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Asclepius911

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You are dispatched to private residence for a 96y Female pt reporting pain on the left upper extremity, (upon arriving at destination what is the first thing you do?) Pt family member gives you Hx: Dementia, skull fracture, recent CVA /c L body weakeness and facial droop. Family member informs that she had sudden pain in her arm and gave her tylenol for that pain and placed lidocaine patch resulting in no affect. Pt appears distress and in pain, A&Ox1, left lateral on bed, leaning on arm with pain. (What do you do now?) A: patent B:RR is 18 /c normal tidal volume C: unequal radial pulses (R: 62 L:84) BP:140/82, skin is warm and regular with 2s < cap refill. Both arms appear unequal one is swollen and warmer than the other. Alright EMTs what would you do after?
 

leoemt

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Since I am a noob EMT - Basic, I'll give it a shot. Always good for learning.

First thing I am doing is forming my impression of the patient. From what you describe she is sick...however at this time I don't think I'm going to upgrade to ALS yet. No sign of spinal injury / trauma? Roll patient over into a position of comfort. Is patient bedridden?

Airway is patent and RR is good, no mention of hypoxia or cynosis so I don't think o2 is warranted at this time. I am concerned with the unequal radial's but nothing I can do about them. I'm going to be considering a possible embolism. How are the Pedals?

Because of the history of stroke I am going to do a F.A.S.T. (aka Cincinnati pre hospital stroke test). Any signs of stroke?

What is the pain described as? Is it radiating? Did pain go away when patient was moved off of left side? 1-10?

A&O x 1...What is she Oriented to?

Vitals look ok from what you gave. If I am with a paramedic I would think a 12 lead would be getting hooked up.

I am leaning towards an embolism. The blockage would account for the edema in the extremity as well as the warmth. I would package patient in a position of comfort, assuming she remained stable she would be getting a nice, smooth ride to the hospital. If patient deteriorates I would request some ALS assistance.
 
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Asclepius911

Asclepius911

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Noob indeed, lol, one of the things I learned In Emt school which appliend in this situation is ... we are looking to much for signs and vitals missing the obvious picture ... anywho, pt has dementia so level of orientation is not relevant, pt. With dementia are frequently disoriented, Or have periods of different orientation (havent you seen "the notebook" chick flick) making it a weak indicator of hypoxia, however it is good to know that she is alert (avpu: alert to verbal/pain)

It's great that you recognized that she is sick lol, of what, if I may ask?, but first things first ... SCENE SAFETY (Penman) , personal partner patient safety (there was a dog at residence) environmental hazard (non), mechanism of injury (moi: pt woke up with sharp sudden pain on left arm, non trauma), additional resources (non at the moment) number of patient (1), need for c-spine (negative since it was non traumatic)

The Cincinnati coma scale will just tell you that she has had a stroke in the past, she has left limb weakness from prior stroke making her unable to pick up left arm, plus dementia causes them to say odd things, and prior cva also caused facial droop, so Cincinnati coma scale tool went out the door , AND family member says that she is normally that way

Bed ridden, you tell me (hint she has left extremity weakness, meaning there is little to non left extremity movement)

Oxygen is always a good form to relief anxiety/distress AS LONG as their CONDITION DOES NOT INCLUDE HYPOXIC DRIVE (what are the Contra indication of supplemental O2?)

And as for ekg leads, it would be great if als was around BUT he isn't you are a BLS unit (unit with Emt-B w/o medic) but on that note, when should you call for als?

Give it another poke your on the right track
 
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Asclepius911

Asclepius911

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It wasn't a lymphnode since it wasn't just a specific regeon it was the whole arm that was swollen (abnormal enlargement of a body part due to accumulation of excess fluid in tissue) with redish coloration
 

Doczilla

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No, I mean was his next closest lymph node swollen? (Brachial plexus?) Induration is important too. Questionable hygeine, plus redness, edema, and (+/- induration)ay suggest cellulitis or another local/regional infection.
 

medichopeful

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You are dispatched to private residence for a 96y Female pt reporting pain on the left upper extremity, (upon arriving at destination what is the first thing you do?) Pt family member gives you Hx: Dementia, skull fracture, recent CVA /c L body weakeness and facial droop. Family member informs that she had sudden pain in her arm and gave her tylenol for that pain and placed lidocaine patch resulting in no affect. Pt appears distress and in pain, A&Ox1, left lateral on bed, leaning on arm with pain. (What do you do now?) A: patent B:RR is 18 /c normal tidal volume C: unequal radial pulses (R: 62 L:84) BP:140/82, skin is warm and regular with 2s < cap refill. Both arms appear unequal one is swollen and warmer than the other. Alright EMTs what would you do after?

