Differential Diagnosis for Severe Dyspnea

A recent call came in as severe difficulty breathing. Upon arrival the patient was tripoding, with rapid, shallow breaths and expiratory wheezes audible from 5 feet away. Rescue had placed the patient on O2, and her pulse ox was in the mid 80’s. When I listened to her chest and back, I heard diminished breath sounds in the lower lobes, and clear wheezes on expiration. We were 3 minutes to the hospital from where we stood, so I started albuterol, and got an EKG (normal sinus without ectopy) and IV enroute. The patient reported significant improvement in her dyspnea with the albuterol treatment, and her pulse ox was quickly into the high 90’s.

While the above fit a nice picture for me, there were some issues that have me pondering. First, the patient had no asthma hx, though most of her family has asthma. Second, at one point she was complaining of tingling in her extremities. Third, the albuterol, which was preceded by my telling her it would provide significant relief, worked VERY quickly. Fourth, the patient required no additional treatments in the ED, and her lung sounds were clear there. If it weren’t for the low pulse ox and the wheezes, I’d argue this patient was hyperventilating and/or having a panic attack. I’m left wondering what exactly I had on my hands and if I handled it properly.

Allergic Reaction to Epi?

That's how the call came in. I was a bit dubious as I was fairly sure most people can't have an allergic reaction to an endogenous chemical. Turned out that the pt's symptoms overlapped perfectly with the side-effect list for epinephrine.

Why take the Epi? Here, I blame the person who prescribed Epi for this patient and did not explain how and when to use it. The pt had a bee sting, there was a localized reaction, and 24 hours later (!) decided to use the Epi to treat the localized swelling! As you can guess, the Epi made her feel horrible. I felt bad for her as she was scared and embarrassed. I am quite sure she'll think twice before she zaps herself with the Epi pen again.

MacMedic's Horrible Call

I'm guessing most of those who read this blog also read The MacMedic, but in case you missed it, he had a call that is a fear of all of us, particularly those working in a small community. You can read it here.

No words can fix that pain.

Overdose Weekend

Here is how my weekend went:

("Drug" here includes but is not limited to alcohol...)

Accidental Drug overdoses: 2
(the consumption was no accident, just the overdose part...)

Purposful Drug overdoses: 1

Severe chest pain with Cardiac hx: 1

Seziures with seziure hx: 1

Ankle injury: 1


The call I felt best about was the cardiac. Nothing heroic, it just felt good. Fast IV start on firt shot, good treatment outcome (O2, ASA and nitro x 2; pain from 8 on 10 to 3 on 10), and proper hospital selection (which meant a 40 min ambulance trip to a Cath lab). This call epitomized why I wanted to be a medic in the first place. The call was a way out of town, and the local rescue got out with firefighters with no EMS certs (they were basically holding her hand when I got there, as they couldn't even give her O2). I was the only medic free in the area, and without me, this patient would have had BLS only care for a trip to our local hospital, which would have had to do a full work up only to transfer her to the hospital up the road for definitive treatment. When I was a basic these calls bugged me because they should be handeld ALS (advanced life support), and many times a call like this would result in a medic being asked for two or three times, to no avail. There are still gaps in our ALS coverage, but I am proud I can provide ALS to my community, and on this call I may well have made a difference in this patient's long-term prognosis. THAT is why I wanted to do this volunteer medic "thing". I'm glad I did.

Predicting Katrina + Laying Blame...

A few things about Katrina I feel compelled to comment on:

If you read this October, 2004 article in National Geographic, you'll see that there were people who saw it coming: "The Federal Emergency Management Agency lists a hurricane strike on New Orleans as one of the most dire threats to the nation, up there with a large earthquake in California or a terrorist attack on New York City." I guess seeing it coming and being prepared for it are two different issues...

If you wonder WHY Katrina happened, you don't need to look far (what follows are my thoughts on and some information derived from a Washington post article by Alan Cooperman, titled "Where most see a weather system, some see divine retribution" Page A27, September 04, 2005. The shitty writing is mine [Mr. Cooperman's article is well written and worth the time to sign in on the Post's web site]):

Some dude named Steve Lefemine notes that Katrina is due to abortion being allowed in the United States (in fact he "sees" a fetus in the satellite photos of Katrina). But of course, he could be wrong, because...

