I Can't Breathe! Help Me!

[Veneficus]

HR/sounds (between yells)- 130/min

regular? Strong/weak?

BP- I don't remember specifically but it was somewhere in the 180s systolic.

definately in occlusion or rupture range. MAP would help a lot. In advanced heart failure BP is usually lower due to LV contractility.

RR-28/min
Breath sounds- Wheezes.

with the COPD would expect to hear that all the time.

Edema- Her lower legs had pitting edema but her family said that was normal for her

probably was, do you remember any edema in the abd? (in other words did she look really heavy?) stage I or II CHF would support that BP, but not the later stages.

Hx- TIA, CAD, COPD, hypothyroidism, HTN, hyperlipidemia, diabetes.

Stongly suggests possibility of PE, especially the lipidemia.


Meds- Warfarin, synthroid, metformin, lipitor, spiriva, some others I can't remember. But family said she had been noncompliant with meds.

Not at all shocking.

Onset- About 10 minutes before they called, don't know what she was doing and of course, I forgot to ask what she had been doing.!

dying.

I think Vent makes an excellent point, I wish somebody early on in my career pointed out that people have more than one disease at one time that affects the others. Would have saved me a lot of grief.

From the original post this sounds strongly of PE, especially with my anecdotal experience. Not that I am trying to defend my Dx on less than perfect information, but I think an acute CHF would have had stronger signs, crackles, absent or diminished sounds, maybe even some hemoptysis.I could see the very strong arguement for a COPD exacerbation too.

Would like to know the follow up.

 

[VentMedic]

I'll try to find out some costs for you from a Pharmicist friend of mine.

Combivent is the only name for the Albuterol/Atrovent combo in the U.S. There is talk of a Xopenex/Atrovent in the future. Considering the cost of a Xopenex MDI, I can't imagine the cost of the combo.

Many of my patients stock up on their respiratory meds in Mexico or the islands. The spacer or holding chamber is also free with the meds unlike the U.S. where it costs on average $50 - $75.

Canadians and those of other countries;
Are they still giving Salbutamol by IV in EMS and the ED?

Pardon the off track question.

 

[remote_medic]

Sasha,

from what you explained it sounds like CHF (vitals, edema, etc) however when they become so comprimised and hypoxic that they are screaming and fighting there is not a lot that can be done prehospital.

These patients are the most frustrating to care for (in my opinion). If you can just get them to calm down and accept CPAP, Nitro, IV, Lasix (although lasix is controversial now) you can turn them around, usually very quickly. No amount of "calm down, we are here to help" will talk these people down.

What it sounds like (again, me not being there) is this patient needed sedation and CPAP/BIPAP...maybe as little as an hours worth...maybe more. Not knowing your local protocols I am making the assumption you can't sedate this patient.

By radioing in report you can have the team ready...sounds like this patient needed more then we could offer pre-hospital.

...just one mans opinion...

Chris

 

[medic417]

Combivent is the only name for the Albuterol/Atrovent combo in the U.S. .

Duoneb?:unsure:

 

[VentMedic]

dying.

I think Vent makes an excellent point, I wish somebody early on in my career pointed out that people have more than one disease at one time that affects the others. Would have saved me a lot of grief.

From the original post this sounds strongly of PE, especially with my anecdotal experience. Not that I am trying to defend my Dx on less than perfect information, but I think an acute CHF would have had stronger signs, crackles, absent or diminished sounds, maybe even some hemoptysis.I could see the very strong arguement for a COPD exacerbation too.

Would like to know the follow up.

This lady has most of the chapters present for a COPD or any chronic pt with chronic illnesses.

With the Warfarin, she may have chronic A-Fib. Still at risk for emboli in non compliant. Combined with the COPD, cor pulmonale; RVH, Right Heart Failure , HTN and pulmonary vascular changes.

Med for HTN?

metformin: Diabetes could be from earlier years which then makes renal status even more brittle. Or could be from years of steroid use which still make renal status brittle.

Spiriva: tiotropium bromide inhalation powder, long acting anticolinergic used for COPD. Excellent meds since COPD patients need the cholinergic blockade that opens the airways to release trapped air. However, it too has been controversial.

lipitor: hyperlipidemia, CAD

synthroid: hypothyroidism The med and the disorder comes with a whole list of precautions and reactions especially for women with heart disease.

