Halloween Came Early This Year

"Medic 21, Engine 31, medical emergency. Third party report of an elderly obese female stuck in a door. They are attempting to get her out with a hatchet. No other information at this time." When we arrived, we found a condemned house. We walked inside to find a hoarders paradise with the wonderful aroma of cats. Eventually, we found a very confused mid thirties male passed out on a couch in the basement. He was arrested for trespassing, and we went back in service. The irony is this was not at night, or the week of Halloween. You never know what the next crazy call could be......

The Secret is in the Telling

Recently, I responded to a call at a local plant. It was dispatched as dizziness. I immediately thought this would be a ploy to get out of work. When I walked in the nurses station, I was immediately taken aback by the patient's presentation. In a cool room, he was pale and very diaphoretic. My initial thought was cardiac etiology. The patient did not complain of chest pain. This is possible in some heart attacks, so I obtained a 12-lead. It was pristine. Next I continued to query the patient as to what medical history he had. This provided no useful information. As we moved the patient to the cot he became violently ill. All other vitals where normal. Lung sounds, temp, blood sugar, BP....all inconclusive. I gave prophylactic zofran to stabilize him enroute to the hospital. I continued to talk to the patient. What he told me next took me aback, and put all the pieces of the puzzle together. With the simple phrase, "my ears started to plug up before this happened," it became clear.
His nausea and vomiting where caused by a failure of his Eustachian tubes to drain the fluid built up and caused pressure on the cochlea in his ear. A simple cause of inflammation due to allergy exacerbation. However, the secret was not in the 12-lead, or the physical exam, or even the past medical it was in the telling of a simple phrase. If I had not asked the right questions, I would have arrived without a working diagnosis and could have caused a greater amount of time to occur before the patient condition was improved. The lesson here is that the secret can sometimes be found in the telling.

Your best efforts are not always enough....

One lesson that is always hard to learn in medicine is that despite all the knowledge, diagnostic tools, and medicines at the disposal of the clinician, patients still die. Although there have been other patients that I have not revived in the past, a few weeks ago, I had my first solo "oh $&?!" patient as a paramedic. As I walked into the residence, I was met by a panicked engine company crew and a patient who was in a tripod position on the floor. The patient was spitting up pink frothy sputum and was one word dyspnic. The engine company had already placed the patient on high flow oxygen and had attempted to get a baseline set of vitals. It was immediately apparent that the patient needed CPAP if not intubation.
The patient did not like the idea of a mask strapped to his face, so an online order was received from the receiving ER for Valium. The patient was quickly transported on CPAP. He was so diaphoretic that the leads slid off and I was only able to glimpse a ten second strip that showed elevation in 2,3, and AvF leads. I could not obtain a 12-lead and arrrived in the ER in less than 5 minutes.
The ER doctor immediate ordered RSI (rapid sequence intubation) and I was sent to advise the family as to what was going on with their loved one. It is always hard to talk to families and I found myself, as I have done in the past, made the procedure seem like a routine step and not the drastic step it represented. I quickly had to leave for a possible cardiac arrest call. I came back into the ER several hours later to discover that the patient had coded and died in the ICU. In retrospect, I did everything could in the short amount of time that the patient was in my care. This is small solace, but it is a lesson that I hope never to forget as my knowledge increases, my tools become more complex, and the list of medications and procedures at my disposal grows at an exponential rate in the long journey that lies before me.

"Battalion One to dispatch issue a level one recall for manpower." these words are not often uttered in a department which has multiple mutual aid agreements with other paid departments. This night it would serve as a reminder of the need to place good Pt. care above any drug or piece of technology. While other members of the department dealt with a working fire, myself and three others ran out of the "backup to the backup" ladder truck. On our way to our first call of the early morning, we quickly realized that there were no SCBAs on board. They had been stripped for the HazMat Tech refresher the week before and never replaced. This was a foreshadowing of later events.
Upon our arrival, we found a middle-aged woman lying on the floor complaining of abdominal pain. The patient had just been released from the hospital after receiving a kidney transplant. I opened the medical bag. To my dismay, it was nearly empty. I found a cheap stethoscope, a BP cuff, a penlight, and two bottles of expired sterile water. "What more could go wrong?" I thought to myself. One should never ask that question, both in ones head or aloud. We were then advised that the next closest Medic unit was 84 blocks away. The patient's lower abdominal was rigid and distended, her BP was low and her plus was high. For the next 20 minutes, I talked to her and heard about the amazing life she had led.
By the time the Medic unit had arrived, the patient's vitals had not changed, but her pain was significantly less. As I handed off Pt. Care to the other paramedic, I could not help but marvel about how in a world of modern medicine, a kind word and a listening ear can do so much to help the patient. I hope that I never forget that lesson as I move up the medical ladder. I want to be the practitioner who takes the time to sit down with my patients and listen. Some times the largest lessons come from the smallest gestures.

Your Patient Is Not As They Appear........

Throughout this blog, I will make reference to cases that I have had in the field or in the hospital. For obvious reasons, all identifying information has been removed in order to comply with HIPAA.

The other night, we were dispatched to a possible stroke. When the engine company arrived on scene, they performed a stroke scale and found the patient to have slurred speech and a sluggish right pupil. The patient was also hypertensive and repeatedly pointed to her head. Pt. vitals were as follows 168/92, P 118 Sinus Tach, R 24, LS clear. 12-lead normal.  Pt. was moving her mouth in a repeated manner that had the appearance of "guppy breathing" Pt. has extensive psych history and multiple medications that include Geodon and Ritalin. What would your differential be? We did not transport to the stroke center since the pt. had an inconclusive stroke scale and was know to have a similar episode last week.

Upon arrival in the ER, the physician having seen her before, took one look and knew what was the issue and gave her Diphenhydramine IV. Have you figured it out yet?

The pt. was experiencing side effects from overdosing on her Geodon. The slurred speech, warm and flushed skin, sluggish pupil, and "guppy breathing" were all a result of too much Geodon. The treatment for Geodon OD is 50mg of Diphenhydramine IVP. As soon as this medication was given her symptoms began to clear up. The "guppy" breathing action is called Tardive Dyskinesia ans is a preexisting condition that is exacerbated by Geodon OD. As you can see, the patient may not always fit you differential in the end, thus your patient may not always have the horses their hoofbeats lead you to suspect.