32 yo Male - general illness

NomadicMedic

I know a guy who knows a guy.
12,098
6,845
113
Dispatched at 0205 to a private residence for a 32-year-old male who is "not feeling well." Dispatcher says it may be a diabetic problem.

You arrive to an apartment building. The caller's Apartment is on the second floor, nicely furnished. Clean. Very angry girlfriend meets you at the door. She says, "he does this stuff for attention all the time. And I'm sick of it."

You walk into the apartment and see a guy sitting on the couch. Actually kind of sprawled there. There's a puddle from fresh vomit on the beige rug. And he just looks wiped out.

You walk in and say, "Hey, I'm the paramedic. What's going on tonight?"

He says, "I don't feel very good..."


And go.
 
Last edited:

VentMonkey

Family Guy
5,729
5,043
113
V/S? Most important and pertinent to this patient a BGL. H/ A/ M? Aside from DM. Is he Insulin dependent, does he take oral meds, or both? Any pain in his epigastrium or elsewhere?
 

DesertMedic66

Forum Troll
11,269
3,451
113
Start of with a good set of vitals (BP, pulse, resp, SpO2, pupils). Medical history? Events leading up to the issue today? Drugs/alcohol? Would also like to get a BGL check and a 12-lead.
 
OP
OP
NomadicMedic

NomadicMedic

I know a guy who knows a guy.
12,098
6,845
113
OK. You get a set of vitals and it looks like this:

HR: 120
BP: 118/62
Resp: 28
Pupils: PERRL
BGL : "hi"

He mumbles, "I took some insulin, I don't member how much. Either eight or 10 or 12 units of Humalog..."

He seems confused, asking several times if you were gonna take him to school. He also says he took some other medication. Maybe a pain pill?

His girlfriend says he hasn't been taking care of himself and he hasn't had much to eat or drink or manage his blood sugar for the last couple of days. She's royally pissed. Stomping around and slamming doors.

He has a history of back pain and PTSD, for which he takes OxyContin, Klonopin, Valium, Cymbalta and some other meds that he can't remember.
 

VentMonkey

Family Guy
5,729
5,043
113
NKDA? Load, place on cardiac monitor, SPO2 with waveform pleth, O2 @ 2 lpm N/C with ETCO2 if available.

Establish IV access and give liberal fluids en route to the ED (500 ml NS FC) with repeat accuchecks as time permits; probably grab a 12-lead ECG en route to the ED, but not as high up on my list currently as rehydration therapies. Grab a second IV via lock, and also administer some Zofran IVP.
 
OP
OP
NomadicMedic

NomadicMedic

I know a guy who knows a guy.
12,098
6,845
113
You and your partner help him down the outside staircase to the ambulance and get him inside. He's really restless and really confused now.

12 lead: Sinus tach at 130 with no ectopy or ST changes.
SpO2 is 100% on ambient air.
HR: 130
BP: 106/52
Resp: 30, non labored. Lungs clear.
BGL: HI (BTW, that's greater than 600 on my glucometer)

He is an extremely poor historian.

The critical access hospital is less than 10 minutes, or you can go to "the city", 40 miles away.
 

VentMonkey

Family Guy
5,729
5,043
113
You and your partner help him down the outside staircase to the ambulance and get him inside. He's really restless and really confused now.

12 lead: Sinus tach at 130 with no ectopy or ST changes.
SpO2 is 100% on ambient air.
HR: 130
BP: 106/52
Resp: 30, non labored. Lungs clear.
BGL: HI (BTW, that's greater than 600 on my glucometer)

He is an extremely poor historian.

The critical access hospital is less than 10 minutes, or you can go to "the city", 40 miles away.
Clearly he's in a metabolic acidosis---probably compensated, or a mixed disturbance, at this point---and cannot R/O HHNK based off of your glucometers reading. I'd head for the critical access, reassess en route, if he remaines agitated transport to the closest; if he perks up, divert to the city.

He needs an insulin gtt, a full set of lab work, and quite possibly potassium; that's all I got for now. Can we get a temp en route, and/ or is he abnormally hot to the touch?
 
OP
OP
NomadicMedic

NomadicMedic

I know a guy who knows a guy.
12,098
6,845
113
clearly in a metabolic acidosis, and cannot R/O HHNK at this point (based off of your glucometers reading). I'd head for the critical access, reassess en route, if he remaines agitated head for the closest, if he perks up, divert to the city.

He needs an insulin gtt, POC, and quite possibly potassium; that's all I got for now. Can we get a temp en route, and/ or is he abnormally hot to the touch?


He not nauseous, so you hold off the Zofran. Access is an 18g in the left forearm and 1000ml of NS running wide open. A temporal temp is 97. Off to the CAH you go.
 

VentMonkey

Family Guy
5,729
5,043
113
He's vomited once (that I know of) already, 4 mg of Zofran can't hurt.
 

