Acres Nursing and Rehab — low O2 sat

Location: Charlie post

Time: 15:50 Wednesday

Conditions: Clear and mild

Equipmentfully stocked with a quarter tank of diesel



Steve is snoring against his seatbelt and you’re staring vacantly out the window as the radio plays something about ambulances. You should probably fuel the truck, and you’re actually across the street from a station with diesel, but you’re having trouble overcoming inertia.

You’re jolted out of your reverie as the radio crackles… (click for audio)

[Ambulance 61, take it priority 3 to the Acres Nursing and Rehab. 386 Longmeadow Rd, Acres Nursing and Rehab on the third floor. Coming in as an 80-year-old female with low O2 sats… stable per the staff, requesting BLS… nearest ALS is at headquarters, no fire response. 61?]

Click to expand



Good old Acres. Steve starts rolling that way.

“What are the chances this patient is actually stable?” you muse.


“Zero point what?”

“Zero point zero.”

Fifteen minutes later you pull up to the front doors. You retrieve the first-in and airway bags, pile them on the stretcher, and head inside. In the elevators, you crack your knuckles as Steve yawns and tucks in his shirt.

Up on the floor, you head for the nurse’s station. A young lady is sitting there filling out paperwork.




“Hi,” you chirp. “You guys sending somebody out?”

“Yes, just one second,” she replies. “I’m finishing the paperwork now.”

“Great. Which room?”

“21 by the window… down the hall on the right.” Steve heads that way with stretcher in tow.

“What’s going on?” you ask.

She pauses and looks up. “It is Jane… she has had a little cough today, and her sat is low. The doctor wants her to send her to Memorial.”

“A cough? Since when?

“Since today at least. I was not on yesterday. She was fine Monday.”

“Is she coughing anything up?”

“I have not seen, she coughs into a tissue and throws it away.”

“How’s her breathing?”

“Okay. She often has a little trouble. She gets 2 liters as needed, so we have had her on that since noon or so.”

“How’s her sat now?”

“Around 90.”

“And usually?”

“Oh, 95, 96, unless she is exerting herself or sick.”

“What’s her history?”

“Ah… a little dementia I know… she is not usually mine…” she flips a few pages. “Diabetes… she has broken her hip many times, she’s not ambulatory now… there is a list here.”

“Can I peek?”

She hands you a few papers. “I am just finishing the transfer note now.”

“Thanks, we’ll grab it on the way out.” You read that this is Jane Polowski, an 80-year-old female with history of:

Dementia NOS

Diabetes Mellitus, insulin-controlled

Fall risk





Bipolar disorder NOS

Enlightening. You’re turning to the med list when you hear Steve’s voice from down the hall: “Hey Sam!”

Now, that’s a familiar tone. “Back in a sec,” you tell the nurse, who nods absently. You start walking, and when you see the stretcher parked by the door of a room, you duck inside.


Initial Assessment

Steve’s standing there with a rolling vitals monitor. Beside him is a bed with a moderately-built elderly-appearing woman lying supine, her eyes closed. He’s got a cuff wrapped around her arm, and she’s wearing a nasal cannula plugged into an oxygen concentrator on the floor, humming along at 2 LPM. She looks pale.

Steve flips the monitor around so you can see the display. It reads:

HR: 107

BP: 88/51

O2: 86%

Temp: 101.9

Wordlessly, you approach. “Ms. Polowski!” you call loudly, shaking her shoulder gently. There’s no response. You pinch her trapezius firmly, while seeking out a radial pulse with your other hand. She doesn’t respond. Her wrist is lukewarm, dry, and you can’t easily find a radial. Pressing the back of your hand against her forehead, she is hot. She’s breathing shallowly at a slow but adequate rate.






“Great,” you mutter under your breath. After a few seconds, you manage to find her radial, which is extremely weak, coming and going — they call it thready, you believe. “Can you throw her on a non-rebreather?”

