Howdy once again, gang. It's been a virtual madhouse in Atlanta, and we've been getting worked every night it seems. Hardly had time to do any "girl watching" last shift. This work thing is really cutting into my social  life. :(

Here's one that seems simple, but got a little complicated considering the history...Have fun, and a very happy holiday season to everyone!!

NOTE: Okay Basics and Intermediates- jump in here with the first crack at this one! Valerie

Dispatch info: 82 year old female, ground level fall, possible leg injury. 
ALS ambulance is the only unit responding. The scene is safe, it is  approximately 1800 hours, on a mild autumn day. There is no rain, snow,
or other weather problems. Response time is 8 minutes.

Scene: Residential area, patient found lying on the sidewalk, moaning. There are three steps to the front door of the house, and the patient is 
lying at the bottom of the steps. There is a small pool of blood near the patient's legs. Family is standing beside the patient.

Physical Exam: 82 year old female, Alert and oriented x 3 of 4, mild confusion. Skin is pink, warm and dry. 

VS: B/P - 142/94, P - 86 
irregular, RR - 22 and tearful, SpO2 97% room air. HEENT: normocephalic and nontraumatic. Ears and nose are clear. 

Airway is patent, respiratory effort easy with no signs of resp. distress. Abdomen is soft, with no 
palpable mass, rigidity, or distention. The pelvis is stable, without crepitus. 

Lower extremities reveals a open fracture of the right Tibia and Fibula, with minor venous bleeding. Upper Extremities are normal. Back reveals a significant kyphosis (outward curve, or "hunch back,") but otherwise normal. The patient keeps saying she feels fine, and "won't you all please go away." Despite this, she screams in pain every time you touch her right leg. She also screams whenever you try to examine her. At one 
point, while listening to breath sounds, she swings a punch at you, grazing your rib cage.

Medical History: Alzheimer's type dementia, Hypertension, and Acid-Reflux.
Medications: Ativan, Lisinopril, and Zantac.
Allergies: Sulfa

What ya gonna do for this poor, dear, sweet, little old lady?

Let's get it on....
Enjoy,Jeff

a list of abbreviation

   Outcome

Hello everyone. I hope you had as much fun over the holidays as I did. Got      a chance to go home and see the family, and I am quite sure I ate way too  much food, but oh well...

Let's take a second to review what happened in this case, and we'll talk  about what we should do about it.

An 82 year old female fell to the ground, causing a fracture of the right  Tibia and Fibula. Her physical exam is unremarkable except for the open  fracture. 
B/P 142/94, P 86, R 22, SpO2 97% room air. She has mild dementia  and hypertension.

Treatment: I splinted the leg and applied a clean gauze bandage to control  bleeding. We started an IV line (saline lock) and gave 2mg MSO4.
Moved her  gently to the stretcher, and loaded into the truck. Once there, we hooked  up the EKG, just out of curiosity cause her pulse was a little irregular,) 
and it showed a Sinus Arrhythmia. (Nice thought on the A-Fib, y'all.) 
Serum Glucose checked out at 92 mg/dL. Oxygen at 2lpm via Nasal Cannula. 
Transport begun, and I repeated the MSO4 once, giving a second dose of 2mg. 
I also put a ice pack on the fracture. Rest of transport was
uneventful.  B/P remained in the same range, and ther was no change is SpO2.

Falls in the elderly are common. They generally happen for a reason.
As Larry, Bob, and others have pointed out, it can be a result of changes in  center of gravity, combined effects of poly-pharmacy, decreased  proprioception, or any of a number of things. For this young lady, it was a  poor judgement of the distance to the steps. She misplaced her
foot, lost  her balance, and fell. It doesn't have to be a great deal of force to cause  fractures in the elderly, as they have brittle bones and those bones break  easily.

Thanks to everyone for their input. Have a happy new year, and I'll see you  in Y2K+1.

Best,
Jeff

"Which-Came-First?"