##############################

Now lets go back to the beginning and walk through how you would have liked to have done this. My input now will be using an aerosol mask with nebulized albuterol and/or atrovent as both an O2 source and to see if some of the wheezes can be decresased to hear what other breath sounds are in there. CPAP with the capapbility of using a neb in line would be nice since that would help with preload and afterload as well as splinting the airways, but if she looks at you like you're the devil, move on.

And good luck getting that 12-lead EKG. That may not happen but try to at least get a baseline rhythm from the standard leads.

Okay Sasha...treat your patient from here... step by step. Some of us have tossed out a lot of different disease processes. Just prioritize from your assessment and do your treatment accordingly without worrying that you can not cure this woman's problems. You as a Paramedic can however initiate enough treatment to make her comfortable and/or give the ED a headstart.

 

[VentMedic]

Duoneb?:unsure:

Duoneb is the trade name from Dey for the liquid and now there is a generic Albuterol/ipratropium bromide available. Many of our Canadians friends as well as those in different parts of the U.S. may not recognize Duoneb.

Combivent is a hold out for the CFC ban and have not been able to reformulate to the HFA version. So far the FDA has granted them an extension but all the other inhalers are now HFA.

I was messing with Outbac1 since the Canadians started this stuff with the MDIs and the HFA regulations.

 

[Outbac1]

Duoneb is the trade name from Dey for the liquid and now there is a generic Albuterol/ipratropium bromide available. Many of our Canadians friends as well as those in different parts of the U.S. may not recognize Duoneb.

Combivent is a hold out for the CFC ban and have not been able to reformulate to the HFA version. So far the FDA has granted them an extension but all the other inhalers are now HFA.

I was messing with Outbac1 since the Canadians started this stuff with the MDIs and the HFA regulations.

That’s OK. Nothing like stirring the pot and feeding the fire a little. Then sit back and watch.

I checked with my friend and Combivent is no longer available due to cfc's.
I guess they are just old ones I'm seeing.

FYI Atrovent MDI $30.00
Ventolin MDI $18.00
Flovent MDI (50) $36.00 (250) $98.00
The new discus is the same price per mcg as the MDI. Prices are Canadian $.

 

[Sasha]

Her pulse was irregular, every so often there'd be a missed beat. I never put her on the cardiac monitor. I know I should have, but it slipped my mind, I was focused on respiratory.Thinking back, I'm wondering if maybe the "missed beats" had been due to an irritable heart due to hypoxia.

I assumed her difficulty breathing had been related to her COPD. I know, don't assume! I had kind of tunnel visioned due to the wheezes. It may be worth noting that I thought I had heard both wheezes and some rales, but my preceptor told me you couldn't have both, one or the other which I see now how much of an ignorant statement that was but back in the call I assumed OK, well then there must have been something rubbing on my scope. So wheezes. Let's try to treat it! And even then I dropped the ball. And I'm also really bad at lung sounds. I call something rales, someone else says ronchi kind of thing.

She didn't look heavy or like she had edema above her lower legs.

Before we go into how to treat, I have a quick question. If it had been CHF, would morphine have been an option? I know it causes respiratory depression, but I also know it can reduce preload, and wouldn't a reduction in preload decrease myocardial oxygen consumption?

 

[Veneficus]

assuming CHF, nitro and morphine are both options, but breathing 28 times a minute, I doubt the respiratory drive was the issue. It sounds more like the gas exchange or transport was causing the problem.

The best way to become good at identifying lung sounds is to spend some time with a RRT or Doc in the hospital and have them teach you one patient at a time.

 

[Outbac1]

No, not really. When we got back to the station he asked for my log book, signed off and said I could leave. On the way back to the station he was talking about having better scene control.

I do plan on calling him so we can go over it later today and I wanna know if he went back to that hospital later and if so how she's doing.

His philosophy is that he is there so I don't hurt or kill anyone, and can ask questions after, citing the fact that (while my school sucks and I'm nowhere near ready) I'm almost done with medic school and will be out by myself when there wont be anyone to remind or reguide.

Sasha

Thats unfortunate that your preceptor has that attitude. He should be guiding you and definately helping you understand what was going on on the call. Not leaving you alone to figure it out. Perhaps you can arrange for another preceptor. Hopefully when you finish you can get a good medic for a partner and they will help you feel more confident and understand what is going on with patients.

I wish you the best.

