Rural Health

[Paseo Del Norte]

Sorry all, it has been a while since I posted a scenario:

You are a paramedic working at a remote clinic in Afghanistan. You are in the mountains and supporting a DOD project at a small airfield. It is late November with generally cold conditions and an evacuation off site would present with logistical and security challenges.

A 48 year-old male presents to your clinic complaining of "feeling bad."

Take it away.

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[EVAQ5700]

nonrebreater 2L/min (this is mostly a joke)

 

[EMS5]

Can i get a set of vitals -- BP, pulse, resp, breath sounds, SpO2, BGL?

General appearance?
prior medical hx?
recent sickness?
any regular meds?
how long has he been "feeling bad"?

Is he a local or is he brought in working on this project?

 

[MedicFL]

Sorry all, it has been a while since I posted a scenario:

You are a paramedic working at a remote clinic in Afghanistan. You are in the mountains and supporting a DOD project at a small airfield. It is late November with generally cold conditions and an evacuation off site would present with logistical and security challenges.

A 48 year-old male presents to your clinic complaining of "feeling bad."

Take it away.

Find out what the last MRE he ate was? If it was choices such as the meatloaf, beef patty or other unpleasent dishes you may have your answer. I am j/k of course.

 

[Paseo Del Norte]

Can i get a set of vitals -- BP, pulse, resp, breath sounds, SpO2, BGL?

General appearance?
prior medical hx?
recent sickness?
any regular meds?
how long has he been "feeling bad"?

Is he a local or is he brought in working on this project?

180/94, 118 regular, 22, clear upper lobes and diminished bases, no adventitious sounds, 95% on room air, 122 mg/dl.

Obese, pale and anxious without severe distress.
HTN, takes Toprol XL and had an appy "many years ago."
No recent other than this current problem.
Been feeling bad approximately a few hours.

Find out what the last MRE he ate was? If it was choices such as the meatloaf, beef patty or other unpleasent dishes you may have your answer. I am j/k of course.

He has been eating a mixture of local food (naan and lamb) and cafeteria food.

 

[deleted6669]

when did he fly in from the states?
tachycardic(on a beta blocker) and tachypneic I'm worried about pulmonary embolus.
I've seen this present atypically as syncope or fatigue many times without chest pain or c/o dyspnea.

 

[Paseo Del Norte]

when did he fly in from the states?
tachycardic(on a beta blocker) and tachypneic I'm worried about pulmonary embolus.
I've seen this present atypically as syncope or fatigue many times without chest pain or c/o dyspnea.

He has been in country for several months. No history of recent flights and he has been less than compliant with his medication. Nobody specifically asked but I will throw this in. His temperature is 101.3 F.

 

[deleted6669]

more questions: malaria endemic area? taking prophylaxis?
exam: specifically neck, cv(MURMUR?), abd, skin( New rash/bites/lesions?), pv?

 

[Paseo Del Norte]

more questions: malaria endemic area? taking prophylaxis?
exam: specifically neck, cv(MURMUR?), abd, skin( New rash/bites/lesions?), pv?

Yes, but it's winter time in the mountains. No prophylaxis due to the time of year and location. No rash, bites, lesions noted. Physical exam is basically unremarkable except for fever, tachycardia and a "pale" appearance.

 

[deleted6669]

what lab studies are available at this location?

 

[Paseo Del Norte]

what lab studies are available at this location?

None, other than basic point of care testing such as blood glucose. You can draw and send it out to a clinic in Kabul with a turn around of about two days.

 

[deleted6669]

None, other than basic point of care testing such as blood glucose. You can draw and send it out to a clinic in Kabul with a turn around of about two days.

seriously? can't even do a hemoglobin or dip a urine? guy certainly sounds anemic with some type of infectious process. did this come on 12 hrs after eating a local lamb meal? any diarrhea?
I had a "bad goat experience" in Haiti my first time there and suffice it to say I am now a "Haitian vegetarian...."
the differential for "pale/febrile/tachycardic/weak" is huge in the developing world...any other symptoms besides malaise and fatigue?
pt ever had an episode like this before, either stateside or overseas?

 

[Lawsonc]

What medication do you have access to? Is the idea to EVAC? What kind of timeline do you have?

HX of bowel movements? Urine output?

This is interesting, was this a real patient of yours? I'd like to see where this goes for my own learning.

 

[Paseo Del Norte]

seriously? can't even do a hemoglobin or dip a urine? guy certainly sounds anemic with some type of infectious process. did this come on 12 hrs after eating a local lamb meal? any diarrhea?
I had a "bad goat experience" in Haiti my first time there and suffice it to say I am now a "Haitian vegetarian...."
the differential for "pale/febrile/tachycardic/weak" is huge in the developing world...any other symptoms besides malaise and fatigue?
pt ever had an episode like this before, either stateside or overseas?

No episodes like this. Urine dip is negative. No diarrhoea. Also complains of chills

What medication do you have access to? Is the idea to EVAC? What kind of timeline do you have?

HX of bowel movements? Urine output?

This is interesting, was this a real patient of yours? I'd like to see where this goes for my own learning.

You will need a good case for a evac. Reports no bowel or bladder complaints. This is based on a real patient. Some details have been changed a bit however.

This is what we did:

Gave him a gram of APAP and sent off blood for a CBC and CMP. After two hours he significantly improves and his fever resolves. He is able to tolerate fluids. We send him "home" with a tentative diagnosis of viral syndrome and with APAP and orders to rest and push fluids with a 48 hour follow up pending lab results.

