Running on Empty

   Attack One responds at 4 a.m. for a woman with difficulty breathing. They find a 52-year-old lady in moderate respiratory distress, alone in the kitchen of her apartment. She reports the shortness of breath came on during the warm evening hours, and she found no relief using her nebulizer treatment over the last hour. She denies chest pain, fever, productive cough, nausea or swelling in her extremities. She has a history of "heart and lung problems" but can't provide much more detail about either. She is too short of breath for lengthy conversation about her medical problems.

   The patient has a tight chest and a lot of wheezing on initial evaluation. The crew asks her if she'd be willing to repeat a nebulizer treatment in an attempt to relieve her wheezing, even though she reports having one about an hour ago. She agrees, and they fill the nebulizer cup with albuterol and ipratropium and turn on the oxygen to power the system. As they complete her assessment, she reports feeling better and can reply to some medical questions.

   The crew asks about her specific heart and lung problems, and she says she had lung cancer and an irregular heartbeat, as well as COPD and asthma. She knows she was under treatment for diabetes also. She says she doesn't have a list of her medicines and doesn't know what her allergies are. "Where are your medicines?" a crew member asks, wanting to collect them to take with her to the hospital.

   "There are some in the kitchen, some in the bathroom and some in my sitting area where my machine is," she replies, referring to her nebulizer.

   The EMT sets out to collect them and place them in a bag. As he finds them, he reports them to the paramedic to compile a list on the run report. There are bottles everywhere, with various pharmacy names and physicians who had prescribed them. The paramedic finds a number of medicines close to the nebulizer and adds them to the bag. As she collects these medicine bottles, she notes the inhalers are old and, shaking them, finds them empty.

   "Where are your new inhalers?" she asks the patient. "And where is the medicine you add to your nebulizer to help you breathe?" The paramedic had only found small nebulizer containers of saline, and no small containers of albulterol or similar medications.

   The patient replies: "Those are all my breathing medicines. I just don't understand why they don't work!"

   The patient is in the kitchen completing her nebulizer treatment, and the paramedic with her contemplates that second sentence.

   "Ma'am," that medic asks, "can we ask you to walk out to the sitting area with us to show us your medicines? We don't want to miss anything. We will carry the nebulizer out there so you can continue your treatment."

   The patient walks out and sits down. She looks at each of the inhalers and confirms those are her breathing medicines, which she uses two or three times a day by spraying them in her mouth the way her doctor showed her to. The normal saline packet, she says, is the medicine she uses three or four times a day in her nebulizer.

   The paramedics look at each other in simultaneous recognition. The female medic speaks first: "Ma'am, we are going to take you to the hospital so the staff there can treat you. We'll ask them to help you understand your medicines and how to use them better. Right now all the inhalers you're using are empty, and your nebulizer doesn't have the active medicine in it. That's why they aren't helping."

   The patient still doesn't seem to understand, and the paramedic tries a couple more times, using different terms, to explain the problem. Still not getting through, she decides they'll take in all the medicines they found in the house, as well as the nebulizer, and ask hospital staff to explain the use of all the medicines once the patient is feeling completely better.

   As the paramedic logs the medicines, she recognizes some of the names but not others. But she sees a pattern: There are medicines from many different hospitals and pharmacies, under different physician names. She also recognizes that some medicines she usually finds in similar situations are not in this patient's bag.

   "Ma'am, your heart rhythm is one where they usually put you on a blood thinner, and I don't see one," she says. "You also said you are a diabetic, but I don't see any medicine or insulin. Do you have those medicines somewhere else?"

   The patient says she keeps those medicines in the refrigerator, and forgot to tell the crew to find them there. The refrigerator contains insulin, Coumadin and a bottle of narcotic cough medicine.

Transport and Emergency Department

   By arrival at the hospital and completion of the nebulizer treatment, the patient is much improved, her wheezes almost completely cleared. She is able to introduce herself to the emergency department staff using full sentences.

   The crew gives its report and delivers the bag of medications. The medicines the patient needed to treat her lung problems were all empty, and she was using saline in place of whatever was supposed to be in the nebulizer. When the patient received the albuterol and ipratropium from the EMS crew, she improved immediately.

   The ED staff is grateful for the diligent work. The physician reports they see this patient at least once a week, sometimes day after day, and each time she reports she has all her needed medications at home. Her official medication list doesn't contain many of the medicines the crew found at the house.

   The patient responds quickly, and no major problems are found on her workup in the ED. But she is admitted to the hospital in stable condition to allow the inpatient staff to educate her on proper storage and use of all of her medicines, and to have a visiting nurse program set up to assist her on an ongoing basis.

Case Discussion

   The crew here looked beyond the obvious treatment needed by this patient to identify the real problem. More patients are at home these days, on more medications (and other treatments). There are many reasons why a patient may not be able to store, use and account for all the medicines and treatments prescribed for them. It is also impossible for EMS providers to remember all the different names and types of medicines, and how they are stored and administered.

