# call from when i was in basic school



## EMSDude54343 (May 19, 2011)

Heres one for ya, lets hope i remember it all;
Get called to an elderly community for a fall. Upon arrival asking the family on scene what happened, they adv they came home from the store and found our pt on the floor 'out of it'. No actual fall occurred according to family, also no evidence of a fall.
We find the pt supine on the floor of his bedroom, rolling side to side, almost like a kid having a fit. pt is awake and moaning, pt does not resp to verbal stimuli, does resp to pain. Vitals are WNL, no med hx and pt was last seen 'a couple hours ago'. 
Pts skin is dry and warm, pupils ERRL. Room and house is clean.
Upon transfer to the rig, pt starts to become combative and swing at us and spitting, a mask is placed and taped down after the placement of an NPA, pts limbs are also tied to the stretcher, O2 is applied at 15lpm via NRB for added protection from pts spitting, Vitals are again checked and reemain WNL, (dont remeber exact, was years ago) 
And because i forgot to mention this, pt is in his mid thirties
During transport and arrival at the ED pt continued to become more combative, was awake, but not alert and only responded to painful stimuli. 

Any questions?
What do you think is wrong with this pt?


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## Handsome Robb (May 19, 2011)

Did you get a BGL? Was the pt incontinent? How long was your transport time? Possibly a seizure with your pt being postictal(sp?) upon arrival and during transport or diabetic event would be my first two guesses.


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## mycrofft (May 19, 2011)

*Did he keep saying something.....*

Like "Who are you and what are you doing this to me for?" ?
Was he verbal, mental status? 
Too many ways to get that way, but waking up in restraints with an airway and a mask fastened on will not help with behavioral issues.


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## Euclidus (May 19, 2011)

Maybe I'm confused here, but how come a 30 year old is living in an elderly community? Is he staying with relatives, or is there a medical reason, ie, is this a nursing type facility? I know you said no medical history, but I am hung up on this part. And if there's no medical history, is there any social history as to why a 30 year old is living with relatives in a retirement community, if that is indeed the case? (Drug use? Prison?)


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## Hellsbells (May 19, 2011)

Sounds like hypoglycemia. Why the npa? Was there evidence of respiratory distress, hypoxia?


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## medicstudent101 (May 19, 2011)

There's quite a bit of info that's not there.


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## EMSDude54343 (May 19, 2011)

I knew id be missing info, sorry bout that. this is my first post..... 

We did get a BGL, was a while ago so i dont remember the exact lvl but it was normal enough that we didnt treat for any abnormality. 
As for the NPA, pt was pt wasnt alert and spitting at crews so more for training than anything and to have a 'secure' airway if pt vommited and choked. (suction was made ready in case)

No hx of siezures, 

transport time is 5 - 7 minutes.

Community is an elderly mobile home park, (many of those in florida) lives with family who is elderly. When attempting to get a history from the family they advise that pt is thier son, has lived with them for some time and when they left in the am (call is in the afternoon) pt was normal mental state, taking a shower. (no history of mental illness) 
 Pt has no medical history or history of drug abuse or depression (as far as they klnow). 

No evidence of resp distress or hypoxia (sats were 99-100 i believe, without o2) . The NRB was tried first more as a spit block but pt was able to remove it by moving is mouth around, even with the strap around his head, so a heppa (sp?) mask was applied as it is harder to move and covers more facial area. 

Pt was unable to form words, was mumblleing (sp?) incoherantly, and looking around. 

If i am missing anything or you have more questions, let me know.

Anyone have a clue yet? Euclidus is starting to get there.....


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## phideux (May 19, 2011)

"We did get a BGL, was a while ago so i dont remember the exact lvl but it was normal enough that we didnt treat for any abnormality. 
As for the NPA, pt was pt wasnt alert and spitting at crews so more for training than anything and to have a 'secure' airway if pt vommited and choked. (suction was made ready in case)"

You are putting in an NPA because the patient is spitting??? And for training??? And to have a secure airway in case they vomit and choke????
I don't see any of those as reasons for an NPA.
My guess on this patient is he either did fall and sustained some sort of head injury, or got into something toxic.


