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  1. #121
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    Probably not the issue for your wife but my dad is going through blood pressure issues. His blood pressure will be fine sitting down and as soon as he stands up it drops to 60ish and he will either pass out or nearly fall down. Dr's couldn't figure it out and finally after almost every test that they could do they determined his heart was fine. The issue ended up being the little one way valves in his arteries aren't working properly so when he stands up instead of keeping blood in his brain it all drains down to his legs.

    He is 86 this year and they said they couldn't do anything for him so now he takes blood thinners (for blood clots that keep forming in his lungs due to lesions there from when he was on a submarine) and blood pressure raising medication. Also he exercises a lot. But he is stuck with a walker now because of the blood pressure issue.

  2. #122
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    The circumstances sound like syncope related to orthostatic hypotension. That could be caused by a number of things, such as valvular disorders as Zoob outlined. Could be as simple as needing a blood pressure meds adjustment. She could've been on the same meds for years, but outlying circumstances could necessitate a change in meds or dosages. Weight loss, new meds, new disease process are some examples. Could be other things, namely, as kuro said, electrolyte imbalances (calcium, magnesium, those things) or para/thyroid disorders (which would cause electrolyte imbalances due to disturbances in hormone secretion) or arrythmias. Ultimately, see a cardiologist. As far as expectations, she will likely gets some labs, an EKG, and possibly a holter monitor (heart monitor she will wear for a few days and cardiologist can review any weird shit that happens with her heart).

    Until you see someone and figure it out, there is something that MAY help (if it's orthostatic)...take your time getting up and down from a seated position. Get your wits about you. Stand up near a bed or chair and don't move for a few seconds before walking. You know how sometimes when you stand up really quick you get dizzy for a few seconds? That's your BP bottoming out. For some people, their heart can't compensate quickly, and it can happen very often to the point you pass out. This is especially true if you're already low to start with because meds dosages need adjusted. So don't get in a hurry with sudden position changes until you get a diagnosis.

  3. #123
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    Thanks for the replies y'all. I forgot to mention, they did give her potassium saying hers was low. And she has been on the same meds for quite some time. First thing Monday we'll be contacting our PCP and get this done. She got up later last night saying she felt better so that's good. We'll see. I think we are entering the "we aren't kids anymore" phase of life and need to start acting accordingly.

  4. #124
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    Which meds?

  5. #125
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    Amlodipine 5mg and Lisinopril 10mg.

  6. #126
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    I'm inclined to agree with Tyche that it's likely orthostatic with some underlying dehydration/overexertion, but they need to look at the thyroid and heart to rule out structural arrhythmia. If they had to replace electrolytes that can also cause arrhythmia but they need to figure out why.

  7. #127
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    Question for EMS transport.

    You arrive at the home of the patient. They're literally screaming in agony in the fetal position. Severe stomach pain. They can not stand nor cloth themselves. Their wife is home.

    At this point, what should the next move for EMS be? Offer to help? Get the gurney? Stand there staring at the wife saying "you need to get some clothes on him?"

    Wife manages to haphazardly get pants and shirt and shoes on after a severe struggle.

    Patient is still screaming in agony. You tell them they need to stand up. They say that they can't.

    Again, get a gurney? Continue to tell them they have to stand up? Offer a hand to try to get them on their feet? Offer a hand after the wife falls over trying to help the patient up?

    Screaming they manage to grab your hand and get up, nearly falling over, several times, pausing, several times, trying to cling to the one hand that was offered by one of the two EMS personnel, on the way to the ambulance.

    Once inside, you let them figure out how to get on the gurney by offering instructions. "Sit there."

    At this point, is there any requirement to help secure the patient that's clinging with one hand on the rail of the gurney? Or do you just let them ride to the hospital like that? The ambulance hits a speed bump on the way out of the apartment complex and the patient nearly falls off. Still just let it ride? Turning out of the complex, same thing.

    This happened to me this past Friday night. The only questions ever asked were drug use, location of pain, drug use, if I still had my gaul bladder, drugs use, still have appendix, drug use, drug use, oh and drug use despite the answer being the same fucking thing every single time.

