Hypoventilation not Hyperventilation

We were called for an OD, unconcious, but when we got there we found a 32-year-old extensively tattooed woman standing, looking slightly dazed, saying she was having trouble breathing and just needed an inhaler. I listened to her lungs (in the lower lobes) and they were clear, which I announced to the assembled room of five firefighters, my partner, two cops, and three bystanders. Then with the next breath, she coughed and sounded very rhoncorus to the naked ear. "She doesn't sound clear," one of the bystanders said like I was an idiot. "She's talking fine," I said, "using complete sentences." Then I asked the patient what hospital she wanted to go to. She said she didn't want to go, she just wanted a treatment. I said, we don't do home treatments, if she was having trouble breathing we needed to take her to the hospital. Now in the meantime, I am hearing one of the bystanders explain to my partner that someone had found her unresponsive in the bathroom with blood all over the floor and walls that she either vomited or coughed up. I looked in the bathroom, only to see a woman just finishing cleaning it all up. The patient still just wanted a treament, but with the help of the cops, we insited she go with us. I helped her walk down one flight of narrow stairs down to where we had the strethcer. She wanted to walk to the ambulance -- at the same time she was begging with me to give her a treatment. We had her lay on the stretcher and I set the back up straight. Out in the ambulance, I put her on the pulse ox, and while her fingers were cold -- it was a wet, raw day, the pulse ox read less than 50, and then got up to 70. She was really sort of panicking now, and I listened again to her lungs - this time to the upper lobes and oh, my -- they were coarse and rhonocous and nasty. I put her on the capnography thinking that I would see low numbers, and this is what I had. ETCO2 - 70!

She got more and more panicky as I gave her a treatment by mask and had my partner drive lights and sirens the three blocks to the hospital, where we raced her in. The triage nurse and the other crew waiting in line looked at me maybe like I was crazy as I insisted we cut in front and that my patient was in true distress and not just your typical anxiety attack. I had to explain about the capnography -- why she wasn't hyperventilating and how I though maybe she has aspirated. They sent us down to a priority room, where I got the same looks and had to again explain that this wasn't what it first looked like. The doctor listened to her lungs -- lower lobes -- while a nurse coaxed her to slow her breathing down, and I had to have them listen to the upper lobes and show them they she was in fact hypoventiliating.

It didn't take them long to understand and see she was hypoxic. She then coughed up some blood and then admitted she had done two bags of heroin. I will try to check back to find out the final story, but the respiratory therapist agreed he thought she probably had aspirated.

The bottom line for me was while I was at first poo-pooing her complaint -- she appeared after all the typical junkie whiny borderline asthmatic anxiety type with a chest cold, the capnography slapped me in the face to what maybe I should have been seeing all along. It screamed out -- she is having a big problem!

I gave her a treament, which didn't seem to help her too much, although her ETCO2 number did come down into the high 50s. Her respiratory rate also picked up, which may have driven the number down some.

Just why the number was elevated, there are a number of possibilities. She had possibly been apneic before being found, her tachycardia -- 136 -- increased cardiac output drove the C02 number up, the aspiration tired her and limited air movement.


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