116 Montague St — shortness of breath

Location: Bravo Post

Time: 14:15 Tuesday

Conditions: Cloudy and warm

Equipment: fully stocked



The radio crackles… (click for audio)

[Ambulance 61, respond priority 1 to 116 Montague St. for shortness of breath. That’s A61 to 1-1-6 Montague, cross of Madison Ave, for the conscious and breathing adult female with shortness of breath. Response is with Engine 2. Time out 14:16. A61?]

Click to expand



You respond with lights and sirens. Engine 2 calls itself on scene over the fire radio, and less than a minute later, you pull up — a 5 minute response time. You see an average two-story residential house with five stairs.

Scenarioville Engine 2 is parked at the curb, as is a Scenarioville police cruiser. You grab the airway and first-in bags while your partner Steve takes the portable radio and stairchair. The house is a duplex, so you enter the open door and climb another twelve tightly-winding stairs to reach the second floor. It’s a nicely kept home, and you pass through the kitchen to enter the living room.



The room is crowded with three firefighters, a police officer, and a middle-aged woman milling around. In the middle of it all is a well-dressed elderly-looking female seated upright in an easy chair.

A firefighter waves at the seated woman and tells you, “This is Jocelyne Maynor, trouble breathing for the past couple days.”


Initial Assessment

You approach. “Hi! Ms. Maynor?

She looks at you immediately and responds with a strong, friendly voice, “Hi.” She appears to be alert, calm, and in no apparent distress. She is skinny and her skin is slightly pale overall. There is no obvious respiratory distress.

“I’m Sam. What’s going on?” You kneel beside her and touch her left wrist. She is warm and dry, with a strong, regular radial pulse, unremarkable in rate.

“I’ve been having trouble breathing.”





“You’re having trouble breathing right now?”


“What’s it feel like?”

“Just… I’m having trouble getting enough air.”

“How long’s that been going on?”

“I think it started Saturday… but I really noticed mostly on Sunday… then it’s been getting worse since then. I called my doctor yesterday, and he said if it got any worse, I should go to the hospital.”

“Is this totally new, or do you feel this way often?”

“Sometimes I get short of breath when I’m walking around, but just for a moment, and when I sit down I feel better.”

Looking over to your partner Steve, who’s loitering around and looking at the framed photos, you ask — “Could you grab some vitals?” He digs the blood pressure cuff from the first-in bag and moves to Ms. Maynor’s other side. You turn your attention back to her.

“How are you feeling otherwise?”


“No pain?”


“How’s your chest feel?


“Any fever or chills?”

“Not really. But my daughter took my temperature yesterday, and it was 100.”

The other woman in the room — presumably her daughter — interjects. “100.2.”

“Do you feel nauseous? Like you want to vomit?”


“Have you been feeling weak?”

“Maybe a little. I usually walk with the walker, but I’ve been awfully tired lately, so I’ve mostly been resting.”

“Have you been coughing?”

“Well…” Her daughter says: “She’s been coughing for days now. All night too. She sounds awful. ”

You look back to Ms. Maynor, who grudgingly seems to endorse this.

“Are you bringing anything up?”


“When you cough, are you coughing up any phlegm or anything?”

“Oh, yes.”

“What color is it?”

“A little yellow.”

“Been eating and drinking?”


“Any other recent issues?”

“No, I’ve been feeling well.”

Using your stethoscope, you auscultate her chest, asking her to breathe deeply. It sounds generally clear, somewhat dim, with some coarse, intermittent crackling sounds in the middle of the right side. After her third deep breath, she breaks out into a brief fit of coughing. Nothing notable comes up.

Steve hands you an index card with vital signs scribbled. As you take it, you’re already relaxed; he usually mentions them out loud if they’re worth remarking upon.

HR: 88

BP: 112/50

RR: 22

“What kind of medical history do you have?” you ask.

“I had a heart attack five years ago… high blood pressure… arthritis… two fused discs in my back… cataracts…” She trails off.

“What medications are you taking?”

Her daughter brings you a scrap of paper with a carefully handwritten list in beautiful cursive:






“What hospital do you usually go to?” you ask.


“When’s the last time you were there?”

“Oh, over a year, I think.”





“Okay,” you tell her, “shall we bring you over and get you checked out?”

“Yes, I think that would be a good idea,” she answers. “What do you think is wrong?”

Steve starts to open his mouth, but immediately clamps it shut as you shoot him a dirty look; he has a bad habit of running off his mouth.

“Well, I don’t know. You’re going to need to be seen by a doctor, and they’ll do some tests. Could be some sort of pneumonia, could be something else.”

