Apparently an ALTE

Late one evening my unit was called for an 11 day old baby girl with difficulty breathing. Dispatch provided that the baby may have stopped breathing, and had no prior known problems. When we arrived the fire department was exiting the residence nonchalantly, stating “they baby’s find… This is mom’s first child and she got a little scared”. I walked by them to find mom at the door carrying baby out to the ambulance,  and heard a couple of weak cries from the baby. Mom provided that her daughter is her first child, and was delivered vaginally at full-term without complications. They had breast fed 30 minutes earlier. Then 10 minutes ago baby had coughed severely several times, become briefly limp and “she wasn’t breathing”, was aroused somewhat by stimulation and bulb-syringe suctioning by mom, and now remained depressed.

We examined the child finding that she was breathing, albeit quite irregularly with a sometimes gasping quality, and that she appeared centrally cyanotic with poor tone.  Her airway was notable for moderate quantities of thin clear spittle. Her heart rate was initially just under 100, and her respiratory rate was slightly below normal though with continuing concerning effort. During a brief transport we provided blow-by O2, and continued bulb-suctioning and stimulating. We checked her glucose finding it normal.

By arrival  at hospital baby’s heart and respiratory rate had improved, she was centrally pink, and had an activity level much closer to normal. After I had transferred care, the physician seemed puzzled, almost doubtful, at the contrast between the baby’s nearly normal present appearance versus the more dire earlier appearance the mother and I had reported. The doctor commented, “if what it says in your report is correct than this is a very sick child”. I confirmed that I the baby’s appearance had been every bit as concerning as the signs I had described, and that “I briefly thought we might be starting CPR”.

I later discussed the call with a friend who is a NICU and critical-infant transport nurse. I had seen the phenomena of baby coughing and briefly appearing dyspneic or apneic concerning caregivers (particularly the inexperienced), but those children usually appeared well by my arrival. This patient had stuck me as much more concerning. My friend made the points that:

• This baby suffered what is called an “ALTE“ – apparently life-threatening event, which is distinguished by fright to the caregiver,  and demonstration by the baby of (central or obstructive) apnea or coughing/gagging, color change (cyanotic, pallid, erythematous or plethoric), and poor tone.
• 11 days of age is  rather late for the sudden manifestation congenital cardiac problems.
• GERD is identified in many  feeding or gastric difficulty, though again 11 days is late for most congenital problems.
• This baby was admitted due to very high risk of sepsis, particularly GBS (Group B Streptococcus, pronounced “jeebs“. (I read later that

Past GSWs and Present ECG Axis

We recently ran a 56 YOF with diffuse abdominal pain, n/v, and syncope. Vitals were of little remark. History was most notable for previous (10+ years past) multiple (n=9) gunshot wounds to abdomen and chest. We performed a routine 12-lead ECG. I was struck by the patient’s peculiar axis. Because every frontal plane wave was substantially biphasic in character, she probably counts as having an indeterminate axis. I felt an argument could also be made that she was deep into the right inferior axis quadrant because III (120°) and aVR (-150°) were mildly positive (R wave dominant), and she was therefore right axis deviated. Unfortunately I did not retain the numbers from the monitor (Zoll E) to compare the algorithm’s opinion. I found myself wondering – whichever the appropriate category – whether her abnormal axis could be secondary to the extensive past penetrating chest injury. She detailed damages to her liver, pancreas, and spleen, but was less knowledgeable about which of her thoracic structures may have been damaged from the assault.

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City Ambulance: Seizing deep into the lineup

Dispatched for witnessed seizures by a male in his 50s – we find a man supine on a couch unconscious and breathing, with nystagmus. Family on scene reports PMH includes seizures and alcohol abuse. No present trauma, unknown EtOH or drugs. While moving him to the unit he begins to exhibit clonic activity with inadequate breathing and cyanosis. With suctioning, O2, and 2.5 mg Valium we achieve respiratory adequacy and desisted seizures for transport. At the hospital he resumes status epilepticus with tonic-clonic activity. He receives 3.0 mg of Ativan which has negligible effect, and subsequently a Phenobarbital, which succeeds in breaking the seizure.

Learning point: Barbiturates were once the most common first-line treatment for seizures but have now been widely replaced by benzodiazepines. Barbiturates and anesthetics (typically Propafol) are common used second- or third-line for refractory status epilepticus. Phenobarbital is still the most widely-used anti-seizure medicine globally, and is on the WHO Essential Medicine list (along with Glyburide and Metformin).

City Ambulance: Anything but Epi!?