Howdy everyone. I hope you had fun with the last case. I know I did. We  had a little discussion about EKG changes, cardiac tamponade, and cardiac  ischemia. 

Wanted to toss in a little plug (I hope Valerie doesn't mind!)  for the following book: 12-Lead ECG - The Art of Interpretation, by Garcia  and Holtz. This is a fantastic book on 12 leads, written by Dr. Garcia and Neil Holtz, Paramedic (Neil is a member of this list, and a close friend.)  Check into the book at www.12leadecg.com You won't be disappointed.

Staying with the medical concept, and also considering I've hit y'all with  trauma recently, here's a good brain-scratching, which-came-first medical  call. Let's see what we can do for this guy....

Dispatch info: 50 year old male, unresponsive, and bleeding from the nose. 
There is heavy rain, it is about 2230 hours, and you are in an ALS 
ambulance. There is a BLS fire engine responding as well. You are three  miles from the scene, and fifteen miles from the hospital.

Scene Size-up: The apartment is on the first floor. There is no danger to  you or the firefighters. The patient is an obese black male, lying supine  on the floor. The apartment is well kept, and the family relates that the  patient was standing in the kitchen, when he suddenly fell over. There was  no witnessed seizure activity, and the family denies recent trauma.

History: Hypertension, controlled with medication. Non-insulin dependant  diabetes. Arthritis. Mild Asthma.

Medications: Lasix, Enalapril, Celebrex, and Albuterol.

Allergies: None Known.

Physical Exam: Unresponsive black male, approx 350 lbs, lying supine. He has snoring respirations, but his airway is open and patent. Radial Pulse present. HEENT: Normocephalic and atraumatic. Pupils equal and reactive, looking upward. Ears clear of fluid or blood. There is blood in the right nare. Mouth is clear of fluid or blood. No JVD. Trachea midline and mobile. Breath sounds clear, irregular resp pattern. Abdomen soft with no masses or rigidity. Extremities have strong pulses, and localize pain. EKG 
shows sinus tachycardia at 125-130, with no ectopy or abnormality in conduction. Serum Glucose (via accucheck) reads > 700 mg/dl (reading of "hi" on the accucheck.) SpO2 is 88% on room air. There are no signs of trauma, drug use, or ETOH consumption. Vital Signs: B/P 180/90, P 130, R 18-42, SpO2 88%, Glucose >700 mg/dL.

Enroute, the patient remains unresponsive, but begins to have tonic-clonic seizure activity.

Well?

Jeff

   Outcome

Hey Gang. Hope you enjoyed the head scratching that this case involved. I know a bunch of trauma-junkies on the streets, but I'll take a good medical call any day of the week.

Luckily for me, the textbooks in my picture did not fall on my head, and I don't have a head injury. Wonder when we'll get to see a current picture of Valerie?

Anyway, let's review:

We've got a 50 year old male, unresponsive, with VS: B/P 180/90, P 120's, R 18-42 and irregular, SpO2 88%, and Glucose >700 mg/dL. We've got a fair drive ahead of us, and it's raining...

Anyone worry over the decision between fluids or no fluids? What about Medications? Airway options?

Here's what I did. Y'all feel free to tell me where I went wrong if you think I was in error...

First, a nasal airway was placed, and this was tolerated well. Oxygen via non-rebreather mask at 12lpm provided, and SpO2 increased to 93-95%. We (I mean we....me, my partner, and four firefighters) picked him up, placed him on the stretcher, and loaded into the ambulance. IV line established with 18G in the left forearm. And we start driving.

I'm getting ready to hang fluids (I'll explain why in a minute...) when he began to seize. Versed 2.5 mg slow IV push did nothing. A repeat dose of Versed 2.5 mg was effective, and the seizure stopped. No change in vitals.

