# Maybe Really Altered?



## Bigcha40 (Oct 7, 2012)

Pt is a 20yom that law enforcement found walking in the middle of the street in front of student dorm at around 0330. 

Patient is in handcuffs standing leaning against squad car, officer relays _"He is not acting right and his heart is pounding."_ Patient is currently awake and breathing but appears altered. He is diaphoretic, tachycardic, and is semi combative. Attempts to obtain any kind of history from him are unsuccessful. 

His roommate is at scene an provides very minimal history: No past medical history, NKDA, non user of alcohol or illicit drugs. 

*Vitals:* HR 142, Resp 22, B/P 138/72, SpO2 99% room air, D-Stick 128.
14ga IV to left AC with no response to stick, 12 lead shows sinus tach, pupils PEARL, and lung sounds clear.

While obtaining vital signs, a classmate of the patient arrives an states _"They were at the pep-rally for the college earlier, that he was hypnotized by a magician and has not been acting right since then."_ at approximately 1500 today.

0.4mg narcan administered with no change in mental status. 

Where do you go now?


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## EMSpassion94 (Oct 7, 2012)

The nearest Psych Facility.


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## martor (Oct 7, 2012)

Smell of ETOH? Vitals are stable. Maybe a few sweet shirley temples? you know COLLEGE? (that is my EMT-B opinion.)

EDIT: Increased HR might be because he is being detained.


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## VFlutter (Oct 7, 2012)

Bigcha40 said:


> 14ga IV to left AC



Really? That is beyond unnecessary and borderline assault. How can you justify anything larger than an 18ga for a medical call? If I was your medical director you would be fired.


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## LostViet408 (Oct 7, 2012)

Maybe because he wants to slow down his heart rate with the 14 gauge IV?

If he's altered, I would check all the possibilities of AEIOU-TIPS


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## Bigcha40 (Oct 7, 2012)

ChaseZ33 said:


> Really? That is beyond unnecessary and
> borderline assault. How can you justify anything larger than an 18ga
> for a medical call? If I was your medical director you would be
> fired.


Really?
Have i mentioned any treatments other than narcan?
Have i revealed my general impression?
Have i stated anything else about the call other than being on scene?
I sure am glad my medical director would give you a chance to justify treatment before he fires you.


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## Handsome Robb (Oct 7, 2012)

ChaseZ33 said:


> Really? That is beyond unnecessary and borderline assault. How can you justify anything larger than an 18ga for a medical call? If I was your medical director you would be fired.



Eh, I wouldn't drop a 14 but a 16 might have been in the cards. When you need lines that big you need them now and you better be good at starting them. I'd rather practice on the inebriated/altered person who wont complain/remember/feel it than grandma that fell down and muffed up her hip. 

Just my opinion. 



Bigcha40 said:


> _**Quoted post removed**_



Everyone simmer down now. I'm interested in this case, I smell either run of the mill psych/etoh/drugs or some random zebra related to the hypnosis

What size were his pupils? Appropriate? Blown bilaterally? Pinpoint? Nystagmus?

Sounds like a stimulant with the tachycardia, tachypnea, hypertension and his presentation. Even if his friends deny drugs/ETOH remember what Dr. House would say...everyone lies. 

Any recent trauma? Complaining of anything prior/post hypnosis and now? Does he feel febrile?

Roommates know of any psychiatric hx? Any chance we can get information from his dorm, some maybe even all will have information on the student which may include H/A/M or at the bare minimum an emergency contact number. 

Why narcan? His SpO2 is fine and his respiratory rate is elevated, not depressed...

Hypnosis was at 1500, its now 0330 that's 12.5 hours since he was last seen normal.  Does he move all of his extremities appropriately? Any notable neurological deficits? See if you can get him to walk around, how's his gait?

Roommate been sick recently? When PD found him was he just walking or was he behaving erratically? Psychosis?

My thoughts are stimulant of some sort, ETOH, psych or a real random one...CVA?


