# Scenario For Bls Providers



## skyemt

you are dispatched to an elderly female, difficulty breathing.

you arrive on scene, and find an elderly female, 78 y/o, sitting in a chair...
your general impression is that she is having labored breathing...
ALS was not available earlier, but you put out for an ALS crew...

she is alert and oriented, and denies much difficulty breathing, even though you see the s/s... you ask who called 911, and she tells you her daughter did, because she was concerned.

her airway is patent, seems to be breathing quick and shallow, with accessory muscle use... you hear wheezes bilaterally... her pulse seems a bit quick, but regular... you feel she is a high priority pt, so you want to get your history and get going...

so, time to assess...

what do you want to know...


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## TheMowingMonk

if there is a history of asthma or lung related issues


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## KEVD18

s-
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## skyemt

there is no history of asthma of lung issues...

a- no allergies
m-no meds
p-no real hx... been relatively healthy
l-dinner last night
e-nothing special

o-woke up early in am, could "feel" gurgling in lungs
p-nothing makes it better
q-feels like "stuff gurgling"... pt states it is "very annoying"
r-none
s-5/10, but more of an annoyance
t-since early am


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## LucidResq

I'd start her on 02 via NRB @ 15 lpm. 

What are her vitals? Including spo2 and temp. if possible? How's her skin? Breath sounds (more info than already given if there is any)

I'd examine the chest and maybe even her ankles for pitting edema - worth a shot. 

Coughed up any junk?
Ever smoke?
Pleuritic pain?
Recent surgery, airplane trips?


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## skyemt

LucidResq said:


> I'd start her on 02 via NRB @ 15 lpm.
> 
> What are her vitals? Including spo2 and temp. if possible? How's her skin? Breath sounds (more info than already given if there is any)
> 
> I'd examine the chest and maybe even her ankles for pitting edema - worth a shot.
> 
> Coughed up any junk?
> Ever smoke?
> Pleuritic pain?
> Recent surgery, airplane trips?



pulse is 96 regular
BP is 92/64
RR is 30, shallow-- pt still denies being in resp distress
skin is pale, warm, dry
breath sounds- expiratory wheezes bilaterally

there is edema in the ankles, pt states that edema is normal for her

no junk coughed up
no hx of smoking... no pleuritic pain, no recent surgeries, or plane trips


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## LucidResq

Her vitals are concerning. It sounds like it might be a pulmonary embolism, but it could be several other things. The treatment will be the same regardless. Considering her respiratory rate and depth I would strongly consider bagging her. I would load and go unless ALS was nearby. Position of comfort... reassess vitals every 5 min. or so. Keep a close eye on her airway and mental status. Prepare to ventilate, suction, and defibrillate.

Where's the daughter by the way? Does she have anything to say?


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## skyemt

LucidResq said:


> Her vitals are concerning. It sounds like it might be a pulmonary embolism, but it could be several other things. The treatment will be the same regardless. Considering her respiratory rate and depth I would strongly consider bagging her. I would load and go unless ALS was nearby. Position of comfort... reassess vitals every 5 min. or so. Keep a close eye on her airway and mental status. Prepare to ventilate, suction, and defibrillate.
> 
> Where's the daughter by the way? Does she have anything to say?



the daughter is present, btw, if you want to ask anything...

didn't mention the spo2, which was 95 on 100% O2 15 lpm via NRB

you seem fixated on PE, when there is really no indication of that... and it is not a PE...

you have a patient who is able to talk and tells you she is not in resp distress... she is obviously tolerating the rapid resp rate... why in the world would you bag her now... you would not...

if it's asthma, you could call for albuterol... if it's not, then you wouldn't...but, the treatments are NOT the same...

this scenario is about thinking... so what are we thinking? what could it be? what more info could we get?


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## LucidResq

skyemt said:


> the daughter is present, btw, if you want to ask anything...
> 
> didn't mention the spo2, which was 95 on 100% O2 15 lpm via NRB
> 
> you seem fixated on PE, when there is really no indication of that... and it is not a PE...
> 
> you have a patient who is able to talk and tells you she is not in resp distress... she is obviously tolerating the rapid resp rate... why in the world would you bag her now... you would not...
> 
> if it's asthma, you could call for albuterol... if it's not, then you wouldn't...but, the treatments are NOT the same...
> 
> this scenario is about thinking... so what are we thinking? what could it be? what more info could we get?