I get the fluids running, infusing it wide open (I gave a total of about 
500mL) and just sat back, watched him, and kept re-checking vitals. The B/P and pusle rate decreased slightly (160/88 and 114) after the Versed, but he continued to breathe, and there was no changed in the SpO2. Arrived at the ER, where he was paralyzed, sedated further, and intubated. They started insulin IV, boogied over to the CT, and later did a angio. The CT was positive for a small bleed (sorry, don't know where exactly, or if it was 
Sub-arachniod, Epidural, or what...) and the angio showed a mild sized Pulmonary Embolus.

So...

Hyperglycemia and the resultant hyperosmolarity can cause 
hypercoagulability. What I think happened is this: His sugar went sky-high (for whatever reason.) Somewhere in his vasculature, he developed (at least) two clots. One went to his brain, one to his lungs. The brain clot caused a cerebral aneurysim, hence the head bleed, and hence the unresponsiveness and irregular breathing. The pulmonary embolus caused his hypoxia, and that hypoxia caused (due to catecholamine release) the tachycardia. Combine that with the head bleed, and that causes the hypertension. And since they all feed upon one another, it's a pretty nasty spiral.

I went to see him about a week later, and he'd been extubated the day before, was still unfamiliar with what happened. He was in a step-down unit after four days in the ICU. He's doing better, and was discharged home after a 10 day hospital stay. He's also taking a few new medications.

Comments?

Jeff

"When doctors start changing things around"

Take a look and see what happens when doctors start changing things around....

History:  61 y/o Male, complains of feeling dizzy when he stands up.  No other complaints, and the dizziness goes away when he lies down.  The patient is found lying on his bed at home, the scene is safe, and your ambulance is the only responding unit.  The patient states his doctor recently changed the dose on one of his medications, but he doesn't know which one.

Past History:  Hypertension, left sided nephrectomy (secondary to trauma 10 years ago.)  No drug or alcohol use.

Medications:  Dilacor XR 240 mg, Tenormin 100 mg, Aspirin, Multi-vitamins.  (Pill count is accurate and appropriate.) 

Allergies:  NKDA

Physical Exam:  Alert and oriented white male, well developed and well nourished.  Skin pink/warm/dry.  VS:  B/P 88/48, P 36, R 18, SpO2 97% room air.  HEENT:  Normal, with no trauma.  PERRL.  Ears/nose clear.  Airway open/self patent.  No JVD.  Breath sounds clear. Heart tones normal without murmur/rub/gallop.  Abdomen soft.  Extremity CMS normal except slightly weakened pulses.  Serum Glucose 94 mg/dL.  EKG shown here  -in a new window 

The patient requests transport to his "usual" hospital, about 30 minutes away.  Your protocols allow full ALS interventions as needed, with Morphine and Valium as "on-line approval" only. 

What is the problem, and what is the solution?

Best,

Jeff

   Outcome
(psssst- Jeffs' New Bio)

Howdy once again, gang.  Thanks to those who gave us input on the Peachtree Case this month.  Let's review a moment, then I'll tell ya what I did.

We have an elderly male who recently had a change in dose of one of his medications.  He complained of feeling dizzy when he stood up, but was otherwise fairly stable.  His ECG showed a bradycardic rhythm, and his blood pressure was slightly hypotensive.

Here's what happened:

I saw this patient, and after the basic assessment, I started looking for rule-outs.  There was no sign or history of recent trauma, nor was there sign of internal bleeding.  While most people who are bleeding will compensate with tachycardia, if the patient takes Beta Blockers and Calcium Channel blockers, this tachycardia may not be present.

I doubted any narcotic involvement, as his pupils were not constricted, he had a normal respiratory pattern, and no altertion in mental status.

He appeared well nourished, well hydrated, and not victim of neglect.

So...I landed on the old stand-by of polypharmacy.  He has only one kidney, remember.  And since Dilacor (a.k.a. nifedipine or Procardia) is a calcium channel blocker that is cleared by the kidneys, I went with the odds and played it as an accidental Ca++ Channel Blocker OD.  IV access, EKG monitoring, and oxygen via nasal cannula.  A fluid bolus of 300 mL was given, and Calcium Chloride 10% 2 mg/kg slowly IV was also given.  His heart rate improved only slightly during transport, and his B/P also increased slightly, but by the time I checked in the ER an hour or so later, he was in a normal sinus rhythm at 68, with a blood pressure of 132/84.  Inotropes were deferred, his repeat 12-lead was normal, and all cardiac enzymes were negative.  Cardiology admitted him for 23 hour observation, and reduced his Dilacor dose by half.  He has not, to the best of my knowledge, had any adverse effects after that.

