Avoiding Common Errors in the Emergency Department

by Amal Mattu [second edition] 2017 Wolters Klurer. Emergency medical practice is evolving. Emergency medical practice is relatively new and is saving patients from life threatening illness and injuries. Reading “Avoiding Common Errors in the Emergency Department” gives you a very good idea of how vulnerable we are throughout our lives, from birth to old age, to many kinds of organ failure and infections and injuries affecting the head, the mouth, the pharynx [throat] , the neck, the circulation [of blood], and the torso. No one can give an exhaustive medical history during a medical emergency [eg. …….and then there was the time when I was 2 , when I am told I survived a severe asthma attack and needed resuscitation, and then, ……].

A look at an acute medical complaint that brings a person to the emergency department will not uncover a hidden injury from past illness [possibly starting at birth] requiring supportive medical care to prevent deterioration and a chronic course of disability.

Remember that emergency care is a young science. Remember that emergency care, even the it saves lives, is not without consequence. remember that the long term effects of intervention are not always known to the patient or doctor . And the effects may not make themselves felt till much later in the patient’s life.

Forwarding a depressed or manic or paranoid or demented or psychotic patient to a “psychiatric” pathway for investigation and treatment without a first aid emergency physical assessment may cause major errors in diagnosis. .

Sending a patient who fits the behavioural patterns recognized superficially as depression, mania, psychosis, paranoia and dementia to psychiatry is to stop all medical investigation. The psychiatric history is psychological and the treatments of psychotherapy and drugs we do not understand is a failure to investigate further because the doctors have given up because the problem is too hard and too scary.

A super easy way to detect treatable injury posing a threat to baseline mental status, condition, memory, mood and locomotor abnormalities is to carefully measure the vital signs of these patients during the different locomotor stages of their illness.

Depression with onset of new accompanying mental dullness in a previously competent person, is the best example to use to try to convince you that we need to investigate these neuropsychiatric syndromes more expertly and look for obvious [yet hidden till measured], injuries that the patient may have incurred in the past [often as a result of life saving emergency room treatment involving damage to the pharynx, neck and torso [think infection and sore throats] impairing a patient’s ability to recover from infection, injury, conditions affecting the blood [eg. blood loss, thiamine deficiency and low ferric iron without signs of anaemia- yet, causing heart problems and cognitive problems and circulatory problems- pretty common in young adult females with monthly blood loss from heavy menstruation or in females after childbirth who have lost a lot of blood].

Emergency medicine is hard. Nonspecific signs and symptoms have to be investigated. Altered mood, personality, mental status, and locomotor activity [from external behaviour changes such as lethargy [as in depression or organ failure] to abnormal hyperactivity, as in mania or endocrine changes can occur due to occult [hidden ] injury and blood loss..

Psychiatry is a cop-out. The very idea of psychiatry is basically a confession that we do not know what to do and haven’t yet thought to expand emergency medical investigation to look into these syndromes.

And syndromes they are! Many organ systems will be affected together, often in an integrated physiological fashion, depending on the insult.

How do we begin to advance emergency medical investigations into the investigation of altered minds, mood and activity [amount and speed]?

Easy, we take a step back to the early days of first aid training, which anyone can learn. When a young adult comes into the emergency department with distress, depression, dread, pressure in their heads or chest, changes to their voice, fatigue, cognitive changes [hard to detect if patient does not speak much or even realizes that their cognition and memory are altered], or have become psychotic, have reflexes which are abnormally fast, speech tumbles out with panting breath [mania], etc….we can recognize this syndrome and begin a first aid assessment of the circulatory system and the vital signs.

Basic assessments of circulation and vital signs [respiratory rate at rest, blood pressure at rest, heart rate at rest, heart signs [arrhythmia’s, palpitations, murmurs, et..] and body temperature [mild hypothermia or hyperthermia] is so easy to perform and will inform the health care provider of possible injury or pathophysiology that could easily [in the 21st century] be treated by supportive medical care.

