Embracing the Alternative Diagnosis


By Robert Donovan

A paramedic squad was dispatched Code 3 for a middle-aged man for severe respiratory distress. On arrival, the team found the patient sitting up, in tripod position. The patient was in severe distress, slightly diaphoretic, but was alert and did not appear to be tiring.

Following ALS protocols, the team assessed the patient, applied oxygen, and started an IV. Initial sats were in the 80s, but went up to 95 percent with supplemental oxygen. Physical exam showed retractions and wheezing, so Proventil breathing treatments were started and repeated during the transport to the ER.

On arrival, the patient looked better, although I could see he was working hard. He still was sitting up, but could talk better, and his skin had dried up.

I should have remembered 'The Fog of EMS'
I thought this was a straightforward case. Here's what I found upon examination:

• Nose and throat were normal.

• No stridor noted and lungs showed diffuse wheezing.

• Cardiac exam showed a regular rate, no murmurs.

• Abdomen was soft and non-tender.

• Skin was dry and no edema was noted.

Initial impression: Exacerbation of COPD, and I treated him as such.

Rx:

• Solumedrol (a steroid) was given via IV to help reduce lung inflammation.

• Continuous full strength Albuterol and Atrovent bronchodilators were given by an hour-long nebulizer.

• Intravenous magnesium was also given to help as a bronchodilator (the literature is slightly weak on using it, but I'll take any port in a storm!).

Labs:

• Electrolytes normal.

• Cardiac enzymes normal.

• White count slightly elevated (not too unusual when the body is physiologically stressed).

• EKG showed a sinus tachycardia.

• Chest x-ray was read by the radiologist as being "normal".

New surprises everywhere
After an hour, I thought he was improving so I began to make arrangements to admit him to our hospitalists. However, I was called back to the bedside when his condition drastically changed.

When I returned, he looked miserable! He was tripoding, sweaty, with retractions. I could hear the wheezing, even without a stethoscope. Despite oxygen, his sats were dropping back into the 80s; he was obviously tiring.

I can recognize a sinking ship as well as the next guy, so we prepared ourselves to do a RSI (Rapid Sequence Induction) and intubation. We switched him to a 100 percent non-rebreather mask as equipment and medications were gathered. We have a new device in our ER, the Glidescope, which I have recently started using. The Glidescope is an intubating device with a camera. You may think this is just another "gee whiz" gadget for an electronics geek like me, and it would be true (I know it’s shallow, but I can't help it!), but it really is a life saver for difficult intubations.

There are exceptions, but as a general rule, I like to sedate and paralyze my patients before intubating. Etomidate was given first, followed by Norcuron as a paralytic agent. At this point, events started to get exciting. The Glidescope was easily introduced, and a perfect view of (insert drum roll here) a vocal cord massappeared on the screen. I had a 7.5 ET tube ready, but wasn't able to pass it due to the obstruction.

Roller coasters or Ferris wheels?
I could see it was time for game plan B, and quickly. You know that feeling that arises when you could be facing imminent disaster? Questions run through your head such as, "Should I continue to: 1) try to intubate this patient, or 2) run home to Mother for milk and cookies? She'll tell me I'm wonderful!"

I chose number one above. For me, at these moments, I feel like I enter a time warp. Everything seems to move in slo-mo. It's what helps to keep me thinking. Fortunately, I could still ventilate the patient with a bag-valve mask. I then used a gum elastic bougey and was able to easily pass it through the cords, and slid a 6.5 ET tube in. Whew, another disaster averted! My patient and I could now breathe more easily.

Surprisingly, the wheezing went away! At that point, I started to rethink the entire case. I once again learned what I've been preaching repeatedly, and perhaps you'll recall this idea from my LOC article:

If you have in your mind only one possible diagnosis, you aren't thinking hard enough. Keep your differential diagnosis flexible. Keep getting more information, eg: response to treatment, changing lab values, etc.

I think that this patient had been having intermittent episodes of partial obstruction from this mass. What was unusual — and the reason I initially favored COPD — was that typically we are taught that airway obstructions have stridor and inspiratory wheezing. This patient had neither; no one sent him that memo.

What are the lessons that I learned or rather, re-learned? Don't be too confident about your diagnosis; be ready for surprises. Always enjoy the amazing profession that you and I are in. After all, aren't we doing this because 1) we love medicine and the joy of helping others, and 2) we prefer administering our treatment from the thrilling seat at the front of a roller coaster rather than a Ferris wheel?

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