# My call suggestions?



## sdafbkfsdbkjdsf (Nov 14, 2012)

I can't get over this call and I would like your in put here.

I was dispatched to a 80 y/o F who was having difficulty breathing. I arrive on scene and see her in the tripod position sitting on her bed. The family states that she has been having a hard time breathing for the last 2 days and it got worse today. She has a history of CHF, COPD, Asthma, and hypertension. she was on a home nasal cannula when I arrived.

She wasn't able to speak to me but she would make these sounds per say and she could not follow commands. v/s were bp 136/86, P62, RR-12, BGl 96. We replaced her NC with a NRB because here sat was 80 on the NC. My partner took her lung sounds and said they were diminished

We moved her to the ambulance all the while she was trying to take the mask off her face. I start up a neb treatment in the back and her sats start dropping 80, 50, 20, 12% and my partner said she stop breathing. I go and pop an NPA in and start bagging her and I added the capnography I got her sat up to 90% and 34 on co2. 

After a couple bags she starts breathing on her own as we enter the hospital, I do my pass off with the doc and he listens to her lung sounds and say there wet and her skin is cool. They hook her up to the CPAP. In my standing orders we can't use  CPAP because the pt could not follow my commands which could turn into gastric distention. I just feel like CPAP would of worked pre hospital because the DR did it. I just need some in put on this call for what I  can work on.


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## mycrofft (Nov 14, 2012)

"She would make these sounds per say"


What does that mean?


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## sdafbkfsdbkjdsf (Nov 14, 2012)

Like mumbled words sorry bad at describing that


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## mycrofft (Nov 14, 2012)

"mumbling" does it pretty well.

"_Per se_" means "exactly this, infer nothing else".

Or per the dictionary, "Of, in, or by itself or oneself; intrinsically".


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## NomadicMedic (Nov 14, 2012)

And yeah, I'd say she was a CPAP candidate. :/

A shame she wasn't alert enough to meet your criteria. And in hindsight, not hearing her lungs, sounded like the Albuterol wasn't what she needed... More like NTG and CPAP. 

Were you in charge? Why didn't you listen to the lung sounds?

I'm guessing you're an Advanced or a basic with add on skills?


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## sdafbkfsdbkjdsf (Nov 14, 2012)

Yeah that was what I was thinking with the CPAP, it just sucks that my protocols wouldn't allow it because she wasn't able to follow my commands. And yes I was in charge, I trusted my partner in what he was saying sounds like a stupid idea now. I was going off of o2 wasn't getting in all the way to the bases and if I were to open them up then she would able to breath better since they were diminished and she has a history of COPD which made me thing of Albuterol.


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## VFlutter (Nov 14, 2012)

Do you carry the nasal cannula capnography? That may have helped before they went into respiratory arrest


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## sdafbkfsdbkjdsf (Nov 14, 2012)

I wish we did but sorry we don't


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## IrightI (Nov 14, 2012)

With her not liking the NRB, CPAP would do no good. In our service, she would have bought herself a tube and nice ride in with a dx of chf exacerbation.


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## NomadicMedic (Nov 14, 2012)

With a history of both CHF and COPD, I would have been a lot more aggressive with CPAP right off the bat. If she can try and take the mask off, she'll probably take CPAP. Better to try early, than be behind the 8 ball. 

And I missed what your level of training is. This just doesn't feel like a paramedic level assessment, treatment or protocols.


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## leoemt (Nov 14, 2012)

lill91210 said:


> I can't get over this call and I would like your in put here.
> 
> I was dispatched to a 80 y/o F who was having difficulty breathing. I arrive on scene and see her in the tripod position sitting on her bed. The family states that she has been having a hard time breathing for the last 2 days and it got worse today. She has a history of CHF, COPD, Asthma, and hypertension. she was on a home nasal cannula when I arrived.
> 
> ...



Why did you go with a NPA? Were there any other sounds besides "diminshed"? Rales? History of CHF, pulmonary edema is a possibility isn't it?

Can your service give paralytics and drop a tube? Could you have called medical control to get authorization to use CPAP?


