Case 36: A Good Story

“No,” Ivanka* says dismissively. “You can go: we’ll take it from here.”

They’re about fifteen feet away from me, at the end of the hall. The paramedic has his hands on the back of a wheelchair that’s occupied by an elderly woman. “You don’t want to know anything at all?”

“Nothing at all,” she says, not even looking at him.

“Well, we just checked her blood sugar it -”

Ivanka cuts him off. “I said you can go.”

The paramedic raises both hands as if he’s surrendering to police. “Okay,” he says, “fine.” His face is red as he hands her the chart and walks off.

“Idiot,” Ivanka mutters under her breath.

***

It’s morning.

I’m seeing a seventeen-year old with abdominal pain when there’s an urgent page overhead. I get to the room just as the paramedics are wheeling in the stretcher. The patient is in trouble. His skin is dusky, a heart-rate monitor is zipping along at one fifty, and under the mask that covers his nose and mouth, his lips are half-way from red to blue.

“Seventy-four year old with emphysema,” a paramedic says. “Former heavy smoker. Wife called the ambulance after he became acutely short of breath at the breakfast table.”

“Has he been sick recently?”

“Just the last few days,” his wife says. “He caught a cold and has been using his puffers more than usual, but his breathing really went downhill this morning.”

“His oxygen saturation was eighty-percent when we got to him,” the paramedic says. “It’s only eighty-eight on four liters now.”

“Mr. Colville!” I say, speaking over the Ventolin that’s misting through his oxygen mask. “Can you sit up a little? I need to listen to your lungs.”

He doesn’t respond. He’s using all the muscles of his chest and abdomen to draw in air. He’s drenched in sweat. A nurse helps me lift him forward. Air is barely moving. A respiratory therapist (RT) is at the foot of the bed. “We may have to intubate this guy,” I say. “He’s pretty tired.”

I order intravenous steroids to bring down the inflammation in his lungs, and more Ventolin to open his airways. I call for a stat portable chest x-ray.

“Did this happen suddenly?” I ask.

“He sure wasn’t this bad last night.” His wife shrugs. “Actually, I was still in bed this morning when it happened. He went down to have breakfast and it was my daughter who came running up and told me to call 9-1-1.”

The paramedics are sweating. They found him splayed under the kitchen table, blue and barely breathing. They assessed him quickly, applied oxygen, and heaved his oversized frame onto their stretcher. I shiver when I think of some of the places in which they’ve dealt with emergencies – bathrooms sprayed with human excrement, car accidents in icy ditches, excavation sites in one-hundred degree heat. All this while resuscitating patients and transporting them to hospital as quickly as possible. Their job is tougher than mine. If Mr. Colville is just an inch too low for me, I can use a lever to raise his head to exactly sixty-degrees, or step on a pedal and bring him up a bit.

I turn to his wife. “Did he have any chest pain?” I put my stethoscope to his back once again and pay close attention to his lung bases. “Has he had congestive heart failure before?”

“His heart is perfect,” the wife says.

“You think this is failure?” the respiratory therapist says.

I shrug. “I don’t hear crackles,” I say, “but I don’t really hear anything else either – he’s not moving air. I just don’t want to miss anything.” I consider ordering intravenous Lasix, just in case there is fluid in his lungs, but it might drop his blood pressure and it’s already a little low – ninety-five over sixty. “Maybe he’s septic,” I say.  “Any fever?”

“No fever with us,” the paramedic says.

“Where’s your daughter?” I ask Mrs. Colville.

“Just after this happened, she got a call from the school because her daughter – my granddaughter – was sick. She said she’d meet us here.”

The x-ray tech is just outside the room with the portable machine. “You guys ready for me?” she says.

I nudge Mr. Colville. “We’re going to do an x-ray of your chest!” I don’t even know if he can hear me. His eyes are closed and when he breathes, it’s as if he’s pulling in breaths with his entire body – his neck, his belly, his arms. I wonder whether or not he has time for an x-ray. I consider intubating him and putting him on a ventilator before the x-ray. I turn to the respiratory therapist. “Do you have a tube and a blade?”

