r/ems • u/Speedogomer • 2d ago
Clinical Discussion Asthma OD, wtf moment.
Called for a 48 year old male asthma attack. We get there and the dude is on his bed, with his cat, very mild wheezing, joking about his very friendly "attack cat". In other words, mild distress. He's noy sure he even wants to go to the ER, as his uncle called 911 for him.
Vitals are fine, SpO2 93% room air, EKG fine. Said he's out of his inhaler, and his nebulizer wasn't working.
Give him a duoneb, after the neb he said he should probably still go to the ER because he wasn't 100% yet and he will need a doctor note to call off work.
We leave for 2 minutes to grab the stretcher, and come back to him diaphoretic, clutching his chest, screaming in pain, couldn't hold still for even a second. BP is now 240/120, HR like 140.
As he's screaming he can't breathe, he reaches between his legs and grabs another inhaler I hadn't even saw and takes 2 puffs before I can even see what's happening. I check and it's an epinephrine inhaler.
I ask how many puffs he took while we were getting the stretcher said he took 20 puffs... 2.5mg of epi total. He's screaming "I'm freaking out man".
Maybe just double check your asthma patients aren't trying to self medicate with epi before grabbing the stretcher.
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u/DocOndansetron EMT-B/In Doctor School 2d ago
These new vapes are getting crazy
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u/hungrygiraffe76 Paramedic 2d ago
I hear the triple berry blast epi is the new favorite
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u/-Blade_Runner- 2d ago
âGives you wings!â Or âMakes that blood pumping!â. I think first one already taken by someone⊠đ€š
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u/POLITISC 2d ago
My first in air medical emergency was a kid maybe 18 or 19 who was having an anxiety attack and his older brother thought it was asthma and just started blasting. His HR was ~170 and climbing by the time I saw him.
Turns out he got ultra drunk the night before, had been nonstop puking, had an anxiety attack, and now his brother was trying to stop his heart.
This was ~34kâ above the Gulf of Mexico and at some point the brother wanted to give him moreâŠ
** edit
IV fluids, Zofran, low flow o2, and some box breathing meant we didnât have to divert!
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u/feralbeekeeper 2d ago
They are selling epi inhalers otc now. Saw it in Walgreens the other day.
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u/EphemeralTwo 2d ago
They have been selling them for a long time. They were pulled for a bit after 2011 with the CFC ban.
https://pmc.ncbi.nlm.nih.gov/articles/PMC7051476/
It's been a fight with the medical community for a while, because for some people it's the only option they have access to, especially for situations like mine recently where I was traveling and had no inhaler. Got a call from the neighbors that the house was on fire (it was not), sprinted back home to rescue the cat, gave myself an Asthma attack.
I loved having access to it, and since my sister and I tend to be on the low blood pressure side of things (orthostatic hypotension), the whole "it's epi" thing is a plus, not a minus.
Asthma docs hate it, and argue that by having an OTC asthma medication, people will sometimes not use them, and may miss necessary medical care.
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u/11twofour 2d ago
I think that may be by state, because I know I used to buy them when I was in college around 08.
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u/D50 Reluctant âFireâ Medic 2d ago
Theyâve been selling em for decades!
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u/feralbeekeeper 2d ago
Oh wow I only saw it for the first time the other day, but I also never really looked for it so I out have missed it. Was with my friend who also works in healthcare and they were surprised to see it as well though
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u/FullCriticism9095 2d ago
Primatine Mist. Commercials for it used to run on TV all the time in the 1980s.
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u/Curious_Version4535 2d ago
I believe some stores keep them behind the counter in the pharmacy rather than on the shelf. It doesnât require a prescription, but you do have to ask for it.
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u/Typhoid_Mari 2d ago
Not EMS just really admire you all! Whatâs wrong with Epinephrine?
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u/asystolic_alcoholic 2d ago
Itâs very helpful when you need it. That inhaler can help with respiratory issues and anaphylaxis. Only problem is when you donât use it as directed, then itâs going to rocket your heart rate up and could cause cardiac issues because of it
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u/Atlas_Fortis Paramedic 2d ago
Technically nothing, but it will really Jack up your heart rate and blood pressure. It acts directly on the receptors in your heart that increases the rate and the ones in your blood vessels that make them smaller, so if you do what this guy did and have a aneurysm in a vessel you could theorically rupture it and cause a stroke.
Don't take stuff if you don't know how it works
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u/Ch33sus0405 2d ago
Basically the above situation can happen where people won't use it as directed and it'll be very, very bad. Anecdotally my sister also had an adverse reaction to one and went into severe respiratory distress, but I don't exactly know what the issue there was. Point is that they're not a replacement for a rescue inhaler if you're asthmatic.
