Debatable Call?

[CBentz12]

Ok so I had a call today for a PT with abd pn and vomiting up blood. PT BP @ 168/102 and pulse @ 118. PT had PN when I palpated his RUQ and LUQ, PT also had jaundice eyes and skin with the shivers. PT has Hx of liver disease @ 32 and PT does not take meds for it due to lack of funds.

Now mind you nor us or ALS witnessed him throwing up blood so my partner who is in the back calls BS on the vomiting. I on the other hand can believe this to be true due to my assessment and PT vitals. So we get to hospital and head RN calls BS as well so they put him in the ER waiting room with a convenience bag.

Come to find out 1 hour later we arrive back to same hospital and the RN tells us he threw up a bunch of blood and they had to call a trauma alert on him because he was at this point to have ruptured his liver. Now my question is on scene would you have sent him with ALS for proper meds or do you feel comfortable with this PT? I honestly would have kept him with ALS especially after seeing his jaundice and shivering with c/c of vomiting blood which all indicate Renal failure.

 

[Aidey]

I think you mean liver failure, not kidney failure. And there are almost no meds ALS can give a patient with liver disease that severe. A lot of the meds we carry are processed in the liver, and if someone is in liver failure they can't process the meds right.

 

[CBentz12]

DOH yes I meant liver failure and forgot to mention PT had Hx of kidney disease as well which is why that was on my mind. His kidneys could be failing as well though due to the liver not working right and the PN in the UQs correct? I don't know all interventions as a medic but I would rather have him with a paramedic then a EMT if he does go south fast. So would you have called his bluff or demand he be seen now?

 

[DrParasite]

So two BLS providers assessed him and found him to be fine, at least one ALS provider assessed him and thought him to be fine, the head RN gives him a quick once over and thinks he's fine, where is the problem?

let me ask this: what would an ALS transport have done? what intervention would they have done? They already assessed, and found nothing that warranted an ALS treatment before he arrived at the hospital.

was his jaundiced, and suffering from liver failure? maybe/probably. but how would a medic treat him differently than an EMT would, esp considering advanced providers had already assessed him and found him to be stable?

 

[CBentz12]

So two BLS providers assessed him and found him to be fine, at least one ALS provider assessed him and thought him to be fine, the head RN gives him a quick once over and thinks he's fine, where is the problem?

let me ask this: what would an ALS transport have done? what intervention would they have done? They already assessed, and found nothing that warranted an ALS treatment before he arrived at the hospital.

was his jaundiced, and suffering from liver failure? maybe/probably. but how would a medic treat him differently than an EMT would, esp considering advanced providers had already assessed him and found him to be stable?

I never thought he was "fine" lol The guy was obviously going south because like you said there are really no interventions other then dialysis correct? My point is a Medic could assist in more emergency interventions then a simple EMT could. I understand what you mean though but considering what happened is what I thought to happen I just didn't agree with the RN or my partner for that matter.

I believe he showed late signs of liver failure and they just tossed him to the waiting room in a wheelchair which I questioned initially but what do I know I guess I'm a EMT compared to a RN. I couldn't of done anything more for him then what I did and after transfer of care it's all in their hands. BTW The PT BP started to drop rather fast within that 15 minute transport going from 168/102 to 132/74 and then 104/60. I really am just trying to learn from this experience though.

 

[Cawolf86]

Dialysis is a treatment for renal failure. End stage renal disease.

If he was truly showing signs/symptoms of decompensated shock then I agree ALS transport would be appropriate. I have seen a fair share of cirrhosis/hep patients and their complaints are typically not acute events. I am not saying this always the case but with the patient you presented initially I see no definitive reason to start and IV and transport with ALS.

 

[CBentz12]

Dialysis is a treatment for renal failure. End stage renal disease.

If he was truly showing signs/symptoms of decompensated shock then I agree ALS transport would be appropriate. I have seen a fair share of cirrhosis/hep patients and their complaints are typically not acute events. I am not saying this always the case but with the patient you presented initially I see no definitive reason to start and IV and transport with ALS.

Im not 100% but im pretty positive dialysis can be used for liver failure to remove the toxins that the liver can not filter. However I just might be Monday morning QBing it and thinking too much about what else could have possibly been done for next time. I appreciate the comments though fellas because im trying to get a different POV.