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## IrightI (Nov 14, 2012)

n7lxi said:


> With a history of both CHF and COPD, I would have been a lot more aggressive with CPAP right off the bat. If she can try and take the mask off, she'll probably take CPAP. Better to try early, than be behind the 8 ball.
> 
> And I missed what your level of training is. This just doesn't feel like a paramedic level assessment, treatment or protocols.



Since when is CPAP not an ALS treatment or protocol since this doesnt seem like a medic assesment to you? Maybe the OP is a new medic and doesn't have the experience or is just getting used to a certain style of assessing there patients. Every medic has to start somewhere, give em a little credit.


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## IrightI (Nov 14, 2012)

leoemt said:


> Why did you go with a NPA? Were there any other sounds besides "diminshed"? Rales? History of CHF, pulmonary edema is a possibility isn't it?
> 
> Can your service give paralytics and drop a tube? Could you have called medical control to get authorization to use CPAP?




My thoughts exactly. This was a real good RSI pt.


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## sdafbkfsdbkjdsf (Nov 14, 2012)

Since Im in a urban environment and the hospital was literally 2 minutes away we do not carry anything for RSI. I got my lungs sounds from my partner and he said they were diminished I should of listened for myself but I went off of what my partner said which was a stupid idea. I went for an NPA because it was easier to drop and I had a great mask seal with my bagging and I got the sat up so I didn't feel like switching to an OPA since I was doing fine with the bagging.

And IrightI thanks for having my back I am a new Paramedic and just wanted some input on everything so I can learn and get better not being ridiculed on my level of training.

Also,  should of called medical control that should of been something that should of popped in my mind, but man it never crossed it I was so tunnel visioned on getting her sats up.


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## NYMedic828 (Nov 14, 2012)

lill91210 said:


> Since Im in a urban environment and the hospital was literally 2 minutes away we do not carry anything for RSI. I got my lungs sounds from my partner and he said they were diminished I should of listened for myself but I went off of what my partner said which was a stupid idea. I went for an NPA because it was easier to drop and I had a great mask seal with my bagging and I got the sat up so I didn't feel like switching to an OPA since I was doing fine with the bagging.
> 
> And IrightI thanks for having my back I am a new Paramedic and just wanted some input on everything so I can learn and get better not being ridiculed on my level of training.
> 
> Also,  should of called medical control that should of been something that should of popped in my mind, but man it never crossed it I was so tunnel visioned on getting her sats up.



In my anecdotal experience early recognition of pulmonary edema and administration of NTG can be the difference between an ER visit and an ICU admission.

Lung sounds can be hard to hear in many patients especially if they have diminished air movement such as cases of fully filled lungs.

12 lead, NTG, O2.


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## sdafbkfsdbkjdsf (Nov 14, 2012)

not tell me would there be any changes in the 12 lead that I should look for


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## NYMedic828 (Nov 14, 2012)

lill91210 said:


> not tell me would there be any changes in the 12 lead that I should look for



Signs of heart failure, primarily infarction. 

Acute pulmonary edema is a common symptom of chronic congestive heart failure and acute heart failure such as substantial left sided infarction.


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## leoemt (Nov 14, 2012)

lill91210 said:


> Since Im in a urban environment and the hospital was literally 2 minutes away we do not carry anything for RSI. I got my lungs sounds from my partner and he said they were diminished I should of listened for myself but I went off of what my partner said which was a stupid idea. I went for an NPA because it was easier to drop and I had a great mask seal with my bagging and I got the sat up so I didn't feel like switching to an OPA since I was doing fine with the bagging.
> 
> And IrightI thanks for having my back I am a new Paramedic and just wanted some input on everything so I can learn and get better not being ridiculed on my level of training.
> 
> Also,  should of called medical control that should of been something that should of popped in my mind, but man it never crossed it I was so tunnel visioned on getting her sats up.



I think you did a great job. Sure, other things could have possibly been done but you got her breathing again and got her to the hospital safely and alive. There are plenty of calls I have been on where I could have done things differently. Hindsight is always 20/20. Use every call as a learning tool.


