Post by Tony Held on Dec 10, 2016 16:42:21 GMT -6
Don't Sleep on Sick Person Calls
Street Medicine Sucks – Case Study Series by Anthony Held, NR-P
The Universe taught me a lesson on this one. A very simple change in my practice may have left me looking a lot smarter, and we all like to look smart. More importantly, this change will help you catch a very serious disease that the ER may not even find.
The call: “Father is dizzy and vomiting.” This is really the meat and potatoes of our job. Folks think all I go to are car wrecks and gunshots and dead people. No most of the day consists of people that didn't know what to do so they called 911. I love it. Lots of opportunity to provide excellent care and compassion. Reasons I got into the job. Paged out as a fainting but only because dizziness is lumped into the same dispatch code.
Arrival on scene: Fire department is on scene reporting that the patient is in his mid-80’s, is dizzy and nauseated on his bedside commode, and is experiencing severe diarrhea. Yeah that whole “reasons I got into the job bit”... That excluded diarrhea. Home is pretty normal, not outrageously well-kept, but clean.
Initial Assessment: Patient was indeed found sitting on a bedside commode, expressing his severe nausea, dizziness, and diarrhea. Skin parameters were normal, vitals reported by the fire department were normal, severely hard of hearing (normal per family). Just a sick case. Hey I know it starts boring but there's a reason this one is called ‘Don't Sleep on Sick Person Calls’.
Treatment: Fire department wants to carry this guy to the stretcher. I recommended that we move him however he normally moves so we can determine his deficit, if any. It's really quite important to establish how compromised a patient may be from their normal quality of life. We grabbed his walker, assisted him to a standing position, and helped him walk to the stretcher. We also helped him clean up and get his pants back in order. A little dignity in life really does go a long way in how you feel. Bowel movement in commode is soft but not diarrhea. His gait is weak and shuffling, requiring two people to help him to the stretcher. Family reports that he often needs assistance but not to this degree. Initial vitals: BP 160/64, HR 72, RR 18, SpO2 95%, GCS 15 (but poor historian), BGL 142. Patient is loaded for transport, EKG is here, 12-lead EKG is here, IV is established with 4mg Zofran administered. And off to the hospital of his choice we go.
Let's explore patient history briefly: Family reports a history of atrial fibrillation and nothing else. Patient's wife had been out of state for the past week. Patient identifies his wife as primary caretaker. Clearly patient has some physical deficits in which he would require assistance for most household tasks including bathing, voiding, and eating. His medication list is: Flomax, Lasix, Diltiazem, Lisinopril, Proscar, Warfarin, Catapres, Aspirin, Citalopram. Sure is a lot of medication for A-Fib. The likelihood that he could follow that medication schedule by himself is low. I also find a history of stroke high considering the physical deficit, anti-coagulants, A-Fib, and hard-of-hearing. Probably should have paid more attention to this piece of information right here. More on that in a minute.
Reassessment: BP 198/75, HR 82, RR 18, SpO2 93% (corrected to 97% with O2). Patient slept during latter portion of transport, causing his desaturation. I suspected his drowsiness to fit in line with his general sickness, and the Zofran gave him enough relief to fall asleep.[/i]
Emergency Department: Patient is discovered to have fallen two days ago, and a CT scan reveals a cerebellar hemorrhage.[/i]
Hospital Course: Patient goes to inpatient rehab and spends the better part of a month in a skilled nursing facility. He is then discharged home in better physical capacity than was presented to me as his norm. He also happens to have a set of hearing aids that make it remarkably easy for him to communicate.
So what in the world happened?
The combination of dizziness, nausea, and vomiting is the holy trinity of differential diagnosis. Just about every disease ever discovered or created causes these symptoms especially in the elderly.
The Big Mystery: How does a hemorrhagic stroke mimic a generally sick person? Without a lab result or precise intuition, quite easily. It wasn't discovered that this patient had right leg drift and right leg ataxia until after it was revealed that patient had a fall two days prior to coming to the hospital. So why did the family neglect to give me that information? Was it because I was somehow deemed untrustworthy or cruel? No not at all. It was because I didn't ask. The physician in the ER saw that his patient was anticoagulated, and he simply asked if there had been a recent fall. When the family confirmed this, the physician performed an extremely thorough neuro exam and found a deficit. CT performed the remainder of the diagnosis. Check for ataxia. It doesn't take any extra time.
