateral hemos with a T5 T6 shift. Our med control battled that this was a trauma pt and should have went to the trauma center and my company felt different. The case went to Rounds with good discussions but no resolution. So my question with this scenario is there a time limit on "traumatic events" and going to trauma centers? Example if a fall happened lets say 10 hours before would you still go to a trauma center?



If a fall happened 5 minutes before I got there I still may not go to a trauma center. Trauma =\= trauma center


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## Burritomedic1127 (Aug 14, 2014)

DesertEMT66 said:


> If a fall happened 5 minutes before I got there I still may not go to a trauma center. Trauma =\= trauma center



Agreed. Our med control felt different. Interested in people thoughts on trauma center or not with this pt


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## chaz90 (Aug 14, 2014)

Burritomedic1127 said:


> Agreed. Our med control felt different. Interested in people thoughts on trauma center or not with this pt


I would not have transported to a trauma center based on your scenario. Unless they're using the magic of hindsight, they probably wouldn't have advocated it at the time before knowing the end diagnosis either.


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## chaz90 (Aug 14, 2014)

Side note: If you transported 2 minutes to the local hospital, how did you have time for a missed IV, a 22G thumb IV with fluid running, and a numeral head IO with enough fluid bolused to increase his BP to 100 systolic?


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## Burritomedic1127 (Aug 14, 2014)

Both went for IVs at the same time once in truck, IO with pressure bag until transferred pt to hospital bed. Their first BP was in the low 100s


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## Burritomedic1127 (Aug 14, 2014)

chaz90 said:


> Unless they're using the magic of hindsight, they probably wouldn't have advocated it at the time before knowing the end diagnosis either.



Exactly. They had no complaints from the initial report but after the magic of x ray they were singing a different song.


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## Handsome Robb (Aug 14, 2014)

I wouldn't have taken him to the trauma center based on what's here.


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## DrParasite (Aug 17, 2014)

Burritomedic1127 said:


> My bad slow response here
> 
> Pt walked to truck, no obvious signs of trauma, skin color WPD, no signs of respiratory distress. Pt started complaining of non radiating back pain between the shoulder blades. No head neck or back pain on palpation. Pt refused backboard because it makes his breathing worse but allowed for BP once in the truck. Pt was hypotensive in the 80s. Afib on the monitor in the 70s, 12 lead unremarkable, 98 on RA, NIBP 60/40
> 
> ...


Honest answer?  depending on the local hospital (and what surgical options they have immediately available), I might head to the trauma center.

When I hear back pain between the shoulder blades, and really hypotensive (esp if old and/or a previous history of smoking), AAA bells start going off in my head.  if he gets dizzy when he stands up or passes out, then they are really going off.

If it's a triple A, then he will need surgical intervention, and need it fast.  if the local hospital can do it, go there.  if not, go to the trauma center.  no trauma alert

btw, you gave an IO to a conscious frequent flier with poor vascular access?  ouch, he must have loved you after that.


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## Burritomedic1127 (Aug 20, 2014)

DrParasite said:


> btw, you gave an IO to a conscious frequent flier with poor vascular access?  ouch, he must have loved you after that.



Yeah he's well known through the city for having episodes of rapid Afib and poor access. He's no stranger to prehospital IOs. There's a perfect EJ but our medical director frowns on them and is in favor of IOs. We give 40mg of lido real slow initially through the IO if they're conscious to try and help with the pain of the rapid flush that follows. Still would rather have an unconscious pt for an IO but they do work well.


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## Uclabruin103 (Aug 20, 2014)

Do you have anywhere in protocols that has this addressed?  Trauma or destination?  I know we want to go to the most appropriate facility with our patients but everywhere I've worked if they're not specialty like trauma cva stemi they go to the closest.


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## benasack2000 (Aug 22, 2014)

I'm guessing your from Boston?


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## Burritomedic1127 (Aug 31, 2014)

Uclabruin103 said:


> Do you have anywhere in protocols that has this addressed?  Trauma or destination?  I know we want to go to the most appropriate facility with our patients but everywhere I've worked if they're not specialty like trauma cva stemi they go to the closest.



http://www.mass.gov/eohhs/docs/dph/emergency-services/trauma-hospital-destinations.pdf. Here's our state Trauma POE Plan. The medical control doc felt this Pt met the physiologic criteria of having a SBP < 90 (in the setting of a "trauma")." Myself and my company felt since his "traumatic event" happened greater than 12 hours prior, the closest hospital was fine. Nothing set on time limits of traumatic events. So I'm assuming somewhere in between the golden hour if your urban and the golden day if your in the wilderness would be the call haha


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## jrm818 (Aug 31, 2014)

You just need a better retro-specto-scope for your ambulance.

Though this guy is rather hyotensive, but not knowing his baseline BP and with essentially no physical findings and not even a bit of tachycardia, I don't think many people would really say "SICK!"  I doubt many would even go the IO route.  I wouldn't (and even knowing the outcome don't) feel like that trauma protocol applies - it's supposed to identify patients who are dropping their blood pressure in a rapid and life threatening manner in the immediate aftermath of the trauma.  Until the dx. was made, I don't see any evidence that his BP was related to his fall at all.

Sure rupturing aneurysms/dissections may be better served at the trauma center.  I might have chosen a big hospital for that reason - but I'd probably make that decision independent of his trauma.  I would not have predicted the actual diagnosis based on your findings.

I don't get all the flak you're getting.  Was there a bad outcome due to the destination?  Sounds like it didn't end up mattering in the end - pt. got what sounds like very good care, was diagnosed, and presumably treated just fine.


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