Steve nods, pulls the stretcher into the room, and starts setting up a mask. Meanwhile, you pull on your stethoscope and listen to her lungs, high and low on each side. She has some coarse biphasic crackling audible bilaterally, but worse on the right around the middle, and you can hear expiratory wheezing from that side as well.

Her abdomen is soft, not distended, and deep palpation elicits no response. There’s no Foley or other urinary catheter, and you don’t see any significant edema in the lower extremities. Moving back up, as Steve secures the mask you take a look at her pupils, which are fairly small and equal.

“Cool. Let’s get her into the stretcher.”

Steve start to rearrange things (pulling the bed out from the wall with a grunt and yank instead of taking the time to lower it onto the wheels), and you notice that one of the CNAs has materialized in the doorway. “How is she?” she asks.

“You tell me,” you reply. “Is she usually like this? Or is she more with it?”

“She… what do you mean?”

“Is she normally alert, verbal, talks to you? Or mostly unresponsive like this?”

“Oh, no, she talks to you, she’s real friendly. Confused sometimes, but…”

“When’s the last time you saw her that way?”

She pauses. “Well… yesterday she seemed okay, maybe a little tired. She went to sleep very early without eating. But she has been this way all day.”

“Does she usually eat on her own?”

“Yes, just thickened liquids.”

As you’re talking, you have the glucometer in your hands, and you stick one of her fingers. It doesn’t give you much, but you’re able to milk out a usable drop of blood. The meter reads 104. Damn it.

“All righty.”

You key your radio. “Ops, A61?”

“Go ahead, 61.”

“Any ALS available?”

… ah… the P9 will be coming from the base.

“Okay, not sure if they’ll catch us, but bring ’em in.”

“Copy. P9 on the air?”

You tune out the radio. Steve is ready with the stretcher alongside the bed, and together with a “1-2-3!” you pull Ms. Polowski over. You give her one quick boost, sit her up to around 30 degrees to compromise between perfusion and breathing, then start buckling her in.

Steve switches the oxygen over to your portable tank. You take the opportunity to clip the pulse ox probe back onto a finger for a brief moment. Her heart rate remains around 105, but her sat has reached… 89%. Underwhelming.

You start rolling out to the hall. As you pass the nurse’s station, the nurse hands you a packet of papers; you quickly thank her, and Steve punches the “down” button. “Is she a full code?” you ask while you wait.


“Thanks.” You take a second to reassess Ms. Polowski. She hasn’t changed much, and didn’t stir at all when you plucked her out of bed. You’re actually becoming a little more worried; she’s even more zonked than you typically associate with a septic patient.

The radio crackles incomprehensibly. You share glances with Steve, but neither of you can make anything out. Fortunately, a moment later the doors slide open, and you head out toward the truck. As you open up the back, your radio buzzes again: “Paramedic 9’s on the road. 61, do you have an update?”

Ah, yes. You thought you knew who was manning the P9 today. As you bend over to lift the stretcher wheels, you reply, “61… we’ve got an 80-year-old female, unresponsive, febrile, satting 89% on a mask, pressure 88/50. Shooting for Memorial, we’ll be rolling in just a minute.”

“P9 has it. We’re about four minutes out, coming up Summer.”

You climb into the back and make a little “let’s get going” gesture at Steve. Into your mic, you say, “Copy, we’ll come down Washington, try and catch you near Bravo.”

Steve nods in acknowledgement and shuts you in. “You got it, cowboy,” Doug Pinelli’s voice crackles from the radio. You smile.

From up front your partner calls, “You sure about Memorial?”

“Yeah, let’s head out.”

“I think we can make it there before the medics. Do you want them or the hospital?”

While you switch the oxygen over to the onboard tank, you reflect upon that one. Hmm.






“Let’s try to meet the medics,” you answer. Although Memorial does its fighting best, they don’t see enough high-acuity patients to maintain really smooth familiarity with their care, and you’d rather knock out some early goals right away, which you know that the P9 will do. Bringing the patient in ALS with wires and tubes will also help ensure she’s triaged appropriately.

