Thursday, January 10, 2008

Wondering...

Have you ever had one of those calls that you wonder about? You know, the ones that you're not sure if you did the right thing? I have them every once in a while. This is one that happened a little while back.

We get called out for a difficulty breathing. We get there and there is this 50-ish year old male sitting up and talking. He has a home health nurse and she is there giving us the report on why she felt it was necessary to call us.

The patient in question had a history of stomach cancer, COPD, hypertension, recent pneumonia and a productive cough with green tinged sputum. He doesn't seem to be in any distress at the moment. The nurse said that he had been suffering from dehydration and she had started an IV and had been administering fluids. That is apparently when the trouble began. The patient started getting short of breath and anxious. So she stopped the fluids and discontinued the IV.

The patient didn't want to go to the hospital, but apparently trusted his nurse and wife and various other family members on scene, and decided to take the trip to the Big City Hospital down the road.

We put him on some O2 and get him loaded up. His vitals were within limits, O2 saturation was good and his lungs had some diffuse congestion throughout all quadrants. 12 lead and capnography were both normal. I started an IV just for precautionary measures and kept it at a KVO (Keep Vein Open) rate. He still said that he felt fine and he didn't seem to be in any distress.

On the way down, I do a little more detailed exam and find that his ankles and abdomen are swollen. He says that this is normal for him from time to time. His abdomen has some bruising and he doesn't know why. I take another look at his medication list and he isn't on any blood thinners or diuretics.

He still says that he feels fine and I have to agree that he does not seem to be in any distress. He says that he is a little tired and just wants to sleep. So I lay his head back and turn down the lights so he can take a cat nap for the remainder of the trip.

That is when I notice the JVD (Jugular Vein Distension). I put the puzzle pieces together and come up with pulmonary edema. I take another listen to his lungs and still only hear ronchi or congestion. I was taught that if you have the patient cough while listening then the sounds will clear and then return if it is ronchi, besides the obvious sound difference between ronchi and rales. Well, this is what happened when I had him to cough.

This is my dilemma; his pedal and abdominal edema, JVD and the fact that he started having trouble breathing when he was getting IV fluids all point to pulmonary edema. The other half to the equation was that he wasn't having any trouble breathing, he wasn't anxious, his blood pressure was normal and I didn't hear any fluid in his lungs. The blood pressure and heart rate I could explain away on the beta blockers he was taking to control those very things.

I didn't treat him with anything other than O2. He made it to the hospital fine and never once displayed any signs of respiratory compromise. But I have wondered since then if I shouldn't have treated him. Maybe he did have edema and I just mistook it for ronchi. Who knows? But I still wonder...

BRM

4 comments:

Anonymous said...

the number one thing I say to people in our line of work is that you can't look back on calls like that and think "was I wrong"

your patient made it to the hospital in the exact same condition. no changes. Had you run bi-lateral large bore IVs wide open, i'd think you screwed up.

but the fact that you identified a problem (or possible problem) and you watched for signs of distress, and his condition didn't change. there were no more interventions needed at the time.

Detail Medic said...

All I can say is that I would have done the same. It's always been our policy here to treat emergency situations and make sure you communicate all of your findings to the doc. Sounds like you did great!

Gary said...

You handled this correctly. What you described is likely right sided Congestive Heart Failure caused by the nurse over hydrating the patient. The problem corrected itself, at least in the short term.

The patient you describe is a bit of a train wreck and your chances of making him worse are better than of making him better.

If he could take a nap without distress, he obviously didn't need aggressive treatment.

Good job.

by: PM, SN said...

I think the reason some of the assessment findings you were expecting to find were absent has to do with him being a COPDer, he's probably used to higher CO2 concentrations and lower O2 concentrations (same reason you'd try not to put him on high levels of oxygen, might knock out his breathing reflex).