# You have a call.... try this one



## trauma1534 (Nov 17, 2006)

You are dispatched to a private residence of a man who is "sick".  Upon your arrival at this safe scene, you find a 75 yom on the living room couch attended to by a middle aged female.  Patient appears awake and moaning with some increased work of breathing apparent.  Female reports "He's been really sick!!!"  

General Impression:  Elderly male patient on the living room couch with dyspnea
Airway:  Patent
Breathing:  Fast, Labored breathing, some fine crackles in the bases upon auscultation
Circlulation:  Radial pulses are weak.  Skin is cool and moist in the periphery.  Cap refill delayed.
Mental Status:  Patient is slightly disoriented

Hx of present illness:
This all began 2 days ago.  Acetaminophen was helping.  Now, when he stands up, he passes out.  He is complaining also of abdomonal ache and cramping.  No radiation of pain.  Aches all the time.  On scale of 0/10, his ache is at a 4-5.   Nausea and fever present for 2 days.  NKDA.

Medications:  Metformin, Captopril, Atenolol, ASA
PMHx:  DM, corinary artery bypass graft, multiple abd surg for adhesions and some sort of "kidney Cancer" according to wife.  

Patient has had a poor appetite lately, sick for 2 days, but syncopal this am only.

Vitals:  B/P 68/Doppler, Pulse 68, Resp. 32.  Skin cool in periphery, and warm on torso.  

Patient also has small tubes coming from anterior flank areas.  Wife states these are for urine drainage.  

What would you do, and what is going on with this patient???

I am targeting BLS provider's responce, however, ALS provider's are welcome too.


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## FFEMT1764 (Nov 17, 2006)

Being an ALS provider here is my ALS response:

The usual to start: Oxygen by non rebreather, IV NS KVO due to crackles, EKG and 12 lead. BGL to rule out hypoglycemia secondary to the poor appetite. Considering the hypotension with the respiratory distress I would also place patient in trendelenburg. I would consider a fluid challenge, closely monitoring lung sounds and SPO2. I would probably start a second IV and run in dopamine for both the hypotension and to aid in drawing off the fluid. Keeping away from lasix and morphine due to the hypotension. I would keep the patient warm. I would then transport to a level 1 trauma center as they have all the needed specialties the patient may need as opposed to the local ER which is more of a band aid station.

As for whats wrong, there is a lot that it could be. Sepsis, bowel perforation, AAA, bowel obstruction, kidney failure (acute), liver failure (maybe), effects of the cancer, flash pulmonary edema, CHF, just to name a few.

Well those are my thoughts anyways...


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## yowzer (Nov 18, 2006)

Load and go, in Trendeleburg. A couple liters of O2. Glucometry. Feel anything in his abdomen? Temperature?

It sounds like it could be septic shock, in which case he's probably a goner.


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## fm_emt (Nov 18, 2006)

Doesn't sound like a kidney infection because his extremities are cool and not hot & flushed. The tubes for urine drainage - were they working? Has he been able to urinate at all? What was the color? Odor? The mention of a fever would make me think "something in the drainage system isn't working right" and suspect septic shock. He'd get O2, a blanket, and a swift trip to the nearest level 1 facility. after someone gathered up all the pill bottles they could find.

Interesting to note - nausea/vomiting/etc is a known side effect of Metformin. "kidney disorders" is also a contraindication of Metformin. Lactic acidosis is a big problem too, more frequent in those with impaired kidney functions. Would I know that in the field? Highly unlikely. I just happened to look up the drug names and my girlfriend is a walking PDR.
Metformin = diabetic 
Captopril = hypertension, and preserves kidney function in diabetics.
Atenolol = hypertension.

Again, as a BLS responder, most of that information wouldn't be available to me in the field. We don't carry around a PDR and the county protocol book certainly doesn't mention those particular drugs. If online medical control was available, I'd contact them and then continue bringing the patient into the hospital.


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## EyeOn (Nov 19, 2006)

This patient seems to be showing classic signs of shock.  One person can call for ALS, collect medicine bottles, interview the woman and get a SAMPLE and the other can provide O2, a blanket and transport once ALS arrives, continue to monitor ABC’s and do a physical exam.  I’d suggest bringing the woman too to consult with doctors or suggest the woman to contact the man’s doctor or to give a number or name to providers.  Forget trying to diagnose.  Too much going on with the man, plus it’s not our job.  Do the basics and get ALS.

Considering the level of training so far, this is what I would do.


