What do you think was wrong with this patient

[Inthecity]

No basically I was just wondering how urgent the situation was. Not wanting to point fingers at paramedics. I am sorry if it came off that way. They were really good to me . Its the 2nd time I have been in an ambulance although the first time was just from a dislocated patella so nothing life threatening. Those paramedics were REALLY good to me as they gave me several doses of morphine!

[DwayneEMTP]

ITC,

Not mocking you, truly. I did get a little bit frustrated with your attitude towards the suggestion of an anxiety attack, and I'll explain why.

I've dislocated both of my knees, broken both of my elbows, broken some fingers, ruptured two discs in my back and had at least two concussions. Yeah, I grew up redneck. But nothing in my life compared to having an anxiety attack, and I've seen enough in others since to know that they've all felt the same.

During medic school I had an anxiety attack and it is truly the most horrifying thing that's ever happened to me. My chest hurt, I couldn't get my breath, I was praying for the ability to breath faster and deeper yet couldn't seem to get any air to move in and out of me. There was no question in my mind that I was in the last few moments of my life.

Unfortunately this happened to me in the middle of a paramedic class, (Imagine about 100 monkeys trying to hump 120 footballs and you'll get a decent picture.) so despite tons of things happening really fast, I can't really rate the treatment as great. We were playing at some type of scenario, I wasn't involved, wasn't even nervous. In fact I was having a great time. And suddenly thought that I was going to die. I certainly wasn't panicked as I wasn't then, nor have become since a big panicker.

In the situation that you mention it's truly not uncommon to feel a shortness of breath, begin to breathe faster to compensate, and faster still when that doesn't resolve the problem, and end up breathing fast enough so that it becomes part of the problem instead of the solution. See?

I would have been more receptive had your response been something like, "What makes you think that? Do you believe that the doctor could have been mistaken? How come?" Than "It was not!" It appeared that you were offended by the thought, and there's very little educational value in being offended instead of curious.

I'm confident of one thing only in your case. That being in that condition sucked. I must have been terrifying, and I'm truly taken back by your statement that the medics treated you really well. People much more often than not, when in pain and afraid, misunderstand so much of what happens in the back of an ambulance so that the medics are very often seen as clumsy villains instead of medical professionals doing the best that they can will very few tools at hand.

If you felt that it was my goal to mock, or embarrass, or belittle you, then I'm truly sorry for that. My goal was to try and force you from a point of view where you seemed certain of the error of a possible diagnosis and push you to explore instead of simply deny.

I'm glad that you're here! I hope that you'll stay. There is not requirement to be involved in EMS, only that you have a desire to teach, and to learn, and to explore. You have bigger chops than many medics I know, who would have turned tail and run away at the first contrary comment. It would be my guess that being a teacher is no less hardcore than being a medic sometimes is.

Have a great day girl. Thanks for looking after our kids!

I truly learned much from this thread that I would have been cheated out of had you not posted it. Thanks for doing that...and thanks for participating. I mean that with all sincerity.

Dwayne

[Inthecity]

Thank you Dwayne. That was really nice. I can understand what you are saying about a anxiety attack and maybe it was both the condition I was in made it harder to breathe and that freaked me out so I kept breathing harder and faster. It was 1.5 years ago and I still think of that night and the days to follow often. Yes the paramedics were really nice to me. It was a lady and she was mainly trying to get me to slow my breathing down but I couldnt. I would never belittle a paramedic because I honestly think they are heros. Im sure you and many others on here have saved many peoples lives and they would be dead if it were not for you. So it was definitely not my intention to speak negatively of them. I was just curious about the condition I was in and thought lots of you have seen conditions like this. BTW my dad is a EMT but its for a volunteer fire dept, his actual job is a CHP officer so I truly do have respect for everyone in this field of work. Its a job I know for a fact that I could not handle.

[DwayneEMTP]

Hell, you're a teacher, your dad's a cop...do your mom and husband do psycho jobs as well?

Just curious... :-)

[Inthecity]

Nope! My mom is also a teacher and so is my sister. My husband is a supervisor at a casino.

