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Home > Topics > Medical / Clinical
December 11, 2013
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Sticking to the basics
by Patrick Lickiss

Clinical scenario: Man down

A homeless male is found lying on the sidewalk — what’s your treatment plan?

By Patrick Lickiss

Editor's Note: Post your diagnosis in the comment section below, and the person with the best answer will receive one of our exclusive EMS1 Challenge Coins!

“Medic 7, pre-alert. Respond to the bottom of the Interstate 176 overpass above 5th St. We’re on with the caller now, more to follow.”

Before hearing anything else, you and your partner both have a good idea of what you’re responding to. This overpass is frequently used during the winter by the area’s homeless population to keep warm. The weather has been cold, in the 20s at night, and call volume for transient patients has increased.

“Medic 7, an update. Caller reports an approximately 50-year-old male lying on the sidewalk along 5th St. Caller is no longer on scene. This will be a Priority 2 response.”

You are flagged down by two men standing near a third lying on the sidewalk. All three are dressed in multiple layers. You slip on your jacket and hat and step out of the ambulance. Your partner grabs the jump bag from the vehicle as you walk up. “What seems to be the problem today?” you ask.

One of the men standing replies “George is pretty sick; he’s weak and can’t walk.”

You kneel down next to the patient and introduce yourself. George makes and maintains eye contact following verbal stimulus. Although he seems lethargic, he is able to answer your questions. He reports a recent upper respiratory infection and confirms that he has been feeling weak. He has had increasing pain in both legs for several days as well.

George reports a history of hypertension and diabetes. He does not regularly take medications for either. His blood pressure is 152/98, pulse is 116 and respiratory rate is 22. The pulse oximeter is unable to measure a reading.

Your partner brings over the stretcher and you lift George onto it. As you wheel it to the waiting ambulance, ask yourself:

What is your working diagnosis?
What treatment options are you considering?
Does the fact that your patient is homeless present any special challenges during assessment and treatment?

Let us know in the comments, and stay tuned for the conclusion of the case next week. 

