AMS calls at the ARC

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bahnrokt

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My small Vollie squad covers two ARC homes that are fairly active. They generate about 30 calls a year for residents there that according to the staff "are not acting right". At a BLS level I have a hard time evaluating this group of PTs and wonder if anyone on here has some experience with them.

With a normal person it is fairly easy to judge their level of alertness and you can get a decent read on them through a quick conversation of lack thereof. But with a mentally challenged (is that the current PC term?) PT there is often no conversation, no "this hurts". Just the word of the staff that So and so is less reactive or alert than normal.

At first I was trying to fall back on vitals and found that to be nearly as ineffective. Most of the ARC residents are walking chemistry sets with meds sheets 3-4 pages long (Im sure that could be its own thread). They have so much running through them that a single set of vitals is almost meaningless.

Last night I had a 51 y/o F non verbal, non ambulatory pt with the famous "Not acting right". Her vitals were decent, BP 108/60, P 56reg, Resp 14 labored w/ heavy wheezing. SPO2 was 90 ra, 97@6. O2 didn't wake her up at all, BG 115. No known history but her meds list had 37 entries. Ranging from butt cream to ativan and a bunch of stuff I've never seen before. She is mildly reactive to pain, but how do you judge what a proper pain response is for her?

What would you look at and how would you proceed? You have no ALS coverage late on a Sunday night. Only ALS available would be a borrowed medic unit from the city that is 15 minutes out and only a few minutes from the hospital.

I skipped ALS and had my driver go P2. At 2300 on a Sunday you may gain 3 minutes with lights on...not worth the risk IMO.I checked her vitals every 5min looking for a rapid decline or pattern and lowered the cabin lights and put on soft music to keep her calm. Once I turned on the smooth jazz my partner offered to stop at CVS for condoms...he's a ****.
 
90% on room air is pretty hypoxic.

Was she a COPDr?

Why was her breathing labored?

How was the lung sounds?

At a BLS level your only real treatment is support ventilation, increase her FIO2 and drive to hospital. (albuterol if COPD)
 
Lung sounds full of fluid bilateraly.

No known hx of anything according to staff. I doubt a non verbal, non ambulatory ARC resident would have ever had the chance to take up smoking.
 
But you don't have to be a smoker to have COPD. Granted, that is a pretty common cause, but maybe this patient lived with a chain smoker and was exposed to tons of second hand smoke prior to ending up in their current living arrangements. Maybe they have other conditions that make them susceptible to developing COPD.
 
bahnrokt said:
My small Vollie squad covers two ARC homes that are fairly active. They generate about 30 calls a year for residents there that according to the staff "are not acting right". At a BLS level I have a hard time evaluating this group of PTs and wonder if anyone on here has some experience with them.

With a normal person it is fairly easy to judge their level of alertness and you can get a decent read on them through a quick conversation of lack thereof. But with a mentally challenged (is that the current PC term?) PT there is often no conversation, no "this hurts". Just the word of the staff that So and so is less reactive or alert than normal.
Click to expand...
The key to evaluating these patients is the staff, unfortunately they usually have the "Not my patient... I was on vacation... I am/they are new here..." excuse. You really need to interrogate staff and get what you can:
"What is different today from normal?"
"Are they normally only moaning to pain?"
"Can she usually tell you what is wrong?"
"How long have you noticed this change?"
"When was she last seen at her baseline?"
"Has she fallen recently?"
"Has she been eating and drinking like normal?"

Unfortunately staff is usually clueless about anything, but don't let them leave without interrogating them and getting everything you can about the patient's normal mental state. Too often I see new EMT/Medics (heck I still do it when I'm tired or distracted) let the staff walk out of the room after a few questions, or give up to easily on asking the staff questions.

Another key to evaluating these patients is their paperwork, like you said these patients have a laundry list of medications, unfortunately sometimes the answers are hidden in there. Did they increase the dose of the patient's painkiller or other medication? Was the patient on antibiotics recently (they could have a worsening infection)? Has a new medication been started recently? Or an old one get discontinued?

Sometimes there is no specific answer we can find in the field or the information that is supposed to be there just isn't. If all else fails fall back to the ABC's, rule out the obvious (hypoxia, hypoglycemia, hypotension, hypothermia, infection etc), and just take them to the ER.

As far as your patient, without more information we really can't tell you what was going on. And with 3-4 pages of meds I assure you she has a medical history :) . I think you did the right thing at the BLS level, waiting for ALS when you are close to the hospital is silly and you corrected the things you found to the best of your ability.

As I side note I interpreted ARC to be an old folks home, but the ARC we have here is an Alcohol Recovery Center, either way the evaluation is about the same.
 
bahnrokt said:
Lung sounds full of fluid bilateraly.

