My call suggestions?

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I can't get over this call and I would like your in put here.

I was dispatched to a 80 y/o F who was having difficulty breathing. I arrive on scene and see her in the tripod position sitting on her bed. The family states that she has been having a hard time breathing for the last 2 days and it got worse today. She has a history of CHF, COPD, Asthma, and hypertension. she was on a home nasal cannula when I arrived.

She wasn't able to speak to me but she would make these sounds per say and she could not follow commands. v/s were bp 136/86, P62, RR-12, BGl 96. We replaced her NC with a NRB because here sat was 80 on the NC. My partner took her lung sounds and said they were diminished

We moved her to the ambulance all the while she was trying to take the mask off her face. I start up a neb treatment in the back and her sats start dropping 80, 50, 20, 12% and my partner said she stop breathing. I go and pop an NPA in and start bagging her and I added the capnography I got her sat up to 90% and 34 on co2.

After a couple bags she starts breathing on her own as we enter the hospital, I do my pass off with the doc and he listens to her lung sounds and say there wet and her skin is cool. They hook her up to the CPAP. In my standing orders we can't use CPAP because the pt could not follow my commands which could turn into gastric distention. I just feel like CPAP would of worked pre hospital because the DR did it. I just need some in put on this call for what I can work on.
 
"She would make these sounds per say"


What does that mean?
 
Like mumbled words sorry bad at describing that
 
"mumbling" does it pretty well.;)

"Per se" means "exactly this, infer nothing else".

Or per the dictionary, "Of, in, or by itself or oneself; intrinsically".
 
And yeah, I'd say she was a CPAP candidate. :/

A shame she wasn't alert enough to meet your criteria. And in hindsight, not hearing her lungs, sounded like the Albuterol wasn't what she needed... More like NTG and CPAP.

Were you in charge? Why didn't you listen to the lung sounds?

I'm guessing you're an Advanced or a basic with add on skills?
 
Yeah that was what I was thinking with the CPAP, it just sucks that my protocols wouldn't allow it because she wasn't able to follow my commands. And yes I was in charge, I trusted my partner in what he was saying sounds like a stupid idea now. I was going off of o2 wasn't getting in all the way to the bases and if I were to open them up then she would able to breath better since they were diminished and she has a history of COPD which made me thing of Albuterol.
 
Do you carry the nasal cannula capnography? That may have helped before they went into respiratory arrest
 
With her not liking the NRB, CPAP would do no good. In our service, she would have bought herself a tube and nice ride in with a dx of chf exacerbation.
 
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With a history of both CHF and COPD, I would have been a lot more aggressive with CPAP right off the bat. If she can try and take the mask off, she'll probably take CPAP. Better to try early, than be behind the 8 ball.

And I missed what your level of training is. This just doesn't feel like a paramedic level assessment, treatment or protocols.
 
lill91210 said:
I can't get over this call and I would like your in put here.

I was dispatched to a 80 y/o F who was having difficulty breathing. I arrive on scene and see her in the tripod position sitting on her bed. The family states that she has been having a hard time breathing for the last 2 days and it got worse today. She has a history of CHF, COPD, Asthma, and hypertension. she was on a home nasal cannula when I arrived.

She wasn't able to speak to me but she would make these sounds per say and she could not follow commands. v/s were bp 136/86, P62, RR-12, BGl 96. We replaced her NC with a NRB because here sat was 80 on the NC. My partner took her lung sounds and said they were diminished

We moved her to the ambulance all the while she was trying to take the mask off her face. I start up a neb treatment in the back and her sats start dropping 80, 50, 20, 12% and my partner said she stop breathing. I go and pop an NPA in and start bagging her and I added the capnography I got her sat up to 90% and 34 on co2.

After a couple bags she starts breathing on her own as we enter the hospital, I do my pass off with the doc and he listens to her lung sounds and say there wet and her skin is cool. They hook her up to the CPAP. In my standing orders we can't use CPAP because the pt could not follow my commands which could turn into gastric distention. I just feel like CPAP would of worked pre hospital because the DR did it. I just need some in put on this call for what I can work on.
Click to expand...

Why did you go with a NPA? Were there any other sounds besides "diminshed"? Rales? History of CHF, pulmonary edema is a possibility isn't it?

Can your service give paralytics and drop a tube? Could you have called medical control to get authorization to use CPAP?
 
n7lxi said:
With a history of both CHF and COPD, I would have been a lot more aggressive with CPAP right off the bat. If she can try and take the mask off, she'll probably take CPAP. Better to try early, than be behind the 8 ball.

And I missed what your level of training is. This just doesn't feel like a paramedic level assessment, treatment or protocols.
Click to expand...

