Acres Nursing and Rehab — AMS

Location: Alpha post

Time: 08:08 Saturday

Conditions: Cool and misty

Equipment: fully stocked

 

Dispatch

Not long after your shift begins, as Scenarioville is beginning to wake up, the radio crackles… (click for audio)

[Ambulance 61, respond priority 3 to 386 Longmeadow Rd on the second floor. That’s a cold response for A61 to the Acres Nursing and Rehab, for a conscious, breathing person with altered mental status, reported as stable. 386 Longmeadow Rd is between Ridge St and Old Middlesex Path. Fire is not responding. Time out 8:08. A61?]

 

Response

“Figures,” you remark, as Steve heads toward an address you know well. Acres Nursing is a typical local nursing home, handling both long-term care and short-term rehab. You expect that staff found a patient abnormal during their morning rounds, and regardless of whether they think it’s a “stable” complaint, you seem to end up walking into a sick person about half the time.

Eight minutes later, you pull up to the ambulance entrance. You toss the first-in and airway bags onto the stretcher, pull it out, and head inside. The elevator is around a corner, and you twiddle your thumbs for a couple minutes until it finally opens; staff are probably jamming it up while they serve breakfast. Finally, you emerge on the second floor and find the nurse’s station, where a woman in flower-print scrubs hands you a packet of paper.

 

Scene

While you open it, you ask, “Which room?”

“17.”

Steve heads that way as you eyeball the papers. To the nurse, you inquire, “What’s up?”

She leans back in her chair. “This is for Ms. Reilly. When we woke her up this morning, she has been acting different, saying things hurt, generally seems off. She just had surgery last week on her back at St. Vincent’s, so the doctor says to send her there and they will take a look.”

Looking at the transfer summary in your hands, you utilize your powers of handwriting-decryption and read:

“BELINDA REILLY

81 yo f h/o MI CVA DM OA s/p kyphoplasty, AOx1-2, eval for ^ confusion + chest pain x1 day. 138/71 HR81 RR18 97%RA 99.8° BS+ xxxxx” The last few words are illegible, and you presume the writer lost interest.

To set the stage, you ask, “How long has she been here?”

“Belinda? Oh, three or four years.”

“Is she normally alert and oriented?”

“No, usually she is a little confused, pleasant.”

“But more so today?”

“Yes, she is very confused this morning.”

“Anything else going on recently? Has she been normal until this?”

“Yes, but she had surgery on Monday.”

“What surgery?”

She flips through some papers. “Kyphoplasty.”

“But that went well, no complications or anything new until now?”

“Yes, she has been fine.”

“Does she usually go to St. Vincent’s?”

“No, usually Memorial. She only went there for her surgery.”

“No other recent issues? Any changes in her meds or diet?”

“N… well, the doctor took her off the Percocet, because she doesn’t need it now.”

“It says chest pain here?”

“Well, yes, she has said that her chest is hurting a little, but she doesn’t know what hurts.”

“Does she usually have that?”

“No.”

You scan the rest of the papers, finding this list of diagnoses:

CVA 2007, R weakness

MI s/p stent

Depression

Dementia

Recurrent UTIs

Diabetes mellitus (insulin-controlled)

PVD

GERD

Compression fx, multiple

Sepsis 2009

Osteoarthritis

And this list of meds:

Lisinopril

Colace

Milk of Magnesia

APAP/oxycodone [crossed out]

Metoprolol

Lasix

Metformin

Lantus

Acetaminophen

Aspirin

She is noted to be allergic to sulfa and IV dye.

“Full code?” you confirm.

“Yes.”

You thank the nurse, fold together the papers, and walk down the hall. Inside room 217, you find Steve beside an elderly lady in the first bed; an automated vitals monitor is beside him, and he’s removing a blood pressure cuff from her arm.

