DwayneEMTP

Wait, can you say that here?

Heh...He DID have clubbed fingers, but I had remembered that being attributed to heart disease and didn't give it much thought after the XII lead. And he wasn't significantly barrel chested, but then the Papuans tend to be pretty deep in the chest naturally so I may have missed it in him..

I couldn't be happier! Good on you... I'm counting on you being less of a pain in my ass as a nurse than you were as a basic...

He didn't Biebs, though it would have been difficult to tell I guess as he's really black, almost purple black. But I did check his nails and didn't notice anything, though they were mostly stained with Betelnut... Yeah, see, I'm not nearly as good at scenarios as Biebs... The ultimate diagnosis was long standing COPD exacerbated by altitude with relative dehydration from the altitude masking his pathologic lung sounds. Not sure the flavor. It made me pretty crazy because I was medicating and trying to create some improvement on room air, even just a few points of SPO2 but I just couldn't. (In case you'd never heard this, there appears to be no acute treatment that cures COPD, so you might want to save your time.) I'd assuuuuuumed that he's had a prehire physical, which cause me to assuuuuumme that the issue was acute, which cause me, of course, to try everything that I knew to do for an acute issue... Then it occurred to me that he wasn't really altered with an SPO2 of 72%. Upon his initial presentation he was somewhat diaphoretic, showing air hunger, SPO2 72%, so he kind of presented as I expected and I didn't consider his mentation right away. It wasn't until I'd gotten baseline vitals, then put him on an O2 neb of albuterol that it kind of struck me that something was weird, and not until I'd trialed him on r/a again a few times that I noticed that neither his mentation nor resp effort changed regardless of treatment when he was at rest.. Now, to some of you COPD might seem obvious, but I'd never had one that presented like this. In fact most if not all (assuming I've missed some) have presented, even if in extremus, I've been able to manage them in some way, and I guess that I've always assumed that someone smart made them better. That if I'd seen them later that night that I'd have seen a completely different presentation and vital set. Know what I mean? His lungs sounds were full and clear, but I'm guessing, and the doc's agreed that relative dehydration from the altitude might have masked pathologic lung sounds... Anyway, I thought it was a pretty interesting case that took me about 6hrs to figure out. It wasn't until I thought, "Shit, I might as well save the O2, he's just as good without it..." Then, "yeah...he is...why is that?" I guess I'm not aware of ever seeing an asymptomatic though significantly ill COPDer...It never really occurred to me that people might be walking next to me with SATs in the 70's yet look more or less normal when not exerting themselves. So the bottom line is long standing undiagnosed COPD exacerbated by the altitude. We sent him to the hospital in Lae by road, about 5-6 hrs depending on road conditions, and before he got there he felt fine and didn't want to go to the hospital...

Very dark skinned.... Hmmm...I thought that the above would clear this up. I'm glad it didn't, as I always assume you guys will figure out instantly what took me hours and I feel smarter when you don't. It truly hit me in the face when it occurred to me... Of course the second phase of insecurity is preparing to explain my reasoning and have someone say, "What? That doesn't make any sense at all? You guessed wrong but got lucky..." Who is unaltered at 72% SPO2? And who might get little or no relief by relieving that condition? What class of patients?

In this patient you can assume that the pulse ox is telling the truth... What other symptoms would we expect to see with anemia? Are we seeing them here?

A couple of things bothered me... That his mentation seemed unaffected at an SPO2 of 72%, as well, I saw no increase in mentation at 100%. I expected him to be 'sharper' or more alert with increased sats. Also, that when given oxygen, his sats jumped to 100% in, probably, less than 30 seconds, while it took them 6 or 7 minutes to drop back down again. He was pretty thin so I would expect it to take him a while to de-sat, but it still seemed odd to me... After I removed his oxygen, at rest, and monitored him closely, I saw no change in breathing effort nor change in mentation as his sats settled back down to the low 70's. Also, he reported no relief when given Oxygen except in the few minutes immediately following the effort of walking, but after those few minutes had passed he didn't care about the O2 any more. Anyway, that's what I noticed...and could only resolve in my mind in one way..

