Patient Care

Not All Clinical Clues Point in the Right Direction

Issue 6 and Volume 39.

“Medic 72 from the comm center.”

“Go ahead comm center, this is Medic 72.”

“I need you to respond to 314 Woodward Street on a delta response for an unresponsive overdose, 19-year-old female, police and fire are en route.”

The address isn’t in Medic 72’s usual response area, but the city’s other ambulance was already transporting a patient. While en route, they overhear an officer on the police frequency ask that they “step it up” because the patient is unresponsive and not breathing normally. Because of the distance, Medic 72 is a few minutes behind law enforcement and the engine company.

The crew arrives on scene, parking behind the fire engine and police cruisers about half a block from the house. While moving their equipment to the house, the crew members notice there are four police cars—an unusually high number for an EMS response.

The house is poorly kept with a significant tobacco smoke odor and numerous empty containers of alcoholic beverages strewn about. There’s a substantial amount of garbage littering the floor and the sparse amount of furniture.

“This place looks like my frat house in college,” the EMT muses.

A police officer calls them to come upstairs. They find the patient lying on a couch in a small bedroom surrounded by police and firefighters. Two officers are talking to a male subject in the room and the engine crew looks concerned while taking the patient’s vital signs

“We found her like this and haven’t been able to get a response,” the engine company lieutenant says. “She’s breathing and has a carotid pulse but we can’t get a radial. They’re trying to get a blood pressure now. The guy said he found her like this when he came home but he’s not much help.”

He adds, “When we got here her shirt was pulled up and her pants were around her ankles. We also found this empty pill bottle on the table next to her.” The lieutenant hands the paramedic an empty prescription pill bottle marked as containing Paxil (paroxetine).

As the paramedic begins to assess the patient, one of the police officers pulls the EMT aside. He informs him that the police are familiar with this address due to the high level of reported drug activity.

The patient is thin but not emaciated and, from her general appearance, doesn’t appear to be in the best of health. She responds to a sternal rub with non-specific movement and a slight groan.

Her airway is patent as evidenced by deep, gasping and rapid respirations. Her skin is pale, hot and dry. She doesn’t have a radial pulse but her carotid pulse is 124 beats per minute. There are no obvious signs of recent trauma found on a rapid head-to-toe exam, but the paramedic finds old scar patterns on the patient’s anterior wrists that appear to be evidence of previous self-harm via cutting.

The ambulance crew members direct a firefighter to retrieve a stair chair and bring their cot to the door so they can take the patient to the ambulance.

Once in the ambulance the crew performs a secondary assessment. The patient’s level of consciousness hasn’t improved. Her airway is still patent and her respirations are still noted to be deep, regular and rapid. There are no other signs of recent trauma or additional markings on her body.

The patient’s pupils are sluggish and her eyes don’t seem to accommodate when her eyelids are opened. Her trachea is midline and mobile and her chest is noted to have equal rise and fall with clear lung sounds on auscultation. Palpation of the patient’s abdomen reveals it to be soft and not distended, but she groans slightly upon palpation of the lower quadrants. The patient’s extremities are cool to the touch with diminished distal pulses and capillary refill.

The patient is put on end-tidal carbon dioxide monitoring via nasal cannula sensor, which shows a reading of 20 mm/hg and a respiratory rate of 26 breaths per minute. Her blood pressure is obtained via automatic noninvasive blood pressure at a questionable 68/48. The providers are unable to obtain a pulse oximetry reading, but her respiratory rate is deemed to be providing her with adequate oxygenation.

The patient is placed on a 4-lead ECG, which revealed sinus tachycardia without ectopy, and the paramedic initiates an IV with an 18-gauge catheter in the patient’s left antecubital fossa. The EMT checks the patient’s blood glucose level off of the catheter, which reveals a reading of “HI.” Based off this assessment finding, the paramedic elects to rehydrate the patient with boluses of IV saline and transport her to the downtown hospital for potential admission for her diabetic ketoacidosis (DKA).

