# 84 y/o Acute medical



## martor (Oct 2, 2012)

Ok I work at a private BLS contracted to SNF. We get an ER call for high fever.
AOS TFA 84 y/o F. RN tell us that patient's base line is confused with very little verbal response. Pt appears to be sleeping. We tried yelling at her to wake her up but it didnt work. Pt is full code (no DNR)

resp- 40 bpm gtv labored,  82% R/A. wheezing, we put her on high flow and SpO2 inc to 93% breaths at 36 bpm.
pulse- 104 strong at radial. 
BP- 100/66
Skins - warm, moist, pale, temperature at 100.2 F
pupils- constricted at 1mm
Nuero exam- A&O x0, GCS - E- 2  V- 1  M- 1 (yeah patient slightly opened her eyes at the painful stimuli but no body movement. No even extension. I tried trapezoidal and sternum)

We decided to upgrade it to ALS. Pt being practically unconscious, low GCS, and resp difficulty. We had the pt on O2 for the 8 minutes it took for the FF to arrive and 2 minutes later for Paramedics. 


 I just wanted to see if you guys agree with my decision. Any suggestions as far as what I should have done more.

FYI: We were requested to tx to a hospital 16 min away, while there was a hospital 2 blocks down the road. I dont know why, didnt ask. I assume pt had most of her medical Hx at the requested hospital.


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## DrParasite (Oct 2, 2012)

based on the limited information patient sounds septic.  that means there is very little that can be done in the field to reverse the patient's condition.

if it was me, I'd be bagging the patient, and have been calling for ALS once i couldn't wake the patient.  I would also have been out the door with the patient, along with the appropriate paperwork from the facility, and transported to the hospital 2 blocks away, especially with you having a potentially sick patient and no ALS.  They can always transfer the patient once the ER has stabilized them.  I know it's frowned up to do that at IFT companies, but most 911 agencies I am familiar with say "closest appropriate hospital shall be the destination."  I know my supervisors would have backed me if I did that, I can't say the same for others.

or if you were going to the hospital that is 16 minutes away (for whatever the reason), fine, put the patient on your cot, continue to assist w/ ventilations, and meet up with the paramedics somewhere enroute to the hospital.

but that's just me, and different systems operate under different rules.


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## Tigger (Oct 2, 2012)

I would have gotten on the road with the patient. I don't wait for ALS unless they are only a few minutes away (around three if I had to pick a number). They can intercept with you, or more likely you will just beat them to the hospital, and that's what this patient needed. I certainly would have called for them though.


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## Melclin (Oct 2, 2012)

I'd say this pt is going to god regardless of what the BLS ambulance does.

I'm so confused about why FF would turn up to a job like this. So you call for ALS and a bunch of FF turn up who can't transport and will only "treat" the pt for a handful of second before the paramedics arrive? I'd love to watch people's expressions when a FF walks in the door for a sick person. Although I suppose it must be what people expect if that is the norm over there. 



DrParasite said:


> if it was me, I'd be bagging the patient,
> 
> .....
> 
> and transported to the hospital 2 blocks away, especially with you having a potentially sick patient and no ALS.





Bagging them? Why?

Why transport to the closest hospital if its not at all the best place for the pt.  You take them to the far inferior hospital that fart arses around for 5 hours doing almost nothing before transferring them to a real hospital...all for the sake of 10 mins transport time. I don't mean that this is necessarily true in this case, I'm just making a broad generalisation about the fallacy of all EDs being able to "stabilise" pts. Just take them to the hospital they need in the first place. Maybe things are different there, but I can certainly see why one might bypass a hospital that was incapable of dealing with sick pts. There are "hospitals" around here to which I wouldn't take a stubbed toe, let alone an actually sick pt. Same went for when I was practising in the city.


