I Can't Breathe! Help Me!

[Sasha]

Today I had a clinical.

I thought I had lost my black cloud because we spent almost the entire clinical sitting around the station only leaving to pick up supplies from the main station. But at 7ish the tones FINALLY go off. 78 year old Difficulty breathing. I LOVE respiratory calls, I think the respiratory system is so interesting and amazing and it was my favorite chapter in our book.

Every respiratory call I've been on has been classic book patients. one or two worded sentences or something along those lines, helped by a mask, etc. We get there and the woman is screaming "I CANT BREATHE I CANT BREATHE" and grabbing and pulling at anything and everything. And she looked like crap. Cyanoticish, fingers were cold, tripoded, in general distress.

Her family standing around screaming at us to help her while we were on scene, etc. I had never had someone yell and scream at me like that before on clinicals. I got so stupid and clumsy due to nervousness. We were putting her on the stretcher while trying to put a NRB on her, which was promptly ripped off because she felt it was suffocating. Tried a Nasal cannula but it wasn't giving her ENOUGH air. In the truck we tried to give her a combivent, tried to coach her into inhaling it in deep breathes but she wouldn't take it because she felt like she was suffocating. I kept trying to get her to take take the combivent because I couldn't think of what to do next. Then we got to the hospital. The nurses weren't happy because in all of it, making a radio report had slipped my mind (and my preceptor didn't remind me, citing "Everyone has got to make that mistake sometime. Better to experience the scorn while you're still a student!")

I hate the helpless feeling of not being able to effectively treat the patient and get them to the hospital in BETTER condition. At the hospital we were rejoined by her family who just saw the "STUDENT" written on my shirt and the daughter flipped out, yelling at me and the preceptor that if her mother dies it would be because of the incompetence of a student treating a serious emergency and she would sue us both.

After that call, my preceptor let me go home early ( I don't know if it was because I was upset because I tried not to make it outwardly obvious or if it was because he didn't want to give my black cloud a chance to bring him another call.)

What would you have done for this call? Driving home I could kick myself as I started remembering what else could have been done. Solu-Medrol, Mag Sulfate, CPAP. ARGH!

Ask questions, and I'll answer to the best of my ability. Help me learn from this!

 

[HasTy]

Wow Sasha I probably would have cried and been extremely pissed off at the family when I got back to the station...I am also not sure it was fair for your preceptor to send you home early all that does is hurt your education and hinder your self confidence...

 

[VentMedic]

Welcome to my world.

This is one of the reasons I became a Respiratory Therapist. There was so much I didn't know and wasn't able to do as a Paramedic to understand and help someone in respiratory distress.

At least I didn't say EMT so this shouldn't get the thread locked.

 

[MSDeltaFlt]

Today I had a clinical.

I thought I had lost my black cloud because we spent almost the entire clinical sitting around the station only leaving to pick up supplies from the main station. But at 7ish the tones FINALLY go off. 78 year old Difficulty breathing. I LOVE respiratory calls, I think the respiratory system is so interesting and amazing and it was my favorite chapter in our book.

Every respiratory call I've been on has been classic book patients. one or two worded sentences or something along those lines, helped by a mask, etc. We get there and the woman is screaming "I CANT BREATHE I CANT BREATHE" and grabbing and pulling at anything and everything. And she looked like crap. Cyanoticish, fingers were cold, tripoded, in general distress.

Her family standing around screaming at us to help her while we were on scene, etc. I had never had someone yell and scream at me like that before on clinicals. I got so stupid and clumsy due to nervousness. We were putting her on the stretcher while trying to put a NRB on her, which was promptly ripped off because she felt it was suffocating. Tried a Nasal cannula but it wasn't giving her ENOUGH air. In the truck we tried to give her a combivent, tried to coach her into inhaling it in deep breathes but she wouldn't take it because she felt like she was suffocating. I kept trying to get her to take take the combivent because I couldn't think of what to do next. Then we got to the hospital. The nurses weren't happy because in all of it, making a radio report had slipped my mind (and my preceptor didn't remind me, citing "Everyone has got to make that mistake sometime. Better to experience the scorn while you're still a student!")

