Memorable Misdiagnosis

[ERDoc]

Don't know. I'm not a doctor. That's what he said. I can see if I can find some info for you but it will take some time as I am working the next several days.

I am a doctor and I don't get it. The best I could come up with was that maybe she was hypoxic and hypercarbic from resp depression. I was thinking that maybe the family heard carbon dioxide as carbon monoxide when the doctor was explaining what was going on. Just a thought.

[akflightmedic]

Well, mine just happened. Actually I just came into work and found out the result of my misdiagnosis.

My medic partner is in surgery as we speak.

41 year old male presented with sudden onset of N/V/D. Left work a few hours early and went to his room to sleep it off. Came back approximately 5 hours later, pale, diaphoretic and dehydrated. States he has been puking and pooping explosively.

Started an IV, snowed him with phenergan and monitored him in clinic. Slightly febrile at 99.3 F, rest of exam was unremarkable. ABD SNT, but there was persistent cramping, no specific area.

No brainer, looks like we got gastroenteritis. Other differentials were E.Coli, salmonella, shigella, appendicitis and IBS. C Diff was ruled out due to no previous use of antibitoics recently.

Did the tylenol and motrin, and rehydrated with 3 liters NS. At one point his temp spiked to 103 but it quickly retuned to normal.

Pt is a medic and is adamant about getting better as his RnR begins in 3 days. After 12 hours as inpatient, he states he wishes to return to his room as the N/V has resolved, and the cramping/diarrhea has slowed down.

8 hours later, pt returns to clinic with complaint of explosive diarrhea. This is his only complaint. He is still pale, and dehydrated of course but no other symptoms. Pt again is rehydrated with IV and after several hours is able to do oral hydratrion as well. Throughout this visit, the abd cramping persists and he is started on Cipro and Bentyl. Phenergan is still given to help him sleep thru the worst of the cramping.

No one else on camp is experiencing similar symptoms so I am r/o food poisoning at this time. Pt starts to improve and his color is starting to return. He is able to tolerate jello and toast and states the cramping has almost completely subsided and he has not had a BM in several hours and has been urinating just fine with no complications.

Pt is released from clinic at his request and he goes to the room for the evening. The next day he is set to leave on the convoy to head out for RnR. I spent the morning with him and he did still appear weak and pale but said he was no longer having BMs. He complained of feeling bloated and his stomach did appear as such. Again his ABD is SNT and there is no specific pain complaint.

Pt got on convoy and went to a different site for fly out. While there, he had sudden relapse, went to the clinic there and had a U/S performed. His appendix was not visible. He was rushed to surgery and is there now for a confirmed ruptured appendix.

Right now I am beating myself up over this because I am doing a ton of should've, could've , would'ves......I feel I dropped my guard due to the fact that my patient was a medic who I have much respect for especially in his knowledge of medicine. I took his word on several different assessments and I did not push as hard as I would have on regular patients for further testing or treatments. I can think of several things I did not do that would have maybe led to a different conclusion. I pretty much zeroed in on gastro and held to it. I did consider other diagnoses and treated for such but I was positive it was gastro and no big deal.

Basically I failed to maintain a high index of suspicion and assume the worst until proven otherwise.

[VentMedic]

Ok. I gotta ask. How does hydrocodone affect Carbon Monoxide (CO) levels in a patient?

I can't find anything that supports this idea. Can some help enlighten me? Or was there just some mistyping going on above?

-be safe

Carbinoxamine was linked to hydrocone and is mentioned in the investigation of children's deaths.

Carboxyhemoglin levels are rarely measured in children so there is insufficient research. If the levels do show high in the ED or PFT lab, it is attributed to exogenous (parents smoking near the child) or they are in the ICU in RDS and there may be some endogenous things happening to which the links in my previous post explained. There were several chemicals that could bring about an elevated COHb level.

Hydrocodone: there is a chance for Stevens-Johnson Syndrome and TEN. The pts are often sent to a Burn Unit for specialized wound care and possibily HBO therapy.

[paramedicmike]

I am a doctor and I don't get it. The best I could come up with was that maybe she was hypoxic and hypercarbic from resp depression. I was thinking that maybe the family heard carbon dioxide as carbon monoxide when the doctor was explaining what was going on. Just a thought.

Thanks, Doc. I was thinking along the same lines as you but just wanted to make sure I wasn't missing something.

I also considered that it was just what the patient's family member said without realizing s/he had no idea what was being said.