Before they leave, the back doors to the ambulance open and a police officer steps in with more information. He informs the crew the patient was the girlfriend of one of the residents of the home and that she’s been complaining of feeling unwell for the last few days. After speaking with her mother, whose number they found in the patient’s cell phone, police learned that the girl had been released from a regional hospital a week prior after a suicide attempt and hasn’t been seen by her family since. They suspected she’d been living with her boyfriend and were worried because the patient is an insulin-dependent diabetic and she didn’t have her insulin supplies with her. Armed with this information and a diagnosis, the subsequent transport is uneventful. The patient doesn’t regain consciousness during the trip

At the ED, the patient’s blood glucose was determined to be 1,440 mg/dL and her pH was 7.1. A serum test for substance abuse shows the presence of cannabinoids but no other substances are detected. She’s admitted to the ICU with a diagnosis of severe acute DKA meeting criteria for a hyperglycemic hyperosmolar state. A review of the patient’s medications reveals that the empty pill bottle had most likely been taken as prescribed as per the date on the bottle.

EMS providers in the field have both advantages and disadvantages when it comes to assessing unresponsive patients. Because we generally see the patient at the point where their condition may be most acute, we have the advantage of being able to check the scene for potential clinical clues. However, we also have the disadvantage of not having access to the laboratory and other diagnostic tests that are available in the hospital environment.

As this case demonstrated, not all clinical clues point in the right direction. Dispatch’s initial description and the empty medication bottle are suggestive of an overdose, as are law enforcement’s suspicions of drug activity in the house. Since the patient couldn’t communicate and answer questions, the providers needed to rely solely upon their assessment skills to create their working diagnosis and treatment plan. As always, it’s important to consider potential causes of the patient’s conditions that aren’t indicated by on-scene clues.

EMS providers are taught to perform a number of different assessments to zero in on a patient’s condition. These assessments start with the primary assessment, which is a rapid assessment intended to find and correct immediate life threats, and is followed by the secondary assessment, which is a head-to-toe examination covering much more detail. Other EMS assessments include focused assessments for specific problems and the ongoing assessment, which tracks changes in the patient’s condition. Providers should also become adept at other examinations such as the “review of systems,” which looks at the body’s functional systems like the neurological, circulatory and gastrointestinal, and be able to consider “differential diagnoses” for patient presentations.

A differential diagnosis is a potential condition that may or may not be present in a patient’s condition. Considering differential diagnoses is taking into account the multiple possible causes of a patient’s condition and using a process of elimination to determine what actually may be the true cause or causes of their illness or injuries. This requires the provider to have a good grasp of anatomy, physiology and pathophysiology, and is a process of thinking that is of enormous value to a good clinician.

Examples of EMS-focused differential diagnostic considerations can be such as the PAPPA assessment for life threatening causes of chest pain (pericarditis, aneurysm, pneumothorax, pulmonary embolism, and acute coronary syndrome), or, as in the case presented here, the act of ruling out potential causes of the patient’s unconsciousness and presentation.

The paramedic was reliably able to rule out narcotic intoxication by the patient’s respiratory rate, generally rule out trauma by performing a detailed physical assessment, reasonably dismiss hypoglycemia because of the absence of pale, cool and diaphoretic skin, and determine the DKA by observing the dehydration, Kussmaul respirations and high blood sugar. The waveform capnography of 20 mm/hg also helped zero in on the DKA, as an EtCO2 of 24.5 or higher is a reliable method to rule out DKA.1

EMS providers should attempt to generally standardize their assessments in order to make a habit of providing a thorough, methodical patient assessment that minimizes the chances that important clinical clues might be missed. The more practice a provider obtains through thoroughly assessing every patient, the greater the likelihood that those patients who need assistance the most won’t be neglected. Consider differential diagnoses and try to obtain as much information as possible to provide the best care for every patient.

1. Soleimanpour H, Taghizadieh A, Niafar M, et al. Predictive value of capnography for suspected diabetic ketoacidosis in the emergency department. West J Emerg Med. 2013;14(6):590–594.

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