There is nothing more irritating than incompetent nurses...

[NYMedic828]

Had a call this morning in my volly area for a 94 year old female with acute on-set dsypnea at 8am. (im sure most people know what the problem is already)

Medic flycar is there before me, he takes vitals and puts her on O2. Tells me she hasn't been able to urinate x 2 days and has SOB with Rales bi-lat.

BP 164/82
HR 80 Irregular (a-fib)
RR - 18
SPo2 - 96 on room air.
ECG - A-fib stable.

Patient takes a cornucopia of meds but has Hx of CHF, A-fib and HTN.

She said this happens occasionally and she just needs IV lasix, which is available on standing orders here.

I gave her one nitro tablet 0.4mg SL.

After the nitro she said she felt worlds better, I asked her if she felt another would help and she said no she feels ok now. (Rales still present but improved)

Bp dropped to 144/62

Due to the stability of her condition, and being 5 minutes from the ER I opted not to bother starting a line to give Lasix. The Lasix didn't seem necessary pre-hospital. (the ER is just going to rip my line out to do their own anyway, and I didn't want this poor old lady to get poked for no real reason)

So I walk into the ER and this nurse asks what is going on. I told her

"Shortness of breath secondary to APE with bi-basilar rales"

She gives me a completely blank stare has no idea what im talking about. I put it into English for her and just said "Fluid in the lungs."

I then told her I gave 0.4mg of nitro and she still has rales but feels better. She then gave me this attitude over the fact that I felt it was wise to give nitro without starting an IV.

Since people don't take their own nitro without an IV at home all the time or anything... Its not like I gave nitro to a hypotensive she was 160 systolic.


Sorry just had to get all that off my chest. Nothing irks me more than nurses thinking they are better than us just because they have a higher title.

 

[Veneficus]

I don't know, I find the paramilitary cookbook medics to be much more disturbing.

The nurse may not know. These medics do not care.

 

[R99]

How can you possibly "know what the problem is already" without having laid eyes on the patient nor preformed an examination?

Why did you give her GTN? Did any clinical signs of myocardial ischaemia present themselves? Did your ECG show any signs of myocardial ischaemia? Did you even do a 12 lead ECG or did you just do a single lead rhythm strip?

The old "GTN before IV" debate died here a decade ago so I'll give you that

Also remember that for a patient who is hypertensive usually their 160 systolic might actually be like Joe Moron's 120; you drop their BP down 20 or 30 points from a very high number that does not mean its "safer" but could be comparable to dropping an average person from 120 down to 90. There is an old saying here that the "good old more is better ambo trick is not always true" and this is one of those situations.

You do know that there are many more causes of "rales" than just cardiogenic pulmonary edema? How do you know she did not have pneumonia or something? It's up to you as the clinican to establish an adequte differential diagnosis of exclsion regardless of what the patient tells you "usually happens". The very limited information you give makes this sound condusive to a mild exercabation of left ventricular failure but if the information you present here is the only examination that you performed then that ain't too flash mate.

Also, "rales" is a term which was pointed out for historical interest only when I last heard it used, which was during the Advanced Ambulance Aid course ... that was in FEBRUARY OF 1994!

I am not surprised that nurse looked at you the way she did honestly if you said "bi-basalar rales" to me I'd quietly discredit you as a moron to myself because nobody in the entire history of medicine probably EVER said "bi-basalar rales" ... hang on, hey Semmelweis, did anybody ever say "bi-basalar rales" back there in the 1800s? Nope, didn't think so.

I'm siding with the nurse on this one mostly, except on that GTN before IV thing.

 

[Veneficus]

Wow.

Ummm. I still use the term "rales."

and "EKG"

Never said "bi-basilar rales though."

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2262205/pdf/tacca200043-0215.pdf

 

[Aidey]

Ummmm....Okie dokie then.

Nitro is frequently used here for pulmonary edema secondary to CHF, both in and out of hospital. Rales is still in common use here. Very very rarely I'll hear it called crackles, but rales is what everyone calls it (at least in my region, and the other regions I've worked).

And last time I checked rales and rhonchi sounded different, and thus made it possible to differentiate between pulmonary edema and pneumonia. The pts history also helps with that.

 

[NYMedic828]

How can you possibly "know what the problem is already" without having laid eyes on the patient nor preformed an examination?

Why did you give her GTN? Did any clinical signs of myocardial ischaemia present themselves? Did your ECG show any signs of myocardial ischaemia? Did you even do a 12 lead ECG or did you just do a single lead rhythm strip?

