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Wondering...

Posted Jan 27 2009 8:26pm
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
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