goofymedc8

Fiznat... I'm sorry if my last post seemed a bit sharp, which is not my intent at all...I read your post and did take it to heart. It certainly bids a re-look on my part to make certain my understanding of the pathos is as it should be. I never EVER take offense to constructive critiquing, which you were kind enough to give. Another perspective on a call like this can only serve to broaden my own understanding of the pathos of these patients. Again Fiz...THANKS!!

My defense for thinking pneumonia...He had NO JVD; NO pedal edema; had NO complaints of orthopnea; Has recently finished ATB treatment for bronchitis; and has absolutely NO hx of COPD, Asthma, or any pulmonary disease; CHF; or Heart problems outside of HTN. I pretty sure he had no flash pulmonary edema because his sputum was green/yellow/brownish and not frothy pink in nature. And from the last few flash pulmonary edema peeps I had, NONE of my treatments helped and we don't carry CPAP (yet). I can't really justify treating this pt for CHF without the hx. Please correct me if I'm wrong, but unless there is a congenital cardiac problem, CHF is USUALLY a secondary condition. Again, as always, I am open to thoughts and constructive critiquing.

I guess I should've clarified a bit...I've seen a higher instance of long term COPDers that can develop CHF. Perhaps this is a tertiary process as a result of the Cor Pulmonale. I'm currently going back through ye old medic book to make certain I'm not too far off base. But it seems somewhat logical to me that over time Cor Pulmonale can also eventually lead to left HF due to the seemingly chronic reduction of the pump's ability to move fluid. I would welcome wisdom from the doc on this as well. I'm always willing to learn, refresh, and broaden my knowledge. I'm not perfect and the day I believe I am is the day I need to find another career. Woohoo!!

AK... That was exactly my thinking...My thing is, if it's screams at me first and says "hey! Stick here!", then that's exactly where I'm gonna go...especially if they have the high potential to crump on me. I usually start IV's in the hands/forearms. Someone crumping on me or having the high possibility to, I always try to place more than one IV if I can. I'll be happy with one if that's all I can get. As far as RNs not listening...'tis unfortunately true where I transport to. However, if the RN has a background in EMS, they tend to pay closer attention. Thanks for the feedback! btw...goofymedc8 is a SHE!! )

Little bit of a late reply...still new to this site and playing catch-up.. I work at an inner-city level I trauma center ER and boy this post hits home!! It is nothing for us to have every room full, the lobby bustin' at the seams and tempers running high and hot! I would daresay that 60% of our pt load is a steaming pile of crap! I have learned the fine art of sniffing out drug seekers. When we get peeps in complaining of abdominal pain, eating chips and drinking a soda, my tolerance and compassion drop through the floor. These are the peeps that scream the loudest about the wait! Nevermind the cardiac arrest that just arrived, the 17yo male in trauma arrest because he has a 2" knife wound to his left ventricle and the NP is doing internal cardiac massage as the trauma surgeon puts 7 staples into his heart to stop the bleeding, the little old lady who can't breathe; or the 40+ yo male having a HUGE inferior MI! The ones that scream the loudest understand the triage process, but don't care that there are squads lined up with the truly ill and injured people waiting for the drug seeker to vacate the room after they get the footies, the snack-pack, and the warmed blanket! Nor do they care when a person who is truly ill, walking through the doors, gets a room before them when they've waited for nearly 2 hrs! I remember telling one person that there are 8 other hospitals in the city who are just as full as we are...they were more than welcome to leave and go to one of them and wait for their "Perkies". One other pt, one of our frequent flyers, came in complaining of a variety of issues. Triage medic brought him back to a room. I politely asked him to hop into a gown. He grouched at me and asked me "what for". I told him he knew the drill, the doctor will need to examine him so the gown needed to be on him. I told him I would be back to start his IV and draw his blood work. Well he hates IVs in the first place and withing 10 minutes he eloped AMA and did not return. That just fried me when the room was needed for an AMI coming in by medic. Sorry...Got on the soapbox again. I just wish there was a solution to this problem...before it drives every good medical professional from the ER.

