"He Keeps Falling Out" in the Bathroom

Scene
Attack One responds to a report of a person "passed out in the bathroom." The nice lady who greets you at the door tells you that's where she found her husband unconscious. You follow her to a little bathroom in the back of the two-story house, where the man is sitting on the toilet, confused but conscious and able to respond.

You bring him out and lay him on the open floor in the dining room. He says he's having no pain, and his wife offers that he "keeps falling out." The couple agrees that he has passed out three times today. He has never passed out before. No pain, no diaphoresis, no palpitations. Each episode lasts for about 30-60 seconds, then he spontaneously awakens. There is no trauma associated with these episodes. He has had heart disease, and underwent coronary catheterization and stenting about three years ago. Prior to that he had severe angina. He has had no recurrence of that angina since the procedure. He is on medicine for hypertension, high cholesterol and gout.

Your assessment finds a friendly elderly man who is now alert and oriented, with stable vital signs and cardiac rhythm. His pulse oximetry reading is normal. You load him onto the cot and move him toward the front door. Approaching the door, your fellow crew member notes the man's skin color looks a little pale. He then uses the natural outdoor light to evaluate the man's conjunctiva. They are noticeably pale.

"Have you been bleeding?" you ask the man. He says he has not.

"Are you on any blood thinners?" No.

"Do you take aspirin?" Yes. No one had mentioned that.

"Where were you when you passed out the other times?" In the bathroom.

"Which one?" Upstairs.

Time to check that bathroom. You have the wife escort you upstairs. The answer is apparent as you enter the bathroom: There's the distinctive smell of a GI bleed. In the toilet is some quantity of dark, tarry stool.

You now start a large bore IV and deliver a bolus of saline. Just after you place the IV line, the patient asks to sit up. He gets lightheaded, and vital signs taken as his head is raised reveal a significant drop in blood pressure and increase in heart rate. Time for him to lie back down.

Hospital
At the ED, the patient is assessed by the emergency physician, who accepts your advice to leave him lying supine. You review your examination with the doctor, noting again the pale conjunctiva. As the wife lists the patient's medications for the ED nurse, she again forgets to mention the aspirin he takes each day. You remind her not to forget that important drug when she talks about his medications.

The ED staff formally attempts a tilt test, and when the patient attempts to stand up, he sinks to the floor. Back to the supine position he goes. The patient has a hemoglobin of 7, and no indication of any heart problems. His later hospital workup finds a small ulcer in his small intestine, likely from his aspirin therapy. He does well on a heart stress test after his blood volume is restored, and his heart rhythm is stable for two days. The conclusion: His syncope was due to acute blood loss from the ulcer, and the ulcer was related to his aspirin therapy. He is switched from aspirin to a prescription medication that has a lower incidence of gastrointestinal irritation and bleeds.

Discussion
Large numbers of patients are on some form of blood thinners, and that number increases daily. As we grow more effective in preventing premature death from cardiovascular disease, a growing number of persons live on thinning agents. The most common medication for prevention of clotting is aspirin, but many people forget that drug when asked in emergency situations. This patient was not able to give complete information to the crew on initial assessment, and it required some investigative work to determine the cause of his syncope.

The crew found the key clue while looking at the patient's conjunctiva. Regardless of age, race or ethnicity, the conjunctiva should have the same rich pink color. It is the most accurate site on the outside of the body to locate the pale color of anemia. (It is also a good site to find jaundice.) The EMT needs to look at a lot of conjunctiva to be astute at identifying this physical finding. Ask an emergency physician to show you pale or jaundiced conjunctiva the next time you're doing ED observation. This observation requires adequate lighting to make, and the Attack One crew made the necessary change in location to facilitate doing so with this patient.

We find many of our acute patients in the bathroom, therefore many clues to acute problems are found there as well. Small bathrooms are not adequate work areas for very ill patients, so removing them to larger spaces is an important part of our initial work. Adequate lighting is also a plus. But check the bathroom for medications, blood and other clues to significant illnesses.

Smell is also a key sense for the astute EMT. There are unmistakable smells: GI bleeding, burns, ketones, infected urine, exhaust (for CO poisoning) and other hazardous materials, to name a few.

Finally, this patient had a modified "tilt test" to check for volume status. This is a procedure more commonly performed in the ED, but it's a good procedure to discuss with your medical director. The test is performed by laying the patient down, then sitting him up, then standing him up (carefully). Pulse rate and blood pressure are checked about one or two minutes after reaching each stage, and the patient is asked how he feels. The most sensitive reading is the pulse rate. For persons with healthy vascular systems, a pulse rate change of more than 20 when going to a sitting or standing position indicates a relative volume deficiency. The patient who complains of lightheadedness or becomes syncopal (like this patient) is also likely to have an acute volume deficiency.

Persons with syncope require a complete history and examination, and the EMT is integral to the complete evaluation of such patients. This patient had the necessary clues available in the home, and a complete prehospital evaluation allowed the diagnosis to be made as the patient entered the ED.