What would you do...

[tcripp]

Ready for another? Based on the post regarding mag sulfate, I thought I'd post another "what would you do?" scenario. For the record, these have been patients of mine. As a new paramedic, I know how and why I chose to treat my patient but I like seeing how and why others choose their course of treatment(s). That is one of the reasons I provide very specific tool box items. This avenue helps me to learn and grow (through experiences of others). I hope it does the same for you.

You are called out for a 55yom, COPD, at a private residence (ground floor apartment). You arrive to find your patient lying in bed, with very shallow respirations. Auscultation does not reveal wheezing and you do hear some semblance of air passing through the lungs, but with very short/shallow breaths. Your first set of vitals are BP 116/73; RR 32; HR 118; SPO2 51%; ETCO2 31. Your patient is alert and talking to you, but is very tired - there is no accessory muscle use. You are 10 min away from the closest facility and you are 1.5 hours away from the closest appropriate facility by ground. History includes COPD and anxiety (PTSD - post traumatic stress disorder) / meds include predinisone, a rescue inhaler and nexium / no known drug allergies.

Items in your tool box include

1. albuterol
2. ipratropium bromide
3. xoponex
4. epi 1:1000
5. methylprednisolone
6. magnesium sulfate
7. lidocaine
8. BVM
9. RSI / Intubate

What is your course of treatment and transportation? What would you do?

[fiznat]

No CPAP??

[tcripp]

Good catch. Yes, you have cpap as well.

[Lone Star]

What was the patient's original reason for calling?

Were there signs of cyanosis?

Was the patient on supplemental O₂, if so,what was the rate/delivery device?

[tcripp]

What was the patient's original reason for calling? His wife said that he was having difficulty breathing.

Were there signs of cyanosis? Yes.

Was the patient on supplemental O₂, if so,what was the rate/delivery device? He was on an oxygen concentrator at 2 lpm. The last time he was having difficulty breathing, he pushed it to 5 lpm and then lost consciousness upon arrival to the ED.

[DwayneEMTP]

Lets set this gent up first thing and get some Os on him, 6Lpm NC for now.

General condition of the pt? (I'm willing to bet there is an ashtray and smokes somewhere near the bed)

When was the last time that he self medicated with his prescribed meds?

What makes your appropriate facility more appropriate than the nearest facility?

Does he use CPAP when he sleeps? Other times?

Os at home? Times and delivery rate?

No lung sounds other than just a little air movement?

Great scenario. These are tough calls for me when the transfer time is long. There are a lot of things to consider...

Dwayne

[fiznat]

Our general protocol for this guy would be:

Vents/Oxygen - Sounds more NRB than N/C but I'm not looking right at the guy. If the patient looks sick enough (sounds like he is!) he'd be getting CPAP. Works sweet for situations like these. BVM on standby if he really is that tired.

Nebs - A combivent or two to start followed by albuterol dosing PRN.

Steroids- Solumedrol 125

General stuff - ETCO2 would be a nice assessment tool here. IV, monitor (3 and 12), don't make the guy walk down the stairs, etc etc etc.

[tcripp]

Great scenario. These are tough calls for me when the transfer time is long. There are a lot of things to consider...

Thanks, Dwayne for the feedback. I was really anticipating someone saying, "Enough already!"

Also, I am also hoping those participating won't just look to the simple, "Let's fly the patient." Whether or not it's accurate, I'll pull the card, "Air not available for whatever reason."

Now, to your questions.

1. General condition of the pt? (I'm willing to bet there is an ashtray and smokes somewhere near the bed) "No bueno" comes to mind. He is lying in a right lateral recumbant position in bed with his head elevated by one pillow. When asked his name/age, he gives inappropriate information. Patient does not appear to be in distress, but rather is tired. He pretty much will do whatever you ask. Oddly enough, you don't see any asthrays/smokes nor does the room have an aroma of such. You do note that it's very, very stuffy.
2. When was the last time that he self-medicated with his prescribed meds? He is compliant with his meds.
3. What makes your appropriate facility more appropriate than the nearest facility? Best to say that the local community hospital just isn't set up for critical patients. They are good for stabilization, but if you go that route, they will be transferred at a later time.
4. Does he use CPAP when he sleeps? Other times? No.
5. Os at home? Times and delivery rate? See above post regarding concentrator.
6. No lung sounds other than just a little air movement? No audible wheezing, crackles, rhonci, rales. You hear short bursts of air in his lungs in all fields on auscultation.Thanks for playing!

[tcripp]

Just a little follow up on this scenario. I sat through a case review with about a dozen paramedics and 6-9 BLS/ILS providers. It was very interesting to see as we went around the table how each medic would have handled that call.

First guy...RSI and intubate.

Next guy...BVM w/ O2.

Next guy...nasal intubation.

It's refreshing to know that we don't have a recipe book for patient care...but rather an arsenal of different ways to accomplish the same task.

Vents/Oxygen - Sounds more NRB than N/C but I'm not looking right at the guy. If the patient looks sick enough (sounds like he is!) he'd be getting CPAP. Works sweet for situations like these. BVM on standby if he really is that tired.

Although he'd be a candidate for it, I'd have to say he was too tired to use the CPAP.

[Timmy]

Challenging indeed, a very good scenario.

Let me just go over some history. The dude has a resp rate of 32, a pulse of 118, SP02 of 51%, his in respiratory distress with the possibility of it turning into a silent airway entry (based on ‘some short burst of air’). We assume his been compliant with his regular medication which includes a corticosteroid, he has a past history of CAL, his giving inappropriate information which could suggest hypoxia, his getting tied and were 1.5 hours away from help.

The dudes working hard. I’d like to quickly consult someone more senior before I move onto the next step but in this situation I think the saying treat for the worst and hope for the best would come into play. The last thing we need is acidosis.

To take a stab in the dark I’m going to assume this is an exacerbation of CAL but until we can get him to hospital, get some ABGs, FBEs, sputum, Chest Xrays and so on I will go with an RSI and Tube. Sux, midaz and fent. I know it’s difficult to manage vent pressures, complications with extrabation and the like with CAL patients but things are only going down hill with this guy. His already tired, maybe a little agitated so a BVM may cause some combativeness as would CPAP. With on scene time and transport lets say this dude will be in hospital within 2 hours by road I think the benefits would out weight the risks of an RSI.

BUT

On the other hand, we could get a line in and push some corticosteroids, gets some bronchodilators on board and go with the non invasive ventilation BUT I still have an little alarm bell sounding, is this patient a little to sick? If I did go down this path I’d like to see an improvement within a few minutes BUT has this patient been working to hard for to long? Will our non invasive efforts be rewarded with a massive crash down the slippery slide and we ended up in respiratory arrest.

Tricky indeed, tricky indeed… I think someone with such a crappy respiratory and perfusion status the more invasive the better until we can get a clear picture of what happening. But I’d defiantly like to consult someone more senior before I’d take the invasive approach.