CE Article: Getting the Most From Your History and Physical, Part 3: Respiratory Patients

This is the third of a four-part series that appears bimonthly. Find Part 1, dealing with chest pain patients, at www.emsworld.com/12149999 and Part 2, covering neurological patients, at www.emsworld.com/12171904. In addition, find a video to accompany this article at www.emsworld.com/12220374.

Objectives

• Review strategies to accurately differentiate pneumonia from CHF in the field
• Examine several deadly causes of dyspnea
• Discuss common but less dangerous etiologies of shortness of breath

You and your crew are called to a nursing home for a patient complaining of shortness of breath. You find the elderly female patient hypoxic and, after initial stabilization, perform a full history and physical examination. Your protocols offer specific treatment guidelines depending upon the etiology of the shortness of breath. Is this pneumonia with sepsis that requires large boluses of IV fluids? Or is this CHF that requires CPAP, nitroglycerin and possibly diuretics? Are you dealing with COPD, pulmonary embolism or spontaneous pneumothorax? What clues should you look for in your history and physical examination to help you arrive at the correct prehospital diagnosis?

It is well known that differentiating between pneumonia and CHF can be difficult in the prehospital arena.¹ It is also known that giving a diuretic like furosemide to a patient with pneumonia can potentially cause harm.² While many agencies have pulled diuretics off their rescue vehicles in recent years, many others continue to administer them for cases of suspected CHF. This means that accurately making the correct prehospital diagnosis of CHF is even more important. Both diagnoses can present with crackles on lung exam. How can they be accurately differentiated in the field without the use of an x-ray?

In this third installment of the series, we will review the simple strategies to accurately differentiate pneumonia from CHF in the field. In addition we’ll examine several deadly causes of dyspnea as well as some of the common but less dangerous etiologies of shortness of breath (SOB). By performing a focused, systematic history and physical examination, you can rapidly diagnose and treat life-threatening respiratory emergencies.

However, as always, rapid stabilization and transport are top priorities. A focus on controlling the airway, correcting hypoxia, reversing bronchospasm and improving ventilatory rates and tidal volume comes first. After initial stabilization of the patient, gathering the necessary information will allow the skilled paramedic to refine the prehospital diagnosis and treatment.

CHF vs. Pneumonia

Before discussing the details of a history and physical examination for a chief complaint of SOB, let’s begin with the simple strategies and clues to assist the street medic in correctly differentiating CHF and pneumonia. Some of these strategies necessarily oversimplify complex physiological problems. However, when used in combination with a thorough history and physical exam, these tricks of the trade can often make obtaining the correct diagnosis much easier.

Pneumonia

Pneumonia can be thought of as a disease of the lung. Patients with underlying lung disease can be thought to be at risk for more lung disease. This means your patients with a history of COPD, asthma or other lung pathology, or who take respiratory medications such as albuterol, should be considered high-risk for pneumonia.

Since pneumonia is an infectious disease, your patient is more likely to catch it from other people. Consider the patient’s address in your diagnosis: Patients who reside in high-population-density living arrangements, such as nursing homes, are at particular risk. In addition to residing with many potential infectious contacts, these patients are often debilitated, run down and chronically ill. Infections are common in this population, since this background generally translates to a weakened immune system and large opportunity for infection to spread.

Patients who have lost their ability to swallow normally are generally given a feeding tube. While that tube solves the issue of nutrition, what happens to the saliva? They have to try to swallow it. Often they aspirate this infectious liquid into their lungs and end up with aspiration pneumonia. Consider any patient you see with a feeding tube and a chief complaint of SOB to have aspiration pneumonia until proven otherwise.

While fevers do not last 24 hours a day or 7 days a week, and the absence of a fever does not rule out an infection. If a fever is present, consider the cause of shortness of breath to likely be an infection, and therefore consider the diagnosis to be pneumonia. However, do not be lulled into the false idea that an absence of fever means absence of pneumonia. Many chronically ill patients are too ill and their immune systems too weak to ever create a fever. If present, consider pneumonia. If not, don’t rule it out.

