August 15, 2015

Just What He Needs. Another Problem...

A few years ago, my partner and I were sent on a non-emergency response to a cheap residential hotel-apartment-type place on the report of a seizure. In my system, when a patient has a history of seizures but has stopped seizing it is not usually an emergency response. In any case, we arrived and were met by the building manager. On the way to the third floor of the other side of the building (because of course that is where the call is), the manager explained that he had let himself into our patient’s room to do some maintenance. He found the patient on the floor having a seizure. (This is the kind of place where one could reasonably expect the manager to be able to recognize a seizure. This wasn't his first rodeo.) The manager’s description of the activity certainly made it sound like a generalized seizure.

We arrived to find that the patient’s room was big enough for a bed, a television, and a hotplate. There were a pile of clothes in one corner and a pile of empty liquor bottles in another. Let's just say the maid hadn’t been to this room in a while. The patient was a male in his late thirties, but looked like he was older. He was supine on the wood floor, and he had indeed stopped seizing. His eyes were open, but he was unresponsive to any stimuli. His skin was pale but dry. There was circumoral blood and an old puddle of bloody vomit next to him. There was also bloody diarrhea in his drawers. After checking for other clues in the apartment (I found a half-full bottle of Seroquel and no other meds), I got to work setting up extrication (a probable hassle due to the previously mentioned frankly bloody diarrhea) and my partner palpated a quick set of vitals: 80/p, with a heart rate of 80 and a deep, sonorous respiratory rate of 22. We placed a nasal trumpet to stop the snoring (successful), moved the patient to the pram without getting anything on me (successful), and moved to the ambulance (also successful).

So where were we? Seizure, check. Gastrointestinal bleeding, check. Hypotensive, check. Unresponsive, check.

In the ambulance, my partner began working on an IV line while I placed a 12-lead and pulse oximetry. During the IV placement, my partner checked the patient’s blood sugar and found it to be 488. I didn’t find any sign in his room that dude was a diabetic. Another issue for the patient to overcome, check.

The patient was satting at 100% via the non-rebreather mask and the NPA and I got this 12-lead:
The quality is not good on this ECG, but you can still see what you need to see.  Click to enlarge

When I saw it, I said aloud: “Oh, that’s good. Just what he needs. Another problem.” My partner glanced up from taping down the IV line and recognized the significant finding, as well. 

Do you see it?

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