# Try This Call



## FF/EMT Sam (Apr 18, 2007)

You are dispatched for "general illness."  Upon arrival, you find a female patient in her mid-50s.  Friends report that she has been "sick" for the past couple days, but that when they stopped at her house to check on her just now, she was markedly worse.  They tell you that she has no history of diabetes, heart disease, heart attacks, cancer, or CVAs.

Your patient is seated in a chair, cyanotic.  Vitals are as follows:
BP: 134/76
Resp: 28 and short
O2 Sat: 82%
Pulse: 136
Glucose: 298

She has an altered LOC, and believes that it is the middle of the night, even though it is about 4PM, and she can see the sun shining from where she is.  She is alert, but highly disoriented.  She can only speak a couple words at a time.  She denies any chest pain.

You see no indications of drug or alcohol use.  

ALS is on the way.

Whaddya do?


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## emtwannabe (Apr 18, 2007)

BVM w/ 15L O2. Do the med control thing for the IV, NS, KVO. Place pt on stretcher, and apply high flow diesel when ALS arrives...

Jeff


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## Glorified (Apr 18, 2007)

problems with breathing and circulation. she has an airway. Altered mental status, hyperglycemic.

high flow 02 via NRB mask. I wouldnt bag valve unless respirations got above 30 even though normal is 12 to 20 I don't think a BVM is appropriate, rapid transport or rendevous with ALS. treat for shock. detailed physical exam enroute if time. monitor vitals every 5 minutes, maintain ABCs


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## FF/EMT Sam (Apr 19, 2007)

You place the patient on 15L O2 via NRB, as a BVM is a bit excessive given the circumstances.  She "comes around" as soon as she is put on the stretcher, and you can literally see her color change to a more reassuring, normal shade of pink.  She is now able to speak in full sentences, and tells you that she has no medical history other than some minor difficulty breathing for the past few days.  She is fully alert and oriented.

You load the stretcher into the ambulance.  ALS arrives, but is unable to get an IV established.  

Vitals:
BP: 130/P
Resp: 20 and normal
O2 Sat: 100%
Pulse: 126

You are transporting to the hospital, and are in the midst of calling in your report when the patient says that she is uncomfortable on the stretcher.  She rolls over onto her side, and within a minute is turning cyanotic again, and her respirations skyrocket.  You can tell that she is in genuine distress.  She looks at you, and asks "What's happening to me?!?"  The ALS provider looks blankly at you, just as puzzled as you are.

Anything you can think of that you want to do for this patient?


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## Glorified (Apr 19, 2007)

now is when to assist with ventilations. place her on her back and treat for shock and assist ventilations at a rate of 20 bpm. ask ALS provider to try again to get an IV. :censored::censored::censored::censored: and get


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## BossyCow (Apr 19, 2007)

FF/EMT Sam said:


> She rolls over onto her side, and within a minute is turning cyanotic again, and her respirations skyrocket.  You can tell that she is in genuine distress.  She looks at you, and asks "What's happening to me?!?"  The ALS provider looks blankly at you, just as puzzled as you are.
> 
> Anything you can think of that you want to do for this patient?



Rolls to her side before becoming cyanotic?  Is there a possible airway obstruction?  

I've also seen the rapid drop in oxygenation from pulmonary embolism.  High flow O2 and pedal to the metal with the airway kit out, open and ready.  Also, trying to reassure the pt as much as possible since resp. emergencies have a high sphincter factor and anxiety can aggravate symptoms.


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## Epi-do (Apr 19, 2007)

Does a physical exam reveal anything remarkable?  What are her breath sounds like?


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## FF/EMT Sam (Apr 19, 2007)

You put her on her back again and her breathing returns to normal.  You continue an uneventful transport to the hospital.  It is later learned that she had a tumor somewhere in her airway that was physically blocking air, and causing her distress.

She underwent surgery to have it removed, and survived the surgery in good condition.  Before she was discharged from the hospital, however, she had a massive heart attack and died.

As R/Rid has been known to say, "When you hear hooves, think zebras."


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## Mercy4Angels (Apr 22, 2007)

unfortunatly here in jersey 15lpm O2 is the best we can do till medics get there. dont see a need for bvm yet but its close 12-24 is normal but if the breaths are shallow and her o2 sat dosent rise with supplemental O2 then yes BVM. cant do oral gluecose cause of altered mental status. we cant do IV so that leaves just o2 and wait for medics.


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## hockeypaul81 (Apr 22, 2007)

Mercy4Angels said:


> unfortunatly here in jersey 15lpm O2 is the best we can do till medics get there. dont see a need for bvm yet but its close 12-24 is normal but if the breaths are shallow and her o2 sat dosent rise with supplemental O2 then yes BVM. cant do oral gluecose cause of altered mental status. we cant do IV so that leaves just o2 and wait for medics.


You wouldnt want to do oral glucose anyway, HYPOglycemia Is not her problem at this point.


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## Airwaygoddess (Apr 22, 2007)

Sam, going by the assessment I wonder if the patient had an PE? :unsure: I know this much, hi flow O2 via NRB freq. VS with continuous SPO2, transport in postion of comfort.  What were her lung sounds?