Patients who are not ambulatory are at high risk for infections. Look for evidence of poor ambulation. Are there wheelchairs present, walkers, special boots to prevent bedsores for bedridden patients? If so, consider pneumonia high on the list of possible causes of SOB.

Timing is important. Infections usual present gradually. Slowly increasing SOB over days is more likely to be pneumonia than CHF. This is especially true if there is also a history of recent viral upper respiratory tract infection.

Vital signs give clues as well. Low systolic BP, diastolic hypotension, wide pulse pressure and fever all favor pneumonia over CHF. The skin exam in pneumonia is often dry. If fever is present, the skin may feel hot as well.

CHF

Just as pneumonia can be considered a disease of the lungs, CHF should be considered a disease of the heart. Patients with a history of heart disease are more likely to go on to have more heart disease. Look for signs of cardiac surgery (sternal scar) and evidence of cardiac medications such as beta blockers and prior diuretic use like furosemide.

Unlike the often chronically debilitated pneumonia patients from the nursing homes, many of these patients are quite healthy between CHF exacerbations. They tend to come from private residences. After they get treated for an episode of CHF, they usually get to go back to their home. If their residence has been converted to look like a nursing home or hospice care environment, strongly consider pneumonia, because the chronically ill patient is more likely to succumb to it. Otherwise, a normal private residence may indicate a generally healthy patient, which favors a diagnosis of CHF. Consider the address when deciding between these two diseases. The living environment can give clues to their baseline health.

Fever does not generally occur with CHF. If it is present, it likely means the SOB patient has pneumonia. Diuretics should generally be avoided in patients who present with a fever.

The physical exam in CHF is likely to reveal some combination of JVD, hepatojugular reflux, ascites and pedal edema. The history may suggest orthopnea (SOB when supine) or paroxysmal nocturnal dyspnea (SOB waking up after lying supine). All of these are evidence of fluid overload and point to CHF. Their complete absence should make the paramedic doubt that CHF is the problem, and therefore diuretics should likely be withheld.

Timing of the illness is important to consider. There is a subset of patients with chronic CHF who have weak hearts with chronically very low ejection fractions. These patients generally live constantly with some degree of CHF. In this subset, a gradual worsening may occur. They typically will have several of the fluid overload signs noted above to assist in differentiating them from those with the characteristic gradual onset seen in pneumonia. More typically, CHF patients have a rather acute onset of worsening. The deterioration is faster than in pneumonia, and in extreme cases patients can have “flash” pulmonary edema over a matter of minutes. The shorter the onset of illness, the less likely it is pneumonia.

Vital signs can give clues as well. Blood pressure values tend to be higher in CHF than pneumonia. Flash pulmonary edema cases typically have extremely high systolic pressures, often over 200.

Using these tricks of the trade can give paramedics a shortcut to the diagnosis, but only if CHF and pneumonia are the exclusive etiologies to consider. While both are common, there can be more to SOB than just these two problems. Therefore, the skilled medic will have a good understanding of how to perform a focused history and physical examination for the chief complaint of shortness of breath.

Respiratory H&P

Because the respiratory and cardiovascular systems are so closely related, chief complaints such as SOB, dyspnea on exertion (DOE), wheezing and coughing must be carefully assessed to determine the correct body system responsible so that an accurate prehospital diagnosis can be made and the correct treatment administered.

To be proficient in conducting the H&P, your process must be organized and systematic. Practice makes perfect. Utilize the following outline as a guide for shortness of breath assessments and a template for writing patient care reports. Explore the following categories in patients with a complaint of SOB:

1. Chief complaint: the main reason 9-1-1 was called;

2. History (HPI, PMH, SH, FH);

3. Review of systems;

4. Physical exam;

5. Form the prehospital and differential diagnosis.

History

Chief complaint—The chief complaint sets up the framework for the rest of the questions to discover the diagnosis. With a chief patient complaint of shortness of breath, the paramedic should immediately consider the life threats associated with that complaint and organize questioning to help refine or narrow down the possible etiologies.

