Sucker!

A couple of weeks ago I went to a shelter first thing in the morning. My shifts start at 0630 and we picked up this call at 0640 or so. We arrived to find a 30-something male with intractible vomiting. There was no gastrointestinal bleeding, but he couldn't stop shouting for his friend Ralph. It was hard to even communicate with him about his basic history and his situation. Being that I am trying to be more liberal with Zofran, and being that he looked sincerely pathetic and uncomfortable, I gave him 4 milligrams intramuscularly.

We were closest to a nearby community hospital, but the patient was adamant about going to the city trauma center. He said he had been followed there for a long time. It wasn't significantly farther to go there, so I was okay with that. On the way to the hospital, the retching and vomiting eased and I could chat with the patient and complete an exam.

He sat on the bench as we drove. He was pale and diaphoretic, but appeared feverish with goosebumps and chills. He was tachycardic (HR 130) but normotensive. He was a little tachypneic, as well, but I attributed that to the recent grandiose emesis. He said he hadn't been feeling well when he went to bed the night before, and woke about two hours ago with the nausea and vomiting. He claimed no medical history (at which point a little voice tried unsuccessfully to tell me how it was odd that he was followed at the city trauma center without any medical problems). There was no diarrhea, but he did have some abdominal cramping so maybe he was saving that for later. 

I got out my laptop and started filling in his demographics. I collected his name, birthdate, and such, and asked if he takes medications. "Methadone," he told me.

Methadone. 

"When was the last time you had some?"

"Two days ago," he answered.

"When are your appointments at the clinic?"

"Everyday at seven A.M." he replied.

I looked at my watch. It was about seven o'clock. The whole picture clicked into place. 

We got to the hospital, the patient crossed the threshold into the ED entrance, and loudly proclaimed that he was respectfully refusing further care. He said it as though it was rehearsed; like he had to say this certain thing at a specific time. He turned around, left through the ambulance entrance, and turned right to head to the methadone clinic next door.

And that, ladies and gentlemen, is how I transported a patient to his methadone appointment. Oh, yeah, I gave him Zofran too. You win some and you lose some...

The Nosebleed

This is not my story, but it made me laugh so I had to share.

An airport medic I work with was assigned to the report of an epistaxis at one of the airline gates. For those of you who aren’t from Colorado, nosebleeds are pretty common due to dry air and an apparent propensity for Coloradans towards forceful and insistent nosepicking. So epistaxises (espistaxi?) are common and not usually a big deal, outside of hypertension, blood thinners, or trauma. We get called because people don’t know how to stop them. Rather than applying pressure by squeezing the nares against the septum, most people go with the dab and check approach. But there are other ways that people try to stop nosebleeds.

This is a lithograph from the 1830s showing a maid attempting to stop a man's nosebleed by putting a key down his shirt. Source

The medic arrived to find a young girl with a little blood on her upper lip, from a minor right nare nosebleed. She was about 10-years old, so blood thinners and hypertension were not a problem. There was no trauma reported. This call looked to be no big deal, except for the whiskey-tango-foxtrot dynamic.

See, she was lying on the filthy airport floor with her arms extended over her head and one shoe and sock off. An airline representative was intently slapping the sole of her bare foot.

Whiskey. Tango. Foxtrot. What in the unnatural f*** is going on here? our hero thought to himself.

The patient’s mother immediately told our medic that his help was not wanted. Mom seemed to be unimpressed with the nosebleed, and didn’t want any more of a scene to be made. The medic is like me in that he wasn’t looking for excuses to inflict unwanted care upon a patient who didn’t need it. But he also knew he couldn’t leave things like this, either. So he vocalized his bewilderment to the footslapping airline worker: “Excuse me. What are you doing to her?”

“Taking care of her nosebleed,” the representative answered without looking up, as though it was obvious. Smacksmacksmack, she continued her work on the bottom of the girl’s foot.

“I am swallowing the blood,” said the supine patient.

