Epistaxis-Syncope, SYNCOPE-HYPOTENSION-epistaxis

The call is for a nosebleed. Person unconscious in a car. We get updated that the patient is now conscious, but still some bleeding from the nose.

The first responder tells us the man has had a nose bleed all day and finally called a neighbor to drive him to the hospital. On the way, he passed out. The responder says the bleeding is down to a trickle.

We are at the side of a busy road so my partner and I lift the thin, frail man out of the front seat of his neighbor’s car and right onto the stretcher and then we wheel him over to the ambulance and get him in the back.

He is extremely diaphoretic and asks repeatedly if he locked his door. I try to tell him that we just picked him up from his neighbor’s car. He is in his eighties and I am guess he may some dementia. I take a blood pressure and just barely hear it at 90. While my partner tries for an IV, I do a quick 12-lead, but the electrodes just won’t stick. The man holds a Kleenex in his hand that is just dabbed with blood. There is no way a nosebleed would cause this kind of diaphoresis. Maybe it is posterior bleed, but there is no sign of throwing or spitting up clots. The man can tell me his date of birth, but not the names of his medicine. The only medical history I get is hypertension. I ask if he is on a beta blocker, but he doesn’t seem to know what I am talking about. I ask because his heart rate is only in the 80’s.

My patch to the hospital is brief, “We’re seven minutes out with an 80 year old with a supposed uncontrolled nose bleed earlier, had a neighbor drive him to the hospital, on the way he had a syncopal episode so they called 911. The nose bleed has stopped. He’s alert, but slightly confused, very diaphoretic with a BP of 90/50. Heart rate 88. Denies any pain. Only history I can get from him is hypertension.”

Not the best patch, but it’s about what I said. Generally to this hospital, they want short and sweet, just so they have an idea of what is coming in, so they know where to make room in ED. A major medical or trauma room, the Main ED, a Less Acute Wing, the psych ward or the waiting room, and whether or not this will need a doctor at the ready.

His skin looks a little mottled to me now and his hands are very cold. I try to take another pressure, but can’t hear anything. When I use the electronic cuff on the monitor I get 74/40 and then 66/38. I have by now popped in a second line — a 16 this time and am running the fluid in wide open. At triage I have to emphasize the syncope and the hypotension and deemphasise the nosebleed. We get the patient in the room. I give another quick report to the nurse. The nose bleed’s been stopped for me. He’s really cold and clammy and the last pressure I got was 66/38. When I come back to the room with my report, I see their monitor also has his pressure in the 60’s and the bag of saline is just about empty. The doctor in the room is asking the patient about his nosebleed. I give him the report then, and he listens attentively.

Then we clear the hospital and life continues on.

Two things happen this morning. First the night medic, who I recently precepted, tells me that it is her feeling that it really important that medics work patients up as thoroughly as possible because at least some of the hospitals(because they are so overcrowded) tend to listen to what we have to say. If we say the patient is sick, they take it seriously. If we don’t, they may put the patient in the hall or out in the waiting room. We are the patient’s advocate and we need all the information we can get in order to advocate most effectively. And after all, it is only one patient we are taking care of, while the ED is taking care of easily a hundred — with each nurse having seven or eight patients. For all we might bitch about it when we are ignored, the hospitals abd nurses do tend to rely on us. I really like what the medic is saying and how she is saying it, and I am pleased that she takes her responsibility as a medic seriously.

It makes me think about how in patches to the hospital or reports at triage, it is very important how I frame the information, and the order I put it in. If I had to do the patch over again, I might not even mention the nose bleed over the radio, while giving less weight to it in the direct paramedic-to-nurse report. Syncope. Hypotension. Also Epistaxis.

This morning I am at the hospital and a nurse comes over to me and tells me the man had a dissecting aneurysm. He lived in the ICU for five days till he expired. She theorizes that the nose bleed was from the hypertension. When the aneurysm ripped, his pressure plummeted and the nose bleed stopped.

Since few people with a ruptured aneurysm survive, I don’t know if a more urgent patch would have made much of a difference. Perhaps, if I had been more urgent, he would have gone into a major medical room with a doctor right there with a true sense urgency — not one pondering the nose bleed. At least, I suggested there was something more than a nosebleed at play. Nevertheless, it illustrates the point. We have to fight for our patient. The patients deserve it, and for the most part the hospitals expect us to do it. In many cases, a full assessment and an articulate, and at times passionate report will do as much or more for an ill patient than any actual care we render.


  • Gary says:

    A lot of the respect that a triage nurse or even physician will accord a report depends on the reputation of the service. Around my area, most of the private ambulance services aren’t well regarded. No doubt there are individual medics who are trusted by the nurses that know them, but over all the nurses are skeptical of their reports. In your area, it may well be different. If you’ve been around a while and the nurses know you, they probably will listen to you. The same likely goes for the doctors. Many of the medics in my service are on a first name basis with a good number of the attending physicians. It creates a bond and trust that I don’t think most medics have. It’s also a powerful weapon because our word is generally given a lot of weight. If we are wrong, then what we tell the nurses and doctors can lead them down the wrong road to the detriment of the patient. Which is why it’s important to be honest and when you don’t know what’s going on, say exactly that. I’ve done it more often than I care to admit, but it’s also a relief to have a resident or attending come out and say “I don’t know what’s going on either, but it’s bad”. Sorry to have comments that are almost as long as your post, but it’s an interesting topic.

  • kvegas911 says:

    You going around punching people in the nose again? *laughs*

  • PC says:

    Thanks for the comments. For the most part, in our state, 911 calls are handled by commercial services. What I find continually interesting is the different receptions you can get at different hospitals (much of this depends on the staff)depending on how well they know you. There are two hospitals I go to most every day(and have been for almost 15 years), two more I go to fairly regularly and then another eight or so I go to very irregularly. It is always amusing to encounter a new distrustful triage nurse (which is not by any means to say all new triage nurses are distrustful — most are open and professional). I had a young one recently demanding to know why I gave nitro to a patient without chest pain. How about to reduce preload to ease their dsypnea? They are in heart failure. For the most part the triage nurses are very good around here.You make a good point about admitting when you don’t know. I find myself doing that more and more.Thanks again for the comments.

  • Gary says:

    The more I practice, the more I realize how much I don’t know. Some people don’t get the dyspnea – nitro thing at all. I’ve had doctors ask my why I gave nitro to CHF patients. Maybe they should invest in an ACLS class!

  • FireResQGuru says:

    wow. Sometimes you just never know. I tell my students at the academy – Every single day I go to work, and even some times when I am teaching them, I learn something new.

  • Rogue Medic says:

    I read your more recent post about the IVs first. Here you describe putting large catheters in a hypotensive individual, who seems to change gender in the hospital – was it Dr. Deborah Peel? The hypotensive ones always seem to be the most difficult.As far as your report is concerned, you brought the doctor to the patient, gave an accurate report, and the doctor and nurse assessed the patient. Is there something else you should have included? No.If the doctor is not able to spot the signs of instability without your report, there is a problem with the doctor, not with your report.Yes, we should be advocates for the patient, but this patient seems to be a no brainer, clearly unstable patient. And I haven’t seen the patient, only read your description.More than likely, this patient was not going to have a good outcome if you had arranged for a trauma bay.

  • PC says:

    Thanks for the comments. I’ve corrected the gender issue. Due to HIPPA I have to change certain details and sometimes I don’t catch the gender switches.

  • Gary says:

    Or the typos. Fix the HIPPA thing, dude. Gary

  • PC says:

    Thanks. I thought I fixed the gender switch, but then saw I still left on in. I think I caught the typo too.

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