Chris, blood sugar is within normal limits. Biebs, good summation. You may be at a loss, but you're not without the skills. There is one part of this presentation, from the beginning, that didn't make sense to me, though Chris may say that he sees it all the time. I didn't really get it until I'd trialed him on room air several times though and then it finally clicked. I came up with only one theory that made any real sense to me, I consulted with some Aussie docs in Sydney who agreed, and then it was 'verified' though I've no idea how, at the hospital in Lae. You're thinking possible altitude sickness, possible P/E, both of which come with significant hypoxia, right?

I'm not good with heart tones, so, no. A congenital heart issue is something that I would have no idea how to explain here, and would almost certainly be written off as silly and unimportant if I could. Curses and weather kill people, not anatomy and physiology. Malaria test shows negative, and the absence of other markers makes me tend to agree. P.E. is possible but he's been in this condition to the best of our knowledge for 24+ hours now...So that would bump it down on my differential, whether it should or not I'm not positive. I guess I haven't consider tachycardia without an associated/diagnostic change in any of the complexes as remarkable. Maybe I used the wrong term? Serious question, would you call tachycardia secondary to hypovolemia a relevant finding? Know what I mean?

About 24hrs, maybe a little bit more. AAOx4 (Alert to person, place, time, event), aware of surroundings, able to carry on conversations with clear appropriate language. He denies all of the above symptoms and I see no obvious reason to disbelieve him. No chance to take him down to sea level for a test, but he reports that he doesn't have this issue at sea level. Clear also. This made me really batshit because I knew that I was missing something obvious. But to my not always so bright ears it sounded as if he was moving good air, at least there was good air movement noise in all quadrants, I even went over his lungs inch by inch with the supplied $12 stethoscopes hoping that, though he was afebrile, I could track down some pneumonia or other obstruction. If you'd allowed me to examine this patient without a history, age, or viewing him I would have sworn that I was examining the lungs of a much younger person. I'm not saying that a better provider would have sworn that, but I would have. I'm not sure, but Amoxicilin is the cure all, or at least treat all for everything here...So that would be my guess... Yeah, it's so funny. Tons of stuff that broken, but if it wasn't most of us wouldn't know how to use it anyway. And basic, cheap stuff that should be required that's not. But wouldn't anemia make it abnormally low on the top end too? When you put him on Os his sats jump up to 100% very quickly. I did consider that the machine was off and tried him on two battery powered and one wall mount SPO2 unit, and they all agreed. Why did I try so many? When I argue that we don't need them if we're decent clinicians? Because I just couldn't make this patient match what the pulse ox was telling me. Washed his hands, warmed them, he had good cap refill in all fingers, etc. But CO poisoning would elevate his SPO2, right? Not drop it? He's sleeping with a heater, but it's electric only. No reported sickle cell history, but like a dumbass it never occurred to you to ask about that... Pt denies night sweats, DOB at sea level, productive cough. But those are all things that people know by rote in environments where the best paying jobs won't hire you if you answer them incorrectly. Though I'm guessing you see that too. So all of those types of questions are just sort of dotting Is and crossing Ts because you can't trust the answers at all... Sorry guys, I had to edit down my post to get it to post correctly as I had too many quotes. I'll try and hit the others later...

Hey Mike, Were your sats in the 70's from the altitude? Though of course your logic is sound. You're only treatment for him would be observation for the next two days to determine if you're right about the altitude issues? That seems like a pretty long verification of treatment period... :-) Antibiotics have appeared to have no effect at this point. No significant cough, no sputum upon forced cough for assessment. He claims to be 45 years old, but you, as well as a local nurse put his age near 65/70. He appears to be what you would expect from a 65 year old man living most of his life outdoors without regular medical care. Skin is wrinkled, but is p/w/d except when he exerts himself very much, and then temporarily diaphoretic, thin, well muscled in that older sense, not appearing malnourished, many missing teeth and those remaining stained from betelnut use, inside of eyelids is slightly pale, but you're unsure if that color is normal for this environment and it could even be a normal variant for this individual. Either way the difference isn't extreme. Eyes clear, focused, following activities and tracking sounds as expected. No option for blood panels. About 6,000 feet. (approx. 2,000m) You have what appears to be a pretty nice microscope, though the lenses have been missing for an unknown period of time and you (of course I really mean me) don't know how to do stains even if they were available. We have to think about the things that are available in the back of an ambulance at a non progressive service, only older. The exceptions being antibiotics, malaria tests, etc. But in terms of diagnostics, the other will get you pretty close.

