To the OP:
Overall, I would say that the basic process of this call went fine. There's some fine-tuning that should be done for both you and the medic partner, but on the whole, not bad.
What you BOTH appear to have missed is that the patient has a low-ish BP and is tachycardic, especially in the setting of someone that's normally hypertensive. Yes, this patient has CHF, is probably having an exacerbation of this, but she's also showing signs of sepsis. The low SpO2 should have been corrected, and it looks like you took steps to correct it but you attempted to "compensate" for the COPD by lowering the O2 flow rate through the NRB. While the action itself wasn't ideal, I think I know where you were coming from, and I think you were trying to prevent shutting down oxygen-related respiratory drive. This tells me that you're trying to think through problems your patient is presenting with. I suspect your Medic noticed something wasn't working or saw that the patient could probably benefit from CPAP and started that therapy instead. What would I have done in that instance? I'd look at her work of breathing. If she's working really hard and not doing well despite her effort, I might go straight to CPAP. In the short-term, I'm not too concerned about shutting down her respiratory drive with too much oxygen. If her breathing stops, the BVM will do just fine. She certainly tolerated the CPAP just fine and sounds like she was improving because of it.
Getting a line (even if it's a saline lock) was probably a GREAT thing for the ED because you have vascular access and they're likely going to start giving her a decent amount of fluids because of her soft BP and high-ish heart rate and they can do it a bit more quickly because you did get that line placed.
While I think the medic should have attended this patient, you were also in a position to potentially be able to address anything that might have been needed. If the patient became more hypotensive, you could have possibly initiated a fluid bolus. You (and the medic) would have needed to be watchful for this and ready to react if needed. So, mostly this was a wash, but leaning toward medic attending, good learning call for both.
Whatever you do, don't beat yourself up over this call or think we're trying to beat you up either. Pretty much all of us have been doing this stuff for years and we all remember what we were like when we were newer to the field. There's a LOT to learn! This patient has a few problems all running concurrently and sometimes it's just not that easy to sort them all out.
My guess as to what happened? CHF probably was getting slowly worse, her lungs probably started getting more wet than usual, eventually becoming a GREAT place for infection to start, and as that got going, it probably exacerbated the COPD, which probably was what caused her (or her husband) to call. I think she probably called sooner than most of the patients like this that I've seen.
I think as long as you approach this from "what could I have done better" and learn from calls like this, you'll only get better and better at doing the work you do.
