what do you guys think?

emt19723

emt19723

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i will give you guys the low-down for a call i had last night:

tones drop for an unknown problem, class 2 response(BLS only emergency, for those of you not from PA). we go responding, dispatch comes across and is upgrading us now to Class 1 for trouble breathing. ok, no problem.

get on scene, pt is a female having a SEVERE emotional crisis. she was hyperventilating (the "breathing problem"). asked the pt a bunch of questions, and all i can get out of her is her name, and she has no pain. checked vitals...they look good. i placed the medics back in service.

95% of the whole time i was in contact with this pt, whenever i would ask her something, she would do nothing but look at me and start crying. thats about it. i felt bad cuz she was frustrating the crap out of me by not answering me. then i felt bad for the hospital, cuz all i could give them was her name, and that her b-day was in May. that was the only thing this girl told me. thought maybe she'd talk to my partner cuz she was a female....nope......same reaction. she would just bawl.

so....opening up here for some feedback and suggestions for how to handle another situation like this if it were to come back up again. id like to think i have a very long span of patience, but this girl definitely pushed the limit.
 
There's nothing you CAN do for an emotional crisis. She needs either one of two treatment modalities: 1) a licensed social worker, or 2) a swift kick in the pants - depending on the situation. Neither of which you can offer.

You did the only thing you could do; transport. Don't sweat it.
 
Was anybody on scene with your pt when you arrived? Who called for the ambulance? You have to find something common that you can talk to your pt about, such as pets, music, ask what they are interested in. Don't show your frustration to your pt, they will lock up on you. You have to build up security between your pt and yourself. Did you put your pt on O2, to calm them down and maybe than she would have been more responsive to you. I have had a couple of calls like this and that is what I have done.
 
That is why there are many different professionals with many years of education for many different problems.

Neither EMT-B nor EMT-P adequately prepares one for many different problems especially those dealing with psycho-emotional issues. All you can do is provide supportive care while treating what you can assess.

Hyperventilating is an overused term. Unless you can truly rule out a medical problem, as there is also a chronic disorder that requires continuous medical observation and treatment known as Hyperventilation Syndrone (HVS), you might best stick to using descriptive terms such as tachypnea unless you have lab values to prove otherwise and know about acid-base issues.

Labeling with a term such as "hyperventilation" or assuming that is the only problem can skew your assessment and cause you to miss a bigger problem.
 
Ativan?

I was watching a bunch of old Emergency! episodes recently. Has anyone noticed that they almost always portray woman as emotionally unstable creatures who are just prone to snap? Everyone but Nurse Dix, that is. She's cool, controlled and sharp.

Anyhow, I've had a bunch of these sorts of patients. It's certainly not ideal and there isn't much we can do for them other than make sure they are safe and provide for transport to the ER (assuming they don't AMA).
 
O2 and transport is what most BLS providers can do. Talking to your patient helps if you can get a firm piece of common ground.
 
the only one that was with the pt was her manager(as she was at work). the only info she could give me was that she has been under a lot of stress recently. ok.....who isnt? but i understand that everyone handles stress differently too.

as far as finding common ground.....tried that. i try to build rapport with ALL of my pts. thats the only way youre gonna be a successful provider. but like i said, all she would do was just start crying whenever i would talk to her. so, i was pretty much at a loss.

i did, however, at least get a nod out of her when i asked if her fingers were tingling. thats how i came up with the hyperventilating conclusion. so, i just encouraged her to slow her breathing down as much as possible. and she wouldnt answer me anymore when i asked her if it helped with the tingling. so, hopefully the tingling stopped.

as far as the O2 thing goes.....i explained what i was going to do, but this girl had a look on her face like i was going to hang her with the cannula i wanted to put on, and she kept pushing it away. so, after the 4th attempt, i gave up on that idea.

and as far as letting a pt see that im getting frustrated.......i have never let it show to a pt in 8 years, and i dont intend to start. like i said, i have a pretty strong patience level. and when i do hit the steaming point, i still dont let it show to my pt. if anything....ill vent when the call is cleared, and we're back in station.
 
ok, o2 by mask i would have been at least partially on board with. but a cannula??? why bother. in this case, it has no clinical value, short of the "placebo effect" which i place little faith in. she was experience an emotional crisis. 2lpm o2 n/c is like spitting into a river and expecting it to rise.
 
bstone said:
Ativan?

I was watching a bunch of old Emergency! episodes recently. Has anyone noticed that they almost always portray woman as emotionally unstable creatures who are just prone to snap? Everyone but Nurse Dix, that is. She's cool, controlled and sharp.
Click to expand...

I have three big frequent fliers with anxiety issues like this. All three are male.

I've found that the only thing that has ever worked in this situation (and it doesn't always) is to give the pt something to focus on besides how crappy they feel. Concrete questions that require the pt to think instead of just yes/no answers. I've found its a fine line between buying into the drama and letting the pt. know that you are listening instead of being dismissive.

An anxiety pt thinks they are dying. They need to know that you take that seriously, otherwise you become part of the problem and feed the fear "I'm dying and this moron isn't going to help me because he/she doesn't believe me" I've found that sometimes it helps to let an anxiety pt see the monitors, SPO2 readings, etc. because the normal readings can sometimes allay the fears. It shows you are taking it seriously because you are looking for that organic cause of their emotional issue and ruling out things they think they have.
 
