# Scenerio 4



## Chris EMT J (Apr 7, 2022)

This scenerio is based on a recent case so s few details are changed for patient privacy. 

Male 50s CC of weakness
Vitals are
HR in low 100s 
BP around 99/48 
O2 98% on RA 
RR 20 
Temp 101.6
BGL 104 

SAMPLE:
Weakness, no allergies, taking ibuprofen for pain post surgery, past medical history of a ankle surgery about 2days prior, no other pmx, last oral intake was some water, events leading was resting.

I started a IV (not running anything)
High HR + Low BP got a intercept
Paramedic agreed that fluids may help so started 250cc of normal saline. We were very close to hospital so not much time to do anything else except paramedic did do a quick ECG which was normal.

Suspecting possible sepsis from post surgery but not 100% sure 

So any feedback on how to improve here?


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## mgr22 (Apr 7, 2022)

I don't understand why you'd call for an intercept for this patient when you're "very close" to the hospital. Was the transport delayed for the IV and fluid bolus?


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## Chris EMT J (Apr 7, 2022)

mgr22 said:


> I don't understand why you'd call for an intercept for this patient when you're "very close" to the hospital. Was the transport delayed for the IV and fluid bolus?


No we were close when I met with the intercept. The overall ETA was 15min but we started driving with patient then met up with a intercept on the way. No delay in IV or fluids


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## DrParasite (Apr 7, 2022)

ChrisEMTA said:


> This scenerio is based on a recent case so s few details are changed for patient privacy.
> 
> Male 50s CC of weakness
> Vitals are
> ...


what was your differential diagnosis?


ChrisEMTA said:


> I started a IV (not running anything)
> High HR + Low BP got a intercept


why does high HR and low BP = intercept?  isn't that a normal reaction?  again, dumb hose dragger here, and A&P isn't my strong point.  Also, not saying your wrong, just asking a question. 


ChrisEMTA said:


> Paramedic agreed that fluids may help so started 250cc of normal saline. We were very close to hospital so not much time to do anything else except paramedic did do a quick ECG which was normal.
> 
> Suspecting possible sepsis from post surgery but not 100% sure
> 
> So any feedback on how to improve here?


What is the paramedic going to do for sepsis?  low BP and elevated temp can def lead to possible sepsis, so an IV with running fluids might be appropriate; what made you decide not to hang a 250cc or 1L bag on the patient?    what other paramedic interventions do you think the patient needed?


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## Chris EMT J (Apr 7, 2022)

DrParasite said:


> what was your differential diagnosis?
> 
> why does high HR and low BP = intercept?  isn't that a normal reaction?  again, dumb hose dragger here, and A&P isn't my strong point.  Also, not saying your wrong, just asking a question.
> 
> What is the paramedic going to do for sepsis?  low BP and elevated temp can def lead to possible sepsis, so an IV with running fluids might be appropriate; what made you decide not to hang a 250cc or 1L bag on the patient?    what other paramedic interventions do you think the patient needed?


My differential is infection, surgical complication, or the chance it's unrelated. I wanted a intercept because patients hemodynamic status was questionable and if BP drops a bit more the medic could give a presser unlike me. Medic may not be able to help with sepsis but can help with a questionable hemodynamic status. I only did a 250cc because I wanted a paramedic opinion about ether 1L of fluids or 250cc of fluids and a presser. I really wasn't sure which would improve hemodynamics more. Patients BP did come up some and did become more stable but after the 250cc we were pretty much already there so the ED can decide what they want to do after that.


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## mgr22 (Apr 7, 2022)

ChrisEMTA said:


> No we were close when I met with the intercept. The overall ETA was 15min but we started driving with patient then met up with a intercept on the way. No delay in IV or fluids


This isn't a big deal, but you say you're looking for feedback. Did you consider cancelling the intercept when you got close to the hospital? All the medic did was start a fluid bolus, which could have waited (not that I'm criticizing the medic). I think you're spending too much time looking for solutions in search of problems.


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## DrParasite (Apr 7, 2022)

I'm not an expert on pressors (I would differ to almost anyone else about their use) but you might benefit from reading this article about them: https://www.ems1.com/drugs/articles/understanding-push-dose-pressors-hTtV3qvgjn0W3rFt/


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## Chris EMT J (Apr 7, 2022)

mgr22 said:


> This isn't a big deal, but you say you're looking for feedback. Did you consider cancelling the intercept when you got close to the hospital? All the medic did was start a fluid bolus, which could have waited (not that I'm criticizing the medic). I think you're spending too much time looking for solutions in search of problems.


I considered cancelling intercept yes, but decided not to so the medic could give input. Like interpret the ECG we did on a advance level. Btw we ECGs for a lot of reasons at my company including the complaint of weakness.


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## Chris EMT J (Apr 7, 2022)

DrParasite said:


> I'm not an expert on pressors (I would differ to almost anyone else about their use) but you might benefit from reading this article about them: https://www.ems1.com/drugs/articles/understanding-push-dose-pressors-hTtV3qvgjn0W3rFt/


Thanks for the link. I will definitely look at it and keep it in mind


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## silver (Apr 7, 2022)

ChrisEMTA said:


> So any feedback on how to improve here?


Obviously your post is abridged of information that you gathered from the patient about their history. However, after reading a few of these posts I would recommend really focusing on history taking and developing an assessment with differential. From there, people (colleagues, ED staff, random strangers on the internet) will be able to better guide you on management, and you will more often pick the most reasonable management options on your own.

When I read the scenario I'm not 100% convinced an ankle surgery 2 days prior causes sepsis. Pretty unusual to have surgical site infection that early especially not in the setting of prior ankle hardware, joint infections, chronic wounds, poor perfusion.


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## Chris EMT J (Apr 7, 2022)

silver said:


> Obviously your post is abridged of information that you gathered from the patient about their history. However, after reading a few of these posts I would recommend really focusing on history taking and developing an assessment with differential. From there, people (colleagues, ED staff, random strangers on the internet) will be able to better guide you on management, and you will more often pick the most reasonable management options on your own.
> 
> When I read the scenario I'm not 100% convinced an ankle surgery 2 days prior causes sepsis. Pretty unusual to have surgical site infection that early especially not in the setting of prior ankle hardware, joint infections, chronic wounds, poor perfusion.


Thank you for the feedback I will try to take better histories and create more of a differential. Thanks for being clear on what I can improve I really appreciate!


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