[Aussieaid]

There is the probability that there was some anxiety involved that could contribute to a higher RR and would be understandable but sepsis, fever and anemia are all have higher oxygen requirements.

They fever and sepsis causing acidosis is going to increase the CO2 which she would be attempting to blow off with increased RR.

The anemia means that even though she may be saturating almost 100% of the red blood cells there are not enough of them to carry the body's increased oxygen requirements with the sepsis and therefore she has to breathe faster to get more oxygen to the tissues.

Short and sweet!

[Asysin2leads]

From the sounds of it you have rather dipshit crews running in your area. When I read the presentation the big three that popped out were eclampsia, sepsis, and PE. I was going to ask for protein levels in the blood tests but you beat me to it.

The aforementioned ambulance crew were indeed dipshits. Anyone with a pulse rate of 225 with shortness of breath is textbook ACLS unstable tachycardia. If you are in an area without appropriate ALS response, then rapid transport to the hospital was clearly indicated. Not only that, but my personal feeling is that someone who has passed the hyperthermia threshold of 104.0 and into hyperpyrexia land is also a priority patient who needs to be at the hospital.

The ER at least was able to recognize your tachycardia, but they get a D+ after that. If I, a simple ambulance driver paramedic, immediately thinks of underlying causes when I read the presentation, then a full physician should definitely do the same rather than just jump for the adenosine first thing. While your heart rate was rather high, I still probably would have tried a 500cc NS bolus on the grounds that its possible your heart rate and temperature were exacerbated by hypovolemia secondary to dehydration, a common presentation in the ill. After that, I would also probably started working with some adenosine. I guess all in all the ER didn't do too bad. I'm not sure what the diazepine was for, you weren't seizing, unless they thought maybe you were doing the nose candy or were preparing to cardiovert. After the labs came back with your magnesium and protein levels, I think a mag sulfate drip would have been the most appropriate course of action.

[ERDoc]

I may be biased, but I think the ER did the right thing. A heart rate of 225 is a little too high even for sepsis/fever/dehydration. That is a lot of stress on an already sick system, even in an otherwise healthy person. If we want to use ACLS as gospel (not saying you did asys, just adding to the conversation), she should have been shocked. I'd give the adenosine right off the bat (as well as giving the fluids and tylenol).

[Kiwiology]

A fever by itself can also cause tachypnea. I have to admit that I don't know the mechanism, but I would guess it has something to do with thromboxane. Maybe our resident Kiwi house consultant surgeontologist can help us.

Isn't thromboxane part of the haemostasis cascade?

Are you suggesting I have some understanding of biomedical science and/or pathology? with encouragement like that I might just apply to medical school, oh look medical school applications open next week hmmm ....

And under no circumstances am I to be referred to as a surgeon, I can barely cut fruit and am hopeless at sewing the hole in my jeans up; um yeah Ambreas Pare would be spinning in his bloody grave forever perturbed at the notion. I'd probably resort to hacking it off with a giant saw I stole from the orthopaedic registrar when he was not looking or something and be unable to close so the patient would die of nosocomial septicaemia; see if that happened I'd have Ignaz Semmelweis and that Baron Lister bloke come after me with their dead people powers ...

So in short no operating for Kiwi; and yes I find medical history quite fascinating in case yo couldn't tell

I may be biased, but I think the ER did the right thing. A heart rate of 225 is a little too high even for sepsis/fever/dehydration. That is a lot of stress on an already sick system, even in an otherwise healthy person. If we want to use ACLS as gospel (not saying you did asys, just adding to the conversation), she should have been shocked. I'd give the adenosine right off the bat (as well as giving the fluids and tylenol).

I think it's way too high; I was taught 220-age or 220+age or something as the maximum a person should be able to sustain (+/- clinical judgement)

In September, 2011 Intensive Care Paramedics finally got adenosine for SVT

[celticcare]

Slow that puppy down, especially if it was PSVT on the monitor or anything like that, even if it was AT, slow it down, I agree with Adenosine and then sync cardiovert, with her vitals like that how they were, I'd have looked at fluid's anti pyretic and either DCCV or Adenosine. Why strain all the system with one of them going out of whack, slow the heart then at least one is in control and then able to focus on the others.