Dr. Paul Biddinger: Today’s case is that of a 73-yearold man involved in a motor vehicle crash (MVC). On arrival at the scene paramedics found an unrestrained driver sitting in the front seat of a car that had struck a telephone pole. There was moderate front-end damage to the car, a bent steering wheel, and a cracked windshield. The patient was awake and alert, breathing spontaneously, and appeared to be in significant pain. He spoke Spanish only. With imperfect translation at the scene by a bystander, the patient described vague anterior chest pain and shortness of breath. The patient denied loss of consciousness. He also denied extremity pain or weakness. The patient was placed on a backboard with a cervical collar, and an intravenous (IV) line was inserted. Vital signs in the field were: blood pressure 170/80 mm Hg, pulse 110 beats per minute, respirations 24 breaths per minute. The patient was transported to our facility without incident. Are there any questions about his prehospital course? Dr. Chris Richards: The patient complained of chest pain and shortness of breath, and was slightly tachypneic. What was the lung examination in the field? Were there decreased breath sounds unilaterally suggestive of pneumothorax? Dr. Biddinger: Breath sounds were described as equal bilaterally, with bibasilar rales present with the patient sitting upright in the vehicle. Dr. Robert Murray: Was there any knowledge of the patient’s past medical history or medications? Dr. Biddinger: The paramedics reported that the patient had a complicated medical history including atrial fibrillation (AF), coronary artery disease with bypass grafting 10 years prior, insulin-dependent diabetes mellitus, congestive heart failure (CHF), and history of a right upper pulmonary lobectomy for malignancy. The patient was maintained on Enalapril, Digoxin, and Warfarin. Dr. Chris Moore: Were there any skid marks at the scene? With any single-car MVC it is important to consider whether an underlying medical condition was responsible for the patient losing control of the car. Hypoglycemia, dysrhythmia, cardiac ischemia, syncope, seizure, cerebrovascular accident, or intoxication may have been the cause of the accident. Dr. Biddinger: There were no skid marks at the scene. The paramedics reported no alteration in mental status and no focal neurologic weakness. Blood sugar at the scene was 110 mg/dL. On arrival in the Emergency Department (ED), the patient was alert and appeared to be in significant distress. The airway was patent, and the patient was able to speak only in short sentences. He was also coughing up small amounts of pinkish sputum. Vital signs in the ED were: systolic blood pressure 100 mm Hg, pulse 134 beats/min, respirations 30 breaths/min. Auscultation of the patient’s lungs revealed crackles throughout all lung fields on both sides. The oxygen saturation was 81% on 100% oxygen by facemask. A second large-bore IV was placed. At this point the decision was made to intubate