I hate the helpless feeling of not being able to effectively treat the patient and get them to the hospital in BETTER condition. At the hospital we were rejoined by her family who just saw the "STUDENT" written on my shirt and the daughter flipped out, yelling at me and the preceptor that if her mother dies it would be because of the incompetence of a student treating a serious emergency and she would sue us both.

After that call, my preceptor let me go home early ( I don't know if it was because I was upset because I tried not to make it outwardly obvious or if it was because he didn't want to give my black cloud a chance to bring him another call.)

What would you have done for this call? Driving home I could kick myself as I started remembering what else could have been done. Solu-Medrol, Mag Sulfate, CPAP. ARGH!

Ask questions, and I'll answer to the best of my ability. Help me learn from this!

OK, what were the breath sounds? Were they Rales? Or were they wheezes? Because the breath sounds on this patient will dictate the course of action.

Wheezes will warrant bronchodilators (Combivent, Albuterol, Solu-Medrol, MgSO4, yadda, yadda, yadda) because they mean bronchospasm. Bronchospams need to be stopped. OK, the Solu-Medrol isn't a bronchodilator, but it decreases the inflamation associated with bronchospasm.

Rales will warrant CPAP and NTG (with a high enough MAP) because they mean fluid. Fluid needs to be pushed and/or pulled out of the lungs.

Now this may be stating the painfully obvious even to a student, but even us old dawgs need reminding every now and then.

 

[VentMedic]

HR/sounds (between yells)
BP
RR
Breath sounds
Edema
Hx
Meds
onset


Look also at the cardiac status. Anything that presents a sudden change in cardiac output will give the same sufficating feeling. Rapid A-fib, ventricular rhythms and MI may have a person stating they can't breathe even if you hear them screaming which indicates some air is moving but not being distributed. Pulse and electrical HR may also be totally different.

COPD or any chronic lung hx? Blebs? Pneumo possibitity? If so, CPAP might not be a good idea. And, COPD can have several cardiovascular disorders to accompany it such as cor pulmonale, Pulmonary HTN and PVD.

The CPAP may also not have been tolerated since she didn't like a mask. The prehospital machine may not have provided enough flow to meet her demands. Redistributing the fluids by decreasing preload and afterload may improve breathing if the BP supports it. But, more agitation may make breathing worst. The hospital may use BIPAP (Respironics trade name) or one of the newer modes and knock her down (sedation and blow down PaCO2 if needed) a little if the EKG and CXR warrants.

The blood work up including a BNP (CHF) and an ABG showing acid/base as well as oxygen/ventilation will determine the next moves. The lactate level will be an indication of sepsis and a bilateral PNA will also qualify for the protocol.

Depending on the success of the hospital technology and the diagnostic findings, she may get an ETT.

And yes there will be combinations of exacerbation, CHF, PNA and rapid A-fib or all of these on some chronic lung patients. You can also toss in sepsis to that mess also. General statement since you didn't include her history yet.


Check out the links I posted on the Definitive care thread about V/Q mismatching and shunting.

BTW, preceptors are also there to guide you. If you appear to be stuck or heading off the path, they are there to get you back on track...not leave you and the patient hanging. This would also include a reminder to call the hospital. You should not expected to be expert at everything yet.

Was there a review of the call with the preceptor and/or your instructor after the call?

 

[Aidey]

The CPAP may also not have been tolerated since she didn't like a mask. The prehospital machine may not have provided enough flow to meet her demands.

Vent beat me to it, but this is what I was going to say. I have asthma, and while I don't have attacks very often, when I do have them they are bad bad, and I turn into your patient. The last one I had was in Paramedic school, and I perfectly understood what as going on and I still ripped off the NRB, threw my (ringing) phone at the medic, and was generally a pain in the arse. I'm about 99% sure I would have just ripped off a CPAP mask also. Mag is also only indicated if it's status asmaticus, refractory to other treatments. If she was suffering form something like flash pulmonary edema, steroids wouldn't have been much help either. Given how vocal your patient was, I think Vent made a very good point about how she may have been moving air fine, but it wasn't able to oxygenate the blood adequately.