You say one arm was unequal, yet you didn't say which one. Having worked with patients with confusion, I can think of at least one instance where the patient said their right side hurt when their injury was on the left.

What do you mean by "leaning on their arm?" Do you mean they're completely on their side with the arm under them? Or are they propping their upper body up with it?

How long has the swelling been going on, and if you re-position the patient does it do anything? In addition, while we're at it what's the apical pulse? Extremity pulses are clearly out of whack, I want a true (or as true as we can get) measurement (the fact that the left has a faster rate considering that is the supposedly affected side - keeping in mind the possible side confusion, which may just be a miss-communication :p - strikes me as odd for some reason)
 

leoemt

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Noob indeed, lol, one of the things I learned In Emt school which appliend in this situation is ... we are looking to much for signs and vitals missing the obvious picture ... anywho, pt has dementia so level of orientation is not relevant, pt. With dementia are frequently disoriented, Or have periods of different orientation (havent you seen "the notebook" chick flick) making it a weak indicator of hypoxia, however it is good to know that she is alert (avpu: alert to verbal/pain)

It's great that you recognized that she is sick lol, of what, if I may ask?, but first things first ... SCENE SAFETY (Penman) , personal partner patient safety (there was a dog at residence) environmental hazard (non), mechanism of injury (moi: pt woke up with sharp sudden pain on left arm, non trauma), additional resources (non at the moment) number of patient (1), need for c-spine (negative since it was non traumatic)

The Cincinnati coma scale will just tell you that she has had a stroke in the past, she has left limb weakness from prior stroke making her unable to pick up left arm, plus dementia causes them to say odd things, and prior cva also caused facial droop, so Cincinnati coma scale tool went out the door , AND family member says that she is normally that way

Bed ridden, you tell me (hint she has left extremity weakness, meaning there is little to non left extremity movement)

Oxygen is always a good form to relief anxiety/distress AS LONG as their CONDITION DOES NOT INCLUDE HYPOXIC DRIVE (what are the Contra indication of supplemental O2?)

And as for ekg leads, it would be great if als was around BUT he isn't you are a BLS unit (unit with Emt-B w/o medic) but on that note, when should you call for als?

Give it another poke your on the right track

I was half asleep before, fully awake here goes:

Since this was a scenario I didn't do all the scene safety stuff we did in class. I treated this like a real call, not a class. I don't walk into my scenes saying "BSI, is my Scene Safe?" Yes, I take it seriously, I just don't verbalize it. Patients would probably give us strange looks if we did.

I have yet to perform a F.A.S.T. test in the field, but it is my understanding that it is an indicator of a possible stroke. Not a past stroke. While it is possible that a patient may still exhibit some signs from the previous stroke I doubt all the signs would be there. Family should also be able to tell you if something is normal for that patient or not.

I am aware of the Hx of Dementia, however that doesn't change the fact that I am going to do an A&O questions. How severe is her Dementia? Are her answers consistent with her dementia based on family. What is my gut feeling based on seeing this patient on her level of Dementia? Do I think her answers are Dementia related or am I thinking her lack of awareness is something else based on what I am seeing?

Is her A&O altered because of the dementia, or because of the Lidocaine Patch? Confusion and altered mental status can be a side effect of the patch. Again, need family to tell you what is normal for this patient.

You gave no indication of if she was bed ridden or not. However, I doubt you would post this if she was a minor dementia case so I will assume she is bed ridden due to the Hx of dementia, and CVA. How long ago was the skull fracture? What caused her to fall and any other injuries associated with it?

