Would you have ALS'd this patient?

[Ridryder911]

You get the call at 0702 hrs, your shift was over at 0700 (latelate call on your way back from a late call) so your already experiencing a moderate case of the tourettes.

Initially "Alpha" response for a sick call, pt c/o diarrhea.

You enter his apt to find a 74 yo M pt, seated in his LR chair watching the news. He appears a little pale but otherwise no obvious distress. As you approach and ask him whats going on he says the most aggravating thing a pt can say (IMHO), "I don't know."

Me: "Well Sir, why did you call for an ambulance today."
Him: "Something has to be done."
Me: "Okay, what is it you want something done about."
Him: "Two months ago I had a colonoscopy. I have had diarrhea ever since."
Me" "Okay, well have you talked to your regular physician about your onging diarrhea?"
Him: "I told'em in Biloxi last week. They said to go back to my Dr."
Me: "Have you noticed any blood when you go?"
Him: "Nope. Just a lot of poop all the time."
Me: "Are you hurting anywhere?"
Him: "Yesterday, my stomach hurt over here. But it seems a little swolled up. And I lost weight. I used to weigh 220 pounds in October, now I am down to 200."

He goes on to deny CP, SOB, N/V, Syncope. His ABD is SNT in all 4. BBS CTA.

Initial Vitals:
BP 136/91
HR 90, regular
RR 22
SaO2 96% RA

Meds:
Digoxin
ASA
Lortab
Toprol
No allergies

Pt stated Hx: HTN, "Heart Troubles" where his heart regularly "skips a beat or two"

As your partner is arranging things to get the stretcher in, the pt gets up and walks to where the stretcher is, about 6 feet. He appears a little out of breath from the short walk. He admits to feeling a "little" winded.

He doesn't want to go to the hospital that is literally 1 block from his house and 4 miles from your going home point. He wants to go to the hospital that is across town, and 10 miles from your going home point.

Now, would you go ahead and ALS him for a c/o diarrhea for 2 months, or just give him a ride in and have the chart done when you get there?

I will tell you my choice and why after some discussion

As the old saying goes:....."If you asked the question, should I ? Then you should had!..."


There is a true legitimate ALS response here! Hmmm.... lost >20 pounds in < 2 months (Mayday!), SHoB upon exertion, Postitive Cardiac History with an irregular pulse, currently taking Digoxin! ...


Can you say severe electrolyte imbalance, possible Dig tox! Potential cardiac arrest?... Hello..!?

Your Honor, I rest my case!...

....I don't care if they are 15' from the ER! How far is from an ER that a patient cannot arrest on you?...

Chalk it up on experience, and count yourself lucky...

R/r 911

 

[MedicPrincess]

I was wonder what to R/R so long to jump on this. But I am actually impressed at the number of you that would call for ALS, or do it, if your able.

I did ALS him. Took 3 text messages enroute with some teasing about talking patients into transport..... new medic.... the usual.

Now, what caused him to call today? Well he told them about when he was in Biloxi at the VA clinic. They told him to get seen and he was just tired of it.

With the diarrhea x2 months alone and weight loss I was wondering about Potassium, Mag, Sodium.... all those deficienies. But you know, its common for medics to BLS pts that are being transported for "abnormal labs" when the labs that are abnormal are the critical low Potassium and Mag. The Digoxin raised some flags. The weight loss had me a little worried. THe SOB on exertion sealed the ALS deal for me.

It was one of those cases where something in my head told me this wasn't going to turn out well. Call it Murphy's Law.... Its that late/late call, seems fairly simple, an ongoing problem, that no apparent distress patient.... Murphy would tell you this pt will go south on you.

So I told my partner to just get going, Monitor/IV enroute, O2 was in place as soon as he hit the stretcher.... save a little time. Initially, SR with PVC's every 4-5 beats. Pts reiterates that is his norm. He got an 18g RAC with LR KVO. Accucheck was 74.

He began with trigemny about the time I was calling in my report... about 5 out. During the radio report, bijemny ensued.

After the radio report, with hosptial about 3 blocks away, his PVC's went from unifocal to multifocal, and then R on T.... Unconscious and V-Tach followed. (Along with a very long string of tourrets silently and something along the lines of "Oh no you don't!")

Dropped to supine, with the unintentional thump to the chest as I was saying, "SIR!".... and he went back into bijemny and very lethargic. Quick call back to the ER to let them know of the change as we pulled in.....

and quite a bit of the teasing to follow about making my late call "Worth it" and sending my pt into V-Tach.....

 

[Ridryder911]

Glad to see you did the right thing, as well as some aerobic pucker power ...

