Case of the Month
July 2005

19-year-old female — breathing difficulty

At 0730 on a Wednesday morning your crew is dispatched to a 19-year-old female who is short of breath. As you are responding the dispatcher confirms the original dispatch information and adds that the patient has no history of breathing problems.

You arrive at the entrance of an apartment complex and are met by the patient's mother. She is anxious, but not panicked. While leading you to her apartment she states that her daughter has no medical history.

As your crew enters the apartment, you find the patient sitting on the sofa with a worried look. She is a tall, slender, 19-year-old woman with long hair. She appears to be breathing rapidly, however it does not seem labored. She is wearing sweat pants and a sweatshirt. Her hair is wet; her skin is pink and dry. She has a strong radial pulse at about 110, but when feeling the radial you notice her skin is cool.

She explains that she was in the shower and felt a sudden sharp pain just down from her armpit on the left side of her chest. She quickly began to have some difficulty breathing. Both the pain and the shortness of breath persist. They do not seem to be getting worse. She adds she feels as if she can't get in a full breath. As she talks you notice that she is speaking in six to eight word sentences. Vital signs reveal the following:

LOC	—	Alert to time, place, name, and event
RR	—	28/min
Pulse	—	110 regular, radial
BP	—	108/68
Skin	—	Cool, color is pink, and dry
Pulse Ox	—	97% on room air, 99% after 2 minutes of oxygen at 4 lpm via nasal cannula

Further evaluation reveals that the patient has no history of shortness of breath. She has not sustained any trauma in the past 48 hours, and cannot attribute the pain and shortness of breath to anything she was doing in the shower. She takes birth control pills and Effexor (a SSRI antidepressant often used to treat mild anxiety). She has no other medical history. Auscultation of the lungs reveals a quiet area in the lower left lung field. The rest of her lung sounds are normal and the rest of her physical exam is unremarkable. Oxygen administration by cannula has improved, but not eliminated, her shortness of breath, and this in turn has decreased her anxiety.

S	—	Shortness of breath and localized chest pain
A	—	None
M	—	Birth control pills, Effexor
P	—	No past medical history
L	—	Had popcorn while watching a movie last night
E	—	Sudden onset of localized chest pain and shortness of breath while showering

Due to her presentation and response to the oxygen, you and your crew decide to keep the call at a BLS level and transport the patient to the local hospital. The transport to the hospital is without incident and the patient remains stable.

In the hospital a chest X-ray confirms the physician's initial suspicion that the patient is suffering from a spontaneous pneumothorax. The patient has an excellent outcome after a day in the hospital.

Pneumothorax

You learned about pneumothorax in EMT training. It is a condition where air escapes the interior of the lungs and forming a pocket between the lung and the chest wall. A pneumothorax can be self-limiting or it can advance to the point of being deadly. The classic sign of tracheal shift that is associated with a tension pneumothorax is a very late indicator; we should be able to identify a pneumothorax well before this occurs. We most often associate pneumothorax with penetrating chest trauma for obvious reasons; however this is only one of the causes.

Some other causes of pneumothorax:

• Blunt force trauma - Blunt force trauma can cause fractures of the ribs or sternum resulting in puncture of the lung. Even without fractures, a pneumothorax might occur due to the stress of the impact on the lung tissue.
• Aggressive use of the bag-valve mask - Over-aggressively breathing for a patient may lead to pneumothorax. Think of the overly delicate tissue of the very young patient, or the older patient who suffers from COPD, lung cancer, asbestosis, or any other of a number of lung diseases.
• Spontaneous pneumothorax - Sometimes a pneumothorax occurs with little or no contributing factor in an otherwise health individual. This can occur in any person, but young, tall, slender persons of northern European heritage seem to be at higher risk.

Treatment is as follows:

• ABCs
• Oxygenation dependant on severity
• Call the medics if the patient is more than mildly short of breath or if the signs and symptoms are becoming worse
• Use an occlusive dressing on any open chest/back wounds
• Rapid transport if the patient is 'SICK'

The lesson learned from this case: The EMTs in this case could not confirm that the patient had a pneumothorax, but they still gave appropriate care based on the patient's initial presentation and the EMT's index of suspicion. She did not appear SICK based on clinical indicators of mental status, respiratory status and circulatory status. They made an appropriate decision to give oxygen and perform a thorough medical history and a detailed physical exam. However, given the respiratory nature of the call, they were prepared for a sudden change in the patient's status.

Patients with respiratory complaints have the potential to deteriorate. Maintain a high index of suspicion (IOS) under such circumstances.