A new puzzler

[Guest guest]

You are dispatched to a private residence for a possible " mental case. "  

You arrive at a mobile home in a neat mobile home park.  Outside are several

neighbors who report that the man who lives there has " gone crazy " and has

been shouting and throwing objects inside

the house.  One of them attempted to enter the house and talk to him and was

met with a man who screamed, " Get out before they get you. "   The neighbor

exited and called 911.  One neighbor says that the occupant is a retired police

officer, and that he has been ill lately, but that she has never seen him act in

any violent way before.  She is unaware of whether or not he has guns in the

house. She says that he keeps to himself, is not friendly, and seems to have

no friends, but has never caused any trouble. 

Shortly thereafter, two sheriff's deputies arrive.  One of them knows the

occupant and says he will attempt to talk to him.  He calls the occupant by

name,

and the occupant screams, " Get Thee Behind Me, Satan, and " You are all worms

and don't think I don't know it.  You will not kill me again. "

More officers arrive, and after a few minutes, they make entry into the

mobile home and subdue the patient. 

You enter and observe a man lying on his side on the floor, with his hands

cuffed behind his back.  He appears to be in his 50's, and is alternatively

screaming and raving incoherently.  After consulting with medical control you

administer lorazepam 4 mg/IM and haloperidol 5 mg/IM.  After a few minutes the

patient begins to calm down but remains disoriented.  He tells you that his name

is , but he does not know what day it is, where he is, or why you are

there.  He continues to talk about CIA " worms " and aliens from space. 

As he becomes more calm you manage to get a blood pressure, 178/96, a pulse

of 110 and irregular, and note his respirations are 24 and shallow.  He appears

to be jaundiced, with yellow skin and sclera.  He also appears at first to be

grossly obese, but your partner points out that his abdomen seems to be

distended, and palpation confirms that.  Your patient is unable to tell you

anything about his medical condition.

One of the sheriff's deputies brings you a bottle with a liquid in it labeled

" Oromorph, " and a prescription bottle for oxycodone.

Physical exam reveals no traumatic injuries. 

Based upon what you know so far, what is this patient's problem and why is he

" acting crazy? "

Docs, please give the medics a chance before you jump in.

Gene Gandy, JD, LP

EMS Education and Consulting

Tucson, AZ

**************

Vote for your city's best dining and nightlife. City's Best

2008.

(http://citysbest.aol.com?ncid=aolacg00050000000102)

[Guest guest]

Yes, the patient has a long history of alcohol abuse.

GG

> Are there any signs of alcohol abuse?

>

> W. Vondran EMT-P

>

>

> To: texasems-l ; Paramedicine@...:

> wegandy1938@...: Fri, 13 Jun 2008 00:47:53 -0400Subject:

A new

> puzzler

>

>

>

>

> You are dispatched to a private residence for a possible " mental case. " You

> arrive at a mobile home in a neat mobile home park.  Outside are several

> neighbors who report that the man who lives there has " gone crazy " and has

been

> shouting and throwing objects insidethe house.  One of them attempted to

enter

> the house and talk to him and was met with a man who screamed, " Get out

> before they get you. "   The neighbor exited and called 911.  One neighbor

says

> that the occupant is a retired police officer, and that he has been ill

lately,

> but that she has never seen him act in any violent way before.  She is

> unaware of whether or not he has guns in the house. She says that he keeps to

> himself, is not friendly, and seems to have no friends, but has never caused

any

> trouble. Shortly thereafter, two sheriff's deputies arrive.  One of them

knows

> the occupant and says he will attempt to talk to him.  He calls the occupant

> by name, and the occupant screams, " Get Thee Behind Me, Satan, and " You are

> all worms and don't think I don't know it.  You will not kill me again. " More

> officers arrive, and after a few minutes, they make entry into the mobile

> home and subdue the patient. You enter and observe a man lying on his side on

> the floor, with his hands cuffed behind his back.  He appears to be in his

> 50's, and is alternatively screaming and raving incoherently.  After

consulting

> with medical control you administer lorazepam 4 mg/IM and haloperidol 5

> mg/IM.  After a few minutes the patient begins to calm down but remains

> disoriented.  He tells you that his name is , but he does not know what

day it is,

> where he is, or why you are there.  He continues to talk about CIA " worms "

and

> aliens from space. As he becomes more calm you manage to get a blood

> pressure, 178/96, a pulse of 110 and irregular, and note his respirations are

24 and

> shallow.  He appears to be jaundiced, with yellow skin and sclera.  He also

> appears at first to be grossly obese, but your partner points out that his

> abdomen seems to be distended, and palpation confirms that.  Your patient is

> unable to tell you anything about his medical condition.One of the sheriff's

> deputies brings you a bottle with a liquid in it labeled " Oromorph, " and a

> prescription bottle for oxycodone.Physical exam reveals no traumatic injuries.

> Based upon what you know so far, what is this patient's problem and why is he

> " acting crazy? " Docs, please give the medics a chance before you jump in.Gene

> Gandy, JD, LPEMS Education and ConsultingTucson, AZ**************Vote for your

> city's best dining and nightlife. City's Best

> 2008.(http://citysbest.aol.com?ncid=aolacg00050000000102)[Non-text portions of

this message have been

> removed]

>

>

>

>

>

>

> _________________________________________________________________

> Now you can invite friends from Facebook and other groups to join you on

> Windows Liveâ„¢ Messenger. Add now.

> https://www.invite2messenger.net/im/?source=TXT_EML_WLH_AddNow_Now

>

>

[Guest guest]

Are there any signs of alcohol abuse?

W. Vondran EMT-P

To: texasems-l ; Paramedicine@...:

wegandy1938@...: Fri, 13 Jun 2008 00:47:53 -0400Subject: A

new puzzler

You are dispatched to a private residence for a possible " mental case. " You

arrive at a mobile home in a neat mobile home park. Outside are several

neighbors who report that the man who lives there has " gone crazy " and has been

shouting and throwing objects insidethe house. One of them attempted to enter

the house and talk to him and was met with a man who screamed, " Get out before

they get you. " The neighbor exited and called 911. One neighbor says that the

occupant is a retired police officer, and that he has been ill lately, but that

she has never seen him act in any violent way before. She is unaware of whether

or not he has guns in the house. She says that he keeps to himself, is not

friendly, and seems to have no friends, but has never caused any trouble.

Shortly thereafter, two sheriff's deputies arrive. One of them knows the

occupant and says he will attempt to talk to him. He calls the occupant by

name, and the occupant screams, " Get Thee Behind Me, Satan, and " You are all

worms and don't think I don't know it. You will not kill me again. " More

officers arrive, and after a few minutes, they make entry into the mobile home

and subdue the patient. You enter and observe a man lying on his side on the

floor, with his hands cuffed behind his back. He appears to be in his 50's, and

is alternatively screaming and raving incoherently. After consulting with

medical control you administer lorazepam 4 mg/IM and haloperidol 5 mg/IM. After

a few minutes the patient begins to calm down but remains disoriented. He tells

you that his name is , but he does not know what day it is, where he is, or

why you are there. He continues to talk about CIA " worms " and aliens from

space. As he becomes more calm you manage to get a blood pressure, 178/96, a

pulse of 110 and irregular, and note his respirations are 24 and shallow. He

appears to be jaundiced, with yellow skin and sclera. He also appears at first

to be grossly obese, but your partner points out that his abdomen seems to be

distended, and palpation confirms that. Your patient is unable to tell you

anything about his medical condition.One of the sheriff's deputies brings you a

bottle with a liquid in it labeled " Oromorph, " and a prescription bottle for

oxycodone.Physical exam reveals no traumatic injuries. Based upon what you know

so far, what is this patient's problem and why is he " acting crazy? " Docs, please

give the medics a chance before you jump in.Gene Gandy, JD, LPEMS Education and

ConsultingTucson, AZ**************Vote for your city's best dining and

nightlife. City's Best

2008.(http://citysbest.aol.com?ncid=aolacg00050000000102)[Non-text portions of

this message have been removed]

_________________________________________________________________

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[Guest guest]

Sounds like his ammonia level is elevated.

