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DwayneEMTP

65 year old male, difficulty breathing...

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You're the lone medic in Hidden Valley PNG, and by far the highest level of care. Upon reporting to the clinic in the morning are informed by the night nurse that she had an 'old man' with difficulty breathing the night before.

He reported with DOB upon walking short distances, has only been on site one day prior. Nurse reports an initial set of vitals... P 120, B/P 166/98, SPO2, 72% r/a.

She gives him an Albuterol neb, puts him on O2, while on the neb and O2, she sees that his SPO2 has come up to 88%, gives him a schedule of Amoxicillin, some PO steroids and sends him back to work.

Nurse felt it wasn't necessary to call you because the "antibiotics will probably take care of it."

Surprise, he's back in the morning.....

Upon your first contact you find P 122, RR 28, SPO2 72%, B/P 156/96.

What would you like to do?

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Duh, anaesthetise, paralyse and intubate him ...

Put him on some oxygen

What is his medical history

Respiratory exam?

Where does he work?

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You put him on 'some' oxygen. It brings his sats up to 100% in just a couple of minutes.

No reported medical history. Pt states that he's never been to a doctor.

You listen to his lungs and notice that they seem to be filling well with air, no pathologic noises.

He was meant to be a drilling assistant at Hidden Valley, but he's not started yet. Just going through orientation. You have no idea what that means.

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Recent long distance flight?

Hazardous substance exposure?

What altitude are we at and what altitude does he normally live at?

What diagnostic capabilities do we have?

Can we get a baseline set of vital signs to include a temperature and a XII lead?

You seem to have interesting nurses?!? Let me know if you guys need a good one who loves paramedics and I'll send her your way.

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Previous history of similar symptoms? History of recent illness of any kind? All of the questions Chris asked plus a BGL just because. Do we have the ability to obtain laboratory values or imaging?

Also... let's take him back off of the oxygen and see what happens...

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Recent long distance flight?...

None.

...Hazardous substance exposure?..

None

What altitude are we at and what altitude does he normally live at?..

6,600ft/Sea level

What diagnostic capabilities do we have?...

Most of what you would find in the back of an ambulance of a non progressive service, only much older.

Can we get a baseline set of vital signs to include a temperature and a XII lead?...

P 122, B/P 156/96, SPO2 72% r/a, XII unremarkable, temp afebrile.

You seem to have interesting nurses?!? Let me know if you guys need a good one who loves paramedics and I'll send her your way.

Heh..I'd love to have her if you mean your girl!

The entire manual for the nurses is made up of four little books, say, 3 inches by 5 inches, by 1/4 inch thick. Like you'd expect to get with a new printer or such, only without the thin paper.

Previous history of similar symptoms? History of recent illness of any kind?...

None.

...plus a BGL just because. Do we have the ability to obtain laboratory values or imaging?...

BGL is within normal limits, no imaging or lab values. (Are you kidding me?? My ECG has clamps and brass bells with suction cups on them that leave big hickies wherever they're placed....No labs.)

Also... let's take him back off of the oxygen and see what happens...

You take him off of the Oxygen and after about 3-4 minutes he's back down into the low 80's and falling...

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Does the patient report symptomology? Can he give a timeframe, describe how he feels, has this ever occurred in the past? Any history of insect/arachnid bites? I don't suppose you have side stream capnography? History of substance use (smoker, recreational drugs and so on).

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Does the patient report symptomology? Can he give a timeframe, describe how he feels, has this ever occurred in the past? Any history of insect/arachnid bites? I don't suppose you have side stream capnography? History of substance use (smoker, recreational drugs and so on).

He says that he doesn't feel bad now, just short of breath. He says that it started about 12hrs after arrival onsite because it's "so cold up here...the cold air (45-75F depending on time of day) makes it hard to breath." Says that he's not had like symptoms before. Denies any symptoms other than the shortness of breath.

(Note: Not trying to mislead above. Remember that most illness here is attributed, according to most villagers which comprise most of the labor pool, to cool/cold breezes, curses, or evil spirits.)

No history of detected bites, no ETCO2 detection, lifelong smoker but stopped 6 years ago, pt denies history of any drug or alcohol use other than Betelnut. (Believable as alcohol and drugs are wicked expensive here with the exception of pot and betelnut, and pot is very frowned upon by the mature generations.)

He's placed back on O2 at 3L/min/simple mask with holes cut in it (No nasal cannulas here. On order with the urine dips) which brings him quickly back up to 97% SPO2...

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It's the evil spirits stealing some of his oxygen but maybe his body hasn't acclimated to the altitude and the low oxygen content at 6600 feet.

how long did you say he's been there? Maybe he needs some more time to acclimate to the high altitude.

When I went to colorado springs for my first week on site at Memorial hospital Dwayne, I spent the first day at the ER on low flow oxygen due to a low pulse ox. It took 2 days for me to really get acclimated to the altitude. After the 4th day I was fine. Got a couple of breathing treatments and then discharged with a couple inhalers. My 2nd trip I had no issues and I was able to fly in and out with no issues. I tend to think that this guy might be just like me.

I say watch him a couple of days and he should be fine.

So he's been on the antibiotic for 24 hours now, any change?

Edited by Captain ToHellWithItAll

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Does he have productive sputum? Cough?

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?

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

EDIT: Do you have a microscope and stains available?

Edited by DFIB

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