Bieber

Previous history of similar symptoms? History of recent illness of any kind? All of the questions Chris asked plus a BGL just because. Do we have the ability to obtain laboratory values or imaging? Also... let's take him back off of the oxygen and see what happens...

Ack... sorry, Mike, I meant you!

I'll echoe chbare's post and add that I too use "denies" to indicate that I have ruled out pertinent negatives (patient complains of dyspnea but DENIES any chest pain, productive cough; abdominal pain in a pregnant female who DENIES any associated vaginal bleeding; etc). Hang in there, man, and just do what you got to to get through this rough period.

Yeah, I agree, I wish I had gotten a 12-lead but it seemed like I just didn't have enough hands to get everything done that I wished I had. That seems to be what I've heard too as far as it either working great or not working at all. I've never used it myself, though our new protocols will have it by standing order so hopefully I'll get the chance to in the near future. From what I've heard CPAP works pretty good on COPD, although I do think that BiPAP might be more beneficial to help prevent air trapping. TicTok, thanks so much for participating man! It was great to get the perspective of someone working in a completely different EMS environment than what I'm used to and I know enough about South Africa and EMS there to know that you guys are some of the best out there and run critical calls on an extremely frequent basis. Thanks for giving your input and for sharing some of your kind words. As far as the EJ goes, I would tend to agree with you--I just wanted you to share your reasoning aloud for everyone to see where you were coming from. Thanks again man! Chris, thanks for sharing a bit more on NIV and for the book reference. If I ever get some free cash floating around I'll definitely have to check it out. Kiwi... don't lie, bro, you were totally hard for this scenario. Lol. Dwayne, as always, thanks for bringing your knowledge and experience to this scenario. You really made me think about things I could have done differently and made me realize some areas of weakness that I'll work to avoid next time. To answer your question, I definitely think that presenting these scenarios is just as much if not more helpful than participating in them. In the heat of a call it can be hard to avoid getting that tunnel vision and going over calls is a great way to learn from them and to improve the next time around. You guys were amazing! Thanks again! I go back to work on Tuesday and hopefully I'll have some more scenarios to post soon.

I can see where a blanket protocol of sedating any psychiatric patient might not be the wisest decision out there, but I can also see it from the policy makers' point of view that that's a couple million dollars of aircraft, equipment, and irreplaceable human life. At the same time, there's the chance for any and everyone to freak out once they get up in the air. Are they sedating people with a fear of heights? What about anxiety/panic disorders? You also said that most of the people being sedated are going to a psych ward? Is that what they're being transported for? Because if so that's a massive risk being undertaken (air transport) for no major benefit. Could they not transport people by boat or ship?

