The whole way there I had pulmonary edema on the brain. Dispatch information wasn’t very alarming; “70s male, shortness of breath, coughing up blood.” But as soon as my boots hit the garage floor, that’s all I kept thinking. I’ve had three calls before with pulmonary edema – and two of those times it was the same patient. I’ve never been to this address, and despite nothing screaming clearly in the dispatch information, my gut says its pulmonary edema. 3am thoughts or gut instinct?

So the trip out to the country road consists of me, all the way awake in a way you understand if you’ve ever seen pulmonary edema – bonus points for the pucker factor that is flash pulmonary edema – I’m chattering. My partner is an EMT tonight and he’s still waking up. He bears with me though. I explain what we will need to do in a short period of time if it is pulmonary edema. He gets it, he’s a great partner and I know I can concentrate on what I need to do. Knowing he will do what needs to be done and he isn’t the sort of partner who requires a lot of hand holding and validation.

We arrive on scene, he puts it in park and I hop out the passenger side, round the side corner and spy a man approaching. He’s well dressed, fully dressed, and walking spryly. Coat neatly zipped up to the chin. Dapper hat atop his head. He looks like a retired cowboy, tan skin and western button up shirt. I ask if he’s the patient and he nods. I’m able to get the side door open and my patient is loading himself right up the steps before I can say much.  Climbing up after him, I catch my first auditory of my patient.

Pucker. Factor. Right there. Right now. Yep, we’re about to do medicine. I nod at my partner, and we go to work in the choreographed steps we worked out while the truck winked and blinked its red and blue strobes down this back road and across the corn still waiting to be harvested.

Sublingual nitro – check. CPAP – check. IV – check. Nitro drip – check. Furosemide – check.

My patient is working to breathe, and working hard. The telltale wet sounds of crackles and rales are screaming the alarm for me, for anyone, to notice this man is attempting to exchange gasses at the alveolar level through liquid. Sternomastoids, scalenes, and intercostals – they’re all desperately doing their level best to move air in and out. The air is going in and out. The problem is that the air can’t pass into the blood through all the liquid filling the lung fields. He’s breathing fast, tachypnic, and blood pressure is high. His body is trying to compensate and from the looks of things, it has been for a while. There is no pink frothy sputum, and while acute, I’m not sure this presentation paints a picture of sudden, flash pulmonary edema.

Transport begins. We’re maybe eleven minutes out and we need to be at the ER yesterday. He needs a tube, but out here on this pitch dark country road I’m the only paramedic in the county. State law states intubation is a dual medic skill and so we get to work. We’re making the pavement disappear between us and the ER with all of its equipment and people. I’ve always been one of those medics who is not fond of transporting emergent, and I do so seldom. Given the amount of medications and procedures we can perform in the patient compartment of our trucks, the due regard we need to demonstrate in driving, the aggressive protocols under which we operate, we are able to enjoy the ability to do many of the things on scene that the ER would do. There is not often a need to endanger ourselves, our patients, or the general public with the heightened level of adrenaline that comes with lights and sirens. Not to mention the effect on my patient, quite often the heart rate and blood pressure increase if we need to use the sirens and lights. Evidence-based practice is what we have learned, and we have learned to take the time to manage our patients before and during transport, driving non-emergent towards definitive care rather than just throwing them in the truck and “apply diesel therapy” as we used to say.

But when my partner asks me if I want him to transport emergent, I consider it, then say yes if there happens to be any traffic, use the lights and sirens to move them, then just lights. It is the wee hours of the morning in this farming community and there is no need to awaken every coon hound between here and the ER.

My patient seems determined to ask me questions and speak beneath the CPAP mask. It’s not as loud as the model we used to have, but it’s loud enough that I can’t hear him. PEEP is between 5 and 8 mmHg, the nitro is blurping along and the Lasix should be starting to kick in. His SpO2 shows oxygenation in the gutter though, and falling. He’s tiring out. I lean forward and speak quietly in his ear. I always do this and it seems to help them in their soundless mask, to feel less alone. I start with the basics; is he having pain, does he understand what is happening, has this been going on for more than a little while? He denies pain, indicates understanding and answers in the affirmative that this has been going on longer than a bit. Yes’s and no’s get me worked around to, he’s been up most of the night, he thought it would get better, he used inhalers, and he’s had this before. Then the big question I have to ask, has he been intubated before? He nods. I ask him, in the hospital? And he shakes his head, points to my gold patch. “By EMS?” I ask. He nods again, eyelids closing. He’s so tired, still hypertensive, still tachypnic. I keep speaking, verbally coaching him to remain awake. We cover that he is a former smoker, lots of years. He lives alone. It must’ve been a long night before 0300.

I wonder if he wonders at my inactivity after the flurry when he first got in the truck. I explain to him what the nitro under the tongue – and now in the IV – is doing to help his breathing by reducing the workload on his heart. I tell him about the injection of Lasix, and its role in pulmonary edema management to begin to move the excess fluid out of the lungs. I promise him that the CPAP mask is helping push the fluid out, too, with positive pressure. He nods weak thumbs up. SpO2 is 74%. I give radio report. 71%. This is killing me. He needs a tube.

ER. Bright lights. People. So much help, now. Handoff report at bedside. Remain and watch the C-MAC and Bougie make short work of the tube placement. Confirmation, tube is good. X-ray comes, lab. RT. I get a facility acceptance signature, accept the face sheet registration hands me. Walk out to my truck.

There’s his hat and coat. Can clothing look forlorn? These did. Take them back inside.

Hours go by. Flight team comes for him; he’s not hypertensive anymore now that the respiratory drive isn’t so desperately triggered. The ventilator is sedately moving air in and out of lungs that are much more baseline. RT tells me “his lungs were full”. I nod. Guess this nursing student does still have a medic’s gut instinct.

Shortly after, I watch the EC145 spool up. The horizon is ever so faintly light, and somewhere over my head now, the hat and coat are dutifully following their owner.

I wonder how many people would’ve put down their last cigarette and never picked up another – if they could’ve seen him, valiantly moving air in and out – and essentially drowning in front of me. I wonder what he would tell them, if he could.