Lessons Learned: Patient history is king in diagnosing symptoms that could be from numerous sources. Although patient history was poor on scene, having pointed questions to rule out each possibility is paramount. Check for ataxia in your standard neuro assessment.
How to Avoid This Pitfall: Look at incomplete patient histories as a puzzle and find solutions to fill the gaps. The ER identified that this patient had right leg drift and right leg ataxia but only after discovering patient had recently fallen. The following exam would have highlighted this patient’s real problem
Street Medicine Sucks – Case Study Series by Anthony Held, NR-P
The Universe taught me a lesson on this one. A very simple change in my practice may have left me looking a lot smarter, and we all like to look smart. More importantly, this change will help you catch a very serious disease that the ER may not even find.
{The Guts - Click Here for the Quick and Dirty}The Patient: Fainting, dizzy, nauseated, vomiting, diarrhea. Mid-80’s year old male. Alert and oriented, severely hard of hearing.
Initial Treatment: None required, found on bedside commode, skin parameters normal.
Initial Vitals: BP 160/64, HR 72, RR 18, SpO2 95%, GCS 15 (but poor historian), BGL 142
Medical Hx: A-Fib, wife serves as caretaker as patient is physically compromised from unknown origin, uses a walker, has shuffling gait that family reports is normal
Neuro exam:Equal grips and pedal strength, no arm drift, gaze normal, symmetric grimace, speech normal. Shuffling gait
Medication list:Flomax, Lasix, Diltiazem, Lisinopril, Proscar, Warfarin, Catapres, Aspirin, Citalopram
Treatment: 12-lead (A-Fib, bigeminal PVC’s), Zofran IV, transport
Trending vitals: BP 198/75, HR 82, RR 18, SpO2 93% (corrected to 97% with O2)
What Happened?: Patient had a fall two days prior to patient contact and sustained a cerebellar hemorrhage
Lessons Learned: Patient history is king in diagnosing symptoms that could be from numerous sources. Perform an ataxia exam during your neuro assessment.
How to Avoid This Pitfall: Look at incomplete patient histories as a puzzle and find solutions to fill the gaps. The ER identified that this patient had right leg drift and right leg ataxia but only after discovering patient had recently fallen. Adding an ataxia exam to your normal neuro assessment will yield valuable results.
Initial Treatment: None required, found on bedside commode, skin parameters normal.
Initial Vitals: BP 160/64, HR 72, RR 18, SpO2 95%, GCS 15 (but poor historian), BGL 142
Medical Hx: A-Fib, wife serves as caretaker as patient is physically compromised from unknown origin, uses a walker, has shuffling gait that family reports is normal
Neuro exam:Equal grips and pedal strength, no arm drift, gaze normal, symmetric grimace, speech normal. Shuffling gait
Medication list:Flomax, Lasix, Diltiazem, Lisinopril, Proscar, Warfarin, Catapres, Aspirin, Citalopram
Treatment: 12-lead (A-Fib, bigeminal PVC’s), Zofran IV, transport
Trending vitals: BP 198/75, HR 82, RR 18, SpO2 93% (corrected to 97% with O2)
What Happened?: Patient had a fall two days prior to patient contact and sustained a cerebellar hemorrhage
Lessons Learned: Patient history is king in diagnosing symptoms that could be from numerous sources. Perform an ataxia exam during your neuro assessment.
How to Avoid This Pitfall: Look at incomplete patient histories as a puzzle and find solutions to fill the gaps. The ER identified that this patient had right leg drift and right leg ataxia but only after discovering patient had recently fallen. Adding an ataxia exam to your normal neuro assessment will yield valuable results.
The call: “Father is dizzy and vomiting.” This is really the meat and potatoes of our job. Folks think all I go to are car wrecks and gunshots and dead people. No most of the day consists of people that didn't know what to do so they called 911. I love it. Lots of opportunity to provide excellent care and compassion. Reasons I got into the job. Paged out as a fainting but only because dizziness is lumped into the same dispatch code.
