With about a minute, out I decided to decompress the right lung. Using a 3" needle I was unable to reach muscle tissue or even rib due tothe depth of sub-q.
Arriving into ER I was only met by the nursing staff... I went into the fishbowl (ER Doc office) and informed them.. (unfortunately, the staff only reported swelling of arm) respectfully, both ER docs immediately went to assess the patient.
They too were perplexed.. an immediate PCXR was performed, while RSI equipment was prepared. The patient was still alert.. and attempting to tell us about his "chest pain". I was instructed to attempt to decompress the right side with a "spinal needle" until x-rays were returned.
I anesthetized with lido and was able to decompress with immediate return of air... again, lung sounds verified by physicians.. becoming distant but audible.
X-ray revealed right clavicular fxr and rib fxr's of 1,2 and 3.. with only about a 30% pneumothorax on the right side.
Patient was RSI and severe difficulties were encountered and a tracheotomy had to be performed. Chest tube was inserted with approximately 300 ml of blood and sangeous fluid return. Patient was placed ventilator and continuous sedation. Central line placement was placed in the right femoral with a triple lumen. Sub-cutaneous emphysema was even beginning to be noted to occur in the scrotal area.
Due to the suspicious nature and unknown etiology a CT of head, chest & abdomen was performed
It was at this time another pneumothorax was detected by the radiologist on the left side while in the ICU and another chest tube was placed.
We had to respond to another call .. and later returned to checked on him.
He was later weaned off the ventilator and it was determined that he apparently had become intoxicated and fell outside striking unknown object and passing out?... later to only awaken with the chest pain.
After four days off ventilator patient acutely became worse, placed back on ventilator and developed ARDS. The patient subsequently later died due to respiratory complications of pneumonia/ARDS about a week later.
I felt this call was unique for several reasons:
Patient chief complaint NEVER met with injuries, symptoms, history of events or even etiology.
There was no significant external clues that would indicate underlying injuries, bruising only started occurring approximately 3-4 hours after occurrence.
My partner is a well educated and experienced Paramedic. We both agreed that we felt that was not much more that we could change or do on this call. This was one of the fastest most rapidly sub-q development I have ever seen. Within 5 minutes, sub-q had developed from isolated area to diffuse. Even in the ER sub-q had developed into the orbital area so much conjunctiva was exposed.
We discussed maybe a faster decompression or could had occurred, but with bi-lateral lung sounds it was difficult to determine which was the affected side (albeit it turned out to be bi-lateral). We both agreed it would had not been productive to enter ER with bi-lateral decompression with unsure knowing of which was the true affected side. The reason I mad the right was due to the inital sub-q on the right side.
As well if we were further from hospital we would had to attempted RSI, but both of us agree that we were glad it was not us that had performed RSI. Seeing the difficulty that occurred is something we were glad that we avoided.
Like I always say .. "one learns something every day ".........
R/r 911