We respond to a 21 YOF with acute dyspnea. She reports that her throat feels “itchy, closing” after eating a takeout sandwich she believes was contaminated by latex, to which she has an extensive history of allergy. She presents with frank distress, including tachypnea, wheezing and accessory muscle use. She remains fully oriented though conversation is confounded by her respiratory state. Vexingly, she is completely insistent that she cannot take epinephrine, and that she only needs Benadryl. Her rationale for this belief is not clear, beyond the claim that it has always worked in the past, and also, essentially, that her mother told her so. Resolved thus, she carries neither Benadryl nor Epi on her person. We comply with her wishes, treateing with  IV Benadryl, DuoNeb, and bated breath. A university emergency physician who happened to be on scene assisted with care and also helped convey to the woman and her mother that “yes, she has to go the hospital” even though initial treatment led to improvement, and “it’s finally time to get an EpiPen prescription”.

City Ambulance: Not a Taxi

A 21 YOM summons our ambulance for an emergency response in the wee hours of a Saturday morning. He relates to us that earlier in the night he was tended to by another City ambulance  for a traumatic shoulder dislocation, and transported to the university hospital. After being fully treated and released from the ED, he returned home by use of the Medicaid taxi voucher provided by the hospital. His present problem is that he is locked out of his mother’s house, seemingly because her unfriendly boyfriend is there for a sleep over, and “she gotta work in the morning”. He asks us to drive him back to the hospital waiting room, so he can stay there overnight. We assist this young man by using the very cell phone on which he had placed his 911 call, to call an uncle who lives nearby, and to arrange a taxi ride there for him.

City Ambulance: 5 cups of Joe

A gentleman in his early 60s reports that he is miserably unable to sleep, and is experiencing some tremors and palpitations. Self-administration of a Colt 45 has not helped. He reports that he drank 5 cups of coffee in the past 12 hours to make it through a double shift at work. He normally drinks <1 cups of coffee per day. “Do you want to go to the hospital”? “Well no, but can you check my vitals?” Upon doing so we discover the gentleman is running a BP of 220/140. Because he is pending re-qualification at the free clinic he has been out of his blood pressure medicines for over a week. We go to the hospital after all.

City Ambulance: Trazodone OD

 

20s y.o.m. claims that within the past hour he overdosed on 15 x 100 mg capsule of Trazodone, which is prescribed to him  PRN. Pt is alert and ambulatory. No physical signs. Patient denies all present complaints. Denies other substances on board. Vitals normal. PMH: PTSD, depression, also diagnosed with bipolar which he is dubious of. Patient transported in stable condition. Poison Control contacted out of curiosity.

Learning point:

• Trazodone is a seritonin modulator. It is generally well tolerated in moderate doses. Primary s/s to expect are CNS depression, hypotension, and priaprism.

 

City Ambulance: Altered in the Alley

We transported an unconscious but breathing adult male found in a gravel lot at night, exhibiting only a slight bleed to his lip, reeking of alcohol, incontinent of urine. We immobilized and assessed him, and started an IV. He was coming around by the ER without further intervention, but some basic findings prompt me to review:

Learning points:

• Type I diabetics don’t make insulin. Type II diabetics make insulin but resist its effects.
• Diabetic Ketoacidosis (DKA). Absence of insulin (most likely in DMT1) causes body to increase glycogenlysis, raising blood glucose. Of more concern, excess production of “ketone bodies” (β-hydroxybutyrate) resuting from metabolism of fatty acids. This lowers blood pH, increases risk of cerebral edema.
• In the presence of starvation or alcoholism ketoacidosis can occur in the absence of hyperglycemia (the liver already done run out of glycogen).
• Hyperosmolar Hyperglycemic State (HHS, formerly HHNC) more typical of DMT2, as presence of some insulin inhibits lipolysis. Note polyuria and hyperglycemia. Of greatest concern are shock, increased hemoconcentration leading to emboli, and cerebral edema.
• Hyperglycemia in the field is treated with careful fluid bolus in addition to any interventions necessary for hemodynamic preservation.
• Glyburide is a sulfonurea, and works by inhibiting pancreatic β cell K+ channels, ultimately promoting insulin release. It may be the most popular sulfonurea, and is one of two oral hypoglycemics on the WHO Essential Medicine list.
• Metformin is a biguanide, found to reduce cardivascular risk compared to insulin and sulfonureas, and preferable for obese type II diabetics. It is the other WHO Essential oral hypoglycemic.

Periodically: JEMS 01/2012

On the truck:
*** LATE-NIGHT WHEEZER *** An 8 YOF in Las Vegas who presents to EMS with asthmatic SOB has been taking lots of albuterol in the past month. Her inhaler has been depleted for 2 weeks but she has continued on home nebulized albuterol. Nebulized albuterol/atrovent provided by EMS achieves only slight improvement in respiratory status. In the University of Nevada ER the pt receives Xopenex (levalbuterol)  and Pediapred (prednisolone), and improves over the coming hours; “Tachyphylaxis… [a.k.a.] decreased response to a medication that is given over an extended period of time… is common with the sympathomimetic drugs… and the decongestants used in symptomatic cold treatment… [also] does  not occur to the same degree in the anticholinergic agents… [also] can be avoided by switching to a different medicaiton in the same class”; “Standard albuterol solution contains both enantiomers of albuterol (racemic) while levalbuterol (Xopenex) contains only the R-enantiomer”; “administration of corticosteroids will probably not benefit the patient while in the prehospital setting, [but] adding this to the prehospital asthma regimen can conceivably decrease the asthmatic patient’s length of stay in the ED”.

