Respiratory madness

I have been working for 30 straight hours. I am on the second half of a 48 hour shift. Today, my EMT partner also happens to be one of my paramedic students. Since the class just had their midterms, I tell him that he can run the calls today, and I will only step in if he needs help.

Our first call of the morning goes rather smoothly, it is a woman complaining of vertigo. She has a history of it, and it is a pretty easy call. Our second call of the day did not go quite the same way.

It came in as a non-emergency call for a man who has not eaten in three days. When we arrive, I let my partner enter first. I hear him talking to the patient as I get the stretcher ready. As soon as I finish that task, I enter the room. The patient is cyanotic, he is tripoding, and he has one word dyspnea. He is covered in sweat. I have seen this look before, and a patient that has it never does well. My partner is busy asking about his eating habits and is oblivious to the state his patient is in.

I tell him we need to be moving to the truck. When we get there, the patient has no lung sounds at the bases, and almost no lung sounds at the apexes. He is begging us to sit him up. His SaO2 is 88%. He has COPD is normally on home oxygen, but he says he took it off so he could smoke a cigarette.

He is struggling to breathe, and I cannot believe that he will be conscious for long. I call for backup as we hook him up to the CPAP machine. My partner secures an IV, and as the backup arrives, I tell one of them to get in front and drive us to the closest hospital. The patient balks. He says that he doesn't want to go THERE, he wants to go to another one almost 10 minutes further. I tell him that I am not going to bypass a perfectly good hospital with a patient who is about to die. He tries to argue, but not being able to breathe cuts him off from too much protesting.

When we get to the hospital 3 minutes later, he is barely responsive. I am trying to keep his airway open, as he breathes 40 times a minute. At least his SaO2 is now 99%. I tell the nurse what is going on, and she tries to tell me that because I put a COPD patient on CPAP I knocked out his respiratory drive. I gave her a stupid look. Right about the time I was warming up to my answer,the charge nurse (who was a street medic himself) saved me from the disciplinary action that was soon to follow my remarks by taking over for nurse clueless.

CPAP is indicated in the treatment of pulmonary edema, especially in the presence of COPD or CHF. In the short amount of time that EMS has contact with COPD patients, oxygen is not going to knock out the respiratory drive of the patient. This was indicated by his respiratory rate of 40.

and the next time my partner sees "the look" he won't get tunnel vision, and he will know what is coming. That is how we learn, folks.