# 30 Y/0 M Sick Person



## frdude1000 (Apr 27, 2012)

Dispatched for a sick person on side of highway.  Arrive on scene to find male laying in box of a moving truck, moaning in pain.  He vomited a large amount before our arrival.  Paramedic Engine arrives before us.  Pt. states he has LLQ abd. pain 10/10 sharp.  Vitals were pulse 30, BP 170/110, O2 sat 96.  Pt. stated no prior medical problems, not taking any meds.  Transported priority 2, upgraded by ALS engine medic.  Enroute, medic started the patient on a bag of normal saline and placed pt. on lifepak.  While transferring to hospital staff, he begun to vomit again.

What do you guys think this might be?  We are thinking it was either a aortic aneurysm or bad kidney stones.


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## Anjel (Apr 27, 2012)

frdude1000 said:


> Dispatched for a sick person on side of highway.  Arrive on scene to find male laying in box of a moving truck, moaning in pain.  He vomited a large amount before our arrival.  Paramedic Engine arrives before us.  Pt. states he has LLQ abd. pain 10/10 sharp.  Vitals were pulse 30, BP 170/110, O2 sat 96.  Pt. stated no prior medical problems, not taking any meds.  Transported priority 2, upgraded by ALS engine medic.  Enroute, medic started the patient on a bag of normal saline and placed pt. on lifepak.  While transferring to hospital staff, he begun to vomit again.
> 
> What do you guys think this might be?  We are thinking it was either a aortic aneurysm or bad kidney stones.



I don't think it was an aneurysm. 

Probably stones of some sort. Maybe colitis, or some bad food poisoning. 

Pulse of 30 though? That is very odd. I would suspect 130?


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## fast65 (Apr 28, 2012)

Could be colitis or diverticulitis. However, I would like to see a 12 lead on him.


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## Handsome Robb (Apr 28, 2012)

How was his abdomen? Distended? Discoloration? Pulsating masses? Tender to palpation? Referred pain anywhere? Rebound tenderness? Blood in the vomit? "Coffee grounds" in vomit? Did it smell like feces or just regular puke (weird question I know but it's not something you have to really go out of your way to assess)? A&O? Skin signs? Onset? Last BM? Diarrhea? Changes in diet or abnormal foods recently? Hx of kidney stones? Did he feel the pain descend? Any pain in his back? Dizziness? Chest pain? SOB? Hx or family Hx of diverticulitis/diverticulosis? 12-lead done?

HR of 30 a typo or actual rate? AAA would usually be hypotensive and tachycardic not the other way around. Kidney stones would usually present with descending flank pain rather than LLQ abd pain. Wondering your thought process on these two differentials? Not saying you're wrong just wondering how you came to this conclusion. 

No zofran/phenergan or pain management? Pain management is presuming he isn't altered. 

Could be a perforated bowel causing peritonitis but I'd think it would be more diffuse pain rather than LLQ. Could be a severe bowel blockage (hence the poopy smelling vomit question). HR could also be secondary to a vasovagal response but I'd think his pressure would be dumped out too, "bearing down" or similar pressure secondary to a bowel blockage. Could be diverticulitis or colitis.

edit: dammit, fast beat me to the colitis/diverticulitis.


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## fast65 (Apr 28, 2012)

NVRob said:


> edit: dammit, fast beat me to the colitis/diverticulitis.



It's what I'm here for, you said everything I was too lazy to say, so it's the least I can do.


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## Veneficus (Apr 28, 2012)

NVRob said:


> How was his abdomen? Distended? Discoloration? Pulsating masses? Tender to palpation? Referred pain anywhere? Rebound tenderness? Blood in the vomit? "Coffee grounds" in vomit? Did it smell like feces or just regular puke (weird question I know but it's not something you have to really go out of your way to assess)? A&O? Skin signs? Onset? Last BM? Diarrhea? Changes in diet or abnormal foods recently? Hx of kidney stones? Did he feel the pain descend? Any pain in his back? Dizziness? Chest pain? SOB? Hx or family Hx of diverticulitis/diverticulosis? 12-lead done?
> 
> HR of 30 a typo or actual rate? AAA would usually be hypotensive and tachycardic not the other way around. Kidney stones would usually present with descending flank pain rather than LLQ abd pain. Wondering your thought process on these two differentials? Not saying you're wrong just wondering how you came to this conclusion.
> 
> ...



