203 Philips St. — shortness of breath

Location: SEMS HQ

Time: 16:02 Wednesday

Conditions: Mild and overcast

Equipmentfully stocked



You and the crew of the P4 are lounging on the sofas watching some show about a pawn shop. You can actively feel your brain cells dying, but that’s okay; you hardly use them anyway.

Still, it’s almost a relief when the tones ring out, and the overhead radio crackles… (click for audio)

[A61, respond priority 1 to 203 Philips St — 2-0-3 Philips for the shortness of breath. A61 to 203 Philips, between Palmer and Webster St. You’re responding with Engine 1 at 16:02. A61?]

Click to expand



You grab the base radio and acknowledge, check the location on the blown-up wall map, then head down to the garage. The crew of the P4 waves goodbye with only a little schadenfreude.

Engine 1 emerges from their station just down the road while you’re still rolling up the doors, and you get hung up behind a UPS truck that won’t clear the street in front of your driveway. By the time you pull up to the address — a single-story home — they’re already walking into the front door. (You don’t see police anywhere.) You grab the first-in and airway bags, Steve retrieves the stairchair, and you head up the (numerous) front steps behind them.

The house is clean and nicely appointed. Inside, you poke your head around a few corners until the sound of voices draws you into a bedroom.




It’s cramped, but you see a hospital-type bed against the wall. An elderly female is in the bed, semi-Fowler’s with a number of pillows behind her, wearing a nasal cannula attached to an oxygen concentrator on the floor; you notice the flow regulator set to 2 LPM. A container of milky-white fluid is hanging from a pole and running through a tube that disappears under her blankets.

Aside from the firefighters milling about, there’s another middle-aged woman and somebody with a stethoscope hanging around her neck.

You eyeball the room, but nobody jumps in, so you offer, “Hi folks. I’m Sam; what’s up?”

The stethoscope-laden lady offers, “Increased work of breathing; she needs to go to the ER.”

“Okay… are you… the visiting nurse?”

“Yeah, I see her twice a week.”

“What’s her name?”

“Gertrude Partridge.”

Of course it is.


Initial Assessment

You approach the bed, calling out, “Ms. Partridge?”

She looks over at you. Her eyes are open, and she localizes you easily. She’s breathing fairly quickly with some labor, and you can faintly hear a wet crackling sound every time she inhales. Her skin is a little pale, and she seems to be in minimal distress. You palpate a radial pulse which is regular, and somewhat quick and weak.

“My name’s Sam,” you tell her. “How are you feeling?”

“Okay,” she answers.

“How’s your breathing?”

“I’m a little short of breath.”

Steve files in behind you, setting the chair against a wall.






“Vitals?” you nod to Steve, who moves in to the other side with a cuff.

“How long has this been going on?” you ask the patient as you slide your stethoscope out of a pocket.

“All day.”

You don your scope and wriggle it until you can hear, then place the diaphragm over her left lower chest. “Deep breath?” You listen at the same spot on both sides, hearing moderately coarse wet crackles — biphasic, but worse when she inhales. You listen in the mid-chest as well, which is less wet, but still crackling… and then at the apexes, which are mostly clear.

Pulling out your earpieces, you ask the nurse, “What’s her history?”

“End-stage stomach cancer, metastatic. Her stomach’s out, she has a J-tube. Uh… two MIs, stents, she sometimes gets A-fib… some dementia, but she’s fairly tuned-in still… she does have CHF.”

To Ms. Partridge, you ask, “Is this how you usually feel when the CHF is bothering you?”


“Okay. So there’s nothing that feels different this time? It just feels like the usual?”

“Yes… it happens sometimes.”

As you talk, you reach down and turn up her oxygen concentrator to 6 LPM. It seems to be working properly and is bubbling through a humidifier. A moment later, Steve hands you a card that says:

92 reg


RR 32

“Thanks. Can you grab her meds?” Steve hauls himself ponderously to his feet and buttonholes the nurse for a medlist.

“How’s your chest feeling?” you ask.


“No pain or anything?”

“No, no.”

“Has anything else been bothering you lately, or were you feeling okay until this started today?”

“I’ve been feeling okay.”

The other woman in the room says, “She’s actually had a cough for a few days.”

You look up. “Ah. Bringing anything up?”

“Not really. But she’s weak, she doesn’t cough very well, you know.”

“Has she had a temp?” you ask the nurse.

“Um… looks like… 99.2 today.”

“Have you been coughing?” you ask Ms. Partridge.

“Oh, a little.”

“Been feeling any fever or chills?”