The medic definitely couldn’t let that statement pass, so he had the young girl sit up. He cleaned her face up and put a plastic clamp on her nose.

“You’re doing that wrong,” the airline agent told him, crossing her arms irritably. “A paramedic taught me to take care of nosebleeds and that is not the right way.”

By this point, the medic in question was not only confused but also rather frustrated. He asked the airline employee what she was talking about. I can only assume that he asked in a sarcastic manner with barely veiled hostility.

“The paramedic taught me to lie the patient down, put their arms over their head, remove their shoes and socks, and hit each of their feet very hard three times. That way the blood in their body thinks they are standing up and it goes to their feet. If there is blood in their feet, it won’t come out of their nose. But she is only a little girl, so I didn’t want to hit her hard. That is why her nose is still bleeding.”

That's why her nose is still bleeding. Of course.

The point of this story is that one of my paramedic peers told the gate agent that ridiculous and convoluted process to stop nosebleeds. Apparently they told the agent in a serious way, with a straight face.

She. Believed. It.

If you are the one who told the airline rep the hysterically “proper” way to manage a nosebleed: You, sir or madam, are sincerely and deeply awesome. You are my hero. I wish I could buy you a beer for that one…

Just Another Nursing Home Transfer

My partner and I went to visit an elderly gent in a nursing home. According to his nurse,* he has baseline type 2 diabetes and dementia, along with some other elderly-related medical problems. He is normally confused, but is slightly more confused over the last few days. The nurse couldn’t really explain how he was more confused than normal; he wasn't her normal patient and she had just began her shift. I asked more specific questions to suss out his baseline mentation. I found out he would normally know his name, but not where he was or any time-related facts. He was not able to perform self-care like bathing or tooth brushing, couldn’t really follow television shows, and he slept a lot. I didn't understand how his mentation had changed, but I wasn't getting closer to finding out.

The patient was recently reported to have some UTI-type symptoms with a little diarrhea over the last week or so. That, along with a possible mental status decline over the last four or five days, resulted in an order for labs to be drawn. His doctor, upon seeing the lab results, asked that the patient be seen at an ED.

I found the patient to be elderly, friendly, and alert to name only. He looked a little dehydrated to me, in that his tongue was dry and he looked like his skin was chapped and flaky. He was a little sleepy, but he woke to voice and interacted in a gentle, confused way.  The patient was neurologically intact, other than his mental status (which I still didn’t understand how it was different than his demented baseline). There were no odors such as ketones on his breath. His blood pressure was 100/50 with a heart rate of 90, but he was a skinny old guy so I found those vitals to be abnormal but not especially concerning. The man certainly wasn’t toxic looking, if that makes sense.  What I mean is that I wasn’t worried about him dying on the way to the hospital or anything. He wasn’t diaphoretic, tachypneic, or comatose. It was a fairly routine transfer from a nursing home to a hospital.

The pertinent parts of his labs, helpfully labeled with L for low and H for high were: 

• Glucose 964 mg/dL     H (60-110)
• Potassium 3.2 mEq/L     L (3.5-5.0)
• Bicarbonate 18.1 mEq/L     L (22-28)
• Total serum osmolality 382 mOsmol/Kg     H (275-295)
• Anion gap 11mEq/L       (8-16)
• β-hydroxybutyrate (serum ketones) normal      (<0.4 mmol/L)

Do you know what is going on? What is your treatment plan?

I think a gummy bear might have less sugar than 964 mg/dL...
Source

The patient is obviously hyperglycemic. But serum ketones are normal, so it isn’t diabetic ketoacidosis.  This is something else – called hyperosmolar hyperglycemic state (HHS). DKA usually affects type 1 diabetics, and HHS is a complication more associated with type 2 diabetes. There are a bunch of other names for it, like hyperosmolar hyperglycemic non-ketotic coma (HHNC) and hyperosmolar non-ketotic coma (HONK – which sounds like a GI issue, not a sugar issue). I like HHS because it is easier to type and remember.

