This is my first visit to EMTLIFE. And this is the first thread I've really read.
My little back-story... spent years working in an urban area on nights. Treated >100 CHF patients every year. My goal when I started there was to be as good as some of the folks I worked around. I never dreamed I figure stuff out that they hadn't. But I did.
In every service I have worked for or been around, respiratory failure is the ONE area where we can make a difference in short AND long term mortality. It is also the one area EVERY service fails in! Mortality of these patient's is around 6%. More in urban areas, less in affluent populations. My experience with these folks was in the days before CPAP. My plan was simple but effective. My mortality to ICU was < 1 %. None of the patients that I was able to follow up on after admission passed away. But my ability to follow up after the ED was too inconsistent to be a reliable measure. My plan then was calm the patient, AIRWAY, calm the patient, BREATHING, calm the patient, CIRCUALTION, calm the patient.... I always got the nitro on board early. I like a sublingual dose followed by 1-2 inches of paste. I gave the nitro and lasix a chance to work before I EVER considered moving the patient. A CHF patient will always get worse to some degree in the process of moving to the ambulance. Often significantly worse! Screw all the academic criteria they teach us about when to start bagging. You bag them when there's a detiorated LOC or you think they're looking too tired to breath.
Since I left the hood I work in a rural area. I don't see that many patients. And the CHF patient's I see are not nearly as "brittle". Race and economics play a huge factor in these patients. Black people just get the short end of the stick in all areas of cardiovascular issues.
I simply haven't had enough experience with CPAP to have an opinion on it. If it comes down to scoop and run with sirens screaming in the background then yea, CPAP does yield better results. But the results I see with CPAP are about the same as what I got in the 90's without. The main difference I see is that most of my patients were in much better shape by the time I got to the ED than many I've seen hours after arrival at the ED with CPAP. I suspect that has to have some effect on mortality but that's just an educated guess on my part.
With this patient, it would be very hard to coach and comfort him if the language barrier was too severe. There are generally three areas that will adversely affect our ability to successfully manage these patients with just meds. Inability to calm the patient (too anxious, language barrier...), inability to calm the crowd (family, fire, your partner), or inability to give the meds (unsuccessful IV). I found I could manage any one of those areas. But if I encountered two areas of problems that was too much and it was time to switch to a load and go process. Fortunately for me, that was rare. But even without the ability to verbally communicate well it is very conceivable that the EMS team's calm and caring attitude could have been enough to give your patient the patient confidence and reduce his anxiety. Calming him and using nitro would likely have negated the need for CPAP. But at the point you guys got to, I likely would have opted for the CPAP before an ET tube. I don't do RSI; we're just too slow here to have the intubation skills that are needed to go with RSI. Short of RSI, nasal intubation is far more likely to create catastrophic cardiovascular collapse than CPAP is. As to the question of position of the patient after intubation, neither is inappropriate or more likely to be beneficial to the patient.
Okay, I will get off my soapbox now (and this is my soapbox
). Oh one more thing. If these patient’s are hypotensive that changes the game plan. Cardiogenic shock is better managed in the ED than in the patient’s home. Those are load and go patients. Dopamine is good but the ED has additional tools if it doesn’t work. We don’t. Either way, cardiogenic shock with pulmonary edema has a >90% mortality.
