collapsed lung and what not to do.

[nego_metuere]

I was working at a hospital in the B'more (JHH).

B'more City FD brings in a Hispanic male (Unable to speak english) 26 y/o. Awake, alert, agitated, Gasping for breath.

Sudden onset chest pain while at rest.
No medical history, Able to speak (spanish) between gasps. Paramedics noted decreased breath sounds to right lung field.

Nitroglycerin Sublingual was given with no relief. Oxygen in place, No cardiac monitor, no IV line.

Placed to patient room, no breath sounds to right lung field, MD notified to room, patient moved to Trauma room, Xray taken (Right Pneumothorax with trachea deviation), Chest tube inserted. (IV, and sedation had taken place prior to Chest tube insertion). Patient admitted.

Can you find all the errors, and the one big thing that shouldn't have been done.

[MIKETM]

What was the nitro given for? The dude is 26 years old. His lungs sounded decreased, just decreased, he had no fluid buildup so what made them think of the nitro? Was he in some way hypertensive? Did the guy say he had a history of heart or a congenital problem? No monitor? The guy is short of breath and they don't wanna check his rate or rhythm? No line, no IV line? No saline lock? They didn't wanna have the safety of IV access before they started Xport? What was the guys sat? What was his O2 saturation? Any obvious trauma? They didn't pick up that the guy was possibly combative because he was hypoxic?...........What would I do? I'd get the medics into a back room and do some "re-education" post-call. That's if I was in charge, otherwise I'd shake my head and leave the ER thankful that I didn't make those mistakes........

[nego_metuere]

On 2002-04-15 15:35, MIKETM wrote:
What was the nitro given for? The dude is 26 years old. His lungs sounded decreased, just decreased, he had no fluid buildup so what made them think of the nitro? Was he in some way hypertensive? Did the guy say he had a history of heart or a congenital problem? No monitor? The guy is short of breath and they don't wanna check his rate or rhythm? No line, no IV line? No saline lock? They didn't wanna have the safety of IV access before they started Xport?
No hypertension, No trauma, no history. I found it unbeleivable that they gave the Nitro. City Medics typically don't come into the hospital with monitor still on. Except with a cardiac arrest.


What was the guys sat? What was his O2 saturation? Any obvious trauma? They didn't pick up that the guy was possibly combative because he was hypoxic?...........
POX was 99% with NRM. We initially thought he was Hyperventilating. Room air PO2 was reported as 99% as well.


What would I do? I'd get the medics into a back room and do some "re-education" post-call. That's if I was in charge, otherwise I'd shake my head and leave the ER thankful that I didn't make those mistakes........


Its one thing to miss a peumo. in the field, It would have been great to do a needle decompression Prehospital. He was in obvious distress, Although it did mimic hypervent. in that he had carpalspasms. The Nitro still baffled me.

That covers most of the prehospital error, anyone guess at the hospital error? Think of peer reveiw on this case as presented to other MD's or Risk Management.

Hint: Chest Xray was taken that showed Right pneumothorax with trachea deviation (usually a late sign)

[Reasonable Rascal]

A day late and a dollar short but here goes.
Nitro? They just hand it out for every complaint of chest pain? Guess it's a good thing he didn't have a knife protruding from his chest. Very obvious faux pas there.

No line? If they were more than a few blocks away they had time *as a general rule.* In any case you give Nitro you start a line. If it's not that serious then why the Nitro save perhaps for an ALS charge.

Now, as far as the hospital end of things they should have recognized the possible (likely) pneumo before the x-ray. Even the pre-hospital folks should have ID'ed it.

Was this guy of very slight build? If so he's right off more prone to a spontaneous pneumo than Joe Average Build. That alone should have raised the index of suspicion in everyone's mind.

He deserved a decompression right off the bat. If perchance it turned out to be unwarranted the induced pneumo - if such occurred - would have been easily handled. I for one would be real interested in reading the pre-hospital report as far as their justification for the Nitro/though processes overall.

RR

[nego_metuere]

The prehospital report was not helpful in justifing Nitro, CP=Nito, simple as that. It's a scoop and swoop mentality, yet they still want to feel like they did something.

The Chest Xray would have killed the Doctor during peer reveiw. It shouldn't exist. The xray should have shown a chest tube inserted.

It's very easy to critique post facto, I admit during the event, I never mentioned , "Uh, Hey maybe we could just put the chest tube in." The ER Doc was doing what was right in his mind, I just pictured taking a second and putting in a angio to decompress, or just putting the chest tube in. It was a interesting situation.

I thought about contacting the City FD medical director that I know, but it really wouldn't have changed things, I didn't even tell you guys about the step down skull fracture that a different city unit brought in as "Just a drunk that got beat up".

[MIKETM]

Those dudes are burnt, (the medics) and they gotta recognize it.......then again, just about everyone is burnt in the big cities and those that aren't are "outted" as "sparks" or "wannabe's"............