Belly Bump

   The local truck stop is a site where many unusual patient presentations and colorful medical histories are found. Attack One is dispatched today for a "man down." The crew finds the patient between two trucks near the store, where he lies on the ground with his feet propped up by a helpful bystander. "He was just completely out," says this lady, an employee of the truck stop. "He fell like his legs were cut out from under him."

   The patient is in his early 20s and able to speak clearly to the crew. He is a long-distance driver from out of state. He'd only been on the road a couple hours this morning when he began to feel light-headed and nauseated, and decided to pull in to the truck stop. He has an empty trailer and is headed home, so is under no deadlines.

   He relates that he'd parked and was walking to the store when he'd had a rapid onset of upper abdominal pain, then nausea, then passed out. He hadn't experienced anything like this before. He says when he woke up, the lady was helping him and his pain was gone, but every time he tried to sit up, he got nauseated and light-headed again.

   The woman confirms the story, adding he was unconscious for about 2-3 minutes. She didn't know how to feel for a pulse, and feeling this patient's pulse is difficult--it's barely present at his wrists. The EMT can only palpate a blood pressure of around 80, with a rapid heart rate. The crew notices the man's skin is pale, he's a little sweaty, and his capillary refill is slow. Signs of poor perfusion are consistent with an initial pulse oximeter reading in the upper 80s.

   "Sir, there is a good reason you feel so bad when you try to sit up," the paramedic tells him. "Your blood pressure is really low, even on your back with your feet up. We need to start an IV and take you to the hospital." The medic then goes through an exhaustive list trying to find a cause for the poor perfusion.

• No bleeding, including no history of black stools.
• Plenty of fluids to drink, and no alcohol.
• No drugs, off the street or prescribed.
• No insect stings/bites, peanuts eaten or medication taken, and no history of any type of allergies.
• No diarrhea or vomiting, and the nausea only started when he had the sharp pain. No history of bleeding in the GI tract.
• No chest or back pain. The abdominal pain has cleared.
• No surgeries, ever.
• No history of bleeding or hemophilia in the family; no bleeding from teeth, gums or nose.
• No recent accidents, trauma or other injuries.

   The man's only history findings are some feeling of tiredness over the last few days, and an episode about three weeks ago where he'd had a fever, sore throat and fatigue that lasted a few days. He hasn't been exposed to any other illnesses or sick persons he is aware of.

   The crew examines him quickly and as well as they can in the lot. He has no signs of trauma or bleeding. His neck veins are flat, his chest is clear. They palpate his abdomen through his clothing, and he describes a mild discomfort in his entire abdomen, saying it feels "bloated." He is a little tender throughout, though his back is not. He moves his extremities and has no neurologic deficits. His pulse is regular and fast, and he appears slightly pale.

   Concerned that they don't find a cause for his poor perfusion, the crew sets up for a rapid removal. They advise the patient that he needs to go quickly to a hospital, and they will need to start an IV and do an EKG in the ambulance. He says he feels better, and is concerned about leaving his truck in a truck stop far from home.

   "Can I just drive to the hospital, and you guys can follow me?" he asks, moving to sit up. But he doesn't make it upright before he sinks back down. "Boy, do I feel dizzy--like I'm going to pass out again."

   The truck stop employee offers to get the truck secured. "Son," she says, "you can't go anywhere unless it's in the back of an ambulance."

Transport and Emergency Department

   The crew loads the patient into the medic quickly, placing the first-in bag under his legs. Inside they undress him to the waist and perform a 12-lead EKG. As they're doing that, the patient again complains of a bloated feeling in his abdomen. He's still tender there, but has no signs of trauma on the abdomen or back. The paramedic attempts to feel his aorta, but the man becomes very uncomfortable with that attempt, and that assessment is aborted. The man has weak, equal pulses in his feet, and the possibility of an aortic aneurysm is pretty small in this young male.

   The 12-lead is normal except for the fast rate--a sinus tachycardia. An IV started, he is pressure-infused with a liter of saline. The crew gives high-flow oxygen, and his saturation finally crawls up to the mid 90s.

   The man's a bit more comfortable now, but his pulse rate and overall perfusion don't improve much. The report to the ED outlines a young, healthy man who is perfusing poorly and complaining of abdominal discomfort, but has no history or signs of trauma and can only stay conscious in the Trendelenburg position. The ED physician asks if he needs the resuscitation bay--a good idea, the crew thinks.

   The paramedic questions the patient about any history of bleeding in his GI tract, and the patient denies any vomiting, dark stools or use of aspirin or other blood thinners. To guard against an acute incident, the paramedic frequently asks the patient en route if he feels nauseated, is going to vomit or feels like he needs to have a bowel movement.