You unfold the stair-chair and situate it alongside her. “If we give you some help, do you think you can move yourself over to here?”

“Oh, sure.” You take her by both hands and assist her to stand and reseat herself onto the stair-chair, then buckle her in snugly.

“Anybody else coming?”

Her daughter answers, “I’ll take my car and meet you there. Memorial, right?”

“Yep.” Together you carry her down the winding stairs, taking special care to ensure you don’t all trip and die in a twitching pile. Scenarioville FD carries out your bags and arranges your stretcher outside; you park the chair alongside and scoop Ms. Maynor over with an extremity lift. Soon you’re rolling down the road.

You attach a nasal cannula to the on-board O2 and poke it into her nose, running 2 liters per minute. “I’m going to give you a little bit of oxygen, okay?” She nods. “Do you have any allergies to anything?”

“Not that I know of.”

Plopping yourself into the tech seat, you unhook the radio. “Say, how old are you?”


“No way!” You dial up Memorial Hospital’s notification channel and hail them. When they acknowledge, you give this notification (click for audio):

[Good afternoon, Memorial; this is Scenarioville Ambulance 61. We’re about five minutes from you with a 72 year-old female, coming from home, complaining of shortness of breath and a productive cough for the past few days. No distress, no chest pain, vitals are unremarkable, and she’s otherwise doing well. We’ll see you shortly; any questions?]

“No questions,” they reply. “See you on arrival. Memorial out.”

You pull in, having jotted down a quick list of her meds and history for your paperwork later. After you slide her into a bed in the ED, you make this report to the receiving RN (click for audio):

[Hi! This is Ms. Maynor, she’s 72, coming from home. On Sunday she started to have some trouble breathing, just feeling like she’s not really getting enough air. She’s been feeling a little weaker than usual, so she hasn’t been doing much walking, and she’s had a decent cough since then, bringing up some yellow sputum. Talked to her doctor, he said to come in if it didn’t improve. Little bit of ronchi in the mid right. Some cardiac history, had an MI a number of years ago, but no pain or discomfort, nausea, dizziness, etc. Doing okay, just looking for an eval. We’ve got her on a couple liters for chicken soup. Here’s a list of her meds, mostly cardiac stuff.]

She thanks you and starts helping Ms. Maynor undress. You pull a blanket from the warmer and throw it over her, then shake her hand and wish her luck. Outside, Steve has cleaned and made up the stretcher, and you hop back into the truck and clear out; dispatch asks you to post at Charlie. You tap away at your computer and complete your documentation on the way.



Diagnosis: pneumonia

This was a typical presentation for a routine, uncomplicated pneumonia. Although in elderly patients with comorbidities, pneumonia can sometimes lead to respiratory failure or sepsis, in this case there was little reason for alarm.

Dyspnea should always put cardiac causes on your differential, but there were no high-risk findings here except for the prior history of MI. Low-priority transport to the requested hospital is appropriate for further workup and probable antibiotic therapy.


  1. A. Barker says

    The most important assessment findings I found were the low grade fever, the lung sounds, and the pt’s skin color being pale. The most important treatments for this patient would be the administration of O2 per protocol. What should be reassessed and/or monitored to determine if treatments are effective would be checking the O2 sat at RA and on supplemental and reassessing temp. Yes, I would assess and/or treat this patient differently starting with the assessment and obtaining a more in-depth picture of the complaint. The pt stated that her SOB started Saturday and worsened Sunday, but today is Tuesday. I would have wanted to know, “what was different about today? What happened today that prompted you to call 911 instead of Sunday?” The medic asked, how often her complaint happens, but the pt gives a general response that doesn’t quite answer the question. The pt states that sometimes she gets SOB when walking. I would have wanted to know if this also happened around or about Saturday as well. The pt also complains of weakness and normally uses a walker to get around; however, she has been resting. I would have wanted to know, “when did the weakness start? Was it also around or about Saturday?” When did the coughing start??? Also, it was stated that the temperature was checked Monday. Again, today is Tuesday. What is the temperature today? Was anything taken for the low grade fever? Did it improve? I feel like the vitals obtained were very basic. Let’s get a pulse ox on this pt since she is c/o SOB and reassess her temp. Wouldn’t the medic want to know if just 2 LPM of O2 is even sufficient? Or even a cannula at that? What is she on RA? She may require a different device. Even though there are no obvious signs of distress, she is still pale. Also, given her cardiac HX, I would have ran a strip on her just to rule out any pertinent cardiac issues.

  2. Hassan.H says

    Thanks for the feedback @A.Barker

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