Scenario For Bls Providers

[skyemt]

you are dispatched to an elderly female, difficulty breathing.

you arrive on scene, and find an elderly female, 78 y/o, sitting in a chair...
your general impression is that she is having labored breathing...
ALS was not available earlier, but you put out for an ALS crew...

she is alert and oriented, and denies much difficulty breathing, even though you see the s/s... you ask who called 911, and she tells you her daughter did, because she was concerned.

her airway is patent, seems to be breathing quick and shallow, with accessory muscle use... you hear wheezes bilaterally... her pulse seems a bit quick, but regular... you feel she is a high priority pt, so you want to get your history and get going...

so, time to assess...

what do you want to know...

 

[TheMowingMonk]

if there is a history of asthma or lung related issues

 

[KEVD18]

s-
a-
m-
p-
l-
e-

o-
p-
q-
r-
s-
t-

 

[skyemt]

there is no history of asthma of lung issues...

a- no allergies
m-no meds
p-no real hx... been relatively healthy
l-dinner last night
e-nothing special

o-woke up early in am, could "feel" gurgling in lungs
p-nothing makes it better
q-feels like "stuff gurgling"... pt states it is "very annoying"
r-none
s-5/10, but more of an annoyance
t-since early am

 

[LucidResq]

I'd start her on 02 via NRB @ 15 lpm.

What are her vitals? Including spo2 and temp. if possible? How's her skin? Breath sounds (more info than already given if there is any)

I'd examine the chest and maybe even her ankles for pitting edema - worth a shot.

Coughed up any junk?
Ever smoke?
Pleuritic pain?
Recent surgery, airplane trips?

 

[skyemt]

I'd start her on 02 via NRB @ 15 lpm.

What are her vitals? Including spo2 and temp. if possible? How's her skin? Breath sounds (more info than already given if there is any)

I'd examine the chest and maybe even her ankles for pitting edema - worth a shot.

Coughed up any junk?
Ever smoke?
Pleuritic pain?
Recent surgery, airplane trips?

pulse is 96 regular
BP is 92/64
RR is 30, shallow-- pt still denies being in resp distress
skin is pale, warm, dry
breath sounds- expiratory wheezes bilaterally

there is edema in the ankles, pt states that edema is normal for her

no junk coughed up
no hx of smoking... no pleuritic pain, no recent surgeries, or plane trips

 

[LucidResq]

Her vitals are concerning. It sounds like it might be a pulmonary embolism, but it could be several other things. The treatment will be the same regardless. Considering her respiratory rate and depth I would strongly consider bagging her. I would load and go unless ALS was nearby. Position of comfort... reassess vitals every 5 min. or so. Keep a close eye on her airway and mental status. Prepare to ventilate, suction, and defibrillate.

Where's the daughter by the way? Does she have anything to say?

 

[skyemt]

Her vitals are concerning. It sounds like it might be a pulmonary embolism, but it could be several other things. The treatment will be the same regardless. Considering her respiratory rate and depth I would strongly consider bagging her. I would load and go unless ALS was nearby. Position of comfort... reassess vitals every 5 min. or so. Keep a close eye on her airway and mental status. Prepare to ventilate, suction, and defibrillate.

Where's the daughter by the way? Does she have anything to say?

the daughter is present, btw, if you want to ask anything...

didn't mention the spo2, which was 95 on 100% O2 15 lpm via NRB

you seem fixated on PE, when there is really no indication of that... and it is not a PE...

you have a patient who is able to talk and tells you she is not in resp distress... she is obviously tolerating the rapid resp rate... why in the world would you bag her now... you would not...

if it's asthma, you could call for albuterol... if it's not, then you wouldn't...but, the treatments are NOT the same...

this scenario is about thinking... so what are we thinking? what could it be? what more info could we get?

 

[LucidResq]

the daughter is present, btw, if you want to ask anything...

didn't mention the spo2, which was 95 on 100% O2 15 lpm via NRB

you seem fixated on PE, when there is really no indication of that... and it is not a PE...

you have a patient who is able to talk and tells you she is not in resp distress... she is obviously tolerating the rapid resp rate... why in the world would you bag her now... you would not...

if it's asthma, you could call for albuterol... if it's not, then you wouldn't...but, the treatments are NOT the same...

this scenario is about thinking... so what are we thinking? what could it be? what more info could we get?

I have a reason to be concerned about PE. Hmmm... sudden-onset dyspnea, tachycardia and edematous legs in an elderly (and likely inactive) woman... of course PE crosses my mind.

Considering as a basic I can't diagnose and my meds for respiratory distress are albuterol and epinephrine if they're prescribed to the pt and she doesn't take either of those drugs, my treatment for her respiratory distress is going to essentially be high flow o2 and rapid transport regardless of the cause.

I would just want to ask the daughter why she called, if she's noticed anything over the past couple of days, and if her mother has any meds/history that she's not telling me about.

There's no sense in hanging around on scene forever trying to figure out exactly what's wrong when my treatment is probably not going to be significantly affected and the woman obviously needs definitive assessment and care at a hospital immediately.

 

[piranah]

well...there is gurgling in her lungs.....fluid?..and wheezing on expiration...possibly a narrowing of the upper airway and maybe some fluid retention issues shes never had checked out...but as a BLS provider in RI i would put her on NRB 15 lpm and transport because in my area your only 20 min to nearest hospital..maybe a allergic reaction....hey there always CHF...