R/r 911

 

[Jon]

something about his call just strikes me as precipitous...

I'm right with you. Question: What's skin turgor look like? Is the dude dehydrated? I know I'd be with that going on.

I'd likely lean towards having an onscene medic initiate care.... however, if we were BLS, I'd probably just go to the hosptial... because our hospitals are close enough, and by the time I get a medic onscene and give a report, I might as well just have ridden it in to the local ER.

Jon

 

[MedicPrincess]

Glad to see you did the right thing, as well as some aerobic pucker power ...

R/r 911

I get a lot of teasing from the "old medics" about talking to many people into transport and "showing off" and ALS'ing to many patients.... you know work smarter not harder. The funny thing is, on my shift anyway, some of the ones doing the teasing also will throw in the IV and work up the iffy pts as quick as I do.

My poor partner laughs at me at least once per shift. He says he can't tell when I am "freaking out a little" unless he looks real close and sees me chewing on my bottom lip. Apparently his last 2 partners outwardly stressed when things were bad..... I bite the inside of my mouth.... So when this happened all he heard was the "Oh no you don't!" without alot of commotion so he changed to emergency response.

 

[KEVD18]

He began with trigemny about the time I was calling in my report... about 5 out. During the radio report, bijemny ensued.

After the radio report, with hosptial about 3 blocks away, his PVC's went from unifocal to multifocal, and then R on T.... Unconscious and V-Tach followed. (Along with a very long string of tourrets silently and something along the lines of "Oh no you don't!")

so hastings, what would your plan have been here. your bls partent is teching, your up front tooling along sipping on your coffee and he pokes his head up and says he's in v tach.

you dont have a line, no previous ekg and thus no monitor attached. basically your screwed becuase you were being hard headed and lazy.

mp may very well have saved this guys life becuase she had the forsight to see this call going south. on your truck, im willing to bet his family would have planted him.


btw, strong work mp, id work with you any day.

 

[triemal04]

so hastings, what would your plan have been here. your bls partent is teching, your up front tooling along sipping on your coffee and he pokes his head up and says the guy's uncoscious now.

you dont have a line, no ekg at all. basically your screwed becuase you were being hard headed and lazy.

mp may very well have saved this guys life becuase she had the forsight to see this call going south. on your truck, im willing to bet his family would have planted him.


btw, strong work mp, id work with you any day.

Fixed that one for you. Now it's time to pull over, get out, get in the back, and start working up the unconscious pt from scratch. Good luck.

 

[KEVD18]

Fixed that one for you. Now it's time to pull over, get out, get in the back, and start working up the unconscious pt from scratch. Good luck.

strong work on the modifications sir. i was using hind sight where we had that info, but you're totally right. all the hapless basic in the back would know is that the excrement had hit the ventilation device.

now, in this case, the truck was mere blocks from the H. how much of that was luck? they could very well have been miles.

who said something about the distance from an er a patient is allowed to code? was that more or less than 6 blocks?

oh yeah, and you get the distinct pleasure of rolling into an er with a code that you made your bls partner take becuase you didnt want to do the work.....ooops, i mean you wanted the basic to have the experience.

the defendant is charged with negligence and involuntary manslaughter.

"so mr paramedic, you decided to overlook a 20lb weight loss in <2 months, dyspnea on excetion, irregular pulse with a cardiac hx and taking cardiac meds and let a basic tech the call."

"yes, your honor. i wanted his to get some experience"

"experience in what, allwoing patients to die?"

"uuuummmmmm......"

"i find the defendant quilty. your sentenced to 18months in the house of corrections and 1.5 million in damages."

 

[daedalus]

An anecdotal example of a thump to the chest. Very cool.

 

[daemonicusxx]

ALS, shortness of breath gets all the als stuff. so does N/V, zofran.

 

[Foxbat]

Reminds me of one of my first ride-alongs.
We were dispatched for a pt. requesting lift assist only; so we lift this old guy, help him get into bed, he refuses to go to the hospital. In the same time, he looks kind of weak and lethargic; after asking him and his wife about it, our medic finds out the pt. has been like that for the last few days. Medic persuades him to call his doctor who advises him to go to the hospital with us, and he finally agrees.
While en route, he goes into VT (still CAO*4). A typical BLS call, yeah.

 

[KEVD18]

ALS, shortness of breath gets all the als stuff. so does N/V, zofran.

dyspnea on excertion isnt quite the same thing as difficulty in breathing/shortness of breath. im fourty pounds overweight and smoke a pack a day. i have a little doe from time to time and i have only ever needed als once.

but i get what you're saying.