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u/D50 Reluctant âFireâ Medic 2d ago
Iâm surprised that 2.5 mg of epi inhaled could do that. We used to give 5mg nebulized on a semi-regular basis, TO KIDS!
I know that MDI delivered medication has better absorption than a nebulizer, but still! Apparently itâs a LOT better absorption.
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u/Speedogomer 2d ago
I would guess a lot of the issue was the dose of epi just sent him into a full blown panic attack too. Not discounting that he could be having legitimate angina too, but a lot of it was him freaking out.
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u/FullCriticism9095 2d ago
Has he ever used an epi inhaler before? I havenât seen this in a long time, but back in the early 90s when these were more common I definitely used to come across patients who had either never used them or only used them sparingly before, who suddenly started taking a lot of hits when a more severe attack came on. People can definitely freak out when theyâre in the middle of an attack and get hit with a rush of tachycardia and some jitteriness from the epi, but as I say, itâs been a very long time since Iâve come across that.
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u/thingswastaken 2d ago
We do it pretty regularly in the ICU. Usually 2-3mg, but sometimes more. Never seen something like OP described here, but that doesn't mean it didn't happen.
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u/Ok_Buddy_9087 2d ago
When people canât figure out why an engine goes with the ambulance, wellâŠ. itâs because having 2 people on a scene sucks.
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u/Thegameforfun17 EMT-B 2d ago
I know where I used to live, fire was auto called for anything chest related. Could be that?
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u/FishSpanker42 CA/AZ EMT, mursing student 2d ago
what did you want fire to do here?
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u/WhoEatsThinOreos 2d ago
Probably not have the guy take 20 puffs of an epi inhaler? Just a guess.
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u/motram 2d ago
If all they are adding is "watch patient every second and not have them do something stupid", then I would say we should save time and money and not have them there. If it means some people that are literally too stupid to live die... that's okay.
We don't need a fireman to play nanny to a grown ass man.
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u/WhoEatsThinOreos 2d ago
I think you were taking my post a little too literally, lol. Also, idk what fire services you all work with that you hate fire so much.
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u/Paramedic237 2d ago edited 2d ago
Bear witness to the ubsurdity
EDIT I'm a moron who can't spell. Bare witness to the absurdity.
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u/SirIJustWorkHereLol A&O In the Negatives 2d ago
What kind of bear? Sun Bears are the best
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u/Kagedgoddess 2d ago
They could get the stretcher, then the patient wouldnt have been unsupervised.
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u/FullCriticism9095 2d ago
One thing I can say with certainty is that I definitely would not want fire at this scene.
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u/Ok_Buddy_9087 2d ago
The scene was fine until the patient was left alone. Wouldnât have happened where I am. Engine guys set up for however weâre getting the patient out while I assess and my partner takes vitals.
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u/FullCriticism9095 2d ago
Where I am, Larry, Curly and Moe would show up on an engine, push everyone out of the way so they can do an assessment and take vitals that will be wrong and need to be redone, and then magically disappear when itâs time to move the patient.
In 25+ years working at 7 or 8 different services across 4 states (including 3 fire departments), and setting aside calls like MVAs and technical rescues, I can count on one hand the number of times an engine company has added any value to an EMS call.
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u/Ok_Buddy_9087 2d ago
Leaving the hyperbole aside, you clearly had some shitty fire departments. That obviously means every fire department is shitty. đ
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u/fireinthesky7 Tennessee - Paramedic/FF 2d ago
Either OP happens to have worked in the worst fire districts possible, or the other responders aren't the problem.
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u/Ok_Buddy_9087 2d ago
Sounds like a lot of private ambulance companies transporting for co-responding fire departments. The worst possible system.
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u/Shobbakhai Paramedic 2d ago edited 2d ago
There are some poor crews out there, but if itâs across 7-8 services and multiple states, you may want to check the mirror my man. Have contracted in several states, even the BFE untrained volly crews can be helpful if you control your scene and lead, like you are supposed to do.
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u/FullCriticism9095 2d ago edited 2d ago
No, youâre wrong. Engine crews have no added value on a routine EMS scene. If you think otherwise you are doing it wrong.
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u/fireinthesky7 Tennessee - Paramedic/FF 2d ago
I can count on one hand the number of times I've had truly negative experiences with any of the two paid and one volunteer FD that responds with us in my county. It's amazing what happens when you don't show up with a superiority complex, act like you like the job, and are willing to actually teach the other responders why cool things are cool.