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## NomadicMedic (Nov 14, 2012)

...And recognizing a PT in severe respiratory distress and then taking definitive steps toward managing the issue is a basic paramedic skill...

I wasn't ridiculing your level of experience, I was curious as to why you seemed to be reluctant to do what was right for your patient. 

I understand AEMTs and add on Basics not knowing the patho and simply following an algorithm, but as a medic you should have been more aggressive. 

If you seriously want to learn, as you said you want input, then drop the defensive tone and realize that this was a call where you could have done better. 

You should have:

A) recognized the level of distress at first contact. 
B) listened to lung sounds yourself to determine if they were truly diminished or rales or wheezes or...
C) applied CPAP early in the contact. 

If you can't do that, at least call and consult with a doc to either get orders for CPAP or tell them to have an RT ready with BiPAP. 

This is a great place to post a scenario and ask questions, but be prepared to face the critique. If you just want a pat on the back and "don't worry slugger, you'll get it next time", it ain't gonna happen.


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## VFlutter (Nov 14, 2012)

NYMedic828 said:


> Signs of heart failure, primarily infarction.
> 
> Acute pulmonary edema is a common symptom of chronic congestive heart failure and acute heart failure such as substantial left sided infarction.



For a chronic CHF patient it may not be as obvious as an infarction. Subtle clues such as LVH, LAE, A Fib, BBBs, frequent ectopy, etc  is more common. 

Or the simple "That QRS looks like :censored:" is usually present in CHF patients


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## sdafbkfsdbkjdsf (Nov 14, 2012)

n7lxi
  I see where you are coming from and I apologize for getting defensive. I understood that my patient was in a big level of distress, I switched her off of the NC she was one and put her on something that can go at a higher dose. And like I said its sad that I can't entrust in my partner in getting lung sounds for me I'll have to do it on my own then. I know CPAP was the right thing I should of done when I saw the  Dr. put it on saying that her lung sounds were wet and I was standing there like an idiot by not getting the lung sounds myself. It just never crossed my mind in calling medical control I was so focused on taking over for her breathing.


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## Outbac1 (Nov 15, 2012)

As others have said you should have listened to the lungs yourself. Having said that maybe all there was to hear was diminished air entry. Make sure you listen in several places. Often a neb of ventolin will open the airway enough to have a little better air entry and you can then hear some crackles. Maybe that is why the Dr heard crackles when you got to the hosp. 
 I agree early agressive CPAP is the tx of choice. If they try to pull off the mask but can't/won't follow commands be agressive and hold the mask on. Coach them thru it. I had one of these pts a few weeks ago. It took two of us to hold the mask on them. We also used numerous shots of ventolin from a MDI into the CPAP mask. But it worked they were much improved in the 15min it took to drive to the hosp.  
 If you have to bag them do you have PEEP valves for your bag? 
 Her b/p would support nitro as well. Usually I see these people breathing 30 - 40 x min. If her RR was only 12, she was tired. A sure sign she may crash on you. 
 We all learn from hindsight things we could have done differently/better. Learn and move on.


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## 46Young (Nov 15, 2012)

A "few" things in the spirit of learning:

-Wheezing can be from a number of different causes. "Cardiac Wheezing" is not bronchoconstriction aka uneven alveolar emptying per se, it is from atelactasis caused by fluid from the blood (cardiogenic pulmonary edema) which causes dilution and washout of the surfactant, which will result in alveolar collapse.

-Many of your interventions are based on L/S and BP. It would be prudent to confirm adventitious L/S with a second provider (you). Same for BP if it is out of the norm.

-The ETCO2 waveform (which I realize you don't have, only the quantitative version, the number) would tell you whether or not uneven alveolar emptying is occuring. 

-If you apply CPAP to a pt with total loss of plateau per quantitative capnography, they have no way to eliminate the air that the CPAP is delivering.

-The O2 dissociation curve begins to steepen downward below 90%, gets even steeper as you go past 80%, then basically freefalls past that, so 100% to 90% should occur more slowly than 90% to 80%, but below 80% the pt will de-sat very quickly. So, if your pt has a sat of 80% or less initially, you need to be pharmocologically aggressive, as well as plan to bag and (hopefully not have to) drop a tube ealier rather than later.

