other people's emergencies: random thoughts of an urban paramedic

For more than twenty years I've worked as a paramedic for the city of Boston, Massachusetts. The opinions expressed in this diary are mine alone, and do not represent the views of Boston EMS. Names, dates, locations, and physical characteristics have been changed to ensure patient confidentiality.

Wednesday, July 09, 2008

A Different Kind of Difficulty Breathing

Three or four times each shift, we respond to calls for difficulty breathing. Along with chest pain, this is the most frequent condition we encounter.

Usually, the patient suffers from a chronic respiratory disease, such as asthma or emphysema. Sometimes the patient’s heart has failed, causing fluid to back up into the lungs. Tonight, though, we handled a breathing problem of a different type.

The patient was close to 100 years old. She’d lived alone in the same apartment for more than six decades. Early this afternoon, as she passed through the kitchen, she bumped against a knob on her stove. She sat in her living room until dinnertime, watching television for nearly six hours as her home filled with natural gas. All things considered, she was fortunate not to blow herself up.

By the time her son came over for a visit, the woman was gasping for air. He threw open the windows, but his mother doesn't get around well, and she was too heavy to carry. He couldn’t get her out of the house.

We arrived to find her seated on the bed. The room still smelled of gas. I listened to the woman’s chest. For some reason, her lungs were filled with fluid.

“Can breathing natural gas cause you to go into pulmonary edema?” one of the EMTs asked when I reported what I’d heard.

I had to admit that I had no idea. The big danger with natural gas, of course, is the risk of explosion. I’d never encountered a patient who’d inhaled natural gas for a prolonged period.

I deferred to my partner on this. “I’m not sure about pulmonary edema,” he said, “but it can certainly asphyxiate you.”

Then came another wrinkle. When my partner explained the situation to the son, the son said, “Her nurse was here yesterday and said her blood pressure was low. She told my mom not to take her blood pressure pills any more. Could that have anything to do with it?”

Most definitely, we told him. In fact, it was probably the lack of blood pressure medication, more than the gas, that was causing the difficulty breathing.

We carried the woman to the ambulance. On the way to the hospital, we started an IV. I gave her an injection of Lasix—the same medication that was supposed to be controlling her high blood pressure, until the nurse stopped her from taking it. She improved greatly in a matter of minutes. She arrived at the emergency department in great spirits, talking to us about the weather.

In a sense, this was an ordinary call. It was a case of congestive heart failure, something we see four or five times each week. What made the whole thing interesting was the gas leak. That added a challenge to the diagnosis. Plus, it made the situation somewhat bizarre. I mean, let’s face it—emergency or not, there’s nothing terribly interesting about an elderly woman getting sick. But an elderly woman who fills her home with natural gas for an entire day, and survives to get sick from an unrelated problem? Well, that’s not something that happens all the time.


Blogger Ryan. said...

Hi, just wanted to say I like your blog.
Can't think of anything else.

12:11 PM  
Blogger TS said...

Thanks, Ryan.

12:32 PM  
Blogger Renee Roberts said...

One issue masking (confounding) the other is something that does occur. I had a head injury that was masked by heat stress in a bike racer. It was only after we were treating the heat stress (and almost released the patient to his mom) that other symptoms popped up, and a bystander told us he
"also hit a tree during the race" that we realized we were dealing with a combo illness/injury. Reassessed, got him C-spine'd, and transferred to ALS medics for further definitive care. On followup at the hospital, it turns out he did have both a heat illness and the head injury... Nasty concussion. Released from the hospital a few days later.

It woke me up to always consider confounders! Especially if things just aren't adding up.

12:59 PM  
Anonymous Anonymous said...

This must be the day of the gas incidents. In Arlington this morning, we had someone who cut through his natural gas pipe, apparently while trying to do other work on his house at 7:00 AM.
The Fire Dept. responded, of course, and they had to shut off the gas connection until Keyspan could respond.
The building inspector doesn't get into his office until 8, but I'm sure he had something today about this do-it-yourself homeowner when he found out.

4:02 PM  
Blogger philthemedic said...

Chest pain and diff. breathing are the two most common calls. Is that why those two are the only scenarios during the patient assessment station on the practical exam?

BTW, I passed the practical and take the written in two and a half weeks. Any tips on the written test?

1:42 AM  
Blogger TS said...

PHILTHEMEDIC: Congratulations on passing the practical exam. I must confess that I have no idea why examiners choose any particular scenarios to test, although I suspect that you're right - it makes sense to test candidates on tasks they are likely to perform often.

As for the written, nope, sorry, can't help you. I took my state exam in 1985. It's probably changed somewhat since then. The only suggestions I can make are the standard, age-old test-taking procedures: skip the questions you don't understand, and go back to them later, if you have time; use leftover time to double-check your answers; don't read too much into the questions; and make sure you don't accidentally skip an answer block, thereby causing all subsequent answers to be incorrect.

If anyone else has any suggestions specific to the state paramedic exam, then please feel free to post them!

10:56 AM  
Blogger TS said...

NOTE: I misquoted my partner in the original post about the physiological effects of natural gas inhalation. I've corrected his comment in the original story. I've also taken the liberty of removing a couple of related comments, since they were based on an erroneous premise.

Sorry for the confusion. It was my mistake, and I take complete responsibility for it.


7:31 PM  

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