“Why don’t we try BiPap first?”

“Good idea.”

Mr. Colville barely moves as the RT straps a mask around his head. “This will help you breathe,” he tells Mr. Colville. “It’s going to force air into your lungs so you don’t have to work so hard. It feels like you’re sticking your head out the window with your mouth open while driving on the highway.”

The mask is on and his oxygen saturation rises from eighty-eight to ninety. The x-ray tech puts a plate behind Mr. Colville and within a minute, the x-ray is on the portable machine’s monitor. “It’s not failure,” I say. “No pneumonia, just hyper-inflated lungs, classic for COPD.”

A second IV line is started and saline is infused. After five minutes of BiPap, his heart rate settles to one-twenty.  “Mr. Colville, is it getting easier to breathe?”

He doesn’t open his eyes, but he nods – slowly, heavily – like a boxer pulled out of a corner after being knocked out.

***

The paramedic Ivanka has sent away isn’t an idiot. And he’s the only one who can tell me why the confused lady in the wheelchair is here, so I chase him down as he’s leaving the department. “Tripped over her walker in the dining room at the Nursing Home. No complaints, walking fine afterward, but the family insisted that she be sent to the E.R. to get checked out.”

“Is she on blood thinners?”

“No blood thinners.”

“Perfect.” He’s just saved me from making a phone call, and he’s saved the patient from what may have been a long, exhausting, and expensive stay in the ER. “By the way, what was that?” I say, pointing behind me. “Why was Ivanka so rude and dismissive with you?”

“Her? She’s always like that. I think she hates paramedics. Either that or she hates me.”

“Either way,” I say. “The story is the most important thing. More important than any test or any part of the physical exam.”

***

Twenty minutes later, Mr. Colville is settling. His eyes are open, his oxygen saturation is ninety-five, and his heart rate is just over a hundred. I tell him that there is no fluid or pneumonia on his lungs, and that this is likely an exacerbation of his COPD. He nods and gives me a tired thumbs-up.

Just then, a thirty-something woman rushes into the room. “It’s his COPD,” Mrs. Colville tells her daughter. “It came back.”

“It just came on so fast,” the daughter says.

I turn toward her. “Did he wake up like this?”

“No!” she says. “He’s had a cough for a few days, but that’s it. He came down, had a couple sips of coffee and suddenly, he was gasping for air. I thought maybe he choked.”

Mr. Colville turns to his daughter and tries to speak through the mask. His voice is too muted to understand. He pulls the mask away slightly and says one word: “Penicillin.”

“You found it?” she says.

He nods. He reaches into a pocket and pulls out a crumpled box of antibiotics.

“When he used to get frequent episodes of COPD,” his daughter says, “his doctor told him to start these right when he started getting sick. It was just a slight cough, so he was debating yesterday whether or not to take one.”

I turn to Mr. Colville and hold the box in front of him. “So you took one of these just before you got severely short of breath?”

He nods. The nurse says it before I do: “so this is all an allergic reaction?”

“Most likely,” I say. “Anaphylaxis. It makes sense.”

Had I known the story, I’d have given him epinephrine and he would likely have settled within a minute or two. There were no telltale signs of a severe allergic reaction other than his shortness of breath (and, in retrospect, his low pressure). There were no hives, no swollen lips, no vomiting. And, without knowing the story of what preceded Mr. Colville’s shortness of breath, I may have treated his presumed COPD exacerbation with the same antibiotic that almost killed him.

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*not her real name

2 comments

  1. Thank you for always showing paramedics respect. Situations like the one you described have been happening more and more and it’s not only insulting as a colleague but detrimental to our patients. You have always been nothing but friendly and respectful with us and we all appreciate it.

  2. Great story. Thank you. I’m going to use this story to illustrate the importance of Hx taking to paramedic students in the future.

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