The bowel obstructed, hypertensive, hypoxic, pt with the flu

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The bowel obstructed, hypertensive, hypoxic, pt with the flu

Post by tails359 » Sat Oct 31, 2009 9:06 pm

To the idiots at the big 'Physicians Building' that calls us every 4 hours.

A room air sat of 92%, at 95% on 2L of O2( and no respiratory distress at all, aside from occasional cough), is not 'profoundly hypoxic'. Especially considering the pt has had the flu for a week (which he came in to be seen for in the damn first place)

A BP of 146/82 is not 'markedly hypertensive' Period.

When you tell me you 'cant see the bottom of his lungs or heart on the xray', and then try to tell me this pt has a possible bowel obstruction large enough to displace the diaphragm into the chest cavity (I'm not making this up), when, a. His abdomen is soft, non-tender, non distended, has no abdominal complaint,and b. he took a -shit- this morning (and has every morning for at least a month), and c. the pt admits to having a coughing spell during the xray.....I will politely point out that you may want to consider -retaking- the xray.

Assuming you are correct, and this pts 'hypoxia' and 'hypertension' are really caused by a tension-fecalthorax collapsing his lungs, the albuterol treatment you gave him would help him how, exactly?

So, this pt who presented to you with flu like symptoms for a week, gets the shock of his life when the paramedics and fire department show up. He doesnt know why hes going the the hospital. I dont know why hes going to the hospital. Hell, the ER Doc doesnt even know why the pt is in his hospital ( and said as much in several colorful ways).

May I suggest that you take the phone you used to call me, apply it to your distal colon, and proceed proximally.
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Re: The bowel obstructed, hypertensive, hypoxic, pt with the flu

Post by sprhldr85 » Sat Oct 31, 2009 9:19 pm

I love those calls. Hahaha. I recommend a beer after the shift. Repeat as necessary.

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Re: The bowel obstructed, hypertensive, hypoxic, pt with the flu

Post by shrapnel » Sat Oct 31, 2009 9:25 pm

>.<

Good god, that was painful just to read about.
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Re: The bowel obstructed, hypertensive, hypoxic, pt with the flu

Post by SweetTea » Sat Oct 31, 2009 10:42 pm

Sigh.

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Re: The bowel obstructed, hypertensive, hypoxic, pt with the flu

Post by andygates » Sun Nov 01, 2009 7:27 am

'fecalthorax' is my new insult for drivers who cut me up. 8)
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Re: The bowel obstructed, hypertensive, hypoxic, pt with the flu

Post by Apache » Sun Nov 01, 2009 8:08 am

tails359 wrote:A room air sat of 92%, at 95% on 2L of O2( and no respiratory distress at all, aside from occasional cough), is not 'profoundly hypoxic'.
Remember this graph?

Image

A O2 sat of 92% I read off as a PO2 of ~70mmHg Vs 100mmHg @ 100%. So a 8% decrease in O2 sats gives you a roughly 30% decrease in partial pressure.

I'd say this bloke did need oxygen (supplementation helped....)

The rest of the tale is a load of tosh, but the O2 sats are of concern. IMO
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Re: The bowel obstructed, hypertensive, hypoxic, pt with the flu

Post by Albuquerque » Sun Nov 01, 2009 12:10 pm

I actually got a patient to refuse treatment once for a similar situation... she was so pissed the doc had called. She went to ER POV.
You just have to hope you aren't one of those people that shuts down or has unhelpful anxiety attacks when the poop hits the fan.

If you are... well, sorry.

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Re: The bowel obstructed, hypertensive, hypoxic, pt with the flu

Post by Dr Jekell » Sun Nov 01, 2009 7:35 pm

Apache wrote:
tails359 wrote:A room air sat of 92%, at 95% on 2L of O2( and no respiratory distress at all, aside from occasional cough), is not 'profoundly hypoxic'.
:Snip:

I'd say this bloke did need oxygen (supplementation helped....)

The rest of the tale is a load of tosh, but the O2 sats are of concern. IMO
That may be correct but you are forgetting to look at the patient as a whole, not every patient will have O2 sat's >95%.

I have treated patients who had sat's of ~72% On air (on two different machines) & have been told that the reading was better than their normal readings. They were awake and talking to me with no cyanosis, GCS of 15.

