The Not Really An Asthma Attack
The call came through as a severe asthma attack. A 41 year old male had used his inhaler multiple times with no relief and had been getting worse over several hours. He was rushed from his F/V to our little island ER by a friend. We met them with a wheelchair — myself — a paramedic — and a laboratory technician — and ran inside with him slumped down in the wheelchair — working as hard as I have ever seen anyone work just to breathe tiny breaths.
My first impression was that this gentleman was severely ill. His breathing was labored and shallow. He could not speak. He could not lay down. He could barely nod yes or no to our questions. He looked exhausted and pale. As the nurse started in with vitals and an IV and the tech started in with labs and a chest xray…I gave him IM Dexamethasone and started a nebulizer and began considering whether or not we would have to intubate this gentleman. His heart was racing and he had a low grade fever. His breathing was so labored I could barely hear distant heart sounds over the wheezing breaths. After the nebulizer and steroids, his breathing improved somewhat — scantly — enough — and he pulled the nebulizer out of his mouth to simply say — “my chest hurts”.
“My chest hurts”.
Did I hear a friction rub? Out came the EKG. At this point my suspicions were rising. He was now out of the slumped position, upright, in tripod, with shallow labored (much improved but still terrible and scary) breathing, and now that he can speak a few words he states he has chest pain radiating into the spine of the scapula, low grade fever…could this man have had an exacerbation of pre-existing asthma on top of something new like pericarditis? Why doesn’t anything normal come into my ER? I feel like I never get “the textbook” cases.
“Have you been sick in the past few weeks with any viral type illnesses?”
“Yes”. His friend piped in — three weeks ago he had “the flu” — which sounded like a coxsackie virus — I hate viruses. I hate viruses as much as I hate mosquitos, ticks, and cancer.
ST elevation in almost every lead. His heart was massive on chest xray. Troponin’s normal. I picked up the phone and called for the medevac to start their at least four hour (depending on the winds) journey from the mainland to us. I have, of course, learned pericardiocentesis IN THEORY — but I have never had to actually do it — and as long as this man stayed relatively stable — I was going to leave that to the cardiologists on the mainland. I don’t allow anyone on my team to use the word “just” in front of what they do but — in this case — I truly felt like “just a PA” in this instance. This is why I have gone back to medical school. I want to know more and I want to be able to do more.
Tripod position seemed to help, the dexamethasone seemed to help, the oxygen and nebulizer seemed to help, we gave him 800 mg ibuprofen and monitored him until the medevac arrived. While I was still concerned about this gravely ill gentleman — he was dramatically improved from his presentation to us.
Medevac arrived, he was transported to the mainland, the cardiologist aspirated fluid from the pericardium and he was monitored in the hospital for several days. He was discharged without further incident.
Waves of relief…he really scared me.