# The man unable to move



## DesertMedic66 (Apr 18, 2016)

You are a paramedic inside a medical tent at a large music festival (100,000+ people) with 4 EMTs, 1 RN, and 1 Doctor in the tent also. You have basic medications with you (standard ACLS meds with versed, fent, Ativan, haldol). You have a transporting ambulance on scene with a hospital about 8 minutes away. We try to limit the amount of patients we send out and try to do mostly treat and release to avoid hospital over crowding. Patients are sent out based on decision from the medic, nurse, and Doctor. 
The weather is about 90 degrees in the desert. 

A crew brings in a mid 20 year old looking male who is unable to move or talk. Patient was with friends when the saw him lay on the ground and then stop moving and called for help about 30 minutes. Friends bailed as soon as the medical team arrived and did not provide any information. 

The patients eyes are open and he is not tracking anyone. Patient is blinking his eyes. Patient does not respond to any painful stimuli and no reflexes are present during Doctor assessment. Patient does not move upon any command. You are able to move the patients arms and legs without any resistance. There is no trauma present and a head to toe is unremarkable. 

Vital signs at the medical tent:
BP: 130/68
Pulse: 120 sinus tach on the monitor with weak radial pulses
Respiratory rate: 20
SpO2: 99% room air
Lungs: clear all fields
Pupils: PERRL 3mm 
Skins: normal color, dry moisture, warm temp

Assessments? Treatments? Differential diagnosis?


----------



## Aprz (Apr 18, 2016)

I'm too lazy to write the whole AEIOUTIPS stuff again, lol.

Am I blind or did you forget to put the blood sugar on here? LOL. I assume it was normal.

Based on the setting, I would definitely be thinking of drugs, metabolic problems secondary to drugs (eg hyponatremia leading to seizures), or psychosis.

Maybe post ictal from a seizure?

Maybe he is actively having like an absent seizure?

Not really sure what else to think. Never heard of or seen something like this. I look forward to hearing the outcome.


----------



## DesertMedic66 (Apr 18, 2016)

Aprz said:


> I'm too lazy to write the whole AEIOUTIPS stuff again, lol.
> 
> Am I blind or did you forget to put the blood sugar on here? LOL. I assume it was normal.
> 
> ...


My apologies, BGL 116mg/dL. 

Patients breath smells normal. Unknown on seizure history. Other bystanders did not see any seizure activity.


----------



## zFrostyy (Apr 19, 2016)

If eyes are indeed PERRL, not dilated or constricted, i'm leaning towards treating it as heat exhaustion/heat stroke even though there's some psychosis going on.


Pulse and RR are consistent with upper/speedish drugs,the inability/unwillingness to move at all is somewhat indicative of a heavy CNS depressant in theory, though I haven't heard of one having that affect, not only is a large music festival a contraindication for depressants, his vitals don't indicate such if that's not being shown in the eyes,there's not much else to go off of here short of a blood test, gentle cooling, semi fowlers and transport.


As far as what's actually going on with that pt, that's for the hospital to find out, as we're not well equipped enough in the field. We can say what ifs all day, could've thrown a stroke x2 weird/random drug mix, some obscure brain injury/inflammation, the list goes on, but there's no way for us as prehospital care to know or find out without a CT. If pt's behavior is/has been consistent w/ initial findings for 20+ mins expediting transport would probably be a good idea.


----------



## zFrostyy (Apr 19, 2016)

Guy could also be borked out on a hallucinogenic. But there's not enough evidence/information to confirm and know for sure enough to give him some haldol for it.


----------



## NomadicMedic (Apr 19, 2016)

zFrostyy said:


> Guy could also be borked out on a hallucinogenic. But there's not enough evidence/information to confirm and know for sure enough to give him some haldol for it.



Why would you give a guy who can't move Haldol?

Did he have dry mucosa? (Can't see, can't spit, can't pee, can't ...poop)

Sounds like a guy I had who took a boat load of Benadryl. Gotta love that anticholonergic effect.

Don't know though. Sounds like a fluid bolus and ride to the ED to rule out all the stuff you can't do in a tent.


----------



## zFrostyy (Apr 19, 2016)

DEmedic said:


> Why would you give a guy who can't move Haldol?



Haldol isn't an ALS drug in my area, so not familliar with the MoA for it, but did notice it's indicated for acute psychosis from LSD, like I said though, not enough evidence/information for it.


----------



## NomadicMedic (Apr 19, 2016)

zFrostyy said:


> Haldol isn't an ALS drug in my area, so not familliar with the MoA for it, but did notice it's indicated for acute psychosis from LSD, like I said though, not enough evidence/information for it.



How about NO indication for use from the OP's presentation. Maybe reading up on Haloperidol might be useful.