In a message dated 6/12/2008 11:48:16 P.M. Central Daylight Time,

wegandy1938@... writes:

You are dispatched to a private residence for a possible " mental case. "

You arrive at a mobile home in a neat mobile home park. Outside are several

neighbors who report that the man who lives there has " gone crazy " and has

been shouting and throwing objects inside

the house. One of them attempted to enter the house and talk to him and was

met with a man who screamed, " Get out before they get you. " The neighbor

exited and called 911. One neighbor says that the occupant is a retired

police

officer, and that he has been ill lately, but that she has never seen him

act in

any violent way before. She is unaware of whether or not he has guns in the

house. She says that he keeps to himself, is not friendly, and seems to have

no friends, but has never caused any trouble.

Shortly thereafter, two sheriff's deputies arrive. One of them knows the

occupant and says he will attempt to talk to him. He calls the occupant by

name,

and the occupant screams, " Get Thee Behind Me, Satan, and " You are all worms

and don't think I don't know it. You will not kill me again. "

More officers arrive, and after a few minutes, they make entry into the

mobile home and subdue the patient.

You enter and observe a man lying on his side on the floor, with his hands

cuffed behind his back. He appears to be in his 50's, and is alternatively

screaming and raving incoherently. After consulting with medical control

you

administer lorazepam 4 mg/IM and haloperidol 5 mg/IM. After a few minutes

the

patient begins to calm down but remains disoriented. He tells you that his

name

is , but he does not know what day it is, where he is, or why you are

there. He continues to talk about CIA " worms " and aliens from space.

As he becomes more calm you manage to get a blood pressure, 178/96, a pulse

of 110 and irregular, and note his respirations are 24 and shallow. He

appears

to be jaundiced, with yellow skin and sclera. He also appears at first to

be

grossly obese, but your partner points out that his abdomen seems to be

distended, and palpation confirms that. Your patient is unable to tell you

anything about his medical condition.

One of the sheriff's deputies brings you a bottle with a liquid in it

labeled

" Oromorph, " and a prescription bottle for oxycodone.

Physical exam reveals no traumatic injuries.

Based upon what you know so far, what is this patient's problem and why is

he

" acting crazy? "

Docs, please give the medics a chance before you jump in.

Gene Gandy, JD, LP

EMS Education and Consulting

Tucson, AZ

**************

Vote for your city's best dining and nightlife. City's Best

2008.

(_http://citysbest.http://citysbhttp://citysbesthttp_

(http://citysbest.aol.com/?ncid=aolacg00050000000102) )

[Non-text portions of this message have been removed]

**************Vote for your city's best dining and nightlife. City's Best

2008. (http://citysbest.aol.com?ncid=aolacg00050000000102)

[Guest guest]

Not being a paramedic, I'm just guessing here. Sounds like he may have

liver cancer or possibly cirrosis. The psychotic behavior could be from DTs.

None the less, he gets transported with a cop on board.

Kirk

EMT-B

In a message dated 6/12/2008 23:48:10 Central Daylight Time,

wegandy1938@... writes:

You are dispatched to a private residence for a possible " mental case. "

You arrive at a mobile home in a neat mobile home park. Outside are several

neighbors who report that the man who lives there has " gone crazy " and has

been shouting and throwing objects inside

the house. One of them attempted to enter the house and talk to him and was

met with a man who screamed, " Get out before they get you. " The neighbor

exited and called 911. One neighbor says that the occupant is a retired

police

officer, and that he has been ill lately, but that she has never seen him

act in

any violent way before. She is unaware of whether or not he has guns in the

house. She says that he keeps to himself, is not friendly, and seems to have

no friends, but has never caused any trouble.

Shortly thereafter, two sheriff's deputies arrive. One of them knows the

occupant and says he will attempt to talk to him. He calls the occupant by

name,

and the occupant screams, " Get Thee Behind Me, Satan, and " You are all worms

and don't think I don't know it. You will not kill me again. "

More officers arrive, and after a few minutes, they make entry into the

mobile home and subdue the patient.

You enter and observe a man lying on his side on the floor, with his hands

cuffed behind his back. He appears to be in his 50's, and is alternatively

screaming and raving incoherently. After consulting with medical control

you

administer lorazepam 4 mg/IM and haloperidol 5 mg/IM. After a few minutes

the

patient begins to calm down but remains disoriented. He tells you that his

name

is , but he does not know what day it is, where he is, or why you are

there. He continues to talk about CIA " worms " and aliens from space.

As he becomes more calm you manage to get a blood pressure, 178/96, a pulse

of 110 and irregular, and note his respirations are 24 and shallow. He

appears

to be jaundiced, with yellow skin and sclera. He also appears at first to

be

grossly obese, but your partner points out that his abdomen seems to be

distended, and palpation confirms that. Your patient is unable to tell you

anything about his medical condition.

One of the sheriff's deputies brings you a bottle with a liquid in it

labeled

" Oromorph, " and a prescription bottle for oxycodone.

Physical exam reveals no traumatic injuries.

Based upon what you know so far, what is this patient's problem and why is

he

" acting crazy? "

Docs, please give the medics a chance before you jump in.

Gene Gandy, JD, LP

EMS Education and Consulting

Tucson, AZ

**************

Vote for your city's best dining and nightlife. City's Best

2008.

(http://citysbest.aol.com?ncid=aolacg00050000000102)

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[Guest guest]

I would suspect the patient is suffering from liver failure and is also going

thru alcohol related delirium tremens (DT).

Vondran EMT-P

To: texasems-l@...: wegandy1938@...: Fri, 13 Jun 2008

02:04:12 -0400Subject: Re: A new puzzler

Yes, the patient has a long history of alcohol abuse.GGIn a message dated

6/12/08 10:49:59 PM, mvondran@... writes:> Are there any signs of

alcohol abuse?> > W. Vondran EMT-P> > > To: texasems-l ;

Paramedicine@...: > wegandy1938@...: Fri, 13 Jun 2008

00:47:53 -0400Subject: A new > puzzler> > > > > You are dispatched

to a private residence for a possible " mental case. " You > arrive at a mobile

home in a neat mobile home park. Outside are several > neighbors who report

that the man who lives there has " gone crazy " and has been > shouting and

throwing objects insidethe house. One of them attempted to enter > the house

and talk to him and was met with a man who screamed, " Get out > before they get

you. " The neighbor exited and called 911. One neighbor says > that the

occupant is a retired police officer, and that he has been ill lately, > but

that she has never seen him act in any violent way before. She is > unaware of

whether or not he has guns in the house. She says that he keeps to > himself, is

not friendly, and seems to have no friends, but has never caused any > trouble.

Shortly thereafter, two sheriff's deputies arrive. One of them knows > the

occupant and says he will attempt to talk to him. He calls the occupant > by

name, and the occupant screams, " Get Thee Behind Me, Satan, and " You are > all

worms and don't think I don't know it. You will not kill me again. " More >

officers arrive, and after a few minutes, they make entry into the mobile > home

and subdue the patient. You enter and observe a man lying on his side on > the

floor, with his hands cuffed behind his back. He appears to be in his > 50's,

and is alternatively screaming and raving incoherently. After consulting > with

medical control you administer lorazepam 4 mg/IM and haloperidol 5 > mg/IM.

After a few minutes the patient begins to calm down but remains > disoriented.

He tells you that his name is , but he does not know what day it is, > where

he is, or why you are there. He continues to talk about CIA " worms " and >

aliens from space. As he becomes more calm you manage to get a blood > pressure,

178/96, a pulse of 110 and irregular, and note his respirations are 24 and >

shallow. He appears to be jaundiced, with yellow skin and sclera. He also >

appears at first to be grossly obese, but your partner points out that his >

abdomen seems to be distended, and palpation confirms that. Your patient is >

unable to tell you anything about his medical condition.One of the sheriff's >

deputies brings you a bottle with a liquid in it labeled " Oromorph, " and a >

prescription bottle for oxycodone.Physical exam reveals no traumatic injuries. >

Based upon what you know so far, what is this patient's problem and why is he >

" acting crazy? " Docs, please give the medics a chance before you jump in.Gene >

Gandy, JD, LPEMS Education and ConsultingTucson, AZ**************Vote for your >

city's best dining and nightlife. City's Best >

2008.(http://citysbest.aol.com?ncid=aolacg00050000000102)[Non-text portions of

this message have been > removed]> > > > > > >

__________________________________________________________> Now you can invite

friends from Facebook and other groups to join you on > Windows Live™ Messenger.

Add now.> https://www.invite2messenger.net/im/?source=TXT_EML_WLH_AddNow_Now> >

[Guest guest]

My guess would be that the patient is in end stage Cirrhosis, his liver is

completely shut down. The psychological manifestations I would guess are

from the livers inability to properly process the medications that he is

taking causing high levels of these narcotics in his system.