-The pt's RR was 12 with an SpO2 of 80%, in tripod,  on home NC. Impending respiratoy arrest, for sure. No wonder the pt stopped breathing. She was tired and probably altered as well. "I start up a neb treatment in the back" should have been "I start up a neb treatment in the house right away as I get the BVM ready."  I noticed you did a BGL in the house, but a neb in the bus. I know you thought it was COPD, my point is that you started meds several minutes too late in favor of a BGL, which is likely not a respiratory pt's primary problem, and also removal to the bus. Most patients can have interventions deferred until you're in the ambulance. This pt needed to be worked in the house. The first time someone dies on you while on the stair chair going down the stairs (happend to me) you'll understand.

-As the pt becomes more alkalotic, the Hb will hold the O2 molecules, but be reluctant to give them up - think of someone with a panic attack getting dizzy, worsening panic breathing, then passing out, typically with a sat of 100% and complaint of dyspnea. Differential Dx could be a PE, but that's another conversation. As the pt becomes more acidotic, the Hb will have a tougher time binding with O2. This is one reason why the O2 dissociation curve starts out shallow than becomes steep quite quickly as you go south of 90%.

-The pt may have a Cardiogenic Pulmonary Edema episode secondary to an MI. If the 12-lead shows inferior changes, a V4R is warranted to help rule out a RVI (infarct), where the RV is heavily dependent on preload, so NTG can bottom out the pt's BP quickly. This is why a fluid bolus should be more beneficial in a RVI (Starling's law aids the sick RV), vs pressors for a LVI. 

-The tripod position was a clue that the pt was in extremis and needs aggressive Tx. The pt pulling the mask off her face suggests a change in mental status presumably from worsening hypoxia. Prepare to assist ventilations if CPAP is out of protocol at this point. If we were thinking COPD instead of CHF, then bag in the neb Tx in-line with the BVM if available.

-Get a good Hx to narrow your differentials towards the CHF - you didn't tell us anything about the pt's HPI except dyspnea x 2 days. Cool skin leads more towards CHF/APE. The distressed heart should cause a catecholamine response to help with perfusion. The pt's BP was WNL, but was likely elevated earlier before you were called. It seems that you caught the pt on the way back down with respect to BP and effort in breathing -resp failure due to fatigue.

Not trying to beat up on you, just want to make you aware of a few critical thinking items


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## Sublime (Nov 15, 2012)

I was about to make a somewhat detailed post but 46Young said everything better than I would have. I'll just go ahead and say I think you've already learned your lesson on this one, but be aggressive with CPAP in these patients.


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## 46Young (Nov 16, 2012)

Sublime said:


> I was about to make a somewhat detailed post but 46Young said everything better than I would have. I'll just go ahead and say I think you've already learned your lesson on this one, but be aggressive with CPAP in these patients.



Sorry to steal your thunder - I usually get to a medical thread too late to offer anything new most of the time


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## Akulahawk (Nov 16, 2012)

As I was reading the initial post, the 1st thing that came to mind was some kind of respiratory failure/respiratory distress. One of the things that caught my mind was the description of an elderly patient, history of COPD, tripodding, with an oxygen sat of 80%. I think you did the right thing by taking her off of the nasal cannula, and attempting to put her on a non-rebreather. The fact that she thought the non-rebreather tells me that she was probably in a severe level of distress, probably actual or impending respiratory failure, and a good candidate for CPAP or bagging with the BVM. The only thing I would consider after that would be getting an order for CPAP right away as opposed to waiting for the patient to go into failure and then have to rely on the BVM.

The fact that things started to come around when he started to back her with the BVM, tells me that she really needed the positive pressure ventilation. It is unfortunate that she did not fit the protocol for CPAP usage right away. She might have early on, but certainly later on, she would not have been.

I know it sounds like we all kind of dog piled on you, but this was a very good learning call for you. I hope the next time you will recognize the signs of impending respiratory failure, especially pulmonary edema, and be more aggressive with therapy. With these calls, the things you do right away in the field can mean the difference in how long the patient stays in the hospital, as well as whether or not the patient ends up in the ICU for a while.


