Case summary:

An ALS crew responded to a 50s woman with a history of chronic obstructive pulmonary disease (COPD) and congestive heart failure who called for shortness of breath.  Crew found the patient to be alert and oriented but also very anxious and in respiratory distress.  Her symptoms had progressed throughout the day and when they listened to her lungs, she was diminished everywhere.  The crew gave her breathing treatments and oxygen as well as tried to put her on a continuous positive airway pressure (CPAP) device.  Initial vitals were:

Vitals: BP 202/98,  HR 104  RR 26,  Sat 78% on home 3L, ETCO2 55 mmHg

Patient was in such distress from her respiratory failure, that she continuously pulled off the mask and was not allowing the crew to render lifesaving care.  The crew called medical control to get permission to give intramuscular midazolam to sedate the patient enough to allow for ongoing care.  This indication for midazolam was outside their protocol and the medical control physician gave them the order to use the medication in this way.  A couple minutes after administration, the patient started to relax and tolerated all the treatments that was provided which included CPAP, IV placement, magnesium sulfate, and steroids.  When they re-assessed the patient in route, they noted rales bilaterally, so they also administered sublingual nitroglycerin for presumed flash pulmonary edema.  Repeat vitals just prior to arrival at the referring hospital were:

Vitals: BP 168/77,  HR 103  RR 18,  Sat 96%, ETCO2 38 mmHg

Highlights of the case:

Involve medical control when patients have needs that exceed the protocol.

Protocols provide standing orders that help EMS providers render care for the vast majority of patient encounters.  However, there are situations where patients do not fit the usual mold established by the protocols.  This might be that the patient has multiple disease processes that are simultaneously causing the acute problem, or it might be that the patient has a severe presentation of a disease process.  In either case, patients might need treatments that the protocol does not allow for.  When these situations are identified, we should not simply follow the protocol if we know the protocol is not meeting the need of the patient.  We also cannot deviate from the protocol on our own.  In these situations, we need to involve online medical control to get the order to provide treatments that are outside the protocol.  Once you have online medical control on the phone, EMS responders can do anything provided it is within his/her scope of practice and they have the online order to do so.  In the case of this patient, she was agitated due to her profound respiratory failure, and she was not tolerating the care she needed to improve her respiratory failure due to her agitation.  She was not so agitated that she was preventing transport or posing a danger to the crew.  This created a catch-22.  The crew identified this right away and called medical control to discuss using midazolam to provide just enough sedation to allow her to accept the care she needed, but not too much that it caused respiratory arrest.  They got the order for this treatment, and this allowed the crew to provide aggressive treatment for both flash pulmonary edema as well as COPD exacerbation.  The net result of all of this was that they brought a patient back from the brink of respiratory arrest and spared her the need for intubation.