>

> I would suspect the patient is suffering from liver failure and is also

> going thru alcohol related delirium tremens (DT).

>

> Vondran EMT-P

>

>

> To: texasems-l@...: wegandy1938@...: Fri, 13 Jun

> 2008 02:04:12 -0400Subject: Re: A new puzzler

>

>

>

>

> Yes, the patient has a long history of alcohol abuse.GGIn a message dated

> 6/12/08 10:49:59 PM, mvondran@... writes:> Are there any signs of

> alcohol abuse?> > W. Vondran EMT-P> > > To:

> texasems-l ; Paramedicine@...: >

> wegandy1938@...: Fri, 13 Jun 2008 00:47:53 -0400Subject:

> A new > puzzler> > > > > You are dispatched to a private

> residence for a possible " mental case. " You > arrive at a mobile home in a

> neat mobile home park. Outside are several > neighbors who report that the

> man who lives there has " gone crazy " and has been > shouting and throwing

> objects insidethe house. One of them attempted to enter > the house and

> talk to him and was met with a man who screamed, " Get out > before they get

> you. " The neighbor exited and called 911. One neighbor says > that the

> occupant is a retired police officer, and that he has been ill lately, > but

> that she has never seen him act in any violent way before. She is > unaware

> of whether or not he has guns in the house. She says that he keeps to >

> himself, is not friendly, and seems to have no friends, but has never caused

> any > trouble. Shortly thereafter, two sheriff's deputies arrive. One of

> them knows > the occupant and says he will attempt to talk to him. He calls

> the occupant > by name, and the occupant screams, " Get Thee Behind Me,

> Satan, and " You are > all worms and don't think I don't know it. You will

> not kill me again. " More > officers arrive, and after a few minutes, they

> make entry into the mobile > home and subdue the patient. You enter and

> observe a man lying on his side on > the floor, with his hands cuffed behind

> his back. He appears to be in his > 50's, and is alternatively screaming

> and raving incoherently. After consulting > with medical control you

> administer lorazepam 4 mg/IM and haloperidol 5 > mg/IM. After a few minutes

> the patient begins to calm down but remains > disoriented. He tells you

> that his name is , but he does not know what day it is, > where he is,

> or why you are there. He continues to talk about CIA " worms " and > aliens

> from space. As he becomes more calm you manage to get a blood > pressure,

> 178/96, a pulse of 110 and irregular, and note his respirations are 24 and >

> shallow. He appears to be jaundiced, with yellow skin and sclera. He also

> > appears at first to be grossly obese, but your partner points out that his

> > abdomen seems to be distended, and palpation confirms that. Your patient

> is > unable to tell you anything about his medical condition.One of the

> sheriff's > deputies brings you a bottle with a liquid in it labeled

> " Oromorph, " and a > prescription bottle for oxycodone.Physical exam reveals

> no traumatic injuries. > Based upon what you know so far, what is this

> patient's problem and why is he > " acting crazy? " Docs, please give the

> medics a chance before you jump in.Gene > Gandy, JD, LPEMS Education and

> ConsultingTucson, AZ**************Vote for your > city's best dining and

> nightlife. City's Best > 2008.(

> http://citysbest.aol.com?ncid=aolacg00050000000102)[Non-text portions of

> this message have been > removed]> > > > > > >

> __________________________________________________________> Now you can

> invite friends from Facebook and other groups to join you on > Windows Live™

> Messenger. Add now.>

> https://www.invite2messenger.net/im/?source=TXT_EML_WLH_AddNow_Now> >

>

[Guest guest]

how about increased levels of ammonia in system which is impacting

mental status due to the end stage cirrhosis

>>> " Stotts " 6/13/2008 8:52 AM >>>

My guess would be that the patient is in end stage Cirrhosis, his liver

is

completely shut down. The psychological manifestations I would guess

are

from the livers inability to properly process the medications that he

is

taking causing high levels of these narcotics in his system.

>

> I would suspect the patient is suffering from liver failure and is

also

> going thru alcohol related delirium tremens (DT).

>

> Vondran EMT-P

>

>

> To: texasems-l@...: wegandy1938@...: Fri, 13

Jun

> 2008 02:04:12 -0400Subject: Re: A new puzzler

>

>

>

>

> Yes, the patient has a long history of alcohol abuse.GGIn a message

dated

> 6/12/08 10:49:59 PM, mvondran@... writes:> Are there any

signs of

> alcohol abuse?> > W. Vondran EMT-P> > > To:

> texasems-l ; Paramedicine@...: >

> wegandy1938@...: Fri, 13 Jun 2008 00:47:53 -0400Subject:

> A new > puzzler> > > > > You are dispatched to a

private

> residence for a possible " mental case. " You > arrive at a mobile home

in a

> neat mobile home park. Outside are several > neighbors who report

that the

> man who lives there has " gone crazy " and has been > shouting and

throwing

> objects insidethe house. One of them attempted to enter > the house

and

> talk to him and was met with a man who screamed, " Get out > before

they get

> you. " The neighbor exited and called 911. One neighbor says > that

the

> occupant is a retired police officer, and that he has been ill

lately, > but

> that she has never seen him act in any violent way before. She is >

unaware

> of whether or not he has guns in the house. She says that he keeps to

>

> himself, is not friendly, and seems to have no friends, but has never

caused

> any > trouble. Shortly thereafter, two sheriff's deputies arrive.

One of

> them knows > the occupant and says he will attempt to talk to him.

He calls

> the occupant > by name, and the occupant screams, " Get Thee Behind

Me,

> Satan, and " You are > all worms and don't think I don't know it. You

will

> not kill me again. " More > officers arrive, and after a few minutes,

they

> make entry into the mobile > home and subdue the patient. You enter

and

> observe a man lying on his side on > the floor, with his hands cuffed

behind

> his back. He appears to be in his > 50's, and is alternatively

screaming

> and raving incoherently. After consulting > with medical control

you

> administer lorazepam 4 mg/IM and haloperidol 5 > mg/IM. After a few

minutes

> the patient begins to calm down but remains > disoriented. He tells

you

> that his name is , but he does not know what day it is, > where

he is,

> or why you are there. He continues to talk about CIA " worms " and >

aliens

> from space. As he becomes more calm you manage to get a blood >

pressure,

> 178/96, a pulse of 110 and irregular, and note his respirations are

24 and >

> shallow. He appears to be jaundiced, with yellow skin and sclera.

He also

> > appears at first to be grossly obese, but your partner points out

that his

> > abdomen seems to be distended, and palpation confirms that. Your

patient

> is > unable to tell you anything about his medical condition.One of

the

> sheriff's > deputies brings you a bottle with a liquid in it labeled

> " Oromorph, " and a > prescription bottle for oxycodone.Physical exam

reveals

> no traumatic injuries. > Based upon what you know so far, what is

this

> patient's problem and why is he > " acting crazy? " Docs, please give

the

> medics a chance before you jump in.Gene > Gandy, JD, LPEMS Education

and

> ConsultingTucson, AZ**************Vote for your > city's best dining

and

> nightlife. City's Best > 2008.(

> http://citysbest.aol.com?ncid=aolacg00050000000102)[Non-text portions

of

> this message have been > removed]> > > > > > >

> __________________________________________________________> Now you

can

> invite friends from Facebook and other groups to join you on >

Windows Liveâ„¢

> Messenger. Add now.>

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>

[Guest guest]

Simple adverse reaction to the oromorph, but rule out

overdose. All the signs given are side effects of the

medication. Which was given to treat an hepatic

failure.

how long has he been taking the medications? Was any

other medication found? How much information does the

office that knows him give?

[Guest guest]

Hepatic Encephalopathy as a result of the liver failure. He's got the

classic hallmarks for liver failure: jaundice, icterus, and ascites... With

signs of obvious hepatic failure, one should use caution in administering

4mg of Ativan, which is really not a small dose. Taken from epocrates:

" mild-severe impairment: caution advised, consider decr. dose; hepatic

failure: avoid use "

Joe Percer, LP

> You are dispatched to a private residence for a possible " mental

> case. "

>

> You arrive at a mobile home in a neat mobile home park. Outside are

> several

> neighbors who report that the man who lives there has " gone crazy " and has

> been shouting and throwing objects inside

> the house. One of them attempted to enter the house and talk to him and

> was

> met with a man who screamed, " Get out before they get you. " The neighbor

> exited and called 911. One neighbor says that the occupant is a retired

> police

> officer, and that he has been ill lately, but that she has never seen him

> act in

> any violent way before. She is unaware of whether or not he has guns in

> the

> house. She says that he keeps to himself, is not friendly, and seems to

> have

> no friends, but has never caused any trouble.

