This unfortunate gentleman was stopped at a checkpoint by ANA soliders. They wanted him to give one of the soliders a ride and the guy refused, so they shot him. He came in in bad shape. They put a chest tube in which drained at least 400cc of blood immediately (as you can see he has a hemothorax on chest xray) and he died of hemorrhage within an hour of arriving. They poured tons of fluid and blood into him, but his low blood pressure eventually went away. They do not have a cardiothoracic surgeon, so not a lot they can do. I was not there for this event, but I heard the story as we rounded on his grandson, who was in the back seat. The bullet went through his grandfather and hit the young boy in the shoulder. Fortunately it was just a flesh wound, but a sad story.

S I, Q III, T III

So I get a call from one of the ANA docs asking me to see a pt. He states he is a young guy with tachycardia and it won't go away, so he wants my help. A month or two ago, we had a young guy with AVNRT(arrhythmia), so I was thinking it was something like that. When I show up I could tell this was not going to be what I was expecting. There is a 24 y/o male in obvious respiratory distress, pulse oxygenation (little thing that goes on your finger) is 88% on a face mask (not good) and his heart rate is 120. The doc states he is treating him for pneumonia for the past 36 hours (it was a three day holiday weekend), and tries to communicates that also in his differential diagnosis is pulmonary edema(fluid in the lungs) and pulmonary embolism (clot in the pulmonary arteries). I was a little confused because I thought he was trying to communicate that the patient was getting better, ie: his heart rate was now only 120, and it was 180 the day prior, his hypoxia and respiratory status are better. The patient told me he felt better too. So I look at his chest xray, which was not that bad, and if I looked hard, could kinda see a pneumonia, but nothing overt that could explain his hypoxia (low oxygenation). I also look at his EKG because after all, the whole reason he called me in was for tachycardia. There is an incomplete RBBB, and some other "odd" changes, but at first I wasn't sure why, I just knew things didn't add up. So I asked the pt why he came in, he said, I have been short of breath for 6 days, coughing up small amounts of blood and I passed out the day I came in. As soon as he mentioned the blood and passing out I knew it was going to be something bad. I listen to his lungs and they were unfortunately clear... I knew immediately he had a pulmonary embolism. I look at his legs and the right one is red and swollen. We immediately treated him with lovenox. We decided not use thrombolytics (tears up the clot in his lung) because his blood pressure was stable and once we sat him up, his oxygen sat came up to low 90s. The patient did well for the first 10 days, came off oxygen, heart rate in the 80s.....until very early one morning he decided to get up and walk to the bathroom, which we had warned him not too do, and he passed out. I get woken up to come to the hospital, but they coded him for about 20 or 30 minutes and he was dead by the time I got there. I told them not to feel bad, there was nothing they could have done.

In hind-sight, the interesting thing about his EKG is that he had an S wave in lead I, Q in lead III and abnormal T wave in III, which fits the classic but rarely seen EKG pattern for pulmonary embolism.

Saved from iatrogenia twice!!

I get a call at 530 PM tonight from an ANA doc stating that, in fragmented English, a guy has a bad heart, intubated and they need help. I was thinking some old guy was having a heart attack or heart failure. To my surprise the guy was in his early 20s. At first glance his vitals were stable, so I knew I had time to quiz the ANA docs before intervening. (Story goes: he was playing volleyball when he suddenly passed out. He was brought to the spanish hospital down the street. All they did was intubate him and transfer. No labs no EGK no xrays). I asked what they (ANA) had done, and they said nothing. So I instructed them to examine the patient. I examined him after the duty doc was done and immediately noticed that the left side of his lung had no breath sounds. I asked him to listen again because he said the exam was initially normal. After a second listen he noticed there were no breath sounds on the left. So we moved the tube back 3 or 4 cm back. On re-examine breath sounds were normal bilaterally. Then we spent about 5 minutes discussing the differential, while the nurse obtained an EKG. All he could come up with was seizure, which is true. I told him most likely is arrhthymia. His EKG is above. In short, I think the guy has WPW - an unfortunate conduction pathway in his heart. Since our resources are limited, I went to find a cardiology textbook to look for alternative long term treatments, since we do not have first line treatment (ablation and other anti-arrhythmic medicines). When I came back, I noticed the labs were done. His pH was 7 and CO2 was 100!!!! normal is 7.4 and CO2 of 40. Of course no one looked at the labs!!! I told them to repeat it STAT while I tried to figure out what was going on. The ventilator was acting wierd. Tidal volume (measured breath the machine gives the patient) going from 0 to 1200 cc (it was set for 400). Repeat blood gas was still horrible. So I told the doc to get another machine while I manually bag the patient. Well, there was no resistance while trying to "bag" the patient, so I knew that the tube somehow came out. either I did not inflate the cuff enough or the cuff had a leak. In a very commanding tone, I tell everyone to grab me the intubation kit and get meds ready. I pull out the tube and lower the head of the bed and try to put a mask on his face to hand bag him. It was difficult because he was fighting me. I figure since he is fighting me, he can probably breath on his own. We repeat a blood gas and it improved dramatically, still slightly abnormal, but not nearly as bad. Guess I had to just relieve the obstruction in his throat. It was good learning for all. Still not exactly sure about long term treatment. I emailed a cardiology friend of mine with the options available to us to see what he would do.