Video 2: Emergency Case Review: Randy Sherman

Dr. Nelson (00:00):

Welcome back. I’m Dr. Nelson. We are playing Full Code. Let’s get started on our case.

We are taking care of a patient, Randy Sherman, who is a 29-year-old male. As we get started on this case, let’s see what initial information we have before we see our patient.

The first thing that we’re going to get is the EMS report, and this is usually a paramedic or EMT that is calling us via a radio in the back of the ambulance and giving us a preliminary update of what our patient is experiencing. And in this case, they found the patient to be somnolent, meaning sleepier than expected, and they were found on a couch with a respiratory rate of six, or RR, which means respiratory rate of six breaths per minute. Now that is low. Typically, an adult male would breathe between anywhere from 12 to 16 times a minute.

Dr. Nelson (01:07):

In fact, if you want to try to breathe at six restorations a minute, you’ll find very quickly that that is uncomfortable and not sustainable. Because of that hypoventilation or low respiratory rate, we are finding SpO2, or oxygen saturation of 88%, on room air. What that means is 88% of this patient’s molecules of hemoglobin have oxygen attached to it. Hemoglobin is a protein within our red blood cells that carries oxygen to our tissues and typically between 94 and a hundred percent of those hemoglobin molecules are occupied by oxygen. If it’s less than that, then we are what we call hypoxemic, or we don’t have enough oxygen attached to our hemoglobin molecules. 

Therefore, our tissues then would become hypoxic and not get enough oxygen for them to take care of their metabolic processes such as generating a TP or energy. So once we find out that this patient’s respiratory rate now is six and their oxygen saturation is 88%, we know something is not going right, something is very wrong and the somnolence only adds to that.

Dr. Nelson (02:32):

In the field, the paramedics placed a nasal cannula of supplemental oxygen and the oxygen saturations did come up to 94%, which is better, but still not ideal. Once the patient arrived, the triage nurse has directed them into one of the emergency department areas and the triage nurse gives us further information that this 29-year-old male was found lying on a couch, very difficult to rouse, and EMS transported him to our facility and placed oxygen on him in transport with some improvement of his oxygen saturations. Now, the patient is waiting in triage bay number one for us.

Before we go to see this patient, let’s talk about the AAMC Premed Competencies. So I’m going to switch to the AAMC Premed Competencies website, which you can find…Google AAMC Premed Competencies. You’ll see several different competencies that they find important for pre-medical students to work on as skills in order to succeed in medical education in becoming a physician.

Dr. Nelson (03:48):

And you can see that their skills from anywhere from teamwork, resilience, adaptability, reliability, communication, and so forth. As you’re going and gaining your extracurricular experiences, we encourage that you work on as many of these different competencies in order to succeed in your medical education.

And in fact, I believe in this case, the competency of Scientific Inquiry applies greatly where we are applying knowledge of the scientific process to integrate and synthesize information, solve problems, and formulate research questions and hypotheses. We are facile in the language of the sciences and use it to participate in the discourse of science and explain how scientific knowledge is discovered and validated.

With that in mind, I want you to start thinking about what could be causing our 29-year-old male patient to be somnolent, hypoventilating, and be hypoxemic. Why don’t we take a break and have you think about and talk about what could be the cause of this problem?

⁉️What could be causing our 29-year-old male patient to be somnolent, hypoventilating, and be hypoxemic?

Even if you don’t know where to start, brainstorm together and make a list of Randy’s symptoms and what questions we could ask Randy and his family, with your group!

Key Terms:

• ATP (adenosine triphosphate): the source of energy for use and storage at the cellular level.
  
  
• Hypoventilating: When a patient’s breathing that is too shallow or too slow to meet the needs of the body.
  Read more about hypoventilation here.
  
  Also, note that hypoventilating is different from hyperventilating.
  
  
• Hypoxemic: A low level of oxygen in the blood.
  Read more about hypoxemia here.
  
  
• Somnolent: A medical term used to describe a patient that is difficult to awaken.

• First, discuss these questions with 2-5 HSAFP members for a few minutes
  
  
• Then, one Chapter Officer should ask/find volunteers to share your groups’ answers with your whole chapter!