“Got it,” he says and starts rolling. You palpate a quick pressure at 84, which is unchanged as far as you’re concerned. You’re willing to bet that Ms. Polowski would tolerate an NPA, but she’s maintaining her airway okay right now — at least without bagging her, which you might start pretty soon at this rate. The medics can sort out what they want to do.

You’re sitting there with a finger over her brachial pulse, following its gentle (and slightly irregular) pace, when you feel Steve pull over. Over the radio you hear, “P9, we have the intercept.”

A moment later, the rear doors open, and Doug Pinelli is silhouetted in the fading light. Behind him is Jim… Jim somebody, a medic of a couple years you don’t know too well, but reportedly a nice guy. You’re parked on the side of the road where there’s a good-sized shoulder,

“Gentlemen,” you greet them.

“Sam the man! Whaddya got?”

“This is Ms. Polowski, 80 years old, from the Acres. Typically alert and pleasant, just a bit confused, gets a couple liters PRN for COPD. But, since today at least she’s been like this: completely unresponsive, satting about 86% on 2 liters, pressure of 88/51, tachy around 110, temp 101.9. Lungs junky on the right with a little wheezing. Diabetic, sugar is about 100, CAD, COPD and asthma, dementia. Sat only bumped to 89% on the mask.”

Doug is already sliding into the tech seat; you make room on the bench for Jim, who starts attaching electrodes to Ms. Polowski’s hips and shoulders. Doug slips his scope into his ears and has a quick listen at the lungs.

“Blech. No history of CHF?”

“Not from what we’ve got, just the COPD.”

“What was the temp again?”


“And this has been going on since when?”

“Unresponsive pretty much all day, sounds like nothing much happening yesterday, maybe a cough.”

“Did she aspirate?”

“Unknown. She eats on her own, but it’s thickened liquids, so there must be some swallowing issues.”

Doug nods. “So it sounds like we’re going down a sepsis pathway, then.”

He looks around; there’s no response. “Yes? Anybody disagree?”

You shake your head. “That’s my thought, maybe with some other things mixed in there. Might want to rule out cardiac, though.”

“Oh yes, we’ll get a 12-lead. Meanwhile, let me see about some veins here.”

He moves to Ms. Polowski’s right arm. Jim has hooked up the monitor, and squiggly lines are dancing as he prints a short strip. “Sinus tach,” he says. “Some PVCs.”

“Okay, why don’t you get a big ol’ line over there. Sam, can you hook up a 12-lead? The pulse ox too.”

You clip the probe to a finger, plug in the 12-lead extension, and start threading out wires. A few seconds later, you look up to the monitor and and remark — “Sat’s about 90%. That’s where we had her earlier.”

“Do you know what her baseline is?”

“They said she was 90% on 2 liters earlier, but that she usually sits around 95%.”

“Okay. Sounds like we’re a little shunted, but maybe we can bump her a little. Steve, can you give her a cannula under that mask? Just hook it to the second regulator. Six liters. Then run up the non-rebreather to… oh, just twist it a few times.”

Steve starts working on that while you finish with the 12-lead. As you press the print button, Jim says, “There we go. I’ve got an 18 here.”

“Beat you, just got a 16,” answers Doug.


“Jeez yourself. Let’s hang some saline here. Can you guys spike a couple bags?”

As they medics secure their IVs, you and Steve each spike liter bags of saline with macro dripsets. They’re soon attached and running wide open into Ms. Polowski’s antecubital veins.

“We’ll bolus her up and then maybe step it back a bit,” says Doug. “Where’s that 12-lead?”

You hand it to him. “Looks… okay,” he says after a moment. “Lots of ectopy. Where are we with that sat?”

“93%,” you read off the monitor.