 

[jochi1543]

Are those of you north of the border keeping Combivent in Canada?

We don't have prepackaged Combivent on our BLS ambulances, but we are taught how to mix Atrovent and Ventolin (which are on all BLS ambulances) and free to use it.

In BC, Atrovent is not in the BLS scope, so neither is Combivent. I don't know about other provinces.

 

[VentMedic]

Thats unfortunate that your preceptor has that attitude. He should be guiding you and definately helping you understand what was going on on the call. Not leaving you alone to figure it out. Perhaps you can arrange for another preceptor.

but my preceptor told me you couldn't have both, one or the other which I see now how much of an ignorant statement

Sounds like the preceptor had a stellar education from a medic mill where his instructor may also have been a graduate.

Her pulse was irregular, every so often there'd be a missed beat. I never put her on the cardiac monitor. I know I should have, but it slipped my mind, I was focused on respiratory.Thinking back, I'm wondering if maybe the "missed beats" had been due to an irritable heart due to hypoxia.

I assumed her difficulty breathing had been related to her COPD. I know, don't assume! I had kind of tunnel visioned due to the wheezes. It may be worth noting that I thought I had heard both wheezes and some rales, but my preceptor told me you couldn't have both, one or the other which I see now how much of an ignorant statement that was but back in the call I assumed OK, well then there must have been something rubbing on my scope. So wheezes. Let's try to treat it! And even then I dropped the ball. And I'm also really bad at lung sounds. I call something rales, someone else says ronchi kind of thing.

She didn't look heavy or like she had edema above her lower legs.

Before we go into how to treat, I have a quick question. If it had been CHF, would morphine have been an option? I know it causes respiratory depression, but I also know it can reduce preload, and wouldn't a reduction in preload decrease myocardial oxygen consumption?

Wheezes can be present in almost anything including the healthy person having a cold/flu and having a productive cough or sinusitis that irritates the lungs. You may hear them in CHF, COPD, PNA, obstructive lesions and aspirated scrambled eggs. The same for rhonchi. Crackles or rales can be heard for CHF, PNA and atelectasis to name a few. The sounds may also be dependent on body position. Another healthcare provider could hear something totally different after a cough or a change in position.

In some patients you may find almost every breath sound in one set of lungs. That is why we listen to different several different areas.

http://www.meddean.luc.edu/lumen/MedEd/medicine/pulmonar/pd/step29e.htm

And some observations:
http://ruby.fgcu.edu/courses/80277/lungassess.html

The patient:

The irregular HR could have A-Fib, PACs, PVCs or MAT(WAP). She was on Warfarin but she also had a couple of disease processes that would have needed a clot inhibitor.

She had pedal edema.

She had COPD.

She had a hx of HTN.

Wheezes (COPD or Fluid or both - could also be PNA which may have caused the exacerbated state)

Any strain on a brittle COPD patient's body may lead them to exacerbeation. This will also be true for their CV system. Once you've taken care of the obvious move on with your assessment. Were there enough clues to lead you to CHF? Could you have asked a few more fact finding questions? Anything else you should have assessed? Anything to lean to PNA? Could be both?

Write this scenario down as if you were striving for an A at a good Paramedic school or wanted to present it as a case study to a group of doctors. The pieces should fall into place as will your treatment plan.

 

[Ridryder911]

Not to be rude, but it is a shame these student do not sue to recap their money and demand to be really taught. I do wonder, what the instructors do with their time; obviously it is not briefing or reviewing to teach.

I used to blame many of the students, but now see that it is much more problem in the education system than I had thought. Shameful nothing is done to ensure quality education.

R/r 911

 

[remote_medic]

Not to be rude, but it is a shame these student do not sue to recap their money and demand to be really taught. I do wonder, what the instructors do with their time; obviously it is not briefing or reviewing to teach.

I used to blame many of the students, but now see that it is much more problem in the education system than I had thought. Shameful nothing is done to ensure quality education.

R/r 911

To be fair, she is describing her experiences with a field preceptor...not her instructor. I'm sure you have seen (as have I) a student medic show up and ride with what ever crew is around...no training provided to that crew in how to precept, how to guide learning, how to teach, or how to lead. It is assumed that because Jane Doe has been a medic for 7 years that she is going to be a capable field preceptor.

 

[VentMedic]

I used to blame many of the students, but now see that it is much more problem in the education system than I had thought. Shameful nothing is done to ensure quality education.

