A new puzzler

[Guest guest]

Here's another one. If you get this one, you'll just have to bask in your

glory, because all the rooms in Ladonia are booked up, this being the " high

season " there.

You arrive at a residence around 1030 hours to find your patient, a 68 year

old female lying supine on the kitchen floor. Her neighbor is at her side and

says that she became concerned when the neighbor did not come out to walk her

dog as she usually does around 0800. So after calling several times on the

phone she used the key she has to get into the house and found her neighbor on

the kitchen floor.

Your patient has obviously been on the floor for a long time since you note

both urinary and bowel incontinence. Your patient is also cold to the touch.

Her eyes are open and she responds to your questions but is somewhat confused.

However, she complains of constant pain in her right hip which she describes

as being 5 on the 10 scale.

She cannot tell you exactly how long she has been there, nor can she name the

day of the week, the month of the year, or whether it is spring, summer,

fall, or winter. It is winter, but she tells you she thinks it's summer. She

does know her name and birth date.

Pulse is 72 with a capturing pacemaker spike on ECG. Respirations are 12 and

shallow with fine crackles throughout the lung fields, and BP 88/54. Blood

glucose is 94.

While your partner is getting oxygen on the patient you do your head to toe

survey and observe that the patient's right leg is shortened about an inch when

compared to the other leg, and it is laterally rotated. Your patient says

she cannot move it. She cries out in pain when you palpate the area of the

right greater trochanter.

After starting an IV you ask for her medical history, medications and

allergies. She reports that she has had a pacemaker for about 4 years, that she

takes a blood thinner, a blood pressure medicaiton, and another heart medicine.

He find prescription bottles for Coumadin, HCTZ and lisinopril, and digoxin.

You ask her if these medications are what she is taking and she answers " yes. "

She denies any allergies. Her neighbor calls you aside and says that in the

past the patient has been treated for depression but that she seems to have

been doing well lately.

After contacting medical control for an order for pain medication you ask how

much she weighs and she says " 180 " which appears to be in the ballpark to

you. You give peperidine 50 mg SIVP and promethazine 12.5 mg SIVP and

administer

a bluid bolus of NS of 250 ml. After 5 minutes you attempt to move her

onto your scoop stretcher but she still is in great pain with every movement.

You administer another 50 mg of meperidine and another 12.5 of promethazine.

After 5 more minutes your patient is pain free and you move her to your scoop,

onto the stretcher, into the ambulance and proceed to the hospital without

further incident.

Later that day, while in the ER with another patient, one of the nurses

mentions that the patient you brought in that morning with the broken hip is in

the

ICU. It seems that while they were waiting for the orthopedic surgeon to see

her, her blood pressure went up to 220/136, she became agitated and wouldn't

be still in the bed, and finally went into seizure activity. Her body temp

rose to 108 and she is not comatose. She says they don't know why this

happened. The only medications they gave her were more meperidine and

promethazine as

needed for pain and to keep her quiet, since she became very restless and

tried to get out of bed.

You wonder what could have happened. It couldn't have had anything to do

with your treatment could it? You did what your protocols said to do for pain

relief, and the same thing was done in the hospital after she arrived.

Anybody have the explanation?

Gene The Puzzle King