A unique call

Ridryder911

Ridryder911

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Okay kiddos.. put on your thinking cap!

Here is a typical call, that reminds me of the old saying ... If you hear galloping hooves, think of Zebras! ....

You are dispatched to a rural area in your response area on a "post colonoscopy pain".. You and your mumble .. on disgust.

After arriving 25 minutes after dispatch, you arrive to a double wide trailer with several cars in the front yard with out of state license tags.

You are met by a "waver" that greet you to the front door. You then met by three elderly females describing that their "sister is from out of state and has had problems"... as you wind to the back bedroom you finally see your patient laying in bed.

Your initial across the room assesment is an elderly female approximate 80 years old that appears pale. She is very conscous and alert. You ask what is the "problem" and she describes she "has not had a bowel movement in the past three days". You inquire about the colonoscopy and was informed it was in 1969! You then ask ..confused 1969 ?.. The patient reconfirms... after questioning more, you find out they intended to say.."colostomy" in 1969. .. oh.. okay!..at least this makes sense


Initial history:

History: Patient is from out of state. Describes " feeling weak this past few hours".. she has had multiple medical problems. She did have the colostomy in 1969, with bowel removal due to colon cancer and has had no reoccurrences. A "large heart attack" approximately 6 years ago and currently ony being treated for HTN, and prophylactic cardiac such as ASA, NTG (prn), and Prilosec for GERD. Denies any food, latex, or drug allergies.

You decide to do a quick assessment and find an 80 year old female with no complaints except generalize weakness and no noted stool in her colostomy bag for three days. Brief overview patient is alert. well orientated and no noted gross neuro deficits, bi-lat symmetry with lung sounds clear, abdomen is round, soft with noted colostomy bag attached, (and inside visually see noted scant brown stool). Peripheral pulses are very weak and blood pressure is hard to obtain .. according to volunteer first responder.

You realize that you will not be able place stretcher into room, patient refuses to allow you to carry .. and you allow her to gradually sit on the side of the bed. She does without difficulties. She definitely, wants to "ambulate" to the stretcher against your recommendation not to. She does so and approximately 5 steps become syncopal. She is immediately placed onto the stretcher, where she becomes immediately alert again.

You place her into your unit to perform a better assessment and start initial treatment.... You are approximately 30 miles from an a ER.

Now what ?
 
umm you take a blood pressure? start 2 lines, 1 for her and 1 for you?
 
So far this is a very typical call so I can't wait to see what makes it unique.

I would do v/s, ekg, iv NSS with bolus, bgl, temp, pulse ox, maybe 12 lead, CVA assessment with grip strength.

Anything like this ever happen to pt before?
Has she been sick lately? (n/v? temp?)
Dehydrated? Eating?
Constipated on a regular basis or is this rare/brand new for pt?
Was the pt straining or doing anything strange when symptoms started?
Why is pt here from out of state?
Hiatal hernia hx?
what HTN/Diuretics meds is pt taking? (could cause constipation)
any pn anywhere recently?
prolonged bedrest?
hx of anemia?
Varicose veins? (syncope)
psych problems? (ask family)
pt ever have difficulty breathing or fluid in lungs or any other signs of heart failure.
thyroid problems?
JVD?
Anyone else in the house sick?



Some possible causes...bowel obstruction (I would expect weakness and shock with this one), orthostatic syncope possibly caused by HTN meds,
silent MI (old woman), TIA (syncope), mesenteric infarct, clogged colostomy.
 
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Well, looks like Guardian summed up everything that crossed my mind, and then a bit more. I concur with his treatment plan. Can't wait to see the outcome.
 
You load the patient into your unit and perform the usual oxygen, attaching ECG, getting an IV line, etc..

Your partner is unable to auscultate a blood pressure and believes that he is able ot palpate one between 50 and 60. Patient remains very alert and denies any other symptoms except "being light headed" at times.

More detailed exam:
Skin pale, cool and dry. No diaphoresis. Skin turgor WNL with adequate retractibility.
HENT: Normal cephalic, facial symmetry, PEARLA @ 2mm each and sluggish to respond, conjunctiva pale, sclera icterus clear. Oral cavity no lesions, and uvula mid-line.
Neck: trachea midline, JV @ 1-2 cm @ 40 degree angle/ Sternal of Louis Angle. Unable to detect any carotid bruits, thrills
Chest: Normal symmetry, without scaring, lung sounds C/T/A bilat. with APMI @ 4'th ICS/ MCL. Normal breast tissue.
Abdomen Round, non-distended, soft to palpation with some "feeling of increase pressure" with palpation; noted normal colostomy attachment, (did not remove to examine stoma) as described earlier noted scant brown stool (appeared to be non dark or tarry). Bowel sounds absent all quadrants. No masses or pulsations noted.
Pelvic/Gyn/Gen: Attempted to palpate femoral pulses, unable to detect any and patient complained of pain when doing so. (Hx. of bi-lateral femoral grants several years ago)
Extremities Normal appendages, no noted edema, clubbing or or peripheral cyanosis. Radial pulses rated @ grade <1 to +1.

Expecting to see a tachy rhythm, I was surprised that the ECG actually revealed Sinus Bradycardia at a rate of 40 to 56. Noted "q" wave from previous infarct and a possible prolonged "Q-T".

Patient at this time denies any other history as stated prior, and only elaborates that her colostomy had only "backed up once before" and if she had a irrigation device, she would not had notified us.
Patient does complain of slight nausea as described as intermittent, increases with movement. Still denies of any pain, ShOB, or abdominal pain except a mild "full feeling" in abdomen (described as need to defecate).

Patient has a butt load of pills, however they are in a day dispensor and does not know the names.

I.V. is established with a crystalloid solution and you are preparing for transport.