Based on her A&O and Dementia, how do I know this patient is in pain? Guarding? Reaction to touching or moving the arm? Any signs of bed sores?

There is a lot that can be going on with this patient. Arm pain from laying on it to long (I would think that would be gradual onset though). Possible closed fx, etc.

Does she experience any relief when I move her arm? I may or may not stabilize her arm with a sling and swathe, depending on if I feel it would be of benefit in this patient. Based on what you have said, I doubt stabilizing would be a benefit, but I am going to consider it.

Do I see any discoloration distal to the site of pain? Arm is swollen, is the edema below the site of pain?

Interview time SAMPLE / OPQRST questions. I want to ask BOTH the patient (yes I know she is A&O x 1 but I want to see how she responds if at all) and the family.

My initial concern is still an embolism secondary to being in a sedentary position. I am going to package her up in position of comfort and were going to the hospital. I still don't think ALS is prudent in this call. She has several risk factors to develop embolism: Dementia, hx of cva, lack of physical movement, etc.

I don't give o2 to every patient. If your breathing adequately on 21% o2, why should I give 100%? No I won't withhold oxygen but I don't see any reason to give it to her. Further, I would be worried that with her dementia she might freak out seeing the mask. If I did give her o2 it would be via NC at 2-4 lpm. I don't typically give o2 just to relax a patient. I can do that by communication. If a patient needs o2 they will get it based on Signs and Symptoms.

While she appears stable, I am probably going to re-evaluate her closer to the 5 minute mark rather than every 15 mins. Her age, history, and presenting issue make her potentially unstable. Geriatric patients can decompensate rapidly. I would be prepared to address any complications enroute to hospital.

I don't treat numbers, I treat the patient. Numbers are important though and from initial reading they seem remarkably good. Any change in vitals since first set?
 
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Asclepius911

Asclepius911

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Ding ding ding we have a winner lol, we are looking to much into vitals,

I remember Seeing this video back in the Emt school days,

http://m.youtube.com/#/watch?desktop_uri=/watch?v=vJG698U2Mvo&v=vJG698U2Mvo&gl=US

I never understood why they showed this video, it shows that by focusing to much on one thing we miss the most obvious things.

Her left arm was swollen, adema, no lymphadenopathy (well in a sense it would be slightly swollen-enlarged since she cut blood circulation causing lymph biproducts and blood to slowly make its way across), and she was ON her left arm which was the arm that she reported feeling pain on,

any who what medichopeful said was correct READJUST her, (get ready to laugh) she was on her left arm cutting circulation to that particular arm, this explains the swelling and dark red-ish skin coloration on left arm, since she has left extremity weakness she couldn't propped her self up, and she has dementia, thus by saying my arm hurts she meant my arm went to sleep plus, when pt. Was passed on to gurney and readjusted to semi-fowlers the second set of assessment, she reported "I don't feel any pain" and the arm appeared to return the same color, pulse, temperature as her right arm. 911 calls for numbness to the extremeties due to awkward positioning might be something common with the demented elderly especially those with weakness on those extremities.
 
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NYMedic828

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I would drain the arm with a few 14g catheters.
 

AnthonyTheEmt

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I was half asleep before, fully awake here goes:

Since this was a scenario I didn't do all the scene safety stuff we did in class. I treated this like a real call, not a class. I don't walk into my scenes saying "BSI, is my Scene Safe?" Yes, I take it seriously, I just don't verbalize it. Patients would probably give us strange looks if we did.

I have yet to perform a F.A.S.T. test in the field, but it is my understanding that it is an indicator of a possible stroke. Not a past stroke. While it is possible that a patient may still exhibit some signs from the previous stroke I doubt all the signs would be there. Family should also be able to tell you if something is normal for that patient or not.

I am aware of the Hx of Dementia, however that doesn't change the fact that I am going to do an A&O questions. How severe is her Dementia? Are her answers consistent with her dementia based on family. What is my gut feeling based on seeing this patient on her level of Dementia? Do I think her answers are Dementia related or am I thinking her lack of awareness is something else based on what I am seeing?

