Pulmonary embolisms and the danger of assumptions
When we were dispatched for a woman who was having a panic attack, we never thought it would end up as a pulmonary embolism. We pulled up to a Burger King, and there was a very large woman. She was panicked and very dramatic. It was very frustrating because we couldn’t get information from her. She was screaming, throwing her hands up, and rummaging through her car. Nothing appeared to be wrong, other than her state of mind.
When we were dispatched for a woman who was having a panic attack, we never thought it would end up as a pulmonary embolism. We pulled up to a Burger King, and there was a very large woman. She was panicked and very dramatic. It was very frustrating because we couldn’t get information from her. She was screaming, throwing her hands up, and rummaging through her car. Nothing appeared to be wrong, other than her state of mind.
My partner and I pegged this as a likely anxiety attack. We finally decided to get her onto a stretcher. She kept jumping up off the stretcher. Based on our assumption that she was having a panic attack, we strapped her down in order to check her vitals.
She was normotensive. Her oxygen saturation was 98, her blood pressure was normal, and her pulse rate was elevated, but this was expected, given her state of anxiety. When we asked if she had a history of anxiety attacks, she responded that she did. For all of these reasons, we assumed this was another anxiety episode. We chalked it up as a psych issue. Medically, everything seemed fine.
She kept unfastening the top strap and leaning up. One thing was clear, she did not want to be prone on the stretcher. At the time, I didn’t consider this to be an indication of tripoding, mainly due to her oxygen saturation. Her vitals checked out. We were sure she was having some sort of psychological episode and decided to get her to the ER as quickly as possible, for her own safety. My partner is the lead medic. I’m the driver. He says, “let’s go lights and sirens” – because of the way she’s acting. He’s calling the hospital and saying we might need security. We’re having trouble keeping her on the stretcher. She’s panicked.
Her vitals were stable. She did not complain of chest or back pain, or any trouble breathing. Her manic gestures and behavior, taken together with her confirming she had a history of anxiety attacks, confirmed our assumption that this was a psych issue.
On the way, I hear my partner shout, “She’s unresponsive.”
We hit the front doors – all of a sudden she’s not breathing – and we hit the second set of double doors, and she doesn’t have a pulse. Now I’m in the ER, in the triage room, and the doctors ask what is going on, and I have to tell them I have no idea, but she’s dead. It turns out that she had a PE, a pulmonary embolism.
What is a pulmonary embolism?
Pulmonary embolism is something that’s poorly understood in EMS. Sometimes as EMS providers we get caught up with strokes and heart attacks. Because the lungs bring in oxygen, it’s easy to forget that the lungs also need perfusion. The challenge with pulmonary embolism is that the lung tissue is dying and impacting its capacity to bring in more oxygen and perfuse everything else. PE is a very critical emergency.
An embolism is any foreign object in the circulation that lodges in a vessel and stops blood flow. When a blood clot, a thrombus, breaks off and starts traveling and gets lodged somewhere, it becomes an embolism. If an embolism lodges in the lungs, it is a pulmonary embolism.
All of a sudden the lung tissue itself is no longer getting oxygen. It sounds a lot like a heart attack, in that we have a vessel that’s blocked off, we have ischemia of tissue, and eventually death of tissue.
DVT stands for deep vein thrombosis, a deep vein blood clot. DVT is a common cause of pulmonary embolism. Another common cause of embolism is the breaking off of plaques. We develop plaque in our vessels from cholesterol buildup. Pieces of those plaques can break off and become emboli.
Noticing signs and symptoms of pulmonary embolism
One of the most obvious signs of PE is rapid breathing. The body is not getting enough oxygen. Low O2 saturation is a clear sign that there is a problem. Be aware that pulse monitors can show lag readings. So, it is important to monitor oxygen saturation throughout the assessment. This includes acquiring personal data and history as well as reading all possible symptoms. Respiratory rate increases in an attempt to get more oxygen into the body. Of course, the lung is blocked and perfusion is compromised.
The ischemia of lung tissue can be felt as acute pain in the chest and back. It mirrors chest and back pain typical of a heart attack. Another major sign is tachycardia or increased heart rate. When the body is trying to compensate because they’re not getting lung oxygen the heart rate will go up. Panic attacks may also cause tachycardia. It is therefore very important to collect a full spectrum of data to confirm your assessment in the field. Just assuming an anxiety attack or some other condition can lead to a tragic outcome, as illustrated in the unusual call.
One example of how assumptions can lead to incorrect assessment is the incident of the patient constantly leaning up from the gurney. She could not remain prone. At the time, tripoding was not considered because her oxygen saturation was 98, and there were no complaints of pain or any of the other signs. Tachycardia was assumed to be due to the panic and nothing else.
So, what is tripoding? If a person is bending over with their hands on their knees and trying to breathe, this can be a sign of a serious problem.
The combination of stress and loss of perfusion can lead to panic. Anxiety attacks can mirror some of the symptoms typical of heart attack and PE. This is why it is so important to perform a diligent assessment before making assumptions which could lead to missing or dismissing potential critical clues. It is important to provide the emergency department with a complete picture, so the doctors can make their own assessments about emergency treatment.
Treating potential pulmonary embolisms in the field
Breathing can be regulated by coaching or with a bag valve mask (BVM) if the person is breathing too fast or too slow.
We can also give oxygen. In the case of PE, that oxygen is going into a lung with an embolism, and we can’t do anything about that clot until we arrive at the ER. There’s no medication that we can give in the field safely that’s gonna bust a clot or take care of an embolus.
In the hospital, there are medicines that we can give to break up the clot. In the field, we can assess the situation. It is so important that we gather as much information and history as possible, make an assessment and relay this back to the emergency department.
As we have seen, PE can be tricky to assess. The symptoms of a panic attack may put us off the mark. This is why we must do our best to take every patient seriously and consider every possibility. Our job is to do a good assessment and present the doctors with that information. They make the decisions from there.
Whether you are EMS or a family member, providing as much detail as possible to doctors will ensure the best possible outcome. Medicine is an art as much as it is a science. We all need to work together from the patient, to the doctor, to EMS, to the nurse – everybody needs to be working together for the common good of the patient.
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