 

Initial Assessment

Ms. Reilly is sitting semi-Fowler’s, with eyes open. She does not engage you as you approach. She’s a bit pale, fairly thin, and you see the collection bag for a Foley catheter hanging from her bed (about 100ml of dark yellow urine inside).

“Hi, Ms. Reilly,” you announce with a pat to her hand. She is slightly cool to the touch, dry, and as you touch her wrist you’re able to feel a weak, regular radial pulse.

She looks at you as you speak and answers in a distant voice, “Hi.”

“I’m Sam. How’re you feeling?”

She shrugs a little. “Okay, I guess.”

“Is anything hurting you?”

There’s a pause, then she says, “My chest.”

Steve hands you a card with vital signs written:

125/79

HR85

RR 20

94%

“Your chest hurts?”

“Yes.”

“How bad does it hurt?”

“I don’t know.”

“Can you take one finger” — you demonstrate — “and point to where?”

After hesitating, she makes a vague gesture that encompasses her entire chest.

“All over, huh? What’s it feel like?”

She shrugs, and after a few seconds it seems clear she’s not going to elaborate.

“How long has that been bothering you?”

“I don’t know.”

“Is the pain moving anywhere, or just right there?”

She makes the same nebulous gesture.

“How’s your breathing?”

“Okay.”

“Does that pain get any worse when you breathe?”

“I don’t know.”

“Do you feel nauseous? Like you want to vomit?”

Pause. “Yes.”

“Have you vomited?”

“No.”

You look at Steve. He looks at you. You look at the patient.

 

 

---

 

 

You make a decision. Into your lapel mic, you call out, “Operations, A61.”

“61.”

“Start some ALS. Chest pain.”

“Copy ALS. Break. Paramedic 5, Operations.”

“P5.”

You dial down the volume a little while they dispatch a medic unit from Bravo post. Turning your attention back to Ms. Reilly, you ask, “How are you feeling otherwise?”

She shrugs.

“Have you been feeling weaker at all?”

“I don’t know.”

“Have you been feeling any fever or chills?”

“My back hurts.”

Recalibrating, you ask, “Your back? Where?”

“My… in the middle.”

“How long has your back been hurting?”

“A while.”

Rubbing at your temple with a gloved knuckle, you notice that the monitor Steve was using has an oral thermometer attached. “Can you get a temp?” you ask.

Meanwhile, you start to poke and prod. Her lungs are fairly clear, perhaps slightly diminished, with very mild, fine, bilateral crackles at the bases. Her abdomen is soft, non-distended, and palpating it elicits no response. Her legs are cool, with some slight, non-pitting bilateral edema. You find no obvious signs of trauma.

“100.9°” Steve reports.

“Great. Can you get a fingerstick too?”

Meanwhile, you pull the bed out, drag the stretcher alongside, and busy yourself preparing for a sheet transfer. By the time you’re ready Steve tells you, “199.”

“Okay, let’s move her. Ms. Reilly, we’re going to move you over, okay? Just hang onto yourself and relax.” Using the fitted bedsheet, you slide her onto your stretcher.

As you’re buckling seatbelts, you hear “Greetings, gentlemen!” from behind you. Paramedic Doug Pinelli waltzes into sight carrying a drug box and monitor. His partner, a new guy you don’t know, is close behind with more bags.

“Hi Doug. That was quick.”

“Only for you, my little biscuit.”

Doug was a national treasure. “Okay, this is Ms. Reilly, 81. Found this morning with increased confusion; she’s usually a bit confused but more or less conversational and ‘with it.’ She’s complaining of diffuse chest pain which she can’t really describe, as well as mid-back pain, although she just had a kyphoplasty on Monday, so I suspect that’s why. She did say she’s a little nauseous, but didn’t vomit. She’s not really communicating, can’t get much out of her. Staff say she’s been fine until today. Diabetic, history of an MI a while back. Vitals are good. Surgery was at St. V’s, she usually goes to Memorial… I just didn’t want to dump her at either of those without getting a 12-lead first.”

