Status Asthmaticus

Recently, I was called to a local apartment complex for difficulty breathing. When we arrived, I entered the apartment and I could hear the wheezing from the entry hall. The patient is a 58 year old male who is sitting at his dining room table, puffing on a nebulizer. He looks pretty bad- JVD, cyanosis, accessory muscles, the works. This guy could have been a picture in a textbook on respiratory distress.

His roommate tells us that he has used 3 breathing treatments in the last 2 hours, and has been getting worse. My partner asks the roommate if our patient has ever been intubated before. The patient uses what breath he has to say "No tube" and goes back to huffing his inhaler.

Since I am the engine paramedic, there are 5 of us there, including the rescue crew. Of the 5, four of us are medics, and I am the senior ranking of the four. I remark to my partner that we are probably gonna need some Mag Sulfate for this one. The problem is that our protocol specifically states that we need orders to give Mag for asthma.

We get him in the truck, and his vitals are: HR: 120, BP 189/154, RR 36, SaO2(room air) is 67%, EtCO2 is 80 (that is the highest I have ever seen on an actual patient). We place him on CPAP and give 125mg of Solumedrol. His EtCO2 is now 65 and his SaO2 is 84%.

I call dispatch and get them to page our medical director. I want him, because you never know what Doc is on duty in the ED, and they don't always want to give orders for meds. After a few minutes, the medical director still hasn't answered, so we call the receiving hospital for orders. Denied. Instead, he orders .25mg of sub-Q Epi. (I had considered that, but I thought the Mag would be a better choice, especially in light of his hypertension)

When we get there, our medical director is standing in the entry to the ED. Assuming that he was the ED doc, I walk up to him as the rest of the crew is unloading the patient, intending to give a report. Before I can say anything, ha says, why didn't you give Mag? I told him the protocol says I need orders. He tells me, "Funny, you ignore protocol all the time, why start now? Next time, if he needs it, give it. Just give me a call later and let me know, so I can cover for you." I love him. He is the best medical director ever.

The patient is fine. He was discharged 2 hours later.

Edited to add: 24 hours after he was discharged, another crew brought him in while he was in full respiratory arrest. He was intubated, and sent to ICU.