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u/FullCriticism9095 2d ago
Positive experiences are not the same as adding value. I routinely have positive interactions with engine crews. That doesnât mean they add value at a routine EMS scene.
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u/Low-Patience159 23h ago
Fdny firemen: Provided any medical care on <2% of EMS calls. Defibbed a pt on 0.04% of EMS calls they went on, just 17 out of 281,000. It's a joke. Guliani gave them EMS bc they were going days, sometimes weeks wo a fire call so the purpose was to avoid ff layoffs (they had backed him). Read it and weep. https://cbcny.org/research/reviving-ems
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u/Music1626 2d ago
You donât need 2 people to go get a stretcher⊠one person is more than capable of getting the stretcher in 99% of cases. The rest of the world cope just fine with a 2 person response team.
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u/Speedogomer 2d ago
I think it's very different between a true rural setting with no such thing as sidewalks, and a suburban/urban setting where everything is level, smooth, and designed to be accessed easily.
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u/Music1626 2d ago
In true rural setting you can usually drive up the persons drive way to their house then drag the stretcher across their grass to the house. It usually doesnât take more than one person to do that. Where I work most of the country is rural. Most of the country are a single officer response with maybeeeee a volunteer driver to help them. We manage quite well without another 8 people helping on 99% of cases. On the very rare case that you need extra hands they will call for the help of other services but that only very occasionally.
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u/fireinthesky7 Tennessee - Paramedic/FF 2d ago
TIL the rest of the world doesn't have to get the stretcher up stairs, rickety-ass wood porches, or wheelchair ramps with approximately 700 turns, and that everyone lives on ground floors with concrete walkways.
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u/Music1626 2d ago
âŠ.in that case the second person would get a stair chair and park the stretcher where itâs safe? Still only requires a 2 person crew.
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u/Ok_Buddy_9087 2d ago
One for the stretcher, one for the stairchair. Iâm assessing, my partner takes vitals. By the time weâre done everyone is ready to move.
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u/beachmedic23 Mobile Intensive Care Paramedic 2d ago
Throw the stair chair on the cot and bring both with you when you walk up to the house. 100% of the time I'm going on a call I bring the cot to the door
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u/Music1626 2d ago
You donât really need to rush around that much in this case. The patient is stable and fine. 2 trips to the ambulance to get all your supplies is more than appropriate. The rest of the world copes just fine with only 2 people. And even if you do need to hurry you prioritise what needs to be done and your parter initiates treatment and by the time you have the bed ready and stair chair theyâve started treatment and your ready to move anyway.
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u/Ok_Buddy_9087 2d ago
âCopes just fine,â or just makes do because theyâre forced to?
Canât say Iâve ever been on a call with my current department and said âYou know what? I wish I had less equally-people who will do exactly what I ask them to doâ.
I do, however, recall vividly working at a different department where it was just the two of us, and how much slower everything went. Especially when the patient was beyond our capabilities and having to wait for more help, especially during the day when volunteer help is a maybe. Going mutual aid to another community where fire was there to help was a stark contrast.
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u/Katydid84 1d ago
I love my fire crews, they grab vitals if they get there first, start iv's, and anything else BLS. On arrests they almost always drop an igel and handle ventilation so we can focus on other stuff.
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u/SomaticCurrent CCP 2d ago
I have also run in to this phenomenon. Iâve had patients absolutely chiefing on those Epi inhalers because they cost significantly less than Albuterol ones apparently.
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u/EphemeralTwo 2d ago
Only when factoring the cost of doctors appointments or truly terrible insurance coupled with NDAs for pharmacists preventing you from telling them how truly terrible your insurance is.
Primatine Mist is $32.99 at Walgreens. Abuterol using GoodRX pricing is roughly $11.
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u/flamingodingo80 2d ago
I'm sure his lungs were clear after that, if you could hear them over his heart
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u/Who_Cares99 Sounding Guy 2d ago
I think the real lesson here is to continuously monitor your patients and bring the stretcher in with you the first time
Once I make patient contact, that patient is in the line of site of either myself or my partner barring some insane circumstance. They probably got freaked out BECAUSE you werenât there, panicked, gave themselves epi, got more panicked, etc
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u/DoYouNeedAnAmbulance 2d ago
I donât bring the stretcher with meâŠ.ever. I want to get a layout of the scene and scope out the patient before I start dragging a stretcher through snow and mud and up stairs, etc.
If you canât leave a completely stable grown adult in a room alone for 120 seconds without them taking TWENTY PUFFS of their damn inhaler, then maybe itâs lesson time for them. He probably wonât do that again, will he?
