GetMeOuttaThisMess Posted January 19, 2018 Share Posted January 19, 2018 Early middle-aged male today who has a week hx. of ILI sx. and was provided Tamiflu through America's favorite healthcare provider, Tele-Doc, which he completed last night. Comes in today (never should have made it past the front desk in a snot/cough clinic) with dizziness and hitting curbs with tires while driving. What I want to know is whether anyone can top a patient on 10 different psychotropic agents at one time? No focal deficit though a flat affect and speech was hard to understand though not mumbling. No trauma, HA, other focal sx. and had a normal gait. No fever. No confusion, perfectly lucid, and oriented to PPT. Of course, no PCP. Called mom at pt. request, instead of wife who was at work, to determine whether this was his normal baseline state considering his med list since apparently pt. and family live with mom. Mom states that "no" this is not his normal affect and she will provide transportation assuming he still has inflated tires to drive on. Told him to go to ED for further assessment (possible noggin scan and blood work, including one very specific, simple test) which of course he didn't since I called to check at 7 pm local time. Surprise! No interaction with Tamiflu and ANY of the psychotropic agents. Bad for me because I was trying to get him out of the clinic since I had a THREEFER waiting on me with sx. which we also don't see in the clinic (GI). As a result, what is the basic test which we should've done, but didn't, considering we only do rapid tests, UA's, preggo tests, and one other possible test which some include a vital sign? SP, who I spoke with, also didn't think of it. When I called back I did inquire if there were any other folks in the residence with similar sx. thus implying that I was looking for what? Clue: he had no N/V Link to comment Share on other sites More sharing options...
Guest ral Posted January 19, 2018 Share Posted January 19, 2018 Middle of a cold snap here in North Texas, with temps down into the teens some nights. Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted January 19, 2018 Author Share Posted January 19, 2018 10 minutes ago, ral said: Middle of a cold snap here in North Texas, with temps down into the teens some nights. You are SO sneaky. Link to comment Share on other sites More sharing options...
narcan Posted January 19, 2018 Share Posted January 19, 2018 I, too, discourage the rampant use of space heaters in enclosed spaces. And don't forget syphilis. It can always be syphilis. Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted January 19, 2018 Author Share Posted January 19, 2018 In my clinic there is no such thing as this syphilis that you speak of. It was spoken of only by the forefathers who practiced real medicine. Link to comment Share on other sites More sharing options...
Guest JMPA Posted January 19, 2018 Share Posted January 19, 2018 i would consider carbon monoxide in my differential Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted January 19, 2018 Moderator Share Posted January 19, 2018 Can't beat 10 psych meds, but I did once have a pt with a drug screen + for literally everything. she also had a bacterial endocarditis from using IV everything and died 2 days later. Link to comment Share on other sites More sharing options...
south Posted January 19, 2018 Share Posted January 19, 2018 56 minutes ago, EMEDPA said: did once have a pt with a drug screen + for literally everything This happened once a week at county. We also had a lot of professional drinkers with BAC's in the 700's (the most I saw was 777). That takes years of concerted effort. That's a BAL of 0.70 where 0.08 is the legal limit. move the decimal 3 places. Most drug users like to be either "up" (coke, meth) or "down" (heroin, opioids). Some can ride both sides of that dragon. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted January 19, 2018 Moderator Share Posted January 19, 2018 3 hours ago, south said: This happened once a week at county. We also had a lot of professional drinkers with BAC's in the 700's (the most I saw was 777). That takes years of concerted effort. That's a BAL of 0.70 where 0.08 is the legal limit. move the decimal 3 places. Most drug users like to be either "up" (coke, meth) or "down" (heroin, opioids). Some can ride both sides of that dragon. I think mine was + for coke, meth, opiates, marijuana, tricyclics, pcp, and benzos. at one of my rural jobs I regularly see BALs in the high 400s and we often run a pool to guess the level. also it is not uncommon in the 9 bed ED to have 3 patients with total BALs > 1000. have only seen >700 once, although once saw 500 in DTs....usually drank 2 bottles of JD per day. only got one that day.... Link to comment Share on other sites More sharing options...
WeBuyAndSellJunk Posted January 19, 2018 Share Posted January 19, 2018 Umm... where is the blood glucose value? I am guessing this is not it since it seems like the battery of tests that the ED did perform would include it, but no mention above yet! Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted January 19, 2018 Author Share Posted January 19, 2018 And we have a winner (actually two). First rule of EMS/EM, if altered in any way check a FSBS. So why didn't I think to get one? The details regarding a House of God rule that came into play on my way to work disrupted the trip and thus pt. interaction since my mind was elsewhere with my remaining parent (here's the acronym: GGTG and all need football helmets). That being said, while altered, he wasn't the typical hypoglycemic in that he was conversive, though hard to understand, and was able to perform/respond to all requests that I made so my initial impression was zombieosis as a result of his pharmaceutical needs, though I couldn't exclude a CNS issue due to recent illness of some such. JMPA is thinking outside the box as well which is why I actually called to check on him at night to make sure that all weren't out of it (I can access the pt. info from home via the wonders of the web and no one else was ill). He was in no remote way cherry red at time of assessment. Link to comment Share on other sites More sharing options...
