54yo female just discharged

[Rialaigh]

So I am going to pose a scenario with limited information starting. You may ask any and all questions you like. Please be detailed in the questions you ask, I can give you the answers to any and all questions you have regarding anything that I paint a picture about. I will be fairly quickly responsive today in giving answers and painting a picture. I am just curious as to how others would treat/not treat this patient.

Background Information -

You work a very poor fairly rural area. There is a high incidence of drug and alcohol abuse as well as tobacco use. Violence is not very common.

You are on a ALS truck, you are a paramedic with a EMT-B partner. You are dispatched priority 1 to a 54 year old female trouble breathing. Your response time is aproximately 20 minutes, you have no backup and no helicopter

Your community hospital is 20 minutes away P-1
Your PCI and stroke center is 30 minutes away P-1
Your level 1 trauma, neuro, etc... Center is 65 minutes away P-1


You are escorted into a clean looking mobile home by family, patient is found in back of home sitting on floor looking weak and appears in no/minor respiratory distress. PT appears to be on home O2 via nasal canula. Patient is being propped up by her sister. PT states she was in the hospital today and hands you her discharge paperwork. Hospital discharge paperwork states the patient was seen today, diagnosed with pyelonephritis, and discharged home with a prescription for Zofran, Norco, and Levaquin. PT states her side still hurts really bad and she feels worse then when she was discharged several hours ago. She states she has not taken any of her prescriptions since leaving the hospital.




Go ---->

 

[phideux]

Been there, done that, got the t-shirt.
The shot of Dilaudid they gave her in the ER wore off and she is in pain.
The boyfriend, or other family member already took and stashed for later, or sold her hydrocodone. Or, after buying beer and cigarettes, they can't afford the scripts.
I bet if you look up her record she has been in all the ERs, repeatedly, all the nurses and medics know her by name, and roll their eyes as she comes in.
Your company has a transport everyone policy, and she wants to go to a different ER than the one she left a few hours ago, so you load her up, stuff your EMT partner in the back and go.
Drop her off, they will give her another shot or 2 of Dilaudid, call the transport ambulance to take her home, again. Of course they can't take her home POV or call a cab, medicare/Medicaid won't buy gas or pay a taxi.
And hopefully they gave her enough Dilaudid so she will sleep through the night and you, the ER, and the transport ambulance guys don't have to worry about her again till your next shift. :rofl::rofl:

Am I close????

 

[TransportJockey]

Vitals, continue O2, small fluid challenge, consider Rocephin IV drip during transport, if vitals are telling of pain consider some pain management (50mcg of Fent should do nicely). Non-emergent transfer to closest ED if pt would like to go.

 

[Brandon O]

Vitals to consider sepsis. Back to the same ED. Might get admitted this time.

 

[Ewok Jerky]

Hard to tell whether this is a case of "the medicine isn't working" or pylo>sepsis. Can we have vitals including temp and resp rate? Past medical Hx? Previously healthy? Freq UTIs? Was she admitted or just in the ED? Anything in the paperwork about her workup, CBC, u/a, Ultrasound, other imaging? Did she receive ABX in the hospital, which one?

 

[OnceAnEMT]

Been there, done that, got the t-shirt.
The shot of Dilaudid they gave her in the ER wore off and she is in pain.
The boyfriend, or other family member already took and stashed for later, or sold her hydrocodone. Or, after buying beer and cigarettes, they can't afford the scripts.
I bet if you look up her record she has been in all the ERs, repeatedly, all the nurses and medics know her by name, and roll their eyes as she comes in.
Your company has a transport everyone policy, and she wants to go to a different ER than the one she left a few hours ago, so you load her up, stuff your EMT partner in the back and go.
Drop her off, they will give her another shot or 2 of Dilaudid, call the transport ambulance to take her home, again. Of course they can't take her home POV or call a cab, medicare/Medicaid won't buy gas or pay a taxi.
And hopefully they gave her enough Dilaudid so she will sleep through the night and you, the ER, and the transport ambulance guys don't have to worry about her again till your next shift. :rofl::rofl:

Am I close????