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u/pluck-the-bunny New York - Medic (retired) 2d ago
While I personally agree from a human perspective about personal responsibility âŠIâm sure that will go over real well in front of a jury
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u/DoYouNeedAnAmbulance 2d ago
If it was the patientâs personal medication, I donât see how they would win that one. They either had it prescribed, in which case the instructions are clearly spelled out for them, or they bought it OTC and the instructions are on the box.
Pt did not express any suicidal ideation so there was no indication they would attempt to hurt themselves. Pt was a grown adult without any developmental delays, fully capable of reading.
Iâm not sure if youâre talking criminal or civil - it would suck to have to hire a lawyer and juries are a crapshoot at best, but I think it wouldnât be impossible to prove the pt is a moron.
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u/pluck-the-bunny New York - Medic (retired) 2d ago
You are responsible for patient care from the point of patient contact until transfer of care.
Youâre not expected to smack the drugs out of their hand, but other than extenuating circumstances like a MCI or a safety issue, explaining why you left a patient under your care unattended is not a good place to be.
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u/DoYouNeedAnAmbulance 2d ago
Your actions. You are responsible for your actions and interventions.
Psych pt in belts on the cot, takes them off, gets up, and throws themself out the back door. Are you responsible for that?
You explain that you needed two people to get the stretcher in the residence, highlight your intervention and the stable nature at the time, and point out that the usage instructions are fully available for the pt to read - nothing will happen. They want to push it, fine. But nothing will come of it.
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u/Speedogomer 2d ago
Either you leave the patient alone for a few minutes while you get the stretcher into the scene, or you leave the patient alone for a few minutes after you make contact and done an evaluation. There isn't really any easy way out with only 2 people on the ambulance.
For me, I prefer seeing the patient 1st, and seeing what we need to get the patient out of the residence before bringing the stretcher inside.
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u/insertkarma2theleft 2d ago
... your partner can't just grab the stretcher? I run with just two of us on scene most times and I can't remember a time where we needed two to grab it. Not saying I can't imagine a scenario, just that it'd have to be something fairly unique
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u/Speedogomer 2d ago
There were a few steps, so 2 people made it easier. The patient was also 100% stable at the time. If it was an oh shit moment, she probably could have got the stretcher herself, albeit with some difficulty dragging it through the soggy yard.
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u/insertkarma2theleft 1d ago
Oh I totally see how that could go down. Pretty funny call in the end haha
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u/DoYouNeedAnAmbulance 2d ago
You can carry a stretcher up stairs by yourself? Damn. Is you the Hulk?
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u/DoYouNeedAnAmbulance 2d ago
You can carry a stretcher up stairs by yourself? Damn. Is you the Hulk?
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u/SnowyEclipse01 Paramagician/Clipped Wing FP-C/CCP-C/TN P-CC 2d ago
Anyone old enough to remember when OTC epinephrine inhalers were banned because they were killing asthmatics?
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u/FullCriticism9095 2d ago edited 2d ago
Itâs had safety issues since it was introduced in the 1980s, but the reason it was pulled from the market was because it had a CFC propellant. They reformulated it with a new propellant and reintroduced it and got it reapproved a few years later.
It was never really the inhaler itself that was killing asthmatics, it was the way it was being advertised as a sort of miracle treatment for an acute asthma attack. If anyone remembers the old commercials, they use to have a guy whoâs huffing and puffing and a stopwatch. Guy takes a hit from the inhaler, and 15 second later he can breathe free again. Then there was a voiceover that said something about how Primatine mist was the fastest and most powerful asthma relief known to man.
The biggest problems with it are (a) selling inhalers OTC leads to people self-medicating for a serious disease thatâs tricky to manage and that really should be under a physicianâs care, and (b) inhaled epinephrine doesnât really work very well for adult asthma attacks, especially as the only treatment someone uses, which many people were doing because of the TV ads.
They also used to sell Primatine tablets, which were just pure ephedrine. You can imagine what a patient would look like in the middle of an asthma attack whoâs taken 2 ephedrine tablets and 10-15 hits off an epi inhalerâŠ
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u/EphemeralTwo 2d ago
inhaled epinephrine doesnât really work very well for adult asthma attacks, especially as the only treatment someone uses, which many people were doing because of the TV ads.
It works a lot better than the alternative of "nothing" sometimes, especially when one's in a pinch without your regular inhaler.
They also used to sell Primatine tablets, which were just pure ephedrine.
Really miss those. I prefer them to pseudo, and they saved me in high school. I get migraines from congestion, and prior to my recent nasal surgery that fixed my deviated septum and reduced my turbinates, I couldn't breathe without it.
