Wednesday, December 12, 2007

A Bigger Picture

I'm still feelin pretty good about myself. I'm sure it won't last, but you take what you can get, eh?

Last night was actually quietly busy. Did I already tell you that? I can't remember... the department was stuffed, but with few real sickies. Which is nice. These days it seems a real rarity if our Resus Bays aren't overflowing.

It doesn't take much, though. Another midnight call, another breathless punter. At the best of times, I'm a resus hog, an adrenaline junkie, an SHOs nightmare. Turn around, and there I am, champing at the bit. No matter how quick you think you are... I'm faster. The SHOs I like the best are there quickly, too. I see in them a kindred spirit; they want to see the difficult cases, the interesting cases. This is markedly unfair to the many excellent docs who come through EDs but aren't especially interested in the Acute end of the spectrum. Sorry, guys. No offence meant.

I digress; the elderly breathless is pretty much bread and butter. Since pretty much everyone smoked in the 30s and 40s, they now all have COPD. If they don't, they have heart failure. As with all of medicine, the devil is usually in the details; history is almost all of it. If they're on inhalers up the wazoo, it's COPD. If their drug cupboard rattles with diuretics and other 'heart' meds, its their heart.

Usually. And for all my esteemed physician colleagues, I know it's never that simple, but it's pretty close, eh?

So, last night's arrival had a long smoking history, several admissions with 'exacerbation COPD', and a cabinet full of inhalers and nothing else.

COPD, right?

So much for history...

As I'm sure my medical colleagues know, these patients also have a look about them. This guy was exhausted, sweaty, cold at the edges and had a sky high BP. JVP virtually punching through the roof.

Heart failure.

Chest... pretty quiet, a few wheezes, a few fine creps. The good old fashioned ED mixed bag.

In short, his history was good for COPD, but his exam spelled heart failure. The difference is rarely as clear cut as we would like. When I was on the house, we used to call the treatment 'nebulised frusicillinalol'. Some bronchodilator, some diuresis, some antibiosis.

I was pleased to see my SHO run it like a pro. Good history, rapid assessment, right diagnosis, prompt treatment. The joy of it is, of course, that COPD-ers need limited oxygen and nebs, whereas heart failure needs as much oxygen as you can cram in, and offloading. Get it wrong, and...

Sometimes, whatever you do, it's too late to stop them circling the drain.

We used nebulised frusicillinalol nitrate. X-ray and subsequent intubation confirmed the clinical suspicion of left ventricular failure.

I spent most of the time with the family; it's one of the good things about having competent SHOs. I hope it's because we taught them something. Because I taught them something? I guess it doesn't matter as long as they learned it.

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