# This call was interesting!!



## Lisa (Aug 24, 2008)

Dispatched to a 39 yo male, Diabetic Emergency.
First Responders arrive on scene and report pt is incoherent, BP 214/104, R 14 and labored, Pulse 114. They are also reporting pt had a shunt placed in the Rt arm approx 4 weeks ago. HX of MI x 2, HTN, IDDM, Hep C, renal failure.
Arrive on scene FR placed pt on o2 via NC at 5 lpm. PT laying supine in living room floor. Many families members present. Some clear fluid draining from Rt arm where the shunt was placed. PT has a blood glucose of 36. IV access nill. EJ started and 1 amp D50 pushed. No change. 2mg Narcan pushed due to evidence in the house as well as PT is a known drug user. Still no change.Loaded pt in unit. Cardiac moniter show Tachycardia. BP now up to 220/134. Pt combative. Pupils 6mm(rt) and 3mm(lft)and sluggish. Air medical contacted and en route. Pt continues to become more aggressive/combative. Pt intubated per Dr at recieving hospital.  Any guesses as to what is going on with this pt?
Need anymore info let me know.


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## fma08 (Aug 25, 2008)

evidence of head trauma?


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## akflightmedic (Aug 25, 2008)

Even without evidence of head trauma, I would be considering a bleed.


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## Ridryder911 (Aug 25, 2008)

Could be several factors. Of course as pointed out it appears to be a Frank Head Bleed with the neuro signs deficits as well with a recent installation of a shunt, free floating fragments could have caused the bleed. The other is severe electrolyte and possible high ammonia levels to occur (ARF, Hep C). The patient being combative could be r/t many factors from hypoglycemia to > ICP, ammonia levels.  

No matter what, I personally would have suggested an RSI in the field and placed patient on the vent to help reduce ICP and eliminate combativeness. Making notations of a good and thorough neuro assessment just prior if possible. 

This patient appears to have multiple complications and probably not a good outcome wil follow. 

R/r 911


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## Lisa (Aug 25, 2008)

*Last I heard*

We all know how HIPPA laws are but the last time I heard this pt DID NOT have a bleed!! That was what my money was on too, flight crew says CT scans were normal and so were all the other test,(not sure what all they did) The only thing that hadn't come back yet was his tox screen. They were assuming he shot meth into his shunt?!?!  Of course this was second hand info. I would have liked to follow up on this one, it was an interesting case.


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## Lisa (Aug 25, 2008)

*P.s*

Oh yeah... No evidence of head trauma and he was RSI in the field.


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## BossyCow (Aug 26, 2008)

Lisa said:


> We all know how HIPPA laws are but the last time I heard this pt DID NOT have a bleed!! That was what my money was on too, flight crew says CT scans were normal and so were all the other test,(not sure what all they did) The only thing that hadn't come back yet was his tox screen. They were assuming he shot meth into his shunt?!?!  Of course this was second hand info. I would have liked to follow up on this one, it was an interesting case.



First.. its HIPAA. Second HIPAA does not stop you from doing a follow up on a pt. If you want to know the outcome of a pt you treated, you are entitled to that information. There may be a process you have to follow in order to get the information, but you can find out. In our area, we do a run review with the MPD once a month where we have the opportunity to ask questions and discuss our tx on scene and what happened to the pt following the call. Talk to your supervisors to find out what the process is for your agency. 

Fear of a misunderstood regulation shouldn't stop you from accessing information that will help you learn.


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## BruceD (Aug 26, 2008)

When was the last time the shunt was used legitimately?

You said the family reported him as incoherent, did he speak to you or communicate in some way?  Slurred speech? Wernicke or Broca type aphasia?

Did he ambulate?  Did all 4 limbs move properly and have equal strength?

Has he been examined before by you or has anyone noticed if he is one of those people with pupils that are just naturally different sizes? (albeit, that's a decent difference).

I only ask out of curiosity, I've no idea how much time you had or how agreeable the patient was to your exam.

With his gosh-awful history of MIx2 at 39yo, DM, and HTN - he's a CVA waiting to happen and it's not terribly uncommon to see such bps in recent ischemic strokes.

I agree with Rid though, way too much going on here to dx w/o more info & would love to hear the result if you find out. 

TC
-B


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## Lisa (Aug 27, 2008)

Talked with the pt myself yesterday. He is still in the hospital and he says "they are getting him straightened out" He was not very forthcoming with his DX. To my knowledge that shunt had not been used yet as they were arranging his dialysis. Didn't think he would tell me a whole lot anyway...My hubby is a police officer and has run ins with this indiviidual. If I hear anymore I will let you guys know. Just thought this was interesting case and wanted to share it and see if anyone else came up with something different than we did. Thanks for all your input!


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## mycrofft (Aug 29, 2008)

*Pupils..I've seen something like that before.*

Pt was alcoholic toxic-psychotic as the ER doc called it (blown pupils, hallucinatory and combative on massive tequilla) and pupils were not exactly equal in size, but reacted in concert. Doc said sometimes toxics or other stress to the brain can cause assymetric eyes, which are trying to compensate, to decomp.


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## YouthCorps1 (Nov 13, 2008)

I agree with oxygen...start a line with anti-hypertensive at least due to his B/P, pt needs to be restrained, do so for your own safety, but if this guy was concious and alert with adequate breathing, i dont think that there was any reason to intubate


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## Bosco578 (Nov 14, 2008)

Have partner hold pt. down and punch him in the stomach........Consider Cric at this point.......


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