I feel funny.... BLS , but ALS feel free to contribute

[BKinNV]

This is one I had last week...

You are at an event working BLS without transport capability (backpack EMT), standard BLS loadout. Delay for ALS response is 25 minutes, 60 minutes for chopper. Nearest facility is 30 min. away by ground, all Las Vegas hospitals 25 - 30 minutes away by air after waiting for chopper.

Call comes in for a patient who "feels funny" and wanted to get into the AC to cool down. Outside temp is 112 F and 5% humidity.

Pt. presents with chief complaint of transient tunnel vision (which abated once removed from heat) and a flutter feeling in his chest. He is A&O x 4, calm, patent airway, breathing unlabored @ 12 rpm, radial pulse x2 @ 35 strong & regular (but extremely slow), BP 148/85, SpO2 @ 98 on room air, skin pink, cool, and dry, lungs clear and equal BILAT and pt. is neurologically intact.

HPI - onset 15 min prior to call of "funny feeling" and partial tunnel vision. Position/activity change does not provide relief, though tunnel vision abated after removal from heat. Feeling localized to central chest without radiation or referral. Pt. denies description of "pain" and insists on calling it a "fluttery weird feeling" and once called it "slight pressure". No severity score given. Pt. reports allergy to penicillin only. Medications consist of Amlodipine, Losartan, Paroxetine, Terazosin.

PMI - pt. denies any cardiac, stroke/TIA, nor hx of respiratory problems, but admits to high cholesterol, BPH, HTN. Pt. refuses to disclose any further hx.

Approx. 5 min after initial vitals, second set taken: HR 68 RR 12 unlabored BP 140/90 SpO2 97 on room air.

ALS called due, primarily, to the brady HR, but also a "bad feeling" about this guy - response time 25 minutes. Pt. insisted he is fine, does not need an ambulance, and wants to just rest for a while before rejoining group. Pt. is told that he can refuse the ambulance when it arrives but his participation is over until cleared by Dr.

5 min. later, vitals are HR 35 RR 12 unlabored BP 148/96 SpO2 98 on room air.

Pt. is remaining absolutely calm and mentally consistent throughout.

15 min later, vitals are HR 62 RR 12 unlabored BP 146/96 SpO2 98 on room air.

What is your field assessment and what do you do for 25 minutes while waiting for ALS?

 

[NomadicMedic]

Put him in the ambulance and drive to the hospital.

Can't really tell what's what until he's on the monitor. Is that really a true bradycardia or is he throwing bigeminal PVCs that are not perfusing? (That's my guess as the "fluttery feeling" might be those PVCs) At any rate, a HR of 35 deserves to be evaluated.

This isn't a BLS call other than keep him comfy until ALS can take it.

 

[Flying]

Start with an ice pack, towel, and stare of life.

What event? Age? Taken his meds?

 

[STXmedic]

What is there to do at the BLS level? You got him out of the heat, requested transport, and monitored his vitals. That's about all you've got. Well done.

 

[BKinNV]

Start with an ice pack, towel, and stare of life.

What event? Age? Taken his meds?

Sorry - new to posting scenarios...should have included some more info...

64 yo male, event is an outdoor training experience, fairly sedate - not rock climbing or anything, but it's damn hot and damn dry in southern NV. He's from IL.
You can't "drive him to hospital." You have to wait for ALS. Any BLS interventions to be done?

 

[Flying]

Any BLS interventions to be done?

Not really.... Just talk to the guy and try to make things easy for the medics?

 

[NomadicMedic]

Nope. Your best BLS intervention is don't let him wander off til the medics get there.

 

[BKinNV]

Not really.... Just talk to the guy and try to make things easy for the medics?

Exactly right, and two months out of EMT class I was at a loss and honestly, freaking out a bit. O2 contraindicated and I had no other options other than to mentally rehearse what I would do if/when he went into arrest. But here's my takeaway....I got this from Dr. House....after hearing from my friends at the FD what this person's outcome was.

Everybody lies.

Guy had history of angioplasty, stent placement, bilat PE, multiple TIAs and was on a SSRI for some reason (had to look up the generic name for Paxil)- never found out why (but I suspect it has to do with an inability to tell the truth or trust people without a fire department uniform...mine just says EVENT EMS).

When medics showed up, they immediately did a 12 lead. Sinus bradycardia with occasional PVC's. The guy immediately gave the medics the above history that he omitted when I questioned him. Had I heard it to begin with, I would have called the chopper as the local hospital would refuse him and send him to Vegas anyway. As it turns out, that's exactly what happened, he just had to wait longer. The medics called the chopper and he was flighted to a hospital in Vegas where the ER sent him to the cath lab for another stent. Am told he almost crashed on the chopper (that's probably the wrong phrase to use...) meaning he went unresponsive and HR started falling. I didn't hear what the medics did to bring him back, but evidently they were successful!

