# I Can't Breathe! Help Me!



## Sasha

Today I had a clinical. 

I thought I had lost my black cloud because we spent almost the entire clinical sitting around the station only leaving to pick up supplies from the main station. But at 7ish the tones FINALLY go off. 78 year old Difficulty breathing. I LOVE respiratory calls, I think the respiratory system is so interesting and amazing and it was my favorite chapter in our book. 

Every respiratory call I've been on has been classic book patients. one or two worded sentences or something along those lines, helped by a mask, etc. We get there and the woman is screaming "I CANT BREATHE I CANT BREATHE" and grabbing and pulling at anything and everything. And she looked like crap. Cyanoticish, fingers were cold, tripoded, in general distress.

Her family standing around screaming at us to help her while we were on scene, etc. I had never had someone yell and scream at me like that before on clinicals. I got so stupid and clumsy due to nervousness. We were putting her on the stretcher while trying to put a NRB on her, which was promptly ripped off because she felt it was suffocating. Tried a Nasal cannula but it wasn't giving her ENOUGH air. In the truck we tried to give her a combivent, tried to coach her into inhaling it in deep breathes but she wouldn't take it because she felt like she was suffocating. I kept trying to get her to take take the combivent because I couldn't think of what to do next. Then we got to the hospital. The nurses weren't happy because in all of it, making a radio report had slipped my mind (and my preceptor didn't remind me, citing "Everyone has got to make that mistake sometime. Better to experience the scorn while you're still a student!")

I hate the helpless feeling of not being able to effectively treat the patient and get them to the hospital in BETTER condition. At the hospital we were rejoined by her family who just saw the "STUDENT" written on my shirt and the daughter flipped out, yelling at me and the preceptor that if her mother dies it would be because of the incompetence of a student treating a serious emergency and she would sue us both.

After that call, my preceptor let me go home early ( I don't know if it was because I was upset because I tried not to make it outwardly obvious or if it was because he didn't want to give my black cloud a chance to bring him another call.) 

What would you have done for this call? Driving home I could kick myself as I started remembering what else could have been done. Solu-Medrol, Mag Sulfate, CPAP. ARGH!

Ask questions, and I'll answer to the best of my ability. Help me learn from this!


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## HasTy

Wow Sasha I probably would have cried and been extremely pissed off at the family when I got back to the station...I am also not sure it was fair for your preceptor to send you home early all that does is hurt your education and hinder your self confidence...


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## VentMedic

Welcome to my world. 

This is one of the reasons I became a Respiratory Therapist. There was so much I didn't know and wasn't able to do as a Paramedic to understand and help someone in respiratory distress.

At least I didn't say EMT so this shouldn't get the thread locked.


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## MSDeltaFlt

Sasha said:


> Today I had a clinical.
> 
> I thought I had lost my black cloud because we spent almost the entire clinical sitting around the station only leaving to pick up supplies from the main station. But at 7ish the tones FINALLY go off. 78 year old Difficulty breathing. I LOVE respiratory calls, I think the respiratory system is so interesting and amazing and it was my favorite chapter in our book.
> 
> Every respiratory call I've been on has been classic book patients. one or two worded sentences or something along those lines, helped by a mask, etc. We get there and the woman is screaming "I CANT BREATHE I CANT BREATHE" and grabbing and pulling at anything and everything. *And she looked like crap. Cyanoticish, fingers were cold, tripoded, in general distress*.
> 
> Her family standing around screaming at us to help her while we were on scene, etc. I had never had someone yell and scream at me like that before on clinicals. I got so stupid and clumsy due to nervousness. We were putting her on the stretcher while trying to put a NRB on her, which was promptly ripped off because she felt it was suffocating. Tried a Nasal cannula but it wasn't giving her ENOUGH air. In the truck we tried to give her a combivent, tried to coach her into inhaling it in deep breathes but she wouldn't take it because she felt like she was suffocating. I kept trying to get her to take take the combivent because I couldn't think of what to do next. Then we got to the hospital. The nurses weren't happy because in all of it, making a radio report had slipped my mind (and my preceptor didn't remind me, citing "Everyone has got to make that mistake sometime. Better to experience the scorn while you're still a student!")
> 
> I hate the helpless feeling of not being able to effectively treat the patient and get them to the hospital in BETTER condition. At the hospital we were rejoined by her family who just saw the "STUDENT" written on my shirt and the daughter flipped out, yelling at me and the preceptor that if her mother dies it would be because of the incompetence of a student treating a serious emergency and she would sue us both.
> 
> After that call, my preceptor let me go home early ( I don't know if it was because I was upset because I tried not to make it outwardly obvious or if it was because he didn't want to give my black cloud a chance to bring him another call.)
> 
> What would you have done for this call? Driving home I could kick myself as I started remembering what else could have been done. Solu-Medrol, Mag Sulfate, CPAP. ARGH!
> 
> Ask questions, and I'll answer to the best of my ability. Help me learn from this!



OK, what were the breath sounds?  Were they Rales?  Or were they wheezes?  Because the breath sounds on this patient will dictate the course of action.  

Wheezes will warrant bronchodilators (Combivent, Albuterol, Solu-Medrol, MgSO4, yadda, yadda, yadda) because they mean bronchospasm.  Bronchospams need to be stopped.  OK, the Solu-Medrol isn't a bronchodilator, but it decreases the inflamation associated with bronchospasm.  

Rales will warrant CPAP and NTG (with a high enough MAP) because they mean fluid.  Fluid needs to be pushed and/or pulled out of the lungs.

Now this may be stating the painfully obvious even to a student, but even us old dawgs need reminding every now and then.


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## VentMedic

HR/sounds (between yells)
BP
RR
Breath sounds
Edema
Hx
Meds
onset


Look also at the cardiac status. Anything that presents a sudden change in cardiac output will give the same sufficating feeling. Rapid A-fib, ventricular rhythms and MI may have a person stating they can't breathe even if you hear them screaming which indicates some air is moving but not being distributed. Pulse and electrical HR may also be totally different.

COPD or any chronic lung hx? Blebs? Pneumo possibitity? If so, CPAP might not be a good idea. And, COPD can have several cardiovascular disorders to accompany it such as cor pulmonale, Pulmonary HTN and PVD.

The CPAP may also not have been tolerated since she didn't like a mask. The prehospital machine may not have provided enough flow to meet her demands. Redistributing the fluids by decreasing preload and afterload may improve breathing if the BP supports it. But, more agitation may make breathing worst. The hospital may use BIPAP (Respironics trade name) or one of the newer modes and knock her down (sedation and blow down PaCO2 if needed) a little if the EKG and CXR warrants. 

The blood work up including a BNP (CHF) and an ABG showing acid/base as well as oxygen/ventilation will determine the next moves. The lactate level will be an indication of sepsis and a bilateral PNA will also qualify for the protocol. 

Depending on the success of the hospital technology and the diagnostic findings, she may get an ETT. 

And yes there will be combinations of exacerbation, CHF, PNA and rapid A-fib or all of these on some chronic lung patients. You can also toss in sepsis to that mess also.   General statement since you didn't include her history yet.


Check out the links I posted on the Definitive care thread about V/Q mismatching and shunting.

BTW, preceptors are also there to guide you. If you appear to be stuck or heading off the path, they are there to get you back on track...not leave you and the patient hanging. This would also include a reminder to call the hospital. You should not expected to be expert at everything yet. 

Was there a review of the call with the preceptor and/or your instructor after the call?


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## Aidey

VentMedic said:


> The CPAP may also not have been tolerated since she didn't like a mask. The prehospital machine may  not have provided enough flow to meet her demands.


  Vent beat me to it, but this is what I was going to say. I have asthma, and while I don't have attacks very often, when I do have them they are bad bad, and I turn into your patient. The last one I had was in Paramedic school, and I perfectly understood what as going on and I still ripped off the NRB, threw my (ringing) phone at the medic, and was generally a pain in the arse. I'm about 99% sure I would have just ripped off a CPAP mask also.   Mag is also only indicated if it's status asmaticus, refractory to other treatments. If she was suffering form something like flash pulmonary edema, steroids wouldn't have been much help either.  Given how vocal your patient was, I think Vent made a very good point about how she may have been moving air fine, but it wasn't able to oxygenate the blood adequately.