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## WestMetroMedic (Oct 7, 2012)

Perhaps some of the marijuana analogs or other similarly engineered drugs that are always skirting the edge of the law...  I have had very similar experiences with patients using those.  Demographic fits...


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## Achilles (Oct 7, 2012)

WestMetroMedic said:


> Perhaps some of the marijuana analogs or other similarly engineered drugs that are always skirting the edge of the law...  I have had very similar experiences with patients using those.  Demographic fits...


You mean synthetic drugs like K2?


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## bigbaldguy (Oct 7, 2012)

Interesting thread I think I'll watch it for a while.

It will stay on topic.


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## DrankTheKoolaid (Oct 7, 2012)

Actually if you do some extra reading narcan has been documented as reversing the effects of hypnosis.  Though I doubt the op gave it for that reason.  Typical my protocol for altered is narcan, so he gave it blindly not knowing the real reason to use it


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## VFlutter (Oct 7, 2012)

Bigcha40 said:


> Really?
> Have i mentioned any treatments other than narcan?
> Have i revealed my general impression?
> Have i stated anything else about the call other than being on scene?
> I sure am glad my medical director would give you a chance to justify treatment before he fires you.



I apologize if my post was harsh but this is a topic I feel strongly about. Many practitioners reach for the biggest IVs possible just because they can without any thought into the actual medical indication and necessity of the intervention. I tried looking and there is not really any good criteria out there which outlines what gauge catheter to use in what type of situation. It is left up to the discretion of the practitioner based on their assessment, patient anatomy, and type of medications anticipated to be given. But the expectation is that the practitioner will use the most *appropriate * for the situation. You want to use the smallest size possible that will still allow you to perform the interventions necessary. Medics start IVs but rarely see the complications (Phlebitis) from them.

Flow rates...

18G - 103 (ml/min) 10min (To infuse 1L)
16G  - 236 (ml/min)  4.2min (To infuse 1L)
14G - 270 (ml/min)  3.7min (To infuse 1L)

You can argue there is a decent difference between an 18G and 16G however increase in flow by going from a 16G to a 14G really is not significant except for the most extreme situations. 

How often do you give fluids faster than what an 18G is capable of?

If you would have went for a 16G I would have shook my head but kept my mouth shut. Dropping a rail road spike 14G crosses a line in my opinion and makes me think that it was used because you could not because you should have. *Not an attack on you, that is just my first reaction. 

If you can justify using a 14G then I am all for it however I think that will be extremely hard to do. 

Also, since I am guessing this will be a response, the fact that the patient may not have felt it or did not react to it does not make it any better.


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## usalsfyre (Oct 7, 2012)

Chase, then how do you justify in your mind the introducer and dilator for a central line? Both of these are considerably more invasive than a 14ga.

I get what your saying (and have threatened decredentialing of medics if I catch them performing such shenanigans) but realistically in an altered pt with a HR of 142 I'm tagging the biggest line I can because I don't know who's going to be using it for what how far down the road.


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## Milla3P (Oct 7, 2012)

14g? Wow...

Why the Narcan? His RR was 22 with a 99% RA. Would you give him D50 because his sugar was ONLY 130s? 

Did you put him on the monitor before you jammed a garden hose in his arm? I'm sure there would of been another borderline reason to administer another medication into a relatively healthy college kid who's probably on drugs. 

But I digress...

Now you say that he was mildly combative in handcuffs. Did you start your IV while he was cuffed? Did he stop fighting when a stranger in a uniform tried to stick a needle in his arm? This part confuses me. 

Also did you draw any blood tubes before you gave any meds?


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## Veneficus (Oct 7, 2012)

ChaseZ33 said:


> I apologize if my post was harsh but this is a topic I feel strongly about. Many practitioners reach for the biggest IVs possible just because they can without any thought into the actual medical indication and necessity of the intervention. I tried looking and there is not really any good criteria out there which outlines what gauge catheter to use in what type of situation. It is left up to the discretion of the practitioner based on their assessment, patient anatomy, and type of medications anticipated to be given. But the expectation is that the practitioner will use the most *appropriate * for the situation. You want to use the smallest size possible that will still allow you to perform the interventions necessary. Medics start IVs but rarely see the complications (Phlebitis) from them.
> 
> Flow rates...
> 
> ...