Information obtained from the chief complaint must be expanded to include the onset, palliative/provocative factors, quality, radiation, severity, timing and associated symptoms (OPQRSTA). This framework ensures a thorough exploration of the chief complaint and should be completed prior to moving on to the next section of the history. The answers obtained from this section will point to a more specific etiology as the cause of the shortness of breath.

Past medical history—Questions regarding past medical history are very important when it comes to a chief complaint of SOB. If the patient has any of these pre-existing conditions, the odds greatly increase that the current episode is an exacerbation of a prior disease process. Ask about the presence of:

• Asthma;
• COPD/emphysema;
• CHF or any history of heart disease;
• Pulmonary embolus or DVT.

Social history—Risk factor analysis helps to determine the likelihood of a given prehospital diagnosis. Ask about the following:

• Smoking (increases risk of COPD and pneumonia);
• ETOH (increases risk of aspiration pneumonia);
• Recent travel (increases risk of pulmonary embolus);
• Living conditions (patients in nursing homes and other high-density living arrangements are frequently exposed to infections and are at higher risk of pneumonia).

Medications—The most commonly prescribed medications and their indications should be committed to memory. The skilled paramedic will find that the current emergency is often related to the patient’s prior underlying medical problems, and the medication list will give useful information regarding what should be considered in the list of potential prehospital diagnoses.

Diuretics such as furosemide, as well as hypertension and cardiac medications, are associated with CHF. Respiratory medications such as albuterol suggest asthma or COPD. Oral contraceptives increase the risk of DVT/pulmonary embolus.

Physical Exam

Once the history has been obtained, the paramedic should be able to formulate a list of likely prehospital diagnoses. The physical exam is then performed looking for evidence to support or refute each.

Vital signs—Looking at specific vital signs gives an enormous amount of information about the patient’s condition.

• Pulse rate: Normal is 60–100. A rapid rate occurs in response to several etiologies. However, as a simplification, tachycardia can be thought to occur in three general instances: 1) The tissues are not getting enough nutrients/oxygen, and the body is compensating for this (i.e., the patient is in shock/has high metabolic demand); 2) the patient is taking a medication or has a condition that causes tachycardia, such as a stimulant/anxiety/pain; 3) the patient has an arrhythmia.
• Respiratory rate: Normal is 12–20. Tachypnea, or a fast breathing rate, as a simplification, can be thought to occur for one of three main reasons: 1) The oxygen level is low; 2) the acid level is high (as in shock or high metabolic demand states); 3) pain, anxiety or certain drugs.
• Blood pressure: Normal is a systolic of 90–120 over a diastolic of 60–90. The top and bottom number both give significant information. Systolic BP depends on stroke volume and strength of myocardial contraction. It occurs during systole. The bottom number occurs while the heart is at rest during diastole and indicates the vascular tone of the patient’s arteries. The difference between the top and bottom number is known as the pulse pressure. A wide pulse pressure occurs in septic, anaphylactic and neurogenic shock. A narrow pulse pressure occurs in hypovolemic/hemorrhagic shock.

As an example, a patient with the vitals of pulse 110, RR 24 and BP 105/50 is likely in septic shock. The fast heart rate may be an indication of shock. The rapid respiratory rate indicates the patient is blowing off acid (which increases in shock) and/or compensating for a low oxygen level. While the systolic blood pressure of 105 is often falsely reassuring, the skilled paramedic will look closely at both numbers. In this case 50 for a diastolic pressure is below normal. Diastolic hypotension indicates the patient has low systemic vascular resistance, a condition known to occur in sepsis. If your patient also complains of shortness of breath, you are probably dealing with pneumonia and sepsis. In a case like this, the vital signs plus chief complaint can give you the entire diagnosis.

