Sweatin' on the Sidewalk

The old fall in the community job. A classic some would say. Quintessential paramedic work. Whenever I am asked what the most common sort of job that I go to as a paramedic people expect me to say something like a cardiac arrest, or a car crash, or an assault. And whilst these do come around every now and again the number one job that I seem to go to (and my colleagues will likely corroborate this) is an elderly person having a fall in the community.

What is really meant by a fall anyway? Not a fall from height typically that’s for sure. What we meant is that someone has gone from either a standing position or transitioning to or from a standing position, and has ended up on the ground. Seems pretty simple, and when you are young fit and healthy this sort of mechanism would rarely result in any sort of serious injury. But as our bodies age, our physical resilience weakens, our bones grow brittle and our skin more fragile, we become less resilient to this sort of trauma.

Paramedics need to be very diligent when attending to a person who has had a fall in the community. We need to know exactly how the fall happened, what direction, which movement preceded it, what surface was landed on. We need to know what was injured, whether or not someone hit their head on the way down, whether or not someone lost consciousness throughout the fall. And most importantly of all, we need to know whether the fall was the product of a more sinister pathology, or just something that happened out of the blue.

I remember heading off to attend to a man in his sixties that had fallen over on a footpath in a suburb not far from where I was stationed some number of years ago. This normally isn’t the sort of job that gets triaged as an emergency, and today was no exception. It was nearing the end of shift, the sun was beginning to set and a balmy evening was upon us. It had been hot all day, as in mid thirties celsius. I remember dropping my wallet on the asphalt of a car park a few hours prior and distinctly noticed how hot the ground was.

We pulled into the street we were directed toward and it wasn’t long before we could see a small group converging around someone on the footpath. A moment later, someone caught sight of our presence and began waving frantically in our direction. This is pretty normal, the urgency of waving never corresponds with how sick the patient really is so we tend not let it bias our initial impression of what’s going on. Stepping out of the ambulance I offered some brief introductions to the crowd and asked any relatives of the patient to identify themselves. A lady introduced herself as the patient’s daughter and confirmed his name was Steve. I kneeled down next to Steve and introduced myself to him. “What are you doing all the way down here Steve?”, I state as a weak attempt to break the ice. “Well, to be perfectly honest with you Dave, I have no idea. I remember walking along the street with my daughter then I must’ve passed out because next thing I knew there were a bunch of people standing around me and they told me you guys were on the way.” This is a very important piece of information.

Steve was walking along fine, then suddenly he lost consciousness and woke up on the ground. The daughter endorses the same history, adding another crucial piece of information. That being she caught Steve in her arms as he fell, gently lowering him to the ground. This confirms that he didn’t strike his head violently and lose consciousness, something has happened for him to suddenly lose consciousness then fall. An important distinction. They also denied any seizure like activity or any history of seizures previously.

I take a moment to observe Steve’s breathing. It appears somewhat rapid, but that's to be expected when you’re out for a walk. I look at his face, his pupils are considerably dilated on both sides, certainly odd for being outside. He is sweaty, so very very sweaty. Far more sweaty than he should be despite how hot the pavement may be.

“Has anybody poured water on Steve’s face since he fell?”, but am met with silence in return. An odd question, I know, but you need to make sure.

I reach for Steve’s left wrist and feel for a pulse. The medico-centric word to describe what I felt is thready. In layman’s terms, it was irregular in its rate, strong and weak beats could be felt, seemed to be at about one hundred beats a minute, not super fast. Felt the same on his other arm.

“Any pains anywhere Steve?”, he shakes his head. “Any shortness of breath or breathing troubles?”, another shake of the head. “Can you feel how sweaty you are? Is that normal for you?”

“Well now that you mention it, I can feel how soaked my clothes are, and-”, he wipes his forehead with the back of his hand, “-I’ve never been this sweaty before in my life”

A quick palpated blood pressure gives me a number around one hundred systolic. Again, same on the other side. Low, probably for this guy. Not super low, but low enough for me to be cautious. I put the pulse oximeter on his finger and wait for the reading on his pulse rate and oximetry percentage.

