# syncope case



## CritterNurse (May 23, 2013)

Ok, this is my first time trying to post a scenario. This happened a little while back, so I don't remember the exact numbers, but I know about where they were. My goal here is to find out if there was anything else I should do, because I know I will be seeing this subject again with summer coming.


I get a call on my cell-phone on my way home from work. The subject's family wants me to check him out, but didn't want to call an ambulance. (It's not unknown for people in this rural area to call an EMT directly instead of calling 911, due to nosy neighbors listening to the scanner, or coming over when they see the flashy lights. I am a member of that town's EMS department, so no worries about 'jumping a call')

The subject is reported to have passed out, but had just come around. Was unconscious for about 30 seconds.

I happened to be a couple minutes away, so I went right over. No, I did not have my jump kit with me, I was on my way home from work. Only tool I had with me was the stethoscope I use on animals.

Arrived to find a male in his mid-twenties reclining on the couch with his knees up, a glass of water in one hand, and a strip of marshmallow peeps in the other. 

He was pale, sweaty, and a bit shaky. First thing I did was ask for the glucometer that I knew that family had. While they went to get it, I checked his blood pressure with the home blood-pressure cuff they had, and it was a bit low for the subject, but not enough to set off alarm-bells for me. It was somewhere around 110/70. He was usually closer to 120/80 according to family. I don't remember what his respiratory rate was, but it was slightly faster than normal. His pulse was also a bit fast, but I don't remember the number. I know it was not high enough to be called tachycardia though. His blood sugar was in the 130's.

When asked about what he had eaten that day, he responded that he didn't eat much all day, and that he had exerted himself. Subject denied alcohol use. Subject has a history of syncopal events about once a year, usually corresponding to not eating well and exerting himself. The first time this happened he was at work, and was told he was going to the ER. The ER found nothing wrong, and had him on one of those 24 hour heart monitors with no significant findings. The next 3 times it happened at home and he did not go in. One of those times I happened to be over at the house, but this was before I went to school for EMT. This current event is the 5th time this has happened to him. Subject has no significant medical history other than an allergy to mold. No known drug allergies, only medicine he takes is Zyrtec daily for his allergy.

While gathering history, the subject stated he was going to vomit, and proceeded to throw up water, and bits of marshmallow. Subject was advised to sip the ice water, not gulp it.

Subject reported that he was feeling better after vomiting, but he was still visibly sweaty and a bit shaky. I went and made him a PB&J. Subject did not want to go to the hospital because he knew this would pass. Subject could not be convinced, so instead I sat with him for an hour, until he was no longer sweaty or shaky, and vitals were back to his normal rate. I called the next day and the subject was completely back to normal.


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## NomadicMedic (May 23, 2013)

And you're an EMT-B, correct?


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## CritterNurse (May 23, 2013)

Yeah


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## NomadicMedic (May 23, 2013)

Did you take orthostatic BPs? If he was normal, then you did all you could do, short of driving him to the ED. 

If it were me on the call, he would have got a 12 lead, bloods drawn and some fluid. And a nice ride to the hospital.


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## CritterNurse (May 23, 2013)

He stated that he felt dizzy when he tried to stand, so I only took the BP while he was reclining. I did take one with him standing up before I left, when he seemed to be back to normal.


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## MountainMedic (May 24, 2013)

I wouldn't see a need for a 12-lead with those vitals and generally sick appearance in a 20 something y/o M, but agree with you that he should get one given his syncope Hx. Pity he didn't get a halter monitor earlier. Gastroenteritis FTW. You vomit, get hypotensive, maybe pass out, and make a full recovery in 24h. 

Fluid bolus, 4 mg of Zofran, and nonemergent transport. As a basic, you did everything right.


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## sir.shocksalot (May 24, 2013)

MountainMedic said:


> I wouldn't see a need for a 12-lead with those vitals and generally sick appearance in a 20 something y/o M, but agree with you that he should get one given his syncope Hx. Pity he didn't get a halter monitor earlier. Gastroenteritis FTW. You vomit, get hypotensive, maybe pass out, and make a full recovery in 24h.
> 
> Fluid bolus, 4 mg of Zofran, and nonemergent transport. As a basic, you did everything right.



I don't think I would be so quick to label this gastroenteritis. We really don't know enough about his symptoms or if he has been febrile for me to attempt to put a name to his condition. Nausea, vomiting, sweating, and syncope to me doesn't come close to screaming gastroenteritis. In fact all of those symptoms can precede or follow a vasovagal syncope. There is just too much unknown to place a label IMO.

To the OP: I think you did what you could. It sounds like this is an ongoing problem that requires further physician evaluation and follow up. You can't really drag him kicking and screaming to the hospital but it was nice of you to stay by him until he recovered. I know rural is a different animal but I would definitely get some sort of written refusal in the future just for liability reasons. I don't think the whole EMS department needs to show up but I would just want some written record. I am from suburbia so maybe my concerns are just from my lack of perspective. Definitely tell him to see a doc, recurrent syncope can be bad news.


