Friday, January 4, 2008

This kind of emergency is too common...

The following is from an emergency physicians BLOG posting which happens quite a bit in the ED.
" Last night in the ER...
....was very busy. And "busy" in a good way. Lots of codes and respiratory distress. Not so much "weak and dizzy" and "TMD (todo me duele)". The kind of night that reminds you why you chose emergency medicine as a specialty, and not primary care.
Anyhoo, there was this one guy...
A 36 yo morbidly obese Samoan man with a past medical history of diabetes, hypertension, and has lots of 'bad habits', was brought in by paramedics complaining of chest pain which started 10 minutes prior to the 911 call. He was sitting on the sofa watching reruns on TV when he suddenly felt a tightening in his chest. He got up to get a cup of water, and the pain got worse. Then he felt weak and lightheaded so he sat down on the nearest chair. He then called for his wife, and she took one look at him and called 911.
In the field EMS established a very tiny finger IV (because 'his veins could not be accessed secondary to excessive adipose tissue.' i.e. he was too fat). They gave him an aspirin, and after he denied using Viagra, a nitroglycerin sublingual. Immediately thereafter his blood pressure dropped from 150s systolic to low 80s. He became very diaphoretic (lots of sweating), and short of breath.
Upon ED arrival the patient was alert and oriented, but very agitated sitting upright on the gurney, in moderate/severe respiratory distress. He weighed about 450 pounds, and was extremely diaphoretic, and c/o worsening SOB. EKG could not be obtained by the paramedics because the stickers wouldn't stick to the body for all the sweat. Also, the patient was so agitated and anxious that a good reading couldn't be obtained even when the EKG leads were held in place by assistants.
In the ED we attempted to obtain an EKG...for over 20 minutes. We cannot make a diagnosis of acute MI requiring thrombolytics if we cannot obtain an EKG. Afterall, there are other deadly causes of chestpain, some of which absolutely cannot be treated with thrombolytics (or else you kill the patient). It's one thing for someone to die. It's another thing to kill them. So we worked to obtain that EKG...over, and over, and over, and over again.
During this time we worked to establish a better IV with ultrasound guidance."
Here is where I need to jump in. Ultrasound is very useful for line placement and other procedures. I teach ED physicians line placement procedures at my school. We practice on phantoms instead of real human volunteers, and the procedure works well for subclavians, and other veins when obesity or other issues arise making placement difficult.
I would also be called in to perform an echocardiogram in a situation like this (where getting the EKG is problematic) to look at basic cardiac function, and try to see if there were any heart wall motion abnormalities. Granted in this patient the echo would not be very diagnostic, but it would be worth a try. I also train ED physicians to perform basic echocardiography useful in cases like this.
More often than not, I would also be called upon to look for DVT if the patient were in respiratory distress, but even this procedure is difficult in the morbidlly obese. Just some thoughts for a cold January day. To continue with the article please click on the link below.
Have a great day,
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