If the patient the OP is describing was mine I would not administer O2 as he has O2 sat's of ~92% & does not have severe respiratory distress.

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Re: The bowel obstructed, hypertensive, hypoxic, pt with the flu

Post by AZMedic » Sun Nov 01, 2009 11:59 pm

Hmm reminds me of a call I recently had.

Pt started new meds and had a swollen face with redness and felt like her throat was tightening up. Also pt had difficulty breathing. Pt goes to Urgent care. Urgent care calls the medics. Tells medic its either a PE or an Allergic reaction.....


I give benadryl....

Pt says I fell better. Tired but better. ER doc says wtf a PE?

I lose faith in a lot of urgent cares.

On topic now: Ya I would say screw the cannula but whatever its on them already I would just let it stay.
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Re: The bowel obstructed, hypertensive, hypoxic, pt with the flu

Post by tails359 » Mon Nov 02, 2009 9:22 am

AZMedic wrote:Hmm reminds me of a call I recently had.

Pt started new meds and had a swollen face with redness and felt like her throat was tightening up. Also pt had difficulty breathing. Pt goes to Urgent care. Urgent care calls the medics. Tells medic its either a PE or an Allergic reaction.....


I give benadryl....

Pt says I fell better. Tired but better. ER doc says wtf a PE?

I lose faith in a lot of urgent cares.

On topic now: Ya I would say screw the cannula but whatever its on them already I would just let it stay.

Ran a call out of one of those Docinabox workmans comp places. We get called out for spontaneous pneumothorax, guy just started having trouble breathing. Looked pretty bad, but his breath sounds were equal and -wheezing-. Pt had hx of asthma. Had him talking and smiling by the time we got to the ER. *twitch twitch*

As for the SaO2 on the OP pt, I left the two liters in place ( it did bring him up to 95%) but didnt put him on any more. This guy was fine, talking, no distress. No cyanosis, no DIB, no alt LOC. Nothing to indicate hypoxia. I dont trust Sao2, never have. Got that drilled into my head in EMT school. Its a great tool, but they can be very unreliable. Anything from the light you are standing in, to the pts perfusion status, to CO exposure ,to cold hands can alter the reading. I keep the reading in mind, but Ive had more then one blue pt who read 99%.

From what I have read, a more reliable indicator of a pts respiratory status is waveform capnography. If only my service would buy the nasal cannula probes, we only carry the ET tube probes. Even if I had that, I would remember the old saying, Treat your patent, not the monitor.
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Re: The bowel obstructed, hypertensive, hypoxic, pt with the flu

Post by Dr Jekell » Mon Nov 02, 2009 11:23 pm

tails359 wrote:I would remember the old saying, Treat your patent, not the monitor.
QFT

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Re: The bowel obstructed, hypertensive, hypoxic, pt with the flu

Post by AZMedic » Tue Nov 03, 2009 10:41 am

Dr Jekell wrote:
tails359 wrote:I would remember the old saying, Treat your patent, not the monitor.
QFT

Definately...Doc hes in walking Vtach....ya hes stable. Was not my patient but a close buddies.
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Rush2112 wrote:
the_alias wrote:
AZMedic wrote:'86 damn almost missed this cutoff. I remember baywatch ya then I became a lifeguard and was like wtf this isn't the same......
I honestly thought you were around 45 + :lol:
He's crotchety enough.

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Re: The bowel obstructed, hypertensive, hypoxic, pt with the flu

Post by Vicarious_Lee » Tue Nov 03, 2009 3:45 pm

tails359 wrote:Assuming you are correct, and this pts 'hypoxia' and 'hypertension' are really caused by a tension-fecalthorax collapsing his lungs, the albuterol treatment you gave him would help him how, exactly?
"Tension-fecalthorax" :lol:

God, that's hilarious. I can feel your rage. I love making up medical words for nonsense when I'm pissed off. Often, in clinic, It's all I can do to not put in the chart that the patient's pressure ulcer was, in fact, a "glutischiosacranteric" ulcer, FTL.

Or my "modified medical adjective scale of relative badness":


Radiologically
Insignificantly
Minimally
Mildly
Moderately
Severely
Profoundly
Ridiculously
Unbelievably
Fantastically
Wickedly
Heinously
Retardedly
Fatally (please do not inform patient of this fact)

I'm keeping tension-fecalthorax in my vocabulary now!
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Re: The bowel obstructed, hypertensive, hypoxic, pt with the flu

Post by Paragon » Tue Nov 03, 2009 6:12 pm

Vicarious_Lee wrote:"Tension-fecalthorax" :lol:

God, that's hilarious. I can feel your rage. I love making up medical words for nonsense when I'm pissed off.