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## jeepmedic (Nov 20, 2006)

Somethings I would like to know with this pt. is how long has he been on his meds? Any recent changes? How long ago was the "Kidney Cancer" Surgery

Sounds like Septic Shock. but could also be related to the Kidney problems, or if his meds were recently changed for his blood pressure then it could be adverse reactions to the changes in the meds. Could be a stomach flu. but my treatment would not change for him no matter what. 

Airway, breathing, and circulation. On a BLS side I would place him on 15L via NRB, trendilenburg position and xport to ED. On the ALS side I would Place him on 15l via NRB, IV NS 250 bolus and reasses, I would not use Dopamine D/T the Kidney issues in the past. Also place in trendilenburg position. Place blankets on the PT. and xport to ED.


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## FFEMT1764 (Nov 20, 2006)

jeepmedic said:


> I would not use Dopamine D/T the Kidney issues in the past.


 
I can't find anything that would contraindicate dopamine in a patient with kidney failure, other than it is excreted through the kidneys, but nowhere does it say dont use in patients with kidney cancer.


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## Ridryder911 (Nov 20, 2006)

I believe the issue for potential kidney problems is Dopamine at the level required to cause an increase in pressure/vassopressure range is at the alpha level does so because of vasoconstriction and by restricting ADH and causing vasoconstriction to the kidney area. Thus, yes a very GOOD potential kidney problems... but, again don't look at the forest for the trees. 

It does not really matter, because in a very few short minutes this patient will die due to poor perfusion and the kidneys are already getting damaged at a cellular level. (remember s/s of shock, anuria) Shock supersedes normal functions, yes it should be definitely be concerned but maintaining cerebral and coronary perfusion is the ultmost priorty (30-48mm/hg). Possibility of use of a pre-load such as Dobutamine will decrease the need of a high dosage of Dopamine to be maintained at the renal-dopanergic range (2-6 mcg/kg/min). 

P.S... Tredelenburg position being effective is a myth..
R/r 911


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## wolfwyndd (Nov 20, 2006)

As a basic myself, I'm opting for ALS FIRST.  If I can't get an ALS then 15 L O2 via NRB and run like hell.  On the way I'll try to get a glucose level, but noting the heart surgeries and kidney issues, I'm thinking AAA as my first choice, septic shock as a second and if that's not right, I have no idea.


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## Epi-do (Nov 20, 2006)

Sounds like this patient is in shock to me.  I would administer O2 15 lpm via NRB and request ALS if they hadn't already been started.  If they were a significant distance away, I would begin rapid transport and intercept, or if ALS wasn't available for some reason then simply rapid transport to the ER.  

Like rid already stated, trendelenburg is ineffective, so I wouldn't even bother.  I would contact medical control because it is required by our protocols and follow any additional instructions I may be given at that time. 

Around here, at the BLS level that is all you can do for this patient except for comfort measures such as blankets, pillow/blankets behind his head, etc.


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## trauma1534 (Nov 21, 2006)

Negative on the trendelenburg being a myth!!!  I've used it, seen it work!!!

However, you are all right on the dx.  This was a case of septic shock.


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## Ridryder911 (Nov 21, 2006)

Sorry, but scientifically proven Tredlenburg is no better than supine position. and does not work. 
http://www.merginet.com/clinical/trauma/TrendelenburgPosition.cfm

Another urban myth's like MAST, fluid resuscitation and now rapid defibrillation before CPR. 

R/r911


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## MarcoEMTpolo (Nov 21, 2006)

*possitioning*

I would rather put in supine possition and elevate legs. That'll keep abdomen from streching and bring a little perfusion to vital organs. Or how about left latteral?


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## trauma1534 (Nov 21, 2006)

ridryder911, again... I've used it, I've seen it work!!!  I don't need scientific studies to know what I have seen used time and time again in the field work.   Also, it is specificly in our protocols.  I don't think our OMD would want it done if it doesn't work.  I've brought patients into the ER and they have done it many times there also.  I work at a level one trauma center... guess what... we use it there too. 

I guess you know more than all those great providers of higher level than you though, huh!  Don't bore me with your "scientific studies"!!!!!


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## jeepmedic (Nov 21, 2006)

I do recall the artical written by Dr. Bledsoe about the Trendlinburg position. Although this is a study it is still in our local protocals. So I stand by my treatment. 

Also this along with other things has changed in the past only to be brought back to the way it was done in the past. Amniodrone vs. Lidocaine. Vasopressin vs. EPI and so on. 

