Fall patient

[Shishkabob]

Seems straight forward, right? Well it threw me through a loop tonight:


You're dispatched to a local nursing home at 2am for a patient who has fallen and is called out as "lethargic" by the nursing home. You arrive to find the patient, a 73yo female, in her bed, and a nurse greeting you with paperwork.

 

[SanDiegoEmt7]

Before the medics arrive, let me try.

What are vital signs? What's her orientation? I can't do EKGs, but since you're ALS does her rhythm look like? Treat trauma for the fall and start diff diagnosis on ALOC?

Alcohol? Eyes pinpoint? any odor of ETOH?
Endocrine/electrolytes?
Insulin? History of diabetes? Last BGL? Breath odor?
Overdose/street drugs or prescribed meds?
Trauma? (Hard to tell if trauma is secondary or primary cause unless it was witnessed, was it?)
Infection? What's her temp? Is the patient on any antibiotics, for previous infection?
Psych? History of dementia? What's her baseline orientation? Any other hx of disorders?
Shock? again vitals?
Stroke? Eyes PERRL? Stroke scale? If she's able to respond, headache/blurred vision/nausea?

History of seizures?


Surprisingly, I get this call pretty often on a BLS/non-911 truck (to my great dismay, damn SNFs) but I always upgrade if its a truly altered person, since I am a lowly EMT

 

[MrBrown]

So exactly how did Nana fall if she is in bed?

 

[Aidey]

Is she on any sleeping meds? Or meds with sedation as a common side effect, like Seroquel?

 

[rescue99]

Seems straight forward, right? Well it threw me through a loop tonight:


You're dispatched to a local nursing home at 2am for a patient who has fallen and is called out as "lethargic" by the nursing home. You arrive to find the patient, a 73yo female, in her bed, and a nurse greeting you with paperwork.

Don't know how this could be a shocker. NH pick up the fallen 50 times a day and only call when compplications surface. Being greeted with paperwork usually means they're worried the resident will crash in their facility. Nobody ever dies in a NH don't cha know, eh??

 

[TransportJockey]

How many times did she fall, how long did she lay on the floor before they bothered getting her up out of bed? Vitals (CBG, PR, RR, SPO2, BP, pupils)? 4 lead and 12 lead? IV. A&O (your assessment not the SNF staff)? History? Meds? Any med changes? Look for extra Fentanyl patches that have been 'forgotten' about (from experience on that one)

 

[Hockey]

4mg Narcan. Shes hardcore heroin addict. Cspine for giggles. Transport monitor vitals, and ABC's.


I win

 

[Akulahawk]

"Weakness & Lethargy" is a very common "complaint" that SNF's use to basically mean "this patient has a problem, we don't want the statistic on our books if there's a complication, you take them and make it someone else's problem".

 

[Shishkabob]

What are vital signs?
What's her orientation?
I can't do EKGs, but since you're ALS does her rhythm look like?

Pulse 50.
BP 130/90.
Resp 16.
SpO2 of 98%
Skin warm and dry.
Pupils sluggish, then not sluggish... then sluggish again... then not sluggish again.
AOx0
Initial GCS of 7-- 2, 1, 4




"Funky" as per the doc at the ER. I see a block, some PVCs, possible BBB.

Alcohol?
Insulin? History of diabetes? Last BGL? Breath odor?
Overdose/street drugs or prescribed meds?
Infection? What's her temp? Is the patient on any antibiotics, for previous infection?
Psych? History of dementia? What's her baseline orientation? Any other hx of disorders?
History of seizures?

No ETOH.
Hx of Type II DM. BGL I got when doing stick on hand-- 117. Ate at 6pm.
Patient takes 10/325 Norco, but was only given one by nurse.
Pt released from hospital in March for Pneumonia... not on any antibiotics, temp of 96.8
According to nurses, patient is usually able to conversate.
No hx of CVA or seizures.

So exactly how did Nana fall if she is in bed?

Here's the funny part--- She'sType II DM with some pretty gnarly diabetic sores on her legs, and the NH claims she's ambulatory. They say they found her near the door (Bed is at the far end of the room)

Is she on any sleeping meds? Or meds with sedation as a common side effect, like Seroquel?

Negative

How many times did she fall, how long did she lay on the floor before they bothered getting her up out of bed? Vitals (CBG, PR, RR, SPO2, BP, pupils)? 4 lead and 12 lead? IV. A&O (your assessment not the SNF staff)? History? Meds? Any med changes? Look for extra Fentanyl patches that have been 'forgotten' about (from experience on that one)

Not known for falls, or when fall occured, but they found her at 0130, and when asked the last time she was normal, they stated they saw her normal at 2200.

No med changes and physical exam is negative on findings.


Some more info--- Patient was initial GCS of 7. She would open eyes when i would say her name, look directly at me, than go back out. The few times I was able to rouse her, I'd ask her to squeeze both of her hands, and she had a weak left hand grip. I'd ask her to do something else, such as move her hand, and she wouldn't. I'd ask her to show her teeth, and she wouldn't. I'd say "Nod your head if you understand me" and she wouldn't.

At other times, she would have a GCS of 3, totally unresponsive, doesn't even respond to pain (trap squeeze and sternal).

 

[Akulahawk]

The HR and low GCS concerns me... I very much suspect that she's not perfusing her brain like she should. She may have gotten out of bed normally, had a cardiac problem resulting in the low HR, then she has + LOC and falls. You might also have been seeing some signs of a head bleed or a concussion.

 

[SoCal]

I'm with ^^ him.

Head bleed, this is a critical call, take over the airway, control what you can and get her to the hospital ASAP.

 

[Shishkabob]

Sorry for late reply... this was my long weekend and pretty much worked and slept.