He says that he doesn't feel bad now, just short of breath. He says that it started about 12hrs after arrival onsite because it's "so cold up here...the cold air (45-75F depending on time of day) makes it hard to breath." Says that he's not had like symptoms before. Denies any symptoms other than the shortness of breath. (Note: Not trying to mislead above. Remember that most illness here is attributed, according to most villagers which comprise most of the labor pool, to cool/cold breezes, curses, or evil spirits.) No history of detected bites, no ETCO2 detection, lifelong smoker but stopped 6 years ago, pt denies history of any drug or alcohol use other than Betelnut. (Believable as alcohol and drugs are wicked expensive here with the exception of pot and betelnut, and pot is very frowned upon by the mature generations.) He's placed back on O2 at 3L/min/simple mask with holes cut in it (No nasal cannulas here. On order with the urine dips) which brings him quickly back up to 97% SPO2...

None. None 6,600ft/Sea level Most of what you would find in the back of an ambulance of a non progressive service, only much older. P 122, B/P 156/96, SPO2 72% r/a, XII unremarkable, temp afebrile. Heh..I'd love to have her if you mean your girl! The entire manual for the nurses is made up of four little books, say, 3 inches by 5 inches, by 1/4 inch thick. Like you'd expect to get with a new printer or such, only without the thin paper. None. BGL is within normal limits, no imaging or lab values. (Are you kidding me?? My ECG has clamps and brass bells with suction cups on them that leave big hickies wherever they're placed....No labs.) You take him off of the Oxygen and after about 3-4 minutes he's back down into the low 80's and falling...

Yeah Brother, I use 'denie(s/ed)' a lot for pertinent negatives. It shows that I asked, they denied, it's been covered. And I'll visit it again as a sign instead of a symptom if necessary. And also, I would have bit his fucking nose off and spit it back at him if he claimed that I had multiple spelling errors on a PCR in a room full of people when I knew I didn't. Ok, maybe not, but I would have handed it to the nearest literate looking person and asked them to point them out for me. No worries Brother. You'll soon be rid of him but he'll have to live with his tiny penis forever...

You put him on 'some' oxygen. It brings his sats up to 100% in just a couple of minutes. No reported medical history. Pt states that he's never been to a doctor. You listen to his lungs and notice that they seem to be filling well with air, no pathologic noises. He was meant to be a drilling assistant at Hidden Valley, but he's not started yet. Just going through orientation. You have no idea what that means.

You're the lone medic in Hidden Valley PNG, and by far the highest level of care. Upon reporting to the clinic in the morning are informed by the night nurse that she had an 'old man' with difficulty breathing the night before. He reported with DOB upon walking short distances, has only been on site one day prior. Nurse reports an initial set of vitals... P 120, B/P 166/98, SPO2, 72% r/a. She gives him an Albuterol neb, puts him on O2, while on the neb and O2, she sees that his SPO2 has come up to 88%, gives him a schedule of Amoxicillin, some PO steroids and sends him back to work. Nurse felt it wasn't necessary to call you because the "antibiotics will probably take care of it." Surprise, he's back in the morning..... Upon your first contact you find P 122, RR 28, SPO2 72%, B/P 156/96. What would you like to do?

Yeah...it's a quandry...Pushing harder for the urine dips, but until that happens, which is probably never, then we'll have to use b/p, pulse rate, and reported symptoms. Thanks for your help all...

I've been here a few days now and I can't think of 10 threads I'll bet that went so long that hadn't turned to shit after about the 25th post. I can't even begin to tell you how cool the participation was, but more so, how hard it is to run these scenarios without having them get all tangled up at some point. You should be really proud Biebs. I wasn't truly confident at any point but I had complete faith that if I walked down my treatment plan that I'd get the information that I needed to know if my path was a good one or not. Certainly one of the most excellent scenarios we've ever had. I hope that you'll do more. Did you find that presenting them is at least as good of a learning experience as participating in them?

Wait a second... This super progressive, better than all the rest system that you're constantly crowing about has no CPAP, Mag Sulfate or inline nebs? Huh.....

