I Can't Breathe! Help Me!

[Sasha]

I believe Sasha is making preparations for that now.

I am. Keep your fingers crossed for me! I just mailed out two college applications! :]

 

[medic417]

I am. Keep your fingers crossed for me! I just mailed out two college applications! :]

What and ruin the diploma mill training you got with some real education?

Glad to hear it. Are you going to go ahead and get certified or wait until you graduate the college program?

 

[Sasha]

What and ruin the diploma mill training you got with some real education?

Glad to hear it. Are you going to go ahead and get certified or wait until you graduate the college program?

It's actually a degree program... Haha! Degree Mill! I plan to take the test, get the card, and work as an ER tech or something. I'm not taking a college paramedic program. I plan on taking a&p, pharm and patho at an actual decent college and go to nursing school.

 

[Ridryder911]

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.

Does not matter. Preceptor is allowed from the school? Then its the schools problem as well. Why not have selected preceptors? Would one want to place a student with anyone? Are the preceptors truly recommended or experienced enough for a student, are they familiar with the grading and evaluating criteria, is this medic experienced and educated enough to teach the student properly?

If schools were more selective of preceptor(s) may these problems would decrease. I would even say students would pay more if they could receive a better quality education.

R/r 911

 

[el Murpharino]

If your program has critique forms for your preceptors, USE THEM...and don't sugar-coat them either. Granted there are times that you may feel like they don't work, but I'm sure if enough students have the same gripes about the same few preceptors, some action would (should) be taken. If nothing gets done at the class level, I would suggest taking it up the chain - even if it means talking to the medical director himself. Extreme, perhaps...but this is YOUR education, not theirs.

It's a tough road to "narc" on bad preceptors, especially if your school lets you ride at one or two agencies. Compounding that fact is the reality that these preceptors were probably trained at the same facility by the same instructors who have some rapport with each other.

 

[MSDeltaFlt]

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?

Not jumping your butt by any stretch of the imagination, but now you know. You can't teach experience. I believe that now you'll put these pts on the monitor, even if they fart funny.

Yes, you can have multiple breath sounds throughout the lungs. You can have a pt with bilateral wheezes, rales, rhonchi, and even a pleural friction rub thrown into the mix just for kicks and giggles. Not to mention having to assess how much air exchange is or is not taking place.

Just to recap the possible painfully obvious, let's put into country terms (my personal favorite) the analogies of breathsounds.

Wheezes - Sound like you have 2 cats fighting in your chest.
Rales - Sound like "crackles", which is why they're called that now.
Rhonchi - Bubbling. Easily cleared with coughing.
Stridor - Crowing
Pleural Friction Rubs - Dry your finger off and press hard and slide it across the kitchen counter. Usually at the beginning or end of the breath.

Remember that breath sounds are not a "pah-ta-toe" - "pa-tah-toe" kind of thing. It's either an is or an isn't kind of thing. Once you learn breath sounds, you'll know what I'm talking about.

Morphine is an option if they're still having chest pain despite multiple doses of NTG.

Bare in mind, Sasha, you're a student. You're still learning.

 

[VentMedic]

If your program has critique forms for your preceptors, USE THEM...and don't sugar-coat them either. Granted there are times that you may feel like they don't work, but I'm sure if enough students have the same gripes about the same few preceptors, some action would (should) be taken. If nothing gets done at the class level, I would suggest taking it up the chain - even if it means talking to the medical director himself. Extreme, perhaps...but this is YOUR education, not theirs.

It's a tough road to "narc" on bad preceptors, especially if your school lets you ride at one or two agencies. Compounding that fact is the reality that these preceptors were probably trained at the same facility by the same instructors who have some rapport with each other.

Sometimes when an area becomes accepting of lower educational stanards, it is difficult to get the point across. This is especially true if the majority of the FFs and Paramedics are trained at the same schools or other medic mills that practice the same philosophy.

It is not until someone is hungry to learn more and steps outside of the herd to find that there may be more to being a professional Paramedic than what they are being told or taught.

 

[Sasha]

Ok. I typed this last night but the darn site was down!!

I was intially thinking CHF because of her history of CAD and the edema, before the family had stated that was normal for her. Also because she has a history of COPD, but the "I can't breathe!" only started very recently. Also because the position of her pillows in her bed and in her chair had her sleeping near upright. I didn't think pneumonia simply because she didn't feel hot, I know that people who are immunosupressed often present without fever, but based on her med list and history there was nothing that jumped out and screamed "immunosupression!". The only reason I went with her dyspnea being related to COPD had been the wheezes and hx of COPD.

Ok, treating this patient. I think early transport would be vital. I don't think I would have even gone to an NRB/NC, probably straight to CPAP with nebulized albuterol, force air into her lungs, fluid out, and bronchiodilate. I imagine having bronchioconstriction with CHF makes it even harder to breathe, so bronchiodilation could only be beneficial, right? And even it had been her COPD and not CHF, CPAP wouldn't have been contraindicated, right?

Also put her on the cardiac monitor.

So, after that, we would want to reduce preload, right? Sublingual nitro should vasodilate, which reduces venous return, reducing preload.

And now I'm stuck. What else could have been done? What next?

 

[MSDeltaFlt]

Ok. I typed this last night but the darn site was down!!

I was intially thinking CHF because of her history of CAD and the edema, before the family had stated that was normal for her. Also because she has a history of COPD, but the "I can't breathe!" only started very recently. Also because the position of her pillows in her bed and in her chair had her sleeping near upright. I didn't think pneumonia simply because she didn't feel hot, I know that people who are immunosupressed often present without fever, but based on her med list and history there was nothing that jumped out and screamed "immunosupression!". The only reason I went with her dyspnea being related to COPD had been the wheezes and hx of COPD.

