Hematologic Emergencies/ Pre Hospital Style

[Felix Sanchez]

So I'm in medic school debating about Hematologic Emergencies and was curious to see if any of you had such emergencies where a patient's liver or anything hematological (like sickle cell) might have caused issues while in transport or on scene and it wasn't apart of your original diagnosis. Like a medical zebra sort of. We're debating the current effectiveness of prehospital treatment in these type of emergencies, and if you have a "shudda done it this way" moment, please feel free to share, we can always learn from each other's mistakes.

 

[NomadicMedic]

I’m curious what you believe could be done by a typical paramedic, aside from managing pain and symptoms or attempting to correct immediate life threats.

A patient with a chronic disease that has an acute presentation needs to be managed as an inpatient. Fix what you can fix and take them to the person that can effectively manage the patient.

 

[StCEMT]

The liver issues we come across are chronic. A magic wand to fix those problems did not come with my patch, so no scene playing with that. Take notes, treat symptoms, move on.

 

[E tank]

Way back when (around 1986, I think) my partner and I had a mechanical fall while walking a dog on a Sunday morning with an occipital laceration as a result. Nice guy in his 70's, no loss of consciousness etc. He was taking coumadin and while there wasn't a lot of blood at the scene, there was by the time we got him to the hospital. We dressed his head for a routine scalp injury but not for someone on coumadin. He bled down the back of his neck and we didn't notice just how much until we moved him off of our stretcher.

So what I'd say to you is that the hematologic issues you'd be most likely to deal with are coagulopathies and blood loss. Coumadin isn't the only blood thinner now and a fib isn't the only reason people take them. Falls, car crashes, any blunt/penetrating trauma etc. are made more complex in these patients because severity of injury does't necessarily reflect severity of the circumstances of the injury.

 

[Summit]

Hepatic syndromes are rarely acute acute unless you are dealing with a toxicological syndrome, in which case you can do little in the field, so talk to poison control and transport. Otherwise... transport.

Hematological syndromes typically not acute acute unless it is a manifestation of toxicologically mediated coagulopathy, but then you treat that manifestation for what it is: stroke, AMI, DVT, PE, CVA, GIB/hemorrhagic hypovolemia... or an acute manifestation of a leukopoetic malignancy or immunosuppression which you then treat in the field for what it is: eg SIRS/sepsis etc.

Sickle cell crisis (in SCD/SCT) is a more unique one if you know what it is (the SCD patient usually knows... they may even say "I don't have a spleen anymore")... but it can present so many ways, but usually includes severe pain from vascular occlusion and often also presents with (impending) ischemic insult one or more organs appearing as AMI, AKI, TIA, acute splenic sequestration, or whatever... you can have comorbid infection as a result or a precipitating factor. Folks with SCD usually know what they have and they know that opioids help their pain. Don't treat them like an addict. Treat their pain and transport because potential vascular occlusions need further workup stat, particularly if they say the pain is atypical in severity or location, or they have additional signs/symptoms like jaundice, abnormal EKG, etc.

Altitude note: hypoxia should be corrected. At high altitude we see folks who have SCT but never had an crisis before suddenly in crisis.

 

[NPO]

Prehospital treatment of hematological syndromes is mostly supportive. Correct any immediate life threats, otherwise transport. You can treat pain if you see fit.

I've transported several patients with SCD, who appeared to be in crisis. All of these patients, in my experience, are of lower socioeconomic status and rely on EMS and the ER for primary care (however I believe there is a heavy bias based on where I worked.) I have never had to treat any of these patients beyond comfort care, and they have always presented with chronic complaints over several days, frequently with a recent ER visit within the past week for the same issue.

 

[luke_31]

Prehospital treatment of hematological syndromes is mostly supportive. Correct any immediate life threats, otherwise transport. You can treat pain if you see fit.

I've transported several patients with SCD, who appeared to be in crisis. All of these patients, in my experience, are of lower socioeconomic status and rely on EMS and the ER for primary care (however I believe there is a heavy bias based on where I worked.) I have never had to treat any of these patients beyond comfort care, and they have always presented with chronic complaints over several days, frequently with a recent ER visit within the past week for the same issue.

Same here. I've treated very few SCD patients but they were all low socioeconomic status and didn't have any good insurance to get a good doctor to manage their disease. Granted one of them was also a drug seeker too and used his disease to try and get narcotics. He got banned from several local hospitals for his drug seeking behavior too and his tendency to assault the doctors who didn't give him the drugs he wanted.

 

[Felix Sanchez]

Thank you all for the replies. We definitely went at it in class discussing the efficacy of cardiac dysrhythmias Rx in adrenal crisis such as Addison's and Cushing's and beta-blockers w/ glucocorticoids for thyroid crises, but the general consensus is load and go. My stance is that we don't have the overall (EMS in general) medical knowledge and drug access in those rare cases when being a super hybrid medic-pharmacist could potentially save a life in these circumstances. Like for instance, I believe insulin should be practiced with, yes ****ING DANGEROUS, but in a reasonable world with reasonably well trained medics.. yeah it could work.

 

[Summit]

Same here. I've treated very few SCD patients but they were all low socioeconomic status and didn't have any good insurance to get a good doctor to manage their disease. Granted one of them was also a drug seeker too and used his disease to try and get narcotics. He got banned from several local hospitals for his drug seeking behavior too and his tendency to assault the doctors who didn't give him the drugs he wanted.

It's highly likely he got addicted to the drugs because he was taking them for his disease.

There is a reason SCD patients tend to be of low socioeconomics. First, it is debilitating and that impacts individual and familial economics. Second, it is genetic and the genetics are prevalent in ethnic groups with higher rates of poverty in US society. More succinctly, almost all SCD patients are black, and a few Hispanic. SCD is deadly. SCT, however, makes one relatively resistant to Malaria. And now you see the evolutionary reason for genetic prevalence based on tropical latitudes corresponding to ethnic groups. These ethnic groups originated from regions with endemic Malaria.

 

[Bullets]

We just had a SCD patient today in crisis.

Doesnt take any meds, hasnt seen her haematologist in year due to lack of insurance and money. This is a pretty common thing around here, as i work in an area with a decent AA population. treatment is usually just transport. ALS rarely gets dispatched so they rarely get pain management before the ER

 

[MSDeltaFlt]

There is no such thing as a quick fix to a chronic problem. Treat symptomatically, stabilize, and transport.

 

[rescue1]

Other than opioids and maybe IV fluids for a SCD patient (who are hilariously under treated in EMS), I can't think of a hematological issue that should be definitively handled prehospitally. How are you going to diagnose a thyroid crisis without lab work? Insulin for DKA can be dangerous if you don't know the potassium levels, and it's a slow infusion over hours, not something that needs to be done within minutes.

I think it's good to be educated about this, but I think we should get US EMS up to a good educational standard on common and immediately life threatening diseases before we get all crazy with trying to treat Hep B in the ambulance.