Lost in the STEMI case I posted about yesterday was a weird case from the day before. I don’t have any strips, but I do have a tale of weirdness.
Braving the HIPAA gods I’m even going to post a picture of the patient for you.
I’ll give you the short story, although I’m not sure you’ll believe me.
Dispatched about 30 minutes before the end of the shift to a call less than a mile away. “Difficulty Breathing” as are about 50% of our calls. It’s so common to be a meaningless call type. Whatever, we’ll sort it out when we get there. The BLS crew assigned to the call with us left just before us and then turned the wrong way. Not sure what was up with that, but we turned the right way, drove down a street, crossed another street, drove down another street, took a right turn and were on scene. Neither the BLS crew nor the FD were to be seen. OK, not a big deal.
We grabbed our gear and walked into the house to find the patient sitting in a kitchen chair. He wasn’t having much difficulty breathing, but he wasn’t doing a whole lot of it either. The daughter told a tale of a doctor coming to administer oral Methadone to the patient, leaving, and then the patient passing out. The story made zero sense to us as neither of us had ever heard of a doctor making house calls to administer Methadone. Or much else for that matter. There are a couple of home health services that send doctors out, but not that early in the morning and they don’t administer Methadone.
We sort of skipped that part and asked for a list of medications. Which of course produced the obligatory plastic bag of medications which I took a quick look at.
Of course the mention of Methadone seemed to be a clinical clue, as did the pinpoint pupils and sort of breathing, so we produced a prefilled of Narcan and gave 1mg IM.
So much for the clinical clue. Instead of the expected waking up to a groggy state and the inevitable “Wha happen?”, the patient sort of woke up and started sneezing. And seizing.
It was my turn to ask “Wha happen?” and my partner was just as confused. Then the patient thought it would be amusing to start decorticate posturing on one side only. While still sneezing. We got a quick blood pressure which was something like 260/140. The train was now fully off the tracks and heading for the wall of the station.
No sense in sitting there looking dumb, it was time to move the patient. The BLS crew had showed up while this was going on and we got the patient into the chair and ready for the carry out. At least he wasn’t a big guy.
A family member helpfully pointed out that the patient seemed to be seizing.
Yeah, we got that part.
I took a second to look a the big bag ‘o meds and noted that he had one of each class of antihypertensive meds that can be prescribed in the US. Plus a bunch of renal medications.
“Is he on dialysis?”
“No, but they are getting him ready for it.”
Splendid, as my mother used to say when things were anything but.
Once in the ambulance we put the monitor on the patient and got a rhythm strip, pulse oximetry, and ETCO2 readings. And another blood pressure. Everything was now pointing to some sort of neurological problem, probably an intercranial hemorrhage. Patients are just full of surprises some times.
The debate that ensued was around whether we should intubate or not. I was in the not category and my partner was in the maybe category. Suctioning the airway produced a good bite reflex, so we decided to monitor and transport.
I started an IV while my partner alerted the hospital and gave them as much of the story as we had figured out and alerted them to muster their troops to General Quarters.
Which they did.
We got the patient into the resuscitation room and my partner gave his report. The team swarmed around the patient and started to treat him. They wanted to get his BP down, get his airway secured, and get him into the CT scanner post haste.
I was glad that we hadn’t intubated because the ER staff had to make multiple attempts after they sedated and paralyzed the patient. The resident couldn’t do it and the attending physician had to make multiple attempts.
The neurosurgeon came in and looked at the patient. She agreed with us that it was most likely a head bleed, but where and how severe wouldn’t be known until after the head CT. Well where wouldn’t be known, how bad was pretty obvious.
We left about the time the patient went off to CT and probably the Operating Room afterwards. Not that I think that will do much good, because I think the brain train has left the station.
Through the wall.
A dilemma call; great as a Paramedic, with unforeseen twists and turns, interventions and some mental stimulation, on the other hand someone and their family/friends have to suffer for our job satisfaction.
Any follow up on the patient, especially regarding the “methadone”, and the possible effects the narcan had on the patient? Not accusing at all (seems well within guidelines/protocols), I’m thinking the possibility of opiates/opioids int he patients system was suppressing either the seizure or the symptoms, which surfaced after administering the drug.
And strange about the sneezing…contemplating herniation and pressure on the sneezing bit of the brain?!
The Methadone or whatever it was probably masked what was really going on with the patient. By giving it, we merely unmasked what was going on and brought it to light. Not pretty but probably helpful in the long run. The sneezing was more than likely a result of the cerebral insult, but it was just odd. Unmasking the signs of the brain injury meant that the patient did suffer an unexplained death at home. Who knows, he might even survive and be OK. I’m not particularly optimistic, but odder things have happened.