Is her A&O altered because of the dementia, or because of the Lidocaine Patch? Confusion and altered mental status can be a side effect of the patch. Again, need family to tell you what is normal for this patient.

You gave no indication of if she was bed ridden or not. However, I doubt you would post this if she was a minor dementia case so I will assume she is bed ridden due to the Hx of dementia, and CVA. How long ago was the skull fracture? What caused her to fall and any other injuries associated with it?

Based on her A&O and Dementia, how do I know this patient is in pain? Guarding? Reaction to touching or moving the arm? Any signs of bed sores?

There is a lot that can be going on with this patient. Arm pain from laying on it to long (I would think that would be gradual onset though). Possible closed fx, etc.

Does she experience any relief when I move her arm? I may or may not stabilize her arm with a sling and swathe, depending on if I feel it would be of benefit in this patient. Based on what you have said, I doubt stabilizing would be a benefit, but I am going to consider it.

Do I see any discoloration distal to the site of pain? Arm is swollen, is the edema below the site of pain?

Interview time SAMPLE / OPQRST questions. I want to ask BOTH the patient (yes I know she is A&O x 1 but I want to see how she responds if at all) and the family.

My initial concern is still an embolism secondary to being in a sedentary position. I am going to package her up in position of comfort and were going to the hospital. I still don't think ALS is prudent in this call. She has several risk factors to develop embolism: Dementia, hx of cva, lack of physical movement, etc.

I don't give o2 to every patient. If your breathing adequately on 21% o2, why should I give 100%? No I won't withhold oxygen but I don't see any reason to give it to her. Further, I would be worried that with her dementia she might freak out seeing the mask. If I did give her o2 it would be via NC at 2-4 lpm. I don't typically give o2 just to relax a patient. I can do that by communication. If a patient needs o2 they will get it based on Signs and Symptoms.

While she appears stable, I am probably going to re-evaluate her closer to the 5 minute mark rather than every 15 mins. Her age, history, and presenting issue make her potentially unstable. Geriatric patients can decompensate rapidly. I would be prepared to address any complications enroute to hospital.

I don't treat numbers, I treat the patient. Numbers are important though and from initial reading they seem remarkably good. Any change in vitals since first set?

Dude, you are seeing the trees and missing the forest. Don't look too much into this. I just read the OP's answer to what was the actual problem. I was thinking possibly cellulitis before seeing the answer, but don't over think these things. This job is actually pretty simple. Lets not complicate it more than it needs to be.
 

leoemt

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Dude, you are seeing the trees and missing the forest. Don't look too much into this. I just read the OP's answer to what was the actual problem. I was thinking possibly cellulitis before seeing the answer, but don't over think these things. This job is actually pretty simple. Lets not complicate it more than it needs to be.

I wasn't over complicating it, in reality it wouldn't take that long to do everything I said. Just looks that way typed out, especially since I think as I type.

The OP asked what I would do, not for a diagnosis. Ever had to show your work in math class? This is me showing my work, not over thinking. Being a new EMT, I don't have the same experience as some of the other providers so it takes me longer to work through possibilities than someone with more experience. I learn from other providers which is why I gave this a shot.

I am going to go through different possibilities in my mind, especially with her history. I would be doing the patient a disservice if I said "oh your arm hurts because your laying on it" and leave.

The fact the patient was laying on her arm COULD have easily been a distractor hiding the real cause.

If I rolled her onto her back and she experienced some relief I would be happy. But that doesn't change the fact that I am there and I need to do my job.

She was given tylenol and a Lidocaine patch with no relief. Presumably the patient would have to be sat upright to be given the tylenol. If her positioning had caused her arm "to go to sleep" as appears to be the case, then this should have caused her to feel some relief. She apparently did not get the relief so that tells me its more than just her arm being asleep.

At the BLS level there isn't much that I can do for her other than provide her a comfortable ride to the hospital.

I hope for the best, prepare for the worst. Glad her condition was minor. Still got to be prepared for other conditions given her history. How is it over thinking to consider other possibilities? I still have to do my assessment, nothing is going to change that, and I still have to get my history. I can easily be considering other possibilities while I treat what I think is going on.

