Call from hell - difficulty breathing

[Asysin2leads]

Okay, so here's how my life is going

Call for difficulty breathing in subway. Upon arrival find a 60 year old male, indian, sitting comfortably in no obvious distress chatting with attending officers. Pt. states he has been having trouble breathing the past few nights. Quick pulse check reveals tachycardia, around 140, skin warm, removed to ambulance on stair chair on oxygen, because trying to do an assessment in the subway is next to impossible what with the screeching metal wheels and all.

In ambulance, oxygen therapy continued, pt. reports having trouble breathing times 3 days, gets worse when laying down, denies chest pain, denies nausea/vomiting. denies headace, no history asthma, cardiac history, bronchitis, denies fever, denies, being sick. Has had surgery on his left eye. Reports history of type I diabetes. Difficult to gather complete information due to language barrier. P 148, RR 22, BP 140/90, SP02 95% on NRB.

Physical exam reveals right eye cloudy due to cataracts, left eye reactive to light, negative cyanosis, negative JVD, trachea midline, mild accessory muscle use, pt. unable to take full breaths, auscultation reveals fine crackles in left lower lobe. PMS present x 4 in extremities, no edema. Skin warm, dry, unremarkable.

EKG: Sinus Tachycardia/SVT rate hovers between 148 and 154. 12 lead unable to analyze due to rate.

Established IV access 20 gauge in left AC, pt's only complaint is he is having a little trouble breathing. Attempted vagal maneuver, no response.

My presumptive diagnosis tachycardia secondary to possibly a pulmonary embolus. Given his mental state, his symptoms, and his blood pressure, I chose at the time to NOT treat for an SVT outside of the vagal maneuvers, and transport.

En route, pt. complains of increased difficulty breathing. Heart Rate is now 176, blood pressure 170/100. I now administer 6 mg of adenosine, no response, arrival at hospital preempts repeat doses.

Enroute to bed in hospital, patient goes into arrest. Respiratory arrest, definitely, cardiac arrest, possibly, although he'd be the first person I ever seen have ROSC after 10 chest compressions. Who knows.

Pt. is now intubated, rate is 184, BP 220/120. A few minutes later he is spitting up the pink froth of serious pulmonary edema, chest X-ray shows he is filled with fluid. Synchronized cardioversion attempted by ED staff, no result.

Later, I am told pt. is in cath lab, he was having an MI. I assume because he was a diabetic he didn't feel it.

Hindsight is of course 20/20 with this guy. Comments? Anybody have any similar experiences with the so called 'silent MI's'? How about flash pulmonary edema? Want to know what my heart rate was when I watched a patient who a few minutes ago was sitting up talking to me, and is now in cardiac arrest after I treated him?

[Dustdevil]

Hindsight is of course 20/20 with this guy. Comments? Anybody have any similar experiences with the so called 'silent MI's'? How about flash pulmonary edema? Want to know what my heart rate was when I watched a patient who a few minutes ago was sitting up talking to me, and is now in cardiac arrest after I treated him?

I know the feeling! It's spooky when they sneak up on you like that. Suppose the MI was just enough to cause LHF and a slowly progressive PE that took awhile to knock him down.

With those sats, I was leaning towards pneumonia on this guy til the end, so he had me fooled too.

The high "index of suspicion" thing simply cannot be overstated, eh?

[FVFD441]

I have only been a paramedic for a fue months now, we were called out to a elderly male c/o the same complaint.

He looked to be fine had no complaints other then what he states was minor S.O.B when he lays flat. I noted clear lung sounds through out. 12 lead shows A-fib with RVR. How ever the QRS was wide I was thinking that he was in V-Tach with a pulse,

He refused all care other then transport to the hospital. We transported him. of course I had him on o2, re refused IV, and all other care. Got him to the hospital, he was cardioverted in the ER!

[AZCEP]

I was thinking maybe Tb.

I take it this gentleman was an east asian indian, right? In my neck of the "woods", an indian would be a native american, and they rarely give any indication that they are feeling pain.

Short of breath for 3 days would tend to make you think, not so sick. Unfortunately, this guy was indeed VERY sick.

This guy must have forgotten to read the book on how to present.

[buckeyedoc]

I've had a similar experience w/ silent MI. Had a 58 yo female diabetic w/ no cardiac hx. C/O tooth pain, but had a dental procedure 4 days prior, so I chalked the pain up to that. We had the LP12 w/out 12-lead capabilities. Heart rate around 110, B/P was up, but not off the charts. I had just called the ER and was about 10 min. out and she coded. UGH. Was able to get her intubated, defib'd and 1st round of ACLS meds before we got to the ER. I was kicking my self in the butt about not picking up on it earlier. The ER doc said that nothing really should have tipped me off. I still felt inept, though. That's the only one....and I hope the last.

[Asysin2leads]

Same with me, despite being told otherwise by the ER doc, my captain, and even my medical director, I still felt like there was something I should have picked up on, or something that could have been done differently.

This guy was indeed an 'East Indian', I think without sounding too racist, his normal skin color may have masked the onset of pallor, but there was no diaphoresis, and he was wearing about four layers of clothes which probably masked the fact he actually had cool skin. One thing that was interesting was that his sat would occasionally dip down to 85%, but when I see an 85% reading on a conscious, talking patient in no obvious distress, I tend to think the machine is off, particularly on a diabetic.

