It has been a hot, dry weekend and your service has been fairly quiet, although the local fire department has been busy with various grass fires. You are contemplating how grass grows when the alarms go off. You are dispatched to an upscale area of town for a 36-year-old male having difficulty breathing.

On arrival you are met at the driveway to a large home by a 30-year-old female. She reports her husband is in the backyard having problems breathing. She reports he is an asthmatic but has not had any problems recently.

You find the patient sitting on the back deck. A lawn mower is shut off in the middle of the yard. From a distance the patient appears flushed and anxious. He is able to speak in two-word sentences only. He reports he has asthma which is sometimes aggravated by exercise, dust, pollen and stress. He states he and his family have recently relocated from out-of-province and just moved into this house. He says he was mowing the lawn when he suddenly felt constricted and went to use his Berotec inhaler. He was unable to find the inhaler and believes it might still be packed away somewhere. He considered going to a hospital on his own but is not familiar with the area and location of the hospital so he asked his wife to phone for an ambulance. The situation panicked him some­what and the condition worsened prior to your arrival. He reports he has never experienced an attack this severe and has been quite controlled over the past five years, with few episodes at all. He believes there may be a new grass or pollen in the area that has affected him. He denies any other pertinent past medical history or medications.

Primary survey reveals he is orientated and alert but able to speak in two-word sentences only. He is highly agitated and anxious. Pulses at the neck and wrist are strong, fast and regular. Audible wheezing is noted and auscultation reveals expiratory wheezing throughout all lobes with diminished air entry in the bases. There is accessory muscle use noted on inspiration and expiration. Breathing is fast and laboured. There are no signs of trauma on primary or secondary, no edema is noted.

Pulse	120 regular
Blood pressure	140/90
Respiration	33 laboured, wheezing throughout, diminished air entry in bases
Skin	warm, diaphoretic, flushed
Pulse Oximetry	96 per cent
Level of Consciousness	orientated, alert, anxious
E.C.G.

1. The tentative diagnosis for this patient is: A. anaphylaxis B. pulmonary edema C. congestive heart failure D. asthma E. B and D are correct   

2. At a BLS level, this patient should be considered: A. Load and Go B. Stay and Stabilize 

3. The patient’s prescription medication, Berotec, is considered a/an: A. anti-inflammatory B. steroid C. bronchodilator D. antipsychotic 

4. Signs and symptoms of an asthma attack include: A. wheezing B. crackles C. productive cough D. all of the above 

5. In contrast to extrinsic asthma, intrinsic asthma is commonly caused by: A. exercise B. a specific antigen-antibody reaction C. drug allergies D. all of the above 

6. Status asthmatics refer to bronchospasm relieved by standard treatment procedures. A. True B. False 

7. Chronic obstructive pulmonary disease includes conditions of: A. pulmonary edema B. pneumonia C. asthma D. A.R.D.S. E. all of the above   

8. The term ‘pink puffers’ most commonly refers to C.O.P.D. patients with predominant: A. bronchitis  B. emphysema 

9. Predisposing factors for the development of C.O.P.D. include: A. pollution B. inhaled toxins C. cigarette smoking D. all of the above    

10. When investigating past medical history, you should determine: A. how the condition is controlled B. how it has changed C. what happens to cause a change D. all of the above 

11. Environmental conditions that may trigger respiratory complaints include: A. toxic fumes B. changes in temperature C. smoke D. all of the above E. A and C only 

12. On a respiratory complaint call you should observe for: A. environmental conditions B. medications C. breathing aids D. all of the above 

13. A classic position for patients with respiratory complaints is: A. supine B. left lateral recumbent C. tripod D. standing 

14. Accessory muscle use may include the use of: A. intercostals B. diaphragm C. sternocleidomastoid D. all of the above E. A and C 

15. The E.C.G is: 

16. Bronchodilators useful in asthma attacks include: A. methyprednisolone B. Hydrocortisone C. ipratropium D. diphenhydramine E. all of the above 

17. The primary management goal of asthma in the prehospital setting is: A. decreasing venous return B. positive pressure ventilation C. correction of hypoxemia D. decreasing mucous production 

18. Events that may cause a respiratory condition to worsen include: A. stress B. exertion C. recent trauma D. all of the above E. A and B only 

19. Respiratory wheezes are: A. high pitched B. usually louder during expiration C. typical of constrictive pulmonary disease D. all of the above E. none of the above 

20. This patient’s vital signs are indicative of: A. compensatory shock B. non-compensatory shock 

21. The patient described in the scenario should initially be given: A. Salbutamol 2.5 to 5.0 mg in equal amounts NS per nebulizer B. magnesium sulfate 2 g in 10mL D5W C. methyprednisolone 125 to 250mg S.I.V.P. D. Aminophylline 6mg/kg 

22. Bronchodilators which may be used to reverse bronchoconstriction include: A. fenoterol B. Salbutamol C. ipratropium D. all of the above 

23. En route this patient deteriorates to a pulse less ventricular tachycardia. The first treatment protocol should be: A. cardioversion B. Salbutamol via ET tube C. defibrillation D. intubation 

24. A patient in status asthmaticus is at risk for the development of a pneumothorax due to air trapping and intense pressures. A. True B. False 

25. You can improve your response to respiratory distress calls by: A. consulting with local emergency physicians as to the appropriateness of various respiratory medications B. keeping documentation of known respiratory patients and their addresses C. working with local lung association and respiratory groups to provide education and resource material D. all of the above 

The answers to these questions are to industry standards and may not necessarily be correct according to local protocol.  If there is any discrepancy between these answers and local protocol, please follow the protocol for your area as set out by your Medical Director.

Heather MacKenzie-Carey is the Vice President of Turning Point Group Inc.— an Emergency Management consulting firm—and manages its Calgary office. Heather has nineteen years experience in the Health Care Industry as an emergency practitioner, educator, and consultant. Heather has worked in public, private, rural, urban, Mountain Park and multidisciplinary clinical settings. Heather has been an educator/facilitator for the Aberdeen Hospital, Jasper School District, and the Southern Alberta Institute of Technology.

Heather has graduated from Dalhousie University with a Degree in Health Education. She has a diploma in Paramedicine from the Northern Alberta Institute of Technology, and a Certificate of Social Work from the University of Waterloo. Heather is completing a Masters of Science in the Study of Risk, Crisis and Disaster Management from the University of Leichester.

Heather has been widely published in the areas of prehospital medicine, crisis communication, and emergency first aid. She publishes regular columns for Canadian Emergency News, has developed various guidebooks for Quick Books Publishing Ltd., and produced distance delivery curriculum for the Southern Alberta Institute of Technology.. She can be reached at geomac@cadvision.com or www.turningpointgroup.com.

Canadian Emergency News and the author of this quiz grant permission for readers to copy it for personal and departmental educational purposes. All other reproduction and re­publication without written consent is prohibited.

This Article is reprinted by permission from the author (Heather MacKenzie-Carey) and the Canadian Emergency News. It originally appeared in the June - July 1999 issue (volume 22, number 3).