Tough Cases in the ER

I am on emergency medicine in a urban trauma one center and I'm working 12 hour shifts. I work 7 PM to 7 AM for 7 AM to 7 PM. It feels good to be back in my element, my home. This is a scratch that this is a busy emergency department and receive lots of very sick patients tonight

I had an interesting patient the other night. This was a 34 -year-old African-American male with HIV-positive, ESRD (End Stage Renal Disease, and  a rip roaring case of pneumonia with a recent pulmonary embolism (PE). He  was recently in our ICU unit for pneumonia he was discharged  last week and this morning woke up with worsening shortness of breath. He decided to come into the emergency department because of his worsening symptoms when I enter the room I immediately knew this was a sick patient. He was talking just fine but his blood pressure was low and he was having a difficult time getting his oxygen. So I decided to work this individual up for  sepsis. I ordered the appropriate labs and films and imaging and I looked at some of his old records.

He had a low CD4 count which is bad for someone’s immune system. He had moved from HIV+ to  full-blown AIDS. His low blood pressure continued to plummet. I started him on IV fluid, bolus to bolster his blood pressure. His blood pressure started to come up but it was not high enough, so I decided I was going to put a central line in for better access. I started a medication that helps maintain blood pressure.   This medication, seemed to help him and he remained stable  in the emergency department.

We got his chest x-ray back and it showed a worsening left-sided lower lobe pneumonia. He was discharged last week with pneumonia and  today it was worsening which probably explained his worsening shortness of breath and symptoms. His discharge x-rays were much improved  from today’s x-ray. I was fairly certain he was improving and after he was discharged  he continued to improve but then started to get worse. He was a very sick individual and needed to be placed back in the ICU.

So I called the ICU doctor to let them know about this patient. This patient  needed  a  central venous  line. This is a catheter that is placed  into a major vessel like the internal jugular carotid to give better access  for medications and fluids. Placement of a central line is bread and butter of emergency medicine. We place them all the time.  The ICU senior resident came down because she wanted to learn how to do a central line. She asked me if I would show / teach her. I said yes. We started  to do a central line. We had to avoid  doing  a central line on the right internal jugular which is where we normally like to do it, because this patient had dialysis catheter  on the right. This meant we had to place the central line on the left. I begin to show the senior resident how to do the central line.  We were both in our sterile gowns and she was having difficulty getting in the vessel.  After several attempts I asked if I could show her personally and do central line. I proceeded to show her how to get a central line in the femoral. I was able to get the vessel. However when I advanced the wire it became difficult to advance, so I stopped. This could have been due to a clot in the vessel, my attending tried a couple of times but was unsuccessful.

The patient’s blood pressure had significantly improved and he was maintaining his vitals. We decided to get him up to the unit and place the line later if he needed that level of access. The patient was talking and he said he felt fine  and thanked us as he was transferred  up to the ICU. He was checked into the unit and was stable.

A little while later I heard a code RRT (Rapid Response Team) called to the ICU and I had a feeling it was for this patient. It turned out that he was talking on the phone when he just suddenly slumped over. He was found to be in a-systole (essentially dead). He was revived 3 times before finally died. He most likely had a big pulmonary embolism. He most like would have died from his worsening pneumonia given his near zero CD4 count. 

Ultimately I was able to follow up on this patient and it turns out the he had a large saddle pulmonary embolism in his pulmonary arteries that came from a DVT (deep venous thrombosis) in his lower extremities.

These cases rock your world every time.