*** INTRAOSSEUS INTRIGUE *** If, and where to drill? David Page reviews 5 recent studies on IO use. Two field-based studies are in disagreement about the success rate of humeral insertion relative to tibial. They confirm the extra importance of securing the catheter well, and acknowledge the improved flow and centrality are worthy considerations when pursuing hypothermic fluid infusion. One hospital-based study found that, indeed, ultrasound confirms that  people with high BMI have more centimeters of flesh to pass before striking bone. Two others suggest that IO can be placed competently on pediatrics by physicians at non-pediatric EDs, by physicians without IO experience on anybody, and that Lidocaine helps if it hurts a conscious patient.

In the agency:
*** ON TARGET *** Recent high-profile cases suggest that EMS workers are becoming victims of unsafe patients at an alarming rate. Many feel that the notion of safety from patients is under-represented or even mocked in our education. The idea that EMS could and should receive more training to avoid, prevent, and defuse such situations is gaining traction. It is recommended that we better appreciate the potential for routine calls to go suddenly bad, develop our verbal de-escalation techniques, secure or abandon the weapons we carry on our persons (shears, knives), and coordinate with law enforcement for “defense and awareness training”.

Across the industry:
*** E-LINKAGE AT LAST *** The COO of a health technology firm reviews how EMS has been integrated into the Health Information Exchange (HIE) system of the San Diego Beacon Project, which recently began its first implementation phase. San Diego is one of 17 Beacon awardees nationally, which receive funding under federal stimulus legislation passed in 2009 with the goal of piloting grounbreaking IT solutions to improve health care quality, safety, and cost. The San Diego HIE is a carefully-designed network with a central server connected to peripheral hub servers for each participating entity, such as hospital or the health department or California’s Medicare program. Or also, in the unique case of San Diego, EMS. Pertinent patient information can now be transferred more seamlessly among these entities according to well-defined “business rules”, and aggregated for a better longitudinal understand of health practices and needs in the region. There is emphasis on supporting a wide variety of current devices and platforms, and flexibility to easily implement future tools. The EMS hub is designed to facilitate two-way data traffic in near-real time. Crews can obtain PMH information from the hub while with the patient, advance transmit not just EKGs but all charted care data to receiving facilities, have billing and demographic information auto-filled on their ePCRs, and the department can receive prompt diagnosis and outcome. Goals are system-wide (improve immunization rates and public health monitoring, decrease needless re-admissions and repeat imagery, save lives and money) and EMS-oriented (improve QA and better integrat EMS into the contiuum of care).

*** AND THE SURVEY SAYS *** UNC Chapel Hill and the National Association of State EMS Officials (NASEMSO) polled all 56 state and territorial EMS offices to compile a comprehensive snapshot of the state of the national EMS industry, gathering data on over 200 information points based on the EMS Agenda for the Future. Results include a state-by-state census of agencies, vehicles, and providers by category. The survey results also quantify states’ varying clinical, communication, safety, disaster preparedness and data collection practices. The full report will be made publicly accessible online: www.nasemso.org

OB/GYN patients: Molar pregnancy, Depo, dysmennorhea

A 21 YOF cc: 8/10 “sharp”” abdominal pain x 2 hours accompanied by mild nausea. PMH remarkable for a molar pregnancy, poor compliance with her “Depo” birth control regimen, and HIV. The abdominal pain located to upper abdomen midline and lower back, no involvment of flanks, qualatatively “deep” yet tender to palpation… Chief D/D? Ectopic pregnancy, PID, endometriosis. Depo-Provera is a long-acting progesterone birth control injection. Molar pregnancy occurs when trophoblastic tissue of the embryo misform into a hydatid mole, a large mass of grossly swollen chorionic villi (a tennis ball made of ramen noodles?). If some fetal tissue remains it is “partial”, and is typically triploid. If no fetal tissue remains and all villi are swollen it is “complete” and is typically comprised only of paternal chromosomes. If not spontaneously aborted these require treatment with oxytocin or curettage. If even part of the mole is left in the uterus there is risk of becoming a metasticizing trophoblastic neoplasm.

A 17 YOF cc: 10/10 abdominal pain. States the pain began when she began her period this morning, but intensified in the past hour. Normal bleeding (no menorrhagia). Of note, dysmennorhea is typically defined as pain with menstruation that interferes with daily activities.