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CASES WITH A TWIST By David Page, MS, NRP, & Will Krost, MD, MBA, NRP 14 JULY 2016 | EMSWORLD.com B r e a k i n g t h e S e a l What's going on when a festival patron who should be dehydrated instead keeps peeing? A 27-year-old male who had been drinking alco- holic beverages presented with light-head- edness and blurred vision after spending two days at an outdoor summer music festival where temperatures were constantly above 85ºF. Initially the crew found the patient to be bellig- erent, using profanity and refusing treatment. But despite repeated offers by the police to take the man to jail, the crew continued with a more thor- ough medical assessment. The patient was unusu- ally anxious and repeatedly said, "Molly is my friend, she makes me glow in the dark!" and "I'm so hot!" Vital signs were BP 70/40; pulse 120; respiratory rate 24; and blood glucose 108 mg/dL. This crew appropriately began considering acute alcohol intoxication and dehydration as the most likely cause of the patient's symptoms. While trying to ignore the vulgarity, the crew also ignored some of the apparently nonsensical sentences. They estab- lished a large-bore IV and began giving a rapid fluid bolus of normal saline. "I'm sure this will help your hangover, my friend," one of the crew told the man. They also decided to transport him to the medical tent, not directly to the emergency department. Diferential Diagnosis The key to great decision making in the prehospital setting is critical thinking. It is important to consider all potential lethal conditions. In this case, merely assuming (incorrectly) that the patient's problem was simply intoxication could have meant the dif- ference between life and death. Once in the tent, providers considered the patient's presentation to be a medical emergency and began treating him. The twist in this case is that the patient, in his own way, was trying to tell the crew a bit more about what was happening to him. The patient was using the term molly to describe taking MDMA, also known as ecstasy or X. The fact that the man was hot was also key. A bit more investigation by the crew would have yielded valuable information about his hydra- tion. In this case, the patient had been drinking large quantities of neon-colored fruit punch and dancing. Both of these made him sweat profusely and urinate Mypurgatoryyears/Thinkstock David Page FEATURED SPEAKER EMSWorldExpo.com