Comments
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Rickey J Wilson Rickey J Wilson Sunday, December 15, 2013 2:15:51 PM Treat for hypothermia. Oxygen 3by nc, passive rewarming at first. Bgl, temp, 12 lead , baseline vitals. Iv access. Continue to obtain sample & opqrst hx. Physical exam extremities look for frost bite or circulation issues. Transport to trauma center that has ability for active rewarming if required. Watch 12 lead for u waves post hypothermia.
Jimbo Wood Jimbo Wood Sunday, December 15, 2013 2:34:52 PM Baseline VS, passive rewarming, auscultate lung sounds, (suspect pneumonia,) O2 prn, IV x 2 (a-box) monitor, 12 lead, FSBS, assess for cold injuries to extremities, transport to closest, most appropriate ED.
Chris Brennan Chris Brennan Sunday, December 15, 2013 2:37:45 PM assuming that George consents to treatment, and scene was safe with appropriate BSI. We would load George and get him in the ambulance. head to toe assessment for signs of frost bite, get him under some blankets and turn up the heat. Get a Dstick and IV established with ambient temp fluid running KVO at first. 12 lead ECG, asses lung sounds. Working Dx of hypoglycemia and hypothermia. Depending on results from 12 lead and D stick treat with D50 and warming. Special consideration for homelessness would simply be caution to blood pathogens and most likely multiple layering of clothes. Also may have poor history recall. Pt. is sick and would need transport to hospital, may qualify for priority transport depending on the results of further assessment.
Colton Peavler Colton Peavler Sunday, December 15, 2013 2:55:03 PM I want to treat for hypothermia and get a blood sugar on him. Hook up a twelve lead and get a pulse ox reading once i get his fingers warm enough to get a reading. I believe this is a case of hypothermia along with a possable diabetic emergency. I would get an IV going and get a set of vitals.
Matthew Cristea Matthew Cristea Sunday, December 15, 2013 4:08:40 PM The following is done at the EMT level: Start with BSI, scene safety and P.E.N.M.A.N. Check patient for responsiveness and consider c-spine precautions if trauma is suspected. Check the patient's airway, breathing, and circulation, and provide O2 via NRB at 15L/min, in case the lethargic behavior is cased by hypoxia. Once you are done with the primary assessment, move the patient into the ambulance, in order to removed him for the cold environment, and treat for hypothermia. Conduct a head to toe assessment and obtain a set of vitals. If allowed by local protocol, check the patients blood glucose level. If the patient is hypoglycemic and if the patient isn't to lethargic, administer oral glucose. Since the pulse oximeter is unable to measure the O2 saturation, assess the patient for signs of hypoxia and treat accordingly. Transport the patient to the nearest appropriate facility and monitor while en route. The patient may be developing pneumonia as a result of the upper airway infection. Consider the use of masks and eye protection.
Bob Peavler Bob Peavler Sunday, December 15, 2013 4:19:05 PM This could be hypothermia but could diabetic kytoacidosis as well given the pt. Has been sick, our treatment baseline vitals, CBG, 12 lead, O2 and rapid transport.
Terri Christy Terri Christy Sunday, December 15, 2013 4:46:59 PM Making sure the scene is safe and BSI is on. Remove patient from the environment and into the back of the warm ambulance. Give O2 via NRB 10-15L/min could be pneumonia, but could also be TB. Listen to lung sounds find out if he has had a productive cough. Get a IV. Check glucose, if low treat with D50. Obtain EKG, temp, cap refill. Recheck vitals. Do a good physical exam and SAMPLE. Leg pain could be from diabetes, hypothermia, or disecting aorta. If patient hasn't been drinking fluids, give him a fluid bolus for dehydration. Treat any symptoms as they occur. The only challenges with the homeless would be the lack of medical care, so a relativly minor medical problem has the potential to snowball.
Tyler Thorsten Tyler Thorsten Sunday, December 15, 2013 5:14:09 PM I'm still quite new to this but I'll give it my best shot. I have to do a bit of profiling, since I can't just ask the patient about it. First, I assume George is a cigarette smoker. I base this on the prevalence of smoking among the homeless demographic, his hypertension, and the recent upper respiratory tract infection (though not a very good indicator), and it supports possible reasons for some of his symptoms. I am going to assume his smoking has scored him a nice case of COPD. I'm going to assume his COPD was exacerbated by his upper respiratory tract infection. I'm going to venture a guess his infection has developed into a mild sepsis, however his blood pressure is mighty high for that, and I do not know his body temperature (which is still an unreliable factor due to the very cold ambient temperatures). Either way, he has the signs/symptoms to support that bit, and these circumstances are the most likely cocktail of ailments leading to this overall set of symptoms as far as I know. I will also venture a guess that his COPD partially explains the pain in his legs, caused by edema. Now, the diabetes are my explanation for his high BP, in spite of the sepsis (which should be lowering the BP), and it is adding the rest of the pain to his legs. If George had been sick recently, he probably wasn't moving around a whole lot, meaning his legs weren't circulating lots of blood. His lack of insulin intake makes me think that he has way to much glucose built up (especially after a week of inactivity), causing his hemoglobin molecules to become glycalated, which makes the blood thicker and more clot prone. This is another spot where the diabetes and COPD effects tangle and compound. Peripheral Artery Disease is linked to COPD, so my guess is that