Okay, now what ? .. Bolus, atropine, pace, anti-emetic, or none?

R/r 911
 
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Patient seems to be moderatly stable at present... I'd refrain from pacing or atropine unless the patient worsens... How about a 12-lead EKG...

As was said... I'm thinking perhaps some form of silent MI is a possibility.

Patient doesn't seem to have any signs of CHF... so go for a fluid challenge for hypovolemia.

You mentioned anit-emetic, Rid... what purpose would that serve?

In this case, I'd do what one should do when they are clueless.... a really thorough exam and consult my partner, and then Command.
 
My partner was an old veteran medic as well. The ECG really did not show any thing other than was described. It catch us off guard that it was so brady.. and the QRS was remarkable, but "gut" instinct told both of us that we were not dealing with an AMI. The anti-emetic was thought because she had periods of nausea and we did not want her to vagal any more with a rate dropping into the low 40's at times. It was with held because we only carry Phenergan and that can lower a BP even more.

The pallor look, gray conjuntiva.. etc.. My first instinct was a AAA and second was an ischemic bowel, with a bowel obstruction.

Since we were at a great distance away, we decided that this patient was definitely not stable ( hemodynamically compromised). We did initiate fluid therapy at a wide open rate (lung sounds were clear, EtC02 35torr, SpO2 96% room air prior to oxygen tx.)

I notified one of the local medical director and informed him of the condition and my thoughts. He did sound questionable, when I informed him I going to with hold pacer, and vasopressors at first (our protocol for such s/s) but understood after I informed him of what I thought the dx. to be.

After the 200ml or so infusion, her blood pressure rose to 80/64 and the ventricular rate increased to about early to mid 50's. No significant ECG changes. However; her colostomy bag started filling with gas and stool. Enough that it had ballooned outward.. the little old lady even said .."Sweetie, looks like the sh*t is about to fly.. and I do mean literally!.." Along with this she started having back pain in the lower portion of her back and described it as sharp.. and intensifying.

Vitals are now pulse 54, r/r 20, BP 96/80 Total infusion < 250 ml of fluid.

Now what ?
 
Get a bucket (or any other open container), place it under the bag, puncture it so the gas can escape, and... lower the ambulance windows? :P
 
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LIFEGUARDAVIDAS said:
Get a bucket (or any other open container), place it under the bag, puncture it so the gas can escape, and... lower the ambulance windows? :P
Click to expand...
Almost true.. I did vent the bag by puncturing the top part.. so the "chyme" (look that one up) would not leak . (*p.s. note to self, if I do this again, please be sure to turn the vents on!..:o)

She described her pain is now 10/10 and unable to remain still and is becoming very restless. Blood pressure is now 100/60 heart rate 58, r/r 18-24, no ECG changes.

I have decreased the IV flow rate to 50ml/hr ...

Still no Masses or abdominal pulsations, just now able to feel radial pulse. And the poop is beginning to pour into the bag, filling it!

Now what ?????
 
Basically, we've got an old lady with no crap coming out, hypotension, and bradycardia. Then rid shows up and gives some fluid and now we have an old lady with crap flying out and back pn.

We don't know what meds she's on and that sucks ( a lot can cause brady like clonidine, amiodarone ( prolonged q-t), etc.) I'm not inclined to think this is the problem because it wouldn't be corrected with 250ml saline.

I'm starting to wonder if it's some weird kidney stone vagus nerve stimulation thing. This is the only thing I can think of that MIGHT be corrected with NS.



As far as treatment, I wouldn't do anything for a while now that the pt's pressure is up.
 
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Actually, she is now in excruciating pain described from back. I attempt femoral pulses and still there is none, however her pressure should be enough to perfuse femoral.

When the patient informed me she had femoral grafts this alerted me she apparently has arterial vessel wall problems. Those with peripheral vascular disease (PVD) are prone to have more than one vessel.

I immediately notified the ER Medical Director, and requested some anti-hypertensive medication, now to lower her pressure. He agreed and was to administer Morphine Sulfate for the pain and reduction of her blood pressure. He agreed with my initial diagnoses and will have ultrasound unit in trauma bay upon arrival.

Ironically brought her pressure up; just to lower it back down.

The patient became more and more restless and now started complaining of "severe pain from abdomen to back' .. worst pain ever and now is very restless and figidity.

While about two minutes from ER, the patient did admit.. she did have " a blister on one of her arteries?".... Great!

We placed the patient into trauma bay and an emergency U/S was performed and no aneurysm was found not much perfusion either.... a emergency CT w/dye was performed and found that the patient had formed a thrombus in dissecting aorta and occlusion was noted that was actually causing the arterial wall to be obstructed and acting as a faulsa-form type aneurysm. The fluids acted just enough to raise her pressure up to cause pressure to be back up for the bowels to get motility and to act again. (remember gut goes in hibernation in shock)

We had to go to another response and later returned to find her being loaded into the chopper for transport to a facility with a vascular surgeon. She did have the surgery, but unfortunately died on the table from possible AMI and complications from the thrombus...

Moral of the story, even the most mundane call can turn into something bigger...

The physician agree had I followed the usual cardiac protocols, this patient would had coded out on me.. as I say, You learn something everyday .. and sometimes when you hear hoof-beats think of Zebras.. (think outside the box)... This one made me think!

R/r 911
 
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wow, I was leaning towards atropine...guess I would have killed her, oh well :)

I wonder what caused the brady; it was throwing me way off.

On a side note, I think PVD is an epidemic that no one ever talks about.



Thanks for another great one!
 
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Interesting call Rid, you are right, there is always something to learn!!:)
 
Wow.

I would have gone for MS for pain control as well, and the severe back pain had me thinking about an anyurysm, too.

Good Call.
 
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