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## cruiseforever (Nov 16, 2012)

I have had good experiences with using the BVM with these pt.'s.  It looks like she was close to resp. arrest with the RR of 12.  CPAP does not work very well when the pt. is not moving much air.  You need to assist the pt.'s breathing with the BVM.  Many times I have had the pt. relax and let me breath for them after a few well timed breaths.


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## NomadicMedic (Nov 16, 2012)

cruiseforever said:


> I have had good experiences with using the BVM with these pt.'s.  It looks like she was close to resp. arrest with the RR of 12.  CPAP does not work very well when the pt. is not moving much air.  You need to assist the pt.'s breathing with the BVM.  Many times I have had the pt. relax and let me breath for them after a few well timed breaths.









errrr...


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## the_negro_puppy (Nov 16, 2012)

cruiseforever said:


> I have had good experiences with using the BVM with these pt.'s.  It looks like she was close to resp. arrest with the RR of 12.  CPAP does not work very well when the pt. is not moving much air.  You need to assist the pt.'s breathing with the BVM.  Many times I have had the pt. relax and let me breath for them after a few well timed breaths.


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## VFlutter (Nov 16, 2012)

cruiseforever said:


> I have had good experiences with using the BVM with these pt.'s.  It looks like she was close to resp. arrest with the RR of 12.  CPAP does not work very well when the pt. is not moving much air.  You need to assist the pt.'s breathing with the BVM.  Many times I have had the pt. relax and let me breath for them after a few well timed breaths.



You learn something new everyday.  I better take notes......


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## d_miracle36 (Nov 17, 2012)

46Young said:


> A "few" things in the spirit of learning:
> 
> 
> 
> ...




Can you explain these two further please in regards to the waveform and plateau?


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## VFlutter (Nov 17, 2012)

d_miracle36 said:


> 46Young said:
> 
> 
> > A "few" things in the spirit of learning:
> ...




http://www.capnography.com/new/index.php?option=com_content&view=article&id=95&Itemid=61


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## d_miracle36 (Nov 17, 2012)

ChaseZ33 said:


> d_miracle36 said:
> 
> 
> > http://www.capnography.com/new/index.php?option=com_content&view=article&id=95&Itemid=61




Sorry I am aware of the various wave forms but do you mean that if the plateau is too low it means that the patient cannot produce enough effort to overcome the pressure of the c-pap? I am just trying to understand the statement. I may not have worded my question appropriately.


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## 46Young (Nov 17, 2012)

d_miracle36 said:


> ChaseZ33 said:
> 
> 
> > Sorry I am aware of the various wave forms but do you mean that if the plateau is too low it means that the patient cannot produce enough effort to overcome the pressure of the c-pap? I am just trying to understand the statement. I may not have worded my question appropriately.


If you have total loss of alveolar plateau (C-D), the pt is has severe bronchoconstriction. When the pt has severe bronchoconstriction, they cannot exhale much if at all. If they cannot exhale, and the CPAP is delivering air, this will exacerbate the air trapping. 

The plateau refers to phase III of the waveform, which shows expiration (page 15 from the link). Point D is where you get your "End" Tidal CO2, since this is at the end of expiration.

"Quantitative capnography" refers to both the number and the graph. Just having a number is like having the  heart rate but without showing the rhythm.

http://multileadmedics.com/www.mult...y_files/Slap the Cap handout 2012_revised.pdf

Pages 15, 18 and 25 in particular.


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## triemal04 (Nov 19, 2012)

I actually wrote this the day the OP first posted but got very sidetracked, so some of it's redundant, some of it allready has been answered, but oh well.

Everything.  Now don't take offence, I was being facetious and making a joke; it's just that you only gave a pretty brief description for the call, and hopefully left out a lot of the information you actually have.

