Timmy Posted January 9, 2009 Share Posted January 9, 2009 It's 0230. Your called to a 19 year old male with a cardiac history. On arrival you notice the patient is suffering from dyspnea, he is sitting on the couch slightly sitting up. You've been called by the patients mother but the patient is hesitant to receive treatment because he is 'over all this medical crap' and becomes quiet annoyed at you asking questions. The mother states the patient has had a brief syncopal event when he sat up on the couch. The patient is also cyanosed and currently waiting on the transplant list. Vitals: BP: 150/95 Pulse: 101 Resp: 21 Sp02: 90% ECG: AF On auscultation of the chest you hear a loud whooshing heart murmur. Meds: I don't remember the names but they belgoned to: Beta Blockers Calcium antagonists Your the ALS crew in a small country town. The local hospital is a 3 Bed ED, currently on night shift you have a RN with a post grad in emergency care, an RN with a post grad in midwifery and an LPN who is half way through her RN training. The local General Practitioner is on call, about 15 mins drive from the time off calling to arriving at the hospital, this GP has done an a rural ALS course and ACLS course. Your about 50mins drive from the fully staffed emergency department hospital. Link to comment Share on other sites More sharing options...
WelshMedic Posted January 9, 2009 Share Posted January 9, 2009 Timmy, Can you be more specific on the cardiac history? It may help us to put certain things into perspective, the AFib, for example. This is certainly pathological in a pt so young. What would I do? Oxygen titrated to Spo2, possibly starting with a NRB @ 100% 12 lead to further investigate the Afib on the scope IV access I'm not inclined to do anything about his Afib, this is obviously a complicated case with a lot of underlying cocomittant pathology, the rate and haemodynamic response does not warrant intervention, pharmalogically or otherwise. I would however take him to the larger facility. To not do so is delaying the inevitable. I think that he is, at this point, haemodynamically stable enough to endure the 50 minute journey. You want any more? WM Link to comment Share on other sites More sharing options...
WelshMedic Posted January 9, 2009 Share Posted January 9, 2009 I like my own opinion so much I wrote it twice........ Link to comment Share on other sites More sharing options...
Timmy Posted January 9, 2009 Author Share Posted January 9, 2009 I'll give you his cardiac history as it will be hard and drawn out to get. He has hypertrophic cardiomyopathy and his vitals begin to take a dip on transit, he becomes extremely short of breath and begins to complain of sub sternal chest pain. Link to comment Share on other sites More sharing options...
Timmy Posted January 9, 2009 Author Share Posted January 9, 2009 So, the kids had some paroxysmal nocturnal dyspnea trigged by orthopnea. Link to comment Share on other sites More sharing options...
BushyFromOz Posted January 9, 2009 Share Posted January 9, 2009 I'd skip your hospital, call for a MICA intercept and go to the "other" hospital down south :wink: Timmy knows what i mean Link to comment Share on other sites More sharing options...
WelshMedic Posted January 9, 2009 Share Posted January 9, 2009 Well, sit the boy up then!!!!! Link to comment Share on other sites More sharing options...
WelshMedic Posted January 9, 2009 Share Posted January 9, 2009 Bushy, I'm sorry to be dense and spoil the antipodean in-joke but I was wondering something: if you are already ALS, what's the benefit of a MICA? What do they do differently? Carl. Link to comment Share on other sites More sharing options...
Timmy Posted January 9, 2009 Author Share Posted January 9, 2009 In this case his taken to the primary care hospital but MICA are signal one to the hospital as well. To cut a long story short, he arrested upon arrival at the bandaid station – You and the nurses are it until the doc gets in (15mins) and MICA is 30mins off. Link to comment Share on other sites More sharing options...
WelshMedic Posted January 9, 2009 Share Posted January 9, 2009 Then he's FUBAR........... (Sorry, not a very clinical answer, but with this degree of underlying pathology and rapid deterioration then I don't give him much chance) WM Link to comment Share on other sites More sharing options...
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