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## EMSDude54343 (May 19, 2011)

yes looking back prob didnt need an NPA, the medic i was with was the type to try and do extra stuff for training on not alert pt's or unconcious pts. is it right? prob not, but i didt complain i had never placed one before. also it didnt harm the pt or take away any other treatment either.


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## Handsome Robb (May 20, 2011)

phideux said:


> My guess on this patient is he either did fall and sustained some sort of head injury, or got into something toxic.



I'm going to agree with this. Wouldn't more changes in the vitals be present in a patient who had ingested something toxic? 

I do have a question though, If the family came home and the patient was on the floor, how do they know he didn't fall?


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## mycrofft (May 20, 2011)

*Psych meds not necessarily change vitals*

Unnecessary NPA is a felonious assault and battery.


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## systemet (May 20, 2011)

Also, an NPA does not secure an airway.  It opens the airway in an obtunded patient with snoring respirations or apnea.  It does nothing to prevent gastric contents from entering the trachea.

To secure an airway, you need an ET tube, or to a lesser extent combitube / LMA / King  --- bearing in mind that these devices will probably not protect against aspiration as well.

There's no reason to put an NPA in someone fully conscious.


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## usafmedic45 (May 20, 2011)

> Unnecessary NPA is a felonious assault and battery.



The problem is define "unncessary".  If the person documents it correctly, it's a "he said, she said" sort of scenario.



> There's no reason to put an NPA in someone fully conscious.



Actually, there is....just not so much a field procedure.  If you have someone who needs to be repeatedly nasotracheally suctioned because of lots of secretions, it's much nicer, easier and kinder to put in an NPA to pass the suction catheter through.  Just a little trick of the trade.  



> Anyone have a clue yet?



Spontaneous intracranial hemorrhage would be high on my list of rule outs as I've seen pretty much the same scenario due to one. Any history of hydrocephalus?  If he's got a shunt and it's obstructed, you can get some whacked out behavior as the ICP goes up.


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## Euclidus (May 20, 2011)

The family is embarrassed to tell you that their 30 year old son is an alcoholic and this is alcoholic ketoacidosis? 

Any noticeable smells?


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## NREMTroe (May 20, 2011)

Euclidus said:


> The family is embarrassed to tell you that their 30 year old son is an alcoholic and this is alcoholic ketoacidosis?
> 
> Any noticeable smells?




I agree with this, but if it's not, I would think head trauma from the fall, because of the combativeness.


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## EMSDude54343 (May 20, 2011)

Pt was overdosing on PCP and had a Blood Alcohol Content of .379.


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## EMSDude54343 (May 20, 2011)

systemet said:


> There's no reason to put an NPA in someone fully conscious.



pt was not fully conscious as previosly stated.


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## crazycajun (May 20, 2011)

Sorry but there is no way PT had vitals WNL or a BGL that was normal with a .379 BAC and OD of PCP


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## mycrofft (May 23, 2011)

*"Unnecessary" was a generic observation of principal*

Performing a procedure just for practice without signed consent is a tort*; I have read from others and seen here in CENTCALIF that procedures done "just in case" are verboten, and  a gaggle of EMT johnnies on a street corner or in a living room does not constitute a teaching facility. Whether or not it is documented or gotten away with, it's a no-no. Just make sure it's needed, then select the least experienced one and have him/her do it under supervision. (Effective  way to asses LOC though, I suspect).h34r:

*I like blueberry torts mysellf.


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## Anjel (May 23, 2011)

crazycajun said:


> Sorry but there is no way PT had vitals WNL or a BGL that was normal with a .379 BAC and OD of PCP



uh yea. I agree.


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