You do have access to a fair number of oral and a few IV anti microbial and antiviral agents.

 

[Lawsonc]

No episodes like this. Urine dip is negative. No diarrhoea. Also complains of chills



You will need a good case for a evac. Reports no bowel or bladder complaints. This is based on a real patient. Some details have been changed a bit however.

This is what we did:

Gave him a gram of APAP and sent off blood for a CBC and CMP. After two hours he significantly improves and his fever resolves. He is able to tolerate fluids. We send him "home" with a tentative diagnosis of viral syndrome and with APAP and orders to rest and push fluids with a 48 hour follow up pending lab results.

You do have access to a fair number of oral and a few IV anti microbial and antiviral agents.

I don't want to fixate on one issue alone, but in the most "acute" of his issues I'm concerned with his BP, any vision issues, tingling sensation, head ache? Was this a concern for you?

 

[JLM]

wait - is there more to this case? Did he just get APAP and do fine?

B/c this dude meets SIRS criteria. Even if there is no obvious source of sepsis, I would keep looking because something is causing a huge inflammatory reaction.

Also a pulse ox of 95 on room air is a large shunt fraction in an otherwise healthy patient. It corresponds to a PaO2 around 70. PE is definitely in the differential.

In my book, thius guy gets a cannula, IVF and antimicrobials until we can get some labs back or he starts smelling like a rose.

Do you have any means of taking an EKG?

 

[Paseo Del Norte]

Blood pressure is 150/88 after about two hours post APAP. Patient does have a "dull" headache that improves significantly following APAP. A XII lead is performed and shows sinus tachycardia without any conduction abnormalities. Following APAP, the patient is in a NSR without ectopy or or any conduction abnormalities.

Also, the patient is currently living at an altitude of just over 10,000 feet.

I will say what happened after this and there are probably good arguments for and against.

The patient improved significantly and had no complaints at the two hour mark. Labs were drawn and sent with one of the local delivery people. An approximately 2 day wait is expected. Evacuation is possible, but it involves significant logistical requirements and the activation of a QRF (quick reactionary force) escort team and dealing with a French military hospital. After consulting with a physician, the decision was made not to evac and a tentative diagnosis of viral syndrome was made.

The patient was put on an APAP/rest/push fluids profile and would receive daily follow up until labs returned. At the 24 hour follow up, the patient was complaint free and had unremarkable vital signs.

However, at about 36 hours, the patient returned with the same complaints and similar vitals/physical examination. Again, there was significant improvement following APAP. At that time an IV was placed and the patient received 1,000 mg of ceftriaxone.

Labs were returned a bit early and indicated the following:

Mild Leukocytosis, no manual diff available
Mild Anaemia

You can assume that the values were significant but not what most people would consider "panic" values.

 

[Lawsonc]

So there was/is an infection, but now that you've mentioned altitude, how much is that playing a role? How long had he been at altitude? Is this an issue with two things going on?

It could explain all of those signs/symptoms (except the fever).

 

[Paseo Del Norte]

So there was/is an infection, but now that you've mentioned altitude, how much is that playing a role? How long had he been at altitude? Is this an issue with two things going on?

It could explain all of those signs/symptoms (except the fever).

He's been at altitude for a few months. Let's say you just happen to have a microscope and decide to do a blood smear for the hell of it.

 

[turkeyjerky]

So there was/is an infection, but now that you've mentioned altitude, how much is that playing a role? How long had he been at altitude? Is this an issue with two things going on?

It could explain all of those signs/symptoms (except the fever).

How do you know there's an infection? Cause antibiotics were given? That's circular reasoning, and there're plenty of non-infectious etiologies that could explain the patient's findings.

 

[Paseo Del Norte]

How do you know there's an infection? Cause antibiotics were given? That's circular reasoning, and there're plenty of non-infectious etiologies that could explain the patient's findings.

I'll be honest. Initially, I did not give bacterial infection too much thought. We would get several patients a day with fever, myalgia and so on. Viral syndrome was problem of the month that time of year. The actual problem and it's source was pretty unique however.

 

[Lawsonc]

How do you know there's an infection? Cause antibiotics were given? That's circular reasoning, and there're plenty of non-infectious etiologies that could explain the patient's findings.

Its an assumption-

He has a fever, white cells are up, and he is in a remote area with high probability of exposure to some nasty stuff.

 

[turkeyjerky]

Its an assumption-

He has a fever, white cells are up, and he is in a remote area with high probability of exposure to some nasty stuff.

I know you were making an assumption--I was pointing that out. They're plenty of non-infectious etiologies of fever (although the level of his temp certainly does make it more likely), and wbc is so non-specific as to make it nearly useless.

Now that you've posted the diagnosis for us, how'd you treat him. I'd be leaning towards IV therapy for this guy, but I really have no experience in the matter.

 

[Paseo Del Norte]

What exactly do we think is going on with the patient? Are we really dealing with a prokaryotic organism?

 

[Dwindlin]

What exactly do we think is going on with the patient? Are we really dealing with a prokaryotic organism?

If that blood smear is to be believed then no we are not.

 

[turkeyjerky]

If that blood smear is to be believed then no we are not.

Took me a minute to remember what prokaryotic meant, ha.

 

[leviathan]

What exactly do we think is going on with the patient? Are we really dealing with a prokaryotic organism?

Not with those ring forms in the RBCs.