The old "GTN before IV" debate died here a decade ago so I'll give you that

Also remember that for a patient who is hypertensive usually their 160 systolic might actually be like Joe Moron's 120; you drop their BP down 20 or 30 points from a very high number that does not mean its "safer" but could be comparable to dropping an average person from 120 down to 90. There is an old saying here that the "good old more is better ambo trick is not always true" and this is one of those situations.

You do know that there are many more causes of "rales" than just cardiogenic pulmonary edema? How do you know she did not have pneumonia or something? It's up to you as the clinican to establish an adequte differential diagnosis of exclsion regardless of what the patient tells you "usually happens". The very limited information you give makes this sound condusive to a mild exercabation of left ventricular failure but if the information you present here is the only examination that you performed then that ain't too flash mate.

Also, "rales" is a term which was pointed out for historical interest only when I last heard it used, which was during the Advanced Ambulance Aid course ... that was in FEBRUARY OF 1994!

I am not surprised that nurse looked at you the way she did honestly if you said "bi-basalar rales" to me I'd quietly discredit you as a moron to myself because nobody in the entire history of medicine probably EVER said "bi-basalar rales" ... hang on, hey Semmelweis, did anybody ever say "bi-basalar rales" back there in the 1800s? Nope, didn't think so.

I'm siding with the nurse on this one mostly, except on that GTN before IV thing.

Sorry wasn't aware it was dbag day on the forum.

Bibasilar rales is a commonly used term around here. It is entirely possible to only have fluid present in one lung and not both. The term is obviously used to distinguish between the two possibilities. Sorry they don't use such terminology out by you. Feel free to google it, it is an actual term.

Basal or basilar crackles (not to be confused with the basilar artery of the brain) are crackles apparently originating in or near the base of the lung. Bibasal or bibasilar crackles refer to crackles at the bases both the left and right lungs. Bilateral basal crackles also refers to the presence of basal crackles in both lungs.

Also, rales and crackles are the same god damn thing. My PCR has a box that says Rales, not crackles. So obviously someone feels it is still an acceptable term.

And at 8am, a call for dsypnea usually has you thinking APE. Of course that doesn't mean anything till you see the patient. Its just a general size up of the call type prior to arrival.

I also wasn't aware that we only gave nitroglycerin for suspected infarctions. Last I checked it was the first line pre-hospital treatment for pulmonary edema.

Also, please inform me how you plan to diagnose pnuemonia in the field on a patient who isn't coughing or febrile. Has rales, not rhonci and commonly gets pulmonary edema with a history of CHF. I really hope you don't show up for my grandmother.

 

[R99]

We use GTN for cardiogenic pulmonary edema too but I would like to confirm that this is actually cardiogenic pulmonary edema before I administer GTN

The most common cause of cardiogenic pulmonary edema is myocardial ischemia so always look for it on an ECG not a rhythm strip, they might have been acceptable during advanced ambulance aid course in 1994 but not nearly 20 years later

might not be cardiogenic pulmonary edema in which case GTN is contraindicated

if you considered other causes besides cardiogenic pulmonary edema sufficiently then fine but the very limited information you first provided did not state

and if I may ask,what makes you better than a nurse and why is she incompetent because she does not understand your somewhat unorthodox lexicon?

 

[NYMedic828]

We use GTN for cardiogenic pulmonary edema too but I would like to confirm that this is actually cardiogenic pulmonary edema before I administer GTN

The most common cause of cardiogenic pulmonary edema is myocardial ischemia so always look for it on an ECG not a rhythm strip, they might have been acceptable during advanced ambulance aid course in 1994 but not nearly 20 years later

might not be cardiogenic pulmonary edema in which case GTN is contraindicated

Lol what?

Next time I'll take an angiogram and chest xray before proceeding.

Sorry you can't be serious.

 

[Aidey]

Huh, I wasn't aware that you were able to do chest x-rays in the field in NZ.

What exactly is the difference between an ECG and a rhythm strip?

The pt does not appear to be suffering a hypertensive crisis, and given the history I don't think she has been strangled or electrocuted so I think a cardiogenic source of the pulmonary edema is a pretty safe bet.

 

[NYMedic828]

Also, you would be correct in saying that 120 could be low for a person with Hx of HTN, but it isnt low if their BP is maintained by medications at 120-140. Its still high unless they are non-compliant with meds.

 

[FrostbiteMedic]

Wow, my first day back on the forums in a while and I get to watch a heated debate.......99 and NY, ya'll play nicely now...don't make me call in a referree

 

[NYMedic828]

Wow, my first day back on the forums in a while and I get to watch a heated debate.......99 and NY, ya'll play nicely now...don't make me call in a referree

He attacked me not the other way around.

