Flash

Dispatched for a lady not feeling well. The cops have her on a non-rebreather at 15 lpm. She doesn't want to go to the hospital. Her lungs are decreased with a slight wheeze. She has a low-grade fever. She has been treated for broncitis for the last week. She saw her doctor a week ago. Only history is hypertension.

She keeps getting up. She doesn't trust me to lock the back door. She wants to get her purse herself. There is something in a drawer she needs to get herself. We finally get her on the stair chair and carry her out to the stretcher, and get her in the ambulance. Her Sat is 92%. respiratory rate 24. Pulse - 120. BP 180/100.

The paramedic student/ER nurse puts in an IV, and gives her a breathing treatment through a neb mask while we go on an easy lights and sirens.

The patient starts pulling the mask off her face. Too much air, she says. We put the mask back on her and tell her to settle down.

The 12 lead shows lateral ischemia. We give her some baby ASA as a precaution.

She is getting a little grey. She starts to sweat a little. We switch to a non-rebreather, but still she keeps pulling the mask off her face. We are just blocks from the hospital.

"Let's listen to her lungs again," I say.

Before we can put the stethescope to the back, we can hear the bubbling. Imagine bubbling like popcorn starts to pop. You just hear a few pops, then more, then it is popping all over the place. That's how it is with the bubbles.

"She's flashing," I say.

We're in the driveway now. I draw up some Lasix and while the student injects it in the IV line, I give the woman a nitro spray. Her Sat has plunged to the 70's.

The ER doctor takes one look at her -- she is obtunded, grey, diaphoretic, breathing hard -- and calls for the intubation tray. Five minutes later she is on a vent. The chest x-ray shows fluid everywhere. Congestive Heart Failure. Flash Pulmonary Edema.

I tell the student/nurse. "She's flashes five minutes later, we look like idiots."

She nodds. Lesson: trust what the medics say when they tell you the progression of the event.

Later we talk with the ER doc about treatments and flash edema. "I know you want us to give the treatments, but it always makes them flash," I say. "Or at least half the time."

"Studies show it helps."

"I just know what I see. The question is "is the edema there? and the treatment just let's you hear it, or does the treatment worsen it?"

He is about to answer -- this is question is one of the great questions of paramedicine -- but then he gets a phone call, then another, and we get a call, and we never hook up again to discuss it.

I have been asking this question for years, and every doctor has a different answer.

I find the following article that suggests the breathing treatment increases their tachycardia and worsens the edema. It also says, a medic needs to use their head and discretion on giving a treatment to someone with possible CHF. We both thought the lady had a pnemonia-broncitis. She may have, but she also had some new onset CHF.

Pulmonary Edema

Here's a link I found to an old bulletin board discusssion on the question; some for albuterol, others vehemently against.

http://www.uhmc.sunysb.edu/emed/paramedic/archives/1996/1190.html

Here is another detailed article on CHF from Prehospital Emergency Care, whicih says bronchodilators(albuterol) is okay in CHF when the wheezing is caused by bronchospasm, but it should not delay treatment with other drugs such as nitro and diuretics.

Prehospital Emergency Care: CHF Article_

I have to say, I have wavered back and forth on this issue, mainly pushed for it, by the physicians who say use it to open up the airway, and pushed against by occasional experience. Maybe these people were going to flash anyway, but it seems like I've seen it one too many times where they flash shortly after the treatment.

I guess when I sense they have CHF, I may consider withholding the treatment. In this lady, the CHF blindsided us.

***

Busy day. Good for the student. We do an SVT at an insurance company that breaks a minute before we arrive. Fortunately the company nurse captured it on a 12-lead. rate of 236. We do an OD and a bleeding diabetic wound.