   For assistance, some EMS and ED providers utilize software programs on their PDAs, some of which even look for potential interactions between medications. At a minimum, these programs identify correct spellings, common uses and major potential side effects.

   With many thousands of medicines on the market, each with at least two names (generic and brand), EMTs are well served to remember common medicines surrounding (what else?) the ABCDs: airway, breathing, circulation and disability.

   Airway and breathing medicines are commonly administered by inhalers or nebulizers. Many patients now use steroid medicines to provide long-term relief for their diseases, and steroids are important to recognize. These medications have important effects and some powerful side effects; patients using them regularly can have trouble with higher blood sugars, increased risk of infection and gastrointestinal bleeds. Steroids are important medicines, and have names like prednisone, dexamethasone and methylprednisolone.

   Circulatory medicines include medicines for blood thinning, blood pressure and heart rhythm control. These medicines all have critical implications for EMS, especially with patients on blood thinners. Many older patients are on some form of blood thinner; seek that in the history. Millions of people are on medicines to reduce blood pressure, and many classes of medicines are used to support heart function. Beta blocking medicines (like metoprolol, atenolol and propranolol) are important for emergency care because they reduce the ability for the patient's heart rate to respond to trauma, stress or blood loss.

   Disability refers to neurologic function. The medicines most importantly related to change in mental status are seizure medicines, blood sugar control medications, and all forms of sedatives. Seizure medicines have a wide variety of names and side effects. Insulins have powerful short-term blood sugar-lowering effects. Many patients now use pumps to administer insulin; look for those in the diabetic patient who is unresponsive. Blood sugar medications that are taken orally have effects that last for hours or days, and an unconscious patient with a low blood sugar who is taking those medicines needs hours of sugar therapy to stabilize their condition. Sedative medications are critically important to recognize in patients with unaffected loss of consciousness.

   A full discussion of important medicines for EMS providers is beyond the scope of this article but is valuable in ongoing training. Software for recognizing medications is worthwhile in the field.

   The EMS crew in this case also played a critical role in patient care following some excellent practices for a process called medication reconciliation. These practices are:

• Looking for a list of medicines on or near the patient.
• Bagging up all medicines found on or near the patient, and bringing the bag to the emergency department.
• Looking for empty containers and identifying expired medicines around the domicile.
• When children are present, recognizing unsafe medication-storage practices and teaching the adults about safe storage.
• When medicines from many persons are stored together in one place, recognizing the potential that accidental misuse may occur. If there are concerns about that, ask the patient or family to bring everything to the hospital, so the staff can figure out if a patient may have accidentally taken the wrong medicine and had an effect from it.
• Sharing any observations or inconsistencies in medication history with the ED staff.

Initial Assessment

A 52-year-old female with shortness of breath.

   Airway: Intact and uncompromised.

   Breathing: Moderate distress, can speak a few words but not full sentences.

   Circulation: Patient is warm, normal capillary refill, pink skin.

   Disability: No neurologic deficits.

   Exposure of Other Major Problems: No relief with home nebulizer treatment.

Vital Signs

AMPLE Assessment

   Allergies: "I just don't know."

   Medications: A large number of medicines that are ingested, inhaled and utilized by nebulizer. The patient initially didn't remember she was on a blood thinner (Coumadin) and insulin.

   Past Medical History: The patient has a history of respiratory and cardiac problems but knows few details.

   Last Intake: Dinner at 7 p.m.

   Event: Difficulty breathing.

Learning Point: EMS providers must recognize important medications and participate in a process called medication reconciliation to improve patient health and safety.

Customer Service Opportunity: There are great opportunities to improve patient care by finding medication issues in the patient's domicile. EMTs and paramedics are essentially the only healthcare providers who routinely enter the homes of the sickest people in their communities. Some patients have visiting nursing services that track medicines, but others responsible for patient care, including physicians, do not have the opportunity to see the insides of homes, collect patients' medications and see how they are tracked and used. Hospitals are now routinely held accountable for patients' medication reconciliation, but the nurses and physicians have only reports from patients and their families about what medicines are used outside the hospital. EMTs perform a great service when they collect medicines from the home, put them in a container and bring them to the hospital with the patient. In this case, actually observing the patient utilizing the medication was the critical element of identifying a problem and ultimately serving the patient, her physician and emergency department staff who couldn't figure out why she was such a frequent visitor.

James J. Augustine, MD, FACEP, is medical advisor for Washington Township Fire Department in the Dayton, OH, area. He is director of clinical operations at EMP Management in Canton, OH, and a clinical associate professor in the Department of Emergency Medicine at Wright State University in Dayton. Contact him at jaugustine@emp.com.