Change is one of the few things we can count on in life. The things we once did we no longer do. Things we do now we might not do in the future. Are you open to change? What facts, testimonials, or influence do you need to implement change? Medicine is dynamic. We don’t do things that we used to. In the future, we may not do things that we do now. Treatment of congestive heart failure has changed dramatically in the last ten years.
Persistent Respiratory Distress
A 75 year old man with a history of congestive heart failure and diabetes had several days of worsening breathing problems. When he became so short of breath that he could not speak or walk a few steps he called 911. Fire department first responders found the patient sitting on kitchen chair with his hands on his knees (tripod position). The patient was pale and anxious. His breathing was rapid (50 breaths a minute) and very shallow. A few minutes later I arrived with another paramedic. The patient was only able to speak single short words.
A few years ago treatment for this patient would have been non-rebreather mask with high flow oxygen and Lasix. We would have also spent some time debating the merits of nasal intubation. In my experience by the time patients like this call 911 they are in such distress that respiratory/cardiac arrest is imminent. When they say, “I can’t do this anymore.” They mean exactly that and a few minutes later they are dead.
Since medicine is dynamic we had a new set of tools for this patient. Step one was to increase the oxygen delivery. A first responder replaced the nasal cannula with a non-rebreather mask while my partner prepared the CPAP system. I completed a rapid respiratory assessment – breath sounds, rate, examination of his chest for retractions.
I also asked the patient if he had ever “had the mask?” If he had previous CPAP experience he probably would have asked for it already. He had not ever “had the mask.” For patients new to CPAP I like to hold the mask to their face while explaining how it works and what to expect. After a few minutes of adjusting to the mask and flow I then secure it with the head straps. In just those first few minutes the patient’s oxygen saturation and skin color improved. Because his systolic pressure met protocol guidelines we also applied one inch of nitroglycerin paste on his left anterior superior chest wall.
One of the most significant challenges for this patient, and patients like him, was positioning him for transport. He refused to have his legs flat on the ambulance cot. Initially we compromised by having him sit sideways on the cot, resting against the upright cot back with his feet on the floor. As his respiratory distress resolved during transport he was willing to put one leg on to the cot so he could rest normally against the raised cot.
Resolving Respiratory Distress
Twelve minutes later we were at the hospital. CPAP was still in place and the patient was talking three to four sentences at a time. Medicine is dynamic.