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## Veneficus

While I defer to Vent as the expert on this, one thing I have not seen come up here is the possibility of PE. Those patients usually seem to be able to speak, yell, fight off 6 firemen trying to calm them down, etc.

Some people will tell you that any patient who can talk can breathe. I call BS on that one. Perhaps the mechanics of breathing are intact, but the respiration is not. I never one saw a patient screaming “I can’t respire!” There has to be blood moving to get O2 and CO2 where it needs to go and gas exchange at the cellular level. 

Unfortunately, many people who have a massive PE do not live. There was a NEJM article some months ago about a young female who had one and was discharged from one hospital to almost die when she went to another. (Sorry guys I am too busy to search through weeks of publications for the article right now If the day goes well, maybe I will get to it.) She lived with long tern health consequences.

The bright side is that there is nothing EMS is going to do for that other than turn wheels, so you probably didn’t forget anything.  Your receptor might not have been overly aggressive at directing you because he may have been thinking PE as well. 
As for the family, anger is a normal reaction in some. Even some patients don’t take help too kindly. Certain ethnicities are known for becoming angry at care providers no matter what is being done (or not done) too much house and ER for them. 

Emergency patients are like boy(girl)friends. Nothing gets you over the last one like the next one.


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## Outbac1

The question is WHY can't she breath. As others have said there are a number of possibilities. I'll go for now with constriction and wheezes as you were treating with a combivent. It doesn't appear your preceptor was trying to change your treatment so I'll assume they were in agreement. If they weren't in agreement they should have pointed you down a different path. They are still responsible for the proper treatment of the pt. 
   Sometimes it is hard to get pts calmed down enough to accept the mask no matter how hard you try. A nasel isn't going to give a pt like that relief but it won't hurt to have it under the mask. Even keeping the mask near their face can be of benefit to open their airway so they feel like they are getting more air. When they get tired enough they will more easily accept Bipap or Cpap and may even need to be intubated. 
   I probably would have started the combi in the house rather than just an NRB. Sometimes if the pt and family know you are trying to give a medication rather than just O2, they are more tolerant of your efforts. They see it as trying to actually do something for the pt. This can turn the family on your side and they will often try to encourage the pt to accept your help. 
    As to the family, sometimes you have to tune them out. I know easier said than done. Sometimes involving the family by asking them questions about the pt calms them. The pt probably can't answer your questions anyway. If the pt was still fighting at the hosp she wasn't that worn out. 
   If your preceptor is any good and wasn't concerned about the pt to intervene, I wouldn't beat myself up about it. Their job is to guide you. Let you stumble but not let you fall. Why did your preceptor let you go home early? How early, 2hrs or 20min? Have you talked to your preceptor about the call? If so what did they say about it? 
   So you forgot a radio patch, welcome to the club. Sometimes if I'm busy in back I'll get my partner to call it in. 

  Some more info on the pt hx, assessment and tx at the hosp would be nice to know.


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## VentMedic

If she has a chronic lung history, there is a good chance she had already been doing inhalers and/or nebs prior to that. If they have had little effect, unless her techniqued was really bad or the inhaler expired long ago, it is time to think of Plans B, C and D. 

Although the anticholinergic is very important to some COPD patients, too much of a good thing may not be so good. I'll serve up albuterol all day and all night but I rarely will go beyond q4 hours on the anticholinergic and that depends on if the patient has the long acting like Spirva on board.  Of course, your protocols may vary.  

I suggested referring to the links I had posted previously for V/Q mismatching or shunting because the list is very long and it could be anything thing along with everything else. However, A,B,C is still the concern. At the Paramedic level you do have more options to alleviate some things to maintain hemodynamic stability. 

At the moment she is ventilating although it is unknown how effective the gas exchange is except by color, mentation and her vocalizing her symptoms. 

SpO2 readings may not reflect her true state of difficulty since a patient will try to increase their minute volume to compensate. This is especially true with Pulmonary Embolus and some PNAs. 

Circulation: As a Paramedic, you may be able to alleviate abnormal cardiac rhythms which may be decreasing cardiac output. In the cases of Pulmonary embolus, PNA, and/or sepsis, you have the ability through fluids and pressors to maintain MAP for BP. Chronic lungs patients need their fluids balanced to have adequate circulation. Too much is a problem and too little is a problem. You should have protocols for each to do what you must to maintain stability. If you find evidence of an MI, you can start your protocols for that also. But, your goal is still to maintain hemodynamic stability. No one should expect you to pinpoint the exact cause and identify all V/Q mismatches in the field but those problems that can be assessed can be treated to keep stability. Read through all of your protocols and you will find similarities. While one working dx is great but patients are medically complex with many different problems at one time with each exacerbating the other. Yet, the initial management is identifying what you can assess, prioritize, alleviate or initiate treatment and establish some stability.


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## VentMedic

Outbac1 said:


> The question is WHY can't she breath. As others have said there are a number of possibilities. I'll go for now with constriction and wheezes as you were treating with a combivent.


 
Are those of you north of the border keeping Combivent in Canada?  Just curious since it was the Montreal Protocol that changed all the MDIs.  Unfortunately in the U.S. some of the newer inhalers are out of reach due to  cost and insurance coverage.   

Those who are assisting pts with their meds, especially the inhalers, need to learn the correct way(s) for the new HFA inhalers.  That goes for both priming and technique.

Apologies for the off track info message.


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## Sasha

*HR/sounds (between yells)-* 130/min
*BP*- I don't remember specifically but it was somewhere in the 180s systolic.
*RR*-28/min
*Breath sounds-* Wheezes.
*Edema-* Her lower legs had pitting edema but her family said that was normal for her
*Hx-* TIA, CAD, COPD, hypothyroidism, HTN, hyperlipidemia, diabetes.
*Meds-* Warfarin, synthroid, metformin, lipitor, spiriva, some others I can't remember. But family said she had been noncompliant with meds.
*Onset-* About 10 minutes before they called, don't know what she was doing and of course, I forgot to ask what she had been doing.



> Was there a review of the call with the preceptor and/or your instructor after the call?



No, not really. When we got back to the station he asked for my log book, signed off and said I could leave. On the way back to the station he was talking about having better scene control.

I do plan on calling him so we can go over it later today and I wanna know if he went back to that hospital later and if so how she's doing.



> If you appear to be stuck or heading off the path, they are there to get you back on track...not leave you and the patient hanging.



His philosophy is that he is there so I don't hurt or kill anyone, and can ask questions after, citing the fact that (while my school sucks and I'm nowhere near ready) I'm almost done with medic school and will be out by myself when there wont be anyone to remind or reguide.



> too much house and ER for them.



You can't be knocking House!


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## VentMedic

Sasha said:


> His philosophy is that he is there so I don't hurt or kill anyone, and can ask questions after, citing the fact that (while my school sucks and I'm nowhere near ready) I'm almost done with medic school and will be out by myself when there wont be anyone to remind or reguide.


 
How sad that there is little mentorship but rather, what harm can a student Paramedic do philosophy.   His philosophy does not promote learning but rather a "fly by the seat of your pants" mentality and get them to the hospital.    The fact that you are nowhere near ready could be due to a lazy preceptor.   

When given the responsibilty of precepting, it is huge because if that student or trainee is not ready, if reflects back to the preceptors abilities and readiness to identify your weaker areas to see what can be done to develop strengths.   He is assuming the school is providing all the information but doesn't seem to understand his responsibility to see the knowledge from the school is adequately applied directly to patient care in the field.


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## Sasha

> How sad that there is little mentorship but rather, what harm can a student Paramedic do philosophy. His philosophy does not promote learning but rather a "fly by the seat of your pants" mentality and get them to the hospital. The fact that you are nowhere near ready could be due to a lazy preceptor.



That's not so shocking. My entire experience with paramedic school has been "sad". Nothing has promoted learning but rather a "pass the test, get out there, then you'll learn" mentality. The nowhere near ready is a culmination of things, and not soley the preceptor. I've learned a lot from his preceptorship, though. Probably more than I've learned in class.