 

[Veneficus]

While I defer to Vent as the expert on this, one thing I have not seen come up here is the possibility of PE. Those patients usually seem to be able to speak, yell, fight off 6 firemen trying to calm them down, etc.

Some people will tell you that any patient who can talk can breathe. I call BS on that one. Perhaps the mechanics of breathing are intact, but the respiration is not. I never one saw a patient screaming “I can’t respire!” There has to be blood moving to get O2 and CO2 where it needs to go and gas exchange at the cellular level.

Unfortunately, many people who have a massive PE do not live. There was a NEJM article some months ago about a young female who had one and was discharged from one hospital to almost die when she went to another. (Sorry guys I am too busy to search through weeks of publications for the article right now If the day goes well, maybe I will get to it.) She lived with long tern health consequences.

The bright side is that there is nothing EMS is going to do for that other than turn wheels, so you probably didn’t forget anything. Your receptor might not have been overly aggressive at directing you because he may have been thinking PE as well.
As for the family, anger is a normal reaction in some. Even some patients don’t take help too kindly. Certain ethnicities are known for becoming angry at care providers no matter what is being done (or not done) too much house and ER for them.

Emergency patients are like boy(girl)friends. Nothing gets you over the last one like the next one.

 

[Outbac1]

The question is WHY can't she breath. As others have said there are a number of possibilities. I'll go for now with constriction and wheezes as you were treating with a combivent. It doesn't appear your preceptor was trying to change your treatment so I'll assume they were in agreement. If they weren't in agreement they should have pointed you down a different path. They are still responsible for the proper treatment of the pt.
Sometimes it is hard to get pts calmed down enough to accept the mask no matter how hard you try. A nasel isn't going to give a pt like that relief but it won't hurt to have it under the mask. Even keeping the mask near their face can be of benefit to open their airway so they feel like they are getting more air. When they get tired enough they will more easily accept Bipap or Cpap and may even need to be intubated.
I probably would have started the combi in the house rather than just an NRB. Sometimes if the pt and family know you are trying to give a medication rather than just O2, they are more tolerant of your efforts. They see it as trying to actually do something for the pt. This can turn the family on your side and they will often try to encourage the pt to accept your help.
As to the family, sometimes you have to tune them out. I know easier said than done. Sometimes involving the family by asking them questions about the pt calms them. The pt probably can't answer your questions anyway. If the pt was still fighting at the hosp she wasn't that worn out.
If your preceptor is any good and wasn't concerned about the pt to intervene, I wouldn't beat myself up about it. Their job is to guide you. Let you stumble but not let you fall. Why did your preceptor let you go home early? How early, 2hrs or 20min? Have you talked to your preceptor about the call? If so what did they say about it?
So you forgot a radio patch, welcome to the club. Sometimes if I'm busy in back I'll get my partner to call it in.

Some more info on the pt hx, assessment and tx at the hosp would be nice to know.

 

[VentMedic]

If she has a chronic lung history, there is a good chance she had already been doing inhalers and/or nebs prior to that. If they have had little effect, unless her techniqued was really bad or the inhaler expired long ago, it is time to think of Plans B, C and D.

Although the anticholinergic is very important to some COPD patients, too much of a good thing may not be so good. I'll serve up albuterol all day and all night but I rarely will go beyond q4 hours on the anticholinergic and that depends on if the patient has the long acting like Spirva on board. Of course, your protocols may vary.

I suggested referring to the links I had posted previously for V/Q mismatching or shunting because the list is very long and it could be anything thing along with everything else. However, A,B,C is still the concern. At the Paramedic level you do have more options to alleviate some things to maintain hemodynamic stability.

At the moment she is ventilating although it is unknown how effective the gas exchange is except by color, mentation and her vocalizing her symptoms.

SpO2 readings may not reflect her true state of difficulty since a patient will try to increase their minute volume to compensate. This is especially true with Pulmonary Embolus and some PNAs.