 

[DrParasite]

I believe he showed late signs of liver failure and they just tossed him to the waiting room in a wheelchair which I questioned initially but what do I know I guess I'm a EMT compared to a RN. I couldn't of done anything more for him then what I did and after transfer of care it's all in their hands.

I still see nothing wrong with what you did. The nurse made the call, not you. also remember 80% of your patients will either live or die regardless of what you do.

BTW The PT BP started to drop rather fast within that 15 minute transport going from 168/102 to 132/74 and then 104/60. I really am just trying to learn from this experience though.

that's a pretty significant drop in 15 minutes, one that would have definitely set off warning bells in my mind. I wouldn't have stopped to waited for ALS, but would have made sure my patient had a bed waiting for me (yes, our BLS crews can do that, esp if you have nurses who respect you and work with you, not just use to to hold a wall because they don't want to get more staff and more beds) when I arrived at the ER. And if the nurse still sends me to the waiting room, I will either find another head nurse, or one of the doctors who I know, explain the situation, and hope they can convince the nurse to get me a bed (all in the name of patient advocacy).

And if you still can't, well, you did all you can, if a doctor and two nurses wants to turf your sick patient to the waiting room, that's where they go; just make sure you tell the triage nurse what's going on, so when your patient collapses, he or she knows whats going on and why the patient was left in triage.

 

[Ecgg]

Does this patient have a history of alcoholism? Vomiting blood (what color was it bright red or coffee ground emesis?)

The 2 biggest things I am concerned with

1) Esophageal varices due to hepatic portal hypertension. Basically the veins that reach toward to esophagus get engorged and can rupture.

2) The other thing is peptic ulcer and erosion of the lining. Which can produce bleeding and can manifest as vomiting blood and/or blood in the stool (melanotic stools)

As the saying goes if you hear hoof beats look for horses not zebras. These 2 things would be on top of my list especially in a 32 years with a history of alcoholism.

Question to ask the person do you have history of hypertension what does your BP normally run? "168/102 and pulse @ 118" those are not normal vital signs. Perform through medical assessment and run your diagnostics. Certainly ALS assessment and transport would be warranted if that is what you asking?

 

[CBentz12]

PT stated he drinks occasionally and he said his normal BP is in the 130s/80s range. I also remembered that he spent 32 days in the hospital in the beginning of year due to kidney disease. Never witnessed him vomit but RN stated it was blood when we ran into her again. My partner ran through a thorough assessment himself so other then my basic questions while getting vitals I don't know what all else he asked him. Ill ask the nurse how he faired when I see her again but someone mentioned to my partner at HQ that our trauma alert was possibly deceased so I've just been thinking about it.

 

[JPINFV]

So two BLS providers assessed him and found him to be fine, at least one ALS provider assessed him and thought him to be fine, the head RN gives him a quick once over and thinks he's fine, where is the problem?

let me ask this: what would an ALS transport have done? what intervention would they have done? They already assessed, and found nothing that warranted an ALS treatment before he arrived at the hospital.

was his jaundiced, and suffering from liver failure? maybe/probably. but how would a medic treat him differently than an EMT would, esp considering advanced providers had already assessed him and found him to be stable?

4 providers missed a clinical history strongly suggesting a ruptured esophageal varicies, of which 2 of them should have caught it. The paramedic and the nurse have no excuse.

All 4 of them missed the patient in shock (compensated to decompensated). Again, inexcusable, especially once the patient decompensated.

The two BLS providers should have either transported quickly (not necessarily lights and sirens when he was compensating, but not "he's lying, so I'm going to go back to texting on my iPhone"), or called paramedics who should have recognized that the guy was beginning to circle to drain. Yes, paramedics don't have ocreotide or the ability to do band ligation, but when he bleeds out and starts going past permissive hypotension levels, they can at least administer fluids. Furthermore, when he starts aspirating the blood from his varicies they can, you know, maintain an airway via intubation. An ET tube is going to do a heck of a better job than a yankauer down the throat.

Oh, but that's right, he's not warranting any interventions right this second, therefore he must be stable enough to go to the hospital. After all, just as census counts aren't supposed to change in the ambulance, patients don't deteriorate either.