Low perfusion.

Bit odd, I can feel his radial pulse just fine. I try another finger, giving the previously clamped fingernail a squeeze observing for the capillary refill. It looks to be about three seconds.

Low perfusion.

“Any pains in your stomach my friend?”, I push my palm into his abdomen hoping to not feel anything palpating. Nothing.

If my spidey senses weren’t tingling before, they certainly are now. I take a moment to think about the problem I have in front of me. Sudden, transient loss of consciousness, with an associated lowish blood pressure that has caused a fall to the ground. Without seizure or signs of stroke. But the pulse rate doesn’t seem too fast or too slow, just irregular. His pupils are ginormous and he is the sweatiest he has ever been in his life. When I think about this anatomically, I break the problem down into three main areas: the heart, the blood vessels and blood itself, and the brain.

I don’t have any evidence that there is anything inherently wrong with the brain at this point so I tentatively strike that off my mental list.

As for the blood and blood vessels, he certainly could have a bleed somewhere internally, but there hasn’t been any trauma to his body. Whilst not a definitive rule out, his pulses are identical in rate and blood pressure on both arms, and without any chest pain, a dissection of his aorta is unlikely given the lack of accompanying symptoms. Further down, the lack of palpable abdominal mass does rule out a leaky abdominal aortic aneurysm, but again the lack of accompanying symptoms would make this unlikely. But something is causing his blood vessels to tighten up as evidenced by his capillary refill delay. This is the product of a massive release of adrenaline in the body, which would certainly explain the dilated pupils and profuse sweating.

Which leaves us with the heart; the pump.

I remove my stethoscope that has sat idly around my neck and place the diaphragm onto Steve’s saturated shirt, just below his left nipple. It’s a symphony, the normal heart sounds which are akin to a lub dub, were replaced by a more continuous dub dub dub sound. Indicating a heart rate far far quicker than what I was feeling at his wrist. My partner must have already recognised something was amiss because she was already preparing the ecg for me.

“Steve you’re not going to like this, but I don’t want you to exert yourself at all, even to take your shirt off, so I’m going to cut it ok.”, he returns an understanding nod. I open up his shirt and attempt to place the first of the sticky ecg lead dots on his shoulders. It slips off instantly, he is just too sweaty.

“Mate I’m going to have to use the defibrillation pads to get a picture of your heart because these little stickers aren’t working”, another nod this time he looks more concerned.

Within seconds of applying the large adhesive pads the monitor begins alarming and printing something similar to this.

(ecg courtesy of https://litfs.com/)

Without being too technical, what you see here is an electrical representation of a heart that is beating far quicker than it should, stimulated from the bottom half of the heart; the ventricles, as opposed to what would normally be a specific location in the top part of the heart; the sinus node. Think of each one of these repeating shapes as a pulse of electricity through the heart, exciting the heart muscle to contract then proceeding in a circle back to where it started. This corresponds to a heart rate of 210-250 beats a minute, or far too fast to keep it simple. At this speed, the heart cannot refill itself fast enough to supply an adequate volume of blood to the body, particularly when fighting against the force of gravity when someone is standing. As the head is the most vertical part of the body when standing, and the brain is dependent on continuous blood flow to maintain consciousness, a very common initial symptom of this medical emergency is, in Steve’s case, a loss of consciousness. As he was lowered to the ground, the flow of blood to his head was no longer fighting against gravity, so he regained consciousness. Unfortunately in my ambulance service, we do not have a solution for this problem other than to bundle Steve up into the ambulance and race him to hospital. There he underwent what is known as a direct current cardioversion, or an electrical correction of his heart rhythm. This problem needs to be corrected rapidly as there is a potential for this ventricular electrical problem to degenerate from one that is essentially going round and round in a circle, to one that is just firing off in every location; or fibrillating, which is results in no blood being pumped out of the heart. So what causes this problem? Well a number of things can result in this electrical emergency, in Steve’s case it was scar tissue in his heart from a previous heart attack that rendered him susceptible.

Who would have thought that something as seemingly mundane such a fall could result in such an interesting clinical presentation!

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