No known hx of anything according to staff. I doubt a non verbal, non ambulatory ARC resident would have ever had the chance to take up smoking.
Click to expand...

With the BP you gave us, and saying her lungs were filled with fluid, she is probably having some high degree of heart failure be it an exacerbation of CHF or an acute occurrence such as infarction.
 
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NYMedic828 said:
With the BP you gave us, and saying her lungs were filled with fluid, she is probably having some high degree of heart failure be it an exacerbation of CHF or an acute occurrence such as infarction.
Click to expand...

Agreed, that med list would help decide if it's an exacerbation or new onset.

As much as I hate pages and pages of meds, like sirshocksalot said, you can learn a TON about the patient if you know how to dig through all the bull:censored::censored::censored::censored:.
 
bahnrokt said:
Lung sounds full of fluid bilateraly.

No known hx of anything according to staff. I doubt a non verbal, non ambulatory ARC resident would have ever had the chance to take up smoking.
Click to expand...

No history of anything with a 37 medication long list and is a resident in an ARC? Uh huh, right...

BTW, WTF is an ARC?
 
NYMedic828 said:
With the BP you gave us, and saying her lungs were filled with fluid, she is probably having some high degree of heart failure be it an exacerbation of CHF or an acute occurrence such as infarction.
Click to expand...

I was thinking severe pneumonia, he said wheezing too, and she may have just been hypotensive to begin with.

What was her regular bp?
 
shiroun said:
I was thinking severe pneumonia, he said wheezing too, and she may have just been hypotensive to begin with.
Click to expand...

Google fu "cardiac wheezing".
 
Aidey said:
No history of anything with a 37 medication long list and is a resident in an ARC? Uh huh, right...

BTW, WTF is an ARC?
Click to expand...

Maybe I should rephrase that. No history that the minimally paid worker at the home had any memory of.

ARC = Association of Retarded Citizens. County run homes for those that no longer have family to take care of them.
 
shiroun said:
I was thinking severe pneumonia, he said wheezing too, and she may have just been hypotensive to begin with.

What was her regular bp?
Click to expand...

Severe pneumonia more than likely would be febrile/septic vs just fluid.
 
Try one time

#1) Get the staff to clearly define what "not acting right" means
#2) If they can and they do then figure out what the baseline (of vitals, pain, movement, etc.) is and then observe for deviations from what you consider to be stable. Remember, you are not intervening, only transporting.
#3) If the staff can't or don't communicate clearly, and the vitals are stable and you are still curious then seek to find any evidence of trauma (head-to-toe) that they might have neglected
#4) But, really, what's most important? iHow abouts your patient exhibiting any distress? Just because they are mentally impaired does not mean that their wiring is any different than ours; we show signs of distress! It's our body doing what it's supposed to do -- contracting, favoring, hiding, positioning...all that stuff.
#5) If you detect distress, then do what you can, working up from the most basic to more complex according to the situation
#6) But once you decide there's nothing to fix, then just be with the patient; he/she is no longer a puzzle to be solved, but a life to be cared for.
 
One of the keys to treating different patient populations is being familiar with them. Hands-on familiar that is to say.

It sounds to me like this is a perfect opportunity to volunteer at the facility. I'm sure they have some sort of mechanism for it. Plus it'd be a chance to both learn a great deal while educating patients and staff.
 
Every altered patient in a group home of any type has sepsis by either the uro or pneumo route until reasonably proven otherwise.....
 
As someone who spent over 10 years coaching Special Olympics, i have worked with people at all levels of mental capacity. The key is paying attention to the patient and not the numbers.

We had some athletes that had very severe health problems. Our athletes that were in group homes or ARC type facilities did not often have accurate medical info. You would like to rely on staff but often times you need to take the staff report and compare it with what you are seeing.

There were many times we called the Medics and I saw the responding crew shake their heads when reading the reports the facility gave to us. As coaches we were often able to provide more accurate reports than what the CNA's at the facilities could provide.

Just because someone can't communicate with you like normal is no reason to treat them any different. Pay attention to your patient and how they are presenting. Firetender hit the nail on the head.

I started coaching with my mom when I was 8 years old. I finally gave it up at 21. I can tell you that it was an amazing experience that I would trade for anything. Not only was it one of the motivating factors to get into EMS but it taught me alot about compassion and how varied humans can be. In my cop days, it helped me deal with mental people.

It sounds to me like you focus on their retardation and may ignorance (not trying to be disrespectful) is kinda freaking you out. My suggestion would be for you to volunteer at the ARC if possible or failing that volunteer with your local Special Olympics. You will find the experience rewarding and educational. It is amazing how much you can learn from a young adult who is deaf, mute, and quadrapalegic. They can teach you a lot about yourself to.
 
And this is why CPAP should be BLS.
 
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