General impression/ventilatory effort

• Evaluate the patient’s level of consciousness; look for respiratory distress.
• Observe the patient’s position of comfort (tripod positioning: COPD) or discomfort (CHF, COPD, asthma all worse when supine).
• Conversational dyspnea: If the patient cannot speak a full sentence, it indicates a moderate to severe degree of respiratory distress.
• Prolonged exhalation: COPD, asthma. Both COPD and asthma can result in air trapping. Air easily enters the lungs, but damaged or obstructed airways trap air, causing hyperinflation. When air is trapped, breathing transitions from passive exhalation to active exhalation with prolonged exhalation time. Observe the ratio of inspiration time to exhalation time; for patients with prolonged exhalation, consider the diagnoses of obstruction to outflow of air (i.e., COPD and asthma). Chronic air trapping is what is responsible for the barrel chest appearance (increased anterior/posterior diameter) of COPD patients.
• Pursed-lips breathing: Found to improve the sensation of dyspnea and reduce the work of breathing, pursed-lips breathing is often used spontaneously by COPD patients during exhalation.³ It is possible this maneuver helps force airways to remain open during exhalation by creating an effect similar to the use of CPAP.
• Accessory muscle usage: This is a sign of respiratory distress and can be seen in several conditions, including COPD, asthma, pneumonia, pulmonary embolus and pneumothorax.
• Respiratory rate: Patients in general breathe fast for three reasons: They have inadequate oxygen levels, elevated blood acid levels or a psychiatric/pain reason for breathing fast. Discovering the cause for the rapid respiratory rate will aid in the diagnosis. Abnormally slow breathing can be an ominous sign of impending respiratory arrest and may be due, among other causes, to drugs or CO₂ retention in severe COPD.
• Shallow respirations: Pleuritic pain will cause patients to breathe with a lower tidal volume in an effort to avoid the pain. Consider possible causes of pleuritic pain such as pneumothorax, pulmonary embolism and pneumonia.

Respiratory patterns—The pattern of breathing may give a clue as to the underlying etiology of the respiratory complaint.

• Normal respiration: Rate is 12–20. Most adults will have a respiratory rate of 12–16, with the upper end of normal at 20. It is important to take the first set of vital signs manually so you have a good baseline.
• Kussmaul respirations: Characterized by deep, rapid respirations. Commonly caused by diabetic ketoacidosis or other conditions with severe metabolic acidosis.
• Cheyne-Stokes respirations: Characterized by cycles of a gradual increase and decrease in respiratory depth and rate. As the respiratory rates decrease, there is a period of apnea which may last up to 30 seconds. Cycles can last up to 2 minutes. Common causes include head trauma, stroke, hypoxia and brain tumors.

Neck exam—Observe for JVD and hepatojugular reflux (HJR). With the examiner on the right side of the patient, place the patient supine with the head up at about 30 degrees and turned away from the examiner. Then observe the exposed neck for JVD. With the patient in the same position, press down on the right upper quadrant of the abdomen over the liver. If the liver is engorged with blood due to right-sided CHF, the jugular vein will become more distended, making JVD more pronounced and obvious. These are both common signs of CHF. In addition, JVD may be present with tension pneumothorax.

Chest

• Inspection: Inspecting the chest is often neglected in the prehospital setting, but valuable information regarding the level of respiratory distress and the rate and quality of breathing can be determined this way. As you visualize the chest, look for intercostal muscle retractions, rate and depth of breathing, and equal expansion of the chest wall. Note whether the patient has a barrel chest (indicative of COPD).
• Palpation: Respiratory emergencies with associated chest pain should prompt palpation of the chest wall. Palpate over the affected area and note whether the pain can be reproduced. Chest pain associated with respirations or coughing is defined as pleuritic chest pain and associated with pleurisy, costochondritis, pulmonary embolus, pneumothorax, pneumonia and pericarditis. Pneumothorax commonly produces subcutaneous air that can be felt as a crackling sensation while palpating over the affected area of the chest wall.
• Auscultation: The ability to distinguish adventitious lung sounds is a necessary skill to diagnose respiratory emergencies. Too often lung sounds are omitted as part of the physical exam unless the chief complaint is respiratory in nature. As mentioned in earlier articles, lung sounds should be assessed on all patients as part of a limited prehospital physical exam.

