By Robert Donovan, M.D., FACEP
As you may have picked up from reading any of my earlier articles, I have a fascination with the complexity and simplicity of the human body. How we learn to speak is one; how a human life is conceived is another.
A 24 yr. old female standing in line at a store begins to feel a little weak and tired. In a few moments, she began sweating, her vision dimmed, and the next thing she remembers is a crowd of people standing over her. 911 had been called.
The good guys arrive
On arrival, the paramedics assessed the patient. She was still lying on the ground, but was obviously embarrassed by the whole affair. The medic noted she was awake and alert, with no complaints. Vitals taken show a heart rate of 74, respirations of 20, and a BP of 83/53. The vitals were repeated, without any significant change.
The medics helped her to her feet, but she got light-headed again until she lay down upon the gurney. She then said she had been having some pain from “cramps” for a day and she had started a little vaginal bleeding this morning, which she thought was her menstrual period starting. She denied being pregnant. An IV was placed, blood sugar checked, and a fluid bolus was given. Bystanders reported no seizure or incontinence.
The paramedic report was concise, but this experienced medic added an important point. She said, “Dr. Donovan, I’m worried about this patient. I know she looks ok now, but I think something is wrong — I just don’t know what!” I always take those words to heart.
My exam was about the same as the medics. The patient had low BP (improved after the 1 liter NS bolus) but wasn’t tachycardic. She did have some mild tenderness in her lower abdomen, but it wasn’t impressive. An ISTAT quickly showed normal electrolytes, and a hemoglobin of 10. That’s slightly low, but for a woman in childbearing age, not unheard of.
So I asked her some questions. Here are a few pointers for what I believe are pertinent questions.
Syncope pointers:
- Get a good history (have you heard this from me before???). Often, the history that the medics get at the scene trumps any history I may glean later. Being first on the scene gives you a distinct advantage.
- Was there a precipitating factor? Heat, strong emotions, skipped a meal?
- What were they doing just before they passed out? Standing? Sitting? Just getting up?
- Was there any jerking or convulsive activity? That certainly can point towards a seizure as being the culprit, but sometimes you may see just a quick jerk or two with plain syncope, especially if well-meaning bystanders keep the person in an upright position.
- Were they confused afterwards? Confusion for a minute is okay, but longer confusion suggests a seizure occurred.
- Talk to the witnesses and let them tell you the story in their own words.
This patient’s answers to my questions were straightforward:
She felt light-headed right before she fainted and, no, it wasn’t hot. She had eaten a meal 2 hours before. There was no seizure activity reported (per medics) and she wasn’t confused. So, what’s next?
Looking for love in all the wrong places
This is where technology is so useful. I moved our ultrasound machine to the bedside, put the probe on her belly, and, lo and behold, there was a great deal of free fluid in the abdomen! In this case it is probably blood. A quick urine pregnancy test is ... (drum roll) ... positive!
The Fog (see my article The Fog of EMS) begins to lift. This patient has an ectopic pregnancy, and has internal bleeding.
Reviewing the “normal” reproductive scenario (which we all learned in 5th-grade “health” class), an egg is released from a woman’s ovary in a cyclic fashion. If the timing (and extra-curricular activity) is right, millions of sperm from her partner travels up through the cervix and into the uterus. From there it continues into the fallopian tubes, on a collision course with the egg heading in the opposite direction.
After this simple, yet complex, collision, the fertilized egg continues to travel until it reaches the uterine lining, where, in a normal pregnancy, it implants and continues to grow.
In an ectopic pregnancy the fertilized egg is delayed on its travel to the uterus, and starts growing in ... all the wrong places. If it has implanted in the fallopian tube (sometimes implantation occurs in the abdominal cavity), eventually it grows to the point where is too large and ruptures. Blood starts leaking into the abdominal cavity.
So, the medic’s fluid bolus was a good call. I ordered 4 units of blood and called the on-call obstetrician. She is whisked off to surgery, the bleeding is stopped and she goes home the next day. Score one point for the good guys.
In closing, this patient’s presentation wasn’t that unusual. I have seen several cases where young women with internal bleeding from an ectopic don’t get tachycardic. Keep that in mind with your next syncope patient.
Medical pearls of wisdom:
- All patients tell us fibs. No Doc, I swear, I never, I don’t, I can’t (choose one)
• do drugs
• have sex
• know who beat me up
• be pregnant
• have chest pain - The medic was right on target when she said she was worried about the patient, even if she couldn’t say why. She trusted that inner voice, or her “gut” as I’ve referred to in other articles
- Don’t let the absence of tachycardia fool you into thinking that shock isn’t a possibility. This case was a great example. Also, people on beta blockers — or just those with old hearts — might not be able to mount a tachycardia.
- For any syncope, don’t stop your problem solving early. Go through your mind about the possible causes.
- Have fun — the work you do is invaluable, and tough. Enjoy the challenges and learn every day.
One Final Question: Do you think would it be a help in your practice if you had a small, portable ultrasound unit on your rig, and you were trained to do a fast exam. I can train a medic to do the most important view — Morrison’s Pouch — in about 2 minutes. Of course, practice/practice/practice would make you better at it. Drop me a line with your opinions — one way or another — and tell me your thoughts.
If you would like me to come and speak to your group, please drop me a note!
This article, originally published May 10, 2011, has been updated
