65 year old male, difficulty breathing...

[Just Plain Ruff]

Dwayne, before we go down the road of microscope and stains and all that peripheral stuff, why don't you let us know what you do have available for us to use. That might keep us from going down the primrose path of nowheresville.

I mean if he doesn't have cannulas, I'll bet he doesn't have microscopes and stains, but stranger things have happened in this type of place, right Dwayne?

[DwayneEMTP]

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.

Does he have productive sputum? Cough?...

No significant cough, no sputum upon forced cough for assessment.

...What does he look like? What is his physical constitution? Is he well nourished? Can you do a CBC for anemia? What color are the inside of his eyelids?...

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.

...I am sure I am just missing it but what is the altitude difference from where he used to live?...

About 6,000 feet. (approx. 2,000m)

...EDIT: Do you have a microscope and stains available?

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.

[Bieber]

I'm tending to think along the same lines as Mike right now, but I'd like to learn more. How long has he been here at this altitude? What exactly does his orientation consist of? Has he had any other symptoms? Specifically any headache, dizziness, lightheadedness, malaise, etc. Any chance we can take him down toward sea level and see how that affects him?

Also, you said his lung sounds were clear, how about tracheal sounds?

[Just Plain Ruff]

Dwayne, I don't think this guy needs a transport out of there. By the way, where is this guy from? Is he local or is he a travel in? That might give us a idea of what patho's he might be carrying.

But I do think that he does need observation. He's doing pretty good sitting and tolerating the oxygen.

My sats were running in the upper 80's. They had me in the springs ER for 11 hours, breathing treatments for most of that time. then they admitted me for 24 hours and after that they sent me packing after my sats picked up to low 90s. I'm thinking I'd be a bit more concerned with this guy with his sats at low 70s though.

I'd be cautious. Can you observe him for more than 48 hours or do you need the space?

But you then have to decide, can you really take care of him if it's really something worse?

I think you need to get him to a place where you can get a chest x-ray on him. That is going to tell you the most about him lung wise I think.

Can you run a sputum culture? If you can then you can probably get an idea of what he's got growing in there, or at least a basic idea.

He hasn't been on the antibiotic long enough I don't think to really see the benefit, what did your nurse put him on?

Edited May 29, 2012 by Captain ToHellWithItAll

[DFIB]

I thought you might have a microscope! The third world is the same everywhere. The stains were a real stretch.

This guy might have altitude sickness But I am not convinced because his pulse pressure had a pretty decent spread. I am placing my bets on him having anemia of some sort that is compounding the problem. Patients with anemia will have a false low SPO2 reading when the SPO2 is really in the 80's. I mean anemia can make the reading abnormally low. He possibly has TB as well but you need a lab or CXR for that.

Any chance of CO or CO2 poisoning? Is he sleeping with a heater? Would make since if he is from the lowlands. I don't know why but I am leaning towards a hemoglobin problem. any history of sickle cell in his family.

I would keep this patient on O2 and transport him to a lower altitude and make him walk. Who knows that would resolve the atmospheric O2 question. I would get a TB sputum test and CBC before taking him back up the mountain.

[DwayneEMTP]

I'm tending to think along the same lines as Mike right now, but I'd like to learn more. How long has he been here at this altitude?...

About 24hrs, maybe a little bit more.

...What exactly does his orientation consist of?...

AAOx4 (Alert to person, place, time, event), aware of surroundings, able to carry on conversations with clear appropriate language.

...Has he had any other symptoms? Specifically any headache, dizziness, lightheadedness, malaise, etc. Any chance we can take him down toward sea level and see how that affects him?...

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.

...Also, you said his lung sounds were clear, how about tracheal sounds?

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.

...He hasn't been on the antibiotic long enough I don't think to really see the benefit, what did your nurse put him on?

I'm not sure, but Amoxicilin is the cure all, or at least treat all for everything here...So that would be my guess...

I thought you might have a microscope! The third world is the same everywhere. The stains were a real stretch...

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.

...This guy might have altitude sickness But I am not convinced because his pulse pressure had a pretty decent spread. I am placing my bets on him having anemia of some sort that is compounding the problem. Patients with anemia will have a false low SPO2 reading when the SPO2 is really in the 80's. I mean anemia can make the reading abnormally low. He possibly has TB as well but you need a lab or CXR for that...

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.

...Any chance of CO or CO2 poisoning? Is he sleeping with a heater? Would make since if he is from the lowlands. I don't know why but I am leaning towards a hemoglobin problem. any history of sickle cell in his family....

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...

...I would keep this patient on O2 and transport him to a lower altitude and make him walk. Who knows that would resolve the atmospheric O2 question. I would get a TB sputum test and CBC before taking him back up the mountain...

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...

[systemet]

Re: SpO2 and anemia, the SpO2 should read normally, i.e. it will reflect the percentage of available hemoglobin that's saturated with oxygen. In the anemic patient, by definition, the amount of hemoglobin is going to be lower than normal, resulting in a lower arterial oxygen content.

CaO2 (ml 02 / dl) = 1.34 * hgb * SaO2 + 0.003 * pO2

[i hope people will forgive me for leaving out the units].

So this presents one of the major problems with pulse oximetry --- it doesn't directly measure arterial oxygen content, because it doesn't give us information about a major variable (hgb). Also, while in most situations hgb bound oxygen represents the major arterial source of oxygen, it's the pO2 that actually provides the driving force for diffusion across the cell membrane.

So you can have situations, e.g. hemorrhagic shock, where the SpO2 may be 100%, but the actual arterial oxygen content is abysmal, because there's very litte hemoglobin. [These massively anemic patients are among the patients that might benefit from higher FiO2's to raise the concentration of dissolved oxygen carried in the plasma, i.e. pO2, although we've all heard recent concerns about superphysiologic pO2's, and the potential problems.]

re: CO and SpO2, on most pulse oximeters, the CO-hemoglobin will be falsely interpreted as oxyhemoglobin, giving a false high, if you're considering the pulse oximter to read oxyhemoglobin.

[chbare]

Can we appreciate heart tones? Any history of congenital heart disease? Malaria is always on the differential. Pulmonary embolism is also a differential. You say the XII lead is unremarkable, but the guy is tachycardic?

[DwayneEMTP]

Can we appreciate heart tones? Any history of congenital heart disease?...

I'm not good with heart tones, so, no.

...Malaria is always on the differential. Pulmonary embolism is also a differential. You say the XII lead is unremarkable, but the guy is tachycardic?...

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?

[chbare]

Have we assessed the blood sugar?