0834 : “Overdose/poisoning”, unconscious (intentional)”.
You are called to a suicide attempt on a cold morning in semi-rural area. The dispatch information notes that you were dispatched by a third party caller (the pt’s sister), who found a note that had been dropped (ie not posted) in her letter box from the pt, explaining that the pt had taken an overdose and apologising for the grief it would cause.
O/A
You arrive at the pt’s house to find that police have turned out prior to you and found a gentleman in his late 50's in an altered conscious state. They have found a detailed suicide note and a number of empty packets of medications. The note states that he took the overdose last night and that it included oxycodone and diazepam.
O/E
59YOM lying semi recumbent in bed, eyes closed, looking a bit grey. He does not respond to your presence.
He is rousable to a state in which he will nod or shake his head answering yes or not to questions.
-Airway: His airway seems patent, the trachea intact. Nil jugular venous distension.
-Breathing: Shallow breathing is evident. His chest expansion is equal bilaterally. Inspiratory and expiratory phases are equal. There is no accessory muscle use or any apparent respiratory distress. His chest is clear and equal bilaterally on auscultation, perhaps ? reduced air entry to the bases. RR 24, SpO2: 70 (with a good pleth)
-Circulation: He has a regular pulse that appears normal in character and strength. He is greyish in colour and his hands and feet are ice cold. Centrally, he is noticeable warm. P: 120, BP 125/50
-Disability: His GCS is 12 (E3, V3, M6) – he mumbles and groans with the odd few words strung together. He obeys the command to open his eyes and to look left and right, but will not grip your hands. His pupils are equal @ 4mm very minimally responsive to light.
Other bits:
BSL: 5.7mmol/L (102.6 mg/dL). Temp: 39.6 C (103.2 F). Monitored in a sinus tachycardia, with a 1st degree AV block.
Secondary Survey
Entire body is atraumatic. NAD other than a 3 inch vertical surgical scar running across his epigastrum and he is wearing a nappy (diaper). Abdomen is soft with no grimacing or guarding noted on palpation. He has not been incontinent. His skin and mucous membranes look reasonably dry.
Hx: He doesn’t answer any questions other than nodding when you ask if he’s been unwell in any way lately. The suicide note makes reference to a year of disability and to renal cell carcinoma that is in remission. The house is well kept and certainly doesn’t look like the kind of house that a bed bound person might live in. Allergies are unknown.
Meds: Oxycodone, Metoclopramide, Diazepam, Quetiapine, Coloxyl with senna. These are found near the bedside by police, nil other meds evident.
Lets say you are:
- 5 mins from a small rural ED. X-ray, CT for ambulant pts only. No surgical service, ICU or HDU. Gen med wards only.
- 40 mins from what you would call a level two trauma centre I suppose. ICU, CCU, ED with CT. All services except neuro surg and cardio thoracic surg.
- 40 mins by whirlybird from a hospital that has the lot and a bit more.
) you heroicly manage a 20 in his R medial cube. His conscious state does not improve. Surprisingly though, with some coaxing and a little support he is able weight bear and sit on our wheel chair.
