# Weird one



## InsidiousStealth (Jun 17, 2011)

Soooo Get toned out for a 19 y/o male construction worker at the train station for "numbness in legs" so of course we thought he was just trying to get out of work. Show up there and he has no sensation or motor activity in his legs.

So I begin my assessment, headaches, chest pain, SOB etc abdo pain none of that, so then focus on the c/c and I rub my pen on both his legs doesnt feel it. can't move his legs, then I took my pen and squeezed it as hard as i could on his nail bed on his foot and doesn't feel it. He's smiling and seeming casual and unworried so whatever we transported him.

Anyhow so after we dropped him off and we came back after with another patient the nurses told us that he had something called a "spontaneous epidural lumbar hemothorax" or something like that and had to be transferred stat to another hospital for emergency surgery. So you never know! He seemed healthy but i guess he was working in confined spaces all the time underneath the train station platform and probably caused it that way....Very strange and rare too apparently


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## sirengirl (Jun 17, 2011)

Looking at this I would assume from my menial Intro to Med Terms class that this is a random bleeding into the lumbar spine causing pressure on the nerves to the leg rendering them useless? (*googles the term*) I'm not finding much on that exact term, but it soounds pretty crazy. 

My question is, what was your treatment for it? Did you go lights and sirens?


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## mycrofft (Jun 17, 2011)

*Reference*

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2899559/

How about "spontaeous lumbar epidural hemotoma"?


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## bigbaldguy (Jun 18, 2011)

InsidiousStealth said:


> then I took my pen and squeezed it as hard as i could on his nail bed on his foot and doesn't feel it.



Might I suggest that when this guy gets out of the hospital you keep an eye out for a :censored:ed off guy in a hard hat with a limp trying to sneak up behind you with a 2x4


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## InsidiousStealth (Jun 18, 2011)

mycrofft said:


> http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2899559/
> 
> How about "spontaeous lumbar epidural hemotoma"?



Thats the one!

Siren, We were seriously very close to the hospital like within 2 blocks so it wasn't a big deal and at the time he seemed very healthy and we honestly just thought he was trying to get out of work considering he wasnt worried or didnt seem distressed at all. Definitely very bizarre though, not to mention rare. He worked in confined spaces and was always bent over a lot though which probably caused it cause he was only down there for 5 minutes when it happened

as for the nail bed comment....hmmm? lol May I ask what you use for a painful stimulus??


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## MrBrown (Jun 18, 2011)

Put on scoop and take to hospital

 Sent from Browns smartypants phone


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## HotelCo (Jun 18, 2011)

InsidiousStealth said:


> May I ask what you use for a painful stimulus??



Trapezius squeeze. 


Sent from my iPhone using Tapatalk


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## mycrofft (Jun 18, 2011)

*Why use painful stim to test distal sensation?*

Touch and ask. Otherwise, test reflexes...is that in your training?

For LOC, use "noxious" stimuli. I still like ammonia inhalers, used judiciously. I know guys who can take sternal rubs like crazy and not respond, when they are actually conscious. "Painful" needs to be judicioous and last ditch; "annoying", not so much.

Either way, the assumption of Munchausenoid (goldbricking) behavior is natural but it didn't otherwise affect the treatment. Stabilize spine, load and go.


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## InsidiousStealth (Jun 18, 2011)

mycrofft said:


> Touch and ask. Otherwise, test reflexes...is that in your training?
> 
> For LOC, use "noxious" stimuli. I still like ammonia inhalers, used judiciously. I know guys who can take sternal rubs like crazy and not respond, when they are actually conscious. "Painful" needs to be judicioous and last ditch; "annoying", not so much.
> 
> Either way, the assumption of Munchausenoid (goldbricking) behavior is natural but it didn't otherwise affect the treatment. Stabilize spine, load and go.



I've never used a sternum rub. A lot of unconscious patients can be from traumas and i dont think its a smart thing to do if its a good mechanism of injury from a trauma for the spine. The pen on the nail bed works pretty well


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## Akulahawk (Jun 18, 2011)

Patients can hide painful stimulus and lie to you about touch stimulus... but they often can't hide their reflex reactions...


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## usalsfyre (Jun 18, 2011)

bigbaldguy said:


> Might I suggest that when this guy gets out of the hospital you keep an eye out for a :censored:ed off guy in a hard hat with a limp trying to sneak up behind you with a 2x4



I use a pen rolled across the nail bed all the time. Momentarily painful, no lasting effects and much less potential for lasting injury than sternal rubs.


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## Lifeguards For Life (Jun 18, 2011)

InsidiousStealth said:


> The pen on the nail bed works pretty well



Why do you say that?

The results of a peripherally applied painful stimulus are rather ambiguous, if not completely useless.

When you put pressure onto the nail bed, or any other peripheral site, you may engage a spinal reflex response. That's  to say that the painful impulse is picked up by a sensory nerve tract and carried to the spinal cord, where it is immediately turned around by a spinal reflex and sent out via a motor nerve tract to the muscle of that extremity, causing the patient to move.

Any movement elicited by a pen on the nail bed could be either withdrawal, indicating the patient recognized and even localized the pain, pr as alluded to above, the impulse could of never even reached the brain, in which case any response is only indicative of intact peripheral nerve tracts.

I would like to hear your reasoning on why the pen on the nail bed is good way to assess anything.


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## mycrofft (Jun 19, 2011)

*It also sends a messsage upstairs.*

"Ouch!". If that message is reaching a disconnected number, you get withdrawl, and maybe decoricate or decerebrate posturing.
Or they suddenly open their eyes and say "Oh, where am I??".:glare:
Know those dermatomes and learn how to elicit a reflex tapping on a tendon.


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