Could I just ask?

Aside from the pychological implications of actually seeing a 14 guage, do you have anything that actually says a 14g is not appropriate?

I will confess to using 14s quite frequently. Mostly because it takes a bit more skill to use a larger needle than a smaller one and like any skill, it degrades if you don't use it.

Do you think it causes significantly more pain than a 16g?

Do you think it has a higher rate of infection?

In a pseudo-scientific experiment myself and another medic once put in 18s and 14s in each other. We blindfolded each other so the "control" could not see the needle. 

Final outcome was we couldn't reliably tell the difference and in one instance the 18 "hurt more."

edit: if you really want to get all up in arms about needlessly putting needles into people, could I suggest taking issue with the amount of lumbar punctures done in kids to "rule out" meningitis?


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## VFlutter (Oct 7, 2012)

usalsfyre said:


> Chase, then how do you justify in your mind the introducer and dilator for a central line? Both of these are considerably more invasive than a 14ga.



In my mind it is a different situation since with the Seldinger technique they are usually using local anesthetic and accessing a better location than the AC. Also using the introducer/dialtor has a specific purpose and has shown to be safe and effective at reducing risks, not just for ":censored::censored::censored::censored:s and giggles". If they are getting a central line then it is safe to assume that their medical condition justifies it. I have seen many PICCs placed and they usually cause little discomfort on insertion and are well tolerated long term. Many patients prefer them as opposed to multiple large PIV. 

I am all for getting access on unstable patients but I do not see any realistic need to go for a 14 over a 16 in this situation other than to "get the biggest posssible". But as Vene is arguing it is no more harmful to the patient so my argument is somewhat a mute point.  



Veneficus said:


> Could I just ask?
> 
> Aside from the pychological implications of actually seeing a 14 guage, do you have anything that actually says a 14g is not appropriate?
> 
> ...



To be honest, I can not find any actual evidenced based data supporting my opinion. So I guess in reality it is just a worthless opinion based off solely off the philosophy of use.  

Pain on insertion there may be little difference (different people may have different experiences) however I would assume that larger bore catheters are more irritating to the vein and more likely to cause phlebitis. I doubt infection rate would be any different. 

In the hospital I have not yet seen a 14 used. Usually when patients return from surgery they have a 16 or 18 (or 2).Per hospital policy IVs >18 must be removed within 24hrs. I am not sure the specific rationale behind the policy. 
'
aside from the practice, how often do you think a 14 is truly necessary? In those situations would you have been able to effectively performed your interventions with a 16 or even an 18?


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## Veneficus (Oct 7, 2012)

ChaseZ33 said:


> aside from the practice, how often do you think a 14 is truly necessary? In those situations would you have been able to effectively performed your interventions with a 16 or even an 18?



Personally, I do not see any difference between the 16 and the 14 except the length. You can actually get the 14s that are the same length as the rest of the needles, but for logistics sake, usually the longer ones are ordered so you can decompress or start a line.

I have even seen the longer 16g for the same thing. the 18 and 20 long are becomming more popular for ultrasound guided IVs. 

Some facilities will consider a peripheral 14 equally as acceptable as a central line and it is far quicker to insert. I would argue probably has less complications and infection rates too, though I have no evidence. In all of my years, in hospital and out, I have never seen a case of phlebitis from an IV insertion. I have seen some really bad necrosis from exvasiations though.

Most of my experience where anything bigger than an 18 was required was in trauma. But in the severe cases, 2 or even sometimes 3 14g needles were used. We used them so often in fact, most staff would have at least 1 sometimes 2 in their pocket. (along with a 26g for neonates)

If it was really required for antibiotics, I bet I could put the 14 in as a central line in more austere environments.