In no particular order:
1.  Why didn't you listen to the lungs at some point?  Depending on your partner, going off their assessment may sometimes be ok initially, but you should have checked for yourself at some point.
2.  Why did you wait to start treating this patient?  Whatever treatement you decided on, in the house was where it should have been started.  Rapidly moving someone who's having trouble breathing, especially a CHFer can backfire very fast.
3.  Respirations; not just 12, but regular, full/shallow, long expiratory phase, gasping?
4.  Had she been using her own inhaler/nebulizer?  How much?  (even if this was pulmonary edema it's still nice to know, and if you are trying to figure out what is going on it's useful info)
5.  How alert was she really?  Not following commands and "mumbling" paints a bad picture.  In someone with respiratory distress that, coupled with a slow resp' rate is a very bad sign.  Maybe assisted ventilations sooner rather than later would have been a good thing.
6.  You have ETCO2 capabilities; do you just have the adapter for a BVM, or do you also have the nasal cannula's?  Very valuable bit of info, and you can learn a lot from it beyond the expired amount of CO2.
7.  She was cool/wet at the ER; was that consistent with what you saw?
8.  JVD?  Peripheral edema?  Has it increased recently?  
9.  What meds is she on?  Compliant?  Any recent changes to her regime? 
10.  Why would being unable to follow directions cause CPAP to create gastric distension?  I'm really asking you to think about this, not just quote your protocol.
11.  Once she stopped breathing did you consider that more advanced treatements or medications other than albuterol would be needed?  (if you have that capability)
12.  Any audible respiratory noises without using a stethascope?
13.  Since you were treating this as a COPD exacerbation did you continue the neb while using the BVM?  (if you have that capability)
14.  Any other things that may have been going on during the last week?  Recent complaints?  Illness?  Hospitalizations?

Grabbing a patient and running for the ambulance and/or the ER is often not the appropriate course of action and can sometimes make a bad situation worse.  While it may not have changed the outcome it doesn't sound like it did your patient a bit of good.  And all of the above information can be gathered pretty quickly with practise and will help you and the ER decide on what needs to be done.

Learn from this and don't do it again.


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## stairchair (Nov 22, 2012)

You were right not to use cpap I know it would have helped but its protocal for a reason you did what you could sometime that's as good as it gets btw no shame in trusting your partner this isn't a job you can do by yourself


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## Sublime (Nov 22, 2012)

stairchair said:


> You were right not to use cpap I know it would have helped but its protocal for a reason you did what you could sometime that's as good as it gets



I'm going to have to respectfully disagree with you on this. I don't believe not performing a potentially life saving intervention because of a very questionable and subjective protocol was the right move.

My FTO told me once "Treat your patient, then chart your chart". 

Letting your patient get to the point of respiratory arrest and then having to bag them is far from "as good as it gets". 

If nothing else he could have called med control to override his protocol. I would have at least attempted CPAP, if she can't handle it what does it hurt? A lot of times these patients get a massive relief when put on the CPAP mask because now they can actually breath!!



stairchair said:


> btw no shame in trusting your partner this isn't a job you can do by yourself



Yeah no shame in trusting your partner... IF you can actually trust him.


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## VFlutter (Nov 22, 2012)

Was your partner a basic or another paramedic? I have worked with a lot of highly competent people but I still would never make a treatment plan based off someone else's assessment, especially a partner of lower certification. I would still be weary to go off information from a partner of equal level.


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## sdafbkfsdbkjdsf (Nov 23, 2012)

Thank you guys so much for your reply's I have learned a lot and I'm going to go back and hit those A&P books to get those juices flowing. And my partner was an EMT, and after that call I've been really hitting it hard in getting the best patient care there is.


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## Fish (Nov 25, 2012)

lill91210 said:


> I can't get over this call and I would like your in put here.
> 
> I was dispatched to a 80 y/o F who was having difficulty breathing. I arrive on scene and see her in the tripod position sitting on her bed. The family states that she has been having a hard time breathing for the last 2 days and it got worse today. She has a history of CHF, COPD, Asthma, and hypertension. she was on a home nasal cannula when I arrived.
> 
> ...



Just wasn't following commands or was unconcious? I will still put someone on CPAP even if they cannot follow commands, as long as they can protect their own airway. If they are unconconscious or profoundly altered I will not


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