E tank

Caution: Paralyzing Agent
1,574
1,428
113
He not nauseous, so you hold off the Zofran. Access is an 18g in the left forearm and 1000ml of NS running wide open. A temporal temp is 97. Off to the CAH you go.

Slight derail alert....If I had a balanced salt solution, I'd give that over NaCl every time. Hyperchloremic acidosis is a thing and I can't believe we're still giving patients that stuff, let alone ones that might be acidodic.

This isn't a personal criticism, Nomad, it's a system thing and a lot of systems need to catch up. Nothing you're not aware of, I'm sure.

Carry on...
 

captaindepth

Forum Lieutenant
151
60
28
Just jumping in here,

What prompted the pts girlfriend to call? How quickly did he become "wiped out" and "not feeling very good?" Did girlfriend witness any seizure like activity, falls, trauma, other recent illnesses prior to this event? He almost sounds postictal from the mentation description of him throughout the call so far. Clearly he is hyperglycemic and the treatments mentioned so far sound on point and absolutely appropriate, but I feel like something is missing. Was there a count on the remaining pills in his medication containers? He is definitely on some heavy hitters with a pretty good amount of Benzos as well as Oxycontin. How were his pupils? Any sings of oral trauma? Any drugs/alcohol in the house? And also if girlfriend states "He does this kind of thing all of the time!" Then what has been the reasons (other than piss poor diabetes management) in the past? How does he look during this event compared to past events?

I know I just asked more questions then answered but I feel like there is a curveball somewhere in here.

p.s.
If I have a P-student with me, I'm instructing him to smell the pts breath for acetones....... and vomit nastiness
 

DrParasite

The fire extinguisher is not just for show
6,196
2,052
113
skin warm and dry? or hot and moist?

honestly, if his temp was a little higher, i'd be thinking infection that has been left untreated for too long
 
OP
OP
NomadicMedic

NomadicMedic

I know a guy who knows a guy.
12,098
6,845
113
So, you guys are right on. It was totally a DKA call to me. Truck->fluid->Hospital. I didn't even think it could be anything else.

Later on the morning I was sent on a stat transfer from my hospital to the ICU in the city.

Not only was he in DKA, turns out he was also septic, with a lactate >8, elevated white count and creatinine double. Bacterial pneumonia, and in fairly bad shape. I transported him with insulin, zosyn, vancomycin and maintenance fluid running.

His girlfriend minimizing his reported illness and his drug use were big distractors. I didn't do anything wrong with his treatment, but I certainly tunnel visioned on the DKA.

I guess I shared this scenario as a "it wasn't what I thought" experience.

If I had a lactate pro in the truck I would have got a POC lactate and bypassed the local CAH.
 

E tank

Caution: Paralyzing Agent
1,574
1,428
113
If I had a lactate pro in the truck I would have got a POC lactate and bypassed the local CAH.

A pretty high lactate isn't uncommon in DKA. How would you have teased out sepsis from that? Even given that, I'd still think closest would be a defensible call, given what you knew already.
 
OP
OP
NomadicMedic

NomadicMedic

I know a guy who knows a guy.
12,098
6,845
113
A pretty high lactate isn't uncommon in DKA. How would you have teased out sepsis from that? Even given that, I'd still think closest would be a defensible call, given what you knew already.

I didn't realize that. I just googled up some studies. Thanks. And honestly, I might have only had a higher index of suspicion. The treatment would have still been fluid and hospital.

Our local transfers just about everything, I'm thinking he probably should have gone to the city straight off the bat.
 

E tank

Caution: Paralyzing Agent
1,574
1,428
113
I didn't realize that. I just googled up some studies. Thanks. And honestly, I might have only had a higher index of suspicion. The treatment would have still been fluid and hospital.

Our local transfers just about everything, I'm thinking he probably should have gone to the city straight off the bat.

Yeah, maybe so, but the other thing is that his sepsis may not have really declared itself clinically until you dropped him off. Sounds like the lid came off when you began treatment for DKA and moved him. CAH's should be prepared to take, treat and discharge a "routine DKA". Maybe just a regional thing...
 

FLMedic311

Forum Lieutenant
131
102
43
So, you guys are right on. It was totally a DKA call to me. Truck->fluid->Hospital. I didn't even think it could be anything else.

Later on the morning I was sent on a stat transfer from my hospital to the ICU in the city.

Not only was he in DKA, turns out he was also septic, with a lactate >8, elevated white count and creatinine double. Bacterial pneumonia, and in fairly bad shape. I transported him with insulin, zosyn, vancomycin and maintenance fluid running.

His girlfriend minimizing his reported illness and his drug use were big distractors. I didn't do anything wrong with his treatment, but I certainly tunnel visioned on the DKA.

I guess I shared this scenario as a "it wasn't what I thought" experience.

If I had a lactate pro in the truck I would have got a POC lactate and bypassed the local CAH.

Dispatch this is M12, go ahead make that amb red! LoL, good job, great call thanks for sharing! @E tank, great point out about the lactate!
 
Top