I would be equally interested if dual 14s could be used for emergent dialysis in some populations but nobody will let me try yet.

From a non-volume resuscitation point, the catheter makes a really good squirtgun on the end of a syringe for irrigating wounds. I hae also noticed on people with a lot of scar tissue, like substance abusers, the larger the needle you use, the more success there is. The bevel on a 14 is basically a blade, and it cuts the scar tissue really well without kinking the catheter. 

From the standpoint of actual medical conditions, I think hypothermia is about the only reason I could think of.


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## hibiti87 (Oct 7, 2012)

possible postictal state hence the hypertension tachycardia and altered mental state.


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## Bigcha40 (Oct 9, 2012)

Ok, i dont think i went into enough detail with my first post, sorry about that.

So, he was initially standing with assistance from the officer, "more leaning on the squad car to hold him up" The combative part is more of an uncooperative resisting except for trying to donkey kick the officer a few times. 
While trying to secure him to the stretcher, his mental status declines further. He is now unresponsive to voice but breathing on his own. Put a NRB on him at 12LPM.
After we get him in the truck, i had the officer move handcuffs to front of body. Did a sternal rub with no response, no response to ammonia caps either. Vitals are as stated before. pupils PEARL, no no smell of ETOH, D-stick the same = 128. 

So the next step was the IV, which he had absolutely no response to. Then no response with narcan.


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## Medic Tim (Oct 9, 2012)

Bigcha40 said:


> Ok, i dont think i went into enough detail with my first post, sorry about that.
> 
> So, he was initially standing with assistance from the officer, "more leaning on the squad car to hold him up" The combative part is more of an uncooperative resisting except for trying to donkey kick the officer a few times.
> While trying to secure him to the stretcher, his mental status declines further. He is now unresponsive to voice but breathing on his own. Put a NRB on him at 12LPM.
> ...



So why the NRB and narcan. I see no reason(indication) for the administration of these medications.


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## Handsome Robb (Oct 12, 2012)

Did you ever find out what this kid's deal was or are we just taking shots in the dark?
.


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## Bigcha40 (Oct 12, 2012)

Gave the narcan for altered mental status with unknown cause after ruling out hypoglycemia, like someone said earlier, hes in college... 

Since the recent outbreak of this bath salt phenomenon i started to lean towards this after we treated for everything we could. I had done some research on symptoms of bath salts and it fit the profile.

Turns out, about 2 hours after we got him to the hospital, he coded on them. Dont know all the details after that but they got him back. His tox screen came back postitive for opiates and bath salts, they ruled the cause to complications from the effects of bath salts. 

The last i heard about him is he was still alive.


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## STXmedic (Oct 12, 2012)

You gave narcan because you suspected he may have taken bath salts? :unsure:

As someone said earlier; from the information you gave, I see no reason to give narcan. Even if I did suspect he took an opiate, the rest of his presentation would lead me to think it would be laced with an upper, in which I would really not want to give narcan... If you didn't suspect an opiate, and just suspected the bath salts, them still no reason for narcan. Correct me if I'm wrong, but narcan is only effective on opiate overdoses.


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## Milla3P (Oct 12, 2012)

And I may be wrong, under educated and ignorant... But ketamine is used for the bath salts? (For both pt and provider safety?)

But then again I'm hesitant to pull out a needle around someone who is "handcuffed and combative"


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## Bigcha40 (Oct 12, 2012)

PoeticInjustice said:


> You gave narcan because you suspected he may have taken bath salts?



Gave him narcan because hes laying on my stretcher unresponsive... Whats an adverse effect of giving narcan? He loses his "high" if he has one? If that was what was wrong then hey you firgured it out, if not well then you possibly ruled out a cause. 
Its not like a gave a 3rd degree block patient atropine and wonder why they died...  
Not only because i thought he took bath salts. G


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## STXmedic (Oct 12, 2012)

Have you had much experience with overdoses? Specifically of the recreational variety? Ever dealt with a patient speed balling? Not a personal attack, just out of curiosity.