the PAD (from COPD) and the glycalated hemoglobin (from diabetes) are compounding to cause major lack of circulation in his lower extremities. This explains the weakness, increasing pain, and inability to walk. On top of that, in both type1 and type 2 patients, diabetic ketoacidosis can develop as a result of infection. His recent infection makes me concerned that he is experiencing ketoacidosis. On top of those things, it is likely that George is hypothermic. If this is the case, his lack of circulation in his lower extremities will worsen as the body shifts blood closer to the heart, lungs, and brain. Lethargy is probably a result of both diabetes and hypothermia working together. The resp. rate is probably part sepsis, part diabetic ketoacidosis, and part COPD, all working together, though his rate isn't THAT high, just pretty elevated for someone who has been laying pretty still for a week or longer. The non-reading pulse oximeter makes me think he has poor perfusion secondary to hypothermia. I was skeptical of whether George might have hypothermia or not, but I believe that piece of information fills in the blank. Lots of conflicting findings overall, but I think it is just a complex intertwining of all those conditions. I would start by bringing George into the ambulance where it is warm. While en route to a hospital, I would prick his finger to check his glucose levels. It sounds like I should have a dose of insulin ready. If I am not doing this, the hospital should when they take blood to do bloodwork for his sepsis. I would start an IV line or two to prep for treatment for sepsis/ septic shock as well as ketoacidosis. Be careful with fluid temperature. BE EXTRA CAREFUL NOT TO PUT TOO MUCH VOLUME IN HIS VASCULATURE! Blood pressure is already pretty freakin' high so we have to be careful. One IV for broad spectrum antibiotics. One IV for saline fluid replacement/continued perfusion if he suddenly loses BP (although fluid replacement is kind of ineffective for septic shock, the same treatment is given for ketoacidosis anyways). I'm not sure about administering oxygen to COPD patients, but George doesn't appear to be in a hypoxic drive so I would probably give him supplemental oxygen if my partner doesn't object. The hospital should handle the rest. If I am right about sepsis, be prepared for anything as far as BP goes, as his diabetes will mess with blood pressure, and we don't want George falling rapidly into septic shock because we are led away from that diagnosis by the high BP. By that point, we might not have enough time! I would be worried about any toxicity in the blood from the likelihood of tissue necrosis in his legs. George must be treated for the UR infection to ensure the sepsis goes away, and in turn the ketoacidosis should hopefully follow. The patient's homelessness only slightly complicates things. His many layers of clothes will prevent analysis of his legs/ other areas, and I'm sure he would object to cutting them off. The biggest complication I can think of is that George is likely to be hypothermic, throwing off a number of my clinical findings, which could potentially cause me to treat for the wrong thing. He certainly won't be taking a lifetime supply of insulin needles back with him either, since he obviously can't afford that. If George isn't a cigarette smoker, my theory goes out the window, and we treat for hypothermia and ensure he isn't losing his legs as a complication of uncontrolled glucose levels from his untreated diabetes.
Tyler Thorsten Tyler Thorsten Sunday, December 15, 2013 5:22:45 PM UPPER respiratory. I wrote out a whole comment thinking it was in the lower respiratory tract, and when I re-read the story I had to re-do my comment. Pneumonia is lower respiratory.
Smooth Bore Tip Smooth Bore Tip Sunday, December 15, 2013 7:51:42 PM I hate to say it, but I have to. You get to know the "frequent flyers", and/or the locations they always come from. Yes, we always did the standard BLS/ABC's,/glucose, but the sad truth was they were always discharged the next morning after a night in observation and a free breakfast. Standard ALS would be applied if they deviated from the norm. Sad to say, but we all know it's true.
Mary Holland Mary Holland Monday, December 16, 2013 6:09:38 AM BSI, scene safe, once in unit remove clothing, start rewarming, 4 LPM O2 vi a NC. Cardiac Monitor to include 12 lead. 20 ga IV NS KVO. If Bgl is low Thiamine and D50. Head to toe exam. Ask about drug use. Rule out OD. Could be Septic as well as hypothermic. Probably hypoxic due to his respiratory issues. Correct what I can if still lethargic, rapid transport.
Joshua Worth Sr. Joshua Worth Sr. Monday, December 16, 2013 9:46:55 AM I would say Baseline VS and a thorough physical examination. ETCo2 and a 12 lead. IV access and a Fluid bolus with warm fluid if possible. I would keep the patient warm and administer O2 titrated to a saturation of 94% at least. The patent is most likely non compliant with is medications and doesn't see a physician regularly so I would assessment lungs for a progression in his URI and treat accordingly. Transportation to a General Medical Hospital should suffice and make sure to speak with social services and if available in that area a visit from a Community Paramedic.
Richard Cooper Richard Cooper Monday, December 16, 2013 9:54:22 AM rapid physical to r/o gsw and other trauma. Move to heated rig and provide O2 with nasal cannula at 6. liters. Check blood glucose and recheck SPO2. Check breath sounds and do 3 lead and search for medic alert information prior to transporting. Transmit ECG and vitals to hospital along with other observations, e.g. A&Ox---. Administer D&W large bore. Cincinnati Stroke Scale. If AMS transport code 3 to closes appropriate hospital based on findings..

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