# Today's last call.



## NomadicMedic (May 22, 2016)

You are dispatched priority to a church for a reported syncopal episode.

Just to set the stage, it's a hot day, about 85°. You're in an ALS ambulance, both providers are paramedics.  You're about 10 minutes away from a Community Hospital which has CT and that's about it. No surgeon on weekends, no neuro no PCI. Aproximately 50 minutes by ground to the level one trauma center and about 40 minutes by ground to the closest stroke/PCI center.

You arrive on scene to find a 40-year-old female, supine on the floor in the church hall. She doesn't seem to quite be tracking you correctly and is slow to answer questions, but she is answering the questions that you ask appropriately. The bystanders relate that she "just passed out". No seizure. She's new to the church and nobody knows her history or really anything about her. Her 14-year-old daughter is there and said that mom passed out twice at home yesterday. She's alert enough to be able to tell you her name and her date of birth but is adamantly refusing any treatment or transport.

"She does not want to go, she does not want to go, she absolutely does not want to go!"

Your first set of vital signs; strong radial pulse with a rate of about 90, respirations about 16 and unlabored. Orthostatic blood pressure is exactly the same within a point or two, 142/84. You get a blood sugar and it's 91.  Pupils are PEARRL.  She's able to stand up for that orthostatic without issue, not complaining of any pain.

Bystanders, the kid and you and your partner lay on the full-court press because _something_ doesn't seem quite right and you still want her to go to the emergency department to be assessed further. After about 25 minutes of cajoling, you finally get her to agree to go to the local Community Hospital. As your partner goes to grab the stretcher, which had already been put away because you thought it was going to be a refusal, she once again becomes unresponsive.  From talking to you too out cold. In the blink of an eye. Fully.  GCS of three. No one home, nothing you can do to arouse her.

Now what?


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## MonkeyArrow (May 22, 2016)

Well, get down and throw her on the monitor, get the pads on, full set of vitals, check for pulse (I guess this should come first...). If no pulse, do CPR. If not, I would grab a 12 lead, continue asking questions from kid about any possible hospitalizations, medications, etc.

Any pallor or diaphoresis? Peripheral pulses/capillary refill? My first though here is that she is bleeding out somewhere, and is volume depleted leading to the syncopal episodes. Or it could be a cardiac zebra like Brugada syndrome.


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## NomadicMedic (May 22, 2016)

Ok. HR is 78. Respiration slows to 10 and shallow. Pupils still REARRL. BP Is 154/72. Monitor shows a normal sinus, no Ectopy.

She takes a 28f nasal airway with zero flinch and ETCO2 is 48.


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## MonkeyArrow (May 22, 2016)

Ok. 12 lead. And lungs on auscultation? And note any swelling/edema/enlargement around the neck and trachea area? JVD or midline deviation? Epiglottis and oropharynx appearance? And did you happen to get a temp?


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## NomadicMedic (May 23, 2016)

12 is normal sinus, no ST changes, no ectopy. No swelling. Her oral mucosa is dry. No temp taken.


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## RocketMedic (May 23, 2016)

A little high on the capno, but meh. 

Any weird spasms or tetany?

Pupils? Deep tendon reflexes?

IV, liter of saline, transport. I'm...tempted by the L1, but I honestly suspect this is more of a metabolic or endocrine issue. Community ED.


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## NomadicMedic (May 23, 2016)

Pupils are equal and reactive. No tenany, no spasm. Just O-U-T, out. Like she had been knocked down with etomidate.


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## STXmedic (May 23, 2016)

Were you able to pull history or meds from her before she went out?


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## NomadicMedic (May 23, 2016)

She was the epitome of vague on meds and history. I got her to admit to gabapentin. I asked for what, she said "pain". Hmm. No kiddin'. That was it. 

Can you say "Poor Historian"? (I knew you could!)

She said she had no food and no sleep for 4 days. She said she didn't take any meds today. And this was around 2 in the afternoon.


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## RocketMedic (May 23, 2016)

Maybe she's mainlining Amidate lol.


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## MonkeyArrow (May 23, 2016)

DEmedic said:


> She was the epitome of vague on meds and history. I got her to admit to gabapentin. I asked for what, she said "pain". Hmm. No kiddin'. That was it.
> 
> Can you say "Poor Historian"? (I knew you could!)
> 
> She said she had no food and no sleep for 4 days. She said she didn't take any meds today. And this was around 2 in the afternoon.


Sounds like psych. Possibly off of her psych meds for 4 days causing the psychosis and not eating, which is causing her to pass out, although the BGL is fine. Drugs?


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## Kevinf (May 23, 2016)

Encephalopathy due to electrolyte imbalance causing complex partial seizures. Take her to the community hospital.


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## NomadicMedic (May 23, 2016)

Okay. Here's a little more. 

Once we got her in the truck, her respirations slowed to about 6. We started bagging her and she got a trial dose of Narcan (per protocol, not my idea) and the doc on the radio had me repeat it. No effect. She got an EJ and bagged all the way to the ED.


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## meatanchor (May 24, 2016)

Were there any outward signs of stroke (facial droop, asymmetry, slurring of speech)?  Any signs of ETOH history?  If not, I am thinking either a neuro condition (seems too severe for narcolepsy, but maybe), a drug withdrawl, or electrolytes.


