Hey, Look at This

The call is for a possible stroke — a fifty-year old cancer patient can’t move her right side.

I’m thinking it’s not a stroke. Maybe weakness, maybe a tumor. But it could be a stroke. We’ll see when we get there.

The woman is lying in bed. Her eyes look up at me as I come through the doorway. She is alert, her skin is warm and dry. She looks scared.

She was fine a half hour ago, she says when she took a nap. She woke up and now can’t move her right arm or right leg.

Her right arm lies lifeless at her side. She can’t squeeze my hand. I lift the arm up and it falls back to the bed. She can’t lift her right leg, but when I have her try to push against my hand, I feel some force against it, like the strength is coming from her hip. Odd.

Her speech is clear. No facial droop. Never had anything like this happen before.

Her only history is breast cancer that was cured, and then a year ago, cervical cancer. She’s undergoing chemo. And now she can’t move her right side. Fifty years old

We lift her up onto our stretcher. She can’t weigh more than a hundred pounds.

Out in the ambulance, I check her out. Her heart rate is in the 130’s. Her BP is 110/70. Lungs are clear.

No headache. Pupils are equal and reactive. Her right arm is still flaccid. Odd.

I check her other arm for a vein and don’t see much. She tells me she has a port.

Okay, I say. I’ll let them use that at the hospital. Spare you a needle.

Thanks. I’ve had my share of needles lately.

I do have to check your sugar, I say. It’s just protocol. You ever had any sugar problems? Diabetes?

No.

It’s a little prick in the finger. We have to do one on all possible stroke patients. I don’t do it, they’ll ask what your sugar is, and I’ll say, I don’t know, but your not diabetic, but they’ll still need to do it anyway. Its best to just do it.

Okay.

I prick her finger and squeeze out a little drop of blood. I press the glucometer strip against it, and watch as the blood is sucked into the strip, and the machine starts its countdown.

5, 4, 3, 2, 1. Reading — 66.

Okay, that’s interesting. Your sugar is a little low. Not greatly so — the normal range is 70-110 — but a little low. Have you been eating?

Not much. I haven’t had an appetite.

Well, protocol again. I really should put in an IV and give you a little sugar water. Just to cover all the bases. So we can rule out your sugar being the cause, which I doubt it is. I’ve had patients I thought were having massive strokes only to find their sugar down in the 20’s, but 66 isn’t very low.

If you have to, she says.

All I can find is a thin vein in her hand, which I thread a 24 into.

I squirt out half an amp of D50 into the sharps box, and then stick the needle into a 250 bag of saline and draw out 25 cc. I shake the new mix of 12.5 grams of D25 up and then push it through the saline lock. It flows easily. When I am done, I toss the bristojet into the sharps box, and pick up my clipboard to notate it.

As I am writing, I feel a tap on my leg.

I look over at the patient.

“Hey, look at this,” she says. She kicks her right leg up and down and waves her right arm, squeezing her hand in and out, in time like a vaudeville performer.

She has a smile on her face like a little girl at a magic show.

10 Comments

  • Patrick says:

    Why D-25?

  • Ian says:

    Perhaps because of the 24g IV?

  • PC says:

    The D25 certainly made it easier to push the drug through the small guage IV and being less concentrated will be easier in the vein.Recently the pediatric doctors in our region have made it regional policy for EMS to push D25 on all peds 16 years and less. I have also read a number of articles that suggest that D25 or even D10 (D50 mixed into a 250 cc bag of NS) should be the standard instead of D50. Not only less damage to the vein, but easier on the system. Thanks for the comments.PC

  • Anonymous says:

    Why D25, as in why not oral glucose or fruit juice or something?

  • Patrick says:

    I was wondering if it had to do with the borderline blood sugar. I’m always looking for new ideas.We’ve been using D-25 for peds and D-12.5 (cut your D-50 twice) for infants for a while. They don’t get used much.

  • Anonymous says:

    Our protocols are for D50 on adults, D25 on peds, and maybe D10, if I remember, for baby babies.I’ve used the D25 on adults when I had problems with the D50, like the tube was cracked. They seems to be prone to breakage in our bags. The D25 seems to be a wiser option for little bitty veins, particularly finger or hand veins, in the event that you lose the IV somehow. I have never had it happen, but I know that D50 infiltrating means horrible necrosis. Plus it just flows so much nicer.I can’t speak for the treatment as noted here, but if I was in this situation, I would opt for IV dextrose over oral due to the speed of action. While it may be low blood sugar, if it is in fact a stroke with an onset that can be pinpointed to a recent time, half an hour in this case, I wouldn’t want to wait for oral glucose to work.If it was a new onset stroke, and I’m sitting on scene waiting to see if oral glucose will help, and it turns out NOT to help, then I’ve spent a lot of time doing nothing while the patient’s brain is dying.

  • Anonymous says:

    I’d have mixed feeling about pushing D50 into a hand vein, and especially a hand vein that I could only hit with a 24g. I’m still not entirely clear on what was causing the dyspraxia on the pt’s right side.

  • Anonymous says:

    I have been interested in taking a paramedic program at a local college for years now. I’ve been reading through the archives on this site.Thank you for writing such a touching and honest look at this field of work.I had been procrastinating going to school for many reasons…money, employment, etc…but your writing has truly inspired me to pursue my dream of starting a career in this field.I look forward to your future entries on this site, and want to thank you for providing me with that motivation to finally start the process of entering the emergency health care field.

  • Anonymous says:

    I’ve had a number of patients with hypoglycaemia manifesting as hemiplegia. Fortunately, I’ve always known that they were diabetic beforehand!I accept the comment made about not wasting time on scene and recently here, stroke management has become much more aggressive with active thrombolysis if we can get them to hospital within 3 hours from onset of symptoms. Still, there’s nothing to stop you do a blood sugar en route….saves you looking like a muppet when you turn up at the ED!

  • Chrysalis Angel says:

    What about a TIA, that then self corrected in the patient? Possibility? I know with cancer it causes the patients to throw clots. Something about the proteins within the tumors.There is a great article by a Dr. on Toradol at Suture for a Living. Thought maybe you would find that of interest.

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