# What could this be?



## Aprz (Mar 21, 2010)

This is something that happened to somebody I know/a family member. I am just an EMT-b student, but I did what I could do.

So pretty much what I got from her (I had nothing, not even a watch)...

50 y/o obese female c/o chest pain "feels like somebody is punching me in the chest" followed by SOB. (+) Nausea, (+) orthostatic hypotension, difficulty breathing laying down too (only position of comfort was sitting), slow/progressive onset (over a couple of days), yellow/green sputum (occasionally pink too), pain behind left ear also. Huge amount of alcohol consumption throughout the week. Radial pulse felt fast, but it was also strong and regular. Respiration was fast and labored. Skin was pink and warm, but diaphoretic also.

In the ER, I read off the machines that the pulse was 105, respiration was 26, her BP was about 160/100mmHG, and SpO2 kept changing from 94%-97% (not/never was a smoker). Way out of my scope of practice and knowledge as an EMT-b student, but I've been learning to interpret ECGs on my own and after much practice, I could see that hers was normal.

They took several test including a blood test and found that her alcohol level was really high even though she hadn't drank for about a half a day (this happened in the middle of the night while we were all sleeping).

They let her go same day, told us it was most probably the alcohol, and advised her that this was her wake-up call.

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Anyhow, up until before the ER part with just the information I provided, what would you think and do without any equipment? 

What would you think after looking at the numbers I saw in the ER? Do you agree with the conclusion of the healthcare providers?


Oh, and what would you do if you were responding to this call as an on duty EMT of any level?
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As for me, even though it was only a couple s/s of an MI, I thought that's what it was immediately (specially after she said it felt like somebody was punching her in the chest). I figured the (occasional) pink sputum she was coughing up was from too much alcohol consumption. I already gave away what I checked for in my little report before the ER.

After going into the ER, I was very relieved to see her on a nasal cannula (not sure if that's what ERs would do to MI pt., I don't think so, but I am positive an EMT would have her on a NRM) and see that even though numbers where on the high end (especially her BP and respiration), that I didn't think it was an MI anymore (especially after seeing the ECG monitor and seeing that it looked normal). SpO2 had me a lil' curious why it was lower than what I would expected of her (at least 97%+ I would've thought - maybe alcohol lowers that?) I agree with the conclusion of the healthcare providers, but also curious on how alcohol gave her s/s of an MI and how if I ever witness something like this again.. how I would be able to recognize the difference (like I think the pink and warm skin and slightly fast (expected due to anxiety), but strong and regular pulse were signs of it not being an MI). Was a scare, but I would like comments on this to learn from this. 

If I was responding to this as an on duty EMT-b, I would've just done my normal pt. assessment, high flow O2 via NRM at 15 L/m. Try to give her emotional support/calm her down, but also make her aware of what's going on (she was in denial the whole time). I forget the name of this position, but I would also have her in a sitting position on the cot (maybe one of you guys can remind me).


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## TransportJockey (Mar 21, 2010)

Yay mild ETOH poisoning. I'd say 12 lead, 2lpm canula (only if she says she feels SOB, as up here, anything above 90 is tolerable for a non-smoker, above 88 for a smoker), IV, transport.
Usual history and questioning.
I'd see what the 12 lead said and kind of let that lead me to what treatment I'm going to do. If I get a normal ECG and history of massive ETOH consumption throughout this last week, I might lean on the side of ETOH related problems.


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## MrBrown (Mar 21, 2010)

The internet and this site is not a forum for medical diagnosis.

If you want to know what it might be, seek advice from a physician or other health/wellness professional of your choice.


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## Veneficus (Mar 21, 2010)

Where to start…




Aprz said:


> 50 y/o obese female c/o chest pain "feels like somebody is punching me in the chest" followed by SOB. (+) Nausea, (+) orthostatic hypotension, difficulty breathing laying down too (only position of comfort was sitting), slow/progressive onset (over a couple of days), yellow/green sputum (occasionally pink too), pain behind left ear also. Huge amount of alcohol consumption throughout the week. Radial pulse felt fast, but it was also strong and regular. Respiration was fast and labored. Skin was pink and warm, but diaphoretic also.
> 
> In the ER, I read off the machines that the pulse was 105, respiration was 26, her BP was about 160/100mmHG, and SpO2 kept changing from 94%-97% (not/never was a smoker). Way out of my scope of practice and knowledge as an EMT-b student, but I've been learning to interpret ECGs on my own and after much practice, I could see that hers was normal.



The presentation is better than most I have seen here.




Aprz said:


> They took several test including a blood test and found that her alcohol level was really high even though she hadn't drank for about a half a day (this happened in the middle of the night while we were all sleeping).



In the event she really hadn’t drank in a day, excluding on the down low with alternative alcohols, if she is a chronic alcoholic, this is probably normal. (especially if her liver is damaged)



Aprz said:


> They let her go same day, told us it was most probably the alcohol, and advised her that this was her wake-up call.



It doesn’t exclude other ACS, but she probably has a colorful set of problems going on, I wasn’t there, but if they sent her home, there was probably nothing that being in the hospital would help.