Circulation: As a Paramedic, you may be able to alleviate abnormal cardiac rhythms which may be decreasing cardiac output. In the cases of Pulmonary embolus, PNA, and/or sepsis, you have the ability through fluids and pressors to maintain MAP for BP. Chronic lungs patients need their fluids balanced to have adequate circulation. Too much is a problem and too little is a problem. You should have protocols for each to do what you must to maintain stability. If you find evidence of an MI, you can start your protocols for that also. But, your goal is still to maintain hemodynamic stability. No one should expect you to pinpoint the exact cause and identify all V/Q mismatches in the field but those problems that can be assessed can be treated to keep stability. Read through all of your protocols and you will find similarities. While one working dx is great but patients are medically complex with many different problems at one time with each exacerbating the other. Yet, the initial management is identifying what you can assess, prioritize, alleviate or initiate treatment and establish some stability.

 

[VentMedic]

The question is WHY can't she breath. As others have said there are a number of possibilities. I'll go for now with constriction and wheezes as you were treating with a combivent.

Are those of you north of the border keeping Combivent in Canada? Just curious since it was the Montreal Protocol that changed all the MDIs. Unfortunately in the U.S. some of the newer inhalers are out of reach due to cost and insurance coverage.

Those who are assisting pts with their meds, especially the inhalers, need to learn the correct way(s) for the new HFA inhalers. That goes for both priming and technique.

Apologies for the off track info message.

 

[Sasha]

HR/sounds (between yells)- 130/min
BP- I don't remember specifically but it was somewhere in the 180s systolic.
RR-28/min
Breath sounds- Wheezes.
Edema- Her lower legs had pitting edema but her family said that was normal for her
Hx- TIA, CAD, COPD, hypothyroidism, HTN, hyperlipidemia, diabetes.
Meds- Warfarin, synthroid, metformin, lipitor, spiriva, some others I can't remember. But family said she had been noncompliant with meds.
Onset- About 10 minutes before they called, don't know what she was doing and of course, I forgot to ask what she had been doing.

Was there a review of the call with the preceptor and/or your instructor after the call?

No, not really. When we got back to the station he asked for my log book, signed off and said I could leave. On the way back to the station he was talking about having better scene control.

I do plan on calling him so we can go over it later today and I wanna know if he went back to that hospital later and if so how she's doing.

If you appear to be stuck or heading off the path, they are there to get you back on track...not leave you and the patient hanging.

His philosophy is that he is there so I don't hurt or kill anyone, and can ask questions after, citing the fact that (while my school sucks and I'm nowhere near ready) I'm almost done with medic school and will be out by myself when there wont be anyone to remind or reguide.

too much house and ER for them.

You can't be knocking House!

 

[VentMedic]

His philosophy is that he is there so I don't hurt or kill anyone, and can ask questions after, citing the fact that (while my school sucks and I'm nowhere near ready) I'm almost done with medic school and will be out by myself when there wont be anyone to remind or reguide.

How sad that there is little mentorship but rather, what harm can a student Paramedic do philosophy. His philosophy does not promote learning but rather a "fly by the seat of your pants" mentality and get them to the hospital. The fact that you are nowhere near ready could be due to a lazy preceptor.

When given the responsibilty of precepting, it is huge because if that student or trainee is not ready, if reflects back to the preceptors abilities and readiness to identify your weaker areas to see what can be done to develop strengths. He is assuming the school is providing all the information but doesn't seem to understand his responsibility to see the knowledge from the school is adequately applied directly to patient care in the field.

 

[Sasha]

How sad that there is little mentorship but rather, what harm can a student Paramedic do philosophy. His philosophy does not promote learning but rather a "fly by the seat of your pants" mentality and get them to the hospital. The fact that you are nowhere near ready could be due to a lazy preceptor.

That's not so shocking. My entire experience with paramedic school has been "sad". Nothing has promoted learning but rather a "pass the test, get out there, then you'll learn" mentality. The nowhere near ready is a culmination of things, and not soley the preceptor. I've learned a lot from his preceptorship, though. Probably more than I've learned in class.