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## 7887firemedic (Oct 2, 2012)

I had a similar situation, pt was umconcious, diaphoretic, only info i could get from staff was"we checked on her at the start of our shift, she wouldnt respond and her temp was 102" what time was that? 2200, run came in about 4am! sp02 sucked, adaquete breathing, bgl wnl, 3 and 12 lead was sinus tach, bp low, couldnt get a line, was 2 mins from level 1 center. At hospital temp had rose to 106! Besides the 02, a saline bolus, cooling and drive fast there wasnt anything als i could do. Prehospital sepsis care leaves much to be desired


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## johnrsemt (Oct 2, 2012)

It always bothers me when so many people want to go to the closest hospital.    Yes they can stabilize and ship;  but the average back out the door time is 3-6 hours  depending where you are.

   So if a patient is having a stroke and it takes the smaller, but closer (by 15 minutes) hospital 2 hrs to do and read a CT Scan; and then decide how much of what medication to push;  oh wait,  oops we are over the 3 hr window.
   If the EMS crew took the pt 15 minutes further to a Stroke Hospital; and they get the CT done and read in 30 minutes:  hey patient has a good chance of recovery.

  Same with MI's and a hospital that can do a Cath.    It took a small hospital 7 hours to decide to transfer a patient for an Emergent Cardiac Cath;  because the Fire Dept based EMS only transports to the small hospital (except major trauma) that is in their response area.


Even here it is the difference of 45 minutes to 90 minutes.  But we do what is best for the patient


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## martor (Oct 2, 2012)

Thank you. I will make a note of all that was said. ^_^
I was worried pt might become unstable en route and having to do cpr by myself in the back of a moving rig would be hard. A little note: I work in San Diego and the hospital near by was sharp memorial and the 15 min away was scripps mercy. Does it change your opinion?


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## DrParasite (Oct 2, 2012)

Melclin said:


> Bagging them? Why?


they are breathing at 40 times a minute, is a RA pso2 of 82%.  How much oxygen exchange is really being done?  after the oxygen was applied, pso2 did go up to 93%, with a RR decrease to 36.  patient is still breathing really fast, and I'm betting there is a poor air exchange.  If you assist with ventilations, maybe you can bring their RR down to 25, with the amount of oxygen in the blood will increase, and the respiratory drive will decrease to a more normal level.





Melclin said:


> Why transport to the closest hospital if its not at all the best place for the pt....Just take them to the hospital they need in the first place. Maybe things are different there, but I can certainly see why one might bypass a hospital that was incapable of dealing with sick pts. There are "hospitals" around here to which I wouldn't take a stubbed toe, let alone an actually sick pt. Same went for when I was practising in the city.


you are making a pretty steep assumption that the closest hospital couldn't handle the patient.  I said the patient should be transported to the "closest appropriate hospital" so the theory goes if the patient was having an MI, go to one with a CATH lab, trauma etc.  The OP only said the facility requested a certain hospital, not that there was any special reason or that the closest hospital couldn't handle the patient due to lacking of capabilities.





johnrsemt said:


> It always bothers me when so many people want to go to the closest hospital.    Yes they can stabilize and ship;  but the average back out the door time is 3-6 hours  depending where you are... Even here it is the difference of 45 minutes to 90 minutes.  But we do what is best for the patient


that's why you had to take them to the closest *appropriate* hospital.


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## Achilles (Oct 3, 2012)

DrParasite said:


> they are breathing at 40 times a minute, is a RA pso2 of 82%.  How much oxygen exchange is really being done?  after the oxygen was applied, pso2 did go up to 93%, with a RR decrease to 36.  patient is still breathing really fast, and I'm betting there is a poor air exchange.  If you assist with ventilations, maybe you can bring their RR down to 25, with the amount of oxygen in the blood will increase, and the respiratory drive will decrease to a more normal level.you are making a pretty steep assumption that the closest hospital couldn't handle the patient.  I said the patient should be transported to the "closest appropriate hospital" so the theory goes if the patient was having an MI, go to one with a CATH lab, trauma etc.  The OP only said the facility requested a certain hospital, not that there was any special reason or that the closest hospital couldn't handle the patient due to lacking of capabilities.that's why you had to take them to the closest *appropriate* hospital.


This guy hit the nail on the head. I agree with the closets appropriate hospital as well. it's just like trauma PTs you can't take them to doc in the box you take them to an appropriate facility.