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## hockeypaul81 (Apr 22, 2007)

Airwaygoddess said:


> Sam, going by the assessment I wonder if the patient had an PE? :unsure: I know this much, hi flow O2 via NRB freq. VS with continuous SPO2, transport in postion of comfort.  What were her lung sounds?


Its possible to think that early on but as far as i know, and i might be wrong, you cant hear a PE. Also, my assessment of a PE would have gone right out the window as soon as she went supine and returned to normal...ive only seen one person experience a PE right in front of me and no amount of turning here would have kept her from assuming room temp. This Pt was normal and alert and never gave anyone any clues that somethin was severly wrong with her. Over the course of about 45-60 seconds I watched her sats drop from 94% RA to 45% with 15L BVM. It was frickin wierd...
All this took place as soon as we got her into her ER bed...the doc called it in about 5-6 minutes.


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## klogerg (Apr 22, 2007)

i think its awesome you all are talking about pusle ox as a basic.  My company wont let basics have pulse ox.  it sucks


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## Airwaygoddess (Apr 23, 2007)

I know you can not hear a PE, I was just wondering what her lung sounds were as part of the assessment


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## Airwaygoddess (Apr 23, 2007)

klogerg said:


> i think its awesome you all are talking about pusle ox as a basic.  My company wont let basics have pulse ox.  it sucks



It is part of an assessment but don't relay on that alone, folks can get tunnel vision with a pulse ox, if the patient has a low BP or irregular pulse, ot if the patient has cold hands or body temp, it can give a false reading.  Remember to treat the patient, not the machine.


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## hockeypaul81 (Apr 23, 2007)

Airwaygoddess said:


> It is part of an assessment but don't relay on that alone, folks can get tunnel vision with a pulse ox, if the patient has a low BP or irregular pulse, ot if the patient has cold hands or body temp, it can give a false reading.  Remember to treat the patient, not the machine.


Very good. And to the other guy, Your service need a boot in the butt!! Not like a pulse ox is invasive or anything. They are wonderful to have on ideal pts, like airwaygoddess said.


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## Ridryder911 (Apr 23, 2007)

I think there is too much emphasis on SpO2 monitoring. Let make ask, is there is any change in treatment you are going to do if the numbers are different? Again, at a basic level the treatment is usually the same. 

Although, it is a great device it has so many variables and as discussed so many limitations on applications. We should not be treating the patient solely on numbers. 

I believe the physician probably has seen a lot of oxygen therapy placed or withheld because of numbers, when in reality the numbers were skewed.

I have seen so many (including physicians) within the past few years describe ...._"their sat's are okay"_.. 

Does everyone understand to obtain a saturation rate, it might take up to 4-5 minutes before any changes to occur in numbers? What effect does one expect this to take on the body? As well, just because they have an oxygen saturation of 98% maybe in respiratory distress, and those with a saturation of 88% may not be really in distress. 

Again, oxygen saturation is just an assessment tool, and should never replace a good history and exam. 

R/r 911


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## FF/EMT Sam (Apr 23, 2007)

Airwaygoddess said:


> Sam, going by the assessment I wonder if the patient had an PE? :unsure: I know this much, hi flow O2 via NRB freq. VS with continuous SPO2, transport in postion of comfort.  What were her lung sounds?



Lung sounds just a little wet bilaterally.  Nothing serious-sounding.  There will be an autopsy, and I'm looking forward to seeing the results of it.

I can't say exactly why, but losing this patient hit me really hard.  It probably has something to do with doing so much good for her on the way to the hospital, easing her distress, and losing her anyway.  :sad:


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## Ridryder911 (Apr 23, 2007)

This job sucks sometimes. Who knows why one call will affect us more than others.. I know after all this time, it still happens and I still wonder why? 

You did the best you can.. and you have apparently learned something out of this. This scenario will be ever etched in your mind. Now, take those findings and remember them. This will not be the last time you will see this.. this is what develops you into being a good medic... applied experience.

It may be more than one thing. P.E.'s can have rales and pulmonary congestion, and as they can cause multiple problems. As well as mucus plugs, etc.. .. who knows? That is why there is an autopsy, apparently no one is certain. 

As the old saying goes:
_
Interns do not have the knowledge to know what "it" is
Residents are learning what "it" is, but don't want to do anything
General practice have forgotten what it is nor how to fix "it"
Pathologist knows what "it" is, how to fix "it", but "it" is too late......_

Let us know the results...

R/r 911


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## BossyCow (Apr 24, 2007)

I agree about the over-reliance on the Pulse Ox.  If I have a pt who is pale, cyanotic and talking in 3 word answers, I'm not going to withold O2 because the machine says her sats are fine. 

The saturation numbers are nice to back up what you saw and what you did as a result.  But to use the number as the sole indicator of a symptom is silly.  If I have a pt who is breathing normally, pink, talkative, and doesn't want an NC I will use the reading to justify leaving him/her off O2.


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