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## Veneficus

wasn't knocking House, was pointing out the mentality that on medical TV shows everything seems to turn out right in the end, lay persons watching that stuff seem to think it is factual.


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## Sasha

> [lay persons watching that stuff seem to think it is factual



You mean it's not!?


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## VentMedic

However, HOUSE does illustrate the extensive trial and error as well as the all the painful testing a patient must go through. Somethings are not an exaggeration. There have been a few episodes where the outcome is not always favorable. Occasionally there is a death or they do list the life altering complications of a chronic illness. I will say they did botch the hypothermia protocol pretty bad. 

It may take multiple tests and days or even weeks to determine a patient's problem if ever. Some patients get referred to specialists and some must have their "symptoms" treated by GPs for many reasons including availability of specialists and insurance.

Back to the wheezing lady:
Did you have the option to do a nebulizer of either Albuterol or Albuterol/Atrovent combo?


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## VentMedic

Back to the wheezing lady:
Did you have the option to do a nebulizer of either Albuterol or Albuterol/Atrovent combo?  

An aerosol mask is considered "high flow" by true definition in that it can meet the patient's inspiratory demand by design and can be better tolerated.  A NRBM is limited flow and considered low flow except that is uses more gas flow.  

Summary:

An aerosol mask has the capability to meet inspiratory demand but may not provide a high or steady FiO2.  The FiO2 will vary with the inspiratory flow effort of the patient.

A NRBM is a low flow device by true definition.  It is still considered high flow on EMT exams but that should be thought of only from a gas consumption concept.  It can provide a higher FiO2 but the flow limitations and confining mask creates problems with toleration.


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## MSDeltaFlt

Sasha said:


> *HR/sounds (between yells)-* 130/min
> *BP*- I don't remember specifically but it was somewhere in the 180s systolic.
> *RR*-28/min
> *Breath sounds-* Wheezes.
> *Edema-* Her lower legs had pitting edema but her family said that was normal for her
> *Hx-* TIA, CAD, COPD, hypothyroidism, HTN, hyperlipidemia, diabetes.
> *Meds-* Warfarin, synthroid, metformin, lipitor, spiriva, some others I can't remember. But family said she had been noncompliant with meds.
> *Onset-* About 10 minutes before they called, don't know what she was doing and of course, I forgot to ask what she had been doing.
> 
> 
> 
> No, not really. When we got back to the station he asked for my log book, signed off and said I could leave. On the way back to the station he was talking about having better scene control.
> 
> I do plan on calling him so we can go over it later today and I wanna know if he went back to that hospital later and if so how she's doing.
> 
> 
> 
> His philosophy is that he is there so I don't hurt or kill anyone, and can ask questions after, citing the fact that (while my school sucks and I'm nowhere near ready) I'm almost done with medic school and will be out by myself when there wont be anyone to remind or reguide.
> 
> 
> 
> You can't be knocking House!



Sasha,

Despite the above history, I'm still leaning towards CHF Exac, maybe a combo of CHF/COPD Exac for this reason.  Most people with a real bad bronchospasm tend to have a hard time screaming because the bronchospasm is restricting them from getting the air out.  Getting the air in is one thing.  Getting it out is all together different.  Hence the Dx Chronic *Obstructive* Pulmonary Disease.

Now the vast majority of CHF Exac pts I've seen have had no problem whatsoever in screaming from air hunger because they tend to have a hard time getting the air in.  They have no problem getting it out because they are screaming.

Granted.  You never say "never", and you never say "always", but that's just my humble 0.02.


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## VentMedic

MSDeltaFlt makes very good points especially with the BP and edema.  It would be nice if people could just have one disease process at a time but unfortunately chronic illness lead to other chronic illnesses and you never know which one exacerbates more.


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## Outbac1

Vent

 I come accross Combivent MDI's quite often. Usually a generic brand of whose name escapes me now. Other pts are on Salbutemol and Atrovent. Others are also on Flovent (fluticasone). We mix it for nebs in the truck. 1 x 5mg Salbutemol and 1 x 0.5mg Ipratropium Bromide. PCP's here can use Salbutemol all day but you must be an ACP to add the Ipratropium Bromide.

 I'll try to find out some costs for you from a Pharmicist friend of mine.


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## Veneficus

Sasha said:


> *HR/sounds (between yells)-* 130/min
> 
> regular? Strong/weak?
> 
> *BP*- I don't remember specifically but it was somewhere in the *180s systolic.*
> 
> definately in occlusion or rupture range. MAP would help a lot. In advanced heart failure BP is usually lower due to LV contractility.
> 
> *RR*-28/min
> *Breath sounds-* *Wheezes.*
> 
> with the COPD would expect to hear that all the time.
> 
> *Edema-* Her lower legs had pitting edema but her family said that was *normal for her*
> 
> probably was, do you remember any edema in the abd? (in other words did she look really heavy?) stage I or II CHF would support that BP, but not the later stages.
> 
> *Hx-* *TIA*, *CAD*, COPD, hypothyroidism, *HTN*, *hyperlipidemia*, diabetes.
> 
> Stongly suggests possibility of PE, especially the lipidemia.
> 
> 
> *Meds-* *Warfarin*, synthroid, metformin, *lipitor*, spiriva, some others I can't remember. But f*amily said she had been noncompliant with meds.*
> 
> Not at all shocking.
> 
> *Onset-* About 10 minutes before they called, don't know what she was doing and of course, I forgot to ask what she had been doing.!



dying.

I think Vent makes an excellent point, I wish somebody early on in my career pointed out that people have more than one disease at one time that affects the others. Would have saved me a lot of grief.

From the original post this sounds strongly of PE, especially with my anecdotal experience. Not that I am trying to defend my Dx on less than perfect information, but I think an acute CHF would have had stronger signs, crackles, absent or diminished sounds, maybe even some hemoptysis.I could see the very strong arguement for a COPD exacerbation too.

Would like to know the follow up.


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## VentMedic

Outbac1 said:


> I'll try to find out some costs for you from a Pharmicist friend of mine.


 
Combivent is the only name for the Albuterol/Atrovent combo in the U.S.  There is talk of a Xopenex/Atrovent in the future. Considering the cost of a Xopenex MDI, I can't imagine the cost of the combo.

Many of my patients stock up on their respiratory meds in Mexico or the islands.  The spacer or holding chamber is also free with the meds unlike the U.S. where it costs on average $50 - $75.

Canadians and those of other countries;
Are they still giving Salbutamol by IV in EMS and the ED?

Pardon the off track question.


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## remote_medic

Sasha,

from what you explained it sounds like CHF (vitals, edema, etc) however when they become so comprimised and hypoxic that they are screaming and fighting there is not a lot that can be done prehospital. 

These patients are the most frustrating to care for (in my opinion). If you can just get them to calm down and accept CPAP, Nitro, IV, Lasix (although lasix is controversial now) you can turn them around, usually very quickly. No amount of "calm down, we are here to help" will talk these people down.

What it sounds like (again, me not being there) is this patient needed sedation and CPAP/BIPAP...maybe as little as an hours worth...maybe more. Not knowing your local protocols I am making the assumption you can't sedate this patient.

By radioing in report you can have the team ready...sounds like this patient needed more then we could offer pre-hospital.

...just one mans opinion...

Chris


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## medic417

VentMedic said:


> Combivent is the only name for the Albuterol/Atrovent combo in the U.S.  .




Duoneb?:unsure:


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## VentMedic

Veneficus said:


> dying.
> 
> I think Vent makes an excellent point, I wish somebody early on in my career pointed out that people have more than one disease at one time that affects the others. Would have saved me a lot of grief.
> 
> From the original post this sounds strongly of PE, especially with my anecdotal experience. Not that I am trying to defend my Dx on less than perfect information, but I think an acute CHF would have had stronger signs, crackles, absent or diminished sounds, maybe even some hemoptysis.I could see the very strong arguement for a COPD exacerbation too.
> 
> Would like to know the follow up.


 
This lady has most of the chapters present for a COPD or any chronic pt with chronic illnesses.

With the Warfarin*,* she may have chronic A-Fib*.* Still at risk for emboli in non compliant. Combined with the COPD, cor pulmonale; RVH, Right Heart Failure , HTN and pulmonary vascular changes.