I have a reason to be concerned about PE. Hmmm... sudden-onset dyspnea, tachycardia and edematous legs in an elderly (and likely inactive) woman... of course PE crosses my mind. 

Considering as a basic I can't diagnose and my meds for respiratory distress are albuterol and epinephrine if they're prescribed to the pt and she doesn't take either of those drugs, my treatment for her respiratory distress is going to essentially be high flow o2 and rapid transport regardless of the cause. 

I would just want to ask the daughter why she called, if she's noticed anything over the past couple of days, and if her mother has any meds/history that she's not telling me about.

 There's no sense in hanging around on scene forever trying to figure out exactly what's wrong when my treatment is probably not going to be significantly affected and the woman obviously needs definitive assessment and care at a hospital immediately.


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## piranah

well...there is gurgling in her lungs.....fluid?..and wheezing on expiration...possibly a narrowing of the upper airway and maybe some fluid retention issues shes never had checked out...but as a BLS provider in RI i would put her on NRB 15 lpm and transport because in my area your only 20 min to nearest hospital..maybe a allergic reaction....hey there always CHF...


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## skyemt

LucidResq said:


> I have a reason to be concerned about PE. Hmmm... sudden-onset dyspnea, tachycardia and edematous legs in an elderly (and likely inactive) woman... of course PE crosses my mind.
> 
> Considering as a basic I can't diagnose and my meds for respiratory distress are albuterol and epinephrine if they're prescribed to the pt and she doesn't take either of those drugs, my treatment for her respiratory distress is going to essentially be high flow o2 and rapid transport regardless of the cause.
> 
> I would just want to ask the daughter why she called, if she's noticed anything over the past couple of days, and if her mother has any meds/history that she's not telling me about.
> 
> There's no sense in hanging around on scene forever trying to figure out exactly what's wrong when my treatment is probably not going to be significantly affected and the woman obviously needs definitive assessment and care at a hospital immediately.



ok... keep in mind, different basics can do different things... in my system they can do albuterol treatment for resp distress...

as far as the daughter, she called because last night, the daughter also had a syncopal episode...

the issue of onset was not asked, but, it was sudden... she felt no distress before it woke her up out of her sleep...

also, keep in mind that scenarios are also about critical thought, as well as treatments... while your treatment of the patient may not change, you should be assessing for possible underlying causes.

any last guesses?


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## AZFF/EMT

Did you say the daughter had a sycopal episode?


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## skyemt

sorry, botched sentence...

the daughter called because the mother had a syncopal episode...


did you ever type something, then look back and say how the he** did that get there???

sorry...


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## AZFF/EMT

I do it all the time. I started thinking possible CO poisoning but then her sats would actually read higher. 

If I were a BLS provider I would call for ALS no doubt. High flow O2 and transport. I am lucky an we are never without ALS. all mixed crews 50-50 medics and emts.

I would want a Blood sugar for sure. 

Does the wheezing get better with O2?
If not consider SVN albuterol.

where exactly is the pain and gurgling? 

Possible stomach issue, food poisoning?


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## skyemt

this was an actual call, and the presentation was accurate.

the diagnosis was CHF (no prior hx) presentation secondary to a left sided AMI.

the real point of this scenario is to emphasize the awareness of atypical presentations, especially for women, the elderly and diabetics.

we must be aware of this when assessing.

throughout all the replies, possible cardiac was not really considered.

in reality, this woman was suffering the effects of an MI.

hope it is food for thought, if you encounter a similar patient.

thanks for playing.

sudden onset of symptoms that woke her out of her sleep was significant, as was the syncopal episode.  also, while peripheral edema was normal for her, it was much worse than it had been (would not have known that  without asking in detail about it).


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## AZFF/EMT

I guess thats the benefit of never running BLS only calls. This patient would have gotten a 12 lead. I always find it hard to go through BLS scenario's online. It's much easier and fluid in real life. Seeing the patient. Where was her pain? Where did she point when describing it? If it was anywhere near her chest and with ECg interpretation she would have got O2, ASA and transport, possiblly lasix.

