# Call came in as AMS/Combative, crashed en route to ER?



## chunkypeaches (Feb 26, 2017)

A few months ago a call came in for an (appx) 80 y/o male patient to be taken to the ER due to altered mental status. The call came from a nursing home. Pt reported to have backhanded another resident and thrown a metal folding chair at a nurse. upon arrival the man was sitting down eating his lunch like nothing had happened. RN relays to us that he is demented. Pt gets on stretcher on his own and even begins to buckle himself in! during transport he and I have a normal conversation, he doesn't complain of any injury or illness, no difficulty breathing. All of his vitals are within normal ranges and he even answers questions appropriately. He is AXOX4. It was a short transport, only about 7 mins, and we're talking about christmas coming within the week, we arrive at the ER. I turn to the doors on the truck and its raining and really cold, my partner opens the doors and i tell the Pt "get ready mr.xxx it's pretty chilly out!" and i get no response i say his name again and give a sternum rub, no response. we take him inside and hand him over to ER staff. We had a call pending so all i could do was give a report and leave. Next day at ER again his nurse tells us he was intubated within 5 minutes of being there and died later that evening. Any thoughts?


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## NomadicMedic (Feb 26, 2017)

Lupus?


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## chunkypeaches (Feb 26, 2017)

NomadicMedic said:


> Lupus?


Could be? What leads you to that possibility?


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## DesertMedic66 (Feb 26, 2017)

chunkypeaches said:


> Could be? What leads you to that possibility?


Based on what you said Crohn's disease is ruled out which means Lupus is the next logical choice.


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## NomadicMedic (Feb 26, 2017)

From the paucity of information you've given us, that guess was as good as any other. Also, you've apparently never watched House.

If you want us to play guessing games as to why your patient died, provide clinical information. Actual vital signs. Physical presentation. History. Meds.  

Ya know... that stuff that we use to figure out what's wrong.


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## chunkypeaches (Feb 26, 2017)

DesertMedic66 said:


> Based on what you said Crohn's disease is ruled out which means Lupus is the next logical choice.


Good point thanks! I'm still pretty new I this. I've only been working on an ambulance for about 6/7 months now so I'll take any info you guys have! There's still plenty of stuff out there that leaves me scratching my head.


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## chunkypeaches (Feb 26, 2017)

NomadicMedic said:


> From the paucity of information you've given us, that guess was as good as any other. Also, you've apparently never watched House.
> 
> If you want us to play guessing games as to why your patient died, provide clinical information. Actual vital signs. Physical presentation. History. Meds.
> 
> Ya know... that stuff that we use to figure out what's wrong.


Gotcha sorry my post seemed a bit dry in the way of more detailed info. This was a few months ago so the number are foggy for me. But I can say that this patients vitals were stable and unremarkable as I took them and when the staff at the nursing home had taken them prior to our arrival. The pt didn't quite remember his medical history (dementia and Alzheimer's)but presented as stable. (Pink warm and dry skin and equal chest rise and fall un labored. And the staff at the nursing home didn't really provide any info (not to try to put blame on anyone but shift change had just happened for them and they are rather unorganized there)

P.s. Sorry i didn't mention he had Alzheimer's in my OP


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## DesertMedic66 (Feb 26, 2017)

The reality is there are a lot of possibilities. MI, CVA, PE, etc. 

With the amount of info you have been able to remember does not provide any help in narrowing it down.


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## Jim37F (Feb 26, 2017)

My scientific, wild-*** guess? Some sort of TIA causing the initial AMS/combative mental state that resolved prior to your arrival but led to a full blown fatal stroke later?


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## NomadicMedic (Feb 26, 2017)

Jim37F said:


> My scientific, wild-*** guess? Some sort of TIA causing the initial AMS/combative mental state that resolved prior to your arrival but led to a full blown fatal stroke later?



No way to ever know.


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## VentMonkey (Feb 26, 2017)

The patient...just died. People do tend to do that you know?


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## ERDoc (Feb 26, 2017)

chunkypeaches said:


> Gotcha sorry my post seemed a bit dry in the way of more detailed info. This was a few months ago so the number are foggy for me. But I can say that this patients vitals were stable and unremarkable as I took them and when the staff at the nursing home had taken them prior to our arrival. The pt didn't quite remember his medical history (dementia and Alzheimer's)but presented as stable. (Pink warm and dry skin and equal chest rise and fall un labored. And the staff at the nursing home didn't really provide any info (not to try to put blame on anyone but shift change had just happened for them and they are rather unorganized there)
> 
> P.s. Sorry i didn't mention he had Alzheimer's in my OP



The key to this case is right here.  He died from nursinghomeshiftchangeitis.  It's fairly lethal.


