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Pregnant asthmatic… May 22, 2013

Posted by Andy Jagoda, MD in : Respiratory Emergencies , 20comments

While establishing IV access and calling respiratory therapy for your first patient, a 24-year-old Hispanic female with a history of asthma who is 15 weeks pregnant presents with tachypnea and acute shortness of breath with audible wheezing. She has been taking albuterol and fluticasone at home with no relief of symptoms. She has a blood pressure of 110/78 mm Hg, heart rate of 110 beats/ min, respiratory rate of 40 breaths/min, and pulse oximetry of 93% on room air. Physical exam demonstrates accessory respiratory muscle usage, decreased breath sounds, and expiratory wheezing. You recognize that your patient is at risk for deteriorating, and you wonder which interventions are safest to use in pregnancy…

How would you approach this patient’s treatment?

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“Dying on arrival…” Case Conclusion May 8, 2013

Posted by Andy Jagoda, MD in : Psychiatric and Social Emergencies, Respiratory Emergencies , add a comment

Case re-cap:

On a quiet overnight shift, you receive a call from EMS. They are en route to your ED with a 55-year-old woman in respiratory distress. You walk to the resuscitation room and prepare for rapid sequence intubation, wondering what catastrophic event might have precipitated this patient’s respiratory failure. As the patient arrives, you notice that she is cachectic and pale, gasping for breath as she tries to pull off the nonrebreather mask on her face. Her distraught husband walks alongside the stretcher, stroking her hair and crying. The patient appears to be terminally ill, and when you ask her husband what’s going on, he says, “She has lung cancer. We just stopped chemo because it wasn’t working anymore. We’re supposed to get hospice, but it hasn’t been set up yet.” Meanwhile, the paramedics read her vital signs out loud: “temp 99°, heart rate 120, respiratory rate 40, pulse ox 90%, blood pressure 100/50.” You briefly wish that it was the middle of the day so your hospital’s newly formed palliative care service would be available. Faced with this clearly uncomfortable, dying patient, the traditional emergency medicine tools of endotracheal intubation and mechanical ventilation are clearly inappropriate? You have read that patients often receive morphine at the end of life, but you don’t want to be accused of .hastening anyone’s death. Her husband pleads, “Please help her, doctor. I can’t watch her suffer like this.” Despite your desire to do everything possible to make this patient comfortable, you reflect on the unique legal and ethical framework that surrounds care of the dying patient and want to ensure that you are doing the right thing.

Case conclusion:

After an assessment of the patient and review of her chart through the electronic medical record, you become concerned that this patient may be in the last days to weeks of her life. A brief discussion with the patient revealed that she is confused and too distressed to participate in decision-making, so you took the husband to a quiet corner of the ED to talk. When you asked, “What have the doctors told you about your wife’s condition?” the husband responded by saying, “She’s dying. I know. But I can’t manage this at home.” You validated his concerns and decisions about calling EMS and then asked, “Knowing that her time is short, what would your wife tell us is most important to her right now?” Her husband explained that she would want him by her side and that she “doesn’t want to suffocate.” You assured him that you will do your very best to support these goals. You found a quiet, private room in the ED and had the patient transported there. A chair was placed next to the bed so that the husband could be by his wife’s side. The patient already had IV access that was obtained in the prehospital setting, so the parenteral route could be used to deliver medications. Her husband reported that “she takes a Percocet® every now and then, but that’s it,” so you considered her relatively opioid-naïve. You ordered morphine 1 mg IV. After this, her respiratory rate declined from 40 to 35 breaths per minute, but it still appeared labored. You administered 2 mg, and then 4 mg, in 10-minute time intervals. After this last dose, the patient’s respiratory rate decreased to 20 and her face appeared relaxed, with her accessory muscles no longer visible with breathing. Her oxygen saturation increased from 90% to 99% with 3 L oxygen via nasal cannula. You and the husband decided to continue oxygen delivery, with a plan to reassess the utility of this intervention in the morning. You placed a call to the palliative care consult service. Although they were not in-house, they said they would see your patient in the morning, and they agreed with your treatment decisions. They made a plan to transfer the patient to the palliative care unit in the morning, when a bed would be available. When you updated the patient’s husband regarding the plan, he said, “Thank you. I really appreciate everything you’ve done. She looks so peaceful.”

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