I will use Paula [ a 21st century example] and the example of the thousands of patients Dr Emile Kraepelin examined, [albeit over 100 years ago] as an example of what could be done as a first step.

Let us imagine that Paula, after having woken up from sleep in a state of panic and dread and confusion [ her mental confusion preventing her from properly communicating her panic and dread] suddenly became lethargic, strange, incompetent at work due to dulled mentation that she could not explain and due to memory loss, was only partially aware of.

Now imagine that the triage nurse at the emergency department or any family doctor who sees her or any specialist she sees [including the psychiatrist] knows to check her vitals as a first step. The health professional is checking for signs of physical injury which could compromise the function of the autonomic nervous system.

The doctor, nurse, first aid layperson, asks Paula to lie down, so that Paula’s baseline respiratory rate can be measured for one minute using a stopwatch. This test is very reproducible and is easy to perform and has the added benefit of identifying active [laboured] exhalation. Breathing at rest is regulated by the brain stem and the peripheral motor respiratory pump system in order to manage blood gases in the blood.

Bingo! Paula is found to have a regular reproducible [ 5 times in a row, and more ] very abnormal depressed respiratory rate of 3- 5 breaths per minute. This is unheard of right now, but only because modern health professionals currently NEVER measure respiratory rate during first and every contact with a patient.

Respiratory Rate tells you nothing about the lungs. Paula’s lungs are healthy [Xray, Spirometry, etc..] This is NOT a lung problem.

Respiratory Rate tells you A LOT about the neural and mechanical working of the ventilatory system involving sensors and muscles and bone and spine . The ventilatory system physically moves air in and out of the body [and lungs]. The ventilatory system is a pump system without which breathing is impossible, healthy lungs or not.

Paula seems to have sustained some injury, some time during her life, to some part of the respiratory ventilatory pump system.

The next part medical investigation is obvious. What triggered the syndrome that Paula is suffering from? Did Paula recently suffer from some respiratory infection or other illness? Has Paula been exposed to emissions due to workplace or home overcrowding and poor ventilation or outright poisoning, as in being exposed to farm chemicals? Since Paula is too unwell to know or to speak or think, family and friends are contacted.

It turns out that Paula had a respiratory virus a month ago, followed by a stomach virus, lost weight and felt less sharp mentally, for about 3 weeks before her condition deteriorated enough to bring her to the emergency department or to see a doctor, any doctor, any specialty. Exposure to chemicals may have played a role also. Paula worked over 15 years in a heritage [very old] building with inadequate ventilation and very overcrowded conditions [5000 students crowded into a college which was meant to contain 2000 students]. And the college was next door to an experimental industrial farm which housed cows and grew corn and used all kinds of farm chemicals, fertilizer and manure. It seems that the motor illnesses, the decline in weight and the exposure to harmful chemicals overcame her reserve, especially in the face of a depressed breathing rate. WOW, double Bingo!

For the next step in the investigation, the doctor had a host of options; he/she could order a test to measure Paula’s tidal volume and to check out respiratory rate using a special lung function test; they could order a more invasive arterial blood gas test to see if the partial pressure of carbon dioxide is normal, they could test for carbon monoxide or other poisons, and probably do many more tests that I do not know about.

The doctor looked at the other vital signs first; the other vital signs were also abnormal and seemed to conform to the integrated physiological response to hypercapnia and possible accompanying respiratory acidosis. Paula’s heart rate and blood pressure were high, she had all kinds of heart signs [arrhythmia, murmur, etc.. ] and she had mild hypothermia with cold pale extremities and occasional blue lips. These are signs of vasoconstriction in response to the hypothermia or to stem possible increased internal bleeding or both.

Definitely could be responses to an episode of hypercapnia. The deterioration of mental function and the mental confusion and loss of short term memory are effects of chronic [if not corrected] and continuing [if not corrected] hypercapnia. It all fits!

Oh, and did I tell you about how altered regulation of CO2 for any reason, exposure to CO2 emissions, broken ventilatory systems, injury to the head, viruses leaving damage, etc…will affect neurotransmitters; in particular GABA?

To know more, please read the next post:

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