Lungs sounds can be difficult to assess in the field. To improve auscultation, eliminate background noises whenever possible. Position the patient seated if they’re able. Ask patients not to speak during auscultation and to take slow, deep breaths with their mouth open. Place the stethoscope on the patient’s bare skin. Begin auscultation on the posterior thorax at the apex. Move from one side to the other, comparing lung sounds. Listen for a full respiratory cycle (one inhalation, one exhalation), continue moving inferiorly to the bases. Repeat on the anterior chest.

Abnormal lung sounds can be decreased or absent or adventitious (e.g., crackles, rhonchi, wheezing, stridor or pleural rub). These sounds can be heard by themselves but often are heard in combination.

• Normal lung sounds: There are essentially two types of normal lung sounds, vesicular and bronchovesicular. Vesicular lung sounds are soft and low-pitched and are auscultated over most of the peripheral lung tissue. Bronchovesicular lung sounds are heard anteriorly over at the sternal borders at the first and second intercostal spaces and posteriorly between the scapulae. They have a medium pitch since they are auscultated over main-stem bronchi. It is important for the paramedic to listen to many normal patients in order to train the hearing skills to identify abnormal breath sounds.
• Decreased breath sounds: Decreased breath sounds may be caused by chronic conditions such as COPD (emphysema and chronic bronchitis) and asthma, or acute conditions (e.g., spontaneous pneumothorax). Other causes include hypoventilation or obesity.
• Crackles: Crackles can be described as fine or coarse. Crackles are associated with pulmonary edema secondary to left ventricular failure, COPD, pneumonia, bronchitis and asthma. Fine crackles have a sound similar to rubbing your hair between your index finger and thumb. There are subtle differences in the quality of the crackles depending upon the underlying etiology. It takes time and experience to learn to decipher those differences.
• Rhonchi: Rhonchi are gurgling, rattling type sounds and are indicative of secretions in the larger airways. Rhonchi can be generalized as in bronchitis or localized as with pneumonia.
• Wheezing: Wheezing is a high-pitched whistling sound and occurs in response to bronchospasm. Asthma, COPD, bronchitis, pneumonia, CHF, pulmonary embolism and allergic reactions can all produce wheezing. Early wheezing is first heard on exhalation. As bronchospasm progresses, it can be heard on the inhalation phase as well. As it progresses even further, breath sounds may become significantly decreased or even absent. This is an ominous sign that the patient is not able to move air sufficiently to produce wheezing. This means respiratory failure is imminent.
• Stridor: Stridor is a high-pitched sound commonly heard on inspiration without a stethoscope that is indicative of an upper airway obstruction typically caused by infection, anaphylaxis or foreign body obstruction.
• Pleural rub: A pleural rub is the hallmark of pleurisy. It is best described as a creaking sound heard over the affected area of the lung.

Abdomen—A distended abdomen may indicate ascites. This finding can be associated with CHF.

Lower extremities—Routinely examine the lower extremities in patients with a chief complaint of SOB. Pitting edema bilaterally is common in CHF. A one-sided swollen leg can indicate DVT, which would raise the likelihood that pulmonary embolism is the cause of the dyspnea. In addition, the presence of pressure sores would indicate a patient who is nonambulatory. Both pneumonia and pulmonary embolism are more likely in nonambulatory patients.

Respiratory Emergencies

Quickly diagnosing respiratory emergencies can significantly impact a patient’s outcome. Life-threatening respiratory medical emergencies include pulmonary embolism, CHF, pneumonia, spontaneous pneumothorax, exacerbations of COPD and asthma.