Since when is CPAP not an ALS treatment or protocol since this doesnt seem like a medic assesment to you? Maybe the OP is a new medic and doesn't have the experience or is just getting used to a certain style of assessing there patients. Every medic has to start somewhere, give em a little credit.
 
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leoemt said:
Why did you go with a NPA? Were there any other sounds besides "diminshed"? Rales? History of CHF, pulmonary edema is a possibility isn't it?

Can your service give paralytics and drop a tube? Could you have called medical control to get authorization to use CPAP?
Click to expand...


My thoughts exactly. This was a real good RSI pt.
 
Since Im in a urban environment and the hospital was literally 2 minutes away we do not carry anything for RSI. I got my lungs sounds from my partner and he said they were diminished I should of listened for myself but I went off of what my partner said which was a stupid idea. I went for an NPA because it was easier to drop and I had a great mask seal with my bagging and I got the sat up so I didn't feel like switching to an OPA since I was doing fine with the bagging.

And IrightI thanks for having my back I am a new Paramedic and just wanted some input on everything so I can learn and get better not being ridiculed on my level of training.

Also, should of called medical control that should of been something that should of popped in my mind, but man it never crossed it I was so tunnel visioned on getting her sats up.
 
lill91210 said:
Since Im in a urban environment and the hospital was literally 2 minutes away we do not carry anything for RSI. I got my lungs sounds from my partner and he said they were diminished I should of listened for myself but I went off of what my partner said which was a stupid idea. I went for an NPA because it was easier to drop and I had a great mask seal with my bagging and I got the sat up so I didn't feel like switching to an OPA since I was doing fine with the bagging.

And IrightI thanks for having my back I am a new Paramedic and just wanted some input on everything so I can learn and get better not being ridiculed on my level of training.

Also, should of called medical control that should of been something that should of popped in my mind, but man it never crossed it I was so tunnel visioned on getting her sats up.
Click to expand...

In my anecdotal experience early recognition of pulmonary edema and administration of NTG can be the difference between an ER visit and an ICU admission.

Lung sounds can be hard to hear in many patients especially if they have diminished air movement such as cases of fully filled lungs.

12 lead, NTG, O2.
 
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lill91210 said:
not tell me would there be any changes in the 12 lead that I should look for
Click to expand...

Signs of heart failure, primarily infarction.

Acute pulmonary edema is a common symptom of chronic congestive heart failure and acute heart failure such as substantial left sided infarction.
 
lill91210 said:
Since Im in a urban environment and the hospital was literally 2 minutes away we do not carry anything for RSI. I got my lungs sounds from my partner and he said they were diminished I should of listened for myself but I went off of what my partner said which was a stupid idea. I went for an NPA because it was easier to drop and I had a great mask seal with my bagging and I got the sat up so I didn't feel like switching to an OPA since I was doing fine with the bagging.

And IrightI thanks for having my back I am a new Paramedic and just wanted some input on everything so I can learn and get better not being ridiculed on my level of training.

Also, should of called medical control that should of been something that should of popped in my mind, but man it never crossed it I was so tunnel visioned on getting her sats up.
Click to expand...

I think you did a great job. Sure, other things could have possibly been done but you got her breathing again and got her to the hospital safely and alive. There are plenty of calls I have been on where I could have done things differently. Hindsight is always 20/20. Use every call as a learning tool.
 
...And recognizing a PT in severe respiratory distress and then taking definitive steps toward managing the issue is a basic paramedic skill...

I wasn't ridiculing your level of experience, I was curious as to why you seemed to be reluctant to do what was right for your patient.

I understand AEMTs and add on Basics not knowing the patho and simply following an algorithm, but as a medic you should have been more aggressive.

If you seriously want to learn, as you said you want input, then drop the defensive tone and realize that this was a call where you could have done better.

You should have:

A) recognized the level of distress at first contact.
B) listened to lung sounds yourself to determine if they were truly diminished or rales or wheezes or...
C) applied CPAP early in the contact.

If you can't do that, at least call and consult with a doc to either get orders for CPAP or tell them to have an RT ready with BiPAP.

This is a great place to post a scenario and ask questions, but be prepared to face the critique. If you just want a pat on the back and "don't worry slugger, you'll get it next time", it ain't gonna happen.
 
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NYMedic828 said:
Signs of heart failure, primarily infarction.

Acute pulmonary edema is a common symptom of chronic congestive heart failure and acute heart failure such as substantial left sided infarction.
Click to expand...

For a chronic CHF patient it may not be as obvious as an infarction. Subtle clues such as LVH, LAE, A Fib, BBBs, frequent ectopy, etc is more common.

Or the simple "That QRS looks like :censored:" is usually present in CHF patients
 
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