Med for HTN? 

metformin: Diabetes could be from earlier years which then makes renal status even more brittle. Or could be from years of steroid use which still make renal status brittle.

Spiriva: tiotropium bromide inhalation powder, long acting anticolinergic used for COPD. Excellent meds since COPD patients need the cholinergic blockade that opens the airways to release trapped air. However, it too has been controversial.

lipitor: hyperlipidemia, CAD

synthroid: hypothyroidism The med and the disorder comes with a whole list of precautions and reactions especially for women with heart disease.

##############################

Now lets go back to the beginning and walk through how you would have liked to have done this. My input now will be using an aerosol mask with nebulized albuterol and/or atrovent as both an O2 source and to see if some of the wheezes can be decresased to hear what other breath sounds are in there. CPAP with the capapbility of using a neb in line would be nice since that would help with preload and afterload as well as splinting the airways, but if she looks at you like you're the devil, move on. 

And good luck getting that 12-lead EKG. That may not happen but try to at least get a baseline rhythm from the standard leads.

Okay Sasha...treat your patient from here... step by step. Some of us have tossed out a lot of different disease processes. Just prioritize from your assessment and do your treatment accordingly without worrying that you can not cure this woman's problems. You as a Paramedic can however initiate enough treatment to make her comfortable and/or give the ED a headstart.


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## VentMedic

medic417 said:


> Duoneb?:unsure:


 
Duoneb is the trade name from Dey for the liquid and now there is a generic Albuterol/ipratropium bromide available. Many of our Canadians friends as well as those in different parts of the U.S. may not recognize Duoneb. 

Combivent is a hold out for the CFC ban and have not been able to reformulate to the HFA version. So far the FDA has granted them an extension but all the other inhalers are now HFA. 

I was messing with Outbac1 since the Canadians started this stuff with the MDIs and the HFA regulations.


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## Outbac1

VentMedic said:


> Duoneb is the trade name from Dey for the liquid and now there is a generic Albuterol/ipratropium bromide available. Many of our Canadians friends as well as those in different parts of the U.S. may not recognize Duoneb.
> 
> Combivent is a hold out for the CFC ban and have not been able to reformulate to the HFA version. So far the FDA has granted them an extension but all the other inhalers are now HFA.
> 
> I was messing with Outbac1 since the Canadians started this stuff with the MDIs and the HFA regulations.



 That’s OK. Nothing like stirring the pot and feeding the fire a little. Then sit back and watch.

  I checked with my friend and Combivent is no longer available due to cfc's. 
I guess they are just old ones I'm seeing. 

 FYI  Atrovent MDI     $30.00
      Ventolin   MDI      $18.00
       Flovent  MDI   (50)   $36.00   (250)  $98.00
 The new discus is the same price per mcg as the MDI. Prices are Canadian $.


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## Sasha

Her pulse was irregular, every so often there'd be a missed beat. I never put her on the cardiac monitor. I know I should have, but it slipped my mind, I was focused on respiratory.Thinking back, I'm wondering if maybe the "missed beats" had been due to an irritable heart due to hypoxia. 

I assumed her difficulty breathing had been related to her COPD. I know, don't assume! I had kind of tunnel visioned due to the wheezes. It may be worth noting that I thought I had heard both wheezes and some rales, but my preceptor told me you couldn't have both, one or the other which I see *now* how much of an ignorant statement that was but back in the call I assumed OK, well then there must have been something rubbing on my scope. So wheezes. Let's try to treat it! And even then I dropped the ball. And I'm also really bad at lung sounds. I call something rales, someone else says ronchi kind of thing.

She didn't look heavy or like she had edema above her lower legs.

Before we go into how to treat, I have a quick question. If it had been CHF, would morphine have been an option? I know it causes respiratory depression, but I also know it can reduce preload, and wouldn't a reduction in preload decrease myocardial oxygen consumption?


----------



## Veneficus

assuming CHF, nitro and morphine are both options, but breathing 28 times a minute, I doubt the respiratory drive was the issue. It sounds more like the gas exchange or transport was causing the problem. 

The best way to become good at identifying lung sounds is to spend some time with a RRT or Doc in the hospital and have them teach you one patient at a time.


----------



## Outbac1

Sasha said:


> *
> No, not really. When we got back to the station he asked for my log book, signed off and said I could leave. On the way back to the station he was talking about having better scene control.
> 
> I do plan on calling him so we can go over it later today and I wanna know if he went back to that hospital later and if so how she's doing.
> 
> His philosophy is that he is there so I don't hurt or kill anyone, and can ask questions after, citing the fact that (while my school sucks and I'm nowhere near ready) I'm almost done with medic school and will be out by myself when there wont be anyone to remind or reguide.*


*

Sasha

 Thats unfortunate that your preceptor has that attitude. He should be guiding you and definately helping you understand what was going on on the call. Not leaving you alone to figure it out. Perhaps you can arrange for another preceptor. Hopefully when you finish you can get a good medic for a partner and they will help you feel more confident and understand what is going on with patients. 

  I wish you the best.*


----------



## jochi1543

VentMedic said:


> Are those of you north of the border keeping Combivent in Canada?



We don't have prepackaged Combivent on our BLS ambulances, but we are taught how to mix Atrovent and Ventolin (which are on all BLS ambulances) and free to use it.

In BC, Atrovent is not in the BLS scope, so neither is Combivent. I don't know about other provinces.


----------



## VentMedic

Outbac1 said:


> Thats unfortunate that your preceptor has that attitude. He should be guiding you and definately helping you understand what was going on on the call. Not leaving you alone to figure it out. Perhaps you can arrange for another preceptor.


 


Sasha said:


> but my preceptor told me you couldn't have both, one or the other which I see *now* how much of an ignorant statement


 
Sounds like the preceptor had a stellar education from a medic mill where his instructor may also have been a graduate.



Sasha said:


> Her pulse was irregular, every so often there'd be a missed beat. I never put her on the cardiac monitor. I know I should have, but it slipped my mind, I was focused on respiratory.Thinking back, I'm wondering if maybe the "missed beats" had been due to an irritable heart due to hypoxia.
> 
> I assumed her difficulty breathing had been related to her COPD. I know, don't assume! I had kind of tunnel visioned due to the wheezes. It may be worth noting that I thought I had heard both wheezes and some rales, but my preceptor told me you couldn't have both, one or the other which I see *now* how much of an ignorant statement that was but back in the call I assumed OK, well then there must have been something rubbing on my scope. So wheezes. Let's try to treat it! And even then I dropped the ball. And I'm also really bad at lung sounds. I call something rales, someone else says ronchi kind of thing.
> 
> She didn't look heavy or like she had edema above her lower legs.
> 
> Before we go into how to treat, I have a quick question. If it had been CHF, would morphine have been an option? I know it causes respiratory depression, but I also know it can reduce preload, and wouldn't a reduction in preload decrease myocardial oxygen consumption?


 
Wheezes can be present in almost anything including the healthy person having a cold/flu and having a productive cough or sinusitis that irritates the lungs. You may hear them in CHF, COPD, PNA, obstructive lesions and aspirated scrambled eggs. The same for rhonchi. Crackles or rales can be heard for CHF, PNA and atelectasis to name a few. The sounds may also be dependent on body position. Another healthcare provider could hear something totally different after a cough or a change in position. 

In some patients you may find almost every breath sound in one set of lungs. That is why we listen to different several different areas.

http://www.meddean.luc.edu/lumen/MedEd/medicine/pulmonar/pd/step29e.htm

And some observations:
http://ruby.fgcu.edu/courses/80277/lungassess.html

The patient: 

The irregular HR could have A-Fib, PACs, PVCs or MAT(WAP). She was on Warfarin but she also had a couple of disease processes that would have needed a clot inhibitor. 

She had pedal edema.

She had COPD.

She had a hx of HTN.

Wheezes (COPD or Fluid or both - could also be PNA which may have caused the exacerbated state)

Any strain on a brittle COPD patient's body may lead them to exacerbeation. This will also be true for their CV system. Once you've taken care of the obvious move on with your assessment. Were there enough clues to lead you to CHF? Could you have asked a few more fact finding questions? Anything else you should have assessed? Anything to lean to PNA? Could be both? 

