Had a call I wish to discuss....

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So I had this routine bariatric IFT from hospital X to nursing home X. Pt. is 550lbs, hx emphysema, copd, asthma, CHF, diabetes,, chronic pneumonia, etc. Pt. c/o DIB once in the truck to leave hospital X, states its because of the heat in the ambulance. Once cooled down, breathing improves so I no longer worry about the breathing. 3/4 of the way to NH pt. again complains of DIB, is breathing at 22p/m which isn't a big deal, but seems to be forcing it and having some dypsnea and SOB when talking.

Being a basic truck we do not have pulse-ox, and given the work he seems to be doing to breathe I tell my partner to divert to the nearest hospital, which we do. I place the pt. on 8LPM simple mask enroute to hospital. Doctor at ER kind of gets pissed at me because she thinks its silly we brought him here for that. I tell her we have no way of measuring his sat and he seemed to be having trouble so we diverted to the hospital. After learning we were a basic truck she said we did the right thing. What do you guy's think, just curious? I can't see much else we could/should of done.
 
At 550 lbs he is going to have some trouble breathing especially on exertion.

Was he in a position of comfort (sitting up)

Discharged on O2?

How long was he stationary?

The fact that under no exertion he again developed the shortness of breath could be a problem.

What did his lungs sound like?(if assessing them was even possible with his size)

What was his discharge diagnosis, respiratory?

With out laying eyes on him I couldnt really tell you, it comes down to a judgement call, you believed he needed to be evaluated with his Hx not a bad choice.

Better then having him die in some nursing home because he cant reach the call light.

Dont beat yourself up over it.
 
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You can't check a pulse ox? What a handicap.



Did he have any other notable signs or symptoms of respiratory distress? What were the lung sounds, anything adventitious?

What was his respiratory excursion? Any cyanosis? Depth of breathing?

You did the right thing.

The MORE right thing would be to go to walgreens and buy yourself a personal pulse ox and just dont even tell your job you have it in your pocket.
 
Something to learn from is when you have a patient with a history of respiratory problems, ask about any recent episodes of respiratory distress. It could very well be that this patient has short episodes of minor difficulty breathing. Does the patient experience DOE? How long do those episodes last? Remember, at 550 lbs, simply moving around a bit, even while seated, could be significant exertion.

That stuff is in addition to what CAOX3 and 8jimi8 posted.

It's patients like these that you get to experience and learn from. DOE is not uncommon. Be curious. Try to figure out the patient's baseline status. When you pick up patients, don't just grab the paperwork and go... get the RN. Listen to the report. Ask questions. (Don't take all day though.) Those few minutes you spend getting report might just give you a vital clue later that something has gone seriously wrong with your patient.

The point is, simply, keep learning. Be curious, and try to figure out what your patient's baseline is. Why? Deviation from that can be bad. Sometimes one patient's stable baseline can be another patient's OH CRAP!!!! status.

I liked doing IFT's precisely because of that... I could learn about the patients in more detail, and learn more about how different medical problems appear. The patients were often "sicker" but generally stable enough to learn from. Later, it made doing 911 seem easier, even though the "problem" was more acute.

Definitely don't beat yourself up over this and don't second guess yourself about it. It's a learning experience and offers you a good chance to become an even better provider!
 
Yeah I'd say thats about right ... oh btw mate its much easier to say SOB rather than DIB; took me a while to figure out whatchoo on bout.

Buggered up abbreviations and bad handwriting represent major clinical risk.
 
I still don't know what DIB means?

Difficulty ........ Breathing?
 
MrBrown said:
Yeah I'd say thats about right ... oh btw mate its much easier to say SOB rather than DIB; took me a while to figure out whatchoo on bout.

Buggered up abbreviations and bad handwriting represent major clinical risk.
Click to expand...

Unless you find yourself in a situation like I did a year or two ago when I was transporting an elderly individual code 80 from the nursing home to the ER and set my run report down for just long enough for him to read, "SOB".. long story short he told me, "Im not a Son of a b***h " before I realized why he was giving me the look he was giving.
 
Just as a note, some agencies do not allow the use of SOB for the reasons listed by medicrob, I know of one such agency, they require DIB (Difficulty in breathing) and it IS an accepted abbreviation.
 
I have to admit I have never seen DIB used before. Plus "Difficulty in breathing" just sounds awkward and like improper English. You have to remember that accepted abbreviations vary from place to place. The only absolutes are the ones JAHCO has banned, and that doesn't apply to EMS.
 
thanks for all the input everyone, very helpful. Yeah...I agree DIB sound's weird but my company uses it and I use it out of habit.
 
I, too, never heard DIB before today, but understand the reason(s) not to use SOB.

Back to the OP, you made a decision and explained it to the doc. Well done.
 
When talking to the ER I just straight up say Shortness Of Breath.
 
Would DIB not be different to SOB. I've made some form of differentiator in my head but I cant quantify it.


BTW you were right to go to the hospital if you did't have the tools to check him out. I would ask to see if ye can get Sp02 it seems like even Basics should have that for IFT. The other option could have been ALS but its a case of which is more available/easier
 
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8jimi8 said:
The MORE right thing would be to go to walgreens and buy yourself a personal pulse ox and just dont even tell your job you have it in your pocket.
Click to expand...

If I might.

While we normally do agree, i don't suggest doing this.

medical equipment that is used for pts is required to be checked and meet a different criteria of both maintenence and error than that sold for personal use.

If a provider has "personal equipment" that doesn't meet the standards that provider can be in for some big problems if an angry patient sues or some complaint is filed.

A pulse ox is not required to determine if a patient is oxygenating or ventilating. There are more than enough clinical signs and symptoms without a number that tells you very little anyway.

I think the OP did the right thing. Perhaps with the experience that patients don't like to go to nursing homes and will develop everything from SOB to radiating crushing substernal chest pain in order to go back to a hospital.
 
Couple of options not mentioned. One is to ask the patient what he wants to do. If he is alert and oriented and says "yeah, this is my normal shortness of breath, I don't want to go to the hospital," that's a factor in favor of continuing to the nursing home (with good documentation). Same for the converse, if he says "take me to the ER."

Another option would be to call your medical control. You can say "we're doing this IFT, they guy is complaining of SOB etc etc." Helps remove some liability if they say keep going to the IFT.

Third thought is to make sure that you get a good idea of the patient's baseline before leaving the hospital. This isn't always possible but if you notice something like the patient is short of breath, diaphoretic etc. ask the nurse if this is how he has been.

I think the big thing is asking that patient how this compares to his normal shortness of breath. With his obesity, COPD and other issues he could be someone who gets short of breath when he changes the tv stations too fast. If it's a new problem, go to the ED. If it's the same problem that the patient has been having go to the SNF.
 
Veneficus said:
If I might.

While we normally do agree, i don't suggest doing this.

medical equipment that is used for pts is required to be checked and meet a different criteria of both maintenence and error than that sold for personal use.

If a provider has "personal equipment" that doesn't meet the standards that provider can be in for some big problems if an angry patient sues or some complaint is filed.

A pulse ox is not required to determine if a patient is oxygenating or ventilating. There are more than enough clinical signs and symptoms without a number that tells you very little anyway.

I think the OP did the right thing. Perhaps with the experience that patients don't like to go to nursing homes and will develop everything from SOB to radiating crushing substernal chest pain in order to go back to a hospital.
Click to expand...

Spot on Vene, I have been regretting that statement. The most right thing to do is ask your employer to change their protocols and buy y'all some equipment. Thanks for the push-up, Vene
 
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