Many good questions...

Could I just suggest starting with: "Is the patient able to localize the pain or is it diffuse"

edit: also with the description and vitals here, I would not focus on his abdomen alone and would especially look at his head.


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## NYMedic828 (Apr 28, 2012)

Is the heartrate correct?

To have a HR of 30, not be AMS and have a Hypertensive BP is very strange.

Not sure adding more fluid at that point was a necessary move but we weren't there.

A more detailed history would help greatly in this scenario.


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## abckidsmom (Apr 28, 2012)

Veneficus said:


> Many good questions...
> 
> Could I just suggest starting with: "Is the patient able to localize the pain or is it diffuse"
> 
> edit: also with the description and vitals here, I would not focus on his abdomen alone and would especially look at his head.



That's what I was thinking.  

Also, if he's a young healthy guy in a lot of pain, he could vagal his heart rate down that low, and all that pressure would falsely raise his BP.

I don't know about everyone else, but I find that almost everyone is initially hypertensive, and after they settle down a bit, the pressure is more normal.  Maybe not almost everyone, but many, many people.


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## SliceOfLife (Apr 28, 2012)

First thing that popped in my head when I heard back of truck was CO poisoning.  Symptoms seem to fit too.


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## LifelongEMT (Apr 28, 2012)

SliceOfLife said:


> First thing that popped in my head when I heard back of truck was CO poisoning.  Symptoms seem to fit too.



How long was he in the back of the truck? Was it running? was it hot? Was his skin flushed? Had he been drinking alot of fluids? if so what kind? I know from experience some soft drinks are notorious for kidney stones.


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## SliceOfLife (Apr 28, 2012)

LifelongEMT said:


> How long was he in the back of the truck? Was it running? was it hot? Was his skin flushed? Had he been drinking alot of fluids? if so what kind? I know from experience some soft drinks are notorious for kidney stones.



Yup.  All things to consider for your differential.


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## LifelongEMT (Apr 28, 2012)

LOL how many exhaust leaks did the truck have???? Thats a good one too.


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## frdude1000 (Apr 29, 2012)

Yes, heart rate is correct at 30 BPM.  I do not have a 12 lead unfortunately to show.  We never got a complete history because he was moaning in 10/10 pain the whole time, but for a second he told us he had no medical problems or allergies, or meds.  His vomitus was of normal color and consistency.  He stated he didn't eat since earlier in the day and he wasn't drinking very much.  I believe he was only in the back of the truck so he could vomit in the shade in privacy (since we were on the side of the major highway in DC)--he was never riding back there.  This guy was a hard stick and we were 3 min away from ED so he only had a chance to start the IV and hang a bag.


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## LifelongEMT (Apr 29, 2012)

frdude1000 said:


> .  He stated he didn't eat since earlier in the day and he wasn't drinking very much.    This guy was a hard stick and we were 3 min away from ED so he only had a chance to start the IV and hang a bag.



Was it hot out? with him being a hard stick probably dehydrated and maybe heat exahaustion? Just an idea.


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## Veneficus (Apr 29, 2012)

LifelongEMT said:


> Was it hot out? with him being a hard stick probably dehydrated and maybe heat exahaustion? Just an idea.



Usually the heat related patients get better after they vomit.


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## LifelongEMT (Apr 29, 2012)

Veneficus said:


> Usually the heat related patients get better after they vomit.



I had a heat stroke during a late july football game in high school and the more i vommited the more dehydrated and the worse i got until i finally blacked out and woke up,in the ER, but everybodys different. I have seen improvement in heat related pts after they vommit but not all the time. Just another point of view.


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## frdude1000 (Apr 29, 2012)

I was busy putting the pt. on O2, spiking the bag, and getting the patient on the monitor while the medic was doing most of the pt. assessment and getting the line in place during this very short transport.  I believe he was dehydrated though because he was diaphoretic and he stated he hadn't been drinking at all during the day.


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## Melclin (Apr 29, 2012)

How many spare hands did you have? How long does it take to draw up your anagesic and antiemetic of choice?

