Subtle Signs
EMS Reruns addresses dilemmas in EMS. If you think of an example like the one that follows, send it to us. If we choose to publish your dilemma, we'll pay you $50. E-mail ideas to Nancy.Perry@cygnusb2b.com.
"You see only what you look for, and you recognize only what you know."
—Art Kanowitz, MD, FACEP, EMT-P
The lady in front of you must be 90. Her name is Maude Kelsinger, and you've been called to her mobile home address tonight because her daughter (who lives with her) thinks there's "something wrong" with her. Your initial impression of Maude is that she's not in crisis, but you note a hint of diaphoresis near the top of her forehead, just at the hairline.
Bill, a part-timer, is filling in for your regular partner tonight. Without introducing himself, he asks Maude what's bothering her, and she responds—maybe a little slowly— that she's OK, and she doesn't need paramedics tonight.
"O-kaay," he sighs, and picks up his stuff. "Feel free to call us back if you change your mind." His words are appropriate, but the comment is brusque and uninviting. You're not so sure Maude's okay, and with apologies to Bill, you politely suggest an ECG and maybe some vitals while you explore the daughter's suspicions. Justin, one of the firefighters on your shift, moves right in, gets the lady on some Os and pulls out the patches. Bill hooks her up for a 12-lead while Justin gets vitals. The ECG is unremarkable, but the pulse is 100, the blood sugar is 77 and the tympanic temp is 102.5ºF. The daughter says mom has lost her appetite over the past four days and has become unusually non-conversational. The engineer quietly grabs an IV from your kit and spikes it.
Q. OK, so this lady's blood sugar is a little low and she has a temp. But that doesn't mean you need to take an ambulance out of service for her.
A. Actually, the marquee issue here is the fact that the daughter sensed something was wrong. Be alert for that comment; it's almost always significant. It certainly warrants enough interrogation to clarify exactly what observation got the daughter's attention. Beyond the comment, there's another finding that reaches right out to a smart paramedic. It's the diaphoresis. Sweating at rest says "I'm sick" until proven otherwise. As for taking the ambulance out of service, the ambulance is in service—it's just helping someone instead of sitting around, waiting.
You shift your line of questioning to address the daughter's observation. One of the things you wonder about is Maude's loss of appetite. When you ask if she's had trouble swallowing, Maude nods. Sure enough, the daughter confirms that when mom tries to drink water she "slobbers." Next question: Does it hurt to swallow? Maude shakes her head no.
Q. That doesn't sound too significant. Why the interest in swallowing? It's certainly not an emergency consideration.
A. One common reason why people experience a "loss of appetite" is that their food sucks. Another is, they can't swallow normally. There are three common causes for that. One's a physical airway obstruction, which doesn't seem to be a problem here, and two is a sore throat. But the third is a stroke affecting the brainstem (which might also interfere with a patient's speech). A patient who can't ingest liquids would certainly become hypovolemic after four days. Their heart rate and temperature might rise, and especially in advanced age they might also become hypoglycemic.
The vitals do kind of fit that picture. A resting heart rate of 100 is fast in a 90-year-old. A blood sugar of 77 is low. And a temp of 102.5 would be common in kids, but it constitutes high-grade fever in an older adult. Even Maude's diminished conversation and slowness to answer questions say something's wrong. This lady seems to be in trouble. A person who can't swallow at all can die within a week.
Q. Wow, so this lady belongs in a stroke center?
A. Maybe not. It sounds like something happened four days ago, which is a long time. It's a good idea to get an ED consult before you head for a stroke center; but even before you do that, make two more observations. One, hand Maude a small glass of water and see if she can swallow at all. And two, ask her to count to 10 forward and backward. At the same time see if her speech is coherent. Also, find out if something happened that made the daughter call you tonight rather than at some other time during the last four days. You should be especially curious about whether the old woman ever had any headache or neck pain (which might suggest hemorrhagic stroke).
Each of these observations can help your ED physician form a quick conclusion. But there's one more thing.
Maude's LOC may change later on. If that happens, the diagnosis will rest on those other subtle observations of yours.
Thom Dick has been involved in EMS for 38 years, 23 of them as a full-time EMT and paramedic in San Diego County. He is the quality care coordinator for Platte Valley Ambulance Service, a community-owned, hospital-based 9-1-1 provider in Brighton, CO. Thom is also a member of EMS Magazine's editorial advisory board. Reach him at boxcar_414@yahoo.com.