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## Melclin (Oct 4, 2012)

DrParasite said:


> they are breathing at 40 times a minute, is a RA pso2 of 82%.  How much oxygen exchange is really being done?  after the oxygen was applied, pso2 did go up to 93%, with a RR decrease to 36.  patient is still breathing really fast, and I'm betting there is a poor air exchange.  If you assist with ventilations, maybe you can bring their RR down to 25, with the amount of oxygen in the blood will increase, and the respiratory drive will decrease to a more normal level.you are making a pretty steep assumption that the closest hospital couldn't handle the patient.
> 
> ....
> 
> that's why you had to take them to the closest *appropriate* hospital.



When you say poor air exchange, do you mean poor ventilation? Thats the only way this statement makes sense to me, but I still don't agree. Are you saying that a RR of 40 and adequate Vt are mutually exclusive? I can tell you right now its not. An SpO2 of 93 in this pt is probably fine for the time being and likely close to normal for her given her age and likely disease pathologies. I'd be willing to bet money on the fact that an SpO2 of 93 is not whats driving her RR of 36. I would tentatively suggest that you're chasing numbers here without really getting the underlying issue. 

Assuming she is septic, which is pretty reasonable, the RR is a compensatory mechanism for a metabolic acidosis. Firstly, we don't really want to slow it down, its there for a reason. Secondly, in this case Vt is not an issue. We're not fixing anything by clumsily trying to "control" her resps.

An infective exacerbation of COPD also seems reasonable, in which case again, manual vents will probably make her much worse real fast. 

....

I don't know that its a steep assumption given that its what happened and we're looking for a reason for why. The why is likely that they weren't the most appropriate in my mind.

RE the "appropriate" in you argument, I didn't consider the full meaning, so I'll happily offer my agreement


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## leoemt (Oct 4, 2012)

Melclin said:


> I'd say this pt is going to god regardless of what the BLS ambulance does.
> 
> I'm so confused about why FF would turn up to a job like this. So you call for ALS and a bunch of FF turn up who can't transport and will only "treat" the pt for a handful of second before the paramedics arrive? I'd love to watch people's expressions when a FF walks in the door for a sick person. Although I suppose it must be what people expect if that is the norm over there.
> 
> ...



Around here hospitals can stabilize a patient. Once stabilized they can be transferred. Luxury of having a crap load of Hospitals around here. 

You bag them to assist with ventilations. Oxygen does no good if they are breathing too fast to adequately perfuse the oxygen. 36 breaths a minute is not really an effective breathing rate regardless of the tidal volume. By breathing for them with a bvm you are helping to ensure the perfusion is adequate. I know on a responsive patient we can get them slow down their rate by using a BVM...not sure how it would work on an unresponsive patient though since you can't coach them with the BVM.


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## Veneficus (Oct 4, 2012)

*I am going with Melclin on this one*



martor said:


> Ok I work at a private BLS contracted to SNF. We get an ER call for high fever.



This is just screaming sepsis to me. I know a thing or two about this disease, and the closest hospital stabilizing numbers and not the underlying condition will not be beneficial.

I have seen a number of sepsis patients transferred to our academic facility after an outside facility attempted to handle the patient themselves first.

The one thing they have in common is they all died. 



martor said:


> AOS TFA 84 y/o F. RN tell us that patient's base line is confused with very little verbal response. Pt appears to be sleeping. We tried yelling at her to wake her up but it didnt work. Pt is full code (no DNR)



Sound slike unconsciousness to me.

Of course she is a full code, otherwise life wouldn't be much fun.



martor said:


> resp- 40 bpm gtv labored,  82% R/A. wheezing,)



Pneumonia induced sepsis?

Maybe even early onset ARDS... 



martor said:


> we put her on high flow and SpO2 inc to 93% breaths at 36 bpm.,)



Did you consider this because of early onset acidosis? Did you notice if they were Kussmaul's respirations prior to applying O2?

In addition to acidosis it is also a rather reliable clinical sign of renal failure. (in this case AKI or possibly acute on chronic.) That would actually make this a compensatory mechanism. 

