Breath Wish

The Attack One crew receives a call in their first response district as they return from a major hazardous-materials incident. The dispatcher asks that they respond for a patient who is short of breath.

They arrive at a large apartment complex and take their equipment to the apartment assigned by dispatch. The person there says they did not call for EMS, so the EMT asks the dispatcher to contact the caller to get a correct address. The dispatcher gives them another apartment number, and that apartment is empty. The crew again asks for a location and description of the caller, and they are given a different building with the same apartment number and now told it is a young woman with a broken leg. They knock on the third door, but no answer comes from the apartment.

The crew leader asks the other members to fan out across the building to try to find where a patient might be. They recontact the dispatcher, but there is no further information, and now the person doesn’t answer their phone. That information greatly concerns the Attack One crew leader, who fears the patient may be unconscious or otherwise in distress.

The crew members knock on every door in the building and find no one who called for help. Since the Attack One crew is out of their district, they are not familiar with the apartment complex. They finally find a maintenance person, and he suggests they check a third building. That building has a person who is not a resident but he noticed has a broken leg. The crew and maintenance man go to the third building and check three apartments before they try a door answered by the person they’re looking for.

“I just can’t breathe,” she states. “Sorry I couldn’t give a correct address; I’m staying here with a friend and don’t know the building numbers very well. I just got hurt and had to come here to stay. And my cell phone just died.” The crew leader tells her they’re just glad they found her and asks her to sit down so she can be more comfortable as they assess her.

The caller is a young woman with a short cast on her lower left leg. She appears short of breath. They note a heavy odor of cigarette smoke in the apartment, and the paramedic asks if she has any lung problems.

“No lung problems at all,” she replies. “I do smoke and have done even more of that since I broke my ankle four days ago. They put me in this cast today, and I’m trying to use crutches for the first time. I couldn’t do that at my house, which has a bunch of stairs, so I came here to stay with my friend. I can’t drive, and my friend is gone, so I had to call 9-1-1. ”

In rapid-fire fashion, the crew asks the patient about her shortness of breath. It came on suddenly about two hours ago. No chest pain, no cough, no fever, no history of heart problems. Her only medicines are birth control pills and the pain medicine she’s used since the fall that fractured her ankle. She has no history of allergies.

With the patient now sitting, the crew obtains vital signs and listens to her lungs. They collect her medicine information and bottles. Her lungs are clear, but they notice her heart rate is elevated, and the pulse oximeter reading is below 90%.

“Maybe we got this dirty at the hazmat incident,” the EMT suggests, looking at the pulse oximeter and finger probe. He cleans it off and gets the same reading.

They place the patient on oxygen by cannula and note her oxygen level just barely goes above 90%. But the patient reports that she feels better. She asks if she can refuse care, since she has no pain, and wonders if she was just anxious from being alone in the apartment.

“We would not be comfortable leaving you here, since it took so long to find you and your oxygen level is low,” the crew leader tells her. “Your pulse rate is also a little high. That sometimes happens when we first see a patient, but it usually slows down. Your heart rate is still high. You need some more treatment and testing they will provide in the emergency department to fully check your lungs and whatever else might be causing your shortness of breath. It would really not be safe to let you stay here alone.”

Even as they load her onto the cot, the patient asks a couple more times to just stay at home, but the crew continues to explain why she would be better served by going to the hospital.

They load her onto a cot, and during the ride her pulse rate stays over 100, with her oximetry reading just over 90%.

Emergency Department Management

The ED staff nurses take the report and place the patient on a cot. As they make the transfer, they keep her off the nasal oxygen for a few minutes as she checks in. When they finally place her back on the pulse oximeter, her reading is 82%. “Guess your pulse oximeter was giving an accurate reading,” one nurse tells the Attack One crew members still in the room.

The crew members leave the room to complete their care report, and the patient thanks them for talking her into coming to the hospital.

Hospital Course

The Attack One crew stays busy the rest of the night, and at about 0400 they make it back to the same hospital with another patient. The same ED charge nurse is on duty and has an interesting follow-up.

“That young lady you brought in is really lucky,” the nurse says. “Her pulse oximetry reading stayed low in the ED, and her heart rate remained high. We scanned her lungs, and she has a big pulmonary embolism sitting in her main pulmonary artery. She had a few risk factors already, including smoking cigarettes and being on oral contraceptives. Then she fractured her leg and was in a cast. We also scanned her left leg and found a large clot in it. She is doing well now on blood-thinning medication in the intensive care unit.”

The patient is ultimately given heparin, the clot dissolved, and her symptoms cleared. She is discharged from the hospital on oral medicines and recovers from both the pulmonary embolism and the fractured ankle. Later workup reveals that both the patient and her family members have a condition that leads to easy clotting, and they are all started on treatment to reduce the possibility of dangerous blood clots.

Case Discussion

Pulmonary embolism is a common and life-threatening condition where blood clots form, usually in the deep veins of the legs, and pass into the lungs. Common symptoms are shortness of breath, chest pain, a cough with blood in the sputum, rapid heart rate or palpitations, and syncope. But as in this case, there are many patients who have relatively mild symptoms. Physical findings on exam are often minimal. If there is a large clot in the leg, the leg may have pain and be swollen. The patient will have clear lungs and no fever or other symptoms of a lung infection. The classic monitor findings are low oximetry readings and a relatively rapid heart rate.

The patient will often have risk factors that create an increased risk for clotting. Some have a family predisposition for clotting, and they may report that as a concern. Smoking cigarettes is a common risk factor. Other predisposing factors are having cancer, congestive heart failure, strokes or recent surgery. Pregnancy, oral contraceptives and hormone therapy place more patients at risk. Any condition that results in a leg being left inactive will increase the chance that blood clots will form in the deep veins. These include leg surgeries, casts and sitting for a long time without exercising the legs (as on a long plane, train or car ride).

Testing for pulmonary embolism may involve blood tests, checking for blood clots in the leg, and scanning the chest to see if clots are obstructing blood flow into large areas of the lungs. These tests are not available to EMS, so only medical history and physical findings can be used in the prehospital setting.

James J. Augustine, MD, is an emergency physician and the director of clinical operations at EMP in Canton, OH. He serves on the clinical faculty in the Department of Emergency Medicine at Wright State University and as an EMS medical director for fire-based systems in Atlanta, GA; Naples, FL; and Dayton, OH. Contact him at jaugustine@emp.com.