Add on asthma, and it wrecked me.
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u/FullCriticism9095 2d ago
I think thatâs really the argument in favor of keeping it on the market- when you donât have your albuterol inhaler and youâre having a mild attack, you should at least be able to get something to help over the counter instead of having to go to the emergency room.
I can see both sides of the argument. Even if doctors nominally say they understand how difficult and inconvenient it is to get medical care for chronic conditions with serious acute complications like asthma, the medical field has done stunningly little to address the problem. A trip to any doctorâs office is at least a 2 hour event these days, and a trip to the ER is generally at least a 4-6 hour event on a good day. Even getting a call-in prescription filled is going to take an hour or two. The process just takes too long, and you really should be able to just walk in and buy an OTC medication and have some relief in minutes.
On the other hand, asthma really is a complicated disease that needs monitoring and close following, especially at first, so itâs not great to give people the impression that they should manage it themselves.
The really ought to be a middle ground- like a class of OTC drugs that are not accessible to just anyone, but that people who are under a doctorâs care can have a standing order to just walk in and buy off the shelf without needing a specific script that a pharmacist needs to fill. Albuterol inhalers would seem like an appropriate medication for this category.
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u/EphemeralTwo 2d ago
I only have activity-induced asthma. I breathe fine over 99% of the time. I try to carry my inhaler for the other 1%, but it's so rare that it's common for me to not do so. It's also very common for my inhaler to be expired and/or non-functional, because I literally go years without using it sometimes.
My last one came from running to a house I was told on fire. I was thousands of miles from home, not planning on exercising. I have inhalers in my truck, in my house, in my travel trailer, in my go bag, but I was just visiting my sister, and we'd walked. If I'd been at home or work, I don't even think about it - we've got stuff in the ambulance, and it's a non-issue to treat me if I have legitimate medical need.
So, I ran to walgreens two minutes before they closed and bought one and it worked. My alternative was to go to the hospital, since it was the only thing open.
I have obamacare, and the plan I bought in Washington didn't cover anything in Vermont, nor did they have a network. I ditched them after that, but it would have cost me thousands, and the alternative was $33 and worked just fine.
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u/SnowyEclipse01 Paramagician/Clipped Wing FP-C/CCP-C/TN P-CC 2d ago
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u/EphemeralTwo 2d ago
I really don't, especially when it comes from effectively a trade union saying that they think that the public shouldn't be able to care for themselves, but should instead go through that particular trade.
Epi, at least in my case, is demonstrably effective. Not as much as other options, but I have relied on the existence of that very OTC inhaler when in distress.
Tylenol causes 56,000 ED visits per year, yet we keep it OTC. All medication has risks and benefits, and we allow users to possess medication that literally can and will kill them if abused, and sell it nearly everywhere.
For non-addictive things with a reasonable side effect profile, I err on the side of truth in labeling, and patient choice over barriers to care. I believe that OTC epi inhalers meet that threshold.
I say this even as I have a pretty terrible ulcer from Aspirin. I wouldn't ban it, though I would likely modify the allowable OTC formulation, as some other countries have done.
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u/SnowyEclipse01 Paramagician/Clipped Wing FP-C/CCP-C/TN P-CC 1d ago
Epinephrine inhaled is not as effective in acute asthma.as youâre claiming.
Everything else on this is a measure of just asking questions. JAQing off isnât an excuse to offer inferior medications to poor people.
Aspirin is an incredibly safe and effective drug for the side effect profile it has and the indications it has. OTC inhaled Epinephrine is an incredibly inferior drug that is ineffective for anything other than stridor or croup.
Itâs not âglorified trade unionsâ saying that, itâs literally every physician and professional research group associated with the treatment and management of asthma.
OTC epinephrine shouldnât even exist. If we really wanted to lower cost of those medicationâs we would offer OTC albuterol inhalers.
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u/EphemeralTwo 1d ago
Epinephrine inhaled is not as effective in acute asthma.as youâre claiming.
There's a degree of arrogance there in your comment. I never said it worked for everyone, and it is less effective than other options. When those options are available.
Itâs not âglorified trade unionsâ saying that, itâs literally every physician and professional research group associated with the treatment and management of asthma.
Doctors don't want patients having options that don't involve them. Ok.
OTC epinephrine shouldnât even exist.
Talk to me when we have another alternative available.
If we really wanted to lower cost of those medicationâs we would offer OTC albuterol inhalers.
So why are the trade groups fighting OTC epi, instead of lobbying for OTC albuteral?