Your patient is not at all presenting with a typical opiate overdose. He is presenting with a possible stimulant overdose: tachycardic, diaphoretic, combative, pupils regular (as opposed to pinpoint). The fact that he's semi-responsive Could indicate that he's on some sort of downer, such as an opiate or a benzo. But his respirations are good. His sats are good. Overall, he's pretty good right now. My vote: let him be, let him enjoy his high, and monitor him while you drive nice and chill to the hospital 

So as far as side-effects of narcan. Directy? none really, besides maybe vomiting if you want to push it to fast. However, have you ever reversed an OD of somebody who was on an opiate and a stimulant? Your patient was already somewhat combative for you. That opiate may have been the only thing keeping him somewhat chill for you. Do you really want to be around when you push narcan and are now fighting with I opposed stimulant? As someone who's been there, I sure as hell wouldn't! Along similar lines, now would you not only be potentially fighting with the incredible coked-out Hulk, but now you have to worry about potential excited delirium if he really gets up and going. He's already pretty tachy and diaphoretic with the opiate helping keep him down. Those are some side effects I would personally like to avoid


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## Bigcha40 (Oct 12, 2012)

PoeticInjustice said:


> not only be potentially fighting with the incredible coked-out Hulk,



Well played sir! lol
I agree, probably shouldnt have administered the narcan. just me personally i feel this sort of need to figure out what it is/was that made him like he is. 

As for the dealing with the high coked-out patients, yea ive had a few... Specifically the one patient weve run on a few times who likes to: smoke meth, weed, take shrooms, and wash it all down with jack daniels...
Yea he always thinks there is a snake up his a$$ and wants us to pull it out. Hes kicked all of out a$$es before. Haldol, Versed, and Ativan wouldnt even touch that guy...


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## usalsfyre (Oct 12, 2012)

Bigcha40 said:


> Gave him narcan because hes laying on my stretcher unresponsive...


That's not exactly a good reason for anything...



Bigcha40 said:


> Whats an adverse effect of giving narcan? He loses his "high" if he has one?


Acute withdrawal, seizures, pulmonary edema, unopposed sympathetic stimulation, aspiration from vomiting...




Bigcha40 said:


> If that was what was wrong then hey you firgured it out, if not well then you possibly ruled out a cause.


Except Narcan can also reverse Klonopin on occasion, and you haven't really ruled it out till you get a tox back, and you should probably be able to get clues about what's going on by physical assessment before blindly pushing a drug.




Bigcha40 said:


> Its not like a gave a 3rd degree block patient atropine and wonder why they died...


Except atropine for 3rd degree is actually be more appropriate....



Bigcha40 said:


> Not only because i thought he took bath salts. G


A&P, pathophys and pharm are our "stock in trade" so to speak. You should consider all three before you perform any treatment. Going around blindly pushing meds because "he's laying unresponsive on my stretcher" is weak sauce.


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## VFlutter (Oct 12, 2012)

usalsfyre said:


> Except Narcan can also reverse Klonopin on occasion
> 
> 
> A&P, pathophys and pharm are our "stock in trade" so to speak.



Really? I haven't heard that. Just Klonopin or other Benzos? Or Gabapentin


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## usalsfyre (Oct 12, 2012)

ChaseZ33 said:


> Really? I haven't heard that. Just Klonopin or other Benzos? Or Gabapentin



Can't find the reference at the moment, let me get home and I'll see if I can dig it up.


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## Milla3P (Oct 12, 2012)

Bigcha40 said:


> I agree, probably shouldnt have administered the narcan. just me personally i feel this sort of need to figure out what it is/was that made him like he is.



It's nice to figure out what's going on, but not required. Getting the pt (and yourself) to the hospital alive and safe is 
required. 

Figuring out what substances are in his body is what the Hospital Tox screen is for.


