using a bvm on a conscious pt.?

[medic_texas]

I think you dropped the ball on the patient and you deserved to be yelled at, I would have. Not only was his respiratory rate fast he had diffuse crackles, history of CHF with weeping pedal edema. What did his feet look like? A GCS of 5 and you only place a NRB on the guy? He was gurgling while laying supine and stopped when you sat him up? What does this tell you?

What is your first s/s of poor oxygenation? How do you correct it? What is your respiratory distress protocol? What is your airway assistance protocol? Gag reflex? ALS backup? Did the NRB bring his GCS up? How can you be "alert" and have a GCS of 5?

I would have bagged him (if I was a basic); it's hard to time it when they are taking a breath but it's possible.

[AZCEP]

This EMT did not drop the ball near as badly as the system that they work in did by not having an ALS provider available for a patient that desperately needed one.

Even the advice that was given by others in his system has been questionable. Ventilate someone at 28 bpm? Are they serious? What exactly are they trying to achieve with this?

Sometimes, a patient will survive in spite of your best efforts. Given the short transport time, the RN should take the time to educate you instead of deriding you for your system's failure.

[SWM_Medic]

I have assisted ventilations on plenty of CHF patients alot like the one we are talking about. It helps. And to horrify some people in this forum I have done a nasal intubation on a pt like this. In all honesty mine was a little father along and resp rate was slowing. But the point is don't be afraid to do your job. If a patient is not getting good tidal volume because their inspiration time is insufficient. Then help them every couple of breaths. Yes I know they are filling up with fluid. I say bag'em. It's scary the first time, but you get over it when you see pt improvement.

[VentMedic]

bullfrog09,

At what point did your pt go from being alert to a GCS of 5?

[medic_texas]

Regardless of the system, short transport time, and his lack of knowledge/training, he failed to act aggressively and appropriately for this patient.

Let me clear this up, I'm all about educating someone but when it's something that should have been taught in class, I would be frustrated when educating them.. again.

GCS of 5, rales, weeping edema, CHF, RR of 36, and the guy gets a NRB ONLY?

I don't know what your protocols are but I hope they are more aggressive than that. Why did you "feel" the patient didn't need to be bagged? Because he was drowning or because he was dying? :x

[VentMedic]

In the original post the pt was alert. Since CPAP was being considered by a couple other members of the forum, it was not taken that the GCS was 5 or I would hope one would not have considered CPAP on a GCS of 5.

The patient has gone from the orginal post to knocking on heaven's door during the course of this thread.

upon arrival he was alert but not oriented and lying supine.

i monitored his airway with out any change in his status

[mobey]

Ya I think the original poster is confused about GCS scores.

I rate his GCS as 14

[Asysin2leads]

First: Yes you can bag a conscious patient. Its called assist breathing. You coach the patient and tell them to inhale when you tell them, the rate is the same as regular ventilation, 12/min, or 1 every 5 seconds. Hyperventilation is one every 2 to 3 seconds, which gives you a figure of around 28-30, bpm, where 40 came from I have no clue.

Second: Transport time is 4 minutes. However, you shouldn't figure transport time, you should figure time to intervention, be it meds or intubation, and even though the ER is 4 minutes away, between loading, unloading, giving report, and the ER getting set up, you could easily be looking at a 15-20 minute time to intervention. If the medics are 6 minutes out, bag 'em and wait.

[usapride2004]

Rate alone is not enough to determine the need for a BVM. Look at your patient, is he perfusing? Is he cyanotic? Diaphoretic? Pale? How is he mentating? What are his other vitals? What kind of hx does he have? You have to look at the bigger picture and not get tunnel vision. There is no formula for good patient care.

For example, last week I came down with gastroenteritis and a upper respiratory infection (thank you nursing homes!). When I got to the doc I was at 44 bpm. I was short of breath and needed some O2, but I didn't need to be bagged. I had a patient this afternoon, CAOx3/3. Seemed just dandy (he was quite hypertensive--call came from a outpatient surgical center) RR=40 bpm. Did not need a bag. He got 2 LPM via NC and was just fine.

In this case... did the pt have a hx of dementia that would account for the mental status? If no, then I would consider that enough to say he is not breathing adequately. I would much rather not bag the patient because based on your scenario, I say he was in failure. I'd rather not lay him down to bag him if I could avoid it. I would sit him up, get him on some O2, continue to ignore the nurse, whose opinion means more or less squat to me, and evaluate my patient. I can't say how I would treat this gentleman specifically, since I don't know all the facts and was not there, but I would not say that just because he was at 36 bpm that he needed to be bagged--he may have--but I don't know.

And yes, you absolutely can bag a conscious patient. It's not the most fun you will ever have, but it is sometimes necessary. Just drop an NPA and go to town.

If the guys GCS really was 5 (I am betting it was not, since it doesn't really sound like it with the info I have read)... you probably should have been bagging him.

It seems this guy really needed BiPAP or CPAP and some pharmacology.

[UtProsim]

From what I remember about that part of my training, It was told to us that if the patients resp. rate was out of the normal range and would compromise their ability to adequately oxygenate their system, then we could bag a conscious patient on their own inspiration to assist them in obtaining a higher volume upon inspiration, therefore slowing their resp. rate if it was too high, obviously there would have to be great resp. distress for this type of measure to be taken, there is no real negative effect from this, either they tolerate it or they don't. I have never had to bag a conscious patient, hopefully I haven't jinxed myself by saying that, lol.