>

> Shortly thereafter, two sheriff's deputies arrive. One of them knows the

> occupant and says he will attempt to talk to him. He calls the occupant by

> name,

> and the occupant screams, " Get Thee Behind Me, Satan, and " You are all

> worms

> and don't think I don't know it. You will not kill me again. "

>

> More officers arrive, and after a few minutes, they make entry into the

> mobile home and subdue the patient.

>

> You enter and observe a man lying on his side on the floor, with his hands

> cuffed behind his back. He appears to be in his 50's, and is alternatively

>

> screaming and raving incoherently. After consulting with medical control

> you

> administer lorazepam 4 mg/IM and haloperidol 5 mg/IM. After a few minutes

> the

> patient begins to calm down but remains disoriented. He tells you that his

> name

> is , but he does not know what day it is, where he is, or why you are

> there. He continues to talk about CIA " worms " and aliens from space.

>

> As he becomes more calm you manage to get a blood pressure, 178/96, a pulse

>

> of 110 and irregular, and note his respirations are 24 and shallow. He

> appears

> to be jaundiced, with yellow skin and sclera. He also appears at first to

> be

> grossly obese, but your partner points out that his abdomen seems to be

> distended, and palpation confirms that. Your patient is unable to tell you

>

> anything about his medical condition.

>

> One of the sheriff's deputies brings you a bottle with a liquid in it

> labeled

> " Oromorph, " and a prescription bottle for oxycodone.

>

> Physical exam reveals no traumatic injuries.

>

> Based upon what you know so far, what is this patient's problem and why is

> he

> " acting crazy? "

>

> Docs, please give the medics a chance before you jump in.

>

> Gene Gandy, JD, LP

> EMS Education and Consulting

> Tucson, AZ

>

> **************

> Vote for your city's best dining and nightlife. City's Best

> 2008.

> (http://citysbest.aol.com?ncid=aolacg00050000000102)

>

>

[Guest guest]

Could it be elevated ammonia levels and bowel obstruction due to a narcotic

shutdown of the bowel, liver, and kidney functions?

Drew Bohn, EMT-P, EMS-I

Orange, Texas

_____

From: texasems-l [mailto:texasems-l ] On

Behalf Of ph Percer

Sent: Friday, June 13, 2008 11:23 AM

To: texasems-l

Subject: Re: A new puzzler

Hepatic Encephalopathy as a result of the liver failure. He's got the

classic hallmarks for liver failure: jaundice, icterus, and ascites... With

signs of obvious hepatic failure, one should use caution in administering

4mg of Ativan, which is really not a small dose. Taken from epocrates:

" mild-severe impairment: caution advised, consider decr. dose; hepatic

failure: avoid use "

Joe Percer, LP

On Fri, Jun 13, 2008 at 12:47 AM, <wegandy1938@

<mailto:wegandy1938%40aol.com> aol.com> wrote:

> You are dispatched to a private residence for a possible " mental

> case. "

>

> You arrive at a mobile home in a neat mobile home park. Outside are

> several

> neighbors who report that the man who lives there has " gone crazy " and has

> been shouting and throwing objects inside

> the house. One of them attempted to enter the house and talk to him and

> was

> met with a man who screamed, " Get out before they get you. " The neighbor

> exited and called 911. One neighbor says that the occupant is a retired

> police

> officer, and that he has been ill lately, but that she has never seen him

> act in

> any violent way before. She is unaware of whether or not he has guns in

> the

> house. She says that he keeps to himself, is not friendly, and seems to

> have

> no friends, but has never caused any trouble.

>

> Shortly thereafter, two sheriff's deputies arrive. One of them knows the

> occupant and says he will attempt to talk to him. He calls the occupant by

> name,

> and the occupant screams, " Get Thee Behind Me, Satan, and " You are all

> worms

> and don't think I don't know it. You will not kill me again. "

>

> More officers arrive, and after a few minutes, they make entry into the

> mobile home and subdue the patient.

>

> You enter and observe a man lying on his side on the floor, with his hands

> cuffed behind his back. He appears to be in his 50's, and is alternatively

>

> screaming and raving incoherently. After consulting with medical control

> you

> administer lorazepam 4 mg/IM and haloperidol 5 mg/IM. After a few minutes

> the

> patient begins to calm down but remains disoriented. He tells you that his

> name

> is , but he does not know what day it is, where he is, or why you are

> there. He continues to talk about CIA " worms " and aliens from space.

>

> As he becomes more calm you manage to get a blood pressure, 178/96, a

pulse

>

> of 110 and irregular, and note his respirations are 24 and shallow. He

> appears

> to be jaundiced, with yellow skin and sclera. He also appears at first to

> be

> grossly obese, but your partner points out that his abdomen seems to be

> distended, and palpation confirms that. Your patient is unable to tell you

>

> anything about his medical condition.

>

> One of the sheriff's deputies brings you a bottle with a liquid in it

> labeled

> " Oromorph, " and a prescription bottle for oxycodone.

>

> Physical exam reveals no traumatic injuries.

>

> Based upon what you know so far, what is this patient's problem and why is

> he

> " acting crazy? "

>

> Docs, please give the medics a chance before you jump in.

>

> Gene Gandy, JD, LP

> EMS Education and Consulting

> Tucson, AZ

>

> **************

> Vote for your city's best dining and nightlife. City's Best

> 2008.

> (http://citysbest. <http://citysbest.aol.com?ncid=aolacg00050000000102>

aol.com?ncid=aolacg00050000000102)

>

>

[Guest guest]

If you had lab capabilities you would find that, yes, his ammonia level is

elevated.

GG

>

> Sounds like his ammonia level is elevated.

>

>

>

>

> In a message dated 6/12/2008 11:48:16 P.M. Central Daylight Time,

> wegandy1938@wegandy writes:

>

> You are dispatched to a private residence for a possible " mental case. "

>

> You arrive at a mobile home in a neat mobile home park. Outside are several

> neighbors who report that the man who lives there has " gone crazy " and has

> been shouting and throwing objects inside

> the house. One of them attempted to enter the house and talk to him and was

> met with a man who screamed, " Get out before they get you. " The neighbor

> exited and called 911. One neighbor says that the occupant is a retired

> police

> officer, and that he has been ill lately, but that she has never seen him

> act in

> any violent way before. She is unaware of whether or not he has guns in the

> house. She says that he keeps to himself, is not friendly, and seems to have

> no friends, but has never caused any trouble.

>

> Shortly thereafter, two sheriff's deputies arrive. One of them knows the

> occupant and says he will attempt to talk to him. He calls the occupant by

> name,

> and the occupant screams, " Get Thee Behind Me, Satan, and " You are all worms

> and don't think I don't know it. You will not kill me again. "

>

> More officers arrive, and after a few minutes, they make entry into the

> mobile home and subdue the patient.

>

> You enter and observe a man lying on his side on the floor, with his hands

> cuffed behind his back. He appears to be in his 50's, and is alternatively

> screaming and raving incoherently. After consulting with medical control

> you

> administer lorazepam 4 mg/IM and haloperidol 5 mg/IM. After a few minutes

> the

> patient begins to calm down but remains disoriented. He tells you that his

> name

> is , but he does not know what day it is, where he is, or why you are

> there. He continues to talk about CIA " worms " and aliens from space.

>

> As he becomes more calm you manage to get a blood pressure, 178/96, a pulse

> of 110 and irregular, and note his respirations are 24 and shallow. He

> appears

> to be jaundiced, with yellow skin and sclera. He also appears at first to

> be

> grossly obese, but your partner points out that his abdomen seems to be

> distended, and palpation confirms that. Your patient is unable to tell you

> anything about his medical condition.

>

> One of the sheriff's deputies brings you a bottle with a liquid in it

> labeled

> " Oromorph, " and a prescription bottle for oxycodone.

>

> Physical exam reveals no traumatic injuries.

>

> Based upon what you know so far, what is this patient's problem and why is

> he

> " acting crazy? "

>

> Docs, please give the medics a chance before you jump in.

>

> Gene Gandy, JD, LP

> EMS Education and Consulting

> Tucson, AZ

>

> ************ *

> Vote for your city's best dining and nightlife. City's Best

> 2008.

