I have recently seen a patient that confused me, two of my colleagues and a number of ED Doctors, so what do you think is wrong with this patient….?

…..responder on scene about 3 minutes ahead of you. “The patient is presenting with shortness of breath, bi-laterally bubbly chest sounds and maybe a wheeze.  I’m thinking either chest infection or LVF (Left Ventricular Failure)”

He is obviously short of breath, a little grey looking, but when I listen to his chest it sounds clear… His oxygen saturations are low so we decide to give him a nebuliser of Salbutamol to open his airways a little.  His other clinical observations are all normal.

This isn’t an unusual job for us and with the drugs that we carry, its something that we can help to resolve.  He is unable to speak in full sentences and this becomes even worse on mild exertion, so because of this we will take him to the hospital where he had some investigations completed recently.

Once he is on the Ambulance we agree that we don’t need the reponder any longer as the patient has not deteriorated any further but seems to be getting better – excellent!  The trip in is 25mins to the ED and during this time plenty happens!

The first thing that I notice is that his breathing appears to get better and worse in waves, one minute he is bubbly and the next he is clear and so the cycle continues.  Then our patient complains of throat tightening, similar to anaphylaxis (which he suffers from) but without signs of an allergic reaction, this dissipates well on its own, then his condition improves slightly.

Next he complains of a heavy right arm, still no pain anywhere but his concious levels have decreased a little, now I’m thinking that he may be having some sort of cerebral event, a stroke or TIA, but all of my tests for a stroke are clear with the exception of the right arm which has full strength and power, but slightly reduced speed of reaction.

With less than 2 minutes to go before arriving at the ED, his skin colour changes to a nice pink colour, his respiratory rate returns to normal with no noise, his concious levels increase so that he is fully alert and his right arm starts to return to normal.

En route we had called ahead to warn the hospital that we were coming in with someone with severe respiratory distress, but now he appears fit and well…..

…So to recap…

On Arrival at HA – Shortness of Breath, Bi-lateral rales, wheeze – ? LVF Symptoms
En Route – Anaphylaxis style shortness of breath – ? Cause, Heavy right arm – ? Cerebral event
On Arrival at ED – Fit and Well

…So what do you think is wrong?