Vent: I saw some references to the info you mentioned, too. It didn't sound like this so I didn't pay too close attention to it.

AK: Ouch! Man! I hope your partner is ok.

[Dustdevil]

I pretty much zeroed in on gastro and held to it. I did consider other diagnoses and treated for such but I was positive it was gastro and no big deal.

Wow, dude. Tough break, but other than spending a couple of days miserable, he shouldn't be any the worse for wear.

Abdo patients certainly give me the heebie jeebies out here. When the nearest CBC, abd film or sono means a trip through Indian country, it definitely makes you sit on things you wouldn't have otherwise sat on back in the states. That's just out of our hands. The physicians on this camp are in the same boat. I had a 24 hour GI virus burn through camp a couple weeks ago, and every one of them gave me concern. I kept asking myself every time, "Am I getting complacent from seeing all of these? Is this just another 24 hour SIQ, or is this the one guy who is really seriously sick?" I go make house calls on a lot of my abdo patients just because I am so worried that one will go bad on me.

Given who your patient was and what he was telling you, I can't say for sure that I would have done much different. I probably would have become pretty adamant about a surgical consult after the 103 fever though. In both of the hot bellies I have caught out here, the fever was the one thing that sealed the deal for me.

I have just been lucky so far. Very lucky.

[spenac]

Medics are the worst patients. Know what your doing and they either try to hide it or deny it.

[Dooger]

I had a drunk with a sore ankle all day call 911 for a ride to the ER. No swelling or deformity, so I walked (ungainly limp would be more accurate) her out to the rig and drove her the 2 blocks to the ER. Later saw her films... turns out it was a fracture. Oops! :oops:

[Laura Anne]

Were mom and baby okay?

I love it when these young girls deny that they are sexually active and turn up pregnant. I am a prepared chidlbirth instructor and have had a few of those come through my class. I asked them, "If you're not sexually active why are you in a class for expectant mothers?" Their response, "My doctor suggested it would help me." I would then ask, "So you have never had intercourse?" "Nope, we came close but he never put his thing in me." Hello little girls!!

Hmmm, something tells me the girls weren't the 'little' ones if they didn't know it was in there......lol :shock: :wink:

Sorry, had to go there :roll: :twisted:

On a more serious note, Akflightmedic.....you did as I think a lot of us would have done, so please don't beat yourself up for it. There's so many different types of illness that your partners S&S could have been diagnosed for. Plus, I have seen many different types of patients who all reacted differently to having an AP, myself included. My AP was pretty darn close to blowing, but my fever was low grade and I had no specific site of ABD pain and/or rebound tenderness, so they didn't think I had one either. My CBC showed a high WBC count and they kept me in the hospital for that reason on IV antibiotics due to my other Mhx. Later, they scheduled an ABD US and found my AP.

There's only so much one can do w/o the proper resources. I would have no problems ever trusting your judgement and care as a provider from what I know of you here. Hope your partner feels better soon and recovers quickly from his ordeal.

[CBEMT]

Biggest oops for me was the classic pnuemonia for CHF mistake. Fooled me AND the ER doctor.

[pyroknight]

I had an "oops" several years ago that I did not realize was my fault until I took a paramedic refresher a few months ago. I walked into the house of a chronic COPD/CHF patient. My partner had been running EMS in the county forever and had run on this patient multiple times (the patient was the mother of one of the volunteer firefighters present, no pressure, lol). I was inclined to initiate transport and treat enroute, but my partner wanted to try a nebulizer treatment on scene first.

The patient was not really wheezing, but I have had patients who stopped wheezing once their air movement decreased to a certain point.

We provided the nebulizer treatment and the patient appeared no better. As we began moving to the truck, she started looking worse. Halfway into a 45-minute transport, the patient became unresponsive as her sats continued to nose-dive on 100% by non-rebreather.

We wheeled the patient into the ED while providing bag-valve-mask ventilations. She was intubated immediately and proceeded to gush a beige-colored liquid from the ETT.

I visited her several days later in CICU. She was not out of the woods, but had been extubated and was moving in the right direction. She survived to discharge.

What I failed to appreciate was that CHF patients sometimes have a compensatory bronchoconstiction. They are basically giving themselves PEEP. They are attempting to keep enough pressure in their alveoli to hold out a tidal wave of edema. When my partner bronchodialated this patient, she could no longer hold back the fluid.

I had always considered albuterol virtually harmless unless a patient has an allergy to the medication. I will never look at a CHF patient and think that again.