> (_http://citysbest.http://citysbesthttp://citysbestht

> (http://citysbest.http://cihttp://citysbesthttp://ci) )

>

>

[Guest guest]

You are half right. He is in liver failure, but his current problem is not

DTs. He hasn't had any ETOH in a long time.

GG

> I would suspect the patient is suffering from liver failure and is also

> going thru alcohol related delirium tremens (DT).

>

> Vondran EMT-P

>

>

> To: texasems-l@...: wegandy1938@...: Fri, 13 Jun

> 2008 02:04:12 -0400Subject: Re: A new puzzler

>

>

>

>

> Yes, the patient has a long history of alcohol abuse.GGIn a message dated

> 6/12/08 10:49:59 PM, mvondran@... writes:> Are there any signs of a

> lcohol abuse?> > W. Vondran EMT-P> > > To: texasems-l ;

> Paramedicine@...: > wegandy1938@...: Fri, 13 Jun 2008

> 00:47:53 -0400Subject: A new > puzzler> > > > > You are

> dispatched to a private residence for a possible " mental case. " You > arrive

at a

> mobile home in a neat mobile home park.  Outside are several > neighbors who

> report that the man who lives there has " gone crazy " and has been > shouting

and

> throwing objects insidethe house.  One of them attempted to enter > the house

> and talk to him and was met with a man who screamed, " Get out > before they

> get you. "   The neighbor exited and called 911.  One neighbor says > that the

> occupant is a retired police officer, and that he has been ill lately, > but

> that she has never seen him act in any violent way before.  She is > unaware

> of whether or not he has guns in the house. She says that he keeps to >

> himself, is not friendly, and seems to have no friends, but has never caused

any >

> trouble. Shortly thereafter, two sheriff's deputies arrive.  One of them

> knows > the occupant and says he will attempt to talk to him.  He calls the

> occupant > by name, and the occupant screams, " Get Thee Behind Me, Satan, and

> " You are > all worms and don't think I don't know it.  You will not kill me

> again. " More > officers arrive, and after a few minutes, they make entry into

the

> mobile > home and subdue the patient. You enter and observe a man lying on

> his side on > the floor, with his hands cuffed behind his back.  He appears

to

> be in his > 50's, and is alternatively screaming and raving incoherently. 

> After consulting > with medical control you administer lorazepam 4 mg/IM and

> haloperidol 5 > mg/IM.  After a few minutes the patient begins to calm down

but

> remains > disoriented.  He tells you that his name is , but he does not

> know what day it is, > where he is, or why you are there.  He continues to

> talk about CIA " worms " and > aliens from space. As he becomes more calm you

> manage to get a blood > pressure, 178/96, a pulse of 110 and irregular, and

note

> his respirations are 24 and > shallow.  He appears to be jaundiced, with

> yellow skin and sclera.  He also > appears at first to be grossly obese, but

> your partner points out that his > abdomen seems to be distended, and

palpation

> confirms that.  Your patient is > unable to tell you anything about his

> medical condition.One of the sheriff's > deputies brings you a bottle with a

> liquid in it labeled " Oromorph, " and a > prescription bottle for

> oxycodone.Physical exam reveals no traumatic injuries. > Based upon what you

know so far, what

> is this patient's problem and why is he > " acting crazy? " Docs, please give

> the medics a chance before you jump in.Gene > Gandy, JD, LPEMS Education and

> ConsultingTucson, AZ**************Vote for your > city's best dining and

> nightlife. City's Best >

> 2008.(http://citysbest.aol.com?ncid=aolacg00050000000102)[Non-text portions of

this message have been > removed]> > > > > > >

> __________________________________________________________> Now you can invite

> friends from Facebook and other groups to join you on > Windows Liveâ„¢

Messenger.

> Add now.> https://www.invite2messenger.net/im/?source=TXT_EML_WLH_AddNow_Now>

>

>

[Guest guest]

You are very close but not exactly there. Hint: He's in " Stage 2-3 " of

the symptomatic condition he has.

GG

> My guess would be that the patient is in end stage Cirrhosis, his liver is

> completely shut down.  The psychological manifestations I would guess are

> from the livers inability to properly process the medications that he is

> taking causing high levels of these narcotics in his system.

>

>

> >

> > I would suspect the patient is suffering from liver failure and is also

> > going thru alcohol related delirium tremens (DT).

> >

> > Vondran EMT-P

> >

> >

> > To: texasems-l@...: wegandy1938@...: Fri, 13 Jun

> > 2008 02:04:12 -0400Subject: Re: A new puzzler

> >

> >

> >

> >

> > Yes, the patient has a long history of alcohol abuse.GGIn a message dated

> > 6/12/08 10:49:59 PM, mvondran@... writes:> Are there any signs of

> > alcohol abuse?> > W. Vondran EMT-P> > > To:

> > texasems-l ; Paramedicine@...: >

> > wegandy1938@...: Fri, 13 Jun 2008 00:47:53 -0400Subject:

> > A new > puzzler> > > > > You are dispatched to a private

> > residence for a possible " mental case. " You > arrive at a mobile home in a

> > neat mobile home park.  Outside are several > neighbors who report that

> the

> > man who lives there has " gone crazy " and has been > shouting and throwing

> > objects insidethe house.  One of them attempted to enter > the house and

> > talk to him and was met with a man who screamed, " Get out > before they

> get

> > you. "   The neighbor exited and called 911.  One neighbor says > that the

> > occupant is a retired police officer, and that he has been ill lately, >

> but

> > that she has never seen him act in any violent way before.  She is >

> unaware

> > of whether or not he has guns in the house. She says that he keeps to >

> > himself, is not friendly, and seems to have no friends, but has never

> caused

> > any > trouble. Shortly thereafter, two sheriff's deputies arrive.  One of

> > them knows > the occupant and says he will attempt to talk to him.  He

> calls

> > the occupant > by name, and the occupant screams, " Get Thee Behind Me,

> > Satan, and " You are > all worms and don't think I don't know it.  You will

> > not kill me again. " More > officers arrive, and after a few minutes, they

> > make entry into the mobile > home and subdue the patient. You enter and

> > observe a man lying on his side on > the floor, with his hands cuffed

> behind

> > his back.  He appears to be in his > 50's, and is alternatively screaming

> > and raving incoherently.  After consulting > with medical control you

> > administer lorazepam 4 mg/IM and haloperidol 5 > mg/IM.  After a few

> minutes

> > the patient begins to calm down but remains > disoriented.  He tells you

> > that his name is , but he does not know what day it is, > where he is,

> > or why you are there.  He continues to talk about CIA " worms " and > aliens

> > from space. As he becomes more calm you manage to get a blood > pressure,

> > 178/96, a pulse of 110 and irregular, and note his respirations are 24 and

> >

> > shallow.  He appears to be jaundiced, with yellow skin and sclera.  He

> also

> > > appears at first to be grossly obese, but your partner points out that

> his

> > > abdomen seems to be distended, and palpation confirms that.  Your

> patient

> > is > unable to tell you anything about his medical condition.One of the

> > sheriff's > deputies brings you a bottle with a liquid in it labeled

> > " Oromorph, " and a > prescription bottle for oxycodone.Physical exam

> reveals

> > no traumatic injuries. > Based upon what you know so far, what is this

> > patient's problem and why is he > " acting crazy? " Docs, please give the

> > medics a chance before you jump in.Gene > Gandy, JD, LPEMS Education and

> > ConsultingTucson, AZ**************Vote for your > city's best dining and

> > nightlife. City's Best > 2008.(

> > http://citysbest.aol.com?ncid=aolacg00050000000102)[Non-text portions of

> > this message have been > removed]> > > > > > >

> > __________________________________________________________> Now you can

> > invite friends from Facebook and other groups to join you on > Windows Live

> â„¢

> > Messenger. Add now.>

> > https://www.invite2messenger.net/im/?source=TXT_EML_WLH_AddNow_Now> >

> >

[Guest guest]

Yes. Can you give it the name and discuss the other theories about what

causes it?

GG

>

> how about increased levels of ammonia in system which is impacting

> mental status due to the end stage cirrhosis

>

>

>

> >>> " Stotts " 6/13/2008 8:52 AM >>>

> My guess would be that the patient is in end stage Cirrhosis, his liver

> is

> completely shut down. The psychological manifestations I would guess

> are

> from the livers inability to properly process the medications that he

> is

> taking causing high levels of these narcotics in his system.