HHS is usually initiated by physiologic stress such as an MI, stroke, or infection. The stressor results in a relative insulin insufficiency, which allows the patient’s blood sugar to rise. The higher blood sugar results in higher serum osmolarity. Osmolarity is the measurement of stuff (solute) dissolved in a liquid (solution); in this case, the amount of salts, sugars, and such dissolved in blood plasma. In short, the ratio of dissolved solutes in the solution tips towards the solute side, rather than the solution (water/plasma) side. The body tries to correct this situation by urinating out the excess sugars.  The increased urination leads to profound dehydration and volume depletion. In contrast to DKA, ketones don’t form because there is some insulin present in the case of HHS patients.

HHS has been reported to occur in about 1 of 500 diabetic patients, so it is much less common than DKA. It is more common in elderly patients, and nursing home patients are at higher risk. HHS is a big deal: mortality is reported at 10-20% of patients, but the risk of death has been reported as higher than that in some studies. 

Treatment is concentrated on three main problems: dehydration, hyperglycemia, and underlying disease treatment.  Dehydration can be profound in HHS patients. Like, nine liters worth of dehydration, profound. When a person is 9 liters down, I can only assume their blood looks like red motor oil. These patients need fluid resuscitation to help correct the dehydration, as well as the hyperosmolarity that is adding to their problems.  

Maybe honey is a better mental picture than motor oil.
Source

The correction of hyperglycemia is through the use of insulin. Before getting aggressive with insulin, however, the patient’s potassium levels must be assessed. Insulin drives potassium into intracellular spaces, resulting in hypokalemia if the initial level of serum potassium is too low. Finally, it is important to remember that HHS is usually caused by a physiologic insult. In the case here, the patient’s infection probably initiated the hyperglycemic event, but other factors like silent MIs, pulmonary embolism, and CVA should be ruled out or treated. 

In the prehospital setting, treatment for HHS is limited to volume replacement. Most systems don’t carry insulin, and if you do make sure to check the potassium first. Keep in mind, though, that “aggressive” volume expansion means something different for other health care providers compared to field medics. I can get a couple of liters into a patient in about fifteen or twenty minutes, if I am really trying.  Aggressive in this case means more along the lines of a liter per hour. Adding your run of normal saline to deranged blood levels of electrolytes and sugars is probably a complicating factor in the absence of hypotension. So consider some fluids, but maybe take it easy.

So why did I bring all this up? I wanted to point out that I don’t recall ever hearing the term HHS, HONK, or HHNC in paramedic school. My endocrine lecture was probably four hours long, and covered a lot more than just DKA and HHS. I am sure we discussed hyperosmolar hyperglycemia, but it was lost in the fire hose of knowledge from which I was trying to drink. The paramedic text I have on my bookshelf behind me has a paragraph on HHS. It says I should treat it with ABCs, oxygenation, ventilatory support, and fluid resuscitation. Duh.

In your career, you will find that your classroom instruction and paramedic texts are inadequate to your knowledge needs. You should discover that. Take the time to look up conditions, medications, treatments, and other medical information as you come across them. The Google-machine or other search engines are incredible tools. UpToDate is a great program and website, but it requires subscription for most services. Medscape is good too, though. Friggin’ Wikipedia can be pretty helpful. Ask physicians at handoff about their thought process and differential diagnoses (after their initial exam, so you don’t interrupt their work) then look up what you don’t know about. Seek out patient follow-up and research the findings that you don’t understand.

What you learned in p-school is not enough. The case here was just a boring nursing home transfer for altered labs and a possible increase in confusion. We run those jobs all the time, and I work for a 911-only service. But look where it took us. Push yourself and your knowledge base farther.

*I use the term “nurse” in its most generic, loosest sense. I never really have any idea if I am dealing with a nurse practitioner, RN, LPN, CNA, or a random member of the public who wandered in off the streets and likes to wear scrubs.