Glucagon was a good thought if the etiology had been B-Blocker overdose (and it might have been a combination of both the B-Blocker and Ca++ Channel Blocker.)  Glucagon can increase both the rate and strength of contraction of the myocardium, and is generally given in 1-3 mg IVP, every 5-7 minutes to a max of 15 mg.

The use of ASA was also mentioned, and a valid thought.  ASA is cleared by the kidneys, and ASA toxicity could be an issue, though it would not have caused bradycardia and positional hypotension as evidenced in this case. 
But still a good pick up.

So, what do you want for next month?  Trauma? Cardio? Respiratory?  Medical?   OB/GYN?  Let me know, and I'll try to oblige.

Best,

Jeff

 
Heya gang.  I gotta tell ya, that vacation to Florida and New Orleans was about the best thing I've done for myself in a while.  Spending my birthday on the beach in Destin, FL with a rum drink in one hand and a cigar in the the other was cool.  After that, I went to New Orleans for the EMS Expo 2001 conference.  While I generally don't like EMS-only lectures, this was pretty fun.  Dr. Norman McSwain had a great lecture on shock therapy, and Dr. Charles Stewart had another good discussion on hand injuries.  The best part was the chance to network a bit, meet a few folks, and get to know some people.  Only wish I could have spent more time there, but circumstances didn't permit. Jeff

A few side notes...don't forget to:

1) send in your interesting cases for consideration (look for the "Send in Your Case" link on the home page.)
2) Let me and/or Valerie know what you think of the Peachtree cases.  Good or bad, we can take it.  Honestly, we value the input, as it helps us make this site work better for you.
3) Recommend us to a friend if you see fit.

Anyway, enough babble....let's get to the meat of the issue:

Dispatch info:  Male patient, difficulty breathing.  You and your partner are the ALS ambulance crew, and there is nobody else responding.  It is a fine spring day, about 9 am, and you're just a little peeved that this call
came in, as you had just settled down with a cup of Costa Rican coffee andthe Sunday crossword.  You have a seven minute response, and the hospital is about fifteen minutes away.

Scene Size Up:  The house is a single story building, in fair condition.  There are no loose pets or other hazards apparent.  The wife of the patient is waving you down, and shows you to the patient.

Primary:  30-ish white male, kneeling on the floor, coughing very forcefully, and sweating profusely.  Airway is open, respirations appear labored, radial pulse present.  Patient complains of the cough, associated
dyspnea, and pinpoint R sided sharp chest pain.

Secondary:  The patient is Alert and Oriented to person/place/time/event.  His skin is slightly pale, and sweaty.  VS: 148/96, 122, 30, and 90% room
air.  
HEENT: Normocephalic and atraumatic.  PERRL.  Ears/Nose clear.  Minimal JVD.  Trachea midline and mobile.  Breath sounds grossly clear bilaterally, but difficult to fully evaluate secondary to the cough. 
Abdomen soft, with no mass or distention.  Extremities normal, with 3+ motor/neuro/sensation.  No trauma noted, though the patient's wife states he was in a car collision about five days ago, and "bruised his chest."  EKG
reveals a normal sinus tachycardia, with no ectopy.  No significant history,only medications are Ibuprofen and Vicodin (for the "bruised chest," and no known allergies.

Well, what do you think, what do you do, and what more would you like to know?

Best,


Jeff

   Outcome

Guys and Gals, let me tell you about my modem....