>

>

> >

> > I would suspect the patient is suffering from liver failure and is

> also

> > going thru alcohol related delirium tremens (DT).

> >

> > Vondran EMT-P

> >

> >

> > To: texasems-l@yahoogrotexasems-l@: wegandy1938@wegandy1938: Fri, 13

> Jun

> > 2008 02:04:12 -0400Subject: Re: A new puzzler

> >

> >

> >

> >

> > Yes, the patient has a long history of alcohol abuse.GGIn a message

> dated

> > 6/12/08 10:49:59 PM, mvondran@... writes:> Are there any

> signs of

> > alcohol abuse?> > W. Vondran EMT-P> > > To:

> > texasems-l@yahoogrotexasem; Paramedicine@ParamedicineParamed: >

> > wegandy1938@wegandy1938: Fri, 13 Jun 2008 00:47:53 -0400Subject:

> > A new > puzzler> > > > > You are dispatched to a

> private

> > residence for a possible " mental case. " You > arrive at a mobile home

> in a

> > neat mobile home park. Outside are several > neighbors who report

> that the

> > man who lives there has " gone crazy " and has been > shouting and

> throwing

> > objects insidethe house. One of them attempted to enter > the house

> and

> > talk to him and was met with a man who screamed, " Get out > before

> they get

> > you. " The neighbor exited and called 911. One neighbor says > that

> the

> > occupant is a retired police officer, and that he has been ill

> lately, > but

> > that she has never seen him act in any violent way before. She is >

> unaware

> > of whether or not he has guns in the house. She says that he keeps to

> >

> > himself, is not friendly, and seems to have no friends, but has never

> caused

> > any > trouble. Shortly thereafter, two sheriff's deputies arrive.

> One of

> > them knows > the occupant and says he will attempt to talk to him.

> He calls

> > the occupant > by name, and the occupant screams, " Get Thee Behind

> Me,

> > Satan, and " You are > all worms and don't think I don't know it. You

> will

> > not kill me again. " More > officers arrive, and after a few minutes,

> they

> > make entry into the mobile > home and subdue the patient. You enter

> and

> > observe a man lying on his side on > the floor, with his hands cuffed

> behind

> > his back. He appears to be in his > 50's, and is alternatively

> screaming

> > and raving incoherently. After consulting > with medical control

> you

> > administer lorazepam 4 mg/IM and haloperidol 5 > mg/IM. After a few

> minutes

> > the patient begins to calm down but remains > disoriented. He tells

> you

> > that his name is , but he does not know what day it is, > where

> he is,

> > or why you are there. He continues to talk about CIA " worms " and >

> aliens

> > from space. As he becomes more calm you manage to get a blood >

> pressure,

> > 178/96, a pulse of 110 and irregular, and note his respirations are

> 24 and >

> > shallow. He appears to be jaundiced, with yellow skin and sclera.

> He also

> > > appears at first to be grossly obese, but your partner points out

> that his

> > > abdomen seems to be distended, and palpation confirms that. Your

> patient

> > is > unable to tell you anything about his medical condition.One of

> the

> > sheriff's > deputies brings you a bottle with a liquid in it labeled

> > " Oromorph, " and a > prescription bottle for oxycodone.Physical exam

> reveals

> > no traumatic injuries. > Based upon what you know so far, what is

> this

> > patient's problem and why is he > " acting crazy? " Docs, please give

> the

> > medics a chance before you jump in.Gene > Gandy, JD, LPEMS Education

> and

> > ConsultingTucson, AZ********** ConsultingTucson,> city's best dining

> and

> > nightlife. City's Best > 2008.(

> > http://citysbest.http://citysbhttp://citysbesthttp)[Non-text portions

> of

> > this message have been > removed]> > > > > > >

> > ____________ ________ ________ ________ ________ ________ > Now you

> can

> > invite friends from Facebook and other groups to join you on >

> Windows Liveâ„¢

> > Messenger. Add now.>

> > https://www.https://www.<wbrhttps://whttps://wwwhttps://www.<wbhtt>

> >

> >

[Guest guest]

Kirk, yo are correct that he has cirrhosis, and your transport decision is

correct. However, he does not have DTs, having quit using ETOH long ago, but

not soon enough to save his liver.

GG

>

> Not being a paramedic, I'm just guessing here. Sounds like he may have

> liver cancer or possibly cirrosis. The psychotic behavior could be from DTs.

> None the less, he gets transported with a cop on board.

>

> Kirk

> EMT-B

>

>

> In a message dated 6/12/2008 23:48:10 Central Daylight Time,

> wegandy1938@wegandy writes:

>

> You are dispatched to a private residence for a possible " mental case. "

>

> You arrive at a mobile home in a neat mobile home park. Outside are several

> neighbors who report that the man who lives there has " gone crazy " and has

> been shouting and throwing objects inside

> the house. One of them attempted to enter the house and talk to him and was

> met with a man who screamed, " Get out before they get you. " The neighbor

> exited and called 911. One neighbor says that the occupant is a retired

> police

> officer, and that he has been ill lately, but that she has never seen him

> act in

> any violent way before. She is unaware of whether or not he has guns in the

> house. She says that he keeps to himself, is not friendly, and seems to have

> no friends, but has never caused any trouble.

>

> Shortly thereafter, two sheriff's deputies arrive. One of them knows the

> occupant and says he will attempt to talk to him. He calls the occupant by

> name,

> and the occupant screams, " Get Thee Behind Me, Satan, and " You are all worms

> and don't think I don't know it. You will not kill me again. "

>

> More officers arrive, and after a few minutes, they make entry into the

> mobile home and subdue the patient.

>

> You enter and observe a man lying on his side on the floor, with his hands

> cuffed behind his back. He appears to be in his 50's, and is alternatively

> screaming and raving incoherently. After consulting with medical control

> you

> administer lorazepam 4 mg/IM and haloperidol 5 mg/IM. After a few minutes

> the

> patient begins to calm down but remains disoriented. He tells you that his

> name

> is , but he does not know what day it is, where he is, or why you are

> there. He continues to talk about CIA " worms " and aliens from space.

>

> As he becomes more calm you manage to get a blood pressure, 178/96, a pulse

> of 110 and irregular, and note his respirations are 24 and shallow. He

> appears

> to be jaundiced, with yellow skin and sclera. He also appears at first to

> be

> grossly obese, but your partner points out that his abdomen seems to be

> distended, and palpation confirms that. Your patient is unable to tell you

> anything about his medical condition.

>

> One of the sheriff's deputies brings you a bottle with a liquid in it

> labeled

> " Oromorph, " and a prescription bottle for oxycodone.

>

> Physical exam reveals no traumatic injuries.

>

> Based upon what you know so far, what is this patient's problem and why is

> he

> " acting crazy? "

>

> Docs, please give the medics a chance before you jump in.

>

> Gene Gandy, JD, LP

> EMS Education and Consulting

> Tucson, AZ

>

> ************ *

> Vote for your city's best dining and nightlife. City's Best

> 2008.

> (http://citysbest.http://citysbhttp://citysbesthttp)

>

>

[Guest guest]

Great guess, but not the correct one. His opioid levels are within

therapeutic range (once he's at the hospital and the labs are back). And they

are

prescribed for his cirrhosis. Now just dig a little deeper and you'll have the

answer.

GG

>

> Simple adverse reaction to the oromorph, but rule out

> overdose. All the signs given are side effects of the

> medication. Which was given to treat an hepatic

> failure.

>

> how long has he been taking the medications? Was any

> other medication found? How much information does the

> office that knows him give?

>

>

**************

Vote for your city's best dining and nightlife. City's Best

2008.

(http://citysbest.aol.com?ncid=aolacg00050000000102)

[Guest guest]

BINGO JOE!!! Congratulations. You got it. Yes, you're right to pick up

on the sledgehammer dose of lorazepam. I hoped someone would catch that.

However, he's a big guy, a former cop, and even with his condition not somebody

you want to have to fight with. The other major sign I left out that

another bright individual asked about is fetor hepaticus, or " breath of death. "

The gentleman was admitted to the ICU where he died three days later from

advanced cirrhosis of the liver.

Congratulations to all who posted. You're thinking.

