# AMS Female



## Shishkabob (Jan 31, 2010)

You are dispatched to the home of an 80y/o female.  RP states that patient is having difficult breathing.  Upon arrival, you see group of family members and what appears to be a couple of people who look healthcare related, huddled around a hospital type bed.  The patient is lying supine in the bed connected to a BiPap machine.  PTs eyes closed and doesn't notice your arrival.




Go.


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## MrBrown (Jan 31, 2010)

Have one officer ask the family what happened, history, who these healthcare type people are (could they be the naughty nurses from the bachelor party next door for example?) and gather a bit of info

Other officer; primary survey/GCS and do a respiratory assessment

What have we come up with?


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## Shishkabob (Jan 31, 2010)

80yo female with history of COPD, lung cancer, and has been bed ridden for the past 6 years.  Daughter states she came in and "the machine was beeping and my mom wouldn't wake up", so she called the moms caretaker (LVN).  When the LVN arrived, she told the daughter to call 911.  


Second partner finds an elderly female laying supine in bed on a BiPap machine.  Pt is breathing shallow and rapid at about 25 times a minute.  Pt is responsive to pain.  GCS of 8..  Pulse in the 70's.


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## MrBrown (Jan 31, 2010)

Have one officer find out what the mother's wishes are regarding care and get one of her doc's on the phone while the other does a more focused assessment; recent history, SPO2, breath sounds, work of breathing, temperature, odour of breath etc

We don't carry CPAP and I only have a limited understand of the technical workings (I understand the physiologics just fine) so that why I want her GP or pulmonologist on the phone so I can talk to him about how the gizmo works.

I am thinking it's a COAD exacerbation but could be a chest infection or DKA or you know, one of other 398 causes for "altered with tachypnea"


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## Veneficus (Jan 31, 2010)

*sounds like it is time to break out the benzos and opiods*

With a history of cancer, the type would be important to find out.

There are several neoplastic syndromes associated with various lung ca.

To include a short list of paraneoplastic sydromes secreting unregulated:
ADH
ACTH
Parathyroid (including prostaglandin E and cytokines)
Calcitonin
gonadotrops
serotonin
bradykinin

In addition to the usual respirtory suspects.

I would definately think a temperature is in order as well as sputum or other secretions, but it sounds like this one is very near the end. 

Please when posting a scenario, it really helps to have some findings.

It would also be very lucky if the healthcare looking providers were the naughty nurses from the bachelor party. I never get bystanders like that


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## medichopeful (Jan 31, 2010)

MrBrown said:


> I am thinking it's a *COAD *exacerbation but could be a chest infection or DKA or you know, one of other 398 causes for "altered with tachypnea"



In the interest of learning more, can you elaborate on what "COAD" is?  I searched it on Google but it didn't turn anything up.

I'm guessing it may just be a typo. :wacko:


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## Melclin (Jan 31, 2010)

Chronic Obstructive Airway Disease. Also known as COPD (CO-Pulmonary-D). 

http://www.merck.com/mmhe/sec04/ch045/ch045a.html

-I would like to know more about her normal state and whats different from normal from her daughter if possible.

-If the machine is alarming, is there a message popping up on the screen with a helpful animated paper clip directing me?

-Whats the go with her doctors? Can we get anything out of them as too what we should do or anymore information on her condition. (Her normal vitals would be helpful too)

-Has she got any paperwork explaining her situation, advance directives for treatment/resus etc. (Again any infor on normal vitals?).

- What medications is she on, what is her normal regime and has it altered at all today.

-What are all her current vitals? I'd also like a BSL and I'll chuck the monitor on as well.

Seems like this may be one of those jobs where the family are more our pts than the woman in question. Our tea brewing skills may prove to be the most important in this case.


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## redcrossemt (Jan 31, 2010)

I'd take this patient OFF of the BiPap machine to assess her. We don't know if perhaps the BiPap is failing and that's why the patient is crashing. Put her on a NRBM while you assess and decide whether or not you'll continue pressure support.


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## MrBrown (Jan 31, 2010)

Melclin said:


> Seems like this may be one of those jobs where the family are more our pts than the woman in question. Our tea brewing skills may prove to be the most important in this case.



I highly suspect so; its a shame Frank never taught us that


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## Melclin (Jan 31, 2010)

MrBrown said:


> I highly suspect so; its a shame Frank never taught us that



Haha. It's an underated skill for a paramedic. We should have Cuppa Brewing OSCEs.

I'm seeing him today, I'll ask him if he's got anymore old lecture videos kicking around


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## MrBrown (Jan 31, 2010)

Melclin said:


> Haha. It's an underated skill for a paramedic. We should have Cuppa Brewing OSCEs.
> 
> I'm seeing him today, I'll ask him if he's got anymore old lecture videos kicking around



I'm not on til Thursday, what to do at 2am when wide awake? Watch Frank explain chest pain! 

