Tuesday, January 15, 2008

No Clue....

I ran a call last shift and I had no idea what was going on with this guy...

We get called for an unconscious. Dispatch calls us back while en route and says that the patient is now conscious. Upon arrival the patient is a mid-30's male sitting up and talking. He doesn't look as if he feels well, but not in any specific distress.

I start my assessment and found out that he has been having multiple syncopal episodes for more than a week. He had been to see his doctor and had been to the ED and was diagnosed with "Occipital Neuritis". I didn't have a clue what that was, so I started asking questions.

He said that there was something wrong with a nerve in the back of his head and that made him pass out. He was also experiencing severe headaches, sensitivity to light and nausea. The only other medical problem he had was hypertension. His only medication was a anti-hypertension med. He said that he had been diagnosed and treated for the HTN a few years ago.

The reason he had called EMS this time was because he had passed out and hit his head. He had a pretty good goose egg on the side of his head, but otherwise was OK. We obtained orthostatic vitals and there was no change. He said that he had been eating and drinking normally, no bowel or urinary abnormalities, no recent sickness and no recent trauma other than the fall. His blood sugar and 12-lead were also normal.

During all this assessment, he passed out 3 times. At first I thought he was maybe faking. But after a serious sternal rub and an extreme pinch to the web between his thumb and forefinger, I figured he was really out. Plus I've never seen a patient faking and actually smack his head against something hard enough to leave a mark and not flinch. Each syncopal episode ended within 30 seconds and he was not disorientated upon waking up.

We got him to the truck and started a line and put him on the monitor. During transport his headache, nausea and sensitivity to light seemed to get worse. I wasn't sure if it was from his condition or the bumpy/ curvy ride in the truck or both. So I turned off the lights in the back and tried to make him as comfortable as I could. He passed out several more times during transport. His vitals and 12 lead stayed normal during the episodes.

Eventually I have him 4mg of Zofran for his nausea, so he wouldn't puke in my truck and to try to make him a little more comfortable. That helped with the nausea but he still had a lot of pain. I wasn't gonna give him morphine for that and he had already taken 1000 mg of Tylenol before he called us.

We got to the hospital and turned patient care over to the nurse. The doc came in and this is usually where I make my exit but I stuck around for this one. After the doc did his assessment I followed him out and asked him what occipital neuritis was. He looked at me and said that he didn't have the slightest clue.

Since then I still don't really have a clue. I've asked several people and have done an extensive Internet search all with no real answers. So if anyone out there has any information I would be grateful. Since that call a few of my co-workers have run him for the same thing and no one seems to know what's going on...


Thursday, January 10, 2008


Have you ever had one of those calls that you wonder about? You know, the ones that you're not sure if you did the right thing? I have them every once in a while. This is one that happened a little while back.

We get called out for a difficulty breathing. We get there and there is this 50-ish year old male sitting up and talking. He has a home health nurse and she is there giving us the report on why she felt it was necessary to call us.

The patient in question had a history of stomach cancer, COPD, hypertension, recent pneumonia and a productive cough with green tinged sputum. He doesn't seem to be in any distress at the moment. The nurse said that he had been suffering from dehydration and she had started an IV and had been administering fluids. That is apparently when the trouble began. The patient started getting short of breath and anxious. So she stopped the fluids and discontinued the IV.

The patient didn't want to go to the hospital, but apparently trusted his nurse and wife and various other family members on scene, and decided to take the trip to the Big City Hospital down the road.

We put him on some O2 and get him loaded up. His vitals were within limits, O2 saturation was good and his lungs had some diffuse congestion throughout all quadrants. 12 lead and capnography were both normal. I started an IV just for precautionary measures and kept it at a KVO (Keep Vein Open) rate. He still said that he felt fine and he didn't seem to be in any distress.

On the way down, I do a little more detailed exam and find that his ankles and abdomen are swollen. He says that this is normal for him from time to time. His abdomen has some bruising and he doesn't know why. I take another look at his medication list and he isn't on any blood thinners or diuretics.

He still says that he feels fine and I have to agree that he does not seem to be in any distress. He says that he is a little tired and just wants to sleep. So I lay his head back and turn down the lights so he can take a cat nap for the remainder of the trip.

That is when I notice the JVD (Jugular Vein Distension). I put the puzzle pieces together and come up with pulmonary edema. I take another listen to his lungs and still only hear ronchi or congestion. I was taught that if you have the patient cough while listening then the sounds will clear and then return if it is ronchi, besides the obvious sound difference between ronchi and rales. Well, this is what happened when I had him to cough.