R/r 911

I have been preaching this for a while. If the minimally educated and trained are teaching those with few or no education prerequisites, they will produce replicas of themselves. If the school gives preference to hiring their graduates, nothing changes. If the preceptors are also graduates of these schools, the cycles continues.

If EMS is to advance, it may need to start with the education requirements of its instructors. Bubba can be a real nice guy and have lots of cool stories but that does not necessarily mean he/she has the ability or qualifications to teach. This is where we get examples of lacking education in statements such as "lidocaine numbs the heart". This will also be the instructor that will state they have done alright as a Paramedic without any of that book learnin'. Unfortunately, this type of instructor has been too prevalent in the schools. The clinicals have been lax and weak but not always at the fault of the students. Poor oversight has allowed ALS Engine clinicals with limited patient contact in many states.

Oops, sorry...education soapbox.

 

[medic417]

Not to be rude, but it is a shame these student do not sue to recap their money and demand to be really taught. I do wonder, what the instructors do with their time; obviously it is not briefing or reviewing to teach.

I used to blame many of the students, but now see that it is much more problem in the education system than I had thought. Shameful nothing is done to ensure quality education.

R/r 911

Wonder if that can be done and won? Sounds like there are some crappy schools that focus on just what is on the test not actually learning to think. Some talk about NR pass rates as criteria for a quality school. I disagree. I can tell someone with no medical education enough that they could pass the test yet have no clue what they are doing. But I guess thats what many of these fire department diploma mills are doing.

 

[medic417]

To be fair, she is describing her experiences with a field preceptor...not her instructor. I'm sure you have seen (as have I) a student medic show up and ride with what ever crew is around...no training provided to that crew in how to precept, how to guide learning, how to teach, or how to lead. It is assumed that because Jane Doe has been a medic for 7 years that she is going to be a capable field preceptor.

To be fair in many of her other posts she says her school sucks.

And one of the best preceptors I got was only a Paramedic 1 year. They were new enough to recall the book and the newbie jitters but had also started to see what the field was really like. Worst I had was a 20+ tear experience Paramedic. So time in the field does not equal great preceptor/teacher.

 

[VentMedic]

To be fair, she is describing her experiences with a field preceptor...not her instructor. I'm sure you have seen (as have I) a student medic show up and ride with what ever crew is around...no training provided to that crew in how to precept, how to guide learning, how to teach, or how to lead. It is assumed that because Jane Doe has been a medic for 7 years that she is going to be a capable field preceptor.

That's not so shocking. My entire experience with paramedic school has been "sad". Nothing has promoted learning but rather a "pass the test, get out there, then you'll learn" mentality. The nowhere near ready is a culmination of things, and not soley the preceptor. I've learned a lot from his preceptorship, though. Probably more than I've learned in class.

Unfortunately, this is Florida and the reputation of most medic mills are well known. But, they can produce a medic in just a few months which is what our FDs want. That is not a bash on FDs. People who want to be a Paramedic have every opportunity to take classes at a college. I believe Sasha is making preparations for that now.

 

[VentMedic]

Wonder if that can be done and won? Sounds like there are some crappy schools that focus on just what is on the test not actually learning to think. Some talk about NR pass rates as criteria for a quality school. I disagree. I can tell someone with no medical education enough that they could pass the test yet have no clue what they are doing. But I guess thats what many of these fire department diploma mills are doing.

Florida has its own Paramedic test. The argument between the state exam and the NR is the passing score. The state exam is 80%. It also includes state specific information such as the state's trauma criteria.

 

[Sasha]

To be fair, she is describing her experiences with a field preceptor...not her instructor.

Actually, my instructor really sucks too. That's why I'm having a REALLY hard time and why I'm REALLY worried about the end of medic. I can pass a test, I'm an excellent test taker, but due to a lack of education the possiblity of actually getting in the field, by myself, worries the heck out of me. Rid is right. There should be more done to ensure instructors are really instructing. I shouldn't be this close to being "done" and be this dumb. It's almost appaling. Do you know something I've found out? My paramedic classes by themselves don't meet the state requirement and gen eds like a&p and english comp are used to supplement or something. Don't know how to explain it but it's just really sad. God I feel like an idiot for going there!

I know there was actually talk of filing a suit against the school amoung other students.

I've still got the scenario coming, still working on it, just wanted to put that out there.