Tell me, when you respond to a person complaining of Abdominal Pain with Vomiting, do you automatically think "flu" or do you still do your assessment? Even if it is the common flu, how many conditions present with similar symptoms as the flu? Some of which are very serious.

My treatment as stated in my first response was to package for transport in a position of comfort and a nice slow ride to the hospital. Nothing over thought about that.

By the way, I like to type my answers out in detail, comes from being a cop and having what I type go to court. Realistically scene time for this patient would be 5-10 mins depending on how easy it is to get her to the ambulance.
 

AnthonyTheEmt

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I wasn't over complicating it, in reality it wouldn't take that long to do everything I said. Just looks that way typed out, especially since I think as I type.

The OP asked what I would do, not for a diagnosis. Ever had to show your work in math class? This is me showing my work, not over thinking. Being a new EMT, I don't have the same experience as some of the other providers so it takes me longer to work through possibilities than someone with more experience. I learn from other providers which is why I gave this a shot.

I am going to go through different possibilities in my mind, especially with her history. I would be doing the patient a disservice if I said "oh your arm hurts because your laying on it" and leave.

The fact the patient was laying on her arm COULD have easily been a distractor hiding the real cause.

If I rolled her onto her back and she experienced some relief I would be happy. But that doesn't change the fact that I am there and I need to do my job.

She was given tylenol and a Lidocaine patch with no relief. Presumably the patient would have to be sat upright to be given the tylenol. If her positioning had caused her arm "to go to sleep" as appears to be the case, then this should have caused her to feel some relief. She apparently did not get the relief so that tells me its more than just her arm being asleep.

At the BLS level there isn't much that I can do for her other than provide her a comfortable ride to the hospital.

I hope for the best, prepare for the worst. Glad her condition was minor. Still got to be prepared for other conditions given her history. How is it over thinking to consider other possibilities? I still have to do my assessment, nothing is going to change that, and I still have to get my history. I can easily be considering other possibilities while I treat what I think is going on.

Tell me, when you respond to a person complaining of Abdominal Pain with Vomiting, do you automatically think "flu" or do you still do your assessment? Even if it is the common flu, how many conditions present with similar symptoms as the flu? Some of which are very serious.

My treatment as stated in my first response was to package for transport in a position of comfort and a nice slow ride to the hospital. Nothing over thought about that.

By the way, I like to type my answers out in detail, comes from being a cop and having what I type go to court. Realistically scene time for this patient would be 5-10 mins depending on how easy it is to get her to the ambulance.

Dude, dont get so butthurt. Im not taking personal shots at you. I was just saying that you are overcomplicating it. I worked as an EMT for 3 1/2 years before going medic. I know what its like to be in that spot and have had numerous calls where things were a lot worse than originally thought, as well as calls where things were as simple as this scenario. And to answer your question, I dont form any ideas going into a call. I determine what Im gonna do based on what I see, everything included. I take what dispatch says with a grain of salt because, as anyone who has done this long enough knows, what you get dispatched for and what you actually have can be two entirely different things.
 
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NYMedic828

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leoemt

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Dude, dont get so butthurt. Im not taking personal shots at you. I was just saying that you are overcomplicating it. I worked as an EMT for 3 1/2 years before going medic. I know what its like to be in that spot and have had numerous calls where things were a lot worse than originally thought, as well as calls where things were as simple as this scenario. And to answer your question, I dont form any ideas going into a call. I determine what Im gonna do based on what I see, everything included. I take what dispatch says with a grain of salt because, as anyone who has done this long enough knows, what you get dispatched for and what you actually have can be two entirely different things.

Dude if you think I am butt hurt because you said I was Overthinking it you don't know me very well. I spent 10 years in law enforcement and public safety being called names that would get me thrown off here if I repeated them. There is nothing you can say that would offend me or hurt my feelings.

I wasn't denying that I was thinking the scenario through. As I said I don't got the experience that others do. You can probably look at something and go "Oh this is what is likely wrong" I on the other hand need to think it through.

I've spent my career having what I say and write scrutinized in court. It carries over even onto forums like this. I don't give very many simple answers as you will discover.

No hard feelings.
 
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