This is my dilemma; his pedal and abdominal edema, JVD and the fact that he started having trouble breathing when he was getting IV fluids all point to pulmonary edema. The other half to the equation was that he wasn't having any trouble breathing, he wasn't anxious, his blood pressure was normal and I didn't hear any fluid in his lungs. The blood pressure and heart rate I could explain away on the beta blockers he was taking to control those very things.

I didn't treat him with anything other than O2. He made it to the hospital fine and never once displayed any signs of respiratory compromise. But I have wondered since then if I shouldn't have treated him. Maybe he did have edema and I just mistook it for ronchi. Who knows? But I still wonder...


Thursday, January 3, 2008

The High....

I have had lots of different experiences in my life, lots of different highs. From smoking pot in high school, to jumping out of a perfectly good airplane at 15,000 feet, to scuba diving, white water rafting and rock climbing. Other than my son being born, I would have to say one of the biggest highs I've ever had is simply being a Paramedic.

I think that is probably the biggest reason that we all get into this line of work and stay for any length of time. Sure, you can tell people that it's helping people, but all of us love to race down the road to some trauma that sounds nice and juicy. We are all adrenaline junkies at heart.

But the other side of that is just the job, the ability to actually reach people. The other day was just another day. I was working, as usual, with an EMT. He was just about done with his Paramedic, but other than clinicals, he had no experience above a Basic EMT. But he is the type that I love to work with. He likes asking questions and actually welcomes constructive criticism.

I've found that I love to teach. I don't know a whole lot, but what little I do know, I like to pass on to those that actually want to learn. I love it when the student gets this look during our conversation. You know that look, the one where you can almost see the neurons firing inside his head and the light bulb burning brightly.

The other part of the job is just being nice to people and seeing their response. I had two ALS patients last shift. One was a difficulty breathing and the other was chest pain. Both were elderly and had extensive history. Both were terrified of what was happening to them. With kind words and gentle touch, I think I eased their fears just a little. Or maybe it was just my imagination. But both patients seemed more comfortable and relaxed. I always pat a shoulder or shake a hand and tell them I hope they feel better soon and that they are in good hands as I leave them in the ED. I got what seemed like sincere thank you's from both of those patients.

As I left the ED from both patients I had a spring in my step and I felt good. I've read that it costs nothing to be nice and that you get out of something what you put in. I believe it. It was also an excellent teaching experience as I found out later. The EMT I was working with is part-time so he works with many different medics. He commented on my hospitality towards my patients and told me horror stories that we've all heard on how some medics treat their patients.

I told him my philosophy on attitude in EMS:

Always be good to the first responders. They are, for the most part all volunteers, so at 3 in the morning, when the blood pressure that they give you is completely wrong, don't berate them for it. Just take it in stride and thank them. If one of them is in your way, be nice and ask, don't tell, him/her to please step aside, and always listen to what they have to say. Just as our patients are different when we roll them into the ED, sometimes the patient was different when they arrived as to when we arrive. You never know when you are gonna need their help, so don't piss them off and always say thank you for whatever help you do get. Even if they didn't do anything more than just show up.

Always be good to your patients. It is their emergency, no matter how mundane it seems to you. They felt is was bad enough to call 911, so it is worth your time to be there. You are getting paid to do a job, not brow-beat people for their decisions.

Always be nice to the nurses, at all the facilities and the ED. This is something that I have figured out recently. Most people in EMS hate nursing homes. I have no love for the places myself, but the people that work their are not all lazy and ignorant. Someone has to do the job, and I sure as hell wouldn't want it. I've realized that if you give them your attention and listen to whatever it is that they have to say, they remember you and eventually you'll start to get better reports and have plenty of help when you need it. And again, always say thank you for whatever help you get.

Always be nice to the dispatchers. I hear people giving them hell all the time for wrong addresses and cross-streets and wrong dispatch information. This is another job that I wouldn't want, but someone has to do it. Just be nice and take it in stride. These people can always find a way to make your life a living hell if you piss them off.

So the words are, be nice. Eventually it will all pay off in the end and it will make your life and your shift much easier. I've read EMS books about this type of subject and I've seen a few medics that live and work this way. I learned from them and I try to teach that to the ones that I can. That is my high...