GG

>

> Hepatic Encephalopathy as a result of the liver failure. He's got the

> classic hallmarks for liver failure: jaundice, icterus, and ascites... With

> signs of obvious hepatic failure, one should use caution in administering

> 4mg of Ativan, which is really not a small dose. Taken from epocrates:

> " mild-severe impairment: caution advised, consider decr. dose; hepatic

> failure: avoid use "

>

> Joe Percer, LP

>

> On Fri, Jun 13, 2008 at 12:47 AM, <wegandy1938@wegandy> wrote:

>

> > You are dispatched to a private residence for a possible " mental

> > case. "

> >

> > You arrive at a mobile home in a neat mobile home park. Outside are

> > several

> > neighbors who report that the man who lives there has " gone crazy " and has

> > been shouting and throwing objects inside

> > the house. One of them attempted to enter the house and talk to him and

> > was

> > met with a man who screamed, " Get out before they get you. " The neighbor

> > exited and called 911. One neighbor says that the occupant is a retired

> > police

> > officer, and that he has been ill lately, but that she has never seen him

> > act in

> > any violent way before. She is unaware of whether or not he has guns in

> > the

> > house. She says that he keeps to himself, is not friendly, and seems to

> > have

> > no friends, but has never caused any trouble.

> >

> > Shortly thereafter, two sheriff's deputies arrive. One of them knows the

> > occupant and says he will attempt to talk to him. He calls the occupant by

> > name,

> > and the occupant screams, " Get Thee Behind Me, Satan, and " You are all

> > worms

> > and don't think I don't know it. You will not kill me again. "

> >

> > More officers arrive, and after a few minutes, they make entry into the

> > mobile home and subdue the patient.

> >

> > You enter and observe a man lying on his side on the floor, with his hands

> > cuffed behind his back. He appears to be in his 50's, and is alternatively

> >

> > screaming and raving incoherently. After consulting with medical control

> > you

> > administer lorazepam 4 mg/IM and haloperidol 5 mg/IM. After a few minutes

> > the

> > patient begins to calm down but remains disoriented. He tells you that his

> > name

> > is , but he does not know what day it is, where he is, or why you are

> > there. He continues to talk about CIA " worms " and aliens from space.

> >

> > As he becomes more calm you manage to get a blood pressure, 178/96, a

> pulse

> >

> > of 110 and irregular, and note his respirations are 24 and shallow. He

> > appears

> > to be jaundiced, with yellow skin and sclera. He also appears at first to

> > be

> > grossly obese, but your partner points out that his abdomen seems to be

> > distended, and palpation confirms that. Your patient is unable to tell you

> >

> > anything about his medical condition.

> >

> > One of the sheriff's deputies brings you a bottle with a liquid in it

> > labeled

> > " Oromorph, " and a prescription bottle for oxycodone.

> >

> > Physical exam reveals no traumatic injuries.

> >

> > Based upon what you know so far, what is this patient's problem and why is

> > he

> > " acting crazy? "

> >

> > Docs, please give the medics a chance before you jump in.

> >

> > Gene Gandy, JD, LP

> > EMS Education and Consulting

> > Tucson, AZ

> >

> > ************ *

> > Vote for your city's best dining and nightlife. City's Best

> > 2008.

> > (http://citysbest.http://citysbhttp://citysbesthttp)

> >

> >

[Guest guest]

An excellent differential. Elevated ammonia levels, but no bowel

obstruction. The answer was given by the poster just before yours.

Thanks for playing the game.

GG

>

> Could it be elevated ammonia levels and bowel obstruction due to a narcotic

> shutdown of the bowel, liver, and kidney functions?

>

> Drew Bohn, EMT-P, EMS-I

>

> Orange, Texas

>

> _____

>

> From: texasems-l@yahoogrotexasem [mailto:texasems-l@yahoogrotexasem] On

> Behalf Of ph Percer

> Sent: Friday, June 13, 2008 11:23 AM

> To: texasems-l@yahoogrotexasem

> Subject: Re: A new puzzler

>

> Hepatic Encephalopathy as a result of the liver failure. He's got the

> classic hallmarks for liver failure: jaundice, icterus, and ascites... With

> signs of obvious hepatic failure, one should use caution in administering

> 4mg of Ativan, which is really not a small dose. Taken from epocrates:

> " mild-severe impairment: caution advised, consider decr. dose; hepatic

> failure: avoid use "

>

> Joe Percer, LP

>

> On Fri, Jun 13, 2008 at 12:47 AM, <wegandy1938@

> <mailto:wegandy1938mailto:weg> aol.com> wrote:

>

> > You are dispatched to a private residence for a possible " mental

> > case. "

> >

> > You arrive at a mobile home in a neat mobile home park. Outside are

> > several

> > neighbors who report that the man who lives there has " gone crazy " and has

> > been shouting and throwing objects inside

> > the house. One of them attempted to enter the house and talk to him and

> > was

> > met with a man who screamed, " Get out before they get you. " The neighbor

> > exited and called 911. One neighbor says that the occupant is a retired

> > police

> > officer, and that he has been ill lately, but that she has never seen him

> > act in

> > any violent way before. She is unaware of whether or not he has guns in

> > the

> > house. She says that he keeps to himself, is not friendly, and seems to

> > have

> > no friends, but has never caused any trouble.

> >

> > Shortly thereafter, two sheriff's deputies arrive. One of them knows the

> > occupant and says he will attempt to talk to him. He calls the occupant by

> > name,

> > and the occupant screams, " Get Thee Behind Me, Satan, and " You are all

> > worms

> > and don't think I don't know it. You will not kill me again. "

> >

> > More officers arrive, and after a few minutes, they make entry into the

> > mobile home and subdue the patient.

> >

> > You enter and observe a man lying on his side on the floor, with his hands

> > cuffed behind his back. He appears to be in his 50's, and is alternatively

> >

> > screaming and raving incoherently. After consulting with medical control

> > you

> > administer lorazepam 4 mg/IM and haloperidol 5 mg/IM. After a few minutes

> > the

> > patient begins to calm down but remains disoriented. He tells you that his

> > name

> > is , but he does not know what day it is, where he is, or why you are

> > there. He continues to talk about CIA " worms " and aliens from space.

> >

> > As he becomes more calm you manage to get a blood pressure, 178/96, a

> pulse

> >

> > of 110 and irregular, and note his respirations are 24 and shallow. He

> > appears

> > to be jaundiced, with yellow skin and sclera. He also appears at first to

> > be

> > grossly obese, but your partner points out that his abdomen seems to be

> > distended, and palpation confirms that. Your patient is unable to tell you

> >

> > anything about his medical condition.

> >

> > One of the sheriff's deputies brings you a bottle with a liquid in it

> > labeled

> > " Oromorph, " and a prescription bottle for oxycodone.

> >

> > Physical exam reveals no traumatic injuries.

> >

> > Based upon what you know so far, what is this patient's problem and why is

> > he

> > " acting crazy? "

> >

> > Docs, please give the medics a chance before you jump in.

> >

> > Gene Gandy, JD, LP

> > EMS Education and Consulting

> > Tucson, AZ

> >

> > ************ *

> > Vote for your city's best dining and nightlife. City's Best

> > 2008.

> > (http://citysbest. <http://citysbest.http://citysbhttp://citysbesthttp>

> aol.com?ncid= aol.com?ncid=<w aol.

> >

> >

[Guest guest]

Systemic anti-cholenergic reaction to perservatives in Oromorph......

-MH

________________________________

From: texasems-l [texasems-l ] On Behalf Of

wegandy1938@... [wegandy1938@...]

Sent: Friday, June 13, 2008 7:31 PM

To: texasems-l

Subject: Re: A new puzzler

You are half right. He is in liver failure, but his current problem is not

DTs. He hasn't had any ETOH in a long time.

GG

In a message dated 6/13/08 6:45:40 AM,

mvondran@...<mailto:mvondran%40hotmail.com> writes:

> I would suspect the patient is suffering from liver failure and is also

> going thru alcohol related delirium tremens (DT).

