# Interesting call today...



## ffemt8978 (Oct 29, 2004)

We were paged out to one of our local clinics for an "emergent transport".  Upon arrival, we find a 76yoM C/C Dehydration, Bloody Diarhea, and Malaise.  Hx of gall bladder surgery, throat cancer with surgery approx. one month ago with feeding tube in place, and heart stint.  Diarhea has been going on for two to three weeks, with pt. losing approximately 15 lbs since then.

We load him up and attempt to get a round of vitals.  Initial set: HR 55; RR 10 and shallow; B/P unable to get manually or with automatic; Lungs C&E Bilat; Skin pale, cool and dry; Cap refill <2 secs; Pulse Ox of 62% on 15 lpm via NRB.

We then place him on a 3-lead ECG (I know I'm not supposed to read ECG's, but in this case I was later proved correct) which showed what appeared to be Atrial Fib/Flutter.  The clinic already had an IV going, which we ran WO since we were finally able to get a B/P of 90/44.  We were also able to get the pulse ox up to around 88-92%, but never any higher than that.

Vitals during transport: HR 52, RR 24-28, B/P 102/56, Pulse Ox 88%.  We called for an ALS intercept, but were advised that none was available.

Any ideas on what might be wrong with him?  I don't think that dehydration alone will produce these vital signs.


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## MMiz (Oct 29, 2004)

That is an interesting call!  I don't have much to offer, but if you dont mind me asking: What level of care does the clinic provide?  Do they have a crash kit?  RN, MDs?  How long was the transport to the hospital?  Any followup on the case?

Interesting story, and I even learned what Malaise means (thanks Dictionary.com).


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## ffemt8978 (Oct 29, 2004)

> _Originally posted by MMiz_@Oct 28 2004, 10:49 PM
> * That is an interesting call! I don't have much to offer, but if you dont mind me asking: What level of care does the clinic provide? Do they have a crash kit? RN, MDs? How long was the transport to the hospital? Any followup on the case?
> 
> Interesting story, and I even learned what Malaise means (thanks Dictionary.com). *


RN, LPN, CNA, PA and MD's but no crash cart that I'm aware of.  I do believe they have AED's now because of the call I mentioned where they got burned by sending us on a BS transport.

This is the clinic that does not call us when they're ready to close and dump their patients on us, so when they said "emergent transfer" it got our attention.

Our transport time to ANY hospital is listed as an hour, but we made it in 43 minutes on this one.


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## MMiz (Oct 29, 2004)

I got goosbumps when I read the last line, and had to read it twice.



> *Our transport time to ANY hospital is listed as an hour, but we made it in 43 minutes on this one. *



I can't lie, I've only worked solo in the back of a "code" once, being that usually the patient is transported by the ALS unit the arrives at the same time as us.  That one time though, we had a <10 minute or so transport.  It felt like eternity.

Never again will I yell at my partner to speed it up.  I have some stickers around here somewhere from teaching.  You my friend, get two.


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## Chimpie (Oct 29, 2004)

> _Originally posted by ffemt8978_@Oct 29 2004, 01:59 AM
> * Our transport time to ANY hospital is listed as an hour, but we made it in 43 minutes on this one. *


 How often do you guys have to call for a helicopter transport?


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## rescuecpt (Oct 29, 2004)

> _Originally posted by ffemt8978_@Oct 29 2004, 12:13 AM
> * Any ideas on what might be wrong with him?  I don't think that dehydration alone will produce these vital signs. *


 Was he on furosemide (lasix)?  If so, my guess would be CHF.


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## ffemt8978 (Oct 29, 2004)

No, he wasn't.  As a matter of fact, he was on only three meds, one of which was folic acid.

I never thought about CHF, but I don't recall seeing any signs of pedal edema and his lungs were C&E bilat.


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## rescuecpt (Oct 29, 2004)

> _Originally posted by ffemt8978_@Oct 29 2004, 12:44 PM
> * No, he wasn't. As a matter of fact, he was on only three meds, one of which was folic acid.
> 
> I never thought about CHF, but I don't recall seeing any signs of pedal edema and his lungs were C&E bilat. *


That's why I asked about the lasix, because if it was working properly (or too well) his lungs would be dry as a bone and he'd be forcing the fluid out by frequent urinations and/or diahrrea.

Keep in mind not everyone with CHF has pedal edema or even pulmonary edema.


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## ffemt8978 (Oct 29, 2004)

> _Originally posted by Chimpie+Oct 29 2004, 04:11 AM--></div><table border='0' align='center' width='95%' cellpadding='3' cellspacing='1'><tr><td>*QUOTE* (Chimpie @ Oct 29 2004, 04:11 AM)</td></tr><tr><td id='QUOTE'> <!--QuoteBegin-ffemt8978_@Oct 29 2004, 01:59 AM
> * Our transport time to ANY hospital is listed as an hour, but we made it in 43 minutes on this one. *


How often do you guys have to call for a helicopter transport? [/b][/quote]
 Frequently on major trauma since our protocols will not allow us to bypass a hospital to get to a better one for the patient.  On a medical call, we go to patient's choice usually and this allows us to bypass closer hospitals sometimes.


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## Firechic (Oct 31, 2004)

Wow! There's something major going on with this guy. Was this a long term care facility or a non-emergency clinic? 15 days is a long time to be sick like that!
 :angry: 

He would need a lot more tests to know what his diagnosis is. There's a lot going on with guy.
Here are some thoughts and I may be way off base, I'd need some more information, but off the top of my head:

the pt. had a heart stent: A-Fib might be a normal rhythm for him.
Obviously, he was extremely dehydrated, in metabolic acidosis and probably hyperkalemic.     Did you note any tall, peaked T-waves?   Other s/s of hyperk. are diarrhea, hypotension, irregular pulse, (although a wide QRS with peaked Ts is the normal indicator) - I would imagine the heart would be extremely irritated due to the electrolyte imbalances (sodium-potassium pump) perhaps causing A-fib (if not normal for him.)

pt had throat CA with surgery x 1month and a feeding tube in place:
I'm assuming he is going through chemotherapy also. I know one side effect of chemotherapy may be hyperkalemia and pts in chemo are usually folic acid deficient which in turn also causes anemia and could also contribute to a low SPO2 due to the lack of hemoglobin.

OR  (heehee)       he could have a PMHX of Sprue (GI disease) for which he takes folic acid, but the chemo is a folic acid antagonist, causing the diarrhea & low sat problem.......funny how the diarrhea & surgery almost coincide.

OR surgery + feeding tube may = a possible massive infection.

What do you all think?

Those are some of my limited theories! Hope you enjoy them!!
Goodnight!

:huh:


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