# Paramedic quit shortly after teen player's death



## rhan101277 (Apr 14, 2009)

This article points out the importance of making sure you follow protocols and that you make very good patient care report notes.  I am not a paramedic, but if you get to dehydrated then doesn't it get to the point where if effects your blood pressure, since your total volume is decreased from your body keeping you cool?  Also it could effect electrolytes which can cause heart disturbances, its alot to know thats why paramedics get paid big bucks.



http://www.newsobserver.com/news/story/1452060.html


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## Veneficus (Apr 14, 2009)

I am not trying to MMQB this medic, but a lot can be learned from this case. So please see my reply as an effort to point things out, not stand in judgment. The news article is poorly written as well. I didn’t realize there were EMS agencies performing heart echos and “heart attack” is a phrase of laypersons.

This case demonstrates exactly why more education is needed in EMS. There are several subtle signs here that point to a serious underlying problem which probably a large percentage EMS providers may not even know about.

Dehydration among athletes is a serious and complex issue, particularly in fluid and electrolyte balance. During recovery, it is important that pts be “watched.” Probably hooked up to some monitors too. Sports medicine and excercise physiology are their own disciplines and with good reason.

The fact the pt requested an IV shows that this is a recurrent issue. By itself it suggests that either this patient doesn’t properly pace his workouts in a healthy way or may demonstrate his inability to compensate in a normal physiological way to the intensity. Because of fluid and electrolyte shifts, adding IV fluid as a routine field treatment, especially in endurance athletes is not a good idea unless they are going to be transported to a hospital.

Epidemiology counts. The number one way that congenital heart defects, particularly long QT syndrome, DXed in males is in teenage athletes. This is not part of a normal physical and even if a 12 lead were made part of one, because there is a natural range it is very difficult for even experienced physicians to detect. Long QT generally progresses to torsades and obviously if untreated, death. (according to my personal research as part of a recent presentation in the matter, available on request, I am not posting my PPTs here) 

The patient "paced around" is a subtle anxiety response. Which can be looked at as a slightly altered mentation. It is certainly a sign of shock.

Cramping is a sign of elevated uncompensated lactate levels. We all know lactic acidosis is bad, but not everyone knows what it can look like clinically.

When you take it as a whole, the physiology of fluid/electrolyte imbalance in athletes, history of dehydration requiring invasive care, subtle signs of shock, lactic acidosis which is a sure sign of inadequate tissue metabolism, and the number one circumstance leading to the detection of occult genetic heart defects, transport to a higher level of care would be a good idea. Placing the pt on a monitor would have been a very good idea, considering fluid/electrolyte imbalance may (but not always) show up. A 12 lead may demonstrate exactly the electrolyte imbalances.  A simple pulse check may not reveal weak ectopic beats and certainly not the difference in high rate sinus tachycardia and a low rate V-tach.

Unless a minor in the country is not permitted to refuse, as stated could be the case here, I don’t really see any fault, just lack of knowledge which is not part of the current EMS curriculum and not noticing some very subtle signs of a potential serious problem. Perhaps if tachycardia and hypotension were present it would have been more obvious from the EMS standpoint but that is not stipulated here, not to mention if this was a conditioned athlete it most likely would still be within normal limits or even acceptable parameters.

The whole event seems very unfortunate for all involved.


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## rhan101277 (Apr 14, 2009)

Yeah this guy had 9 years experience as well.  You can walk around and be ok with torsades?

The first thing I thought of was acidosis, if he was already dehydrated and his body was attempting to conserve water that stuff would just build up.


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## CAOX3 (Apr 14, 2009)

As Veneficus stated.

Anxiety, cramping, empty water bottles all over, asking for a specific treatment, history of dehydration, minor and unable to locate a parent.

This seems like an easy one to me.  He goes.

He needs to go, dehydration is deadly. Also dehydration can also mimic hydro-hydration(water toxicity or water intoxication) it causes dilutional hyponatremia and also can be deadly.

Just a though on the on the hydro-hydration. 

I wasnt there the article is vague.


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## LucidResq (Apr 14, 2009)

Veneficus said:


> Epidemiology counts. The number one way that congenital heart defects, particularly long QT syndrome, DXed in males is in teenage athletes.



About 100 collegiate and high school athletes drop dead each year thanks to sudden cardiac arrest due to cardiovascular disease. The vast majority are undiagnosed until they die. Hypertrophic cardiomyopathy is by far the most common. The classic presentation is either an older-ish person with a-fib, or a young athlete suddenly dying on the field. 

See Reggie Lewis  for evidence that syncope, faintness, lightheadedness, etc in the athlete needs to be taken very seriously. 

(Sorry, I know this is a bit of a tangent but SCD in athletes is a strong area of interest for me)


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## Veneficus (Apr 14, 2009)

rhan101277 said:


> Yeah this guy had 9 years experience as well.  You can walk around and be ok with torsades?
> 
> The first thing I thought of was acidosis, if he was already dehydrated and his body was attempting to conserve water that stuff would just build up.



Not for very long. But I have seen patients in both monomophic v-tach and polymorphic v-tach as well as hypotensive, ambulate around with some weakness and sit and lay as if nothing was wrong.


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## rhan101277 (Apr 15, 2009)

Ambulate around, that made me chuckle.  Don't know why medicine has to use big works, just can't say walk around, or pt unable to walk etc.


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## mycrofft (Apr 15, 2009)

*I did medical for late elementry/early jr high football. Never again.*

For teens and below, they need to develope paediatric sports doctors.
Also, "sports medicine" has become corrupted as a means to press the human body farther and farther, then work despite insult, versus a specialty practice in preventing and addrssing problems.
I asked the then-medical chief for the TV show "Survivor" (Adrian Cohen) via email if he followed the sports medicine model or the client centered model. He said the medical rep stood by the director, and if things were going poorly, he would essentially tap the dirctor and shake his head, and it was "CUT!".
I wonder how many collapses are linked to self-medicated and devised success strategies, like repeated inhaler applications, ephidrine and pseudoephedrine, and limiting fluid intake prior to an event.


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## Veneficus (Apr 15, 2009)

rhan101277 said:


> Ambulate around, that made me chuckle.  Don't know why medicine has to use big works, just can't say walk around, or pt unable to walk etc.



medicine is its own language, the more you are around it, the more natural it becomes


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## VentMedic (Apr 18, 2009)

rhan101277 said:


> Ambulate around, that made me chuckle. Don't know why medicine has to use big works, just can't say walk around, or pt unable to walk etc.


 
To say "walk" gives the impression of "normal".

To "ambulate" in the medical world means the patient moved from one spot to another but it may be open to more documentation to address the quality and method of movement.   



Here are a few links for more reading about the some of the possibilites that could have been contributing factors.

Hyponatremia
*Exercise-Associated Hyponatremia: Who's at Risk?*

http://www.medicinenet.com/script/main/art.asp?articlekey=47388

.
*Rhabdomyolysis: A Big Problem with a Big Name*
http://www.ems1.com/ems-products/Pa...-Rhabdomyolysis-A-Big-Problem-with-a-Big-Name


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