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## zzyzx (May 24, 2016)

I would be worried about a bleed. She could have had a lucid interval while you were able to talk to her.
That said, the story sounds a bit weird.
 Judging on the side of caution, take her to a hospital that can not only scan her head, but also have a neurosurgeon available to do something about a subarachnoid bleed.


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## ERDoc (May 24, 2016)

Something tells me the daughter is going to be the key here.  Can she tell you anything about mom's history?  Does she know why the pt wasn't eating or sleeping?  Did mom complain of anything over the last few days?  Let's check her pockets and pocketbook.  Let's check her for med patches, signs of trauma, etc.


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## meatanchor (May 24, 2016)

ERDoc said:


> Something tells me the daughter is going to be the key here.  Can she tell you anything about mom's history?  Does she know why the pt wasn't eating or sleeping?  Did mom complain of anything over the last few days?  Let's check her pockets and pocketbook.  Let's check her for med patches, signs of trauma, etc.



The evasiveness of the patient is a tell also.  I had to look up Gabapentin.  It's apparently both an Epilepsy med and used in the treatment of Shingles pain.  Is she embarrassed about having a Herpes condition?  Or is her family doctor treating her for a neuro disorder and the state DMV hasn't found out?


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## NomadicMedic (May 24, 2016)

ERDoc said:


> Something tells me the daughter is going to be the key here.  Can she tell you anything about mom's history?  Does she know why the pt wasn't eating or sleeping?  Did mom complain of anything over the last few days?  Let's check her pockets and pocketbook.  Let's check her for med patches, signs of trauma, etc.




Daughter doesn't really know anything, other than mom and her husband have been fighting and she now has a restraining order. Her purse is empty. No meds, Just an ID and a house key.


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## NomadicMedic (May 25, 2016)

Here's how it turned out. 

I assisted her ventilations all away to the ED, and the doctor gave her _another_ taste of Narcan.   She had never been a patient at this hospital before and there was absolutely no information to be had on her past medical history, current medications or anything other than her name and date of birth which I had obtained before she became unresponsive. She was stripped and the doc was preparing to intubate her, when she suddenly woke up as one of the RNs attempted to place a Foley. 

"What are you doing? I don't want that!"

The she was back out again...

 One of the ER nurses stuck her head in the room and said, "Oh, I know this woman. I've seen her at X hospital, she goes there all the time and she usually winds up getting intubated. I believe it's a polypharm overdose."

 Turned out to be a mix of benzo's, muscle relaxants, antipsychotics, a handful of opiates and others. 

So, there ya go.


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## Gurby (May 25, 2016)

DEmedic said:


> One of the ER nurses stuck her head in the room and said, "Oh, I know this woman. I've seen her at X hospital, she goes there all the time and she usually winds up getting intubated. I believe it's a polypharm overdose."
> 
> Turned out to be a mix of benzo's, muscle relaxants, antipsychotics, a handful of opiates and others.


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## Akulahawk (May 25, 2016)

I'd be surprised if the urine tox screen came back positive for nearly NOTHING. The evasiveness of family can be a tell too. I'd be very surprised if the kid didn't know that mom was taking LOTS of drugs.


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## NomadicMedic (May 25, 2016)

The kid was pretty stoic. She was working on getting Mom to go to the ED with us, but wasn't saying anything substantive.


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## Akulahawk (May 25, 2016)

DEmedic said:


> *The kid was pretty stoic*. She was working on getting Mom to go to the ED with us, but wasn't saying anything substantive.


Yeah, not that kid's first rodeo with Mom.


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## NomadicMedic (May 25, 2016)

Akulahawk said:


> Yeah, not that kid's first rodeo with Mom.



Yep. My thoughts as well.


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## meatanchor (May 25, 2016)

DEmedic said:


> The kid was pretty stoic. She was working on getting Mom to go to the ED with us, but wasn't saying anything substantive.



It sounds like the treatment she really needs is for all of her caregivers to be alerted to her drug issue and work on weaning her down or getting better supervision over her treatment.  And a social worker or similar tactful person probably needs to sit down and make sure her daughter knows she's not going to have a mommy much longer if this continues (especially if she's covering for her).

How good are ERs at this sort of thing?


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## Akulahawk (May 25, 2016)

meatanchor said:


> It sounds like the treatment she really needs is for all of her caregivers to be alerted to her drug issue and work on weaning her down or getting better supervision over her treatment.  And a social worker or similar tactful person probably needs to sit down and make sure her daughter knows she's not going to have a mommy much longer if this continues (especially if she's covering for her).
> 
> *How good are ERs at this sort of thing*?


Frankly, they suck at this sort of thing. What the Mom needs is for her primary care providers to NOT enable her by providing her with a ton of meds. If anyone bothered to take a look at her Narcotic history (everyone prescribed this stuff has a file) she probably is getting a bit more than she otherwise should get. She's probably NOT in a formal pain management program and therefore is probably doctor/ER shopping to get her meds and then she probably accidentally overdoses because she doesn't realize how much/little it takes to do it in a polypharm situation and ends up in the hospital.

I'm sure her "usual" caregivers know but they're not likely paid staff. 

It gets interesting seeing people's reactions when the ER Doc tears up a prescription when he/she realizes that a patient is drug seeking (especially if it's for sale), and does it right in front of the patient.


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