Back when I was in paramedic school, the text we used was “Emergency Care In The Streets” by Nancy Caroline MD. It was a pretty good text book, although not written at the college level. In fact, the original paramedic program that Dr. Caroline ran was intended to provide inner city youths with a job that didn’t involve flipping hamburgers or selling drugs. As such, it was written at, I think, the Eigth Grade level. Some people scoffed at the level of writing used and in fact, we used a number of supplemental texts, but Emergency Care… was our main text book.
One of the things that Dr. Caroline wrote about was what she termed “Cardiac Asthma”. She also used the phrase that I used for this post title. Her point was that wheezing is a sign of airway restriction, not necessarily of bronchoconstriction. All too many people jumped (and sadly still do) to the conclusion that a wheeze must be caused by COPD or Asthma. They then immediately throw nebulized medications at the patient.
People used to laugh at the term “Cardiac Asthma” and in truth it’s not very accurate. Like “The Golden Hour”, it was a conceptual tool to help people get that it’s dangerous (to the patient) to assume that a wheeze can only be caused by Asthma or COPD. At various points in the evolution of a Congest Heart Failure exacerbation one can hear any number of breath sounds. Or one can ominously hear no breath sounds which can fool people into believing they are hearing clear breath sounds.
The point here is that it’s easy to be fooled if 1) You want to believe one particular thing, and 2) You don’t do a thorough exam.
All of which is preamble for rest of the post.
We were dispatched to a call for an elderly man having trouble breathing. No details in the call, not that they are always helpful. Nothing but his age, gender, and the fact that he was having breathing problems.
We arrived behind the fire department and the BLS ambulance, gathered our equipment, and proceeded into the house. Up to the second floor (what else?), and into a tiny, cramped bed room.
The BLS crew arrived a couple of minutes before we had, but had not released the fire company, which just made it more crowded. Turns out the BLS crew had an oops with their portable oxygen tank which left it empty. So, they used the fire department’s oxygen while one EMT ran down stairs to get a fresh tank. What his partner was doing in the mean time is a mystery, since it didn’t involve taking a pulse, blood pressure, asking any questions, or doing even one thing to help figure out what was going on with the patient. Harsh, I know, but for this particular EMT it’s the norm. She’s a wealth of information on a call, none of it useful.
Such is my lot in life.
My partner took a set of vital signs while I asked the patient a few questions.
His story was that he had got out of bed to use the bathroom and upon returning to his bed felt out of breath. This was not normal for him, which is what prompted him to ask his son to call 9-1-1. His son wasn’t particularly helpful, although he was pleasant and tried. He did tell us that his father had inhalors prescribed and had for years, but never used them. Not surprising since his Dad is a veteran and gets his care at a VA clinic. Nothing they do surprises me, although if they did something right, that would in fact surprise me.
While the EMT wrote down an incorrect list of medications, I listened to the patient’s lungs. Normal, except for a fairly localized area of wheezing on one side. Odd, but not concerning… yet. My partner gave me the vital signs which were pulse 120, BP, 200/100, RR 40. O2 saturation on a non rebreather was only 96%. Hmmm. ETCO2 was 45. The plot was thickening.
My early thought was Congestive Heart Failure. I’ll be honest. With most patients over the age of 50 or so, new onset dyspnea, with suddent onset, and no history to suggest otherwise, and after midnight, my early thought is always CHF. As a very wise doctor told me when I was a new paramedic, “People do not suddenly develop Asthma in the middle of the night, but they do suddenly develop CHF in the middle of the night.” I’ve followed that advice for almost 20 years and it’s always held me in good stead.
The 12 Lead, which I include because people like to look at them, was non informative. Which is to say that nothing jumped right out at us.
I suppose you could split hairs and say that V1 and V2 are “suggestive” of an MI, but I wasn’t and still am not convinced. At least not convinced enough that I’d insist on going to a PCI capable hospital. Wouldn’t do to have Rogue Medic accuse me of kidnapping a patient, would it?
I asked the patient’s son if his father seemed to be having trouble breathing or was working harder than normal to breath. He couldn’t really answer, but the grandson offered that the patient was in fact working to breath and looked pale. Hmmm.
The wave form was more instructive, at least I thought so. While I have often said that a O2 saturation of 100% is pretty meaningless, an O2 saturation of 96% on high flow O2 is informative, at least to me.
When looking at pulse oximeter readings, it’s important to make sure that the pulse wave form is good as that affects the accuracy of the readings. This is a good wave form, so I had no reason to doubt the accuracy of the reading. The ETCO2 waveform was similarly informative, showing me that there was no hint of CO2 retention or a “shark fin” wave form. The clinical picture was becoming more clear, but as is usually the case, the numbers were more confirmatory than diagnostic.
You’ll notice that the time on this is later than on the 12 Lead. We had the monitoring probes on much earlier than the print out, but you have to print about six seconds of waveform out for the readings to be set into the Code Summary. Which I constantly have to remind my technophobic partner. Well, oddly technophobic when it comes to some things like a monitor that we’ve been using since about 1998.
My gut feeling was that this was very early Congestive Heart Failure, but I really had nothing to pin that to. The patient wanted to go to the hospital that was the furthest away from us (of course). I wasn’t particularly comfortable with that non only because of the distance, but because care in that ER is marginal on a good day. We had a little bit of discussion and agreed to transport that patient to a closer hospital. Not my first choice, but my role in determining destination is limited in most cases.
The next task was to get the patient into the chair for the carry down stairs. This is actually a good diagnostic test, although that might seem odd. It might even seem a bit cruel, but it often helps to confirm clinical suspicion. If the patient can stand and pivot 90 degrees without difficulty, it’s a positive sign. If he can’t, it’s not so good. Maybe that sound cruel, or like I’m lazy, but it often helps clarify a murky case such as this. Being a paramedic often means being a detective.
Think about that for a minute. If a person who normally can stand and walk without assistance or difficulty suddenly gets short of breath standing, there is a clinical clue for the alert practitioner.
The patient stood (with me holding his arms) pivoted and sat down. And was short of breath. The diagnosis was clinched in my mind.
We carried him down the long wooden stairs and out to the ambulance.
The rest of the call was pretty routine. In the ambulance we listened to his breath sounds again, which were without change. We started an IV and gave some Nitroglycerin. The Nitroglycerin worked as it should, lowering his blood pressure, reducing his preload, and helping his breathing. We stabilized him enough so that the hospital could continue his care and he’d be fine.
Well they could once I convinced them that the wheezing was not due to his non existent COPD or Asthma. The nurse persisted in asking me if he used his nebulizer at home before calling us. This, despite the medication list print out from his clinic which I brought with us and which showed NO, I repeat NO, medications of any sort for Asthma or COPD. At which point the doctor told the nurse that the wheezing was probably cardiac wheezing, not Asthma. Which, as I had pointed out repeatedly, the patient did not have.
At least the doctor had paid attention to my report. Or maybe she had been a paramedic in a previous life. Either way, she ordered CPAP, not a nebulizer and she didn’t even wait for the Chest Xray to come back. She did what we did, only probably better. She used good clinical judgement to determine what was going on with the patient.