All right, folks, here's the epic conclusion to this scenario! First of all, thanks to everyone for participating. I hope you all enjoyed this scenario because I definitely did. Everyone had great ideas (including ones that my dumb ass didn't consider at the time) and I feel like getting your guys' input on this will definitely aid me in the future on similar calls. This was an actual patient, although I changed a few non-critical details just because. I was up for this call, although my partner rode in the back with me while driver drove us in emergency traffic because I triaged the patient code red (severe). The vitals and EKG were all true to this patient, and I was treating for what I thought was a COPD exacerbation due to infection--like a lot of you here did. I gave x1 albuterol treatments on scene and tried for an IV once before we moved the patient to the ambulance. My partner tried to get a line once en route but wasn't able to either, and I decided to start bagging in albuterol via BVM because unfortunately we don't have standing orders to use CPAP on COPD patients and I didn't realize that you could attach a nebulizer to them (thanks for teaching me something, Chris!). I didn't end up going with any epinephrine because of those episodes of tachycardia and the patient's elevated blood pressure, but my partner did give our patient a shot of methylprednisolone IM. By the way, I called those bouts of tachycardia V-tach, based on their similar morphology to the PVC's the patient was throwing and because I've never seen anybody go in and out of PSVT like that and I considered the rhythm most likely due to ventricular irritability secondary to the hypoxia. We bagged the patient with continuous albuterol all the way in and we managed to get their SpO2 up to 96% and their work of breathing significantly improved by the time we arrived at the hospital. I checked back later that night and found out that the patient had been admitted to the respiratory floor for an exacerbation of COPD secondary to pneumonia. I never did hear any crackles and while I briefly considered CHF, the overall presentation of the patient to me seemed to weigh more toward an acute COPD exacerbation than pulmonary edema. Now! Things I wish I had done differently: -IO: I was on the fence about starting an IO or not on this patient, and in the end I admit I honed in on just bagging the patient and pushing albuterol treatments down their throat. I also didn't consider it a priority at the time because I hadn't fully considered the next point... -Magnesium Sulfate: This we don't have by standing order but I could have called for, and I wish I had. I think I may have briefly considered it but for one reason or another didn't go back to the idea. I wish I had now, and maybe it would have helped turn the patient around quicker. -CPAP: Chris, I owe you for making me feel stupid about this one, and again for teaching me something. I really didn't think you could connect a nebulizer to CPAP (maybe because previously we've been so anti-CPAP for non-pulmonary respiratory disease), but now that I know, you can bet I'll be using this in the future. I still think that PPV via BVM was a good second best, but it definitely would have given me a chance to get more done if I hadn't been bagging the patient all the way in and it might have been more beneficial to them as well. -Fluid Bolus: I thought this was one of the best treatments suggested in this scenario, and one I would have definitely liked to have used if I had ever gotten IV or IO access. Kiwi, I know how you mentioned the tube, but to be honest I was there with Dwayne on this one. I wanted to avoid it at all costs, and even if I hadn't, we don't have RSI capabilities where I work and the patient remained conscious throughout transport. If it comes to it it comes to it, but given the DNR and the risk of secondary nosocomial infection, I felt like it was best avoided. I haven't followed up since the day I ran this patient to see if they made it out of the hospital or what, but it was one of the best calls I've had lately and I had a feeling you guys might enjoy it--and I hope you all did! I'm not used to employing mag or CPAP for these kinds of calls (due again to our protocols), but you guys have kind of made me realize I need to be making a better effort to think outside of the box and to call for orders if I don't have them by standing order and start utilizing these drugs and procedures that have been proven effective. So that's something I'm going to work on from now on. Thanks again to everyone who participated! Hopefully you all learned something from this scenario to, whether it's a new technique in respiratory management or maybe just a kick in the ass to get to using a technique you already knew but maybe haven't employed for whatever reason lately.

Dwayne, another great post. Mike, no foley, but good thoughts on it. Does anyone else have anything more to add before we conclude this scenario?

Great response, TicTok! The ambient temperature is around 75 F inside the nursing home; outside it is around 78 F and it is spring. Sticking an IV into the EJ is a good idea, but are you at all concerned about the patient's anticoagulated status with regards to that? We've also got a Lifepak 12 that we're using with full capabilities available to you. Wendy, unfortunately we've got no more info on the details surrounding the events leading up to his dyspnea other than those that have already been mentioned. Sorry! So for another quick recap, we're starting to make some headway with this patient. We've got some CPAP and nebulized albuterol going, we've gotten some magnesium sulfate down, and we've got a couple of folks in favor of steroids and a couple against. We're transporting now. Do we want to go lights and sirens or regular traffic? Also, how many folks do you want in the back with you if any? Any more interventions we want to try or do we want to continue as is and see how it goes for the rest of the trip?

Ack! Sorry Chris I forgot that one. Patient IS in fact on Klor-Con.

