Case of the Month
May 2006

87-year-old male —Difficulty breathing

Dispatch

"Aid 2 to an 87-year-old male, difficulty breathing, possible airway obstruction"

En route your crew discusses the following considerations:

• BSI precautions if patient is coughing (masks for you and patient)
• Treatment of airway obstruction
• Lung sounds

Dispatch updates you that this is a patient in an adult family home who has had difficulty breathing since dinner. She believes he might have aspirated some food.

Scene Size-up
At the front of the group home you are met by a staff member who leads you back to the patient's room. She states he has had difficulty breathing since dinner about 2 hours ago. It is not getting better and she is requesting transport to the local emergency department for evaluation.

Initial Assessment
You find the patient sitting up and having mild respiratory difficulties. You notice that the patient has a gurgle to his breathing and the care giver stated this is not normal. The patient appears to be mildly pale and cool to the touch, but he has dry skin. Cool skin is normal for this patient. He is able to talk but the interview is frequently interrupted by the patient coughing. "I can cough but it doesn't help," he states.

Your partner completes an initial assessment:

SICK or NOT SICK?
Based on what you see so far, would you consider this patient SICK or NOT SICK? What steps will you take based on the direction you choose?

• Types of treatment needed for this patient?
• Further steps for evaluation?
• Need of ALS care?

Initial Treatment
You decide that the patient is NOT SICK based on his mild respiratory complaint but maintain a high index of suspicion (IOS) for change.

You apply a nasal cannula at 2 liters per minute, place a HEPA mask on the patient, and apply the pulse oximetry sensor to his finger. The initial oximetry reading is 95%. You reassure the patient and review the patient's file which the staff has given you.

Physical Exam
Your partner gives you the following information:

SAMPLE

Second Set of Vital Signs

The nasal cannula provided the patient some mild relief but the symptoms persisted. The decision is made to transport the patient BLS to the local emergency department for further evaluation. The caregiver states that the patient usually walks with the assistance of a walker, and with some assistance he can make it down the hall to your stretcher. Following these comments you decide to allow the patient to walk about ten feet to the gurney while assisting the patient. 

As he approaches the stretcher he states his breathing is a little more difficult. He sits down and states it is not getting any better. You increase the oxygen from 2 lpm to 4 lpm to see if it helps but it does not.

The patient is taken out to the aid car and place on board. Once inside, the patient is given a partial non-rebreather mask and flow is increased to 12 lpm (appropriate to the patient's needs). Transport begins.

En route to the hospital the patient states his breathing is improving slightly but is not back to where it was prior to walking to the stretcher. At the hospital the patient is transferred over to the hospital gurney and the emergency department takes over care.

Difficulty Breathing/Shortness of Breath
Difficulty breathing and shortness of breath are some of the most common emergency responses. The reasons for SOB are many, and are often layered (meaning two causes occurring at once, such as a COPD patient who develops pneumonia). 

Our first job as EMS providers is to determine SICK/NOT SICK that allows us to treat the signs and symptoms we see in such a way that we do not make the patient worse.

Obviously oxygen is an excellent treatment for any person with respiratory difficulties and is very appropriate in the care of this patient. However, walking the patient to the stretcher was a bad choice. 

Often people suffering from breathing difficulties will not tolerate even small amounts of physical exertion and so this must be avoided. If possible this patient should be carried to the stretcher. Before lifting the patient, let him or her know what you are going to do and give them a chance to understand the steps you are taking and the reasons for them. The very act of being carried can also cause anxiety for the patient which could also exacerbate his or her difficulty breathing. If you anticipate the patient's breathing may become worse with movement, consider high flow oxygen before the move and if they appear unstable, an ALS evaluation might be in order.  

Another factor in the movement of this patient is his change of position. The 'sitting' position on the stretcher is much different than that in chair or on the side of a bed. On the stretcher with his legs up the patient does not have the freedom of movement of his diaphragm as he does when his legs are down. If CHF is a factor, then the pooling of blood in the legs is minimized when they are level with the pelvis.

Placement of a patient on a stretcher can worsen a patient's breathing difficulties. If you suspect this could be an issue, pre-treat the patient with high flow oxygen and be ready to provide further assistance if the patient decompensates.