Do you waste your time to judge all of your patients this way, or is there a further time-wasting selection process of who you're going to skimp on? I'll say it frankly, your attitude is despicable and I hold no pity for it or anyone who finds it humorous. You've burned out, or are deep in the process. You really, really should look into a way to switch things up and prevent this.

I want to know the vitals. If the 02 sat is low, replace the NC with an NRB. High temp really pushes us towards sepsis, perhaps further sepsis depending on where she was before. Ask if any drips or medications were administered while in the hospital. My guess is that nothing was on-boarded in the ED (which I disagree with by practice), and she was sent home expected specifically to take the antibiotic ASAP. That didn't happen.

About seeking info relating to lab results in discharge paperwork, very good suggestion. However, at least in the ED I'm at, our discharge papers don't include lab results or imaging or really anything other than laymen-worthy wording and prescriptions. Those results would only be included if manually entered by the physician or nurse. Otherwise they could only be obtained through a medical records release request.

Let's see some vitals!

 

[abckidsmom]

Vitals to consider sepsis. Back to the same ED. Might get admitted this time.

Ding ding ding. We have a winner.

 

[Rialaigh]

Hard to tell whether this is a case of "the medicine isn't working" or pylo>sepsis. Can we have vitals including temp and resp rate? Past medical Hx? Previously healthy? Freq UTIs? Was she admitted or just in the ED? Anything in the paperwork about her workup, CBC, u/a, Ultrasound, other imaging? Did she receive ABX in the hospital, which one?

You feel for a radial pulse, skin is dry and warm but not abnormally so. Radial pulse feels about 100. Respiration rate is about 22 with no obvious distress. Initial O2 saturation shows 57%. Initial BP is 83/46, patient is still sitting in floor leaning against her sister. Patient states her O2 sat always stays between 55%-65% and 57% is pretty much normal for her. Patient does not appear in much respiratory distress. Patient states she just feels a little weaker than earlier and is breathing slightly worse then when she was at the hospital

Past medical history includes HTN, Diabetes, Several TIA's, several cardiac caths with stints placed, stints placed in each leg, unknown on PE's, COPD, Ephysema, CHF

Patient states no recent illness, she has battled with UTI's in the past and has them several times a year.

She was just seen in the ER at the small community hospital earlier today and discharged home. Paperwork from discharge has no lab values or imaging studies included in it. Patient received Dilaudid and Phenergan IM and PO norco prior to leaving.

 

[Anjel]

Can we get a temp on her? A 12 lead and a BGL

Start an IV and start a bolus to see how the BP responds.

 

[Brandon O]

Hard to tell whether this is a case of "the medicine isn't working" or pylo>sepsis.

Agreed, and I'd be a bit skeptical that anything has changed bigtime since the discharge if it was really a few hours ago (especially if she looked low-risk enough that they discharged her in the first place), but even then clearly she's not capable of adequate followup and self-care.

 

[Rialaigh]

Can we get a temp on her? A 12 lead and a BGL

Start an IV and start a bolus to see how the BP responds.

Temp is 99.0 Tempanic,

12 lead shows as below at a total rate of around 80 now. Repeat BP is 92/53. BgL is 442. IV access is unobtainable after blowing 2 22's and a 24, her vasculature is very poor and she has no identifiable EJ locations.

EDIT: This is not the actual ECG. It is from a case on Dr. Smith's ECG Blog. See the case here

 

[Anjel]

Bigeminey... nice.

I would up her o2 and transport to probably whatever hospital she wanted. I would probably push a little toward the one with a little more capability than the community hospital.

 

[TransportJockey]

Temp is 99.0 Tempanic,

12 lead shows as below at a total rate of around 80 now. Repeat BP is 92/53. BgL is 442. IV access is unobtainable after blowing 2 22's and a 24, her vasculature is very poor and she has no identifiable EJ locations.

EDIT: This is not the actual ECG. It is from a case on Dr. Smith's ECG Blog. See the case here

SubClavian or IO access.

 

[Rialaigh]

So lets say you get IV access, whats the plan? any medication? assuming her BP is hanging out in the 80-90/40 range...transport decisions?