 

[46Young]

How can you possibly "know what the problem is already" without having laid eyes on the patient nor preformed an examination?

Why did you give her GTN? Did any clinical signs of myocardial ischaemia present themselves? Did your ECG show any signs of myocardial ischaemia? Did you even do a 12 lead ECG or did you just do a single lead rhythm strip?

The old "GTN before IV" debate died here a decade ago so I'll give you that

Also remember that for a patient who is hypertensive usually their 160 systolic might actually be like Joe Moron's 120; you drop their BP down 20 or 30 points from a very high number that does not mean its "safer" but could be comparable to dropping an average person from 120 down to 90. There is an old saying here that the "good old more is better ambo trick is not always true" and this is one of those situations.

You do know that there are many more causes of "rales" than just cardiogenic pulmonary edema? How do you know she did not have pneumonia or something? It's up to you as the clinican to establish an adequte differential diagnosis of exclsion regardless of what the patient tells you "usually happens". The very limited information you give makes this sound condusive to a mild exercabation of left ventricular failure but if the information you present here is the only examination that you performed then that ain't too flash mate.

Also, "rales" is a term which was pointed out for historical interest only when I last heard it used, which was during the Advanced Ambulance Aid course ... that was in FEBRUARY OF 1994!

I am not surprised that nurse looked at you the way she did honestly if you said "bi-basalar rales" to me I'd quietly discredit you as a moron to myself because nobody in the entire history of medicine probably EVER said "bi-basalar rales" ... hang on, hey Semmelweis, did anybody ever say "bi-basalar rales" back there in the 1800s? Nope, didn't think so.

I'm siding with the nurse on this one mostly, except on that GTN before IV thing.

I would have ruled out inferior or rt sided ischemia via 12 lead, and started CPAP (maybe not available to the OP), but I would have treated with nitrates as well. We can give NTG for rales (we use the term "rales" in NY, Virginia, and South Carolina from my personal experience), presumed to be cardiac (there was no unilateral rales, fever, productive cough to suggest pneumonia) without the presence of Cx pain or ischemic 12 lead changes. ACS and Pulmonary Edema may be present simultaneously, or may be mutually exclusive from pt to pt. I can always get an EJ or drill an EZ-IO if I'm that worried about bottoming out the pt.

BTW, the pt's condition improved (reduced dyspnea and diminished rales (yes, rales) after the NTG admin. Apparently you overlooked that fact. The pt's Hx was CHF, Aifib, and HTN. My first differential given the pt's Hx and presentation would be cardiogenic pulmonary edema.

Your approach to giving critique on this scenario is uncalled for. If you're going to resort to name calling, directly or indirectly ("discredit you as a moron"), this forum isn't the place for you.

Hey Vene, I've used "bibasilar rales" since 2002. It must be a NY thing I guess.

 

[46Young]

Lol what?

Next time I'll take an angiogram and chest xray before proceeding.

Sorry you can't be serious.

Yeah, this isn't an ACLS in-hospital scenario. Don't forget to order labs and seek expert consultation in the field.

 

[MedicBrew]

Wow.

Ummm. I still use the term "rales."

and "EKG"

Never said "bi-basilar rales though."

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2262205/pdf/tacca200043-0215.pdf

That's funny sheet right there!:rofl: I read that and dang near fell out of my chair. Everyone in my office was looking at me like I'd lost my mind.

Seriously though, loop diuretics have seriously fallen out of favor here and NTG is first line for APE, followed by CPAP if necessary. Our Medical Director has a staunch stand on the whole NO NTG w/o IV access thing, as well as an 15 lead EKG prior to ANY NTG admin. We carry NTG gtt and is the preferred method, as this affords you an easier controlled vasodilatation.

 

[Aidey]

Would you go CPAP before nitro with an SpO2 in the acceptable range?

 

[FrostbiteMedic]

He attacked me not the other way around.

Didn't say one way or the other...I just said don't make me call in a referree. Ya'll both might end up like this.

 

[MedicBrew]

Would you go CPAP before nitro with an SpO2 in the acceptable range?

I really think that it depends on the acuity of your patient and how they present. Several folks will not be able to tolerate the CPAP for one reason or another, requiring sedation (i.e. benzos).

Believe it or not, we service several rural hospitals that do not have the capabilities to handle a NIV patient. I’ve brought several patients in on CPAP, just to watch them jerk it off and send the patient into flash PE. Every patient is going to respond differently.

 

[MedicBrew]

Interesting read if you've not read it before.

http://www.ems1.com/ems-products/co...s/articles/390568-Furosemide-Lasix-Drug-Whys/

 

[firecoins]

rales is an acceptable term in NY as far as I know.