KEVD18 said:
ok, o2 by mask i would have been at least partially on board with. but a cannula??? why bother. in this case, it has no clinical value, short of the "placebo effect" which i place little faith in. she was experience an emotional crisis. 2lpm o2 n/c is like spitting into a river and expecting it to rise.
Click to expand...

Don't under estimate the effect of just 2 L/m by NC. It is more than just a placebo as its significance is documented many times for therapeutic value and perscribed for patients. While it may depend on the patient's minute volume, one would also have to know the placement of the patient's PaO2 on the oxyhemoglobin dissociation curve and affinity to fully understand that it may not take much oxygen to make a difference even in this case.

Most of you are young and really may not have any idea what stresses life has yet to bring you. Don't judge, keep the patient from harming herself and others, and get her to a facility that can provide the necessary help. It is her day, her emotions and her crisis. One does not know what it is like to be someone else or even begin to understand what triggers complex human emotions.
 
KEVD18 said:
ok, o2 by mask i would have been at least partially on board with. but a cannula??? why bother. in this case, it has no clinical value, short of the "placebo effect" which i place little faith in. she was experience an emotional crisis. 2lpm o2 n/c is like spitting into a river and expecting it to rise.
Click to expand...

was gonna push for 6lpm if that makes you feel any better
 
emt19723 said:
i will give you guys the low-down for a call i had last night:

tones drop for an unknown problem, class 2 response(BLS only emergency, for those of you not from PA). we go responding, dispatch comes across and is upgrading us now to Class 1 for trouble breathing. ok, no problem.

get on scene, pt is a female having a SEVERE emotional crisis. she was hyperventilating (the "breathing problem"). asked the pt a bunch of questions, and all i can get out of her is her name, and she has no pain. checked vitals...they look good. i placed the medics back in service.

95% of the whole time i was in contact with this pt, whenever i would ask her something, she would do nothing but look at me and start crying. thats about it. i felt bad cuz she was frustrating the crap out of me by not answering me. then i felt bad for the hospital, cuz all i could give them was her name, and that her b-day was in May. that was the only thing this girl told me. thought maybe she'd talk to my partner cuz she was a female....nope......same reaction. she would just bawl.

so....opening up here for some feedback and suggestions for how to handle another situation like this if it were to come back up again. id like to think i have a very long span of patience, but this girl definitely pushed the limit.
Click to expand...

You stated her breathing problem was hyperventilating was her problem, why would you put her on an NC instead of a NRFM?
 
Hyperventilation generally presents with a very high SPO2. I would most likely not give oxygen in this case as stated. Instead I would work with attempting to coach the pt on how to slow down her breathing. Eye contact, face to face, "Look at me.. I want you to breathe with me, in through the nose, out through the mouth. Slowly. Can you do that?" I've sucessfully slowed down the hyperventiliation of some anxiety pts by doing this. It depends on how deeply they are into the process.

I don't understand why if someone is having symptoms associated with too much Oxygen from breathing too fast, giving them more is going to make that better. Connecting with this pt on an emotional level is going to do a lot more good than a placebo n/c. I've also seen anxiety pts do these deep full inhales of the oxygen because they think they aren't getting enough, even though their sats are 99-100.

We also need to be very careful because anxiety is also a component of respiratory distress. Being SOB makes pts anxious. So we have to be aware that there may be an underlying physical cause of the anxiety instead of forming a snap judgement.
 
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another big "what if....." i had on this call was "did she mix meds?" i dont know. the O2 would have helped if that had been what was up. O2 NEVER hurts a pt, but depriving oxygen will.
 
i guess vent didnt make his point clearly enough, so i'll give a it another shot:

HYPERVENTILATION IS NOT THE SAME AS TACHYPNEA! they are not interchangable terms.

hyperventilation- increased minute volume ventilation which results in lowered carbon dioxide levels.

tachypnea- abnormally rapid ventilation.

one can breath rapidly without altering the metabolic state of their plasma.
 
What about putting the pt. on a NRB and not turning the oxygen tank on?

I am obviously talking about hyperventilation and although I have very little experience in the field as of yet many of my instructors taught this as a good way to deal with the decreased CO2 levels. Also I don't mean doing JUST that, the keep element would be to try and calm them down and coach their breathing. I haven't heard it mentioned hence I am wondering if it warrants thought?
 
A.Anaka said:
What about putting the pt. on a NRB and not turning the oxygen tank on?

I am obviously talking about hyperventilation and although I have very little experience in the field as of yet many of my instructors taught this as a good way to deal with the decreased CO2 levels. Also I don't mean doing JUST that, the keep element would be to try and calm them down and coach their breathing. I haven't heard it mentioned hence I am wondering if it warrants thought?
Click to expand...

How would you know her CO2 levels are decreased?

Diabetics in DKA also lower their PaCO2 levels to raise their pH. People with pulmonary emboli will lower their PaCO2 while trying to raise their PaO2.

Putting a patient's face into a plastic mask without O2 is not advised.

KED18,
Not knowing the patient and the situation, it is hard to tell what will work for the patient if anything. If a people is breathing rapid and shallow they actually may be hypoventilating and splinting, thus this can actually raise their CO2 while decreasing their PaO2. Some also hold their breath in their emotional state or forget to take breaths between words that can have a similiar effect. A little O2 and some of BossyCow's soothing words might get them back in synch.
 
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