Not such a good idea to knock out compensatory mechanisms...



martor said:


> pulse- 104 strong at radial.
> BP- 100/66
> Skins - warm, moist, pale, temperature at 100.2 F



Looks like septic shock to me.



martor said:


> pupils- constricted at 1mm
> Nuero exam- A&O x0, GCS - E- 2  V- 1  M- 1 (yeah patient slightly opened her eyes at the painful stimuli but no body movement. No even extension. I tried trapezoidal and sternum)



Not surprising for inadequete cerebral perfusion. What laundry list of history did she have?



martor said:


> We decided to upgrade it to ALS. Pt being practically unconscious, low GCS, and resp difficulty. We had the pt on O2 for the 8 minutes it took for the FF to arrive and 2 minutes later for Paramedics.



So what you are saying is it took 10 minutes to get a fluid bolus. How long did it take to package and transport?

If you had a trauma patient in shock would you wait on scene or initiate rapid transport?

Because the patient is likely in septic shock, does it matter to you if shock starts with failure of O2 delivery and progresses to systemic inflammatory response or does it make a difference to you if it starts with systemic inflammatory respose and progresses to failure of oxygen delivery?

My guess is it doesn't. 




martor said:


> I just wanted to see if you guys agree with my decision. Any suggestions as far as what I should have done more.



Load and go my friend. Load and go.



martor said:


> FYI: We were requested to tx to a hospital 16 min away, while there was a hospital 2 blocks down the road. I dont know why, didnt ask. I assume pt had most of her medical Hx at the requested hospital.



It doesn't matter why. 

There could be 100 reasons. 

Go where you are supposed to. 




leoemt said:


> Around here hospitals can stabilize a patient. Once stabilized they can be transferred. Luxury of having a crap load of Hospitals around here.



Again...

I can stabilize vital signs on a corpse. Unless there is an airway that cannot be managed, go to the facility requested. 

Perhaps consider the closer hospital already told the transferring doctor they could not handle the patient for a number of reasons? 



leoemt said:


> You bag them to assist with ventilations. Oxygen does no good if they are breathing too fast to adequately perfuse the oxygen. 36 breaths a minute is not really an effective breathing rate regardless of the tidal volume..



???

Says who?



leoemt said:


> By breathing for them with a bvm you are helping to ensure the perfusion is adequate.



By left shifting the oxygen–hemoglobin dissociation curve?

Seems a bit counter productive to tissue oxygenation in an acidotic patient.

The delivery of O2 is based on blood volume, cardiac output, and amount of heme. Perfusion is the wrong word to use here. Tissue oxygenation would be better, but I think that the lung pathology would influence whether or not this patient needed supplemental oxygen and I am not sure bagging the patient would really help. 

It may even cause harm.



leoemt said:


> I know on a responsive patient we can get them slow down their rate by using a BVM...not sure how it would work on an unresponsive patient though since you can't coach them with the BVM.



What if you do not want to slow the rate in order to use respiratory compensation for acidosis?

There is very little information described that would permit a more indepth analysis and recommendation. But in summary.

Forget ALS, load and go.

You need more info to determine if oxygen or even bagging would be helpful. 

Go to the facility you were told to unless there is an unmanagable airway.


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## martor (Oct 4, 2012)

Thank you veneficus for giving me more stuff to learn during my midterm week. But in all honesty, thank you for such a detailed response.
It will shock you as much as it shocked me that pt had no hx of PNA, MI, CVA, or resp disease. Yeah not very believable. Also her only medication was tylonel which was administered every 4 hours, 24 hours prior to the call.
Medics also said that it looks like sepsis. I found out that pt WAS transported to the nearby hospital and not the requested one.
Thank you everybody for participating.


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## FLdoc2011 (Oct 4, 2012)

leoemt said:


> Around here hospitals can stabilize a patient. Once stabilized they can be transferred. Luxury of having a crap load of Hospitals around here.
> 
> You bag them to assist with ventilations. Oxygen does no good if they are breathing too fast to adequately perfuse the oxygen. 36 breaths a minute is not really an effective breathing rate regardless of the tidal volume. By breathing for them with a bvm you are helping to ensure the perfusion is adequate. I know on a responsive patient we can get them slow down their rate by using a BVM...not sure how it would work on an unresponsive patient though since you can't coach them with the BVM.



