A Gnawing Case: What to ask when presented with vague chief complaints

 

 
 
 

Marc Eckstein, MD, MPH, FACEP | | Monday, August 31, 2009


Why do we have to transport all of our patients? It's certainly true that most patients we transport don't have an immediately obvious, life-threatening problem. However, many patients who have relatively minor or benign complaints in the field indeed turn out to have serious underlying conditions. The following real-life case is one such example.

You're dispatched for a patient reported as "sick." You find a 48-year-old male on the street complaining of leg pain. The patient states he has had increasing pain in his right lower leg for the past few days. He denies any history of trauma. His past medical history is significant for diabetes and alcohol abuse. He says his leg has been swollen and has become increasingly painful during the past few days. He does not recall what he's supposed to take for his diabetes.

What other information should I specifically ask about? In addition to obtaining the AMPLE history (allergies, medications, past medical illnesses, last meal, and events leading to the 9-1-1 call), you should ask if the patient has had any chest pain or shortness of breath, if he has had any fever or chills, if he has ever had this problem before, and what time it was when he last took his diabetes medications or checked his blood sugar.

Your primary survey does not reveal any abnormalities. The patient is awake and alert and in no obvious distress. His vital signs are BP 140/60, HR 116, and respiratory rate 24. The patient's right lower leg looks somewhat red with a slight sheen to the skin, appears swollen compared with his left leg, and has no obvious deformities. He has good distal pulses, and his motor function and sensation (PMS) are intact bilaterally.

What are some "red flags" that this patient is at risk for a potentially serious medical condition? Diabetes (especially when poorly controlled) and alcohol abuse place this patient at much higher risk for serious infections. Also, the facts that this patient is tachycardic, has a widened pulse pressure and is slightly tachypneic suggest he has a serious underlying infection. The pulse pressure is measured by the systolic BP minus the diastolic BP. This patient's pulse pressure was 80, about twice the normal pressure, which may indicate early sepsis from a serious infection.

What prehospital interventions should I perform? In addition to a blood glucose check and saline lock, consider administering morphine for pain and a fluid challenge.

The patient's blood glucose is 295. Because he does not appear to be in any distress, you decide to withhold IV access and simply transport to the nearest emergency department (ED). When you clear the hospital, you and your partner both feel that this transport was unnecessary and that the call was an all-too-common abuse of the 9-1-1 system.

You don't give the incident much more thought until you return to the same ED later in the shift, when one of the nurses informs you that your patient with the leg pain ended up going emergently to the operating room and was in the ICU. What happened?

Hospital Care

Upon examination in the ED, this patient was noted to be tachypneic and persistently tachycardic, with a heart rate steadily rising to the low 120s. His right lower leg was extremely swollen and had marked pitting edema with warm skin, which appeared somewhat reddened. He complained of severe pain in the affected area and was exquisitely tender on palpation of that area. He had a fever of 101_ F, something you failed to detect.

X-rays of his right lower leg showed only soft tissue swelling with no bony deformities. Of particular note, there was no gas seen in the soft tissue between his tibia and the skin. Gas in the soft tissues is a very worrisome finding because it indicates a deep infection in the patient's extremity. The gas is produced by certain types of very invasive bacteria. However, the absence of gas does not rule out serious soft tissue infections.

After receiving 3 L of IV normal saline and several antibiotics, the patient was taken emergently to the operating room (OR) for presumed necrotizing fasciitis, also known as "flesh-eating bacteria." Exploration of his lower leg revealed extensive necrotic (dead) tissue, which included necrotic soft tissue, muscle and fascia (the fibrous tissue that surrounds each muscle group). This necrotic tissue was surgically removed, and the deep compartments of his lower leg were washed out with 10 L of saline and antibiotics. He spent two weeks in the ICU and had three subsequent trips back to the OR. Fortunately, he did not lose his leg and he fully recovered after a long hospitalization.

Discussion

What is necrotizing fasciitis? This severe infection of the soft tissues is caused by various types of bacteria that lead to an aggressive, rapidly spreading infection. Patients at particular risk include diabetics, the homeless, injection drug abusers, alcoholics and anyone with a weakened immune system. However, these infections have occurred in otherwise-healthy individuals after minor scrapes or abrasions. Early recognition of necrotizing fasciitis is important because there may be a remarkably rapid progression from a minor break in the skin to one associated with extensive destruction of tissue, systemic toxicity, limb loss or death. The mortality rate is between 25Ï35%. Necrotizing fasciitis should be considered in patients who appear ill, have a fever or show evidence of soft tissue infection with severe pain on palpation of the affected area.

What's the treatment? Aggressive resuscitation with IV fluids is needed, along with administration of powerful antibiotics and surgical exploration in the OR to remove dead soft tissue and muscle and to wash out the infected areas. These patients often require multiple surgeries and may require amputations or extensive plastic surgery. If this infection is not rapidly diagnosed and treated, death from overwhelming infection will result.

What other conditions might this patient have had, other than an infection? Any patient complaining of unilateral pain and swelling in the lower leg with no history of trauma is at risk of a blood clot (deep venous thrombosis, or DVT), which can travel to the lungs and result in a pulmonary embolism.

Conclusion

Always assume the worst. Just because your patient may not appear to have a life- or limb-threatening problem in the field doesn't mean they aren't sick, and taking a patient's temperature is an often-forgotten but potentially critical part of assessment. This patient would have likely died within 12 hours had he not been transported and promptly treated at the hospital. JEMS

Marc Eckstein, MD, MPH, FACEP, is the medical director of the Los Angeles Fire Department. He's an associate professor of emergency medicine at the University of Southern California Keck School of Medicine and the director of prehospital care at the Los Angeles County/University of Southern California Medical Center. A former New York City paramedic, Dr. Eckstein is a nationally recognized leader with more than 20 years' experience in EMS. Contact him at eckstein@usc.edu.

 




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Related Topics: Patient Care, Special Patients, Marc Eckstein

 
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Marc Eckstein, MD, MPH, FACEPMarc Eckstein, MD, MPH, FACEP is the Medical Director of the Los Angeles Fire Department, which is the nation's second busiest EMS provider. Dr. Eckstein is a Professor of Emergency Medicine at the Keck School of Medicine of the University of Southern California, and the Director of Prehospital Care at the Los Angeles County/University of Southern California Medical Center. A former New York City paramedic, Dr. Eckstein is a nationally recognized leader with 25 years experience in EMS.

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