sk732 Posted January 19, 2018 Share Posted January 19, 2018 Can't say I can top 10 psychotropic agents at once, though have seen some moldy folks on 2 narcotics and 3 or more benzos at a time. We had a guy in the dept the other day that was on 1400mg Morphine equivalents in hydromorphone - 30 contin tid and 24mg rapid for break through tid-qid. I still cringe when I think about the 93 year old lady I admitted in school when I was in a semirural ED that came in with a blood glucose of 1.9 or 2mmol and kept falling down. After I stopped 3 of her antihyperglycemics, the medication orders still came out at 23 - I had to start a second order sheet just for the meds. When patients whine that they're on only double or triple therapy for their BP and take "too many pills", I bring this up and they get sheepish...if they're really annoying, I usually say something some might consider unkind like "get off your ample bottom, go for a walk and restrict your pizza intake to a couple times a month vice per day". Did you ever hear back regarding the carboxy levels? SK Link to comment Share on other sites More sharing options...
thinkertdm Posted January 19, 2018 Share Posted January 19, 2018 With all those psychotropic meds and no one running the show, how about serotonin syndrome? Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted January 19, 2018 Author Share Posted January 19, 2018 No tachy, no hyperreflexia, no diaphoresis, and certainly not agitated. Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted January 19, 2018 Author Share Posted January 19, 2018 Can't say I can top 10 psychotropic agents at once, though have seen some moldy folks on 2 narcotics and 3 or more benzos at a time. We had a guy in the dept the other day that was on 1400mg Morphine equivalents in hydromorphone - 30 contin tid and 24mg rapid for break through tid-qid. I still cringe when I think about the 93 year old lady I admitted in school when I was in a semirural ED that came in with a blood glucose of 1.9 or 2mmol and kept falling down. After I stopped 3 of her antihyperglycemics, the medication orders still came out at 23 - I had to start a second order sheet just for the meds. When patients whine that they're on only double or triple therapy for their BP and take "too many pills", I bring this up and they get sheepish...if they're really annoying, I usually say something some might consider unkind like "get off your ample bottom, go for a walk and restrict your pizza intake to a couple times a month vice per day". Did you ever hear back regarding the carboxy levels? SKNo way to test but household all normal, at least last night. Link to comment Share on other sites More sharing options...
sk732 Posted January 20, 2018 Share Posted January 20, 2018 Downer - take it the ER didn't bother either then? I worked in a place where we had a dual O2/CO sat monitor for stuff like that or for fire exposures and such. We also had some on my last base for the submariners, since our boats are diesel. SK Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted January 20, 2018 Author Share Posted January 20, 2018 He never went, at least yesterday. Sent from my iPad using Tapatalk Link to comment Share on other sites More sharing options...
narcan Posted January 20, 2018 Share Posted January 20, 2018 17 hours ago, south said: This happened once a week at county. We also had a lot of professional drinkers with BAC's in the 700's (the most I saw was 777). That takes years of concerted effort. That's a BAL of 0.70 where 0.08 is the legal limit. move the decimal 3 places. Most drug users like to be either "up" (coke, meth) or "down" (heroin, opioids). Some can ride both sides of that dragon. True with drugs as it is with dancing, you gotta get up to get down. Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted January 20, 2018 Author Share Posted January 20, 2018 OK, just for fun, can a person be a monster alcoholic and consume multiple (>10) alcoholic beverages over 24 hours and never tip the BAC above normal? If your answer is "yes", then how did they do so? I took a class many years ago for work to be certified as a BAC examiner (never did a single one but calibrated the equipment monthly) and this was a question. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted January 21, 2018 Moderator Share Posted January 21, 2018 8 hours ago, GetMeOuttaThisMess said: OK, just for fun, can a person be a monster alcoholic and consume multiple (>10) alcoholic beverages over 24 hours and never tip the BAC above normal? If your answer is "yes", then how did they do so? I took a class many years ago for work to be certified as a BAC examiner (never did a single one but calibrated the equipment monthly) and this was a question. their liver is so ramped up that they have alcohol dehydrogenase coming out their pores and it detoxifies the alcohol as it enters their mouth.....:) or, they are on antabuse and throw up each drink within minutes of consuming it... Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted January 21, 2018 Author Share Posted January 21, 2018 For a normal adult male (not female) he should, with normal bodily metabolism, be able to clear .02 ETOH /hr. Each traditional ETOH dosing as specified by “recommended dosing” would result in a BAC of .02 itself. Based on these findings one should be able to consume one drink per hour for 23 hours w/o tipping the BAC. Sounds crazy but those in the know claim it is correct. Link to comment Share on other sites More sharing options...
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