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## MackTheKnife (Feb 27, 2017)

ERDoc said:


> The key to this case is right here.  He died from nursinghomeshiftchangeitis.  It's fairly lethal.


Just like priapism is caused by lackanookie.

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## EpiEMS (Feb 27, 2017)

1) 





chunkypeaches said:


> Pt reported to have backhanded another resident and thrown a metal folding chair at a nurse








2) You could have requested a follow-up from the hospital, possibly?


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## hometownmedic5 (Feb 28, 2017)

Definitely not lupus. It's never lupus 

From the information provided, I'm 100% confident in diagnosing this as trypanosomiasis  with underlying schistosomiasis causing an acute methane buildup resulting in heavy metal poisining. Or maybe he was just old and boxed. Not every call has an interesting story. 

Here's my question. How did you manage to miss your patient going from coherent speech to a GCS of potato in a seven minute ride? I can kind of see a long transport, pt nods off, you elect to let them sleep and they're dead when you get to where you're going. But a <10min ride, talking to dead? How did you lose track of that one?


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## LaAranda (Mar 2, 2017)

hometownmedic5 said:


> Here's my question. How did you manage to miss your patient going from coherent speech to a GCS of potato in a seven minute ride? I can kind of see a long transport, pt nods off, you elect to let them sleep and they're dead when you get to where you're going. But a <10min ride, talking to dead? How did you lose track of that one?



One of the great disservices charting provides to our patients.


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## Handsome Robb (Mar 2, 2017)

LaAranda said:


> One of the great disservices charting provides to our patients.



You should be able to work on your chart and still pay attention to what is going on in the back of your truck. 


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## LaAranda (Mar 3, 2017)

Handsome Robb said:


> You should be able to work on your chart and still pay attention to what is going on in the back of your truck.



No argument here. But if you want to know how someone could go 7 minutes w/o noticing significant mentation changes, I think you've found your answer.


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## chunkypeaches (Mar 4, 2017)

hometownmedic5 said:


> Definitely not lupus. It's never lupus
> 
> From the information provided, I'm 100% confident in diagnosing this as trypanosomiasis  with underlying schistosomiasis causing an acute methane buildup resulting in heavy metal poisining. Or maybe he was just old and boxed. Not every call has an interesting story.
> 
> Here's my question. How did you manage to miss your patient going from coherent speech to a GCS of potato in a seven minute ride? I can kind of see a long transport, pt nods off, you elect to let them sleep and they're dead when you get to where you're going. But a <10min ride, talking to dead? How did you lose track of that one?


He was responsive and went under within a one minute window from finishing calling in an encode to the hospital to turning the corner to the facility/ parking. It was a rapid drop. I guess thats why it was so strange to me.


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## MikeC (Apr 27, 2017)

something so sudden with all vitals wnl suggests something cardiac related.


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## hometownmedic5 (Apr 27, 2017)

MikeC said:


> something so sudden with all vitals wnl suggests something cardiac related.



I'm not sure how you arrived at that conclusion.  It could just as easily be a neurological problem, and few sudden onset cardiac complaints result in an instant transition from baseline menatation to unresponsiveness. 

If he suffered a sudden cardiac arrest, it would fit. Beyond that, there should have been some sort of lead up, which would have been reflected in the vital signs most likely. This is of course assuming the vitals were taken accurately and often enough to establish a trend. If the last good set of signs was 45 minutes old, or if a good set of signs was never really done(not a personal attack, who of us hasn't phoned in a seemingly stable bls transfer),then this could have been brewing for awhile. 

This sounds much more neuro to me, but with no real information to go on, it really could be anything and arguing about a call with none of the necessarily details is pointless.


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## MikeC (Apr 27, 2017)

hometownmedic5 said:


> I'm not sure how you arrived at that conclusion.  It could just as easily be a neurological problem, and few sudden onset cardiac complaints result in an instant transition from baseline menatation to unresponsiveness.
> 
> If he suffered a sudden cardiac arrest, it would fit. Beyond that, there should have been some sort of lead up, which would have been reflected in the vital signs most likely. This is of course assuming the vitals were taken accurately and often enough to establish a trend. If the last good set of signs was 45 minutes old, or if a good set of signs was never really done(not a personal attack, who of us hasn't phoned in a seemingly stable bls transfer),then this could have been brewing for awhile.
> 
> This sounds much more neuro to me, but with no real information to go on, it really could be anything and arguing about a call with none of the necessarily details is pointless.


 
I was thinking mostly cardiac arrest, which could be d/t something underlining that was "missed" as you pointed out. Potential CVA included in that, so impacting the neurological ultimately.

Who knows. It'd be interesting if the OP got feedback from staff on it.


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