A Pox On This Place (IP: 50.137.198.175) EMT City Rookie EMT City Sponsor 9 posts (Rating) 3 I can't tell you how cool I think this is. 9 posts and a sponsor. Not THAT'S the best of what we do. Giving back when we can... Thanks for that Pox. (What kind of a nickname is Pox? Though I like it somehow!) (Not questioning where it came from as I read your post, just how funny it is shortened as we're wont to do.) And for the record, I don't make a penny from here, get very few special privileges, so it's not a thanks for me financially, but instead for helping to support what has been an essential resource educationally as well as the source of many new and lifelong friends for me. Cool as hell..

Actually, depending on the environment, I might choose to run this guy lights and sirens. It's early morning so in a smaller population it might not matter, but with a half hour transport I'm guessing that we're moving from rural to the city and at a time when the deer are starting to think about getting up and around. It may sound stupid, but I might run rural lights and sirens with this guy, best safe speed, just to keep the critters out of my way. I would also go ahead and set up another 2g of Mag to run in slowly. It 'appears' that we got a decent response to that, and either that or an increased O2 Sat has settled down his heart. I don't see the harm in it. I don't know how much fluid we ended up delivering but I'd run in another 250cc, assuming we're only at 250cc now and see how/if that effects his B/P and pulse rate. I'm going to guess that we'll see a decrease in both if we give him the right amount of fluid. But as we're not completely sure what's going on I don't want to commit until I see some more movement in a happy direction. It appears that we're on the right path now, but I always get a little bit worried when I'm pretty sure that I know why things are happening. So I want to keep moving in the same direction but verify at least every 5 minutes that we truly are moving in the right direction and not simply reacting to something unknown that's partially or completely responsible for this change instead. So, I'd push the steroids, 250cc bolus but let's run it in with another 2g Mag over 10-15 mins, let's recheck our SPO2 and ETCO2 and see if we note any significant changes, rerun a 12 lead if you can do that while moving, otherwise let's go ahead and set it up and have our partner pull over in a place where he can get immediately back underway, as his sats rise let's titrate to 95% (Not I'm not sure if this is a valid concern in this patient?? But let's do it anyway). I don't see any reason that I need anyone in back with me unless we have someone that can learn from patient care. We'll run lights and sirens at a quick/safe speed unless we see that the sirens are adding to our patients anxiety, then lights only, for the reason stated above. And head to the ER.

Welcome Brother. It's good to have you! Thank your for your service and your sacrifice. I, as well as some others here have spent time in Afg as contract medics. Not comparing the two jobs my friend, only the geographical locations. I was in BAF and KAF for a bit. Stay safe...I look forward to your thoughts.. Dwayne

Edit: Anyone still believe that this guy was fine 20 minutes prior to EMS arrival? Yeah, I would have given the steroids following the Mag. Queering his immune system (though that wasn't on my radar until Kiwi mentioned it) at this time is secondary to getting him some air. We are providing some short term relief with our other interventions, but he's going to need something on board that will last a bit longer, at least if our goal is still to avoid intubation. Plus, won't the steroids work towards relieving the bronchconstriction via a different mechanism than the other interventions employed so far? I would also go ahead and run a 250cc bolus and see if there is any noticeable difference at all, though I'll almost certainly run at least another 250ccs after, depending on results. It's my limited experience that dry lungs get really unhappy (though I'm guessing that chbare might use different terminology) and get constricted pretty severely sometimes. If no significant contraindications exist, and at least a half assed belief that relative or true dehydration exists, I'll always try a fluid bolus along with the neb to see if it will create a change. It can be surprising (or at least so it appears so to me) the difference that a bit of fluid as the only treatment can make in some of these patients. Though, perhaps there is something else going on in connection with the fluids and I've incorrectly associated 'moister lungs' with at least a partial relief of symptoms. I don't know. It's my hope that getting him some more air will satisfy his ache breaky heart a bit and we'll stop seeing those transient pissed off rhythms. But, you know, hoping and all... It looks like, this time around maybe, that watching for zebras instead of horses was a prudent course of action? What an excellent scenario, run perfectly. With everyone participating in the true spirit of learning...Man, what a treat.