Case of the Month
April 2006

65-year-old male — General weakness

Dispatch

"Aid 271, 65 year old male, general weakness"

En route your crew discusses the following considerations:

• Reasons for general weakness
• Glucometry
• Postural vital signs

Dispatch updates you reporting that the patient has felt ill for several days and now feels weak when standing.

Scene Size-up
You arrive at the home and you are met by the patient’s daughter at the front door. The daughter is frustrated with the patient as she has been trying to convince him to go to the doctor the past couple days, but he has refused. When he began feeling weak and lightheaded while standing he relented, allowing her to call 9-1-1.  The scene appears to be safe and the members of your team are wearing exam gloves.

Initial Assessment
You find the patient in bed with his head and shoulders propped up. As you approach, he coughs with a moderate amount of force and you notice droplets are projected about three feet.  He groans immediately after coughing and complains that his shoulders and chest are sore and hurt when he coughs. He has warm, pink and dry skin. He has a radial pulse of 110 that feels moderately weak. The pulse is regular.

Your partner completes an initial assessment:

SICK or NOT SICK?
Based on what you see so far, would you consider this patient SICK or NOT SICK? What steps will you take based on the direction you choose?

• Types of treatment needed for this patient?
• Further steps for evaluation?
• Additional BSI considerations?

Initial Treatment
You decide that the patient is NOT SICK based on his body position, slow onset of symptoms, and general presentation.

After seeing the patient cough and spray droplets, you decide that gloves are not going to be a sufficient form of body substance isolation, so all your team members don goggles and face masks. One of the EMTs places the patient on oxygen using a nasal cannula and flowing at 4 liters per minute.  Due to the patient’s lightheadedness when standing it is decided to check postural vital signs.  These yield a blood pressure change of 12 points when sitting and after being allowed one minute to compensate.  While checking the postural vital signs the patient complains of some mild lightheadedness, but nothing intolerable.

Physical Exam
Your partner gives you the following information:

SAMPLE

Second Set of Vital Signs

The patient feels better with lying down and with a little supplemental oxygen.  Your general impression is that this patient is suffering from the flu and is at the point that he needs further medical attention.  Since he appears to be mildly dehydrated, an emergency room visit seems quite appropriate.  Your team loads him onto the Aid Car’s gurney and experiences an uneventful transport to the local hospital.  In this instance stand alone emergency rooms or clinics could also be considered as transport destinations.  Check with your organizations rules regarding this issue.

Influenza
Influenza is a viral infection that can possess a broad spectrum of symptoms.  Some of the most common signs and symptoms include:

• Fever (usually high)
• Cough and sore throat
• Runny nose
• Muscular aches
• Headache
• Fatigue
• Occasionally nausea and vomiting, but more common in children than adults

Though usually not life threatening, some strains can be deadly, particularly to children, the elderly, and those already in poor health.  Influenza can also be very easily transmitted so we must take this into consideration to both protect ourselves from infection, but also prevent the spread from the patient we see earlier in the shift to another we see later on or even taking the disease home to our families and friends.  Therefore good BSI and after-incident decontamination of our equipment is necessary, especially during an outbreak of a contagious disease.

Influenza typically is spread though droplets from coughing or sneezing, however the virus can live on a surface for a period of time and if an individual touches that surface and then touches their mouth or nose infection can occur.  In light of the large number of patients we see who have respiratory components to their emergencies; we should increasingly be utilizing goggles and face masks as part of our routine BSI. 

Another hidden danger is the fact that a person infected with the flu is contagious from 24 hours before the symptoms present until up to five days after they have become ill.  This means you can contract the disease from a seemingly healthy person or spread the disease before you even feel sick.  Remember, BSI is not only for our protection from what the patient has, but also to protect the patient from any diseases we might be harboring.

Currently Local, State, and National organizations are ramping up with the expectation of the possibility of an Avian Influenza A H5N1 outbreak.  It is currently thought that this not an ‘if’ issue but a ‘when’ issue.  It is anticipated that if/when the Avian Flu, also known as ‘Bird Flu’,  becomes communicable between humans it has the potential to rival the influenza pandemic of the early 1900’s which resulted in hundreds of thousands of deaths, and huge impacts on the society and economy for the years following.

Regardless of when the Avian Flu hits us, other disease outbreaks will occur, and being on the front line of medicine, seeing the sickest of the patients in the least controlled environments, we as EMS providers need to make our practices as safe as possible.

More information on influenza in general, and the Avian Flu in particular, is available from the Center for Disease Control ( CDC ) at www.CDC.gov.