Yes, I too went straight to "head bleed" after my assessment. The NH wanted to send us to a local hospital, but they didn't have a CT scanner / stroke team, so I called dispatch and let them know I was diverting to a local stroke center. As soon as we got there they whisked her to CT. Sadly I couldn't find out the results as I haven't been back to the hospital yet.


I didn't think concussion because of the weird stuff her pupils were doing, and the fact that at times, she had a GCS of only 3, though when we got to the hospital and were transferring to the bed, she got semi-lucid and started babbling.



First true emergency as a lone medic

 

[mycrofft]

I'm not wading in too deply, here's one toe's worth.

One pupil: trauma or one eye is fake opr a topical was applied to one eye.

Two pupils: pharmacy, or late effect of some sort of intracranial effect (i.e., a bleed not affecting pupils directly had started to somehow compress other ares...which would probably affect other stuff as well. MAYBE some sort of endocrine deal, but I'm ignorant what that could be. Treatment: quick hx, a photocopy of the pt's MAR ("medication administration record", of what meds the pt is on and when they are scheduled, as well as when they actually have been given, or refused, etc.) and tincture of "Gotta go".

Why would the person replying above want to take over airway?

 

[SeeNoMore]

Why take over the airway? Uh hello, because we can. What do you think we are, nurses? h34r:

My guess is because of the GCS of less than 8.But it does not seem like it would help much/at all.

 

[firecoins]

Seems straight forward, right? Well it threw me through a loop tonight:


You're dispatched to a local nursing home at 2am for a patient who has fallen and is called out as "lethargic" by the nursing home. You arrive to find the patient, a 73yo female, in her bed, and a nurse greeting you with paperwork.

Pulse 50.
BP 130/90.
Resp 16.
SpO2 of 98%
Skin warm and dry.
Pupils sluggish, then not sluggish... then sluggish again... then not sluggish again.
AOx0
Initial GCS of 7-- 2, 1, 4




"Funky" as per the doc at the ER. I see a block, some PVCs, possible BBB.




No ETOH.
Hx of Type II DM. BGL I got when doing stick on hand-- 117. Ate at 6pm.
Patient takes 10/325 Norco, but was only given one by nurse.
Pt released from hospital in March for Pneumonia... not on any antibiotics, temp of 96.8
According to nurses, patient is usually able to conversate.
No hx of CVA or seizures.



Here's the funny part--- She'sType II DM with some pretty gnarly diabetic sores on her legs, and the NH claims she's ambulatory. They say they found her near the door (Bed is at the far end of the room)



Negative



Not known for falls, or when fall occured, but they found her at 0130, and when asked the last time she was normal, they stated they saw her normal at 2200.
No med changes and physical exam is negative on findings.


Some more info--- Patient was initial GCS of 7. She would open eyes when i would say her name, look directly at me, than go back out. The few times I was able to rouse her, I'd ask her to squeeze both of her hands, and she had a weak left hand grip. I'd ask her to do something else, such as move her hand, and she wouldn't. I'd ask her to show her teeth, and she wouldn't. I'd say "Nod your head if you understand me" and she wouldn't.

At other times, she would have a GCS of 3, totally unresponsive, doesn't even respond to pain (trap squeeze and sternal).

So the nurse on shift was able to tell you whether thepatient was known for falls or not. usually they say not my patient. I just got on shift. Here is the paperwork and go.

 

[jjesusfreak01]

I am going to research the shift start times for every nursing home in my dispatch region...

First call on my first ride-along was a sick call to a nursing home. We got lucky...there was a nurse who gave us the patients normal mental status, medications, medical history...all of it...good nurse.

 

[Akulahawk]

Why take over the airway? Uh hello, because we can. What do you think we are, nurses? h34r:

My guess is because of the GCS of less than 8.But it does not seem like it would help much/at all.

My guess is about the same. We're constantly advised "GCS < 8, Intubate". I start looking at airway management when GCS is <12. I might not use any airway adjuncts, but I start seriously checking for airway issues at that point. Any noted airway obstruction (like snoring) then I start doing BLS management. Why? It's quick and can show me if the gag reflex is still intact.

 

[ah2388]

whats the quality of this pt's ventilation?

etc02?

It def sounds like a neuro issue, although its hard to be certain(as always) because of the lack of pt cooperation. Prob a good transport decision to take pt to the stroke center.

 

[MrBrown]

I am very worried about the low GCS of this patient.

Lets get going to the hospital and have somebody set up for an RSI just in case.

How long is it going to take people in orange jumpsuits with "DOCTOR" written on them to get here in thier helicopter?

 

[usalsfyre]

Consider airway control, check and see if she's swallowing her own secretions (much better airway assesment than gag reflex). If she seems to be managing on her own ok, then leave it alone. Otherwise, you probably need to be looking at vocal cords sooner rather than later (IF your both PROFICENT and REASONABLLY CONFIDENT you can secure the airway.) Keep in mind RSI drugs in this age group (especially sux and midaz) can have some nasty side effects. Be very careful with the Versed, as if she is having a brain issue, hypotension is the LAST thing you want.

Her vital signs are not terribly deranged at this point, her rate is a little low, MAP is adquated for an ischemic head issue but not through the roof. Maybe a bleed, maybe a ischemic stroke, maybe a cardiac issue with resultant poor perfusion to the squash (you did say her rhytm was "funky"). Are we 100% sure she got the right (type and amount) of medication? I've been on many NH OD's in my career either accidental (med mixup) or intentional (hoarding meds or staff deliberately overmedicating the patient to keep them quiet). Just to throw one more thing in the mix, has anyone been around her when she wakes up?