----------



## DesertMedic66 (Apr 20, 2016)

Patients temp was 99.8F
Patients eyes were moist along with his gums. 

Communication is established somewhat thru blinking. Patient is AOx4. Patient denies pain, SOB, numbness, lightheadedness, nausea. Patient blinks no for alcohol use but blinks yes to drug use. Patient blinks no to acid, MDMA, meth, heroin, cocaine, whip its, GHB, Ecstasy, Molly, and Ketamine. Patient blinks no to allergies, prescribed meds, and medical conditions. Patient blinks no to this ever happening before. 

We decided not to transport this patient at this time due to stable vital signs. We laid him in the recovery position and had an EMT stay in the room with him. We established an IV and gave him a 2L NS bolus (the majority of what we do at the concert is IV and a couple of liters of NS until the patient is AOx4 and is able to walk and then they get discharged).

After about an hour after the IV was established the patient is now able to move his hands and feet and give us thumbs up or down. After another hour patient is able to speak softly and move around with extreme weakness. Patient states he ate some edible marijuana and it was his first time every trying it. 

After 6 hours in our medical tent the patient was AOx4, GCS 15 and able to walk with no issues. Patient regained his full strength. Patient was discharged from the medical tent and told to follow up with his PCP.


----------



## luke_31 (Apr 20, 2016)

Sounds like he was just really high


----------



## DesertMedic66 (Apr 20, 2016)

luke_31 said:


> Sounds like he was just really high


Pretty much. I had a similar patient about 4 years ago. 16 year old girl who ate a brownie curled up in the fetal position unable to move or talk


----------



## ERDoc (Apr 21, 2016)

Clearly this is hyperkalemic periodic paralysis.  Even a caveman could make the diagnosis.


----------



## Summit (Apr 21, 2016)

Dx: Pt is tripping balls


----------



## zzyzx (Apr 21, 2016)

Considering that he was at Coachella, the diagnosis would be pretty easy: drugs of some kind. I was thinking ketamine, but whatever, DRUGS.
However, wouldn't this case be interesting if you ran on this guy at his home and there was no one there to provide any good history?


----------



## ERDoc (Apr 22, 2016)

Never underestimate the power of crap that can be purchased on the internet.  We had a you guy come recently in cardiac arrest after ingesting some powder he purchased from Mexico.  It turns out the powder was a mix of Rocuronium and Fentanyl.


----------



## DesertMedic66 (Apr 22, 2016)

ERDoc said:


> Never underestimate the power of crap that can be purchased on the internet.  We had a you guy come recently in cardiac arrest after ingesting some powder he purchased from Mexico.  It turns out the powder was a mix of Rocuronium and Fentanyl.


When I buy my drugs I look for price over quality. Half the people at our tents come in and say "I bought some Molly and took it but it wasn't Molly because I know what it's supposed to feel like".


----------



## ERDoc (Apr 22, 2016)

DesertMedic66 said:


> When I buy my drugs I look for price over quality. Half the people at our tents come in and say "I bought some Molly and took it but it wasn't Molly because I know what it's supposed to feel like".



Just remember, you get what you pay for.


----------



## Carlos Danger (Apr 22, 2016)

ERDoc said:


> Never underestimate the power of crap that can be purchased on the internet.  We had a you guy come recently in cardiac arrest after ingesting some powder he purchased from Mexico.  It turns out the powder was a mix of Rocuronium and Fentanyl.



Ouch.


----------



## RocketMedic (May 1, 2016)

ERDoc said:


> Never underestimate the power of crap that can be purchased on the internet.  We had a you guy come recently in cardiac arrest after ingesting some powder he purchased from Mexico.  It turns out the powder was a mix of Rocuronium and Fentanyl.



Party hard


----------



## JIP00 (Jun 10, 2016)

zzyzx said:


> Considering that he was at Coachella, the diagnosis would be pretty easy: drugs of some kind. I was thinking ketamine, but whatever, DRUGS.
> However, wouldn't this case be interesting if you ran on this guy at his home and there was no one there to provide any good history?



My first thought was Ketamine.


----------



## Underoath87 (Jun 10, 2016)

I was thinking shrooms, since you never ruled that one out.


----------



## joshrunkle35 (Jun 13, 2016)

A non-drug diagnosis is possible. He could have had a seizure from light/sound and then fallen and had some sort of C-Spine injury. While strokes are uncommon for his age, I just had a 20 year old in great physical shape with a CVA the other day. All sorts of possibilities. However, the vital signs, for me, would not suggest drugs, stroke or C-Spine. I would lean towards a post-ictal state. I wouldn't think it's an absence seizure as you could communicate through blinking.


----------