Write this scenario down as if you were striving for an A at a good Paramedic school or wanted to present it as a case study to a group of doctors. The pieces should fall into place as will your treatment plan.


----------



## Ridryder911

Not to be rude, but it is a shame these student do not sue to recap their money and demand to be really taught. I do wonder, what the instructors do with their time; obviously it is not briefing or reviewing to teach. 

I used to blame many of the students, but now see that it is much more problem in the education system than I had thought. Shameful nothing is done to ensure quality education. 

R/r 911


----------



## remote_medic

Ridryder911 said:


> Not to be rude, but it is a shame these student do not sue to recap their money and demand to be really taught. I do wonder, what the instructors do with their time; obviously it is not briefing or reviewing to teach.
> 
> I used to blame many of the students, but now see that it is much more problem in the education system than I had thought. Shameful nothing is done to ensure quality education.
> 
> R/r 911




To be fair, she is describing her experiences with a field preceptor...not her instructor. I'm sure you have seen (as have I) a student medic show up and ride with what ever crew is around...no training provided to that crew in how to precept, how to guide learning, how to teach, or how to lead. It is assumed that because Jane Doe has been a medic for 7 years that she is going to be a capable field preceptor.


----------



## VentMedic

Ridryder911 said:


> I used to blame many of the students, but now see that it is much more problem in the education system than I had thought. Shameful nothing is done to ensure quality education.
> 
> R/r 911


 
I have been preaching this for a while. If the minimally educated and trained are teaching those with few or no education prerequisites, they will produce replicas of themselves. If the school gives preference to hiring their graduates, nothing changes. If the preceptors are also graduates of these schools, the cycles continues.

If EMS is to advance, it may need to start with the education requirements of its instructors. Bubba can be a real nice guy and have lots of cool stories but that does not necessarily mean he/she has the ability or qualifications to teach. This is where we get examples of lacking education in statements such as "lidocaine numbs the heart". This will also be the instructor that will state they have done alright as a Paramedic without any of that book learnin'. Unfortunately, this type of instructor has been too prevalent in the schools. The clinicals have been lax and weak but not always at the fault of the students. Poor oversight has allowed ALS Engine clinicals with limited patient contact in many states.

Oops, sorry...education soapbox.


----------



## medic417

Ridryder911 said:


> Not to be rude, but it is a shame these student do not sue to recap their money and demand to be really taught. I do wonder, what the instructors do with their time; obviously it is not briefing or reviewing to teach.
> 
> I used to blame many of the students, but now see that it is much more problem in the education system than I had thought. Shameful nothing is done to ensure quality education.
> 
> R/r 911



Wonder if that can be done and won?  Sounds like there are some crappy schools that focus on just what is on the test not actually learning to think.  Some talk about NR pass rates as criteria for a quality school.  I disagree.  I can tell someone with no medical education enough that they could pass the test yet have no clue what they are doing.   But I guess thats what many of these fire department diploma mills are doing.


----------



## medic417

remote_medic said:


> To be fair, she is describing her experiences with a field preceptor...not her instructor. I'm sure you have seen (as have I) a student medic show up and ride with what ever crew is around...no training provided to that crew in how to precept, how to guide learning, how to teach, or how to lead. It is assumed that because Jane Doe has been a medic for 7 years that she is going to be a capable field preceptor.



To be fair in many of her other posts she says her school sucks.

And one of the best preceptors I got was only a Paramedic 1 year.  They were new enough to recall the book and the newbie jitters but had also started to see what the field was really like.  Worst I had was a 20+ tear experience Paramedic.  So time in the field does not equal great preceptor/teacher.


----------



## VentMedic

remote_medic said:


> To be fair, she is describing her experiences with a field preceptor...not her instructor. I'm sure you have seen (as have I) a student medic show up and ride with what ever crew is around...no training provided to that crew in how to precept, how to guide learning, how to teach, or how to lead. It is assumed that because Jane Doe has been a medic for 7 years that she is going to be a capable field preceptor.


 


Sasha said:


> That's not so shocking. My entire experience with paramedic school has been "sad". Nothing has promoted learning but rather a "pass the test, get out there, then you'll learn" mentality. The nowhere near ready is a culmination of things, and not soley the preceptor. I've learned a lot from his preceptorship, though. Probably more than I've learned in class.


 
Unfortunately, this is Florida and the reputation of most medic mills are well known.  But, they can produce a medic in just a few months which is what our FDs want.  That is not a bash on FDs.  People who want to be a Paramedic have every opportunity to take classes at a college.  I believe Sasha is making preparations for that now.


----------



## VentMedic

medic417 said:


> Wonder if that can be done and won? Sounds like there are some crappy schools that focus on just what is on the test not actually learning to think. Some talk about NR pass rates as criteria for a quality school. I disagree. I can tell someone with no medical education enough that they could pass the test yet have no clue what they are doing. But I guess thats what many of these fire department diploma mills are doing.


 
Florida has its own Paramedic test.   The argument between the state exam and the NR is the passing score.  The state exam is 80%.   It also includes state specific information such as the state's trauma criteria.


----------



## Sasha

> To be fair, she is describing her experiences with a field preceptor...not her instructor.



Actually, my instructor really sucks too. That's why I'm having a REALLY hard time and why I'm REALLY worried about the end of medic. I can pass a test, I'm an excellent test taker, but due to a lack of education the possiblity of actually getting in the field, by myself, worries the heck out of me. Rid is right. There should be more done to ensure instructors are really instructing. I shouldn't be this close to being "done" and be this dumb. It's almost appaling. Do you know something I've found out? My paramedic classes by themselves don't meet the state requirement and gen eds like a&p and english comp are used to supplement or something. Don't know how to explain it but it's just really sad. God I feel like an idiot for going there!

I know there was actually talk of filing a suit against the school amoung other students. 

I've still got the scenario coming, still working on it, just wanted to put that out there.


----------



## Sasha

> I believe Sasha is making preparations for that now.



I am. Keep your fingers crossed for me! I just mailed out two college applications! :]


----------



## medic417

Sasha said:


> I am. Keep your fingers crossed for me! I just mailed out two college applications! :]




What and ruin the diploma mill training you got with some real education?

Glad to hear it.  Are you going to go ahead and get certified or wait until you graduate the college program?


----------



## Sasha

medic417 said:


> What and ruin the diploma mill training you got with some real education?
> 
> Glad to hear it.  Are you going to go ahead and get certified or wait until you graduate the college program?



It's actually a degree program... Haha! Degree Mill! I plan to take the test, get the card, and work as an ER tech or something. I'm not taking a college paramedic program. I plan on taking a&p, pharm and patho at an actual decent college and go to nursing school.


----------



## Ridryder911

remote_medic said:


> To be fair, she is describing her experiences with a field preceptor...not her instructor. I'm sure you have seen (as have I) a student medic show up and ride with what ever crew is around...no training provided to that crew in how to precept, how to guide learning, how to teach, or how to lead. It is assumed that because Jane Doe has been a medic for 7 years that she is going to be a capable field preceptor.



Does not matter. Preceptor is allowed from the school? Then its the schools problem as well. Why not have selected preceptors? Would one want to place a student with anyone? Are the preceptors truly recommended or experienced enough for a student, are they familiar with the grading and evaluating criteria, is this medic experienced and educated enough to teach the student properly?

If schools were more selective of preceptor(s) may these problems would decrease. I would even say students would pay more if they could receive a better quality education.

R/r 911


----------



## el Murpharino

If your program has critique forms for your preceptors, USE THEM...and don't sugar-coat them either.  Granted there are times that you may feel like they don't work, but I'm sure if enough students have the same gripes about the same few preceptors, some action would (should) be taken.  If nothing gets done at the class level, I would suggest taking it up the chain - even if it means talking to the medical director himself.  Extreme, perhaps...but this is YOUR education, not theirs.  

It's a tough road to "narc" on bad preceptors, especially if your school lets you ride at one or two agencies.  Compounding that fact is the reality that these preceptors were probably trained at the same facility by the same instructors who have some rapport with each other.


