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A Typical Night in the ER

When the Patient First Arrives in the Emergency Room

The ambulance call comes in.

"We're running lights and siren with a 67 year old male. He's confused, lethargic, blood pressure 80 over 40, thready pulse (a pulse that is very fine and barely perceptible) and sweaty. We'll be at your door in a couple of minutes."

The nurses start setting up the equipment to care for the patient. We've been through this drill before when someone arrives at the ER with low blood pressure. I hope it's an easy diagnosis and something that we can treat quickly. IV's are set up, monitor pads ready. The respiratory tech arrives with her machines just in case they are needed.

The EMTS unload a man in obvious distress, sweaty, struggling to breathe, and limp.

"He's had a fever for a couple of days with a cough. Past history of COPD, heart problems, and smokes."

The diagnosis could be easy, but there are a variety of factors that could be causing this man's condition. He is in shock; his blood pressure is so low there is not enough pressure to provide blood flow and oxygen to his brain. That's why he is lethargic. No doubt the rest of his organs are at risk too. But why?

  • Is it an infection that has caused dehydration because of sweating from the high fever and inability to drink enough fluid?
  • Are his lungs filled with infection so that they can't get oxygen into his blood stream?
  • Is he septic, (has the infection spread through the blood stream causing the blood vessels to leak fluid)?
  • Has his heart weakened because of lack of oxygen? Is he having a heart attack?
  • Is it a combination of any or all of the above?
  • Or is the fever a "red herring" and something else is going on?

The patient's vital signs are poor. His blood pressure has fallen to a little to 70 over 40, his heart rate is 130, and he's breathing over 30 times per minute. Temperature is 103 F. All bad, but all pointing to an infection and perhaps easily fixed with some IV fluids.

He's struggling to breathe but is awake enough to complain that his chest hurts to breathe. His right lung sounds like there's a pneumonia or infection. But he's also wheezing heavily in both lungs. What else could it be? A pulmonary embolism (blood clot to the lung) could cause shock and fever. Tuck that thought away in case it's needed.

Medically Reviewed by a Doctor on 4/18/2017

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