 

[TransportJockey]

So lets say you get IV access, whats the plan? any medication? assuming her BP is hanging out in the 80-90/40 range...transport decisions?

I'm a little different than most because I'll stabilize the best I can on scene and then transport to a fixed wing. I'd do a lactate level, chem panel, flyid bolus then possibly a levo drip. Ill expand more when I'm not on my phonE

 

[Rialaigh]

I'm a little different than most because I'll stabilize the best I can on scene and then transport to a fixed wing. I'd do a lactate level, chem panel, flyid bolus then possibly a levo drip. Ill expand more when I'm not on my phonE

Sounds good, from the bit of research I have done I am getting the idea that most medical professionals are getting away from trying to convert the rhythm as long as it does not deteriorate into full blown Vtach, Im wondering if a Levo drip and then Amio or lido would be indicated or if we are looking to correct an electrolyte imbalance possibly causing the problem. If my transport time were lets say an hour I am trying to figure out how I treat this patient if she continues to deteriorate.

 

[MonkeyArrow]

Was a 12 lead taken at the hospital? Is a interpretation or copy of it in the d/c papers?

 

[Carlos Danger]

Sounds good, from the bit of research I have done I am getting the idea that most medical professionals are getting away from trying to convert the rhythm as long as it does not deteriorate into full blown Vtach, Im wondering if a Levo drip and then Amio or lido would be indicated or if we are looking to correct an electrolyte imbalance possibly causing the problem. If my transport time were lets say an hour I am trying to figure out how I treat this patient if she continues to deteriorate.

It's hard to come up with a decent plan for a complicated patient like this without having a better history and seeing them with you own eyes. So, all I can add is a couple thoughts:

• This is a complex patient with many interrelated comorbidities. The short of it is that it sounds like a brewing sepsis is aggravating her other problems. But again, it's hard to know without more info. I'd like to see a CBC and ABG.
  
  
• Does she have a pneumonia? Was a CXR done in the ED?
  
  
• I find it hard to believe that her Sp02 is "normally" in the 50's. Is that with a good pleth?
  
  
• I would start with a fluid bolus and some high flow oxygen. I'm guessing that would lessen both her dyspnea and the ectopy. If it doesn't I'd try a small dose of glyco or atropine to see if that helps.
  
  
• I would not use antiarrythmic unless she starts to have runs of VT.
  
  
• I would also avoid norepi if at all possible, due to it's pro-arrythmic effects.
  
  
• Getting an IO now vs. waiting until she worsens clinically is a judgement call; good arguments can be made for either approach but I'd lean towards doing it now.
  
  
• Sometimes the best thing to do is just drive to the hospital. Even a small one with limited capability can usually handle patients like this.

 

[Brandon O]

I think you have to treat this as urosepsis until proven otherwise. Volume load, abx if you have them, go. This is consistent with the hypotension, lethargy, infectious focus, hyperglycemia, etc. No fever, but hey.

Cardiac may be number 2, and you could argue for going 10 minutes further to the PCI facility. Ectopy is pretty appropriate for sepsis. (Let's stop talking about "converting" it...) However...

Try to find the J-point in each lead. Confused? Before I thought it was bigeminy, perhaps with Sgarbossa-type changes, but nope, those all seem to be SINUS beats. Every other P wave is being lost in the big T waves, which is why it's so hard to find those J-points. In other words, it looks like an intermittent RBBB every other beat.

With that said I don't THINK there are any clear ischemic changes, but that is not a normal rhythm and certainly may suggest a cardiac etiology.

The recalled sat is clearly spurious.

 

[Christopher]

This ECG looked so much like a Dr. Smith ECG I googled it just to see. I guess you guys use the same machines

(btw Google says this is "RBBB" when you search by image)

Try to find the J-point in each lead. Confused? Before I thought it was bigeminy, perhaps with Sgarbossa-type changes, but nope, those all seem to be SINUS beats. Every other P wave is being lost in the big T waves, which is why it's so hard to find those J-points. In other words, it looks like an intermittent RBBB every other beat.

Nah, looks like bigeminy; R-R's are long-short-long-short-long-short.