Continued from Part 1

While you chat, your partner helpfully places Ms. Smith on a nasal cannula running oxygen at 4 LPM.

You ask whether she lost consciousness when she fell, and she agrees that she may have briefly. When you ask why she fell, she states she simply tripped on the fringe of the rug. The fall was 3 hours ago, and she first vomited immediately afterwards. Until this morning, she was feeling normal, with nothing bothering her over the previous days. Her chief complaint seems to be her persistent inability to “find words,” although staff state that they called EMS mainly due to her dizziness.

When you pursue the “pressure” behind her eyes, she admits that it’s a pain of sorts, but it is obviously not too severe, and she refuses to quantify it with a number. She clarifies her dizziness by stating that although it may be worse when she stands or walks, it is continuous; she is experiencing it even as you speak.

Her pupils are equal, somewhat small, and react slightly to light. Her eyes track in all directions, with no appreciable nystagmus. When you ask her to show her teeth, she does so with no facial droop. When you ask her to hold her arms straight in front of her, palms up, with her eyes closed, she does so with no unilateral drift. She demonstrates good, equal grips, equal bilateral strength in finger-abduction and wrist flexion/extension, and equal bilateral strength in ankle dorsiflexion/plantarflexion. Her radial pulses are equal, as are her dorsalis pedis pulses, and she notes normal bilateral sensation when you pinch her hands and feet.

Throughout your conversation, she has demonstrated no slurring of speech, normal recall, and excellent orientation.

Consulting with the staff, you learn that her medications include Metoprolol, Simvastatin, Metformin, Lisinopril, Colace, Aspirin, and Coumadin for a recent hip surgery. She is allergic to Penicillin. They are unsure about her baseline BP, but Ms. Smith believes it is normally “in the 140s.” Staff believe her temperature has been recently normal, although they aren’t certain.

Your partner obtains her blood glucose at 149.

The nearest ALS is 15 minutes away.

At this point, what are the leading possibilities in your differential?

With that in mind, what is this patient’s priority?

What is your transport destination?

Is any treatment needed at this time?

Should you make any calls to mobilize further resources?

Many moons ago, there was an enlightened discussion list run by Jeff Brosius and Valerie DeFrance called Live from Peachtree St. The format was this: Jeff would periodically present scenarios based on real-life calls, putting them out for debate on diagnosis and treatment; later he’d provide the outcomes, with a discussion of the relevant clinical issues. It was a great educational model, and I’ve always thought that scenario-based instruction was a fantastic way to learn to parse the details of a call, determine what matters, come up with a working diagnosis, and make your decisions. You can’t learn hands-on skills from scenarios, but you can exercise your noodle, and more noodle-exercise is what this business needs.

Sadly, Live from Peachtree St. closed its doors years ago, although its archives are available online and still a great read. In the same spirit, however, and with permission from the authors, I’d like to revive the tradition. With that in mind, and harkening from my own neck of the woods, I give you: Live from Prospect St!

To juggle the format a little, I’d like to break these cases up. Remember “Choose your Own Adventure” books? In a similar fashion, I’ll give you the first chunk of the call, let you analyze the facts and make some decisions, then go forward with another round of details, and finally present the outcome. Cases are either true to life (obviously edited for HIPAA) or closely based on reality with editorializing for educational purposes. Feel free to send in any cases of your own! We’re not only interested in intriguing or unusual calls, but also more run-of-the-mill cases that illustrate important fundamentals of assessment and care.

All levels are invited to play, but in keeping with our mission, we will assume a BLS scope of practice. Onward!

Dizzy at Hillcrest

You are the technician on A-8, a dual-EMT, transporting BLS ambulance. You are equipped with BLS epinephrine, aspirin, glucose, nebulized albuterol, pulse oximetry, and finger-stick glucometry. Intercepting ALS is available upon request. It is noon and the weather is fair.

The radio crackles: “Ambulance 8, respond cold to Hillcrest Manor, in the lobby, for the patient with dizziness.”

Driving non-emergently, you arrive several minutes later at an assisted living facility. In the lobby, you are met by staff, who direct you toward an elderly woman in a chair. A nurse informs you she has been feeling somewhat unwell all day, and 30 minutes ago began complaining of dizziness. She also states that she failed a finger-to-nose neurological test. They request that you transport her to Mount Doom Hospital, a high-quality community hospital several towns away (20 minute transport routinely; 13 with lights and sirens); it is a cath lab and stroke center, although not the nearest facility for either, and is not a trauma center. The nearest facility is a community hospital of similar size and capabilities (10 minutes routinely; 5 with lights and sirens).

You kneel in front of the patient, noting that she is alert and appears generally well, in no obvious distress. She introduces herself as Ms. Smith, is 68 years old and fully oriented, and tells this story:

“This morning when I was getting out of bed, I fell and bumped my head. After I got back up, I was trying to do my writing assignment for our group, but I kept finding that I just couldn’t seem to think of the words — I’d stare at a sentence for ten minutes without knowing how to finish it. I’ve been feeling a little dizzy most of the day, and a little sick — I vomited a few times. And I feel like there’s a pressure behind my eyes.”

While you talk, your partner obtains these vitals:

Skin: dry; unremarkable at the core; cool and slightly pale in the extremities
Pulse: 90 [at the radial, strong and regular]
Respirations: 14 [regular, normal depth and unlabored]
Blood pressure: 164/98
Oxygen saturation: 96%

When asked, staff report that Ms. Smith’s medical history includes coronary artery disease, diabetes, mild dementia, and hypertension.

What is your current impression of the patient’s priority?

What are the leading possibilities in your differential?

What further assessments or information would you like to better inform your decisions?

What actions or interventions, if any, would you like to take at this time?

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