The Doors of the ED

I don't know what it is about the doors to the ED but they need to be studied. It happens many times a shift that a patient's symptoms will get miraculously better right as they are brought back to a bed. Kid's fevers vanish, abdominal pain goes away and patients tell me they're hungry, and diarrhea dries up. Sometimes it works in reverse though and I think it's a result of people feeling safe once they make it to the bed. The mind is powerful.

I have never seen a dude with flop-sweat before but I just did. EMS brought in a 40'ish Hispanic gentleman with shortness of breath recently and the minute he hit the gurney in the ED he just freaked. EMS said he had been quite calm in transport. When I was called into the room he was pouring sweat and wouldn't sit on the bed. He was up, he was down, he was yelling "I can't breathe" (and even though he was able to form the words indicating he was breathing, the most he could get out was those three words), he was drowning, he was dying.

We intubated him rapidly and the X-ray showed bilateral pneumonia or diffuse heart failure. Then the picture got confusing... His rectal temp was 104 but his white count was normal. His BNP (an indicator of heart failure) was elevated, but not markedly so, and his EKG and cardiac enzymes were normal. His blood pressure was in the mid two-hundreds and we couldn't get it below 180 with a nitro drip so we switched to cardene which is rapidly becoming the drug of choice for hypertensive crises. I gave him lovenox empirically in case he had a massive PE but his D-dimer was normal. His 30 minute cardiac markers, which I ordered to see if he was trending up, were normal.

We flew him quickly to the Mecca somewhat stabilized but without a definitive diagnosis. I felt a little vindicated the next day when I talked to the ICU fellow and they still didn't have an answer. Scared the shit out of me (and his wife)! He is now off the vent. Cocaine? IV drugs? Flash pulmonary edema? Another form of Zebra? I hope to hear someday but I rarely get follow-up. Hopefully he walked out of the hospital.