You know, when people think of the stress paramedics have, they think of cardiac arrests, gory car wrecks, and the like. That's really not the case, most cardiac arrests, unfortunately, are really dead to begin with, and once you see a couple of traumas you've seen all of the traumas. That you can get used to.

For me at least, calls like this are one of things that puts paramedicine, more so than almost any other field, so high in the stress category. It's like Russian Roulette, almost, give me a couple of months of homeless people complaining of difficulty breathing (or was it chest pains? Oh no, maybe their feet hurt) in the subway, and then drop this guy in my lap. It's taking me a little while to get over this call.

[Ridryder 911]

I believe that the EMS gods.... sometimes gives that have some time under our belt a "shake up call" to make us be on our toes once in a while... kinda rattles our expectations and gives a little more experience. Of course we have grown to know this is what makes us better.....and learn off them. I too have been more than once have the unexpected routine turn into terror... enough now, to know that it will occur .. just don't know when.

R/R 911

[vs-eh?]

Any East Indian male who is having any pain (or SOB in this case) from the tip of his dick to the top of his head presume he is having an MI. This is from a friend who was told this by a doctor after having a similar call.

I don't know if it is a medical urban myth but it always comes up...East Indians are genetically predisposed to narrower coronary arteries and thus more susceptible to plaque/thrombus formation and MI's.

[akroeze]

We had one of those a few weeks ago...

Call info:

Call was for C/P with SOB. It was outside the city so our response time was maybe... 15-20mins? Guessing here.

Incident Hx:

First response truck was on scene (Primary Care Paramedic in a pickup truck). She had already assessed him, had him on O2, vitals, rhythm strip, whole nine yards. Before she arrived he was c/o 8/10 pain between his shoulder blades that he states felt like his usual angina, took his own Nitrox2 with total relief, now only c/o SOB speaking full sentences.

Medical Hx:

Past Hx of multiple MI (forget how many) and CHF. Probably other stuff but can't remember. He was on your typical Dig, Lasix, etc.

Physical Assessment:

General: CAOx3, no obvious distress, sitting in chair on O2 via NRB @ 12lpm.

Head/Neck: No trauma noted, No JVD, PERLA 4+

Chest: No trauma noted, A/E = bilat with faint fine crackles lower lobes barely audible

Abdomen: Soft, no trauma noted

Back/Pelvis: No trauma noted

Extremeties: CSMx4, no trauma noted, no peripheral edema

Tretment/Procedures:

-BLS Assessment

-Vitals: Pulse somewhere on high end of normal, resps in the 18 range regular and full, BP 120 something over normal, O2 sat 98% with O2

-ECG: Lead II strip shows NSR with ST depression of I think around 2mm and no ectopy

-35-A Semi-sitting for comfort, move to Ambulance

-Transport Code 4, CTAS 2. (Lights and sirens, on a scale 1-5 with 1 being worst he is a 2 for triage purposes) Only went 2 d/t increasing SOB as per pt

-V/S: No real change

-ASA 2x80mg PO chewed and swallowed (our protocols are to give even if C/P has resolved before medic arrival)

-Close Observation

-Pt c/o chest heaviness about 5 mins enroute

-V/S: No big changes, slight drop in BP I think

-Nitro 0.4mg SL, attempted but unable to give as patient not responsive

-Reassess pt: Pt semi-conscious, eyes open spontaneous but distant gaze to right, no verbal, no motor: GCS 6

-V/S: Resps adequate but slightly shallow, heart rate end of normal, BP unobtainable and unable to palpate radial pulse

-Advise medic driving to get us there ASAP, yesterday if possible

-ECG: Unifocal PVCs about every 10 seconds developing into Trigeminal within about 3 minutes

-Unable to properly auscultate lungs due to road noise (poor road surface)

-Glucometer due to decrease LOC: 6.8mmol/L (for you yanks, that's within normal limits)

-Pray to EMS gods for him not to code

-Frequent V/S (minus BP as per above), watch that rhythm like a hawk, discuss with preceptor if there is anything else we can do

-ECG: starting to see multifocal PVCs

-Clear mouth of secretions with kleenex (don't want to take ANY chances of stimulating a vagal response with suction and kleenex was adequate)

-Arrival at hospital

-Transfer care

-Thank EMS gods and promise them to find a way to repay them

Sorry if that's hard to read but I figured that was the best way to post the story.

So what's wrong with him? Cardiogenic shock and pulmonary edema. In ER they tubed him and had pink frothy fluid come up the tube. They managed to get a BP in the low 50s systolic.

Think he survived? Two days later we were in ICU for a stat transfer of another pt... he was there, concious, extubated with no real complaints! I was shocked![

[medic429]

Asys,

I would have to imagine that you're heart rate when the guy coded probably made his HR at 178 look slow!! I haven't had the silent MI patient (that I know of) yet, but the flash pulmonary edema........oh boy! Twice, with in days, I was given orders for albuterol for wheezes and BOTH pt's had flash pulmonary edema.....and I was brand brand new. Scared the crap outta me!!