I originally thought from the start CHF due to the wet lungs and edema, but got way off track. 

Did you get to see an ECG? what did it show?


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## skyemt

AZFF/EMT said:


> I guess thats the benefit of never running BLS only calls. This patient would have gotten a 12 lead. I always find it hard to go through BLS scenario's online. It's much easier and fluid in real life. Seeing the patient. Where was her pain? Where did she point when describing it? If it was anywhere near her chest and with ECg interpretation she would have got O2, ASA and transport, possiblly lasix.
> 
> I originally thought from the start CHF due to the wet lungs and edema, but got way off track.
> 
> Did you get to see an ECG? what did it show?



this was not an easy call... thing was, despite the s/s of resp distress, she only would call it an "annoyance", and kept denying distress...

she denied any pain whatsoever, and nothing near or in her chest... no pressures, nothing.  i did not get to see the ECG, but was told it was inconclusive...  
also, there was no history of CHF, so not easy to treat it that way.  tests done in the ED revealed MI...


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## AZFF/EMT

nice. well proper treatment would have just been. O2, position of comfort and drive. good job.


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## certguy

Rats ! I didn't get to play before you closed it , but CHF was my guess , this was a good scenerio . Guys , don't get too focused on waiting for ALS when you can scoop -n-haul with a possible intercept on the way . The way she was describing the discomfort should've cued me off on a possible MI too . 



                                     Craig


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## Vizior

skyemt said:


> this was an actual call, and the presentation was accurate.
> 
> the diagnosis was CHF (no prior hx) presentation secondary to a left sided AMI.
> 
> the real point of this scenario is to emphasize the awareness of atypical presentations, especially for women, the elderly and diabetics.
> 
> we must be aware of this when assessing.
> 
> throughout all the replies, possible cardiac was not really considered.
> 
> in reality, this woman was suffering the effects of an MI.
> 
> hope it is food for thought, if you encounter a similar patient.
> 
> thanks for playing.
> 
> sudden onset of symptoms that woke her out of her sleep was significant, as was the syncopal episode.  also, while peripheral edema was normal for her, it was much worse than it had been (would not have known that  without asking in detail about it).



So, I gotta ask you:

if this is a scenario, what was supposed to tip us off to the outcome?  I don't see how it is thought provoking to go through a scenario that is completely "atypical".  I bet that some of the higher educated members here can present cases that present almost identical to this with completely different diagnosis.  

And so, in your scenario, when someone suggests something, you immediately tell them that they're completely wrong(like suggesting a Pulmonary Embolism, or to consider bagging the patient, both perfectly logical considerations.)

So just out of curiosity, what did you do for the pt and what did you think it was... and why?


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## skyemt

Vizior said:


> So, I gotta ask you:
> 
> if this is a scenario, what was supposed to tip us off to the outcome?  I don't see how it is thought provoking to go through a scenario that is completely "atypical".  I bet that some of the higher educated members here can present cases that present almost identical to this with completely different diagnosis.
> 
> And so, in your scenario, when someone suggests something, you immediately tell them that they're completely wrong(like suggesting a Pulmonary Embolism, or to consider bagging the patient, both perfectly logical considerations.)
> 
> So just out of curiosity, what did you do for the pt and what did you think it was... and why?



if you don't like the scenario, move on along... no need to come out here and criticize for no reason.

the point is to realize that there are MANY atypical presentations, and we are supposed to be AWARE of all of them.

assessing is about thinking... the very nature of a thought provoking scenario is to come up with possible differential diagnoses, and atypical presentations.  if you just want to scoop and run, go back to the 70's.

as for giving hints, forgive me if i tried to steer the group in the right direction!

those that participated liked it.  then you come along after the fact to poke holes in it... what is the point of that, really?

since you are so knowledgeable about how to do a good scenario, please, i look forward to seeing yours... although i doubt i will.