As far as early Difib. this is still a recommendation by AHA in witnessed arrest and an AED is there to use AED as soon as possable. If one is not avalible then start CPR and defib as soon as one is abalible. If it is not a witnessed arrest then 5 cycles of CPR (1 cycle is 30 compressions and 2 breaths) then use AED. Electrical  Therapy is still the #1 drug of choice for witnessed v-fib.


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## jeepmedic (Nov 21, 2006)

I think this thread has been HI JACKED :blink:


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## Ridryder911 (Nov 22, 2006)

trauma1534 said:


> ridryder911, again... I've used it, I've seen it work!!!  I don't need scientific studies to know what I have seen used time and time again in the field work.   Also, it is specificly in our protocols.  I don't think our OMD would want it done if it doesn't work.  I've brought patients into the ER and they have done it many times there also.  I work at a level one trauma center... guess what... we use it there too.
> 
> I guess you know more than all those great providers of higher level than you though, huh!  Don't bore me with your "scientific studies"!!!!!



Protocols should be guidelines and used only as such not the Gospel. As well they need to be reviewed every year as new proven medicine changes and new medical results and techniques are developed.  Which ACLS do you use. 2000 or 2005 standards? Those are obtained from "boring research studies."Do you still use fluid resuscitation" and "MAST"as well ? I too have seen those work in the field for years.. but, again they also caused more harm than good.. (again, finding this out by research). 

We in EMS need to be aware of evidence medicine, not doing so is being ignorant of medicine.Scientific studies are what dictates what medicine, types of treatment are going to be used both prehospital and in hospital. I am sure your OMD understands that. Tell them that "scientific studies" are boring and do not change medicine. I am sure they can abreast you of the importance of evidence medicine, and studies as well.. in which, if you do work in a Level I, I am sure they are performing some of those "boring" research at this time. They might not even be aware of the new findings and change the procedure or may even want to debate them, with a new study.

That is part of the problem of EMS, we do not require a formal education to understand medicine and the scientific process it requires. Rather we rely upon high school level books and assume we learn medicine and administer treatment at face value. EMS is a division of medicine and patient care and the best treatment is just as serious, as it is behind the doors.

No I never, claimed to know more, I just read the current standards..

R/r 911


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## VinBin (Nov 22, 2006)

trauma1534 said:


> Don't bore me with your "scientific studies"!!!!!


 
....:huh: :huh: .......


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## Mercy4Angels (Dec 17, 2006)

15 lpm NRB load and run like hell. thats only if ALS isnt available which 99.9% of the time it is available.


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## Stevo (Dec 17, 2006)

so one man's myth is anothers salvation? 

 i'm sure many here remember how a N/R could kill a COPD'er

up until we croaked enough COPD'ers doin' the guppy witholding them

troublesome thing eh?

~S~


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## Airwaygoddess (Dec 18, 2006)

Could be possible sepsis based on the pt's general impression and past medical hx. Care would be NRB mask @ 15lpm, with continuous pulse ox. Place pt into shock position if pt. can tolerate this. Frequent V.S. B.P. checks in  both arms for  and call for a ALS intercept STAT!


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## Nycxice13 (Dec 19, 2006)

If the patients breathing rate is 18 above normal, wouldnt you use a BVM?


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## MeaganIV (Dec 22, 2006)

No BVM unless Pts ventilations are under 10 or above 30 or Pt is unconscious and will accept an OPA.

18 is with in the 12-20.  You can always see if he will accept vents but more then likely he will reject it.  Apply NRB @ 15lpm.


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## Nycxice13 (Dec 22, 2006)

in the scenario, the rate was 38 and labored.


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## MeaganIV (Dec 22, 2006)

Oh yeah, your last post said 18.  My bad.

Then see if he'll accept it... 


In my experience they haven't but you never know.   If not then coach his breathing, try to get him to calm down...


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## MeaganIV (Dec 22, 2006)

IV, NS, TKVO due to lung sounds, if no crackles on ausculation then i would administer a bolus 20ml/kg but c'est la vie.  Transport trendelalenburg , 02 via BVM @ 15lpm if Pt accepts it, if not NRB @ 15lpm. Treat my shock. 

I'm thinking Pulmonary edema due to left sided CHF... Renal failure is a possibility


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## MeaganIV (Dec 22, 2006)

*treat for shock


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## trauma1534 (Dec 29, 2006)

It was septic shock


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## grammarose (Dec 31, 2006)

I think i would see if I can't have dispatch tone for ALS and get them in route. This guy sounds septic but also is very ill. I would probably assist him in his breathing, since it is fast and shallow and 32. Get him on the stretcher and move meeting ALS on the way.


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