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u/VanillaCreme96 1d ago
They still sell ephedrine tablets behind the pharmacy counter if you really need it. The brand name was Bronk-Aid. I bought some from the pharmacy a few years ago (around 2019-2021) for my âasthmaâ.
I actually bought it because I was really struggling to work and go to school with an undiagnosed sleep disorder that Iâd had since my teenage years. I finally got diagnosed with narcolepsy w/ cataplexy in 2021 (+ ADHD in 2022) so now I get the âgood stuffâ, but OTC ephedrine definitely helped me survive before my diagnosis.
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u/SomaticCurrent CCP 2d ago
I have also run in to this phenomenon. Iâve had patients absolutely chiefing on those Epi inhalers because they cost significantly less than Albuterol ones apparently.
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u/Lavendarschmavendar 2d ago
Not sure what level of provider you are but im curious to know what your treatment was after the epi inhalations. Im a medic student learning cardiology now so Iâm wondering if you gave something like metropolol to reduce the htn.Â
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u/Aviacks Size: 36fr 2d ago edited 2d ago
2.5mg of epi really isn't all that crazy. If you wanted to give regular epinephrine for inhalation then 5mg of 1mg/mL epinephrine in a neb is more or less the standard dosing. That's basically your easy alternative to racemic epi as most places these days don't bother carrying it.
Epi inhalers are actually OTC if I remember right, I've seen just a small handful of patients with them in the ED and I seem to remember them saying they literally got it at Walgreens without a script.
Epi has a plasma half life of like 5 minutes. Wait it out and they'll be alright. Treat the dysrhythmias, stick to something more selective to beta 2 receptors (albuterol), and don't be afraid if you see a lot of PVCs for a bit lol.
The htn is bad but giving a bunch of beta blockers, like metoprolol, to an asthmatic is a baaaad idea. Metoprolol has a half life of several hours, epi a matter of minutes.... then we end up blocking beta receptors rendering our beta agonists less effective, depending on the BB but that is the general rule.
If you want to get real wild and say they developed prinzmetal angina from the catecholamine rush then giving some nitro is reasonable, assuming you have chest pain and ECG changes. But otherwise just ride it out and keep them alive. Nothing is going to directly fix it, but yeah alpha blockers like phentolamine, labetalol, and nitrates would be the kitchen sink fix here in the short term. More so if you accidently gave a bunch of epi IV type situation though.
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u/cullywilliams Critical Care Flight Basic 2d ago
They are OTC yeah. Recently I did a RAS refresher in which I took 4 puffs of an epi inhaler (so 500mcg total) and continued presenting to show that it's not that scary. Then when you realize there's like 22.5mg/ml of racemic, things suddenly get a lot less scary giving epi via the lungs.
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u/gasparsgirl1017 2d ago
I was in line at my pharmacy getting my prescriptions filled and it was taking forever. There was a problem with the person in front of me getting prescribed a brand albuterol MDI and they couldn't afford it and no one could reach anyone to get it changed to a generic. This poor person was audibly wheezing, I was about to just ask for an alcohol prep pad and a new spacer and let the poor soul use mine, until the pharmacist took the patient to a rack next to the counter and showed them the Primatine Mist and said, "This is basically the same thing. Just use it like you would the inhaler the doctor gave you until you figure out what you want to do with this prescription." My fiancé and I at the same time audibly and loudly said, "WUT?" and knowing me as he does, he grabbed me by my waist with one arm and put his hand over my mouth with the other hand. This is a maneuver he has performed and mastered from when we were only EMS partners because he is a saint and I am probably going to catch a charge someday.
I got my prescriptions and as I was paying I asked the pharmacist if they could just tell me if my zip code and the person before me had the same zip code. Where we ran rescue at the time, our catchment area was one zip code and also included my address on my scripts (one of which was an MDI of Ventolin). When the pharmacist asked why I wanted to know, I told them it was because I didn't want to be surprised if I got a respiratory or drug induced cardiac call that night from the patient they just tried to kill with that totally inaccurate and dangerous advice. My fiancé just scooped me and my prescriptions up and said, "This is why I get to talk. You have to be nice to these people. How many times do we have to do this? We won't have jobs if you keep trying to prevent people's stupidity!" Fair.
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u/EphemeralTwo 2d ago
It's not the same, but the pharmacist may have been relying on the FTC approval. It's a "FDA-approved over-the-counter (OTC) asthma inhaler for temporary relief of mild, intermittent asthma symptoms in adults and children 12 years and older".