----------



## MSDeltaFlt

Sasha said:


> Her pulse was irregular, every so often there'd be a missed beat. I never put her on the cardiac monitor. I know I should have, but it slipped my mind, I was focused on respiratory.Thinking back, I'm wondering if maybe the "missed beats" had been due to an irritable heart due to hypoxia.
> 
> I assumed her difficulty breathing had been related to her COPD. I know, don't assume! I had kind of tunnel visioned due to the wheezes. It may be worth noting that I thought I had heard both wheezes and some rales, but my preceptor told me you couldn't have both, one or the other which I see *now* how much of an ignorant statement that was but back in the call I assumed OK, well then there must have been something rubbing on my scope. So wheezes. Let's try to treat it! And even then I dropped the ball. And I'm also really bad at lung sounds. I call something rales, someone else says ronchi kind of thing.
> 
> She didn't look heavy or like she had edema above her lower legs.
> 
> Before we go into how to treat, I have a quick question. If it had been CHF, would morphine have been an option? I know it causes respiratory depression, but I also know it can reduce preload, and wouldn't a reduction in preload decrease myocardial oxygen consumption?



Not jumping your butt by any stretch of the imagination, but now you know.  You can't teach experience.  I believe that now you'll put these pts on the monitor, even if they fart funny.

Yes, you can have multiple breath sounds throughout the lungs.  You can have a pt with bilateral wheezes, rales, rhonchi, and even a pleural friction rub thrown into the mix just for kicks and giggles.  Not to mention having to assess how much air exchange is or is not taking place.

Just to recap the possible painfully obvious, let's put into country terms (my personal favorite) the analogies of breathsounds.

Wheezes - Sound like you have 2 cats fighting in your chest.
Rales - Sound like "crackles", which is why they're called that now.
Rhonchi - Bubbling.  Easily cleared with coughing.
Stridor - Crowing
Pleural Friction Rubs - Dry your finger off and press hard and slide it across the kitchen counter.  Usually at the beginning or end of the breath.

Remember that breath sounds are not a "pah-ta-toe" - "pa-tah-toe" kind of thing.  It's either an *is* or an *isn't* kind of thing.  Once you learn breath sounds, you'll know what I'm talking about.

Morphine is an option if they're still having chest pain despite multiple doses of NTG.

Bare in mind, Sasha, you're a student.  You're still learning.


----------



## VentMedic

el Murpharino said:


> If your program has critique forms for your preceptors, USE THEM...and don't sugar-coat them either. Granted there are times that you may feel like they don't work, but I'm sure if enough students have the same gripes about the same few preceptors, some action would (should) be taken. If nothing gets done at the class level, I would suggest taking it up the chain - even if it means talking to the medical director himself. Extreme, perhaps...but this is YOUR education, not theirs.
> 
> It's a tough road to "narc" on bad preceptors, especially if your school lets you ride at one or two agencies. Compounding that fact is the reality that these preceptors were probably trained at the same facility by the same instructors who have some rapport with each other.


 
Sometimes when an area becomes accepting of lower educational stanards, it is difficult to get the point across.  This is especially true if the majority of the FFs and Paramedics are trained at the same schools or other medic mills that practice the same philosophy.   

It is not until someone is hungry to learn more and steps outside of the herd to find that there may be more to being a professional Paramedic than what they are being told or taught.


----------



## Sasha

Ok. I typed this last night but the darn site was down!!

I was intially thinking CHF because of her history of CAD and the edema, before the family had stated that was normal for her. Also because she has a history of COPD, but the "I can't breathe!" only started very recently. Also because the position of her pillows in her bed and in her chair had her sleeping near upright. I didn't think pneumonia simply because she didn't feel hot, I know that people who are immunosupressed often present without fever, but based on her med list and history there was nothing that jumped out and screamed "immunosupression!". The only reason I went with her dyspnea being related to COPD had been the wheezes and hx of COPD.

Ok, treating this patient. I think early transport would be vital. I don't think I would have even gone to an NRB/NC, probably straight to CPAP with nebulized albuterol, force air into her lungs, fluid out, and bronchiodilate. I imagine having bronchioconstriction with CHF makes it even harder to breathe, so bronchiodilation could only be beneficial, right? And even it had been her COPD and not CHF, CPAP wouldn't have been contraindicated, right?  

Also put her on the cardiac monitor.

So, after that, we would want to reduce preload, right? Sublingual nitro should vasodilate, which reduces venous return, reducing preload. 

And now I'm stuck. What else could have been done? What next?


----------



## MSDeltaFlt

Sasha said:


> Ok. I typed this last night but the darn site was down!!
> 
> I was intially thinking CHF because of her history of CAD and the edema, before the family had stated that was normal for her. Also because she has a history of COPD, but the "I can't breathe!" only started very recently. Also because the position of her pillows in her bed and in her chair had her sleeping near upright. I didn't think pneumonia simply because she didn't feel hot, I know that people who are immunosupressed often present without fever, but based on her med list and history there was nothing that jumped out and screamed "immunosupression!". The only reason I went with her dyspnea being related to COPD had been the wheezes and hx of COPD.
> 
> Ok, treating this patient. I think early transport would be vital. I don't think I would have even gone to an NRB/NC, probably straight to CPAP with nebulized albuterol, force air into her lungs, fluid out, and bronchiodilate. I imagine having bronchioconstriction with CHF makes it even harder to breathe, so bronchiodilation could only be beneficial, right? And even it had been her COPD and not CHF, CPAP wouldn't have been contraindicated, right?
> 
> Also put her on the cardiac monitor.
> 
> So, after that, we would want to reduce preload, right? Sublingual nitro should vasodilate, which reduces venous return, reducing preload.
> 
> And now I'm stuck. What else could have been done? What next?



Sounds good to me.


----------



## el Murpharino

Sasha said:


> ...because the position of her pillows in her bed and in her chair had her sleeping near upright.  The only reason I went with her dyspnea being related to COPD had been the wheezes and hx of COPD.



Alot of CHF'ers sleep upright to help with the fluid (some still think gravity is a theory).

Early CHF presents with wheezes - hence the nickname cardiac asthma.

Yes these aren't absolutes...but the little clues help to make the big picture easier to see.

Also, CPAP doesn't really force the fluid out; it improves the ability of the alveoli to diffuse oxygen to the red blood cells by using pressure to drive gas into the alveoli and open up unused or collapsed alveoli.  I used to think CPAP pushed the fluid out...I was harshly corrected by an instructor who was having a bad day (or so it seemed).


----------



## Sasha

> Also, CPAP doesn't really force the fluid out; it improves the ability of the alveoli to diffuse oxygen to the red blood cells by using pressure to drive gas into the alveoli and open up unused or collapsed alveoli. I used to think CPAP pushed the fluid out...I was harshly corrected by an instructor who was having a bad day (or so it seemed).



Wow.. really? That makes a LOT more sense! Thank you for correcting me!


----------



## el Murpharino

no prob...like I said, I thought the exact same thing not too long ago.  I'm sure some of the more experienced members here can elaborate even more on it as my experiences with CPAP are very limited.


----------



## VentMedic

el Murpharino said:


> Also, CPAP doesn't really force the fluid out; it improves the ability of the alveoli to diffuse oxygen to the red blood cells by using pressure to drive gas into the alveoli and open up unused or collapsed alveoli. I used to think CPAP pushed the fluid out...I was harshly corrected by an instructor who was having a bad day (or so it seemed).


 
CPAP can splint the airways open for alveoli recruitment, decrease atlectasis and improve V/Q ratios.  However, to achieve this, it can also increase intrathoracic pressure.  which can benefit preload and afterload to where there is actually an improvement in cardiac index.


----------



## Sasha

My preceptor finally returned my call (In the middle of a nap >:[) It was CHF and as of midnight that night, which is the last time he had been at that hospital, they were trying to find an ICU bed for her.


----------



## johnrsemt

be happy that you have something besides O2 and Albuterol;  that is all we have and we have a miminum of a 45 min transport.   I have had a 1hr 45 min transport a few weeks ago, and that is to a small hospital.  If we need a bird, it may be 20-30 min to meet them, (and we don't wait, we start transporting).


