Belly Bump

   The local truck stop is a site where many unusual patient presentations and colorful medical histories are found. Attack One is dispatched today for a "man down." The crew finds the patient between two trucks near the store, where he lies on the ground with his feet propped up by a helpful bystander. "He was just completely out," says this lady, an employee of the truck stop. "He fell like his legs were cut out from under him."

   The patient is in his early 20s and able to speak clearly to the crew. He is a long-distance driver from out of state. He'd only been on the road a couple hours this morning when he began to feel light-headed and nauseated, and decided to pull in to the truck stop. He has an empty trailer and is headed home, so is under no deadlines.

   He relates that he'd parked and was walking to the store when he'd had a rapid onset of upper abdominal pain, then nausea, then passed out. He hadn't experienced anything like this before. He says when he woke up, the lady was helping him and his pain was gone, but every time he tried to sit up, he got nauseated and light-headed again.

   The woman confirms the story, adding he was unconscious for about 2-3 minutes. She didn't know how to feel for a pulse, and feeling this patient's pulse is difficult--it's barely present at his wrists. The EMT can only palpate a blood pressure of around 80, with a rapid heart rate. The crew notices the man's skin is pale, he's a little sweaty, and his capillary refill is slow. Signs of poor perfusion are consistent with an initial pulse oximeter reading in the upper 80s.

   "Sir, there is a good reason you feel so bad when you try to sit up," the paramedic tells him. "Your blood pressure is really low, even on your back with your feet up. We need to start an IV and take you to the hospital." The medic then goes through an exhaustive list trying to find a cause for the poor perfusion.

• No bleeding, including no history of black stools.
• Plenty of fluids to drink, and no alcohol.
• No drugs, off the street or prescribed.
• No insect stings/bites, peanuts eaten or medication taken, and no history of any type of allergies.
• No diarrhea or vomiting, and the nausea only started when he had the sharp pain. No history of bleeding in the GI tract.
• No chest or back pain. The abdominal pain has cleared.
• No surgeries, ever.
• No history of bleeding or hemophilia in the family; no bleeding from teeth, gums or nose.
• No recent accidents, trauma or other injuries.

   The man's only history findings are some feeling of tiredness over the last few days, and an episode about three weeks ago where he'd had a fever, sore throat and fatigue that lasted a few days. He hasn't been exposed to any other illnesses or sick persons he is aware of.

   The crew examines him quickly and as well as they can in the lot. He has no signs of trauma or bleeding. His neck veins are flat, his chest is clear. They palpate his abdomen through his clothing, and he describes a mild discomfort in his entire abdomen, saying it feels "bloated." He is a little tender throughout, though his back is not. He moves his extremities and has no neurologic deficits. His pulse is regular and fast, and he appears slightly pale.

   Concerned that they don't find a cause for his poor perfusion, the crew sets up for a rapid removal. They advise the patient that he needs to go quickly to a hospital, and they will need to start an IV and do an EKG in the ambulance. He says he feels better, and is concerned about leaving his truck in a truck stop far from home.

   "Can I just drive to the hospital, and you guys can follow me?" he asks, moving to sit up. But he doesn't make it upright before he sinks back down. "Boy, do I feel dizzy--like I'm going to pass out again."

   The truck stop employee offers to get the truck secured. "Son," she says, "you can't go anywhere unless it's in the back of an ambulance."

Transport and Emergency Department