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## CritterNurse (May 24, 2013)

I didn't get a written refusal because it didn't come through the 911 system. The family (who I've known as long as I can remember) called me on my personal phone just to check him out. If something screamed trouble, I wouldn't have hesitated to call dispatch and ask them to send a rig out, and they knew that. In fact, if they felt the need to call for an ambulance, I know they would have called me too.


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## augustHorch (May 24, 2013)

CritterNurse said:


> I didn't get a written refusal because it didn't come through the 911 system. The family (who I've known as long as I can remember) called me on my personal phone just to check him out. If something screamed trouble, I wouldn't have hesitated to call dispatch and ask them to send a rig out, and they knew that. In fact, if they felt the need to call for an ambulance, I know they would have called me too.



i probably wouldnt have gone with the refusal also... it doesnt hurt anything...

I think you did a fine job. I would have had an ambulance come... i would have offered transport, signed a refusal, write a report, log the call... and then go home for dinner


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## NomadicMedic (May 24, 2013)

I certainly won't fault you for helping out a friend. However, "freelancing", that is, responding to calls on your own without activating an agency can come back to bite you.

Some anecdotal experience, a friend of mine who was a firefighter EMT was called to another friends house. It seemed as though the friends daughter had had a seizure. The firefighter was told that she had a seizure history, and he "checked her out" and said that she was fine. The girl later had another seizure, became hypoxic and developed a brain injury. (Or at least that was the claim…) My firefighter friend was named in the suit and got pretty jammed up over the fact that he never called EMS, wasn't qualified to determine if the patient was able to stay home or not and generally got hung out to dry.

Not saying that will ever happen to you, but… Why take the chance. Even if the patient doesn't want to go, at least have an ambulance respond and get a written refusal of service after you explain to the patient the risks and consequences for not being transported. Will that protect you in case the family decides to sue? Probably not, but at least you'll have some standards that were followed to fall back upon.

If anyone calls me, telling me that they want me to come over and check them out… My advice is always, "either drive to the hospital or call an ambulance. If it's bad enough that you need me to come over, you probably need to be seen." Overcautious? Sure. But it's saved some heartache in the past.


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## sir.shocksalot (May 24, 2013)

CritterNurse said:


> I didn't get a written refusal because it didn't come through the 911 system. The family (who I've known as long as I can remember) called me on my personal phone just to check him out. If something screamed trouble, I wouldn't have hesitated to call dispatch and ask them to send a rig out, and they knew that. In fact, if they felt the need to call for an ambulance, I know they would have called me too.


I think I missed that you are close friends of the family. Whether or not a refusal was appropriate in your situation is beyond my guess, you know them so you know what was appropriate. As a general rule I would be hesitant to do any evaluation away from work unless it was family or close friends. I certainly didn't mean for it to be anything more than a side note 

Hopefully he will get a little further evaluation from his PCP. Even with not eating and exerting yourself shouldn't cause syncope. He probably needs to be on the halter monitor for a little longer. A young (20) friend of mine had recurrent syncope and he was actually going into an out of a-fib for several years before it was found. This sounds different but it's better safe than sorry, the fact that this happens fairly often without obvious cause is what makes it concerning.


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## CritterNurse (May 24, 2013)

We've (friends and family) have been trying to get him to get it checked out further for years. He hasn't had the best experience with doctors in the past.


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## Sublime (May 26, 2013)

MountainMedic said:


> I wouldn't see a need for a 12-lead with those vitals and generally sick appearance in a 20 something y/o M, but agree with you that he should get one given his syncope Hx. Pity he didn't get a halter monitor earlier. Gastroenteritis FTW. You vomit, get hypotensive, maybe pass out, and make a full recovery in 24h.
> 
> Fluid bolus, 4 mg of Zofran, and nonemergent transport. As a basic, you did everything right.



A 12-lead is always warranted for a syncopal episode. WPW, long QT, SVT and various other cardiac related pathologies can cause syncope.

OP: It would be helpful to know more about what he is doing when these syncopal episodes happen.


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## Handsome Robb (May 26, 2013)

Sublime said:


> A 12-lead is always warranted for a syncopal episode. WPW, long QT, SVT and various other cardiac related pathologies can cause syncope.
> 
> OP: It would be helpful to know more about what he is doing when these syncopal episodes happen.



Agreed 100%

Now if he didnt drink any fluids all fay, stood up fast and zonked out or something similar A 12-lead wouldn't be the at the top of my list. 

If junior is just sitting in a chair then gets cool, pale, diaphoretic and hits the floor that's a completely different story. 

With him saying he gets dizzy when e stands you can infer (but should confirm) that he is orthostatic. Every syncope AMA I go on gets orthos. It really helps convince them to go when they stand up then wake up with us lowering them to the floor.


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## CritterNurse (May 27, 2013)

Sublime said:


> OP: It would be helpful to know more about what he is doing when these syncopal episodes happen.



I know at least 3 of those incidents happened after working outdoors, with no breakfast or forgetting to eat. That event I wrote about was in the early evening. He had been mowing the lawn about an hour or so earlier. I don't know what he was doing right before it happened. He just put it up as "I didn't eat well today, and I over exerted myself again" or something along those lines.


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