Veneficus already hit on the issue with the pt's respiratory status and questioning the reasoning for BVM and I certainly agree.   

Resp rate and tidal volume are the factors determining ventilation.  Likely this person is septic as others have mentioned and has a high minute ventilation as a compensatory measure.   Oxygen perfusion is a separate issue and I think you're getting a little mixed up with terms and concepts by wishing to assist perfusion due to a high resp rate.    On a conceptual basis, think of ventilation(CO2) and oxygenation as two separate things and in general respt rate and tidal volume will affect ventilation.    Initially this pt was hypoxic but likely from some other underlying defect (PNA, ARDS, cardiac output, etc...) and not her resp rate.  

Ultimately, with a crappy GCS, high resp rate, and overall story, it sounds like she really needs to be intubated.  ARDS is certainly on the list here of possible issues.  In meantime though it sounds like she is not going to protect her airway and not get any better without some time on the vent.  

If you want, search for the EMCRIT podcast, look back for the one or two episodes he did on mechanical ventilation which gives a basic framework on ventilation parameters if you're not familiar with that subject.


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## leoemt (Oct 5, 2012)

Vene - I agree with you. Unfortunately at the basic level there isn't much we can do for resp. issues. This would have been and ALS call from the beginning for us. 

The point I was making is why you would bag a breathing patient. Obviously, you would treat the patient and 36 breaths per minute may in fact be "normal" for that patient. However, if the patient is Tachypneic then we need to address that. Until ALS arrives, in most cases we would be bagging this patient.


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## Aidey (Oct 5, 2012)

The take home point should be that just because it is abnormal doesn't mean you need to fix it.

The blunt point is don't freaking bag a tachypneic patient. Just don't.


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## martor (Oct 5, 2012)

Aidey said:


> The take home point should be that just because it is abnormal doesn't mean you need to fix it.
> 
> The blunt point is don't freaking bag a tachypneic patient. Just don't.



I am inclined to agree with you. Bagging a tachypneic is needed, but not when the rapid breathing is due to pain or stress (at least not right away, first try to calm them down.) I honestly cant tell you if the pt was awake and just couldn't respond to stimuli or pt was unconscious. I know you guys cant help me with figuring that one out. 
 We kept a really close watch over her resp. I only posted two vitals. She was improving progressively so there was no need to risk freaking her out with a bvm (again it is only my opinion.)


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## Veneficus (Oct 5, 2012)

martor said:


> I am inclined to agree with you. Bagging a tachypneic is needed, but not when the rapid breathing is due to pain or stress (at least not right away, first try to calm them down.) I honestly cant tell you if the pt was awake and just couldn't respond to stimuli or pt was unconscious. I know you guys cant help me with figuring that one out.
> We kept a really close watch over her resp. I only posted two vitals. She was improving progressively so there was no need to risk freaking her out with a bvm (again it is only my opinion.)



I don't think you get it.

Bagging the rate down is not needed in a patient who is compensating for metabolic acidosis by increased respiratory rate.

EMcrit is not my favorite, but in patients like these, the tidal volume while being mechanically ventilated is decreased from normal on purpose.


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## martor (Oct 5, 2012)

Veneficus said:


> I don't think you get it.
> 
> Bagging the rate down is not needed in a patient who is compensating for metabolic acidosis by increased respiratory rate.
> 
> EMcrit is not my favorite, but in patients like these, the tidal volume while being mechanically ventilated is decreased from normal on purpose.



 I might have worded it wrong, but it is basically what i figured out from this thread.


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## Handsome Robb (Oct 5, 2012)

I've never understood "bagging a patient down". Bagging someone who is bradypneic or apneic is tough enough, spontaneously breathing is a pain in the butt. 

I agree with sepsis. Altered elderly pt at a SNF who's tachycardic, tachypneic and borderline hypotensive. 

I'm with vene on this, load and go to the facility that's requested, meet ALS en route if that's possible but even then, doing a handoff then the ALS crew's workup is going to delay definitive care.


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