04 March 2010

Medical Unknowns Part II

Maybe this was a bad time to post something needing a reply with everybody at the EMS Expo in Baltimore this week....but let's pick up where we left off.

Just as I walk outside my cell phone rings. It’s the office wanting to know if everything all right. “Don’t mean to be short right now but this guy is kicking our arse…I’m calling the attending now..bye”

Call the ER and just my luck I get one of the doctors who doesn’t particularly like us “para”medical types. I explain the situation to him, tell him what I’d like to do and get shot down mid-flight, “I just don’t like Haldol…just get him here best you
can”, I’m told.

I walk back inside the building and back downstairs and what-do-ya-know, there stands Jim outside the bathroom door, still in his under drawers, just ‘a smiling and looking around at all the attention he’s drawn.

“Hi…how’re you?”, he says to me as I approach him.

“I’m good, how are you?” I ask quizzically

“I’m good too” he says with not a clue as to what’s been going on.

“Ummm, Jim, can I get you to have a seat over here for a second so we can talk?”

“Yep”, he says as he makes his way over to the bench and sits down. He looks down at the monitor sitting in the floor and asks, “What’s that thing?”

“That’s a heart monitor”, I explain to him, “It allows me to take a look at how your heart is behaving…are you having any…..”

“How much you reckon it cost?”, he interrupts me mid-sentence.

Willing to play this out I answer “I’d say around 18 -20 thousand dollars…some a little more depending on the…”

“Phewww, that’s a lot”, he interrupts again and says taken aback by the amount I guess, “how many channels does it get you reckon?”

I realize what he thinks it is and just so I don’t get carried away with the technical aspects of the Zoll M series, I just give him what he wants to know, “Well, this one here gets 12”.

“Phewww…. ours gets about 60”, he goes on obviously talking about the cable T.V. there.

I’m at a total loss here. For the life of me I haven’t a clue about what’s going on. Did a leak solve all his anguish? I know I can get a little bullish too when I’ve gotta go, but I would just let it go if somebody was trying to hold me down to a bench and I had to go that bad.

About that time, two county deputies walk in and look over the situation. “We were told you guys were getting you tails kicked…ya’ll ok?”

Well ain’t this embarrassing now? I spend a second or two explaining what had just happened with the staff trying to butt in at every turn to help recount the incident. They just smile and knod, “We’ve had it happen too” they say. I’m pretty sure they thought I was crazy or something and just left us to our now complacent patient.

I decide I’ll take a chance here at this point to do a proper assessment and ask Jim, “Do you mind if I hook my antenna up to you and see if I can watch channel two?”

‘Ol Jim chuckles a little and grins, “You can try…but it won’t work.”
That old saying, he may be slow but he ain’t stupid…here we have it in real life.

I do a four-lead. My wife and I take the time to explain to him everything that we’re doing. Jim just sits there, straining his neck backwards and down trying as much as he can to see everything were doing.

“Well lookie there…perfect picture…channel two looks good and coming in crystal clear”, I tell Jim while noting a normal sinus rhythm. My wife has also gotten a NIBP and Sp02 which is all in normal ranges. The B/P is a little elevated, to which I attribute to our recent scuffling.

“Awww, that ain’t no T.V. show, that’s just a bunch of lines”, he says calling my bluff.

“But they’re good lines, the kind I like to see….are you hurting anywhere?”


“Any trouble breathing or getting your breath?”


I continue with a full CNS evaluation from the head down, PERL and he can wiggle his toes.…responsive to all commands and no deficits are notable. Not a clue.

I turn to the nurse standing to my right who has since gone to his room and returned with his clothes in obvious anticipation that Jim is going on a field trip, “Do you have all his medications together?”

“He doesn’t take any…just an aspirin every week or so; I think he had one yesterday”, she states.

“Well, I tell you what”, I say directing myself to the two staff members standing there,” you guys go ahead and get him dressed. I’d like to take him on over to the hospital and get him evaluated just to be on the safe side. I don’t see anything obvious and really don’t have any reason to suspect anything specific….but I just want to be sure, for his sake. I’m just puzzled about what set all this off”.
“Oh yes, absolutely, he needs to go”, one states emphatically as if there was a question if I would really take him. Both start fussing about getting his pants and shirt on and making him presentable for his trip to the ER.

Jim stands up, looks around at everybody and says, “Ready?”

Just to be sure, and willing to give the man his due I ask him if he feels like he can walk O.K.

“Yep, come on…this way”. Jim leads off with my partner/wife holding on to his arm, up the stairs and out the door to the ambulance parked right outside.

“We goin’ in that?” he asks pointing his finger along the entire length of the truck.

“Yeah, we’ll sit right back here…I’ll let you lay back so you can take a little nap if you’d like”, I tell him while opening the rear doors and boarding the truck to lead the way for him.

“Phewww, never rode in one of these before”, he says grabbing the hand rails and hoisting himself in.

“Nothing to it, eh?” I get Jim settled onto the cot and I hook the leads and B/P cuff back up.

The trip to the ER is non-eventful and my reassessment unremarkable. We talk about where he’s from and what he likes to do for a while. Jim’s curious about the cars behind us that he can see out the back glass. Over and over he asks why they’re following us, and over and over again I explain to him that they’re not following us; they just happen to be going the same way we are. Then I spend even more time trying to elaborate where they might be going, never really appeasing his curiosity.

Even more was his curiosity about the cost of everything. He wasn’t so much concerned with what it was; he just wanted to know how much it cost, and every time I gave him a ballpark figure he would answer with the same “Phewww, that’s a lot, ain’t it?”

Well, the rides over, Jim’s got to pee again, and we’re going into the ER. Jim is sliding over to the ER bed when he says, “Phewww, my head hurts”.

Oh… really?!?

“Where does it hurt at there Doc?” I ask feeling like goon now that there is a nurse standing there watching and listening to the patient tell me something that no one has mention…and I didn’t ask.

Jim reaches back behind his head with his right hand and rubs gently, “right back here where I hit it when I fell last week”.

Well…well…WELL!! What. Did. Ronnie miss THIS time?!?

I’ll leave it here for the sake of time. But I did find out later that night that he did in fact have a subarachnoid bleed, which of course there was nothing I could do anything about.

He did have to pee, and I think that was a contributing factor to the whole ordeal.

I’m thinking that the fact he woke up and had a full bladder was causing a small fluid overload in the venous system. I further surmise that this increase in venous volume was further elevated when he awoke which triggered the sympathetic nervous system, constricting the veins and thus caused increase ICP to the point where some cognitive function was compromised due to the pressure on the brain. I’m not sure, but I believe the aspirin came into play here as well causing more internal bleeding in a possible unstable clot

I can only see this as a viable option since the symptoms were in fact relieved after urination.

What do you think?

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