    It didn't dawn on me how fucked this was until my surgeon, who married my cousin and is a close family friend obviously, said they probably saw a skinny guy with tattoos and figured I was some doper going through withdrawals or looking for pain meds.

    I had a perforated ulcer, my stomach was bleeding out acid and saliva onto/into (however it works) my intestines, which causes the stomach to go rigid, causing excruciating pain, particularly in the lower right quadrant. I'm sure I fucked that up, but I'm still on meds damn it. It was the worst pain I've ever felt in my life, because I let it go until it became severe because I have such a high pain tolerance (which obviously I discovered my cap). Edit: to compound matters and a huge factor as to the cause of the ulcer, I was aslo in the middle of a regimen of prednisone for injuries from totalling my car the Tuesday prior to this. Pretty much a worst case scenario other than my age and health.

    I'm not looking to kick a hornet's nest and cost people their jobs/careers etc unless it's truly warranted. I want to know if any of this is egregious because I honestly want to get five minutes to talk to them to remind them that although stereotypes exist for a reason, it doesn't mean it's the reason. Because of said doctor friend I can make that happen instead of trying to burn them at the stake. I'm lucky because I live somewhat close to the hospital, but I'm legitimately concerned someone else may end up with more severe trauma or even die because of this nonchalant attitude. I need to figure out how to frame the conversation.

    It absolutely fucking terrified my wife. She called for help. Help came...and did absolutely as little as possible.

    Thanks BG.

    Sidenote - I get discharged tomorrow. Came out of surgery stable so I dodged ICU. Thanks to my overall health I'm recovering rapidly, though it's going to be a few weeks before I get all of my mobility back.

    Sent from my SM-G960U using Tapatalk

  8. #128
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    Unless your doctor friend is the chief of medicine or you live in some small rural community where everyone kinda knows everyone, it would be incredibly stupid and outright unethical to allow you to approach them. He should know better. If I was trying to help someone who didn't like the way I was doing that and that patient reported this outside of the correct protocols and a physician allowed the patient to breach protocol and approach me, I would have his ass hanged by our ethical committee.

    Only thing I'm reading that ems maybe did wrong was not strap you in. Drug use in the situation they walked in on would be near the top of the differential. Those questions weren't out of line. Repeating them was not out of line. Also, no, you didn't need clothes on. They either just cut that off or take it off once you hit ER. Nothing I've read here would get anyone even reprimanded.

    You have to understand ems is first on scene. They know nothing about
    you or your history. They can't utilize information to critically think outside of the acute presentation. It's a young guy, tattooed, screaming. This isn't a common situation not involving illegal substances. They don't know your pain tolerance. They don't know what meds you take. They don't know if you're a rational actor and good historian.

    They know they have a screaming young guy in a floor. They probably judged you, but ems should judge people. They were wrong. They def should have secured you. And maybe they could have had better manners, but nothing here seems intentionally malicious.

    File a complaint with your patient advocate and see where that takes you.

  9. #129
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    Quote Originally Posted by Tyche View Post
    Unless your doctor friend is the chief of medicine or you live in some small rural community where everyone kinda knows everyone, it would be incredibly stupid and outright unethical to allow you to approach them. He should know better. If I was trying to help someone who didn't like the way I was doing that and that patient reported this outside of the correct protocols and a physician allowed the patient to breach protocol and approach me, I would have his ass hanged by our ethical committee.

    Only thing I'm reading that ems maybe did wrong was not strap you in. Drug use in the situation they walked in on would be near the top of the differential. Those questions weren't out of line. Repeating them was not out of line. Also, no, you didn't need clothes on. They either just cut that off or take it off once you hit ER. Nothing I've read here would get anyone even reprimanded.

    You have to understand ems is first on scene. They know nothing about
    you or your history. They can't utilize information to critically think outside of the acute presentation. It's a young guy, tattooed, screaming. This isn't a common situation not involving illegal substances. They don't know your pain tolerance. They don't know what meds you take. They don't know if you're a rational actor and good historian.

    They know they have a screaming young guy in a floor. They probably judged you, but ems should judge people. They were wrong. They def should have secured you. And maybe they could have had better manners, but nothing here seems intentionally malicious.