 

[Aidey]

Im not 100% but im pretty positive dialysis can be used for liver failure to remove the toxins that the liver can not filter. However I just might be Monday morning QBing it and thinking too much about what else could have possibly been done for next time. I appreciate the comments though fellas because im trying to get a different POV.

No. Dialysis is for kidney failure only. There is no such thing as dialysis for liver failure.

 

[Veneficus]

Does this patient have a history of alcoholism? Vomiting blood (what color was it bright red or coffee ground emesis?)

The 2 biggest things I am concerned with

1) Esophageal varices due to hepatic portal hypertension. Basically the veins that reach toward to esophagus get engorged and can rupture.

2) The other thing is peptic ulcer and erosion of the lining. Which can produce bleeding and can manifest as vomiting blood and/or blood in the stool (melanotic stools)

As the saying goes if you hear hoof beats look for horses not zebras. These 2 things would be on top of my list especially in a 32 years with a history of alcoholism.

Question to ask the person do you have history of hypertension what does your BP normally run? "168/102 and pulse @ 118" those are not normal vital signs. Perform through medical assessment and run your diagnostics. Certainly ALS assessment and transport would be warranted if that is what you asking?

You can sit by me.

I would also add anemia and hepatorenal syndrome to his list of possible problems.

I agree, looking at his BP and a report of vomiting blood. Which may likely have been wretching with some bloody streaks if there was no evidence is highly suspicious of a varice.

From the amount of providers who saw him and decided nothing was wrong, sounds like there may have been some social bias in there as well.

 

[Veneficus]

No. Dialysis is for kidney failure only. There is no such thing as dialysis for liver failure.

http://www.ncbi.nlm.nih.gov/pubmed/19788459

Dialysis has a number of uses. Renal failure is only one.

 

[systemet]

Ok so I had a call today for a PT with abd pn and vomiting up blood. PT BP @ 168/102 and pulse @ 118. PT had PN when I palpated his RUQ and LUQ, PT also had jaundice eyes and skin with the shivers. PT has Hx of liver disease @ 32 and PT does not take meds for it due to lack of funds.

Remember this, so that you recognise the potential risk here when you see it again. Your partner's bull:censored::censored::censored::censored: abdo pain became a life-threatening medical problem.

Now mind you nor us or ALS witnessed him throwing up blood so my partner who is in the back calls BS on the vomiting.

This is a completely unscientific opinion. You guys weren't there when he claimed to have vomited, and unless your partner has some sort of clairvoyant powers, you have no way of knowing whether this is true or not.

It's really easy with these patients to see someone in poor health, alcohol, possibly an IV drug user, with hepatitis +/- cirrhosis, and no recent health care, and a vague history, and this that it's not worth your time. You may even be right a lot of the time. But not his time.

Don't beat yourself up over this too much, but realise that there's a lesson here, learn it.

(Everyone, myself included, has done something like this or worse at some point).

I on the other hand can believe this to be true due to my assessment and PT vitals.

You can't really know this either. But it's the most reasonable assumption to make here. He's tachycardic, beyond what you would generally expect for someone who's just had an ambulance pull up. His first reading could be white jacket HTN, but the rapid downward trend, and the third reading argue strongly against this. What is there are several objective signs that the patient might be sick, i.e. tachycardia, HTN, icterus, abdo pain, and a lot of high risk history items.

So we get to hospital and head RN calls BS as well so they put him in the ER waiting room with a convenience bag.

Which is their mistake. But it's worth taking a second to ask yourself whether the manner in which you and your partner treated him, and the report given to the RN influenced his/her decision to place him in chairs.

Come to find out 1 hour later we arrive back to same hospital and the RN tells us he threw up a bunch of blood and they had to call a trauma alert on him because he was at this point to have ruptured his liver. Now my question is on scene would you have sent him with ALS for proper meds or do you feel comfortable with this PT?

Based on your initial description, it would depend on the transport time. If you're in an urban environment, fairly close to the ER, probably BLS. If you're further out, or going to a more distant ER, ALS is definitely a consideration.

In the systems I've worked in, most paramedics wouldn't have issue with taking this patient. Sure, they're just going to get some antiemetic and an IV line, but this isn't unreasonable. If you work in an area with less ALS, standards and expectations might be different.