“Maybe a little.”

You take a moment to palpate her abdomen, which is soft and non-tender. A rubber tube is emerging from her abdomen, with no visible redness or inflammation of the site. Her legs have moderate pitting edema all the way up past her knees.

Steve comes back with another card:





“What’s the oxycodone for?”

“Back pain.”

“Ah. So she’s been getting all her meds as usual? Any recent changes or issues?”

“No, it’s been the same for a while. We give most of them through her tube.”

“And nutrition has been the same? She’s been moving her bowels and making urine?”

“Yes, she just saw her doctor last week, he said she’s doing well.”

You look down at Ms. Partridge. “How’s that oxygen? Feeling any better?”

“Oh, yes; yes, that feels better.” She looks better, too: breathing a little slower and with less labor.

You step away and move to the other side of the room for a moment. “Any allergies?” you ask the nurse.

“Latex and calcium channel blockers.”

You nod and write that on the medlist. “Is she a full code?”

“Oh, no. She’s a DNR.”

“Do you have a copy of that?” In your area, you can’t honor a DNR unless you have the official form physically in your hands.


“Hang on,” says the daughter, and goes into the other room.

“So is she essentially on hospice at this point?” you ask.

“Yes, mostly just comfort care. But that’s pretty recent.”

“So do we actually want to bring her in?”

“That’s up the family.”

“Where’s she usually go?”


The daughter returns with a photocopied DNR form. You examine it briefly; it seems to be valid.





“Is there a healthcare proxy?”

“I’m her proxy, but it hasn’t been invoked yet.”

You can never sort out how this stuff works in your state. Sometimes the durable powers seem to take immediate effect, sometimes they have to be “invoked” by a judge or the like; when in doubt, you usually just ask.

“So she usually makes her own decisions?”


“Okay. What’s your feeling on whether she should come in to the hospital now?”

“The… I mean… I don’t know. She just signed the DNR two weeks ago. She’s still doing really well, she’s sharp, but she doesn’t want to… I don’t know.”

“That’s fine, that’s fine.”

Better get it straight from the horse’s mouth. Returning to the bedside, you pat Ms. Partridge on the back of the hand. “All right, what do you think? Would you like us to bring you into the hospital? They can take a look, help with your breathing… it sounds like you might have a little lung infection, but in any case, they should be able to sort it out and let you know.”

She looks up at you earnestly. There’s fear in her eyes, but also some earnest resignation. “I don’t want to have… any tubes or… machines. Nothing like that.”

“I understand. You can definitely make it clear to them what exactly you’ll want done, and your daughter can help, and so can I. But at this point I think there’s still plenty of basic treatments they can provide that’ll make you feel better.”

“Maybe just some medicine?”

“Sure. I don’t want to try and tell you what’s wrong, because I can’t say for sure — they’ll figure that out at the hospital — but at this point they’ll just be taking a look and helping you breathe. You’ll probably get an IV, maybe some medicine, maybe a mask on your face for a little while — have you had one of those before, a CPAP? Straps onto your face and blows air at you?”

“Yes, I’ve had that.”

“They might try that. If things get a lot worse, they might want to put a tube down your throat, but like I said, it’s up to you whether you want to go down that road. But you might as well try to nip things in the bud before that kind of thing is necessary, right?”

She smiles. “Okay. You’re right.”

“Shall we head over to Memorial, then?”

“Yes, thank you very much.”

You nod to Steve, who sets up the chair. “Are you okay to sit in a chair for a couple of minutes?”

“That’s fine. I can walk a little.”

“Don’t worry about that, we’ll just scoop you up.”

You find the fire company loitering in the hall, jawing about the boat one of them is trying to buy. “You guys mind setting up the stretcher downstairs?”

“Sure thing. Bring some of those bags down for you?”

“Thanks.” You hand them the first-in bag, keeping the oxygen.

In the room, the nurse is disconnecting the J-tube. Ms. Partridge is a wee thing, and her oxygen tubing is plenty long, so you and Steve just position yourselves fore and aft and lift her via knees and pits. Gently plopping her into the chair, you belt her in, then switch her cannula over to your portable tank. Finally, you sling that over your back.

“All set? Are you going to come along?” you ask the daughter.

“Yes, I’ll follow you?”

“Sounds good.”

You wheel out to the stairs, and together with Steve, carry her outside. SFD has the stretcher dropped, so you just park the stairchair alongside, unbuckle the straps, and mirror your earlier lift to plop her on top. You elevate the back as high as it goes and use a pillow to sit her up even more. Blanket, belts, up she goes, and she’s loaded into the 61 momentarily.

