Shunt

Started off the day with an unknown that turned out to be a diabetic. I have worked in this one town (3 days a week) for many years now and it seems half my patients are repeat customers. This lady has Parkinson's and a speech pattern that makes her sound retarded. We found her laying across the bed. After I gave her the D50, she gets up, but has the tremors. My partners thought she was either having a stroke or a seizure. In the ambulance afterwards, I told them she was very familiar to me and this was her norm.

The next call was also a repeat customer. It came in as a vomiting at a nursing home, but it was actually an intercept with a commercial crew outside the nursing home. The patient, whose norm was nonverbal, had vomited coffeee grounds blood and was hypotensive. The EMT asked me if this was a legitamate intercept call. I told her it was hard to say. I hated when I was in the position of having to call for an intercept. So I guess call when you are in doubt. They were probably going to call a medic alert at the hospital, but I really didn't think there was much I was going to do. I couldn't get a pressure or feel a pulse, and his nail beds were white, but he appeared in no distress and was in a sinus at 60 on the monitor. The only cardiac drug he was on was cardizem. No betablockers. Both his core and his extremities were warm. Even his fingertips were warm. He had a history of stomach CA. The nursing home had gotten a BP of 73/34. I got him out of his sweatshirt, by lifting it over his left arm and head, resting it on his right arm. I couldn't find a vein on his left arm, so I put an IV in his right hand and dumped in a couple hundred cc's on the way in (we went nonpriority). When I pulled his shirt the rest of the way off, I noticed he had a diaylsis shunt in his upper right arm. I had the IV in his right hand. You're not supposed to put an IV in the same arm as a diaylsis shunt. Oopps. I hadn't seen the diaylsis notation on his paperwork, but the crew told me he was in fact on his way to dialysis when they picked him up, and the nursing staff because he vomited and his pressure was low called the doctor, and instead ordered him to the ER. At the hospital, they got 76/44 on their machine in triage. While our oximeter didn't work, theirs read 98%. Because his pressure was low, they indeed called a medical alert.

In the medical room, the doctor was upset to hear the man was a full code. "Good, we'll do our best to ensure his quality of life." I hadn't seen this doctor before. He was a young guy. One of my crew members remarked later about how sarcastic the doctor was. One of the nurses noticed the shunt, and so they started looking for an IV on the other arm. When I came back with my paperwork, they had pulled my IV, but still hadn't gotten access. I felt bad about putting the IV in his shunt arm. I suppose I could make a case that with no blood pressure and no palpable pulse, it was justified, but the truth was I simply hadn't noticed the shunt. I did an internet search later to find out how bad putting an IV in an shunt arm is, but I couldn't find much. What I did find was that the main reason for not taking a blood pressure in that arm or doing an IV was not to damage the existing shunt or damage a possible future shunt site. Well, they aren't going to put one in his hand, so I suppose that was better than putting one in his forearm.

Just how emergently sick the man was I really don't know. His pressure was low, but as I said, he wasn't tachycardic, was Satting fine, was warm and seemed in no distress. Some people with chronic illness just have low pressures. I'm sure I'll pick him up again.

Last call of the day was for an old lady with Alzheimer's who vomited. Nothing else wrong.

Got back from the call in time to see the last of the Red Sox game. They won a nice 2-1 victory.