Ok, treating this patient. I think early transport would be vital. I don't think I would have even gone to an NRB/NC, probably straight to CPAP with nebulized albuterol, force air into her lungs, fluid out, and bronchiodilate. I imagine having bronchioconstriction with CHF makes it even harder to breathe, so bronchiodilation could only be beneficial, right? And even it had been her COPD and not CHF, CPAP wouldn't have been contraindicated, right?

Also put her on the cardiac monitor.

So, after that, we would want to reduce preload, right? Sublingual nitro should vasodilate, which reduces venous return, reducing preload.

And now I'm stuck. What else could have been done? What next?

Sounds good to me.

 

[el Murpharino]

...because the position of her pillows in her bed and in her chair had her sleeping near upright. The only reason I went with her dyspnea being related to COPD had been the wheezes and hx of COPD.

Alot of CHF'ers sleep upright to help with the fluid (some still think gravity is a theory).

Early CHF presents with wheezes - hence the nickname cardiac asthma.

Yes these aren't absolutes...but the little clues help to make the big picture easier to see.

Also, CPAP doesn't really force the fluid out; it improves the ability of the alveoli to diffuse oxygen to the red blood cells by using pressure to drive gas into the alveoli and open up unused or collapsed alveoli. I used to think CPAP pushed the fluid out...I was harshly corrected by an instructor who was having a bad day (or so it seemed).

 

[Sasha]

Also, CPAP doesn't really force the fluid out; it improves the ability of the alveoli to diffuse oxygen to the red blood cells by using pressure to drive gas into the alveoli and open up unused or collapsed alveoli. I used to think CPAP pushed the fluid out...I was harshly corrected by an instructor who was having a bad day (or so it seemed).

Wow.. really? That makes a LOT more sense! Thank you for correcting me!

 

[el Murpharino]

no prob...like I said, I thought the exact same thing not too long ago. I'm sure some of the more experienced members here can elaborate even more on it as my experiences with CPAP are very limited.

 

[VentMedic]

Also, CPAP doesn't really force the fluid out; it improves the ability of the alveoli to diffuse oxygen to the red blood cells by using pressure to drive gas into the alveoli and open up unused or collapsed alveoli. I used to think CPAP pushed the fluid out...I was harshly corrected by an instructor who was having a bad day (or so it seemed).

CPAP can splint the airways open for alveoli recruitment, decrease atlectasis and improve V/Q ratios. However, to achieve this, it can also increase intrathoracic pressure. which can benefit preload and afterload to where there is actually an improvement in cardiac index.

 

[Sasha]

My preceptor finally returned my call (In the middle of a nap >:[) It was CHF and as of midnight that night, which is the last time he had been at that hospital, they were trying to find an ICU bed for her.

 

[johnrsemt]

be happy that you have something besides O2 and Albuterol; that is all we have and we have a miminum of a 45 min transport. I have had a 1hr 45 min transport a few weeks ago, and that is to a small hospital. If we need a bird, it may be 20-30 min to meet them, (and we don't wait, we start transporting).

 

[Sasha]

be happy that you have something besides O2 and Albuterol; that is all we have and we have a miminum of a 45 min transport. I have had a 1hr 45 min transport a few weeks ago, and that is to a small hospital. If we need a bird, it may be 20-30 min to meet them, (and we don't wait, we start transporting).

Hmmm well I'm sorry to hear that, but that's what happens when you work in a rural area.

 

[Summit]

..........

 

[zzyzx]

I've been reading Sasha's post and have been thinking along the lines of sedating this patient. I've never had a combative patient like this...of course now that I've said that my next call will be probably a combative 400 lb CHF'er on the second story.

I can't RSI where I work, so all I can do is sedate with Versed. I will use Versed when the time comes that I do get a patient who's very combative and can't be managed, but I'm afraid that after I give it I'll end up with a patient who's knocked out and barely breathing. Can you guys with more experience handling such patients relate your experiences? Thanks; hope I'm not highjacking the thread too much.

 

[VentMedic]

I've been reading Sasha's post and have been thinking along the lines of sedating this patient. I've never had a combative patient like this...of course now that I've said that my next call will be probably a combative 400 lb CHF'er on the second story.

I can't RSI where I work, so all I can do is sedate with Versed. I will use Versed when the time comes that I do get a patient who's very combative and can't be managed, but I'm afraid that after I give it I'll end up with a patient who's knocked out and barely breathing. Can you guys with more experience handling such patients relate your experiences? Thanks; hope I'm not highjacking the thread too much.

The way to stop this lady from struggling is to initiate therapy toward alleviating the problems.

If you sedate the drive that is maintaining her oxygenation, you better have a great airway alternative. She will go down fighting even if you do have the ability to RSI. Sedating may or may not alleviate the combativeness but may present with other problems.

CPAP does NOT ventilate. You may end up bagging and still have a lot more of your protocols to run through to maintain stable BP, assess and continue treatment.

Remember these patients aren't fighting YOU. They are fighting a body that is failing them. Just from her COPD, she has very limited oxygenation and ventilation abilities. Any disease process be it CHF or PNA that can cause just a little more hypoxemia with may cause her PaO2 to fall from 55 mmHg where she probably lives to 40 mmHg where her other organs start to feel the effects.

 

[Sasha]

vent, how would you have treated her stast to finish?