DOI: 10.1097/01.EEM.0000437840.15012.d7
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Issn Print: 1054-0725
Publication Date: 2013/11/01
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Excerpt
The next day paramedics arrive at his house because he has collapsed in the shower. Cardiopulmonary arrest ensues. He is transported to the emergency department and pronounced dead.
“Groin strain.” What exactly did they see in that clinic? What did they feel in his inguinal region and medial thigh that generated this diagnosis? A simple strain of the adductor compartment muscle? Misdiagnosed adductor compartment myonecrosis? Or something else?
That same year, western Colorado. A 16-year-old girl presents to the local ED with pain and numbness in her left arm. She has subjective fever, chills, and multiple episodes of vomiting. She reports having fallen from a trampoline five days earlier. Tachycardic to 100 but otherwise afebrile and not tachypneic. After a physical exam and chest x-ray, the patient is diagnosed with a brachial plexus injury and given neurology follow-up.
Two days later, she is found obtunded at home and brought back to the ED. Febrile to 102.5°F, tachypneic to 50, and tachycardic to 170, she deteriorates and suffers a respiratory arrest in the department. A pulse returns with intubation and resuscitation, and the patient is transferred to the nearest tertiary care center, only to die later that day.
Septic shock and severe metabolic acidosis. Vasodilation and decreased contractility from acidosis drop brainstem perfusion and thereby stifle her respiratory drive. Inadequate CO2 exhalation compounds her metabolic acidosis, and her pH spirals down. The result is worsening vasodilation and plummeting cardiac function causing her to arrest. The respiratory component is reversed with intubation, and the pH rises high enough to regain meaningful myocardial motion and vascular tone. The underlying acidosis and systemic inflammatory response march on, however, and eventually consume her.
Was her brachial plexus injury related? Could motor deficits be attributed to neural dysfunction? Or was strength testing and muscular function actually limited by pain? Just what did they see along the course of the plexus in the supraclavicular area and axilla that drew their eyes and minds to crisscrossing axons and fascicles?
2009, Qinghai Provence, China. A herdsman finds his ailing dog lying in distress 6 km from home. The hound had hemoptysis and hematemesis, and the herdsman carried him over his shoulders to be buried. Four days later, the herdsman developed a fever and cough, and was brought to a local clinic by relatives. Doctors described him as having a pale complexion and bloody sputum. They initiated IV ceftriaxone and recommended he go by private vehicle to the Tibetan Hospital in Xinghai County.
The patient began to vomit violently on the way to the county facility with his brothers. He died later that day. His brothers and father-in-law would transport his body back to be prepared and buried in traditional Tibetan fetal position. The father-in-law, who likely had a prominent role in the preparation of the body, would fall ill with respiratory complaints and expire days afterwards.
The herdsman also had met briefly with a friend from his village before departing, and that friend would soon develop hemoptysis and die. Nine other close contacts would develop symptoms, but survive after timely antibiotic treatment.
Abrupt onset of fever and hemoptysis followed by a rapid clinical decline? Sounds like a necrotizing pulmonary process.
