For my readers old enough to remember Paul Harvey, I probably don’t have to explain the post title. For those not old enough, Paul Harvey was a radio personality who did short news reports. There were two parts to his show and “Part 2″ always featured a segment called “The rest of the story”, which told the back story to some fairly well known news story.
Often EMS is like the first part of a Paul Harvey show. We get the story, but rarely do we get “the rest of the story”. Often I feel like I’m missing the punch line and maybe I am.
Here is one such story.
We were recently dispatched to a “Cardiac”, but reading the call details there was no chest pain. Well, whatever, at least they got the address right this time.
We arrived at a fairly well known sort of transient building and went up to the patient’s room in a fairly ancient elevator. Well, the building is fairly ancient and hasn’t been renovated in some time. It’s sort of run down and decrepit and seen better days, which could describe many of it’s residents as well.
We found the patient sitting in a kitchen chair, working pretty hard to breathe. No, no chest pain. Just this sudden onset of dyspnea and a cough. He was a little bit diaphoretic, but not a lot. He was able to speak full sentences, but then started to breath faster. We dispensed with the room air O2 sat which is of dubious value anyway, and went straight to high flow O2. That seemed to help and we did vital signs and applied the cardiac monitor. Of course it’s more than a cardiac monitor, but that’s what we still call it.
Because I know that my readers like to look at ECG strips, here is one.
This strip was run about two minutes after we put the patient on Oxygen. His respiratory rate had dropped from the 30s to what you see on the strip. His Blood Pressure was 98/64. You can the rest of his numbers on the strip.
Now that he was doing better we started to ask about his history. Hypertension and HIV were his only history. He had medications that supported that. He’d had HIV related pneumonia before, but this didn’t seem the same to him. My partner listened to his breath sounds and said that they were clear, but diminished on the left side. No history of pneumothorax, but that was certainly worth considering. I asked if he’d ever had this before and he said yes. From there the conversation went sort of like this.
“So, what did the tell you was wrong.”
“The doctor said my heart was all fucked up.”
“I don’t know that they’d say it quite like that. Where did you go?”
“Gritty Inner City General.”
“Well, there ARE a couple of doctors there that would probably say something like that, so I take it back.”
Now came the 12 Lead ECG part of the call. Here it is for you 12 Lead junkies.
Nothing really interesting going on there. So, having run out of things to ask, it was time to move on to the moving on portion of the call. Day 8 of EMT school, patient transport.
We had the patient stand up and pivot onto our handy dandy patient moving device. Just that little bit of movement apparently stressed his body and his respiratory rate shot right up into the 40s, but his numbers didn’t really change.
We got him down to the ambulance and once he was in the ambulance on the stretcher, he calmed down and his respiratory distress eased.
With nothing else to do we started moving to the hospital and my partner started an IV. Unsurprisingly, the Normal Saline at KVO did nothing to make the patient better or worse.
When we got to the hospital, we unloaded the patient and went on in to the triage area. While I talked to the nurse, she looked at the patient. Once again he had started being tachypnic and looking like he was struggling to get air. So, we decided to move him right into an acute room and she called for the troops to come to the patient’s rescue.
I gave report to one of the doctors, who turned out to be an Intern, so it was sort of a waste of time. Then I got to repeat it for the attending physician. Who it turned out was one of the two doctors at Gritty Inner City General who would tell a patient his heart was fucked up if that was the best way to get the message across. I mentioned that to the doctor and he cheerfully agreed that he might have said that to this patient because he definitely had said it in the past. He’s what I’d call an effective communicator.
About 15 minutes later while I was writing my report, our patient was wheeled out of the acute area to the not so acute area. He looked pretty good. His chest Xray had shown nothing to explain the diminished breath sounds. No pneumothorax, not pneumonia. Weird.
So, what do you think was going on with this patient?
Tomorrow, I’ll do the Paul Harvey and give you the rest of the story.