You initiate transport per Kiwi and get headed toward the hospital! Patient's current vital signs are: HR: 130 RR: 22 labored but less so than before SpO2: 93% and holding BP: 192/104 Lung Sounds: Wheezes apically, still diminished with some slight wheezes basally. No crackles. EKG: Sinus tachycardia, no more acute episodes of the aforementioned tachycardic rhythm (consensus on that?). Ambient Music: Danger Zone by Kenny Loggins

Your patient suffers one more short burst of the tachycardic rhythm, but after the magnesium sulfate, IO fluid bolus and continuous albuterol treatments and CPAP, his lung sounds are improving. There's definitely wheezes apically, still diminished basally but you can finally hear some airflow down there--if only a little. SpO2 is up to 94% and his work of breathing is slowly coming down. Steroids are still on the table, the question is, do we want to give them or not? Do we want to begin transport?

Great call on the fluids, Chris. Capnograph shows a shark fin morphology.

Heh, Kiwi, you'd be surprised how little a hospital may do if they know they have a DNR... Chris, temp is still 100 F, BGL is 100. Level of responsiveness is still difficult to determine because of the patient's dyspnea, but he responds when commanded by squeezing his hand. Still no crackles, Dwayne!

Capnography and 12-lead are still the same. Lung sounds remain very diminished basally, wheezes apically. JVD's still present, skin and work of breathing are unchanged.

New set of vitals, post mag and CPAP: HR: 136 RR: 24 labored SpO2: 90% BP: 188/100

Yeah, I know you can do that with our setup, I just didn't know that you could do the same with the CPAP. That's good to know, though...

I like your thought process on this one, Dwayne. You got it. It's being given IO. We'll give it a little bit to work its magic. Patient's still throwing frequent PVC's but he hasn't developed any more long strings of tachycardia--for now. You got it man. Does everyone else like the sound of this or does anyone want to try something different? Kiwi? Are you still wanting to go for the tube or do you like Dwayne's treatment plan? Huh. I'm not sure if our CPAP devices permit that (I'm guessing they probably do and I'm just too retarded to figure it out)--so I'll have to double check. No ABG or chest X-ray. You got your IO. Not a bad thing to consider. What does everyone else think? Is everyone set on this being a COPD exacerbation or are we still considering something else like CHF? Does everyone agree with J306's interpretation of the episode of tachycardia? Does anyone think it's anything else? Yep. This is an actual call I ran just recently. Unfortunately, our capnography only works in conjunction to our ET tubes and combitubes, so I didn't have access to it on the call. After we're all done, I'll share with you guys what my impression and treatment was. Awesome point about the lack of peripheral edema. There's still the possibility that this could be pulmonary edema; unfortunately we just don't seem to have much evidence in support of it at this time. Maybe if we can get her opened up a bit we'll have a better idea of which the case is! Everyone else seems to be behind CPAP at this point. Anyone else in favor of throwing some nitro down? I'll give you all a new set of vitals here in a little bit. How about our transport decision? We ready to get going or do we want to sit and work him a little longer?

I think some mag would be a great option for this patient, and one that comes with a lot less strain on his already irritable heart! Great point on the risks of intubation and ventilation... It sounds like this patient might already have an infection, do we want to risk adding a vent acquired infection on top of that? The hospital has an appropriate ICU and respiratory department. They're no trauma center, but they can handle most anything medical. Great question! Nursing staff has no clue, but the daughter states that he usually runs in the low to mid 90's. Not a bad idea, but do we want CPAP or PPV with a BVM along with nebulized albuterol? He seems to be doing better with the BVM, although we've only gotten one albuterol treatment in so far. After Dwayne and Kiwi combine their skills of persuasion, the daughter finally concedes and says "do what you have to". You've got your green light to do what you think is necessary up to the point where the patient codes. Now, with everything we know in mind, what do we want to do? Quick recount: HR: 137 (160's during second bout of the same tachycardia as before, this time lasting only a couple of seconds) RR: 24 labored BP: 192/108 SpO2: 87% Treatment so far: PPV via BVM with x1 albuterol treatments administered so far. No IV access at this time. So far, here's what's been suggested for our next move: *Epinephrine. Things to consider: age, myocardial irritability, hypertension. Risk/benefit? *Magnesium sulfate. Things to consider: less cardiac stress. No IV access. *CPAP. Things to consider: no ability to give nebulized treatments through it. May increase oxygenation, however with the airways closed up so much, do we want to try and open those first or concurrently? *RSI/Intubation. Things to consider: risk of vent-acquired infection. May be more invasive than the patient would want. Can bag in nebulized treatments through it; may increase oxygenation status. Do we want to get a steroid on board? We've got about 25 minutes to the nearest hospital, which means the patient may start to experience some of the effects by the time of transfer of care. Great responses, everyone, really well thought out. Addendum: Also, have we come to a consensus on what we think we're dealing with here?