Speaking from experience, it's better than nothing and works decently for that purpose. The pharmacist should know better, and should have phrased it differently, but it's possible that's where he came from.
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u/Lavendarschmavendar 2d ago
My concern is the blood pressure and s/s. To me, this presents as an unstable patient and is something Iâd be treating w o2 for sure, but id consider giving metroplol if necessaryÂ
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u/Aviacks Size: 36fr 2d ago edited 2d ago
Added some more context in an edit. I would avoid metoprolol if you can, it can negatively impact the asthma you were trying to treat a minute ago and render your albuterol less effective. The other issue here is if their BP is sky high it's from the alpha agonism from the epi, not from the beta agonism. The heart rate will play somewhat of a factor but it will largely alpha causing severe vasoconstriction.
So a competitive alpha antagonist would be preferred, or labetalol for combined alpha & beta blocking. Alternatively if it's just BP you're treating then nitrates have a much shorter half life similar to epinephrine. If it's a sky high BP that's causing s/s that are that concerning then I'd give some IV or SL nitro once til the epi wears off. Oxygen is fine if he's suddenly hypoxic I suppose but that goes for everyone. Either way, it will last a matter of a couple minutes and then subside, so don't go overboard giving a bunch of metoprolol that will now last another 6 hours.
If metoprolol is all you have then I wouldn't bother unless he's having sustained dysrhythmias. Either way, there are studies out there on inhaled epinephrine and many of which are giving subjects 5mg without concerning side effects. It's unlikely the inhaler is going to kill this guy if you don't give a bunch of meds.
My only point is don't do something just for the sake of doing something. It is alright and sometimes preferred to let something play out and be prepared to intervene if/when it does go south for real.
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u/haloperidoughnut Paramedic 2d ago
They're unstable but transiently unstable, and it's not an inherent cardiac problem. S/S will wear off as the epi wears off. A HR of 140 is meh, tachy but not life threatening. BP is pretty high, but it's drug-induced and not an inherent cardiac problem. We don't want to start a cascade of meds trying to treat a number, and when treating cardiac stuff you have to look beyond the number and treat the root cause. This is kind of like if somebody did a shitload of meth and they're tachypneic, tachy, hypertensive, anxious, sweaty, climbing the walls. Their sympathetic nervous system is on fire, but because it's drug-induced, doing cardiac treatment isn't going to do anything because you're trying to treat a cause that isn't there.
In a lower comment OP describes how the patient was climbing the walls in the rig. Best bet for this patient is to give some IM benzos for sedation and monitor.
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u/Speedogomer 2d ago
I think quite a bit of the problem was a full blown panic attack the epi probably helped stoke the fires of. Once I took the inhaler from him, and set it on the bench seat, he literally snatched it back and desperately tried to take a few more puffs before I was able to take it away from him.
The dose of epi wasn't a heroic dose or anything, but it may have just tipped the scale enough to take our normal calm patient to a full blown panic. EKG didn't show much but the artifact from movement wasn't conclusive anyways. Like I said in another comment, most of it was coaching him to relax, breathe slower, and stay on the stretcher.
He's also has HTN, is a smoker, and the epi may have caused some angina, but that's a guess.
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u/AndreMauricePicard MD in MICU 2d ago edited 2d ago
My concern is the blood pressure and s/s.
Think of it like the old "Hypertensive Urgency or Crisis", what today would be called "Asymptomatic markedly elevated BPâ.
Most people during their life are going to have an episode of SBP higher than 200 and DBP 120, but very few of them would require emergency treatment. Even if acute end organ damage is present you don't want to be overly aggressive (besides certain specific situations).
Patients where end organ DAMAGE IS RULED OUT would be discharged from ED. If BP REMAINS within high values on discharge treatment goal would be the start of oral medical therapy, outpatient close follow up and gradual reduction over hours or days.
unstable patient
Probably not. This is a very specific scenario where high BP was caused by a drug and symptoms caused by the drug can be mixed with the symptoms of the high blood pressure. Patient should be monitored closely. But without any previous serious cardiac condition it would quickly (due the short half life) resolve itself and you wouldn't want to deal with the effects of a rushed out treatment. Probably a receiving ED would be pissed if so
But in general, high blood pressure alone doesn't probe an unstable patient.
treating w o2 for sure
Probably not harmful. But not needed. No evidence behind that.
but id consider giving metroplol if necessaryÂ
So far it doesn't look necessary and it can harm (interference with bronchodilators drugs, and aggressive BP lowering isn't indicated). You shouldn't treat a high BP or a low oxygen saturation... You should treat a patient.
