The call is for a nosebleed. Person unconscious in a car. We get updated that the patient is now conscious, but still some bleeding from the nose.
The first responder tells us the man has had a nose bleed all day and finally called a neighbor to drive him to the hospital. On the way, he passed out. The responder says the bleeding is down to a trickle.
We are at the side of a busy road so my partner and I lift the thin, frail man out of the front seat of his neighbor’s car and right onto the stretcher and then we wheel him over to the ambulance and get him in the back.
He is extremely diaphoretic and asks repeatedly if he locked his door. I try to tell him that we just picked him up from his neighbor’s car. He is in his eighties and I am guess he may some dementia. I take a blood pressure and just barely hear it at 90. While my partner tries for an IV, I do a quick 12-lead, but the electrodes just won’t stick. The man holds a Kleenex in his hand that is just dabbed with blood. There is no way a nosebleed would cause this kind of diaphoresis. Maybe it is posterior bleed, but there is no sign of throwing or spitting up clots. The man can tell me his date of birth, but not the names of his medicine. The only medical history I get is hypertension. I ask if he is on a beta blocker, but he doesn’t seem to know what I am talking about. I ask because his heart rate is only in the 80’s.
My patch to the hospital is brief, “We’re seven minutes out with an 80 year old with a supposed uncontrolled nose bleed earlier, had a neighbor drive him to the hospital, on the way he had a syncopal episode so they called 911. The nose bleed has stopped. He’s alert, but slightly confused, very diaphoretic with a BP of 90/50. Heart rate 88. Denies any pain. Only history I can get from him is hypertension.”
Not the best patch, but it’s about what I said. Generally to this hospital, they want short and sweet, just so they have an idea of what is coming in, so they know where to make room in ED. A major medical or trauma room, the Main ED, a Less Acute Wing, the psych ward or the waiting room, and whether or not this will need a doctor at the ready.
His skin looks a little mottled to me now and his hands are very cold. I try to take another pressure, but can’t hear anything. When I use the electronic cuff on the monitor I get 74/40 and then 66/38. I have by now popped in a second line — a 16 this time and am running the fluid in wide open. At triage I have to emphasize the syncope and the hypotension and deemphasise the nosebleed. We get the patient in the room. I give another quick report to the nurse. The nose bleed’s been stopped for me. He’s really cold and clammy and the last pressure I got was 66/38. When I come back to the room with my report, I see their monitor also has his pressure in the 60’s and the bag of saline is just about empty. The doctor in the room is asking the patient about his nosebleed. I give him the report then, and he listens attentively.
Then we clear the hospital and life continues on.
Two things happen this morning. First the night medic, who I recently precepted, tells me that it is her feeling that it really important that medics work patients up as thoroughly as possible because at least some of the hospitals(because they are so overcrowded) tend to listen to what we have to say. If we say the patient is sick, they take it seriously. If we don’t, they may put the patient in the hall or out in the waiting room. We are the patient’s advocate and we need all the information we can get in order to advocate most effectively. And after all, it is only one patient we are taking care of, while the ED is taking care of easily a hundred — with each nurse having seven or eight patients. For all we might bitch about it when we are ignored, the hospitals abd nurses do tend to rely on us. I really like what the medic is saying and how she is saying it, and I am pleased that she takes her responsibility as a medic seriously.
It makes me think about how in patches to the hospital or reports at triage, it is very important how I frame the information, and the order I put it in. If I had to do the patch over again, I might not even mention the nose bleed over the radio, while giving less weight to it in the direct paramedic-to-nurse report. Syncope. Hypotension. Also Epistaxis.
This morning I am at the hospital and a nurse comes over to me and tells me the man had a dissecting aneurysm. He lived in the ICU for five days till he expired. She theorizes that the nose bleed was from the hypertension. When the aneurysm ripped, his pressure plummeted and the nose bleed stopped.
Since few people with a ruptured aneurysm survive, I don’t know if a more urgent patch would have made much of a difference. Perhaps, if I had been more urgent, he would have gone into a major medical room with a doctor right there with a true sense urgency — not one pondering the nose bleed. At least, I suggested there was something more than a nosebleed at play. Nevertheless, it illustrates the point. We have to fight for our patient. The patients deserve it, and for the most part the hospitals expect us to do it. In many cases, a full assessment and an articulate, and at times passionate report will do as much or more for an ill patient than any actual care we render.