“Nice and easy 2 to Memorial,” you call up to Steve.

The concept of the “easy priority 2” is nebulous, but mostly indicates a gentle ride with lights on. No point in tearing off rivets, but you do want to get there before things get any worse (and before you need to use that DNR), and it’s a little ways with traffic.

You switch the oxygen to the main tank, briefly check on her respiratory status — same — and grab the radio. Checking the DNR for the date-of-birth and mentally calculating an age, you raise Memorial Hospital and give this notification (click for audio):

[Good evening Memorial, Scenarioville Ambulance 61. We’re about five minutes out with a 74-year-old female coming from home. History of CHF, complaining of a recent cough and trouble breathing since this morning. Moderate distress now, audible rales, pressure around 160, but doing okay on some oxygen. Any questions or concerns?]

“No, thanks A61.”

You spend the rest of the trip checking another set of vitals (unchanged) and chat with Ms. Partridge about the wisdom of converting her DNR form into the more substantial state form recently introduced, which allows for more detailed instructions, such as do-not-hospitalize, do-not-intubate, and so forth.

At the hospital, you roll into the ED. Nobody gives you much attention, so after a few minutes you just park yourself a little too close to the charge nurse until she turns around.

“Do you need something?”

You point two thumbs at the stretcher. “Bringing one in.”

“Oh. CHF?”


“Room 12 A.”

“Thank you.”

You roll that way, match up the beds, and slide over Ms. Partridge. As Steve switches the oxygen to a wall regulator, you wander outside just in time to meet an RN, asking you: “Okay, whatcha got?” (click for audio)

[This’ll be Ms. Partridge, 74. Lives at home, history of CHF after a couple MIs, uses home O2 on a couple liters. She’s had a dry cough for a few days, not really productive, but she’s not coughing very effectively anyway. Then since this morning, she’s had more and more trouble breathing — she says all very typical for her CHF exacerbations. Doing okay now, bilateral rales up midway, seems to be holding well at 6 liters on the cannula. Pressure 164/90, pulse 92, breathing about 24 now. She’s got metastatic stomach cancer, had her stomach removed, fed by a J-tube now; she just signed a DNR a couple weeks ago, so I don’t know if that’s in your system yet. But she’s very lucid and conversational, so you can chat. Her daughter should be here any minute.]

“What’s her sat?”

You flutter your fingers emptily. “You got me, we’re BLS.”

Wandering back into the room with the nurse in tow, you take the pulse ox probe off a hook and place it over one finger. The wall monitor flashes 89, 92, 94, and settles around there with a nice waveform.

“Thanks,” she says. “Can you register her?”

“You bet.” You find a warm blanket for Ms. Partridge, wish her luck, and head out to the registration desk to let them know she’s here.

Outside, you find Steve replacing your portable oxygen tank. “We were around 400,” he says.

“Cool.” You park yourself in the passenger seat and start tapping at the computer. After a few minutes, Steve hops in and clears over the radio. Dispatch directs you toward Charlie, and you steer that way. Off you go into the sunset.



Diagnosis: CHF exacerbation secondary to pneumonia

Patients with chronic CHF (congestive heart failure) are usually managed by controlling their fluid levels (via diet and medications, particularly diuretics and ACE inhibitors), but even in the best cases, their respiratory status can occasionally deteriorate acutely. The resulting Acute Pulmonary Edema (APE) causes dyspnea and reduced oxygen saturation; this is audible over the lungs as rales, beginning at the bases and rising superiorly with greater severity. Severe cases need nitroglycerin and CPAP (or PEEP, if intubated), but minor cases may be manageable by increasing FiO2 (the concentration of inspired oxygen). All of them, however, will benefit from sitting upright (or even standing, if they can); the fluid in the lungs follows gravity, so the more vertical the lungs are positioned, the more alveoli can remain dry.

Lung infections are one of the more common causes of CHF exacerbations. Along with other mechanisms, infection causes inflammation, increasing permeability of the pulmonary tissues and allowing fluid release.

Jejunostomy tubes (J-tubes) are a type of feeding tube. They penetrate the abdomen, allowing food products (and some medications) to be delivered directly into the jejunum of the small intestine.

The legal details behind Do Not Resuscitate orders (which usually forbid chest compressions, positive-pressure ventilation, defibrillation, and intubation) and healthcare proxies (which cede the right to make decisions of medical consent to a third party) vary widely by region. Know your area to avoid ethical and legal entanglements.

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