When he came back to get his vehicle he claimed there was nothing wrong with him and that we "made him take an expensive helicopter flight and undergo a useless procedure." People amaze me.

Another take away - keep pushing for history - especially if you have no options and a ton of time to wait with someone who could be critical. Assume you are only getting part of the truth (if any).

 

[Flying]

Guy had history of angioplasty, stent placement, bilat PE, multiple TIAs and was on a SSRI for some reason (had to look up the generic name for Paxil)- never found out why (but I suspect it has to do with an inability to tell the truth or trust people without a fire department uniform...mine just says EVENT EMS).

The question that makes the call is "Do you want to go to the hospital?" After having traveled from Cornland to NV, he really didn't want to go.

People from out of state are weird, half are fairly compliant and the other half can't die unless if they're at home.

 

[Gurby]

My partner always says, does it fit? Does it make sense? If not, you're probably missing something.

 

[BKinNV]

My partner always says, does it fit? Does it make sense? If not, you're probably missing something.

Touche. Lesson learned.

 

[gotbeerz001]

Even as ALS, I would have likely established IV access TKO, placed pacer pads (just in case) and transported C2. I am not so concerned with trying to figure out everyones lies. If something doesn't add up, I'd ask some clarifying questions and if they continue to lie, so be it. I'll pass my suspicions on to the charge nurse at TOC. I would not fly this guy.

I would expect this guy to end up with a pacemaker.


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[StCEMT]

This was me last week. Asked about history " anything like high bp, blah blah blah?" "No blah" "So whats this (forgotten bp med) for?" "My blood pressure" *that face to the medic*

As far as what you did, that's about all you could do it sounds like. Don't think I would have called a helicopter based on the info you gave though.

 

[Thatoneguy1313]

Forgive potential ignorance, but 62-70 pulse is bradycardia? Just a little confused there, as we were taught 60-100 as normal range.... Unless I am reading it wrong, which is entirely possible.

 

[Flying]

Forgive potential ignorance, but 62-70 pulse is bradycardia? Just a little confused there, as we were taught 60-100 as normal range.... Unless I am reading it wrong, which is entirely possible.

The heart rate was recorded as 35 at some point on top of 60-ish being on the low side.

5 min. later, vitals are HR 35 RR 12 unlabored BP 148/96 SpO2 98 on room air.

 

[Thatoneguy1313]

Ah yes I missed that one, tried to read it at midnight. Also took that first one (x2 @ 35 strong and regular but extremely slow) as being 35 x 2 = 70 as well.

 

[bakertaylor28]

The thing is with this one is you would have the AED ready, because this is more than likely fixing to fly south.

 

[Tigger]

The thing is with this one is you would have the AED ready, because this is more than likely fixing to fly south.

?

 

[bakertaylor28]

?

My line of thought and reasoning here, is that given the fact that this is a brady, I wouldn't expect to see an AVB, otherwise I would expect that the symptomatology would revert, even temporarily, because at least in my experience, AVB's don't tend to go anywhere. My first hunch without an ECG would have been a Brady-dependent Bundle-branch block, although this is much more rare than the tachycardia-dependent variety. of course, we can't rOeally rule out any of the bradycardia's without the ECG- but without one that would have been my hunch. Because we KNOW that Sinus Brady by itself usually doesn't cause unpredictable and intermittent symptoms, we know this PROBABLY isn't an outright sinus rhythm- but rather something else more properly attaches. sure enough though, there were ocassional PVCs. (i.e. something BESIDES Sinus Brady). PVCs tend to make me a bit nervous, personally. Mainly because every time I've seen them regularly Their much unwanted cousin seems to end up showing up to the party. (AKA a run of VT- which could be defined as three or more multiple PVCs) Bottom line- 9 times out of ten- Without having ECG redilly available I'd be keeping the possibility of a code in the back of my mind until you have more specific information, because even in the ACLS sense (yet alone the BLS sense of things) you DON'T want to be collecting equipment AFTER the crap has done hit the fan and your knee deep in something. I'd rather lug out 3 times the equipment I need than not have something I need optimally in the next 30 seconds, which is going to take a good minute to retrieve. Always consider the worst possible case, and then consider worse than that.

 

[bakertaylor28]

Forgive potential ignorance, but 62-70 pulse is bradycardia? Just a little confused there, as we were taught 60-100 as normal range.... Unless I am reading it wrong, which is entirely possible.

Bradycardia is technically defined as anything lower than 50, though depending on the circumstances and context, some people may possibly may begin to show symptoms at rates slightly higher or lower, depending on the other variables at play- most notably the ventricular stroke volume, which can't be measured directly without a cardiac cath, central line, etc.