Some people seem to forget a cup of tea and a chit chat are in thier scope of practice and it's probably one of the easiest, most effective things ambo's can do.

How is our patient looking? Any more info?


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## Shishkabob (Jan 31, 2010)

Answers to Melcin in order:

Daughter states that the mom is usually aware of her surroundings.

Just beeps.

No doctors able to be reached.  RT is headed to the house, but 15 minutes away.

PT has a valid DNR.

HR is 74, bp is 152/88, resp are high/shallow.  Breath sounds clear on the right, absent on the left.  BGL is 100.  Monitor shows NSR, no abbarency/ectopic beats.  Matches pulse felt. Pulse ox is 72%


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## PrincessAnika (Jan 31, 2010)

DNR does not mean do not treat....
what meds is pt on?  any recent illness/infection?  any recent falls or head trauma??
the o2@72% could be contributing to the AMS.  absent lung sounds could be contributing to that - where is the CA exactly? does the pt even HAVE a left lung? what is her normal sat??
pt/POA/family wishes for treatment/transport?
transport to closest appropriate facility, RX high flow O2 supporting resps as needed, EKG, IV TKO, monitor vitals....


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## mycrofft (Jan 31, 2010)

*Tox screen after pulse ox.*

With VS consistent with life, but a "beeping machine", you could be looking at mechanical suffocation (the machine), airway obstruction (food bolus or refluxed feeding from NG tube), overdose.

Six _*years*_ with lung cancer?? Check the pillows for lipstick.


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## Melclin (Feb 1, 2010)

Linuss said:


> Answers to Melcin in order:
> 
> Daughter states that the mom is usually aware of her surroundings.
> 
> ...



Lets ditch the Bi-pap. Depending on just how shallow the pts resps are we'll assist her vents or chuck a face mask on, see if we can raise the SpO2, which shouldn't be to hard if the problem turns out to be that the that the Bi-pap machine wasn't working properly (I should probably hold off on asserting that until Vent has her say  ). 

How does the chest expansion look? Clear and equal breath sounds bilaterally to all lobes?

Anyway, while we're giving that a try, its *AEIOU TIPS* time I reckon:

-_Alcohol_ - probably a fairly reasonable assumption that she hasn't drunk herself into a coma, but lets have a whiff of her breath and have a quick look around for empties.

-_Endocrine, Electrolytes, Encephalopathy _- I don't know enough about endocrine problems to do anything about that. Hows her diet and fluid I/O been lately (?hyponatremia)

-_Insulin_ - We addressed BSL.

-_Opiates, O2 _- We're addressing the O2 issue. Given the resps its prob not a opiate OD by itself at least. Lets have a look at her pupils and whats her pain management schedule? (? polypharm OD).

-_Uremia_ - any hx of kidney problems? Is she on any corticosteroids?

-_Toxins, Trauma, Temp _- Quick look for any head trauma, buts its a long shot. Lets grab a temp.

-_Infection _- hx of being unwell? Has she got an IDC? Any bed/pressure sores? We already got a temp.

-_Psych _- probs not that. But how's she been feeling about the impending death? (? Intentional polypharm OD).

-_SOL, Stroke_ - Already checked pupils. Nothing much else I can do I suppose. Any obvious differences in muscle tone or unilateral responses to pain? (maybe sorta ? pontine haemorrhage)

EDIT: Mycrofft : wasn't the primary survey clear? It better not be another bloody FBAO. I hates em, I does.


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## MrBrown (Feb 1, 2010)

PrincessAnika said:


> any recent falls or head trauma??



I am not sure, she has been in bed for the last six years hmmmm ........



PrincessAnika said:


> DNR does not mean do not treat....



No but it does clearly signify this patient has wishes about thier care and that they have a terminal illness or other problem where treatment or resuscitation is not in thier best interests.

It's inappropriate to treat this patient so to pronlong life rather than to relieve pain or suffering.  IV fluid, assisted respirations, CPR, defibrillation etc are examples of things that are not in the best interest of the patient whereas supportive care and pain relief for example, are not.



PrincessAnika said:


> pt/POA/family wishes for treatment/transport?
> transport to closest appropriate facility, RX high flow O2 supporting resps as needed, EKG, IV TKO, monitor vitals....




Family do not have a right to decide on transport or treatment, they are not the patient.

It is probably inappropriate to transport this patient to the hospital they are almost certianly near the end of thier life and it would be far better to recommend non transport and allow them to pass at home. 

What is the point of starting an IV? So you can bill the patient for an "advanced" procedure? There is nothing magic about IV fluids and (like oxygen) they are mostly given to patients who do not require them and/or quantities above what is required.

Somebody who flexes purposfully when they are subjected to a sternal rub could be chalked up as "aware of thier surroundings" it doesn't really mean much to me to be honest.