“Beautiful. Okay, looking good to me,” he says as he wraps the automated BP cuff around an arm. “Any last thoughts before we roll?”

Jim gives a thumbs-up and you shake your head.

“Right on, let’s boogie.”

You hop out the back and Steve escapes from the side. As he heads for the P9, you slip into the driver’s seat of the 61. “All set?” you call into the back.

“Yep, go ahead,” Doug replies. You hear him immediately hailing Memorial and running off with: “Memorial, Scenarioville P9. En route with an 80-year-old female from the SNF, unresponsive, hypotensive, fever, hypoxic, tachycardic, wheezing and rhonchi. Currently with a BP of 90/50, satting 90% on 100% O2, maintaining her own airway. Monitor shows sinus with ectopy, no changes on the 12-lead, we’ve bilateral lines running wide open. We’d like to enter your sepsis protocol ASAP. ETA 2 minutes; anything further?”

A few short moments later, you’re pulling into the bay. Steve’s behind you in the P9 with his lights on — which he technically shouldn’t be doing (SEMS policy is that non-transporting units should follow in priority 3), but Steve doesn’t care. You call yourself on arrival, park, and hop out.

As the throw open the back doors, Jim is squeezing a bag overhead, and Doug is finding a place on the stretcher for the monitor. “Go ahead,” he says. You carefully draw out the stretcher, ensuring that nothing snags.

Inside, you’re pointed into one of the trauma rooms, and after pulling off the ECG, pulse ox, and BP cables, you slide Ms. Polowski into a bed with help from the staff. It’s a little crowded, so once they’re situated, you get the stretcher into the hall, and linger by the doorway eavesdropping and tapping at your computer in case anybody has a question for you. Steve steals the stretcher away when you have your back turned; he’s particular about how it’s made up.

Pretty soon, the medics emerge, and you all wander outside. Steve has the stretcher and truck sorted out, and has cleaned and neatly put the ALS gear back together.

“Thanks Stevey, you’re a gem,” says Doug.

“They handled that pretty good,” you observe. “Got some blood right away, started thinking about antibiotics.”

“That’s because we rolled in there making a fuss,” he answers. “If you’d shown up BLS she’d probably be in the hallway.”

“More or less what I was thinking.”

“All right, gents. Always a pleasure. I’m sure we’ll see you around.” Doug raises a hand and starts backstepping toward his truck.

“Catch you later guys, thanks for the help.”

You hop into the 61, and Steve steers you back out into the city.



Diagnosis: aspiration pneumonia with resulting septic shock

Signs of infection in elderly, comorbid nursing home patients should always raise suspicion for sepsis; although many will not progress in that direction, many will and early detection and care can significantly affect their outcome.

Perhaps more than any other syndrome, these are the patients who may not present with frank signs of acute illness, and for whom timely ED care can be determined wholly by EMS voicing concern and making efforts to establish a sepsis course of care. Once a patient sets down that road, most EDs have established algorithms or pathways for suspected sepsis, often based on the tenets of Early Goal-Directed Therapy and the Surviving Sepsis Campaign guidelines. Initial measures should include normalizing oxygenation, maintaining tissue perfusion (this may require substantial infusions of crystalloid fluid), early blood cultures, and early broad-spectrum antibiotics. ALS units can initiate the first two, and in some systems can draw blood for the hospital’s use as well.

See Mastering BLS Ventilation: Hardware for some concepts for maximizing FiO2 delivery using non-invasive BLS techniques.


  1. Immediate Oxygen of 15 liters via non rebreather and blood glucose check. The low grade fever and tissue coughs lead me to think of a possible airway infection such as bronchitis, maybe early pneumonia, small chance of CHF related Pulmonary edema. I would consider giving nasal spray of albuterol assuming it’s not cardiac related edema causing her cough but she is a little tachycardic so I don’t know if I’m ready to commit to that quite yet, start an IV and saline lock, transport emergent and hook up a 12 lead. (AEMT)

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