I'm keeping tension-fecalthorax in my vocabulary now!
Actually, it's a legitimate medical condition.

I agree with you though Lee, I had to google it just to see what would turn up.

Jim

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Re: The bowel obstructed, hypertensive, hypoxic, pt with the flu

Post by AZMedic » Tue Nov 03, 2009 6:21 pm

Hmm shit draining from your chest...eww. I can see a huge infection coming soon....
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Rush2112 wrote:
the_alias wrote:
AZMedic wrote:'86 damn almost missed this cutoff. I remember baywatch ya then I became a lifeguard and was like wtf this isn't the same......
I honestly thought you were around 45 + :lol:
He's crotchety enough.

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Re: The bowel obstructed, hypertensive, hypoxic, pt with the flu

Post by tails359 » Tue Nov 03, 2009 6:35 pm

Paragon wrote:
Vicarious_Lee wrote:"Tension-fecalthorax" :lol:

God, that's hilarious. I can feel your rage. I love making up medical words for nonsense when I'm pissed off.

I'm keeping tension-fecalthorax in my vocabulary now!
Actually, it's a legitimate medical condition.

I agree with you though Lee, I had to google it just to see what would turn up.

Jim
:shock: :shock:

Holy Shit!
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Re: The bowel obstructed, hypertensive, hypoxic, pt with the flu

Post by Ovationman » Tue Nov 03, 2009 9:04 pm

I guess we can rule out a needle decompression :)

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Re: The bowel obstructed, hypertensive, hypoxic, pt with the flu

Post by Vicarious_Lee » Wed Nov 04, 2009 4:40 pm

Damn dude. I just......damn. :shock:
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Re: The bowel obstructed, hypertensive, hypoxic, pt with the flu

Post by tails359 » Wed Nov 04, 2009 10:02 pm

Ovationman wrote:I guess we can rule out a needle decompression :)

Treatment for tension-fecalthorax is plural decompression.

Insert a large bore (14 or 16 gauge) IV catheter through the 2nd intercostal space at the midclavicular line. Take care to pass the needle along the superior aspect of the 3rd rib, as to avoid the nerve and blood vessels on the inferior aspect of the 2nd rib. Insert the needle fully into the chest wall, until the hub is flush with the skin. A soft return of flatulence, acoustically similar to a queef, signals the provider that decompression has been successful.
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Re: The bowel obstructed, hypertensive, hypoxic, pt with the flu

Post by Dark Angel » Thu Nov 05, 2009 9:22 am

tails359 wrote:
Ovationman wrote:I guess we can rule out a needle decompression :)

Treatment for tension-fecalthorax is plural decompression.

Insert a large bore (14 or 16 gauge) IV catheter through the 2nd intercostal space at the midclavicular line. Take care to pass the needle along the superior aspect of the 3rd rib, as to avoid the nerve and blood vessels on the inferior aspect of the 2nd rib. Insert the needle fully into the chest wall, until the hub is flush with the skin. A soft return of flatulence, acoustically similar to a queef, signals the provider that decompression has been successful.


:shock: why am i not surprised that someone here knows how to do that off the top of their head? Secondly, ew and ow in equal amounts.
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Re: The bowel obstructed, hypertensive, hypoxic, pt with the flu

Post by Vicarious_Lee » Thu Nov 05, 2009 11:12 am

Alright, fine. Check this out:

Next time someone does something ig'nant around me, I'm diagnosing them with a tension-fecalcephalus. :lol:

Whaddya think?
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Re: The bowel obstructed, hypertensive, hypoxic, pt with the flu

Post by tails359 » Thu Nov 05, 2009 1:56 pm

Vicarious_Lee wrote:Alright, fine. Check this out:

Next time someone does something ig'nant around me, I'm diagnosing them with a tension-fecalcephalus. :lol:

Whaddya think?
:lol: :lol: :lol:
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Re: The bowel obstructed, hypertensive, hypoxic, pt with the flu

Post by Vicarious_Lee » Wed Nov 11, 2009 11:40 pm

Glad you liked it.
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