A Kuwaiti newspaper quotes someone worth quoting (I guess...) as stating Katrina is a terrorist working for Allah. But of course, he could be wrong, because...

A journalist in Israel points out that it is time for God to stop protecting the U.S. just as the U.S. left Israel vulnerable. But of course, he could be wrong, because...

A fine fellow citizen points out that it CANNOT be a coincidence that Katrina hit the day 125,000 gays and lesbians were going to be in the French Quarter.

Might as well add my own! I think it was the God of hangovers who punished Bourbon St. for what its "hurricanes" did to me several years ago. The God of hangovers does NOT like sweet drinks with high EtOH content and hell hath no fury like a pissed off HangOver God.

So who did it? The Old testament God? Allah? Jesus? Predictable weather patterns which guaranteed that a Katrina would happen at some point to this poorly located and designed city?

If you are going to use anything as an explanatory construct, please DO make falsifable predictions and account for the extant data better than any other theory. Please predict where the next horrific event will happen and why will it occur. Can your predictions be specific enough that they allow us to know it is YOUR God and YOUR reason that something happens? Explain and predict things better than, in this case, meteorologists, urban planners, geologists, etc?

It just kills me that these horrific events took the lives of innocent people and now people want to ascribe this is the planned, purposeful actions of a supreme being. If your God goes out of his or her way to kill toddlers, say, just because a man happens to want to kiss another man, you can keep said God.

I Want a Transfer

My agency doesn’t do many “transfers”(non-emergent transport, usually from facility to facility). The local hospitals and other facilities know we are an all-volunteer agency and try to keep from taking us away from home and work unless necessary (there are two paid agencies within 25 minutes and they happily take the business).

In the last week or so I’ve been on two transfers. The first was an accidental meeting. We had just delivered a patient to the E.D. when a paid crew of two asked us if we could help lifting a patient. This gentleman was large, and they were having trouble moving him even with the Hoyer lift (sort of a human crane). Part way through the process, it became clear they were not going to be able to fit him into their ambulance (they had a smaller, van style rig). They explained that the patient was in his last few days of life and wanted to get home to die there in comfortable surroundings around those he loved and who loved him. If he couldn’t get home, he’d die in the hospital. So, we decided to help everyone out and loaded the patient into our rig, and with the help of the paid crew and the fire department, we were able to get him back into his home and in his favorite chair. I recently learned he died the next day, and while I am sad for his family, I feel good that he got to die where he wanted.

The second transfer was by special request. I had taken a patient in to our local hospital for oral hemorrhaging post tooth extraction (the patient was on Coumadin due to being in atrial flutter). Several days later the patient was in the ICU/CCU of our local hospital, STILL HEMORRHAGING, and needed to be transported to an oral surgeon’s office 25 minutes away, watched while the surgeon worked on him, and returned to our ICU/CCU. The hospital tried to arrange a paid service for the round-trip transfer, but the patient specifically asked for us. Frankly, the idea of going away from home, during dinnertime and my kid’s bedtime, was not appealing. However, it was clear from my conversation with our chief that the patient really wanted us to take him. So, we did. It turned out to be an interesting trip. I got to watch most of the surgery, standing by with ALS drugs and a defibulator (they had these in the office, but it was clear they didn’t get used much). Watching the oral surgeon work was very cool – a LOT of dexterity needed there. The patient is a former professor from the institution at which I work. The oral surgeon is an alumnus, as is his daughter who was assisting. One of my crewmates is a current student. Thus we had an old prof., a current prof., two old students and a current student. The patient was stable the whole time and things were un-eventful, and most of us had a good time (I’m not convinced the patient did…).

Classes are going full bore, and summer is showing signs of making its exit. We’ve had a home football game, and that is usually a sign that the nights are going to start getting colder.

DJ