 

[Veneficus]

wasn't knocking House, was pointing out the mentality that on medical TV shows everything seems to turn out right in the end, lay persons watching that stuff seem to think it is factual.

 

[Sasha]

[lay persons watching that stuff seem to think it is factual

You mean it's not!?

 

[VentMedic]

However, HOUSE does illustrate the extensive trial and error as well as the all the painful testing a patient must go through. Somethings are not an exaggeration. There have been a few episodes where the outcome is not always favorable. Occasionally there is a death or they do list the life altering complications of a chronic illness. I will say they did botch the hypothermia protocol pretty bad.

It may take multiple tests and days or even weeks to determine a patient's problem if ever. Some patients get referred to specialists and some must have their "symptoms" treated by GPs for many reasons including availability of specialists and insurance.

Back to the wheezing lady:
Did you have the option to do a nebulizer of either Albuterol or Albuterol/Atrovent combo?

 

[VentMedic]

Back to the wheezing lady:
Did you have the option to do a nebulizer of either Albuterol or Albuterol/Atrovent combo?

An aerosol mask is considered "high flow" by true definition in that it can meet the patient's inspiratory demand by design and can be better tolerated. A NRBM is limited flow and considered low flow except that is uses more gas flow.

Summary:

An aerosol mask has the capability to meet inspiratory demand but may not provide a high or steady FiO2. The FiO2 will vary with the inspiratory flow effort of the patient.

A NRBM is a low flow device by true definition. It is still considered high flow on EMT exams but that should be thought of only from a gas consumption concept. It can provide a higher FiO2 but the flow limitations and confining mask creates problems with toleration.

 

[MSDeltaFlt]

HR/sounds (between yells)- 130/min
BP- I don't remember specifically but it was somewhere in the 180s systolic.
RR-28/min
Breath sounds- Wheezes.
Edema- Her lower legs had pitting edema but her family said that was normal for her
Hx- TIA, CAD, COPD, hypothyroidism, HTN, hyperlipidemia, diabetes.
Meds- Warfarin, synthroid, metformin, lipitor, spiriva, some others I can't remember. But family said she had been noncompliant with meds.
Onset- About 10 minutes before they called, don't know what she was doing and of course, I forgot to ask what she had been doing.



No, not really. When we got back to the station he asked for my log book, signed off and said I could leave. On the way back to the station he was talking about having better scene control.

I do plan on calling him so we can go over it later today and I wanna know if he went back to that hospital later and if so how she's doing.



His philosophy is that he is there so I don't hurt or kill anyone, and can ask questions after, citing the fact that (while my school sucks and I'm nowhere near ready) I'm almost done with medic school and will be out by myself when there wont be anyone to remind or reguide.



You can't be knocking House!

Sasha,

Despite the above history, I'm still leaning towards CHF Exac, maybe a combo of CHF/COPD Exac for this reason. Most people with a real bad bronchospasm tend to have a hard time screaming because the bronchospasm is restricting them from getting the air out. Getting the air in is one thing. Getting it out is all together different. Hence the Dx Chronic Obstructive Pulmonary Disease.

Now the vast majority of CHF Exac pts I've seen have had no problem whatsoever in screaming from air hunger because they tend to have a hard time getting the air in. They have no problem getting it out because they are screaming.

Granted. You never say "never", and you never say "always", but that's just my humble 0.02.

 

[VentMedic]

MSDeltaFlt makes very good points especially with the BP and edema. It would be nice if people could just have one disease process at a time but unfortunately chronic illness lead to other chronic illnesses and you never know which one exacerbates more.

 

[Outbac1]

Vent

I come accross Combivent MDI's quite often. Usually a generic brand of whose name escapes me now. Other pts are on Salbutemol and Atrovent. Others are also on Flovent (fluticasone). We mix it for nebs in the truck. 1 x 5mg Salbutemol and 1 x 0.5mg Ipratropium Bromide. PCP's here can use Salbutemol all day but you must be an ACP to add the Ipratropium Bromide.

I'll try to find out some costs for you from a Pharmicist friend of mine.