Okay...my turn... 62yo male...as you guessed, a run I had recently... CC: Shortness of Breath... Hx: HTN; Recently underwent treatment for mild bronchitis. HOPI: Pt relates waking up in the morning feeling just a little SOB, coughed, felt better and went about his day. Sitting down for dinner, he noticed that SOB had returned and had been getting progressively worse over the last 45-60 minutes. He denies any CP; but relates feeling "tight" across his chest. Initial assessment/impressions: 62yo white male without hx of lung disease or cardiac hx outside his HTN. Pt is sitting upright on kitchen chair in a tripod position. His skin is pale, cool, and slightly diaphoretic. Sternocleidomastoid retractions noted. Pt is in severe respiratory distress. Central Cyanosis noted. Vitals: BP 182/106; HR 122 and regular; RR 28bpm and labored; SpO2 83% RA. Blood Glucose 152; Sinus Tach on monitor without ectopy or ST changes. Pt is normothermic. Lung sounds are markedly diminished to mid-lobe bilaterally. Very tight wheezes noted on inspiration/expiration. No pedal edema or JVD noted; Pt sleeps on two pillows a night normally for personal comfort. Tx: 100% O2 via NRB; IVx2 (18g/20g in ACs); Cardiac Monitoring (6-lead EKG obtained) Continuous MedNeb (Albuterol x2 UD); 125mg SIVP Solu-Medrol. VS q5 minutes during emergent transport to ER. Calm reassurance as pt was very anxious. Reassessment: BP 178/100; HR 118; RR 24...labored but cyanosis reduced significantly. SpO2 94% on 15lpm NRB. Lung sounds reveal widespread wheezes with rhonchi noted in the bases ant/post auscultation. Pt relates feeling somewhat better, but still feels "tight" in his chest. Pt begins to develop strong, cough productive of thick yellow/green/brownish sputum. Air movement in lungs improved. Field "diagnosis": Acute Respiratory distress secondary to pneumonia. Now, on this run, the ER asked me why I gave Solu-Medrol when she clearly believed he was in CHF. I explained that he had no history of CHF or any pulmonary disease, just a recent bout of bronchitis which he got ATBs for. He had no pedal edema, JVD, or any other signs of CHF that you would expect. Last I checked, CHF is a secondary condition, rarely primary unless it is congenital. I really wanted to ask her why she believed it to be CHF. Did she draw a BNP level, get a CXR, or even listen to what I told her in my verbal report? But, I kept me yap shut and went about my merry way. 2 weeks later, I get pulled into the Chief's office concerning this run. That same RN wrote me up for giving the Solu-Medrol (and I did follow my protocol for acute respiratory distress). I explained to the chief my reasoning behind it and he agreed I did what protocol dictated for this pt and that it was appropriate. Please share any insight you may have concerning the use of Solu-Medrol in a CHF pt vs Pneumonia pt. My medical director reviewed that run and said that even if he was in CHF, the Solu-Medrol would not have hurt him. (BTW...he did have pneumonia, not CHF and was given Lasix anyway at the ER).

Fiznat... Indeed it is fun...especially if you imagine your pucker factor increasing 100-fold if this pt was unstable with a 20-minute drive to the ER! Oh what FUN that would be! Drag the medic kit out kiddies...It's time to see what we learned...

It sounds as though you covered all the bases with this pt. With the yellow sputum production, and I think some of us (myself included), may tend to forget that Chronic Bronchitis is also considered COPD. However, you're not incorrect to suspect pneumonia, either. That really doesn't change the treatment of this pt. 100% O2; IVx2 if you can, but one will do; Med Neb with Alb/Atrovent (My service doesn't carry Atrovent, so I double up on the Albuterol and make a continuous med neb); cardiac monitoring; VS every 5minutes. and 125mg SIVP Solu-Medrol. By the time you get to the ER that will kick in and reduce the inflammation in the lower airways. One thing I'd look for in my assessments is any pedal edema outside what may be normal for this pt; JVD; and any degree of orthopnea as well. Generally, pt's with COPD will eventually develop CHF; Cor Pulmonale (Right-sided heart failure). IF they have the hx of CHF, pushing the Lasix would probably figure in my treatment too. You did everything I would have...

Dig toxicity is a good thought, indeed. But what would happen if you gave this pt Cardizem...even a bolus of it? If it is truly A-Fib with abberancy, slowing the rate down would reveal the a-fib, if I remember correctly. Please, if I missed the mark even just a little bit, please let me know. I'd rather be sure and get it right rather than guessing.