I hear you, man. Unfortunately, the daughter is pretty uncertain about what she wants done now. She said minimum treatment only, but Kiwi's persuasive New Zealand accent has her second guessing herself now. She isn't able to offer any better of an answer; she just says she's not sure what he would want. Looks like it's up to you highly educated, highly experienced professionals to reach a solution to this ethical dilemma. What do the rest of you say? We're getting some response to the albuterol treatment and PPV. Do we want to tube the guy or try to improve his condition via less invasive ways?

Maybe they ought to put those highly educated, highly skilled providers on an ambulance or flycar and save air transport for something else.

Ben, right you are! Next set of vitals are as follows: HR: 135 BP: 192/110 RR: 24 labored SpO2: 87% (after bagging in the initial albuterol treatment per Dwayne) Temp: 100 F Lung sounds are still diminished, but you're starting to notice a little bit of airflow apically and bilaterally. You've hear wheezes. Patient's daughter and DPOA is on scene and requesting that the minimum amount of invasive treatments be performed to stabilize her father. With that in mind, do you want to continue with the IO and intubation, Ben? DFIB, that's a good thing to consider. What do you want to do right now? Everyone else, ideas? So far we're still on scene, we've had one episode of the tachycardic rhythm noted above, we're finishing up bagging in our first albuterol treatment, and so far we haven't managed to establish IV access. What now?

Never had to do anything like this before, but I imagine you could simply start tracking the amount of water people are drinking each day. I know it'll be hard to ensure compliance, but is there any way you could get people to fill out a form where they have to write in how much water they consumed each day for a week or show and compare them all? Just the first thing that came to mind, I'll try to come up with something better later on tonight.

System, I agree with you on the P mitrale. There are labs available in the paperwork from yesterday showing an INR of 2. No signs of DVT on inspection of the extremities. Patient is producing urine and no, the lisinopril isn't new. Baseline GCS is 15, however it's difficult to ascertain the patient's true level of consciousness because they're unable to talk due to the hypoxia. Patient does respond to commands by squeezing his hand when indicated to. Thermometer craps out, but the patient is warm to the touch. Unable to complete a neuro exam due to the patient's level of distress. Mike, I agree with you, however unfortunately the nursing staff insist that the patient didn't report any complaints to them until 20 minutes ago. When you probe deeper into the patient's general state of health recently, the nurse reports that "he isn't her usual patient". Dwayne, percussion of the chest reveals hyperresonance throughout. No signs of trauma or abuse. Waveform capnography shows a sharkfin morphology. The DNR states that no resuscitation including chest compressions, intubation, medication therapy, or other invasive treatments shall be performed in the event that the patient's heart stops. Good call on trying to get another IV, however as soon as you open the line (slowly, at that) that vein also blows. Another good call to bag in the albuterol--you do that and the patient's SpO2 gradually starts to increase. It's up to about 86% now and rising. Lung sounds are still diminished/absent however. As far as the lung sounds go, he's taking big, deep breaths--you can see his entire chest wall move with each breath. He's holding strong for now, but he's obviously working to breathe at a rate which is non-sustainable long term. So, considering epinephrine, what are you thinking, man? Patient's blood pressure is pretty high, plus the history of CHF. Oh, and you get a rhythm change on the monitor. You get about fifteen seconds of this: After fifteen seconds or so, patient reverts to the initial rhythm, with the occasional PVC.

Csc, I agree with all three of your points, though I question the significance of point number 3.