----------



## Sasha

johnrsemt said:


> be happy that you have something besides O2 and Albuterol;  that is all we have and we have a miminum of a 45 min transport.   I have had a 1hr 45 min transport a few weeks ago, and that is to a small hospital.  If we need a bird, it may be 20-30 min to meet them, (and we don't wait, we start transporting).



Hmmm well I'm sorry to hear that, but that's what happens when you work in a rural area.


----------



## Summit

..........


----------



## zzyzx

I've been reading Sasha's post and have been thinking along the lines of sedating this patient. I've never had a combative patient like this...of course now that I've said that my next call will be probably a combative 400 lb CHF'er on the second story.

I can't RSI where I work, so all I can do is sedate with Versed. I will use Versed when the time comes that I do get a patient who's very combative and can't be managed, but I'm afraid that after I give it I'll end up with a patient who's knocked out and barely breathing. Can you guys with more experience handling such patients relate your experiences? Thanks; hope I'm not highjacking the thread too much.


----------



## VentMedic

zzyzx said:


> I've been reading Sasha's post and have been thinking along the lines of sedating this patient. I've never had a combative patient like this...of course now that I've said that my next call will be probably a combative 400 lb CHF'er on the second story.
> 
> I can't RSI where I work, so all I can do is sedate with Versed. I will use Versed when the time comes that I do get a patient who's very combative and can't be managed, but I'm afraid that after I give it I'll end up with a patient who's knocked out and barely breathing. Can you guys with more experience handling such patients relate your experiences? Thanks; hope I'm not highjacking the thread too much.


 
The way to stop this lady from struggling is to initiate therapy toward alleviating the problem*s*. 

If you sedate the drive that is maintaining her oxygenation, you better have a great airway alternative. She will go down fighting even if you do have the ability to RSI. Sedating may or may not alleviate the combativeness but may present with other problems. 

CPAP does *NOT *ventilate. You may end up bagging and still have a lot more of your protocols to run through to maintain stable BP, assess and continue treatment. 

Remember these patients aren't fighting YOU. They are fighting a body that is failing them. Just from her COPD, she has very limited oxygenation and ventilation abilities. Any disease process be it CHF or PNA that can cause just a little more hypoxemia with may cause her PaO2 to fall from 55 mmHg where she probably lives to 40 mmHg where her other organs start to feel the effects.


----------



## Sasha

vent, how would you have treated her stast to finish?


----------



## MSDeltaFlt

VentMedic said:


> *The way to stop this lady from struggling is to initiate therapy toward alleviating the problem**s*.
> 
> If you sedate the drive that is maintaining her oxygenation, you better have a great airway alternative. She will go down fighting even if you do have the ability to RSI. Sedating may or may not alleviate the combativeness but may present with other problems.
> 
> CPAP does *NOT *ventilate. You may end up bagging and still have a lot more of your protocols to run through to maintain stable BP, assess and continue treatment.
> 
> Remember these patients aren't fighting YOU. They are fighting a body that is failing them. Just from her COPD, she has very limited oxygenation and ventilation abilities. Any disease process be it CHF or PNA that can cause just a little more hypoxemia with may cause her PaO2 to fall from 55 mmHg where she probably lives to 40 mmHg where her other organs start to feel the effects.



Very true, Vent.  Remember, They *say* she started to really complain ~10 min before you showed up.  Time is relative.  The amount of time you *feel* elapsing and the amount of time *actually occuring* might not necessarily be the same amount.

*Therefore*, don't be surprised if you can't fix the problem enroute.  Most times you can't.  But you can get the fixing of the problem *started*.


----------



## zzyzx

Vent wrote, "If you sedate the drive that is maintaining her oxygenation, you better have a great airway alternative."

Yes, that's what I'm afraid off. Say you have a combative 400 lb CHF'er and you sedate them, but then they loose their respiratory drive and now you've got a difficult intubation.

The problem is, what if they are just so combative that you can't to any treatment, i.e. they are throwing the mask off, won't let you do a nasal intubation, are fighting you as you try to move them downstairs, etc.

I guess I already know the answer--that it's just a tough call as to what to do. I'd like to just hear people relate their experiences with nightmare calls like this. Besides, I love hearing war stories from you guys.


----------



## Sasha

> vent, how would you have treated her stast to finish?



Sorry, I was typing ^that^ on my phone. Didn't mean it to come out disrespectfully or anything in case it was taken that way but:

Since you and Rid are basically the EMS Gurus and you and MSDelta are certainly the source for all things respiratory, and I've already failed miserably at the scenario, I'd like to know how you, as a Paramedic, would treat this patient so I can learn from you?


----------



## colafdp

VentMedic said:


> Canadians and those of other countries;
> Are they still giving Salbutamol by IV in EMS and the ED?
> 
> Pardon the off track question.



I can't speak for the rest of the country, but here in Saskatchewan, Salbutamol isn't given via IV anymore. Just good ol' nebulized.

Also, Outbac, Atrovent is really an ACP skill out there? hmmm...crazy. Learn something new every day.


----------



## Outbac1

Here in NS atrovent is for ACP use only. There is no reason why it couldn't be given by PCPs. as could IVs, D50 and benedryl. But that's the way the MD wants it.
I have never seen ventolin given iv.


----------



## MSDeltaFlt

Sasha said:


> Sorry, I was typing ^that^ on my phone. Didn't mean it to come out disrespectfully or anything in case it was taken that way but:
> 
> Since you and Rid are basically the EMS Gurus and you and MSDelta are certainly the source for all things respiratory, and I've already failed miserably at the scenario, I'd like to know how you, as a Paramedic, would treat this patient so I can learn from you?



Sasha,

You're a student.  You didn't fail miserably.  The only way you could possibly fail in any shape, form, or fashion is if you didn't do what students are supposed to do... which is *learn*.

Your preceptor, on the other hand, ...well.  I'll leave that alone for now.


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## VentMedic

Sasha,

As I said, start at the beginning and write out this scenario. There are some things that you will do for all medical calls at an ALS level as part of your assessment while you are taking care of the obvious A,B,Cs. As well there will be common therapies initiated reguardless of what path you decide to call your working dx. You also must be aware there will be a little of everything going on. Become methodical in your assessment so that you don't miss anything that is a necessary part of your assessment. Ex. an EKG rhythm strip might have shown a HR of 220 even if the pulse was only 130. A BGL might have been expected to be elevated but could also have been low. COPD pts that can't breathe don't always eat..

You will also have a partner. In this scenario it seemed that you as a student had no one. Multiple things should be happening at one time. I usually prefer to establish the O2 and/or neb tx myself because that gives me direct eye contact with the patient and from there I will have an idea of the difficulty this patient will present and the eyes can tell volumes. If there is a calm family member, I have no problem having them assist with getting some O2 and neb closer to the patient. Sometimes if the patient knows the mask can be removed easily they are okay with it. 

Many here have given you good directions but you need to start at the beginning. That is in your text book and protocols. I am not going to rewrite what is already in print. Sorry but you are the one who should know where to find the answers for some of your questions. As I asked before, type out your treatment plan with your protocols. You can call this lady COPD exacerbation and CHF for working dxs if you feel that is what your assessment indicated. 

You haven't failed at anything yet. You just haven't been able to pull all the info together probably more from the lack of proper guidance. But, if your preceptor wants to behave more like an ambulance driver....


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## brice

how interesting


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## Ridryder911

Hence why we had and still continue to urge you to obtain more clinical exposure and increasing your didactic knowledge. Those of us that may appear to have wise knowledge do so because of continuous studying, having the privilege of our clients to allow gaining more experience and learning off them. 

You are learning more than you may realize. Your now are asking questions instead of just responding spontaneously which is a very positive sign that your increasing your knowledge and wisdom. Remember, when one graduates through the program it only means the just started learning. 

R/r 911


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## Outbac1

Sasha your preceptor may have failed you but you haven't failed yourself. 
How many pts like this have you seen since you got your EMT-B? If you have, were you working with someone who could do something for this type of pt? As Rid said try to get as much clinical experience as you can. The more pts you see the more you will learn. 

