No SOB, no complaints, but wheezing?

[tniuqs]

The pt was the driver who had been texting when he lost control of his vehicle

AH a self inflicted injury, zero tolerance for that.

Change treatment plan to add therapeutic slapping

j/k

[BushyFromOz]

Honestly and realistically, I probably wouldn't do anything. If he has asthma, he's always wheezing; it's nothing new. I'd assume he'd have an inhaler with him, and I'd let him use that if he wanted. I wouldn't start pulling anything out for the short trip to the hospital.

Always? Always walking aorund with an inflammatory response? always mucous plugged and brocho-constricted? Your just wrong dude.

The cookbookers would throw some salbutamol and/or atrovent at this guy based on an adventitious lung sound, but clearly he doesn't fit any category of respiratory distress that im aware of. Nebulised OMHO is to aggressive, i have however got PMDi's and a single use cardnboard spacers here, so id give him 4 puffs and see how he goes if i felt he was slightly compromised.

Maybe getting a bit more throughout history, like what other meds is the patient on, last ER visit, is he on any inhaled roids, when and how frequently does he need salbutamol ?

Yeah, im with you turnip.

Anecdotally, patients with a full field wheeze who do not have any perinent history usually turn out to be ex-smokers with essentially asymptomatic COPD (resp rate constantly on the high end of normal and gets a bit puffy when they walk the dog - but nothing acutely abnormal) and/or have a degree of unrecognised failure which is possible as they have a Hx of hypertension.

Edited August 1, 2011 by BushyFromOz

[DwayneEMTP]

It depends for me on the degree of involvement of the wheezes. Light and localized, probably not, heavier and generalized, probably so.

I am really going to set myself up for a beating here...so here goes. I like to practice medicine. I believe that I can learn from pretty much every patient, and almost certainly from every medication administration if I take the time to try and track the minute along with the gross, so if I can justify the delivery on the pts cost/benefit then often I will treat so that I can watch their responses, and hopefully learn from the cascade of events that follow.

This fellow doesn't sound like he would meet the cost/benny, but bump him along the acute path just a bit, or if I can tell that the wheezes are worse 5 minutes down the road, then I'll treat him on the theory that we'd both win. He'd get some increased gas exchange and possibly mitigate a condition that is worsening and I'd get to track the effects of my treatment on his body as well as his mind, and all would be better for it, in my opinion.

The further I go in medicine the more I come to appreciate the diagnostic value of a patients facial/body movements and expressions when combined with vitals and other physiological markers. But, in my opinion, learning to recognize some of those external markers takes practice...

Let the beatings begin...I can take it...

Dwayne

[BushyFromOz]

I like to practice medicine

Name aside, if we are not competantly practicing something, what exactly are we doing then?

I come to appreciate the diagnostic value of a patients facial/body movements and expressions when combined with vitals and other physiological markers. But, in my opinion, learning to recognize some of those external markers takes practice...

For sure, grossly undervalued IMHO

Edited August 1, 2011 by BushyFromOz

[croaker260]

Most everyone has good points, I will agree with most of them and add one more consideration I didn't see above (though I may have missed it).

Some patients are on regular nebulizer treatments several times a day. If the patient is otherwise asymptomatic (if he has wheezes, is he really asymptomatic, or simply at his symptomatic at his baseline? ) , but due for his treatment then I may administer one to keep his chronic condition from being exacerbated...depending on transport time, etc.

[DwayneEMTP]

Most everyone has good points, I will agree with most of them and add one more consideration I didn't see above (though I may have missed it).

Some patients are on regular nebulizer treatments several times a day. If the patient is otherwise asymptomatic (if he has wheezes, is he really asymptomatic, or simply at his symptomatic at his baseline? ) , but due for his treatment then I may administer one to keep his chronic condition from being exacerbated...depending on transport time, etc.

+1 (I used up my quota of +'s for the day)

Awesome question. Is a patient at his chronic symptomatic baseline symptomatic or not?

I wish you posted more often man...You have something interesting to say in every friggin' post....

Dwayne

[croaker260]

+1 (I used up my quota of +'s for the day)

Awesome question. Is a patient at his chronic symptomatic baseline symptomatic or not?

I wish you posted more often man...You have something interesting to say in every friggin' post....

Dwayne

Pot calling kettle black....

<<Deep Bow >>

[tcripp]

I'm glad I could stimulate some really good conversation today.

[tniuqs]

Some patients are on regular nebulizer treatments several times a day. If the patient is otherwise asymptomatic (if he has wheezes, is he really asymptomatic, or simply at his symptomatic at his baseline? ) , but due for his treatment then I may administer one to keep his chronic condition from being exacerbated...depending on transport time, etc.

Croaker, no intent to challenge your observation, I think I see what your trying to say, but many brittle severe asthmatics have a "silent chest" so would you call that asymtomatic too ?

No intent to pull rank but other than working in the back of a rig have you dealt with a lot of long term care hospitalized COPD patients, your theory is a bit of a stretch although not incorrect as they all do differ, especially those on supplemental O2.

The very broad term used in EMS that of "wheeze" is very often a "catch all" in fact inspiratory vs expiratory was never questioned in this nor any more PMHX nor meds.

I can tell you with all sincerity that I have been informed by many Paramedics and RNs upon taking report of a wheeze, but one cough or one deep tracheal suction and suddenly the wheeze is gone, as I said prior all that wheezes is not asthma, i was intending to introduce cardiac asthma as a possible diff dx .. but when patient was texting while driving, well I suddenly lost interest.

Cardiac asthma is a medical symptom, of wheezing due to congestive heart failure.

cheers

Dear Bushy:

The cookbookers would throw some salbutamol and/or atrovent at this guy based on an adventitious lung sound, but clearly he doesn't fit any category of respiratory distress that im aware of. Nebulised OMHO is to aggressive, i have however got PMDi's and a single use cardnboard spacers here, so id give him 4 puffs and see how he goes if i felt he was slightly compromised.

No cookbooker here mate, do you need respiratory distress with a history of asthma to treat a wheeze (I think your just being a pussy) LOL.

With your post your suggesting MDI with spacer is less aggressive than SVN ... hmm careful there don't make me pull out my studies !

cheers

[chbare]

Does he have a peak flow meter, can we do bedside spirometry? (I actually carry one (PEF) with me now.) Often, many people who are not well controlled may not have any complaints, only to say they never realised how bad they felt after they are stabilised. I may at least consider treating if there are no contraindications. Having before and after quantative measurements would be good, but probably not realistic in most cases of EMS transport. I'm on board with a MDI and spacer, although not because of aggressiveness or anything. It's easier to use IMHO with similar efficacy to a SVN. Also, never want to miss a teaching opportunity while I have my patient as a captive audience so to speak and MDI's are often administered incorrectly. So, I can kill a couple of birds with the same stone before even arriving at the hospital. This is a potential opportunity to make a difference with this patient.

Take care,

chbare.