I honestly would have kept him with ALS especially after seeing his jaundice and shivering with c/c of vomiting blood which all indicate Renal failure.

As others have pointed out, you mean liver (hepatic) failure. The liver is unable to metabolise bilirubin (one of the breakdown products of hemoglobin) adequately, so it accumulates, giving the skin, sclera, etc. a yellow discolouration. The liver's inflamed, giving the abdominal tenderness.

The blood he's coughing up could be coming from a variety of sources, but seems likely to be ruptured esophageal varices. Veins from the GI tract, including parts of the esophagus pass to the liver via the hepatic portal vein. When the liver is diseased, the pressure in this venous system between the GI tract and liver can increase, resulting in distension of the veins, increasing the tension on the vessel walls, and ultimately causing rupture. When larger veins rupture, the hemorrhage can be catastrophic. The small amounts of blood the patient is vomiting are likely due to the rutpure of smaller varices. The patient can lose essentially their entire volume in a matter of minutes.

http://en.wikipedia.org/wiki/Esophageal_varices

The tachycardia and hypertension may represent a combination of pain, psychological stress, volume loss / anemia, and / or some sort of illicit drug use, or alcohol withdrawal.

 

[Veneficus]

This is a completely unscientific opinion. You guys weren't there when he claimed to have vomited, and unless your partner has some sort of clairvoyant powers, you have no way of knowing whether this is true or not.

You could just ask if they cleaned it up, what it looked like, and how long ago.

 

[mycrofft]

Basic anatomy 101

1. How can you rupture a liver? (It's possible, but just asking, and did it relate in any way to these physical findings or history?).
2. And if so, how is it that blood from a "ruptured liver" find its way to the mouth to be vomited out?

(Hint: where does true vomiting originate?)

ans:
1. Liver ruptures are not common and usually occur because of massive blunt area trauma (motor vehicle accident, air crash), or precise very strong blunt trauma (baseball bat swung just right ) and usually also include rib damage. Other factors: a friable (fragile) liver due to gall bladder leakage, cancer, or lethal toxicity. Most of not nearly all descriptions of ruptured thoracic organs, other than vermiform appendices and variceal vessels in the esophagus, are described post-mortem after application of unusual force, or are due to verbal shorthand or lack of education. I imagine there's some rare rural form of worm in New Guinea that does this also, but I've never heard of it yet.*
2. Vomiting originates at the stomach. (We'll, in the brain, but the stomach is the mechanical originator). Find me an anatomic chart with a link from the liver, or the peritoneal cavity, wherein resides the liver) into the stomach.

Most field c/o vomiting blood in persons without liver or esophgeal or stomach diseases are actually coughing resulting in retching and some retronasal blood or some blood from a small ruptured respiratory vein being retched up or coughed up. With hypertension and jaundice plus vomiting blood (let's call it Mycrofft's triad) you MUST entertain a ruptured esophageal varix or varicose as a likely diagnosis and it is a TRUE medical emergency or which you have little to do except get large bore lines established before the pt totally crumps and get to the hospital.


* http://en.wikipedia.org/wiki/Dicrocoelium_dendriticum

OK so it's rare nowadays and not necessarily too exotic.. Eat your mutton well-done.

 

[CBentz12]

Thanks for the vast information that could of been wrong with this guy and I really am looking more into this condition for next time. Im studying as we type and hopefully it will only get better from here on out. As far as the liver rupturing thats what the RN told me when I got back there but your guys explanation of esophageal varices makes complete sense in this case. The ALS company we work with aren't the greatest and there main focus is fire a lot of the times so I'm not surprised they missed this . This all probably started from a drinking problem though especially at his age.

 

[medicsb]

In my opinion, his HR were reason enough to have ALS attend (unless he just got done jogging). Jaundice, liver dz, & hematemesis makes it a slam dunk.

Varices can kill very quickly - I had a "patient" who was alive when he called 911 (for vomiting blood) and dead by the time PD arrived 4 minutes later. Bloodiest scene I have ever been on.

 

[Aidey]

http://www.ncbi.nlm.nih.gov/pubmed/19788459

Dialysis has a number of uses. Renal failure is only one.

Let me clarify. Currently, in the US, there is no dialysis for liver failure that is approved beyond clinical trials.