Pulmonary embolism—Pulmonary embolism typically presents as a triad of sudden onset of shortness of breath, tachycardia and hypoxia. Pleuritic chest pain and hemoptysis can also occur. Large pulmonary emboli can cause hypotension, syncope and cardiac arrest.

The following patients are at increased risk for a pulmonary embolus: patients with a previous DVT or PE, recent hip or knee surgery, leg pain/swelling, immobility (bedridden, long-distance travel via car or plane) or pregnancy, including up to 6 weeks postpartum.

Differential diagnosis: acute coronary syndromes, spontaneous pneumothorax, pneumonia and hyperventilation syndrome.

Spontaneous pneumothorax—Spontaneous pneumothorax presents with a sudden onset of respiratory distress and/or pleuritic chest pain and dyspnea on exertion. Breath sounds are diminished or absent on the affected side. Because a collapsed lung cannot fully inflate, there may be a decrease in chest wall movement on the affected side depending on the size of the pneumothorax. Carefully monitor patients for the development of a tension pneumothorax: severe respiratory distress, hypotension, cyanosis, JVD, altered mental status and tracheal deviation.

Tall, thin adolescent males and activities with changes in altitude (e.g., scuba diving, flying, hiking in high altitudes) increase the risk for a spontaneous pneumothorax. Look for a history of previous spontaneous pneumothorax, COPD, cystic fibrosis, asthma, tuberculosis, pneumonia, lung cancer and/or Marfan’s syndrome.

Differential diagnosis: Acute coronary syndromes, pulmonary embolus.

COPD—Emphysema is a chronic condition characterized by shortness of breath secondary to damage of the alveoli. Damaged alveoli lose their elasticity and the ability to exchange oxygen and CO₂, which results in prolonged respiration, decreased oxygen saturations and CO₂ retention. Chronic bronchitis is a type of COPD that causes inflammation of the bronchial tubes, which produces the classic triad of a chronic cough, increased mucus production and shortness of breath.

Some of the most difficult breath sounds to assess occur in patients with COPD. Due to the destruction of the alveoli, breath sounds are generally decreased. Additionally, wheezing, rales and rhonchi can also be present, especially if associated with pneumonia.

During COPD exacerbations, patients try to manage the increased workload of breathing by assuming a tripod position, utilizing their accessory muscles and breathing with pursed lips. As compensatory mechanisms fail, increased respiratory effort and CO₂ retention can quickly exhaust a patient, causing a decreased level of consciousness.

Look for a history of increasing respiratory distress, typically preceded by infections such as pneumonia or upper respiratory infections, or by exposure to irritants such as air pollution or chemicals.

Differential diagnosis: CHF, pulmonary embolus, pneumonia.

CHF—For the purposes of this article we will focus on left heart failure, as left ventricular failure (LVF) can cause severe respiratory distress. Conditions such as myocardial infarction or cardiomyopathy can damage the left ventricle enough so that a person’s ejection fraction is significantly reduced. This reduction causes blood to back up into the pulmonary circulation, causing the pulmonary venous pressures to increase. The elevated pressure causes capillaries to leak fluid into the alveoli and interstitial space.

Dyspnea on exertion and weight gain may indicate fluid retention in CHF; that and orthopnea are early signs of LVF. They are typically preceded by increased sodium intake, infections and noncompliance with medications.⁴ Symptoms may progress gradually over hours or days. In contrast, flash pulmonary edema occurs rapidly, often becoming extremely severe in minutes. It is often a result of severe hypertension, myocardial infarction or mitral valve dysfunction.

Signs of right heart failure may be present: JVD, HJR, weight gain due to fluid retention, pedal edema.

Differential diagnosis: pneumonia, pulmonary embolus, COPD.

Asthma—Asthma is characterized by bronchoconstriction, inflammation of the airways and increased mucus production. As with emphysema, asthma patients have difficulty getting air out. Patients can quickly become exhausted due to the increased workload of breathing and retention of CO₂.

