Someone on the Ramp

Scene

Attack One is in quarters on a sunny summer afternoon. Another crew is performing vehicle maintenance duties on the front ramp of the station when a vehicle pulls up. The driver, a female, asks if the Attack crew can answer a question. They are paged to the front ramp. There is an elderly couple in the car, and the wife asks if the crew would advise her on what to do with her husband. He has had abdominal pain for the past two hours. He reports no other pain. The wife wants to know if he should go to the hospital now, or if they should call the patient’s internal-medicine doctor for an appointment tomorrow. The wife says her husband has occasional abdominal and back pain, and was once removed to the hospital for kidney stones by the crew at this station.

The patient appears in moderate discomfort. He remains in the front seat of the car, his hand across his abdomen. The crew inquires about his pain and the details of his medical history. Their questioning is brief, and they find he has a long history of hypertension. He has had kidney stones. They ask for a blood pressure cuff from the apparatus on the ramp, and find his pressure is slightly elevated. He has a pulse rate around 72, a blood pressure of 160/100, a respiratory rate around 18, and appears to be perfusing well.

Decisions to Ponder

The patient does not appear in great discomfort. Does the crew initiate a full assessment and then transport, or let the patient and his wife proceed by private vehicle to the hospital of their choice? Do they document the patient interaction?

The wife says she can find her way to a community hospital on the other side of town. It is 1630 hours, and she believes their physician’s office is closed. That physician always admits to that hospital, so she will proceed to that ED and have her husband checked. No patient interaction report is completed.

The couple proceeds off the ramp and toward the hospital. Traffic across town is congested, and it takes about an hour to arrive at the ED. Upon arrival at the entrance door, the patient is diaphoretic and in severe pain. A stretcher is brought to the car, and the patient is loaded onto it by the ED staff. Whisked into the ED, he deteriorates rapidly, and after a short time is taken to the OR. He exsanguinates from a ruptured abdominal aortic aneurysm and dies. The wife states to the ED staff: “I wonder why the crew at the station didn’t tell me about this problem?” The ED staff calls the station…

Medical Issues

What happened? This patient was stable on initial presentation, then took a rapid downhill course, deteriorating to death. Many disease processes can have difficult symptoms to sort out. This patient was evaluated in an atypical environment, and his disease process is one that is often disguised, even to ED staff.

Long-term hypertension places a strain on the walls of the aorta. Eventually those walls can weaken and bulge, and can split between the several layers that compose the aorta. This is like the bulging of a garden hose under pressure.

Ruptured abdominal aortic aneurysm (AAA) results when the wall finally gives way and the patient loses blood volume, and/or blood flow to the abdomen or distal areas is compromised. When an abdominal aortic aneurysm tears or ruptures, the patient may present classically with pain in the abdomen, back or groin area. It is not unusual for the patient or their significant other to offer another explanation for the pain; kidney stones and constipation are favorite alternatives. Until free rupture occurs, the patient’s blood pressure may remain elevated, and the patient may have excellent pulses in arteries of the groin and lower extremities. The aneurysm is sometimes palpable on careful physical examination.

When free rupture occurs, the patient may present in hypovolemic shock and cardiovascular failure. Rapid surgical intervention is critical to save the patient and the major organs, including the kidneys, spinal cord and intestines. The prehospital provider should always consider a ruptured AAA when a patient with a history of hypertension presents with abdominal, back or groin pain. It also should be considered in patients with other history of vascular diseases, and in persons with Marfan Syndrome.

Discussion

The patient presenting in an unusual way is an exceptional challenge to the evaluation and management skills of the EMS provider. The EMS service will want to carefully craft a process to guide the services provided to a patient who requests evaluation under atypical circumstances. This could include those persons “just here to have my blood pressure checked,” those who walk up while the crew is conducting other business (like refueling the vehicle) and those who walk or drive up to the posting station. The elements of the process and policy will include those evaluation services to be provided, the documentation to be completed and the need for transportation service or completion of refusal forms.