An “Each Question May Be Your Last” Respiratory Assessment

I remember the first really bad respiratory patient I went on as an EMT about 12 years ago.  A 40-year-old employee at a Target store had has an asthma attack around midnight. She was in a tripod position, an inhaler was next to her, and her shoulders lifted up each time she took a shallow breath in.  I was partnered was a paramedic who was a true assessment master, and was amazed at how much information he was able to get out of this patient who was unable to speak.  We were in the warehouse, and it was a long walk to the truck.  He assembled a nebulizer, had her stand and pivot onto the stretcher, and started moving.  Then he started his assessment magic.  In a completely calm, deliberate, and monotone voice, he said the following:

I want you to nod your head yes or no.

She was never able to speak a word the whole time we were with her.

Have you ever been intubated for an attack before?

Yes. TOTWTYTR explained why this is bad a few weeks ago.

Was your attack this bad when you were intubated?

No. Good. This means we have some time to try to maker her better.

Do you have any heart problems?

No.  This makes her a good candidate for IM or SQ epi.  At the time that required an order from medical control, which required at least one precious hand to dial the phone.  One more example of the Permission Paradox.  That question also helps to rule out CHF, even though this was pretty clearly an asthma attack.

Did this come on all of a sudden?


Did you wait to call us?

Also yes.  Apparently her coworkers finally made her call.

Did your inhaler help at all?

No.  Not a good sign.  He told me to put a BVM together when we got to the truck, and to put it on the shelf next to the captain’s chair.  CPAP was not around for EMS yet.

Do you take steroids?


Are there any you can’t take?

No.  If there was time to start an IV, and if he didn’t have to start bagging, he could give her Solu-Medrol.  Of course at the time this also required permission from the doctor.

I took less than 30 seconds for my partner to get all of this information, and he got it all while we were wheeling her to the truck.  After the call he explained why he asked those questions in that order.  If she were to stop breathing in front of us, he said, what would we want to know the most?

He went on to say that you should treat every assessment that way, and review each assessment after. Achieving that level of critical thinking takes practice, and calls for the least sick patients are opportunities to prepare for the sick ones.

Because we only get one chance to get it right.



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