I can't begin to describe how much on-line life sucks when your modem gets a jolt from a lightning storm.  Here's what happens:

First, you get these annoying "No Dial Tone" messages.  You hit on the bright idea of taking the handset off the phone base, then clicking "connect."  This works, as the computer then realizes there is, in fact, a dial tone.  It dials, but only connects at slow speeds (19.6 was the best I
could get.)  After that, you think things are gonna be OK, right?  Oh, no, my friends.  You will be connected, but only for a short time...say about 5-7 minutes...before the modem disconnects.  At this point, you get to log
off, shut down your computer (not just re-start, but shut down,) wait at least 30 seconds, and turn the damn thing on again, wait for Windows to do the log-on thing, pick up the handset, click connect, and do it all over again.  For another 5-7 minutes, until you get booted again.  I swear if I had enough string, I'd get two tin cans, string them together, put one in Atlanta, one in Alaska, and send the Peachtree Cases to Valerie that way.  I promise you it'd be quicker.

Today, however, I have installed my NEW modem (with surge protector,) and I'm back....

Here's the results of the Peachtree Case....

We have a mid-30's white male with difficulty breathing.  He presents with obvious respiratory distress and a significant cough.  He was in a motor vehicle collision a week ago.  His Vital Signs are: 148/96, 122, 30, 90%.

My first thought, as was many of yours, was a pulmonary embolis.  The timing, complaint, and presenting condition all pointed at a PE.  I was frustrated that I couldn't get a good listen to the breath sounds, as this guy was coughing way too much, and was in no condition to take a slow
breath.  Such is life sometimes.  Life isn't always good to us medics.

Here's what I did:  High flow Oxygen to start.  I generally don't go straight to a non-rebreather mask, as I like to try and get a handle on the condition first, and then adjust oxygen levels as I think necessary.  But in this case, I just went to the high flow to buy myself a little time.  Got
the guy in the truck, hooked up the EKG while my partner stuck an IV line (saline at a KVO rate,) and sat back to think.  Pulmonary contusion was the one other likely scenario, as was spontaneous pneumothorax.  I switched from the NRB mask to a nebulizer with 5mL of respiratory saline.  My goal here was to calm down the cough, while keeping the SpO2 at a reasonable level, and get the guy in a position where I could LISTEN to the lungs, to rule out
a Pneumo vs. PE.

While transporting, the cough did diminish significantly, and I got the chance to really listen to breath sounds.  They were equal bilaterally, and there was no sign of a pneumothorax.  Whew...one down, two to go.  His
saturations stayed in the middle 90's enroute, and I handed him over with a higher SpO2, a slower pulse, and less respiratory distress.  Stopping by the ER a few hours later, I spoke to the nurse caring for him.  After much
persuasion and a hefty dose of the ol' Jeff-man charm, I found out that he had a spiral CT scan, showing a small right sided pulmonary embolis, with a minor lung contusion.

So if you thought PE, you were correct.  If you thought pulmonary contusion, you were right too.  He was admitted to the ICU floor, and discharged four days later.

Till next month....

Jeff

The Spray Please!

 Greetings once again, dear list members.

Unless you've spent the last two weeks in a cave, on a deserted island, or otherwise out-of-touch with the rest of the modern world, you know of the horrible disasters that have struck New York City and Washington, D.C.  It is a sad time for all Americans, and while we mourn the loss of so many
people, I feel confident that this event will make us stronger as a nation.   That is the end of my political views.  If you wish to discuss this further, contact me off list, and we'll talk.

If you wish to make any sort of contribution, be it money, time, effort, or otherwise, Valerie has many links on her website.  If nothing else, try to say a prayer for those lost, those working, and everyone else involved. 
They've got a long road ahead.

Anyway, here we go with this month's Peachtree Street Case Review:

Dispatch:   
You and your partner (a medic-EMT crew) get sent off to a "man  down, pepper sprayed."  Dispatch advises that the Police Department is on scene, and they have requested a Light/Siren response.

Scene:  
You see about five police cars, and multiple officers on scene.  There is an adult male, approximately 30 years old, sitting on the ground, handcuffed.  There are no other patients.  The police officer in charge
states that the patient is under arrest for assault, public intoxication, and resisting arrest.