Its not even an matter of being humane. You just won't be able to learn much untill he can speak to you. Nobody will. Head is an option. I think abdo problem is most likely (I think those vitals can be explained by vomiting/vagal), but who knows until you actually examine them properly. 

If I were receiving that pt, I would much prefer him delivered to me about 90 seconds later pain free and and not vomiting with a little hx rather than 90 seconds earlier with none of that.


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## frdude1000 (Apr 29, 2012)

I agree with you.  I was not in charge of the pt, the medic was.


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## Melclin (Apr 29, 2012)

frdude1000 said:


> I agree with you.  I was not in charge of the pt, the medic was.



Yeah I understand that. I've been in that position plenty of times so I sympathise. My tone was probably a bit harsh. It wasn't directed at you, so much as the idea.


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## Doczilla (Apr 30, 2012)

Remember that infections and bleeds can cause excessive vagal tone. The SA node can be depressed without seeing the effect on blood pressure, since there are a few vasoconstrictors outside the sympathetic arsenal.


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## mycrofft (May 1, 2012)

When it comes to important stuff, always designate pulse as palp or apical, and whether it is regular, or irregular (regularly irregular or regularly irregular?), and add strength notes if it is not inotropically stable (all pulses same strength). I know this is "shake the magic rattles" stuff to most, but you can take a pulse and have that data while your partner is still untangling the 12 leads and etc., plus the EKG will not give inotropic info (effect of cardiac contractions). It may not be in the protocols but it can start focusing your attention and offer the ED some more info. 

Rant over. Except for the vomiting thing I'd suspect acute gas or distress secondary to hard stool (dehydration,constipation). Renal or ureteral should be more "flanky" or even inguinal or scrotal, usually. Energetic vomiting can make your vitals go all to heck, especially if dehydration (and maybe electrolyte issues) are considered. Bowel sounds would have been helpful too, and a palpation. (Flatus? Tympany?).

Zebras: early appendicitis (it can initially present with nausea, and pain centrally then take a bit to "settle" into McBurney's point).  A diverticulitis? 

Treatment sounds like it was right on except maybe some pain meds and anti-emetic.


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## Frozennoodle (May 12, 2012)

Melclin said:


> Yeah I understand that. I've been in that position plenty of times so I sympathise. My tone was probably a bit harsh. It wasn't directed at you, so much as the idea.



Many protocols in the states don't allow for administration of pain medications for abdominal complaints.  My area is one of them.


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## NYMedic828 (May 12, 2012)

Frozennoodle said:


> Many protocols in the states don't allow for administration of pain medications for abdominal complaints.  My area is one of them.



As is mine, but the only standing orders I can give morphine on are for isolated extremity injuries and burns.

I can also give toradol standing orders for extremity injuries.

The docs are usually hesitant to give us morphine for chest pain or potential visceral pain for fear of changing the assessment for the receiving facility. I thought that mentality was done away with since the furthering of technologies like CT scans, MRIs and ultrasounds.


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## Frozennoodle (May 12, 2012)

NYMedic828 said:


> As is mine, but the only standing orders I can give morphine on are for isolated extremity injuries and burns.
> 
> I can also give toradol standing orders for extremity injuries.
> 
> The docs are usually hesitant to give us morphine for chest pain or potential visceral pain for fear of changing the assessment for the receiving facility. I thought that mentality was done away with since the furthering of technologies like CT scans, MRIs and ultrasounds.



Abdominal pain is our only restriction.  We have fentanyl, morphine, and toradol. Morphine for chest pain. All standing orders.  On-line med control for pediatric pain management.


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## Handsome Robb (May 13, 2012)

NYMedic828 said:


> As is mine, but the only standing orders I can give morphine on are for isolated extremity injuries and burns.
> 
> I can also give toradol standing orders for extremity injuries.
> 
> The docs are usually hesitant to give us morphine for chest pain or potential visceral pain for fear of changing the assessment for the receiving facility. I thought that mentality was done away with since the furthering of technologies like CT scans, MRIs and ultrasounds.



That's ridiculous. I'm sorry. 

We have pretty liberal pain management protocols. I can give 2-5mg MS on standing orders to a max of 15 mg for abdominal pain. 

Like you said, advanced imaging equipment *should* debunk the abdominal assessment problems at the ER.


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## Melclin (May 13, 2012)

That is simply ridiculous. 