“Did you get a sugar?”

“Yeah, 199.”

Nodding, he looks down at the patient for a few moments, then leans in and touches her on the shoulder, smiling: “Ms. Reilly! I’m Doug, one of the paramedics here. We’re going to put some stickers on your skin, okay? Bear with us for a minute.”

He turns and raises an eyebrow at his partner, who hurries in, drops the monitor on the back of the stretcher, and starts placing electrodes for a 12-lead ECG. Meanwhile, Doug examines her arms for IV access. “Might as well walk while we work, folks.” En mass, you start to roll down the hall as everyone does their thing.

By the time the elevator’s made it to the ground floor, wires are in place. “Hang on a second, let’s just get this now.” You flip the elevator hold switch while Doug presses a button, and everyone pauses for ten seconds while the monitor ponders the 12-lead imponderables.

As paper starts to curl out of the printer, you’re walking again, and Doug is peering at it like an ancient scroll. He pronounces his verdict as you reach the outside doors:

“Whole lotta nothing. Just some old Q waves. Sam, do you remember when you brought me interesting stuff? Because I don’t.” He does a “jazz hands” thing to punctuate his annoyance.

You roll your eyes. “All right, well, next time we’ll chop off the arms for you. Who’s taking her?”

“We might as well,” says Doug. “Now that we’re already in deep.”

The P5’s ambulance is parked behind yours, and you steer toward it. Steve removes their empty stretcher, you load Ms. Reilly aboard, and the medics hop in. “You guys need a hand?” you ask.

“Nah,” Doug replies. “I’m just gonna get an IV on the way to Memorial.”

“All right then; thanks guys.” You wave and shut them in.

You throw your bags into your truck while Steve loads the P5’s empty stretcher (now yours) into the back. Climbing in, you key the radio, advising that the P5 will be transporting shortly, and you’ll be clear and available. Dispatch has you post to HQ.

“Breakfast?” you ask, and Steve grunts in agreement.

 

Discussion

Diagnosis: Delirium secondary to UTI

Nursing home patients are often tough to evaluate due to baseline levels of dementia, stroke, sensory disability, and other obstacles. While bedside clinical assessment is the core of EMS diagnosis and decision-making, when it comes to a patient like this, you end up relying more upon objective signs. The physical exam may be revealing, but when it’s not (as in this case), it’s nice to be able to turn to diagnostics. Thus, without ALS assistance, it would have been tough to know what to make of the “chest pain” complaint.

Immediate transport would be an option; however, in this case it would either mean transport to the nearest facility or to one of the hospitals with recent patient records (St. Vincent’s or Memorial), neither of which offers PCI on Saturday. If there does turn out to be an acute MI, that would mean a substantial delay before she could be transferred to JUMC for emergent catheterization. Ms. Reilly does have ischemic cardiac history, and is diabetic and elderly, so she is potentially high-risk for MI and may present atypically. So if we want to keep a high level of suspicion for catching these (and we do), ALS is a smart call. (With the clean 12-lead, Doug could have reasonably bounced her right back to us, but many medics are reluctant to do that due to perceived liability.)

Depending on her usual dose of aspirin (i.e. what she’s already taken today), we might have administered that, but it was also reasonable to wait a couple minutes for the medics. Low flow oxygen would be an option to keep her above 94%, but hardly a priority.

Beyond this, urinary tract infection is a common finding in elderly nursing home patients, particularly those with indwelling Foley catheters, which present an easy pathway for infection. In fact, a concomitant UTI is almost de rigueur in these patients regardless of the circumstances. In some cases, such infections can lead to delirium — altered mental status resulting from an acute medical condition — and that was the case here. Other possibilities on the differential might have been stroke (an unusual presentation), hypoglycemia (ruled out by fingerstick), hypoxia (ruled out by oximetry), or electrolyte abnormality (possible), but the finding of fever supported UTI.