Assessment:  31 y/o normal appearing white male, sitting on the ground.  He appears to be rather uncomfortable, and is coughing, salivating, and crying.   He states a history of asthma as a child, no current medications, and no drug allergies.  His VS:  138/90, 112, 22, and 99% room air.  He denies any drug use, but states he has had alcohol today ("Two beers.")

HEENT:  Normocephalic and atraumatic.  Ears are clear and show no fluid or bleeding.  The pupils are Equal and reactive at 4 mm.  The nares are clear except for some mucus.  Airway is open and patent.  There is no JVD or tracheal deviation.  No C-Spine pain or deformity.  There is a fair amount of pepper spray residue on the patients face.

Chest:  Equal chest rise/fall, normal air entry, and no abnormal breath sounds.  The heart beat is a regular rate/rhythm, and there is no murmur, rub, or gallop.

Abdomen:  Soft, non-tender, and no pulsatile masses, rigidity, or guarding.  Extremities:  Normal pulse/motor/sensation to all four extrem.  No signs of fracture.

What do you advocate as the correct treatment?  What are some possible
complications of OC (pepper) spray?  How would you treat those?  Does the fact that the patient is under arrest change anything?  Why or why not?

   Outcome
Well, did we ever reach an agreement on what to do for this fellow?

In case you forgot, our patient was involved in an altercation with the local police, and got a dose of OC (a.k.a. Pepper Spray,) in the face.

He presents as follows: 138/90, 112, 22, 99%. Other than the irritation from the spray, he has no complaints.

Now, while we've all kicked around various remedies for the patient, many of which will work, there is a "right" way to treat him.

OC spray (oleoresin capsaicin) is a oil based compound that is used as a "non-lethal" weapon. Commonly called Mace, it is a chain of proteins in a oil based solvent. It causes intense irritation of the eyes, nares, and mucosa linings. While the effects are usually transient, it can cause some real problems in certain groups of people (particularily those with reactive airway disease such as asthma, bronchitis, and other pulmonary disease.)

Treatment (as recommended by Tintinalli's Textbook) includes "removal of the patient from the area, copious irrigation of the eyes with normal saline, and skin decontamination with soap and water as indicated."

Remember....OC is oil based. Water and oil don't mix well, and pouring water on the patient isn't going to do much (other than make him wet.) I usually wipe the majority of the OC residue off the face with guaze, paying close attention to the eyes. Then a liter of saline, reconfirm respiratory status, and let them go. I've heard anecdotal success with Coca-Cola 
("Coke, no Pepsi" for you old-time SNL fans,) soaked guaze. I've heard of the Baby Shampoo trick as well. Milk, egg-whites, and other home remidies abound. Still, the best and most sure way to relieve the suffering is to do little. Air will help evaporate the active chemicals, soap and water will break the oil base, and time heals all wounds. IF there is bronchospasm, treat as normal with nebulized Albuterol.

Some references:

Pepper spray antidote successful in one emergency department.
J Emerg Nurs. 1997 Apr;23(2):96.

Chemical and elemental comparison of two formulations of oleoresin capsicum.
Sci Justice. 1997 Jan-Mar;37(1):15-24.

Pepper-spray-induced respiratory failure treated with extracorporeal 
membrane oxygenation.
Pediatrics. 1996 Nov;98(5):961-3.

Pepper spray exposure during a carjacking attempt.
J Emerg Nurs. 1996 Oct;22(5):390-2.

Pepper spray for emergency nurses: a hot topic.
J Emerg Nurs. 1995 Jun;21(3):250-1.

Unexpected death related to restraint for excited delirium: a retrospective 
study of deaths in police custody and in the community.
CMAJ. 1998 Jun 16;158(12):1603-7.

Health hazards of pepper spray.
N C Med J. 1999 Sep-Oct;60(5):268-74. Review.


Keep safe, and see ya next month.


Jeff