Do you not have some sort of recourse where you can do a lit review or an argument and make an application for protocol change?

And isn't there room to bend those rules? Surely everyone agrees its ridiculous and would be in on a change, docs included.


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## Veneficus (May 13, 2012)

*Dog and pony show*



Melclin said:


> That is simply ridiculous.
> 
> Do you not have some sort of recourse where you can do a lit review or an argument and make an application for protocol change?
> 
> And isn't there room to bend those rules? Surely everyone agrees its ridiculous and would be in on a change, docs included.



Lol.

I typed up a long reply detailing how US medicine with the exception of a handful of high profile centers is perhaps the worst in the world while ethnocentrically propagandizing how they are the best and one true faith.

But rather than post it here, I think I will go start a blog about it.

But if you are in pain forget pain meds, they are dangerous, lead to addiction, aren't needed, interfere with diagnostics, and all other manner of BS.

If it doesn't come on a radiology scan with a corresponding chart or scale on what treatment or how bad, the US medical establishment simply can't function.

There is no way this establishment is going to change no matter how much evidence is presented to whomever, by whomever.

The snake oil salesmen will continue pandering their leeches and hot pokers while pricing themselves out of the market charging exponentially higher costs than the rest of the world with end results you would have to go to Africa to find worse.

The only science or evidence they acknowledge is that which supports their postion. The exact same thing was done in the 19th century Europe to create scientific evidence white males were superior to all other humans including white females based on the volume of the cranial vault. (with all kinds of creative ways to alter the measurements, like using child skulls of Africans, or filling male skulls with metal shot and female skulls with seeds.)

Science to justify and enforce socialogical customs and norms.


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## Melclin (May 13, 2012)

Veneficus said:


> But rather than post it here, I think I will go start a blog about it.
> ....
> 
> Science to justify and enforce socialogical customs and norms.



Do. And do post a link. I like me a good blog to read so I do. 

....

Yes well the US, as you point out, certainly doesn't have a monopoly on that. 

The greater argument aside though, surely US EMS systems must have some mechanism by which people can suggest things. Its not the bloody magna carta. Its just a glorified suggestion box. Surely...

On the topic of bending the rules...surely you can say, well yeah I know it says 2-5mg q5 in the protocol, but this dude had 50%BSA burns so I gave the first two lots of ten pretty much just straight up and anyone auditing just says, well yeah...bloody hell he must have been in incredible pain...nice work.


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## Veneficus (May 13, 2012)

*The ultimate stawman argument*



Melclin said:


> Do. And do post a link. I like me a good blog to read so I do.
> 
> ....
> 
> ...



We might get sued...

While I was in the shower, where for some reason I get most of my clear and insightful philosphical thinking done, I think because nobody bothers me, but I digress.

I was pondering the realism of out of control litigation in US society. I have come to the conclusion it is grossly over exaggerated. 

Not because it doesn't happen, but because medical culture has elevated it to the level of divine faith without reason or question. For reasons too long to discuss here and now. 

You can offer your suggestion to the box, I have even worked for employers with groups paid to suggest better practices, you can present overwhelming scientific evidence.

But from field provider to Medical school professor, at the possibility of being the first to change practice, somebody in the chain will raise a voice as if starting the Lord's prayer at church on Sunday, and say:

"We might get sued"

Which will be follwed by much nodding of heads and a unanimous "Amen."

Gone are the days of American spirit of "We are doing the right thing, bring it on."

American medical graduates (doctor is too respecable of term) have lost control of their profession. (Which according to the standards applied to US EMS, should call into question if they still really are still a profession)

Plaintiff attorney who art in heaven, 
hallowed be thy name.
Thy legal action come.
Thy will be done, in hospital as it is in University. 
Give us this day our protocol and forgive us our logical thinking that deviates. 
as we persecute them who trespass against it.
Lead us not into patient advocacy,
but deliver us our paycheque ungarnished.
For thine is the Kingdom of defensive medicine,
Forever and Ever.

Amen.


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## NomadicMedic (May 16, 2012)

Did this scenario ever have a conclusion before we ran off down the pain management road?