 

[skyemt]

I have a reason to be concerned about PE. Hmmm... sudden-onset dyspnea, tachycardia and edematous legs in an elderly (and likely inactive) woman... of course PE crosses my mind.

Considering as a basic I can't diagnose and my meds for respiratory distress are albuterol and epinephrine if they're prescribed to the pt and she doesn't take either of those drugs, my treatment for her respiratory distress is going to essentially be high flow o2 and rapid transport regardless of the cause.

I would just want to ask the daughter why she called, if she's noticed anything over the past couple of days, and if her mother has any meds/history that she's not telling me about.

There's no sense in hanging around on scene forever trying to figure out exactly what's wrong when my treatment is probably not going to be significantly affected and the woman obviously needs definitive assessment and care at a hospital immediately.

ok... keep in mind, different basics can do different things... in my system they can do albuterol treatment for resp distress...

as far as the daughter, she called because last night, the daughter also had a syncopal episode...

the issue of onset was not asked, but, it was sudden... she felt no distress before it woke her up out of her sleep...

also, keep in mind that scenarios are also about critical thought, as well as treatments... while your treatment of the patient may not change, you should be assessing for possible underlying causes.

any last guesses?

 

[AZFF/EMT]

Did you say the daughter had a sycopal episode?

 

[skyemt]

sorry, botched sentence...

the daughter called because the mother had a syncopal episode...


did you ever type something, then look back and say how the he** did that get there???

sorry...

 

[AZFF/EMT]

I do it all the time. I started thinking possible CO poisoning but then her sats would actually read higher.

If I were a BLS provider I would call for ALS no doubt. High flow O2 and transport. I am lucky an we are never without ALS. all mixed crews 50-50 medics and emts.

I would want a Blood sugar for sure.

Does the wheezing get better with O2?
If not consider SVN albuterol.

where exactly is the pain and gurgling?

Possible stomach issue, food poisoning?

 

[skyemt]

this was an actual call, and the presentation was accurate.

the diagnosis was CHF (no prior hx) presentation secondary to a left sided AMI.

the real point of this scenario is to emphasize the awareness of atypical presentations, especially for women, the elderly and diabetics.

we must be aware of this when assessing.

throughout all the replies, possible cardiac was not really considered.

in reality, this woman was suffering the effects of an MI.

hope it is food for thought, if you encounter a similar patient.

thanks for playing.

sudden onset of symptoms that woke her out of her sleep was significant, as was the syncopal episode. also, while peripheral edema was normal for her, it was much worse than it had been (would not have known that without asking in detail about it).

 

[AZFF/EMT]

I guess thats the benefit of never running BLS only calls. This patient would have gotten a 12 lead. I always find it hard to go through BLS scenario's online. It's much easier and fluid in real life. Seeing the patient. Where was her pain? Where did she point when describing it? If it was anywhere near her chest and with ECg interpretation she would have got O2, ASA and transport, possiblly lasix.

I originally thought from the start CHF due to the wet lungs and edema, but got way off track.

Did you get to see an ECG? what did it show?

 

[skyemt]

I guess thats the benefit of never running BLS only calls. This patient would have gotten a 12 lead. I always find it hard to go through BLS scenario's online. It's much easier and fluid in real life. Seeing the patient. Where was her pain? Where did she point when describing it? If it was anywhere near her chest and with ECg interpretation she would have got O2, ASA and transport, possiblly lasix.

I originally thought from the start CHF due to the wet lungs and edema, but got way off track.

Did you get to see an ECG? what did it show?

this was not an easy call... thing was, despite the s/s of resp distress, she only would call it an "annoyance", and kept denying distress...

she denied any pain whatsoever, and nothing near or in her chest... no pressures, nothing. i did not get to see the ECG, but was told it was inconclusive...
also, there was no history of CHF, so not easy to treat it that way. tests done in the ED revealed MI...

 

[AZFF/EMT]

nice. well proper treatment would have just been. O2, position of comfort and drive. good job.

 

[certguy]

Rats ! I didn't get to play before you closed it , but CHF was my guess , this was a good scenerio . Guys , don't get too focused on waiting for ALS when you can scoop -n-haul with a possible intercept on the way . The way she was describing the discomfort should've cued me off on a possible MI too .



Craig

 

[Vizior]

this was an actual call, and the presentation was accurate.

the diagnosis was CHF (no prior hx) presentation secondary to a left sided AMI.

the real point of this scenario is to emphasize the awareness of atypical presentations, especially for women, the elderly and diabetics.

we must be aware of this when assessing.

throughout all the replies, possible cardiac was not really considered.

in reality, this woman was suffering the effects of an MI.

hope it is food for thought, if you encounter a similar patient.

thanks for playing.

sudden onset of symptoms that woke her out of her sleep was significant, as was the syncopal episode. also, while peripheral edema was normal for her, it was much worse than it had been (would not have known that without asking in detail about it).

So, I gotta ask you:

if this is a scenario, what was supposed to tip us off to the outcome? I don't see how it is thought provoking to go through a scenario that is completely "atypical". I bet that some of the higher educated members here can present cases that present almost identical to this with completely different diagnosis.

And so, in your scenario, when someone suggests something, you immediately tell them that they're completely wrong(like suggesting a Pulmonary Embolism, or to consider bagging the patient, both perfectly logical considerations.)

So just out of curiosity, what did you do for the pt and what did you think it was... and why?