If we take mum off CPAP we risk bottoming out her AVR and worsening the respiratory distress.  I'm going to keep her on CPAP and gain some more info from the family about what her normal status is and probably call my Team Manager (who is also an Intensive Care officer) as I am not overly comfortable in this situation because it is not one I have a lot of experience with.

I think the most appropriate course of action is to wait until my OTM and the RT turn up, talk with them, support the family and perhaps look at some pain relief, talk to her primary or pallative care team and recommend non transport.


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## Aidey (Feb 1, 2010)

PrincessAnika said:


> DNR does not mean do not treat....



That depends on the DNR. There are some more in-depth advanced directives that including directions for what types of treatment the patient does or doesn't want. For example, they may specify no intubation, tube feeding, or IV access unless the IV is for pain control. 

I've seen directives that have a "pallative care only" section, and if that is what the patient has selected we are not allowed to do ANY invasive care at all unless it is for pain management or the pts comfort. 



Back to the scenario, do we have equal and bilateral chest rise? With a history of lung cancer, possibly multiple chest surgeries and what appears to be continuous bi-pap use the pt is at risk for a spontaneous pneumo.


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## Melclin (Feb 1, 2010)

MrBrown said:


> It's inappropriate to treat this patient so to pronlong life rather than to relieve pain or suffering.  IV fluid, assisted respirations, CPR, defibrillation etc
> 
> 
> I think the most appropriate course of action is to wait until my OTM and the RT turn up, talk with them, support the family and perhaps look at some pain relief, talk to her primary or pallative care team and recommend non transport.
> ...



That only applies to the condition about which the NFR/DNR is signed. If she's dying of cancer, then that's fine. But if she's dying because something went wrong with her bi-pap machine, then you have a responsibility to do something about it (at least, I think that's the deal here). That said, I wouldn't feel comfortable doing the whole kit and caboodle, but topping up her resps to see if its an issue of hypoxia, I can deal with. I think you're right about waiting for the RT though. If she's stable enough, then we can probably wait for 15 mins for the RT. It'd probably take that long to get all the info I asked for in the first place.


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## MrBrown (Feb 1, 2010)

Melclin said:


> ...If she's stable enough, then we can probably wait for 15 mins for the RT. It'd probably take that long to get all the info I asked for in the first place.



Now might be a good time to see who takes milk and/or sugar .....


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## PrincessAnika (Feb 1, 2010)

unless my state-recognized out-of-hospital dnr specifically states what care is desired, i do everything but resuscitate.
here's my protocol:
______________________________________
Criteria:
A. Patient displaying an Out-of-Hospital Do Not Resuscitate (OOH-DNR) original order, bracelet, or necklace who is in cardiac or respiratory arrest.1
Exclusion Criteria:
A. Patient does not display, and patient surrogate does not produce, an OOH-DNR original order, bracelet, or necklace.
B. An OOH-DNR order may be revoked by a patient or their surrogate at any time. If the patient or surrogate communicates to an EMS practitioner their intent to revoke the order, the EMS practitioner shall provide CPR if the individual is in cardiac or respiratory arrest.
C. Advance directives, living wills, and other DNR forms that are not valid Pennsylvania Department of Health OOH-DNR orders may not be followed by EMS personnel unless validated by a medical command physician. When presented with these documents, CPR / resuscitation should be initiated and medical command should be contacted as soon as possible.
____
notes: 2. An OOH-DNR order, bracelet or necklace is of no consequence unless the patient is in cardiac or respiratory arrest, if vital signs are present, the EMS practitioner shall provide medical interventions necessary and appropriate to provide comfort to the patient and alleviate pain unless otherwise directed by the patient or a medical command physician. Follow appropriate treatment protocols.
_________________________________________

so based on my protocols, thats what i'm sticking with.  and under state laws if it is not a PA DOH OOH-DNR, its not valid.  granted i'm not gonna be aggressive, but yeah.  start BLS, go ALS if needed....


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## Aidey (Feb 1, 2010)

I wasn't saying don't follow your own protocols, just that "DNR doesn't mean do not treat" doesn't apply to everyone. In some places, it does mean do not treat. Or at least do not do certain treatments.


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## MrBrown (Feb 1, 2010)

Sounds like defensive medicine at it's best.

By contrast, this is what we are given



> [It is inappropriate to commence] resuscitation [from cardiac arrest when it] is either futile or not in the best interests of the patient e.g. unwitnessed cardiac arrest with asystole as initial rhythm, patients who are dying from cancer, and patients with severe end stage chronic medical conditions (e.g. end stage heart failure or end stage COAD) who are house bound.
> 
> 
> *6.8 PALLIATIVE CARE*
> ...


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## CAOX3 (Feb 2, 2010)

Sniff test?

Im going with UTI.

Now give me my prize.


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## RDUNNE (Feb 8, 2010)

The only thing I dont recall seeing covered......Is there O2 in the tank?


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