Arrival on scene: Fire department is on scene reporting that the patient is in his mid-80’s, is dizzy and nauseated on his bedside commode, and is experiencing severe diarrhea. Yeah that whole “reasons I got into the job bit”... That excluded diarrhea. Home is pretty normal, not outrageously well-kept, but clean.
Initial Assessment: Patient was indeed found sitting on a bedside commode, expressing his severe nausea, dizziness, and diarrhea. Skin parameters were normal, vitals reported by the fire department were normal, severely hard of hearing (normal per family). Just a sick case. Hey I know it starts boring but there's a reason this one is called ‘Don't Sleep on Sick Person Calls’.
Treatment: Fire department wants to carry this guy to the stretcher. I recommended that we move him however he normally moves so we can determine his deficit, if any. It's really quite important to establish how compromised a patient may be from their normal quality of life. We grabbed his walker, assisted him to a standing position, and helped him walk to the stretcher. We also helped him clean up and get his pants back in order. A little dignity in life really does go a long way in how you feel. Bowel movement in commode is soft but not diarrhea. His gait is weak and shuffling, requiring two people to help him to the stretcher. Family reports that he often needs assistance but not to this degree. Initial vitals: BP 160/64, HR 72, RR 18, SpO2 95%, GCS 15 (but poor historian), BGL 142. Patient is loaded for transport, EKG is here, 12-lead EKG is here, IV is established with 4mg Zofran administered. And off to the hospital of his choice we go.
Let's explore patient history briefly: Family reports a history of atrial fibrillation and nothing else. Patient's wife had been out of state for the past week. Patient identifies his wife as primary caretaker. Clearly patient has some physical deficits in which he would require assistance for most household tasks including bathing, voiding, and eating. His medication list is: Flomax, Lasix, Diltiazem, Lisinopril, Proscar, Warfarin, Catapres, Aspirin, Citalopram. Sure is a lot of medication for A-Fib. The likelihood that he could follow that medication schedule by himself is low. I also find a history of stroke high considering the physical deficit, anti-coagulants, A-Fib, and hard-of-hearing. Probably should have paid more attention to this piece of information right here. More on that in a minute.
Reassessment: BP 198/75, HR 82, RR 18, SpO2 93% (corrected to 97% with O2). Patient slept during latter portion of transport, causing his desaturation. I suspected his drowsiness to fit in line with his general sickness, and the Zofran gave him enough relief to fall asleep.[/i]
Emergency Department: Patient is discovered to have fallen two days ago, and a CT scan reveals a cerebellar hemorrhage.[/i]
Hospital Course: Patient goes to inpatient rehab and spends the better part of a month in a skilled nursing facility. He is then discharged home in better physical capacity than was presented to me as his norm. He also happens to have a set of hearing aids that make it remarkably easy for him to communicate.
So what in the world happened?
The combination of dizziness, nausea, and vomiting is the holy trinity of differential diagnosis. Just about every disease ever discovered or created causes these symptoms especially in the elderly.
The Big Mystery: How does a hemorrhagic stroke mimic a generally sick person? Without a lab result or precise intuition, quite easily. It wasn't discovered that this patient had right leg drift and right leg ataxia until after it was revealed that patient had a fall two days prior to coming to the hospital. So why did the family neglect to give me that information? Was it because I was somehow deemed untrustworthy or cruel? No not at all. It was because I didn't ask. The physician in the ER saw that his patient was anticoagulated, and he simply asked if there had been a recent fall. When the family confirmed this, the physician performed an extremely thorough neuro exam and found a deficit. CT performed the remainder of the diagnosis. Check for ataxia. It doesn't take any extra time.
Lessons Learned: Patient history is king in diagnosing symptoms that could be from numerous sources. Although patient history was poor on scene, having pointed questions to rule out each possibility is paramount. Check for ataxia in your standard neuro assessment.
How to Avoid This Pitfall: Look at incomplete patient histories as a puzzle and find solutions to fill the gaps. The ER identified that this patient had right leg drift and right leg ataxia but only after discovering patient had recently fallen. The following exam would have highlighted this patient’s real problem
- Ask your patient to touch the tip of their nose with their eyes closed. Do it right after you have them perform arm drift with their eyes closed.
- Ask your patient to scrape their heel along their shin from ankle to knee. Do this when checking pedal strength.
