Lenore Jarvis MD, Children’s National Health System
With Pavan Zaveri MD, Children’s National Health System

The Case
3 yo M h/o asthma presenting to an OSH with a CXR concerning for a complete whiteout of the left lung with mild midline shift away from whiteout (rightward). The OSH is calling you for transport to your facility. The challenge of this case is determining the appropriate way to transport this patient.

Here’s How You Answered Our Questions

Denouement
The OSH called back and stated that they were concerned about the respiratory status. Although patient was 100% on a NRB, the patient continued to have tachypnea and retractions. They were not comfortable placing the patient on BiPAP.

A decision was made to send an ambulance with a paramedic, RN, and a RT at a high priority. The PICU was called to “reserve a bed” as they were very full at the time. In discussions with the PICU, they were concerned about a possible mediastinal mass. Conferencing in the OSH, ED, and PICU, it was decided to obtain a quick lateral XR in an attempt to help differentiate between fluid and a mass. The PICU stated that if it was a mediastinal mass, they would want to fly with a doctor on board. The OSH obtained a lateral CXR, stated that it was a “complete whiteout,” and they were still unable to differentiate between fluid and a mass. The decision was made to err on the side of caution and a physician, paramedic, RN, and RT were sent via helicopter to obtain the patient. The patient was transported back with mask oxygen.

The patient was a direct admission to the PICU where he was placed on HFNC and a CT obtained. He was found to have left lung necrotizing PNA and empyema with culture growing S. pneumoniae. He was started initially on ceftazidime and vancomycin which was narrowed throughout hospital stay. A chest tube was placed and a VATS procedure was not required. He clinically improved and oxygen support was weaned. He was eventually discharged home on PO antibiotics with outpatient follow-up.

Teaching Points
We have to rely on the OSH for an accurate report of the patient status. If concerned, err on the side of caution in terms of priority level, transport modality, and transport personnel. Do not delay transport to obtain further labs/imaging in a concerning patient. If questions/concerns about a patient status or diagnosis, bring the patient to the ED to further determine management/disposition.