Many EMS calls, in fact most EMS calls, are pretty straight forward. It’s easy to figure out what is wrong with the patient, the treatment protocol is clear cut, the results predictable. Unfortunately some calls are opaque, as in it’s not clear what is going on with the patient, which means that it’s hard too determine what treatments we should initiate. My fall back position for those type of calls is something I was taught back when I was a paramedic. When in doubt, revert to the ABCs. Airway, Breathing, Circulation. Assess and support those functions and if nothing else, you’ll keep the patient relatively stable during transport to the hospital. Where the doctors will have to figure out what’s going on and correct it.
Then there are the other calls. The ones where you look at the patient, listen to what the patient tells you, examine the list of medications, look at what the technology tells you, and still your gut instinct tells you that something isn’t right and all is not as it appears it should be. It’s times like that I usually rely on my gut instinct. Many times when I don’t, I often come to regret it and the patient suffers. I had one of those calls last night, although the patient didn’t suffer because I reversed course as soon as I realized my error.
We were dispatched for one of our numerous “Difficulty Breathing” calls, which are supposed to be acute calls, but often are ridiculously over triaged. We arrived to find the patient sitting on his front stoop, which is generally not a good sign. The BLS crew had arrived seconds before us and had just enough time to get the patient on the stretcher when we arrived.
Looking at him quickly, I could see that he was having a good deal of respiratory distress, but little else. We put him in the ambulance and started our exam. He was working hard to breath, had slightly prolonged expirations, dry skin, but was speaking only 2-3 word sentences. I listened to his lung sounds, but couldn’t hear much, as he just wasn’t moving a lot of air. My partner du jour, a new medic assigned to cover for my regular partner who was on a day off, listened and said he thought he heard wheezes. I wasn’t sure, but the patient had a long time Asthma and COPD history, still smoked, had been intubated before, and had no overt signs of the other big respiratory problem, which is CHF. I’ve written about how difficult it can be to make a differential diagnosis between COPD and CHF, and this was a prime example. In addition to his Asthma and COPD, the only history the patient told us about was Hypertension. The medications he told us he took matched the history he gave us. For those who want to know, his BP was 162/90 HR 96, RR 96, ETCO2 45, SpO2 96. His capnography waveform was slightly sloped, but not terrible. His expirations were prolonged, but not excessively. His 12 Lead ECG was incredibly non diagnostic with nothing pointing to a STEMI or ACS.
In other words, I was clueless. Except for the little voice in the back of my head that kept saying, “CHF, CHF, CHF.” So, of course I acceded to my partner’s suggestion and we started the patient on an Albuterol nebulizer. I told the patient to tell me if he got better or worse and kept staring at him.
It didn’t take long for my error to manifest itself. The patient started to have more trouble breathing, his BP went up, he became so diaphoretic that the electrodes wouldn’t stick to his chest.
“Can you take Aspirin?”
“No?”
OK, that’s out, which left Nitroglycerin.
“Do you take Viagra or any of those type of drugs?”
“No.” On a side note, I wonder how many patients lie about that?
To my partner, “Take the nebulizer off.”
From my partner, “Do you want to put him back on the non rebreather?”
From me, “Just until I get the CPAP on him.”
So, we gave him NTG, put him on CPAP, did a couple more 12 Lead EKGS, listened to his lung sounds again. This time rales were pretty clearly heard, so the Albuterol did some good. Still, it’s poor form in my opinion to use Albuterol as a diagnostic tool. At least on purpose.
I called the receiving hospital and gave them the story.
Although he said that he didn’t feel better, the numbers started to look a bit better. By the time we arrived at the hospital, his skin was dry, his respiratory rate was down, he looked more comfortable.
At the hospital, more of the story came out. He had quite an extensive medical history, which while not including CHF, did include Coronary Artery Disease and an MI a few years back. Still, I’m not sure it was CHF or that we really did give him the right treatment.
Nor was the attending physician who told me about 20 minutes after we arrived that he still had no idea what was wrong with the patient. Oddly enough it’s always vindication of a sort when I can’t figure out what’s going on with a patient and the doctor tells me that HE can’t figure it out either. Probably not reassuring for the patient, but it’s all about my fragile little ego.
The take home message here is that sometimes your unconsciousness mind will put together a diagnosis even if your conscious mind can’t make heads or tails of what’s going on. There are a lot of theories about what “gut instinct” is and how people can suddenly just KNOW what’s going on when they can’t articulate it. I think the most reasonable theory is that your brain is processing something sub consciously that you conscious (logical) mind is incapable of processing. It’s a combination of buried facts, previous experiences, and past observations, which in combination produce the correct answer.
Whatever it is, I’ve found that I rarely go wrong when I pay attention to it, and often regret it when I ignore it.