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Clinical scenario: Middle-aged man complaining of respiratory distress

You are dispatched to a bank for a man who is weak and lethargic

"Rescue 2991, respond Code 3 with Engine 2933 to 23 Maple Lane. Caller reports that her husband cannot catch his breath. Be advised that ALS intercept has a 25 minute ETA. "

As you start towards the call, you tell your trainee Kristen to think about the potential causes of respiratory distress. Kristen is a new hire EMT with your service and is starting the second week of her field training. Things are going fine on basic calls, but you find that she is struggling with more serious patient presentations.

Kristen recites the PAST MED mnemonic and names of several differential diagnoses for shortness of breath: COPD, CHF, asthma and pneumonia. You remind Kristen that this call is hers to attend and that you hope she knows her protocols because she has underwhelmed on the last few serious calls you’ve run.

After a five minute response you arrive at a well-kept home in a nice neighborhood. You notice that the lawn is half-mowed with a lawn tractor stopped in the driveway. The engine crew waves you through the front door.

You introduce yourself and Kristen. You turn to Kristen and say "All right rookie, it’s all yours." Hesitantly, Kristen introduces herself. She asks the patient, Steve what happened and Steve slowly responds in one to two word sentences that he has been feeling progressively more short of breath over several days, but that he realized something was seriously wrong while mowing the lawn.

Steve states that he has been experiencing rapid weight gain over several days and has had a productive cough. He reports a history of smoking, but states it has been 30 years since his last cigarette.

Kristen asks several open-ended follow up questions about Steve's smoking history and Steve struggles to answer them. Kristen then asks if Steve has emphysema. Steve shakes his head "no."

Kristen asks about COPD; Steve shakes his head. Kristen asks: "Are you sure you don’t still smoke?"

Frustrated, you step in-between Steve and Kristen and suggest that now might be the time to "actually do something for the patient." You place a pulse oximeter on Steve's index finger and ask one of the firefighters to take a set of vitals. You listen to lung sounds and abruptly order Kristen to place the patient on oxygen

Steve’s vital signs are:

  • BP: 210/146
  • HR: 112
  • RR: 28
  • SpO2: 86% on room air

The ALS transport unit is still 15 minutes away. Given what you know about Steve’s presentation and Kristen’s assessment, think about these questions as you consider what to do next:

  • What is your differential diagnosis?
  • What is Kristen’s differential diagnosis?
  • Why might they be different?
  • What are some effective methods to teach "in the moment" while on a call?
  • What are your treatment priorities?
  • What are reasonable expectations for a new EMT?
  • What are traits of a good preceptor?

Post your answers below in the comments and view the clinical solution for this patient.

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