Aprz said:


> Anyhow, up until before the ER part with just the information I provided, what would you think and do without any equipment?



Call 911 



Aprz said:


> what would you think after looking at the numbers I saw in the ER? Do you agree with the conclusion of the healthcare providers?



There is not nearly enough information, including lab and radiograph results to agree or disagree.




Aprz said:


> Oh, and what would you do if you were responding to this call as an on duty EMT of any level?



Proper history and physical, 2LNC, EKG, IV, draw blood, 12 lead, standard ACS pharmacology. 
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Aprz said:


> As for me, even though it was only a couple s/s of an MI, I thought that's what it was immediately (specially after she said it felt like somebody was punching her in the chest).



Thinking MI and being wrong is better than not thinking MI and being wrong. There are a host of conditions that could cause her symptoms, we could speculate ad nauseum. 



Aprz said:


> I figured the (occasional) pink sputum she was coughing up was from too much alcohol consumption. I already gave away what I checked for in my little report before the ER.



I very much doubt she was discharged with pink frothy sputum. In CHF patients this is a histologic finding until the very end stage. She could have had blood in her sputum from the GI, especially if she is an alcoholic. Apparently even the green stuff you mentioned at the start was of little concern. (vitals include a temperature)




Aprz said:


> After going into the ER, I was very relieved to see her on a nasal cannula (not sure if that's what ERs would do to MI pt., I don't think so, but I am positive an EMT would have her on a NRM)



Not a good indicator. NRBs are rarely used in the hospital, doctors among others understand the biochemical concept of Vmax. They don’t add unnecessary oxygen. 



Aprz said:


> And see that even though numbers where on the high end (especially her BP and respiration), that I didn't think it was an MI anymore (especially after seeing the ECG monitor and seeing that it looked normal).



Not all MIs show up on EKG. The determination of an MI is based on myocardial necrosis. Not possible on a vital sign machine.



Aprz said:


> SpO2 had me a lil' curious why it was lower than what I would expected of her (at least 97%+ I would've thought - maybe alcohol lowers that?)



For so many reasons I do not want to try to cover them all here.



Aprz said:


> I agree with the conclusion of the healthcare providers,


A wise decision.



Aprz said:


> but also curious on how alcohol gave her s/s of an MI



She could have aggravated other conditions, like unstable angina. Having no history only means a history is not diagnosed. Some of the worst patients are the ones “so healthy they haven’t been to the doctor in years.”



Aprz said:


> And how if I ever witness something like this again.. how I would be able to recognize the difference



You can’t. You treat it as an ACS and the hospital figures it out.


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## mycrofft (Mar 21, 2010)

*Roger that MrBrown. But generically:*

Without instruments you can listen for breath sounds and an apical pulse without a scope, bare the area or get ito a quiet place and lay ear on chest. (Ditto bowel sounds). You can assess capillary refill, watch for jugular distention as the pt reclines, watch for pallor or ruddiness and changes to them, etc. Don't sell yourself short or fee,l the needs for toys or tools.

Sort subjective and objective as you assess and triage.

Given the c/o, which is completely subjective of course, it still _had_ to be addressed as potential cardiac. IMHO.


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## Aprz (Mar 21, 2010)

Ah, thanks. I like a lot of waht Mycofft said because they were things I did not check: I didn't check cap. refill or JVD.

Thank-you guys for answering.


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## joeshmoe (Mar 22, 2010)

How do you know she had orthostatic hypotension if you didnt have any equipment with you? She just felt dizzy when standing up?


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## Melclin (Apr 1, 2010)

From her presentation, it doesn't sound like an MI, that is to say, if I was a betting man I wouldn't put my money on an MI, but clinically it is still a decent possibility and you absolutely did the right thing suspecting it.  

Vene pretty much covered all the bases. Regarding the various colours of mouth goo (technical term), the colours can easily be from thing you've eaten or drank. And the difference between coughing and regurgitating is important too. Vomiting red after drinking 4 litres of cranberry and vodka mixers is a different deal to coughing pink frothy sputum. 

As long as you've called an ambulance first, doing all those things like cap refills are fine but there's not a lot of point to them really. I mean, its not going to change anything. Taking note of the nature of the mouth goo and where it came from (cough versus vomit. Not always possible to tell, and its never a sure thing even if you can) may be a helpful issue in triaging her I would think, so you can help in that way. 

Also, having been in vaguely similar situations, I have collected any relevant literature/medications (blood sugar log if diabetic, summary of recent operations or complex medical problems are common for elderly or complex patients, collecting their medication if there are lots is also not a bad idea), just expedites the initial assessment process a little. Taking vitals is not terribly useful, the paramedics should and will want their own anyway. Other than that, in similar situations, I've grabbed a pillow and a book and made sure I had my wallet, phone etc - hospitals waiting rooms are boring. Just keeping in mind the potential for your friend/reli/coworker to go down hill (fall unconcious, arrest etc) and need your assistance in some way, too so don't run off for 20 mins to find a bottle of pills and come back to find them dead


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