   The patient is unchanged as they arrive in the emergency department. He and the crew share his history with ED staff. Based on that, the emergency physician has prepared the ultrasound machine. Confirming with the patient that he has not recently been injured in any way, they perform the ultrasound scan using the same technique used with major trauma patients. Within a few seconds of starting the procedure, the physician tells the patient his abdomen is full of blood. He gives orders to get blood for type and cross, call the operating room and pressure-infuse another liter of saline.

   The staff then question the patient intently about his history and prepare him for a quick trip to the OR. The key historical item on which the physician seems to focus is the illness about three weeks ago. The patient was not seen by a doctor at that time. When questioned specifically, he says it was the worst sore throat he'd ever had, and he felt "washed out" for days after his fever resolved.

   By the time the Attack One crew returns to the hospital with another patient, the surgical team has the rest of the answers: The patient had a spontaneous rupture of a very large spleen, apparently enlarged due to a recent infection with mononucleosis. They had to remove the spleen, but everything else looked OK, and they expect a rapid recovery. The recovery does, in fact, go well, and another driver takes the patient and his rig back to his home.

Case Discussion

   Poor perfusion is the key sign of shock, and sometimes patients don't come with convenient signs telling providers what the cause is. Think through the etiologies of shock. The patient with shock due to a spinal cord injury is obvious. Cardiogenic shock usually presents with some symptoms and signs of an acute myocardial infarction, has clinical features of too much volume (neck vein distention, lungs with audible fluid) and an EKG that indicates an acute ischemic heart problem. Septic shock is usually accompanied by signs of severe infection. Anaphylactic shock can sometimes be difficult to diagnose, but this patient had no history of stings, medication ingestion or intake of foods that typically cause allergic reactions. Hypovolemic shock is still a very common cause of sudden unexplained shock.

   There are common places to look for massive fluid loss or bleeding that would cause sudden hypovolemic shock but not be obvious from history and exam. Only the chest, abdomen and pelvis can "hide" enough blood to cause shock. The aorta runs through all three areas, and can rupture for a variety of traumatic and nontraumatic reasons. In a young patient, Marfan's syndrome could be a cause. The GI tract can bleed in a variety of places, and hold a significant volume of blood that finally comes out in the form of vomiting or bloody bowel movements. The spleen is the organ in the abdominal cavity most susceptible to sudden rupture, and that can occur with minimal or no trauma when it has been engorged or injured. Several other unusual causes of sudden intra-abdominal bleeding could cause shock when blood is hidden in the abdominal or pelvic cavities.

   This patient had a grossly swollen spleen due to infection with the Epstein-Barr virus, which we call mononucleosis. There is often some swelling of the spleen with that viral infection, and in some young people this can persist over 4-6 weeks and make the spleen prone to rupture with minimal trauma. This is of great concern to athletes and military recruits in training, so those groups are often examined specifically for that complication and have their activity restricted to prevent rupture.

   In the prehospital environment, it will be easier to diagnose a patient's sudden onset of shock than it will be to pinpoint the cause. The crew performed several abdominal evaluations and recognized something was changing quickly, that a significant site of bleeding was somewhere in the abdomen, and that the patient was worsening. They gave him an IV fluid bolus, maintained him in the Trendelenburg position and notified the hospital of an unstable patient.

   The paramedic was also appropriately concerned that the patient had a sudden bleed into his GI tract. This would have been a much higher consideration if the patient were on an anticoagulant. Many patients today are on blood thinners, and that should be actively sought in the history.

Initial Assessment
A 23-year-old male who suffered a syncopal episode but is now awake. He describes discomfort throughout his abdomen and a feeling of fullness.

Airway: Intact and uncompromised.
Breathing: No distress, can speak in full sentences.
Circulation: Patient is cool, with delayed capillary refill and pale skin.
Disability: No neurologic deficits.
Exposure of Other Major Problems: None found.

AMPLE Assessment

Allergies: Penicillin.
Medications: None.
Past Medical History: Patient has been in good health, but about three weeks ago had an episode of sore throat, fever and fatigue. He's had no prior abdominal surgeries.
Last Intake: Breakfast at 0730.
Event: Syncopal episode, but patient is now conscious.

Customer Service Opportunity

Patients managed by EMS are frequently in need of support services beyond emergency medical assistance. Persons from out of town can present some of the most challenging circumstances, particularly if they need timely medical care. Great relationships with law enforcement can be an enormous asset, but providers should also know how to access assistance from their local emergency management agency, relief agencies (e.g., Red Cross, Salvation Army), faith-based organizations and protective services for children and seniors. Local businesses can also react with great charity in emergency circumstances. Patients' concerns about cars, belongings, distance from families and inability to communicate can be greatly distressing and may interfere with medical care. It is great customer service for EMS to preemptively consider the need to care for important patient belongings and make the patient as comfortable as possible in a location far from home.

   James J. Augustine, MD, FACEP, is director of clinical operations at EMP Management in Canton, OH, and a clinical associate professor in the Department of Emergency Medicine at Wright State University in Dayton. Contact him at jaugustine@emp.com.