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## Vizior

skyemt said:


> if you don't like the scenario, move on along... no need to come out here and criticize for no reason.
> 
> the point is to realize that there are MANY atypical presentations, and we are supposed to be AWARE of all of them.
> 
> assessing is about thinking... the very nature of a thought provoking scenario is to come up with possible differential diagnoses, and atypical presentations.  if you just want to scoop and run, go back to the 70's.
> 
> as for giving hints, forgive me if i tried to steer the group in the right direction!
> 
> those that participated liked it.  then you come along after the fact to poke holes in it... what is the point of that, really?
> 
> since you are so knowledgeable about how to do a good scenario, please, i look forward to seeing yours... although i doubt i will.



I'm not gonna do a scenario on here b/c I don't see the point.  There are plenty of professionals out there that have written books about it.  I understand that you're trying to convey the point that there are many different presentations of different conditions.  

What I'm trying to point out is this:  you proposed a scenario that you consider "atypical", and then you jumped on people that were going down perfectly reasonable paths based on the information given.  You have blinders on, and are convinced that there is only one possible diagnosis, while in the field, there are gonna be many, many different thoughts to consider.  

I want to know is what did you find in the field here that absolutely points to CHF secondary to an MI?  What is a complete contraindication to rule out a pulmonary embolism?  

You can either run a scenario or you can tell a story.  But you can't just expect people to come up with the proper diagnosis, with just BLS diagnostic equipment in the field, the closest you can come is having a bunch of educated guesses.

And thus I'm asking again, honestly, what did you think the issue was from a BLS standpoint going into the hospital, and what interventions did you perform?


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## skyemt

Vizior said:


> I'm not gonna do a scenario on here b/c I don't see the point.  There are plenty of professionals out there that have written books about it.  I understand that you're trying to convey the point that there are many different presentations of different conditions.
> 
> What I'm trying to point out is this:  you proposed a scenario that you consider "atypical", and then you jumped on people that were going down perfectly reasonable paths based on the information given.  You have blinders on, and are convinced that there is only one possible diagnosis, while in the field, there are gonna be many, many different thoughts to consider.
> 
> I want to know is what did you find in the field here that absolutely points to CHF secondary to an MI?  What is a complete contraindication to rule out a pulmonary embolism?
> 
> You can either run a scenario or you can tell a story.  But you can't just expect people to come up with the proper diagnosis, with just BLS diagnostic equipment in the field, the closest you can come is having a bunch of educated guesses.
> 
> And thus I'm asking again, honestly, what did you think the issue was from a BLS standpoint going into the hospital, and what interventions did you perform?



listen, you proclaim that you do not even like scenarios out here, and don't believe in them...
i'm not going to waste my time when you are not interested in them in the first place, and you just want to poke holes.

what i expected were thoughtful questions, and that's what i got. a good job by all, and those who participated liked it.

move along, and whine elsewhere.


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## LucidResq

Vizior said:


> And thus I'm asking again, honestly, what did you think the issue was from a BLS standpoint going into the hospital, and what interventions did you perform?



Yeah I'm curious. What did you think it could be? What did you do about it?

 I think it's fine to use a scenario with an atypical presentation, but don't be surprised when people come up with answers based on typical presentations. Just don't be so quick to cut people down for their answers, especially when those answers are logically based on the information given.


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## skyemt

well, we called for ALS, but didn't get it...

due to the sudden onset of symptoms that woke her out of her sleep, combined with her associated syncopal episode and resp distress, we suspected (feared) something cardiac (all that wheezes is not asthma)...

we called med control to run it by them... they agreed, gave us orders for ASA, and had us call the ER to alert them of possible MI coming in...

so, did it matter? i would like to think so...
have we studied atypical presentations? yes...

did it prevent us from strictly thinking resp? yes... med control wanted our assessment, because they may have considered a resp treatment.

she did not fit the profile of PE, so we didn't really go there...due to her age and presentation, cardiac origin was the chief worry.

so, if you find no value in these exercises, so be it.

i know that medics practice differential diagnoses all the time, and are always thinking about underlying causes.

if you don't think BLS involves good assessments and a good history, i can't really help you.


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## certguy

May I suggest that a scenerio is a learning experience and those of us who post scenerios should not criticise ( I hope I spelled that right ) , but guide the participants through it . This should be an educational , not confrontational enviorment . People will learn more if they enjoy it and are comfortable , rather than offended . 


