Reply to Anonymous.

This was a comment left on the post for the 'Second Night' from the 28th July

Taz, I just have some enquiries about your "Asthma in Extremis" Pt. You have clearly stated that the patient was anxious, so much to the point of being unconscious. You have stated that they have adequate tidal volume. There is no mention of respiratory rates or SpO2%. You have stated at no point did the patient have a wheeze. You have stated that the patient is not a known Asthmatic. I am wondering then how you have justified you use of Adrenaline and repeat doses of Salbutamol and Atrovent? There is no mention of chest hyperinflation. No mention of high inflation pressures. No mention of minimal air movement. No mention of perfusion. And why did you not attempt expiratory assistance?In fact there is little evidence to suggest that the patients condition is servere of extreme at all (which is clearly stated in the protocol). Or little evidence to suggest a mild Asthma attack at all.Let me put to you how you have described the patient's condition a different way.A non-asthmatic patient, hyperventilating to the point of a decreased LOC, no wheeze, still moving air, not cyanosed, not tachycardic.Can you justify Adrenaline or repeat Salbutamol and Atrovent?You have stated the patient had wide spread creps. And you stated you did not take a blood pressure. I want you to now consider the complications of a patient in APO, with a failing left ventricle, to whom you have administered Adrenaline.I will admit I was not there, but I don't think in any way can you justify your drug administration.


So I'm being called out by a peer, but I have already wanted to follow up this pt and been analysing the job because it wasn't any normal presentation.


This not a journal with complete case studies.

Remember Sp02% is a machine reading of the oxygen saturation in the finger the probe is attached to.

The pt never really got to the hyperventilating level, increased WOB & RR yes, but not the 30-40 pre min you normally describe as an anxiety attack.

The pt had dry crepes in the lungs, stated no cardiac Hx also other than controlled HT and had increasing respiratory difficulty for 2-3 days. I was happy to continue down the respiratory track.

So if a pt doesn't fit a protocol are we meant to not treat or to keep our head in a box and not investigate other possible conditions. Education is pushing guidelines not strict protocols.

But correctly you were not there and I have said that the post was not a complete report due to the complexity of the job.



So I had asked the Director of Emergency Medicine at the hospital if they would be able to review the case for me.

Six hours later I got a phone call,

Diagnosis - Respiratory Failure secondary to ASTHMA.
Pt's records also showed an admission six yrs ago for severe asthma.


The hospital still has the pt on a ward due to the overall complexity of their medical conditions. My actions were correct, I have been vindicated by an independent umpire and dear anon you were just a little to quick on your high horse.


So I have now had my say.



Self critique, self analysis is key to being a true professional.





Be careful out there and I'll see you at the Big One.

Taz