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## Handsome Robb (May 16, 2012)

n7lxi said:


> Did this scenario ever have a conclusion before we ran off down the pain management road?



negative ghostrider


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## mycrofft (May 17, 2012)

*OP, what was outcome?*

BTW, I reread this thread.
I never heard of heat *stroke* causing nausea and vomiting. Heat *exhaustion*: every time I've seen it.


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## Doczilla (May 17, 2012)

Probably because by the time they've progressed into heat stroke, they're too busy seizing to vomit


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## mycrofft (May 17, 2012)

But you can have both at the same time, right?

I think OP's who don't finish off their scenarios need to be made to clean the EMTLIFE restrooms with a toothbrush.


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## musicislife (May 20, 2012)

i dont think is was an AAA. Sounds like a kidney stone. If it were an AAA, I would expect to see a blood pressure much lower, and the patient going into shock.


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## Veneficus (May 20, 2012)

musicislife said:


> i dont think is was an AAA. Sounds like a kidney stone. If it were an AAA, I would expect to see a blood pressure much lower, and the patient going into shock.



That is not quite how a ruptured AAA works. 

They either have a "slow leak" or the pt bleeds to death in a matter of seconds to minutes.

A grossly ruptured AAA carries a prehospital mortality rate in the high 90%s.

With the best centers of surgery reducing it to 87%, under the best of circumstances after emergent surgery and 30+ days in the ICU.

The "slow leak" may see initial compensation so the BP would likely be within normal or borderline ranges with tachycardia.

I have even seen a patient (who later died) who went to work at a factory with epigastric pain, did a 10 hour shift, and presented to the ED with "terrible pain" minutes before crashing.(never made it to surgery)


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## musicislife (May 20, 2012)

but would abdominal pain come immediately at the onset of a slow leak? when would one start to notice the blood loss? (we were told we cant always determine the cause of abdominal pain...so I would just transport asap)


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## Veneficus (May 20, 2012)

musicislife said:


> but would abdominal pain come immediately at the onset of a slow leak? when would one start to notice the blood loss? (we were told we cant always determine the cause of abdominal pain...so I would just transport asap)



In the above patient, he reported increasing pain all day. 

I would think the pain would start with the irritation of the peritoneal cavity, however long that takes to develop in a given person.

y the textbook, it is always described as "tearing or stabbing pain radiating to the back" however, life does not always emulate textbooks.

There are 4 classes of blood loss. 

In class I, it looks basically like dehydration. (estimated <15% blood volume loss)

In Class II, you start to see signs of compensated shock ( estimated 15-30%)

Class III starts decompensation (estimated 30-45%) and generally recognized as the last reasonably salvagable level and not responsive to chrystaloid. (water based iv fluid)

class IV is the complete decompensation (estimated >45% blood loss) it is only in the most rare circumsatnaces these patients are saved. Usually the ones who are, have some immediately identifyable and correctable surgical pathology and are in or very close to the hospital they need.


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## Handsome Robb (May 21, 2012)

musicislife said:


> i dont think is was an AAA. Sounds like a kidney stone. If it were an AAA, I would expect to see a blood pressure much lower, and the patient going into shock.



I've seen kidney stones mentioned a couple different times in this thread. 

I don't understand how this looks like a kidney stone. I guess it *could* be but generally it's going to be flank/back pain not abdominal pain. 

Kidneys, bladder and ureters are all in the retroperitoneal space, not the abdominal cavity. 

Well I guess technically the retroperitoneum is in the posterior portion of the abdominal cavity which is separated by the peritoneum. 

Either way I don't see this being kidney stones, but that's just me.


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## Melclin (May 21, 2012)

musicislife said:


> but would abdominal pain come immediately at the onset of a slow leak? when would one start to notice the blood loss? (we were told we cant always determine the cause of abdominal pain...so I would just transport asap)



But often you can give it a pretty good guess. Good enough to mean the difference between transporting L/S with notification and leaving a pt at home.


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## Veneficus (May 21, 2012)

NVRob said:


> I've seen kidney stones mentioned a couple different times in this thread.
> 
> I don't understand how this looks like a kidney stone. I guess it *could* be but generally it's going to be flank/back pain not abdominal pain.
> 
> ...



It doesn't have to be flank pain and can present as abd pain, though it is rare. On a thin person (especially females) you can actually palpate the stone via the abd.


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## mycrofft (May 21, 2012)

OP what was the outcome?


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