>

> Vondran EMT-P

>

>

> To: texasems-l@...<mailto:texasems-l%40yahoogroups.comFrom>:

wegandy1938@...<mailto:wegandy1938%40aol.comDate>: Fri, 13 Jun

> 2008 02:04:12 -0400Subject: Re: A new puzzler

>

>

>

>

> Yes, the patient has a long history of alcohol abuse.GGIn a message dated

> 6/12/08 10:49:59 PM, mvondran@...<mailto:mvondran%40hotmail.com>

writes:> Are there any signs of a

> lcohol abuse?> > W. Vondran EMT-P> > > To:

texasems-l <mailto:texasems-l%40yahoogroups.com>;

> Paramedicine@...<mailto:Paramedicine%40yahoogroups.comFrom>: >

wegandy1938@...<mailto:wegandy1938%40aol.comDate>: Fri, 13 Jun 2008

> 00:47:53 -0400Subject: A new > puzzler> > > > > You are

> dispatched to a private residence for a possible " mental case. " You > arrive

at a

> mobile home in a neat mobile home park. Outside are several > neighbors who

> report that the man who lives there has " gone crazy " and has been > shouting

and

> throwing objects insidethe house. One of them attempted to enter > the house

> and talk to him and was met with a man who screamed, " Get out > before they

> get you. " The neighbor exited and called 911. One neighbor says > that the

> occupant is a retired police officer, and that he has been ill lately, > but

> that she has never seen him act in any violent way before. She is > unaware

> of whether or not he has guns in the house. She says that he keeps to >

> himself, is not friendly, and seems to have no friends, but has never caused

any >

> trouble. Shortly thereafter, two sheriff's deputies arrive. One of them

> knows > the occupant and says he will attempt to talk to him. He calls the

> occupant > by name, and the occupant screams, " Get Thee Behind Me, Satan, and

> " You are > all worms and don't think I don't know it. You will not kill me

> again. " More > officers arrive, and after a few minutes, they make entry into

the

> mobile > home and subdue the patient. You enter and observe a man lying on

> his side on > the floor, with his hands cuffed behind his back. He appears to

> be in his > 50's, and is alternatively screaming and raving incoherently.

> After consulting > with medical control you administer lorazepam 4 mg/IM and

> haloperidol 5 > mg/IM. After a few minutes the patient begins to calm down

but

> remains > disoriented. He tells you that his name is , but he does not

> know what day it is, > where he is, or why you are there. He continues to

> talk about CIA " worms " and > aliens from space. As he becomes more calm you

> manage to get a blood > pressure, 178/96, a pulse of 110 and irregular, and

note

> his respirations are 24 and > shallow. He appears to be jaundiced, with

> yellow skin and sclera. He also > appears at first to be grossly obese, but

> your partner points out that his > abdomen seems to be distended, and

palpation

> confirms that. Your patient is > unable to tell you anything about his

> medical condition.One of the sheriff's > deputies brings you a bottle with a

> liquid in it labeled " Oromorph, " and a > prescription bottle for

> oxycodone.Physical exam reveals no traumatic injuries. > Based upon what you

know so far, what

> is this patient's problem and why is he > " acting crazy? " Docs, please give

> the medics a chance before you jump in.Gene > Gandy, JD, LPEMS Education and

> ConsultingTucson, AZ**************Vote for your > city's best dining and

> nightlife. City's Best >

> 2008.(http://citysbest.aol.com?ncid=aolacg00050000000102)[Non-text portions of

this message have been > removed]> > > > > > >

> __________________________________________________________> Now you can invite

> friends from Facebook and other groups to join you on > Windows Live™

Messenger.

> Add now.> https://www.invite2messenger.net/im/?source=TXT_EML_WLH_AddNow_Now>

>

>

[Guest guest]

An excellent guess. Actually the answer was posted yesterday by two

different folks. He has hepatic encephalopathy secondary to cirrhosis of the

liver.

He is in the end stages of his liver failure.

The reasons for HE are not well understood and there are several possible

explanations. Take a look at " encephalopathy, hepatic, " on eMedicine Online.

A Google search of hepatic encephalopathy will give you lots of good stuff on

it.

A part of the scenario that only a few caught was that I had the medic give

him 4 mg Ativan along with the Haldol. The ativan is relatively

contraindicated, at least in that dosage; however haloperidol is the drug of

choice to

relieve the S/S of HE.

Always think about possible liver or renal failure before giving any drug.

You may have to adjust the dose accordingly.

GG

> Systemic anti-cholenergic reaction to perservatives in Oromorph......

>

> -MH

> ________________________________

> From: texasems-l [texasems-l ] On Behalf Of

> wegandy1938@... [wegandy1938@...]

> Sent: Friday, June 13, 2008 7:31 PM

> To: texasems-l

> Subject: Re: A new puzzler

>

>

> You are half right. He is in liver failure, but his current problem is not

> DTs. He hasn't had any ETOH in a long time.

>

> GG

> In a message dated 6/13/08 6:45:40 AM, mvondran@...<mailto:mvondran%4

> 0hotmail.com> writes:

>

> > I would suspect the patient is suffering from liver failure and is also

> > going thru alcohol related delirium tremens (DT).

> >

> > Vondran EMT-P

> >

> >

> > To: texasems-l@...<mailto:texasems-l%40yahoogroups.comFrom>

> : wegandy1938@...<mailto:wegandy1938%40aol.comDate>: Fri, 13 Jun

> > 2008 02:04:12 -0400Subject: Re: A new puzzler

> >

> >

> >

> >

> > Yes, the patient has a long history of alcohol abuse.GGIn a message dated

> > 6/12/08 10:49:59 PM, mvondran@...<mailto:mvondran%40hotmail.com>

> writes:> Are there any signs of a

> > lcohol abuse?> > W. Vondran EMT-P> > > To:

> texasems-l <mailto:texasems-l%40yahoogroups.com>;

> > Paramedicine@...<mailto:Paramedicine%40yahoogroups.comFrom>

> : > wegandy1938@...<mailto:wegandy1938%40aol.comDate>: Fri, 13 Jun

> 2008

> > 00:47:53 -0400Subject: A new > puzzler> > > > > You are

> > dispatched to a private residence for a possible " mental case. " You >

> arrive at a

> > mobile home in a neat mobile home park.  Outside are several > neighbors

> who

> > report that the man who lives there has " gone crazy " and has been >

> shouting and

> > throwing objects insidethe house.  One of them attempted to enter > the

> house

> > and talk to him and was met with a man who screamed, " Get out > before

> they

> > get you. "   The neighbor exited and called 911.  One neighbor says > that

> the

> > occupant is a retired police officer, and that he has been ill lately, >

> but

> > that she has never seen him act in any violent way before.  She is >

> unaware

> > of whether or not he has guns in the house. She says that he keeps to >

> > himself, is not friendly, and seems to have no friends, but has never

> caused any >

> > trouble. Shortly thereafter, two sheriff's deputies arrive.  One of them

> > knows > the occupant and says he will attempt to talk to him.  He calls

> the

> > occupant > by name, and the occupant screams, " Get Thee Behind Me, Satan,

> and

> > " You are > all worms and don't think I don't know it.  You will not kill

> me

> > again. " More > officers arrive, and after a few minutes, they make entry

> into the

> > mobile > home and subdue the patient. You enter and observe a man lying on

> > his side on > the floor, with his hands cuffed behind his back.  He

> appears to

> > be in his > 50's, and is alternatively screaming and raving incoherently.

> > After consulting > with medical control you administer lorazepam 4 mg/IM

> and

> > haloperidol 5 > mg/IM.  After a few minutes the patient begins to calm

> down but

> > remains > disoriented.  He tells you that his name is , but he does

> not

> > know what day it is, > where he is, or why you are there.  He continues to

> > talk about CIA " worms " and > aliens from space. As he becomes more calm

> you

> > manage to get a blood > pressure, 178/96, a pulse of 110 and irregular,

> and note

> > his respirations are 24 and > shallow.  He appears to be jaundiced, with

> > yellow skin and sclera.  He also > appears at first to be grossly obese,

> but

> > your partner points out that his > abdomen seems to be distended, and

> palpation

> > confirms that.  Your patient is > unable to tell you anything about his

> > medical condition.One of the sheriff's > deputies brings you a bottle with

> a

> > liquid in it labeled " Oromorph, " and a > prescription bottle for

> > oxycodone.Physical exam reveals no traumatic injuries. > Based upon what

> you know so far, what

> > is this patient's problem and why is he > " acting crazy? " Docs, please give

> > the medics a chance before you jump in.Gene > Gandy, JD, LPEMS Education

> and

> > ConsultingTucson, AZ**************Vote for your > city's best dining and

> > nightlife. City's Best >

> > 2008.(http://citysbest.aol.com?ncid=aolacg00050000000102)[Non-text

> portions of this message have been > removed]> > > > > > >

> > __________________________________________________________> Now you can

> invite

> > friends from Facebook and other groups to join you on > Windows Liveâ„¢

> Messenger.

> > Add now.>

> https://www.invite2messenger.net/im/?source=TXT_EML_WLH_AddNow_Now> >

> >