                                                         Craig


TIME OUT ! take a deep breath and work together .


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## piranah

i suggested CHF earlier....but i coulda been many things


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## REMSI Medic 10

start initian assesment so I would start her on some 15L non-rebreather reassess vitals ever 5-10 minutes, contact hospital and give patient stats, arrive at hospital, etc.


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## BossyCow

Given her age and the respiratory issues, she would have been a quick load and go like heck regardless of what is causing it. With ALS unavailable, edema and audible wheezing and gurgling, CHF has to be a concern, whether likely or not. 

Since you listed this as an ALS unavailable, BLS call... treatment would have been based on what I see, not what I think it might be from. High Flow O2, with the combo of 'gurgling' and edema I would have given ASA, kept the monitor on her, kept the BVM close and been ready for when she coded. 

This would have been not much time on scene for questions and Hx taking. Pedal to the metal and get her to the ER.


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## JPINFV

Come on people, it's a scenario. Ok, so you start transport immediately. So what? Are you not going to continue doing an assessment during transport? Even if you (generic) are maxed out with treatments, I don't see why that should preclude you from digging a little deeper and developing a rational hypothesis (better known as a differential diagnosis) based off of what you uncover. If people really don't see a point in actually attempting to examine the patient past the point of "ALS, immediate transport, high flow O2," then whats the point of even running a scenario?


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## emt19723

i was thinking CHF myself before i read the actual diagnosis from the OP.  sudden onset, syncope, 95% on 15 lpm, gurgling as shes breathing, and swollen ankles/feet. sounds pretty textbook right there.


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## YouthCorps1

SAMPLE, when did it start, what does it feel like, has it happened in the past? start this patient on a nasal canula at 7-lpm just in case. any LOC? asthma patient? does this pt have an inhaler? has it been prescribed by a dr? start albuterol via nebulizer or maybe epinepherine? transport with the head elevated .


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## JPINFV

YouthCorps1 said:


> SAMPLE, when did it start, what does it feel like, has it happened in the past? start this patient on a nasal canula at 7-lpm just in case. any LOC? asthma patient? does this pt have an inhaler? has it been prescribed by a dr? start albuterol via nebulizer or maybe epinepherine? transport with the head elevated .



SAMPLE? Welcome to post 3. Inhaler? Welcome to the M in SAMPLE. Nasal cannula at 7 LPM? I'm sorry, that flow rate is in a different castle (try again).


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## reaper

That first week of EMT school, must be getting good!


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## KEVD18

check is profile, he's 15 years old(like that wasnt blazingly apparent)


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## EMTinNEPA

YouthCorps1 said:


> SAMPLE, when did it start, what does it feel like, has it happened in the past? start this patient on a nasal canula at 7-lpm just in case. any LOC? asthma patient? does this pt have an inhaler? has it been prescribed by a dr? start albuterol via nebulizer or maybe epinepherine? transport with the head elevated .



SAMPLE?  Welcome to post #3.  Nasal canulla at 7lpm?  You are aware that nasal cannulas are only used to administer up to 6lpm, right?  And even then they're only delivering about 25% O2.  LOC?  It was established by skyemt that the patient had a syncopal episode which is why the daughter called.  History of asthma?  No.  Welcome to post #4.  You need a perscription from a doctor for an inhaler but your BLS truck carries nebulizers and epinepherine?  Man, I'm working in the wrong region.  You need medical command for epi?


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## EMERG2011

LucidResq said:


> Her vitals are concerning. It sounds like it might be a pulmonary embolism, but it could be several other things. The treatment will be the same regardless. Considering her respiratory rate and depth I would strongly consider bagging her. I would load and go unless ALS was nearby. Position of comfort... reassess vitals every 5 min. or so. Keep a close eye on her airway and mental status. Prepare to ventilate, suction, and defibrillate.



Considering the abnormal lung sounds I'd be thinking simple pneumonia, especially if she's sedentary. While we should have an elevated awareness for PE etc, this presentation doesnt sound like your typical PE. Give her O2 15 by NRB, get ALS on the line and check their ETA. If ALS is too far, load and go to the nearest hospital lights and sirens.


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