Sorry about the wall of text but tried to explain the clinical reasoning because you are studying. Hope it helps :)
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u/Speedogomer 2d ago
Our treatment was just attempting a 12 lead, but he couldn't sit still at all, and attempting an IV that he pulled out from flailing his arms. The vast majority of our treatment was trying to keep him from climbing out of the rear doors.
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u/haloperidoughnut Paramedic 2d ago
Did you consider a benzo for sedation? Just curious about what i would do in this situation.
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u/Speedogomer 2d ago
No, I only do benzos when I'm not working, but I might pop a few of my wife's Xanax when I get home to relax.
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u/SocialWinker MN Paramedic 2d ago
Honestly, epi is so short acting, I doubt youâd really worry about treating the HTN. The epi will wear off basically as fast as any medication you can administer will work, short of dumping NTG in or something.
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u/usernametaken0602 2d ago
I believe metoprolol would or could cause the wheezing to get worse. Better off just riding the hypertension out unless he's showing other s/s
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u/beachmedic23 Mobile Intensive Care Paramedic 2d ago
This is why you never leave your patient alone once you make contact
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u/CriticalFolklore Australia-ACP/Canada- PCP 1d ago
I've heard people say this before, and it seems wild to me. If you've assessed your patient and made the decision they don't need critical interventions or 1:1 monitoring, then there's nothing wrong with stepping away from them provided it's reasonable in the circumstances. I don't see why it's so important to babysit them constantly in our care before ditching them to a waiting room at the hospital.
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u/jasilucy Paramedic 1d ago
Not quite related to asthma but went to a call out for a male with chest pain and known angina. He had 30 PUFFS of his GTN before we arrived which I really doubted until as we were assessing him he continued to be puffing on it as if it was a cigarette!!
Obviously we removed it but he had another stashed and as I went to go get the chair from the ambulance he sprayed it again as I was walking past him and it literally put me on my knees. I had to lie down in his doorway of his living room for 5 minutes feeling like I was going to pass out. The dude was absolutely fine, conscious and talking coherently as if this was just a normal day for him!
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u/SnowyEclipse01 Paramagician/Clipped Wing FP-C/CCP-C/TN P-CC 2d ago
Anyone old enough to remember when OTC epinephrine primatine inhalers were banned because they were killing asthmatics?
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u/EphemeralTwo 2d ago
No, and you aren't either. They were banned for CFCs.
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u/SnowyEclipse01 Paramagician/Clipped Wing FP-C/CCP-C/TN P-CC 2d ago
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u/EphemeralTwo 2d ago
Fair enough. I don't doubt they kiled asthmatics, it just wasn't the reason for the ban.
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u/Strawberry_Poptart Paramedic 2d ago
Jesus. What did you do? Do you guys have any beta blockers on your rig?
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u/twitchMAC17 EMT-B 2d ago
So no medical professional was with him while the stretcher was being retrieved?
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u/hungrygiraffe76 Paramedic 2d ago
If you think thatâs bad you should see what they do at the hospital. Stable patients left alone for minutes!!!
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u/twitchMAC17 EMT-B 2d ago
Sure, but how controlled are the two different environments?
I know in my county there's not really any defending leaving a patient by themselves in a prehospital setting.
I do, however, like those oranges you compared to the apples that were already here.
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u/boomsoon84 2d ago
Youâre saying in your county you canât defend leaving a grown adult alone for 1-2 minutes?
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u/hungrygiraffe76 Paramedic 2d ago
Come on man, what if the patient stabbed himself or committed tax fraud while OP was outside?? Donât want to be held liable for that
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u/Speedogomer 2d ago
So what would you have done in that situation, with only 2 people on our ambulance.
The cat was not able to help move the stretcher.
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u/twitchMAC17 EMT-B 2d ago
I can handle a Stryker without needing another person in most situations.
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u/Aviacks Size: 36fr 2d ago
You're right, on average the patients we're leaving alone in the hospital are much sicker. Do you think I'm staring at my intubated patient's every single second? Yet they still manage to live...
Patient's also do stupid shit in the hospital. That is their right, for better or worse I suppose.
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u/Speedogomer 2d ago
His cat was there, I shouldn't have trusted Tigger that much.
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u/hungrygiraffe76 Paramedic 2d ago
I guess he really was an attack cat. Definitely sabotaged your patient.
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u/Kath_DayKnight 2d ago
Tigger hides in the shadows with an epi inhaler, cats are known to do this. Can't trust em
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u/Juxtaposition19 2d ago
Good grief, is all I have to say to that. đ I sometimes wish I could just scroll through patientâs brains to understand their thought processesâŠ..