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## Melclin (Oct 14, 2012)

My 2 cents, such as its is:

I wouldn't give this guy narcan. Its reasonably safe but not giving it is safer, assuming its not indicated and it doesn't sound like it was. 

It doesn't sound at all like an uncomplicated opiate OD, so I'm still not sure why you gave the narcan. Were you under the impression that it works on bath salt related OD as well? 

If you then hypothetically change this situation such that he does present more like an opiate OD then I still don't think this guy requires narcan. You're trying return the pt to a state in which they protect their own airway and are breathing with an adequate minute volume. Sounds like he had both of those things. So what are you achieving by giving narcan? Once he became unresponsive, was he protecting his airway as far as you could tell? 

Not having a crack at you, but you present a case for consideration so we're considering and providing questions and feedback consistent with the purpose of this part of the forum. 



NVRob said:


> Eh, I wouldn't drop a 14 but a 16 might have been in the cards. When you need lines that big you need them now and you better be good at starting them. I'd rather practice on the inebriated/altered person who wont complain/remember/feel it than grandma that fell down and muffed up her hip.



This.


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## NomadicMedic (Oct 14, 2012)

usalsfyre said:


> Can't find the reference at the moment, let me get home and I'll see if I can dig it up.



I'm interested in seeing this reference, too. I just did some digging and couldn't find a thing.


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## usalsfyre (Oct 14, 2012)

n7lxi said:


> I'm interested in seeing this reference, too. I just did some digging and couldn't find a thing.



Yeah, I can't seem to find it either, it appears I was talking out of my gluteus. I'm trying to remember where I heard it...


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## mycrofft (Oct 14, 2012)

*Trust your assessments and know your algorithms, if not physiology and PE*






Pupillary diameter?

A. If student was drinking or doing drugs, very likely his roomies will not cop to it.
B. Hypnosis may change behavior and mood, but not to the point of raising pulse PLUS normotensive (partial response to endogenous adrenaline:unsure:? Or is the body compensating for some other cause for loss of BP? Or is the pt just transiently angry that he was stabbed in the arm?).
C. Does "semi-combative" mean resistive (which can be a basic irritant response) or want  to fight? A difference clinically as to level of consciousness.

My quarter in the pool says most likely alcohol toxicity or psychoactive drugs, maybe baseline mental illness to boot. Calm everyone down, but get to medical facility as he will need pre-arrest screening including tox screen, blood alcohol.
PS: Another quarter: temp, PE and CBC to r/o sepsis.


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## Veneficus (Oct 14, 2012)

mycrofft said:


> Pupillary diameter?
> 
> A. If student was drinking or doing drugs, very likely his roomies will not cop to it.
> B. Hypnosis may change behavior and mood, but not to the point of raising pulse PLUS normotensive (partial response to endogenous adrenaline:unsure:? Or is the body compensating for some other cause for loss of BP? Or is the pt just transiently angry that he was stabbed in the arm?).
> ...



I like to tell students taking a history and performing a physical is not like solving a mystery.

It is an interrogation and the desired outcome is confession.

"We spiked his drink" is also not something roomies will admit to.


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## mycrofft (Oct 15, 2012)




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## MSDeltaFlt (Oct 16, 2012)

Bigcha40 said:


> Pt is a 20yom that law enforcement found walking in the middle of the street in front of student dorm at around 0330.
> 
> Patient is in handcuffs standing leaning against squad car, officer relays _"He is not acting right and his heart is pounding."_ Patient is currently awake and breathing but appears altered. He is diaphoretic, tachycardic, and is semi combative. Attempts to obtain any kind of history from him are unsuccessful.
> 
> ...



This dude appears to be on a "bad trip", but not suppressed by narcotics.  Respirations are good, so is BP, BGL, and SpO2.  Plus you said pupils were PEARL, not pinpoint.

And suddenly you said he went "unresponsive on your cot" to explain the Narcan.  When did his GCS drop?  What were his VS when they dropped?


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