    File a complaint with your patient advocate and see where that takes you.
    That's exactly why I wanted advice. And yes, it is a rural community where everyone knows everyone (i.e. my mom didn't tell anyone from work what happened over the weekend yet everyone knew when she walked in to work Monday because several of their spouses also work at the hospital, she's an RMA at a family practice here). I know I'm still medicated and not thinking entirely clearly, but clearly enough to know I don't want to unjustly cause a bunch of grief and potentially damage someone's career, life, etc. I'm just not the type of guy to fly off the handle until I fully grasp the situation, so I wanted to get ahead of it, get an objective point of view, and educate myself before any action. I mean hell, I've got nothing but time for the next few weeks to let everything marinate.

    You're always on point Tyche. Thanks. It really makes me feel better about the situation. I can not fathom doing the job they do. It's frustrating from my standpoint for obvious reasons, but you just clicked that struggling little light bulb I have on.

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  10. #130
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    Man Tyche gets all the good ones.

  11. #131
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    One day he's jumping up and down while the rest of the server groans because d.feet dropped, the next he's giving pro medical advice.

    Crazy times. (For some reason that's still one of the most hilarious HNM moments I can remember from FFXI).

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  12. #132
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    If they didn't strap you in they'll probably lose their jobs or certs. You can complain directly to their department. if Volunteer though who knows.

  13. #133
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    Venous insufficiency isn't uncommon in the middle-aged or older populations. The veins in the legs have one-way valves and over time the veins increase in compliance and distensibility, and pressure/backflow on the valves may make them incompetent. More blood can pool in the lower extremities, making it less available to return to the heart, decreasing preload, and decreasing cardiac output - less blood going not just to the head, but pretty much everywhere. There's three mechanisms to return blood to the heart (not every vein has one-way valves in it, but a lot do!).

    1) skeletal muscle - normal activity/walking compresses the deep veins of the legs and arms through cycles of contraction and relaxation returning blood to the heart
    2) respiratory - pressure changes in the abdomen/chest squeeze blood back toward the heart (following the favorable pressure gradient with normal breathing, return is greater with a deeper breath)
    3) ventricular contraction - blood moving through the AV valve from the right atrium to right ventricle has a slight suction effect during systole/ventricular contraction

    The two antihypertensive medications are probably the most likely thing causing the problem. Calcium channel blockers in particular cause peripheral edema (fluid collects in extremities, may have noticed swelling around the ankles). The most likely thing for a doc to do is maybe lower the dose of the amlodipine, for instance if he's on 10 mg daily, drop it to 5 mg daily, and have him do ambulatory blood pressure monitoring. You could do a battery of tests, like CBC, CMP, TSH, an EKG, but the history is so consistent for orthostatic hypotension. The problem a lot of people run into is trying to tightly control blood pressure to 120/80, which is great, you have lower risk of all the sequelae of high blood pressure, but if you drop blood pressure too low then you increase fall risk with reduced blood flow to the brain/orthostasis.

  14. #134
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    A new challenger approaches !

  15. #135
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    Quote Originally Posted by kuronosan View Post
    A new challenger approaches !
    To think this all started around FFXI is pretty awesome. I was in Outspoken, the LS with the infamous CFH on KB.

    Now I am a physician (M.D.). Time flies!

  16. #136
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    Wait what you became a doctor too? That's awesome.

  17. #137
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    Someone done wrote an H&P on BG and dropped sequelae.

    I remember I would talk to you about running a lot. I stopped running after I started school. Just didn't have time for 1-3 hour runs 5 days a week. Now I casually bike.

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    I wanted to do it too but I got too old too fast and landed good jobs with a house and kids and it seems impossible to do now financially. Even if I graduated at 50 I still think about it.

  19. #139
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    I bet you could. I have several classmates in their 40s.

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    Quote Originally Posted by kuronosan View Post
    I bet you could. I have several classmates in their 40s.
    It's doable at any age, I think the oldest in my class was 42, former investment banker prior to pursuing medicine. The biggest consideration for most older med students isn't whether they are capable of doing it, but the debt you have at the end. Assuming you go into a well-paying specialty, you should be able to live like a resident even when you're an attending and pay off your debt quickly as long as you avoid lifestyle bloat.

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