Clinical Case 103: Midnight MacGyver Medicine
This is an exercise in medical minimalism. I am going to throw you a case and a set of resources – you need to say how you would manage it. I am going to release my strategy in a few days. So here we go – here is the case…
Firstly, a little bit of background you get from the old file:
Monica is a 49 yo woman who has had a long history of renal trouble.
She was diagnosed with type 2 DM at age 21, with early nephropathy.
By age 40 she was on CAPD, and by 43 was dependent on haemodialysis.
She got lucky and was the recipient of a cadaveric transplant at age 45….. but, that kidney isn’t doing so well. She has had multiple episodes of threatened rejection and ongoing renal impairment.
In the last year her new kidney started to pack it in and she has had yet another AV fistula formed… in anticipation of ongoing HD.
So here we are – most recently her creatinine was 500, with normal K+ and bicarb of 18. She has advanced renal osteodystrophy, hypertension, anaemia [on darbopoeitin], also has chronic asthma / COPD. Oh, and her BMI is 40, with really tough IV access due to previous fistulae surgery… good luck.
On the bright side – she has no documented ischemic / valvular heart disease.
Meds: prednisolone 5 mg, ramipril 10 mg, amlodipine 5 mg, tacrolimus 1 mg, salmeterol inhaler, CaCO3, cinacalcet 30mg and aspirin 150 mg.
It is 5 minutes to midnight on your night shift at “Janus General” hospital in a remote location. You are on your own.
Here is the scenario:
The Ambos roll in the door with Monica on the stretcher – she is looking pretty crook. She called ‘000’ as she was getting increasingly ‘short-winded’ and her puffers were not helping.
The ambulance crew have her on 8 L/min via a nebuliser mask with salbutamol nebs over the last 20 minutes.
Obs are: Resp rate 36/min, pulse 110/min, SpO2 = 94%, BP is 180/110, she is afebrile and coughing with green sputum. She is alert and oriented. Her new fistula is buzzing nicely
A quick auscultation of her chest reveals diffuse, bilateral, coarse crackles. A few scattered wheezes but reasonable air entry. She is working pretty hard – tripoding.
In between gasps she indicates some (R) sided chest pain – it appears to be pleuritic.
Her legs are both really oedematous – with pitting oedema up to her kneess… maybe a little more on the right.
The monitor shows sinus tachycardia and an ECG the same – with maybe some slight depression of the ST segments laterally.
The differential diagnosis is looking pretty broad at the moment! Take a moment to contemplate the possibilities….
Here is what you have:
- A well stocked, small, rural ED
- Oxylog ventilator – capable of NIV
- a POC blood gas analyser (basic biochem and gas panel + lactate)
- a bedside ultrasound machine [ of course 😉 ]
- two really great nurses
- a telephone to phone a friend / specialist – but none will be able to attend.
Here is what you do not have:
- Any formal radiology
- Any laboratory tests other than the POC machine
- Any immediate, physical backup
- Any way of transferring Monica anywhere in the next 12 hours. [ though the sun will rise in 6- usually makes things seem better!]
So – here is the challenge:
- Get IV access somehow!
- Initiate empirical therapy – what would you use up front
- make some sort of diagnosis (es)
- Make a plan for the next 12 hours (the lab and Xray department will be available then…)
Welcome to Broome. Go!
I would start with lung/cardiac/DVT US.
Assess for fluid overload with diffuse B lines,if localized/consolidation and less B lines in other fields, consider infection/aspiration given green sputum.
Immunocompromised, so need to consider weird and wonderful bugs in addition to usual CAP/HAP.
Cardiac Us to r/o uremic pericarditis/effusion, and if skilled to do so, RV failure in context of possible PE or obvious wall motion abnormality.
DVT compression us of both legs.
IV access possibilities are the non-fistula side, or subclavian line. I’d stay away from IJ because they may need it for tunneled vasc cath later. The other option is to do an axillary vein catheter, no risk of PTX.
I think some CPAP/BIPAP might help if it’s not pneumonia or pericardial effusion. Start off with an ABG on 100% FiO2 and reassess after 30mins on NIPPV to assess for improvement or deterioration.