  There is a reason they call it the PRACTICE of medicine. I have met two Dr.s this week who have just returned or are going to conferences or sessions/courses to learn more. The learning never stops unless we want it to. Don't let this incident get you down.  Pick yourself up and push on.


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## Sasha

> Hence why we had and still continue to urge you to obtain more clinical exposure and increasing your didactic knowledge.



I'm working on that! I'm studying constantly, and am taking as much clinical time as I possibly can. It's coming along slowly, surely, but it doesn't happen over night. Ok, so things aren't really coming together very well but a lot of it has been self teaching and it's taking some time!



> You're a student.


A student, yes, but according to instructors and preceptors I should be able to function out in the field by myself. March 18th is it. That's all she wrote for Paramedic class. Yes, I realize that it's only the start of education and knowledge, etc, And I understand some of it is inexperience, and some of it's lack of education because of a crappy "school" and some not so great preceptors, but damnit I need to stop making huge mistakes and freezing up like that!

Do you understand my frustration now? I've never been so behind in something, and I've never been working so hard to catch up!


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## Sasha

Retracted.


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## Aidey

Sasha, take a deep breath. 

The patient lived. You learned something. It's ok. Even medics who have been doing this for 10, 15, 20 years spin on occasion and feel like they buggered up a call. 

The only time you should freak out is if you have a call like this and you DON"T feel like you messed up and need practice. That is a bad bad sign. 



P.S. I'm not trying to be patronizing, I've just been where you are.


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## Jon

Sasha said:


> That's not so shocking. My entire experience with paramedic school has been "sad". Nothing has promoted learning but rather a "pass the test, get out there, then you'll learn" mentality. The nowhere near ready is a culmination of things, and not soley the preceptor. I've learned a lot from his preceptorship, though. Probably more than I've learned in class.


Sounds like the EMT-*B *program 


Seriously - my program is going through a lot of growing pains... we are year 4, and the biggest class, double the size of last years. Our lead instructor is now realizing that he dropped the ball a time or two and is going back over stuff.

Some of our preceptors are really good. Some of the folks who precept couldn't find their butt with two hands and a road map... one of them didn't even realize that we carry lidocane as a drip. :facepalm:

And some of our preceptors have been removed from precepting - like when they had/allowed their student to intubate a dog on a fire scene.


All in all, now that we are in Stage 2 of clinicals, the preceptors are EXPECTED to allow us and MAKE US run things, and give us enough rope to learn, but not enough rope to hurt ourselves or the patient.


I feel as if I have enough experience that I'll be adequately prepared for life once I pass my NREMT-P :hope: :Big, Obama-Style Hope:    Sure, I'll be new and green, and won't know everything. But I know 20-year medics that don't know everything.  That said, I worry about some of my classmates. Today we were told that as a class, we aren't allowed to push drugs anymore in the local ED, becase at least one student couldn't adequatly answer questions on why a med was being given and what it was.... and it is ON the state Medic Drug list, AND a VERY commonly pushed drug in the ED.  Add that to at least 1 student being unable to preform the psychmotor skill of drawing up a drug... and the ED director has pulled the plug until we get signed off again and she's comfortable we aren't going to make errors for her nurses.... they have enough work already!


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## Jon

VentMedic said:


> The way to stop this lady from struggling is to initiate therapy toward alleviating the problem*s*.
> 
> If you sedate the drive that is maintaining her oxygenation, you better have a great airway alternative. She will go down fighting even if you do have the ability to RSI. Sedating may or may not alleviate the combativeness but may present with other problems.
> 
> CPAP does *NOT *ventilate. You may end up bagging and still have a lot more of your protocols to run through to maintain stable BP, assess and continue treatment.
> 
> Remember these patients aren't fighting YOU. They are fighting a body that is failing them. Just from her COPD, she has very limited oxygenation and ventilation abilities. Any disease process be it CHF or PNA that can cause just a little more hypoxemia with may cause her PaO2 to fall from 55 mmHg where she probably lives to 40 mmHg where her other organs start to feel the effects.


Hey Vent - refresh my memory - what's the healthy PaO2 in a young, nonsmoker?



Great points, all. I saw a PE a few weeks ago - in a 15-minute timespan, between the bedroom and while we were transporting, Pt. went from CAO and in SEVERE respritory distress to Apniec... to DEAD. We worked that for a while, no luck.


Sasha - do you guys HAVE CPAP? given the patient's history, it might have been worth a shot. I've seen it work miricles... and I've seen it fail.


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## MSDeltaFlt

Jon said:


> Hey Vent - refresh my memory -* what's the healthy PaO2 in a young, nonsmoker*?
> 
> 
> 
> Great points, all. I saw a PE a few weeks ago - in a 15-minute timespan, between the bedroom and while we were transporting, Pt. went from CAO and in SEVERE respritory distress to Apniec... to DEAD. We worked that for a while, no luck.
> 
> 
> Sasha - do you guys HAVE CPAP? given the patient's history, it might have been worth a shot. I've seen it work miricles... and I've seen it fail.



Normal PaO2 is 80-100 torr, or mmHg depending on your point of view.


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## Sasha

> Sounds like the EMT-B program
> 
> 
> Seriously - my program is going through a lot of growing pains... we are year 4, and the biggest class, double the size of last years. Our lead instructor is now realizing that he dropped the ball a time or two and is going back over stuff.
> 
> Some of our preceptors are really good. Some of the folks who precept couldn't find their butt with two hands and a road map... one of them didn't even realize that we carry lidocane as a drip. :facepalm:
> 
> And some of our preceptors have been removed from precepting - like when they had/allowed their student to intubate a dog on a fire scene.
> 
> 
> All in all, now that we are in Stage 2 of clinicals, the preceptors are EXPECTED to allow us and MAKE US run things, and give us enough rope to learn, but not enough rope to hurt ourselves or the patient.
> 
> 
> I feel as if I have enough experience that I'll be adequately prepared for life once I pass my NREMT-P :hope: :Big, Obama-Style Hope: Sure, I'll be new and green, and won't know everything. But I know 20-year medics that don't know everything. That said, I worry about some of my classmates. Today we were told that as a class, we aren't allowed to push drugs anymore in the local ED, becase at least one student couldn't adequatly answer questions on why a med was being given and what it was.... and it is ON the state Medic Drug list, AND a VERY commonly pushed drug in the ED. Add that to at least 1 student being unable to preform the psychmotor skill of drawing up a drug... and the ED director has pulled the plug until we get signed off again and she's comfortable we aren't going to make errors for her nurses.... they have enough work already!



Here on clinicals we are allowed to push drugs in the ER, but they must be drawn up by the nurse, first and pushed under a nurse's supervision. One of my favorite nurses would draw up the drug, take a saline flush and inject it into the now empty drug vial, and make the student draw up the saline, to make sure the student knows how to, but you're expected to know the whys, hows, why nots, what to expect, etc if the drug is considered a "prehospital drug". 

We, however, are no longer allowed to start IVs after a student who had never used a spring loaded IV needle, never thought to ask about it, just started an IV and assumed that the button to "spring" the needle back, shot the needle into the vein. Well, it doesn't, but it does make a big mess of the patient's arm, bedding, floor, etc. The patient complained, the nurse complained, and we are no longer able to start IVs in the hospital. Personally I hate the spring loaded IVs, they like to fling blood while they "spring".

My program is "new" too, but it doesn't give the program an excuse to suck so bad. I could kick myself for staying, but before I had floated around here, I thought we were doing okay. Come to realize the school is basically breeding mill medics, and that's not something I want to be. It's hard to ask questions because my instructors don't even know why or how a treatment works, just that if you have this, you give that, etc. It makes it difficult and frustrating to learn.

And yes, we have CPAP, but I kind of froze and forgot about it, and no one felt compelled to remind me.


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## medic417

Sasha sounds like you are going to be OK not because of the school or the preceptors but because you refuse to settle for the bottom.  

A good preceptor lets you run the show then if its critical says we need to do this or that if your not quick enough.  If not critical but should be done the preceptor will initially ask you a question to help you think about what you need to do.  And at no time will they allow a patient to suffer.  If the patient is in bad shape and someone is not addressing patients needs they take over and then educate later so that you do better next time.  Honestly I wonder if you preceptor actually knew what to do.


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