History will include a rapid onset of wheezing and SOB, which may be preceded by a recent upper respiratory infection or exposure to irritants (chemicals, tobacco smoke, air pollution, etc.). Exercise, stress and noncompliance with medications may also cause exacerbations.

Differential diagnosis: COPD, CHF, pulmonary embolus, pneumonia.

Pneumonia—Pneumonia is an infection of the lung characterized by a productive cough, fever and malaise. Risk factors include weakened immune systems due to chemotherapy or HIV/AIDS, chronic illnesses such as COPD, asthma and diabetes, and age over 65.

Look for recent upper respiratory infection or flu, productive cough, dyspnea on exertion, fever/chills and general malaise. Differential diagnosis: COPD, CHF, asthma.

Conclusion

One of the more difficult aspects of conducting a prehospital history and physical exam is deciding which questions need to be asked and what elements of the exam should be done. In each article of this series, we have detailed a history and physical exam based on the body system correlating with the chief complaint. Paramedics are encouraged to develop their own pattern recognition in medicine. Pattern recognition is the ability to see the similarities between several cases with the same diagnoses and medical conditions in order to more rapidly diagnose future similar cases. Over time, using final hospital diagnoses to reinforce correct decisions (or alternatively correct false diagnostic impressions), the skilled paramedic will gain clinical acumen that will help improve the accuracy of their prehospital diagnosis and assist in determining what clues to look for in their history and physical examinations.

With this information in hand, let’s take another look at the hypoxic elderly female patient from our opening. The patient resides in a nursing home. After reading this article, you know that is a major risk factor for infections such as pneumonia. You hear crackles, but before you grab for the furosemide, which could potentially make a pneumonia case worse, you look at her list of medications. Nowhere is a cardiac medication or diuretic listed. This makes CHF less likely. However, you do see listed multiple pulmonary medications such as albuterol. You realize that pre-existing lung disease is a major risk factor for pneumonia.

Next you look at the vital signs. You see the patient is tachycardic with a low diastolic BP, corresponding to possible sepsis. After going through the rest of your history and physical exam, you conclude this patient likely has pneumonia with sepsis. You administer a fluid bolus and call a sepsis alert to the nearest hospital. On arrival, an x-ray confirms the presence of pneumonia in the left lung. The ED staff applauds you for avoiding diuretics and giving the needed intravenous fluids. Congratulations—you and your team have raised the odds that this patient will survive.

References

1. Dobson T, Jensen J, Karim S, Travers A. Correlation of paramedic administration of furosemide with emergency physician diagnosis of congestive heart failure. Australasian Journal of Paramedicine, 2009; 7(3).

2. Jaronik J, Mikkelson P, Fales W, Overton DT. Evaluation of prehospital use of furosemide in patients with respiratory distress. Prehosp Emerg Care, 2006 Apr–Jun; 10(2): 194–7.

3. Nield MA, Soo Hoo GW, Roper JM, Santiago S. Efficacy of pursed-lips breathing: a breathing pattern retraining strategy for dyspnea reduction. J Cardiopulm Rehabil Prev, 2007 Jul–Aug; 27(4): 237–44.

4. Tsuyuki RT, McKelvie RS, Arnold JM, et al. Acute precipitants of congestive heart failure exacerbations. Arch Intern Med, 2001 Oct 22; 161(19): 2,337–42.

Kenneth A. Scheppke, MD, is board-certified in EMS and emergency medicine. He has been practicing emergency medicine for over 20 years and is the EMS medical director for six fire-rescue agencies in Palm Beach County, FL, including Palm Beach Gardens, Palm Beach County, West Palm Beach, Boynton Beach, the Town of Palm Beach and Greenacres. For more than 15 years he has trained paramedics and EMTs as medical director for the Palm Beach State College EMS Academy. He also serves as the assistant medical director of the JFK Medical Center emergency department in Atlantis, FL.

Keith Bryer, BBA, EMT-P, has been employed with Palm Beach Gardens Fire Rescue for more than 25 years. He currently serves as the department’s deputy chief of operations.