Call Review Please: High RR --> Assisted Ventilations

[AnthonyM83]

Personal Background

• 3rd day as EMT.

2-EMT BLS rig (answer 911 & routine transfers)

My EMT class was 1 yr ago

My unthorough EMT class relied on us learning a lot on the job b/c in San Francisco area, EMTs are usually with ambulance medics or FFMedics.

My field training at this company consisted of only 5 transports, 1 of which was routine transport...I only participated in 2 of them.

Hoping to post a lot of calls for review...since I'm on my own in the back of rig, I have no one to critique me. My driver is 1mo new.

The Call

On-Scene

• 91yro male, SOB, seems asleep, taking loud semi-short breaths.

Attendant noticed 1hr ago, so put him on O2@4LPM via NC, checked BGL (at 435), so gave 10 insulin units.

As we're leaving, he mentions fever of 103, 1hr ago

What We Did On Scene

• -I'm still in IFT mindset, figuring these attendants know best whether it's an emergency since they know his baseline and must transport residents all the time when they get borderline needing to go to hospital. They know when to call for a transport versus calling 911.

-But still concerned it's SOB, so let's just get him to hospital fast and make sure he's okay...still treating it seriously...but not as a "real call". Didn't start doing an assessment like taught in class.

-Change to O2@15LPM via NRB

-Nursing facility's O2sat goes from 91% to 96%

During Transport:

• -Pulse 90 and strong

-Try talking to him...unresponsive to pain

-Take BP...won't extend arm...puts strong resistance...trouble getting BP

-Attempt palpate...trouble finding pulse

-Pulse now weak, very hard to track

-RR increases, 44 BPM, shallower, weaker

Treatment[

-Start assiting ventilations. Not sure exactly how to pace when "assisting"...so end up just doing 1 every 4 seconds...not sure if I should take over completely or keep trying to "assist".

Decision Process

• -Do tell partner to upgrade to Code 3 (L/S)?

-This is a call ALS (vitals unstable, SOB) would usually handle and ALS really only does things that need code 3 response (...least that I could think of?)

-Thus, this justified code 3 response for us.

-Additionally, medics on board have told us to go code 3 for more stable patients.

-So if using them as reference point (though they're quite liberal in those decisions), code 3 okay

At the ER

• -Walk in ventilating

-They have me stop to check breathing

-They remove mask completely from face and get O2 sat

-Breathing has slowed and O2 sat in 90s

-Transferred to room with no O2

ER Staff

• -ER nurse makes unintelligible comment

-Another replies, "Yeah, I know....better they do that than bring him in not breathing or beating."

-Later I tell her it's my 3rd day and want to know if what I did was okay. She says I did fine, and she'd rather I do something than nothing and risk the patient.

-(This implies she thinks I went too far...but I'm not sure if it was on the ventilations or on the code 3 or what)

Note: We didn't rush in the hospital doors yelling our report or anything. Calmly walked in bagging and explained what happened when asked.

So, my question:

• What would have been best (not acceptable) responses to noticing pulse weaken and RR go to 44?

Code 3 decision?

Thoughts/Lessons Learned

• -I need to get into mindset of this is a real call for anything other than a routine, regularly scheduled transport

-Be less timid. More aggressive checking things. Don't wait until back of ambulance to "do my thing"...even if partner looks at me weird or I get attention.

-These non 911 hospital admits are great for practicing patient assessment, which we don't get to do often, b/c FFmedics are usually on-scene.

-It's my patient. Be possive of him/her. Do whatever I think might be needed. Basically, more looking to myself for direction...self-confidence. Patient is expecting and trusting me to do this.

-Get rid of old reminents of police explorer, where I was never to make the decisions except for minor stuff or exigent circumstances. It's my job to do this...don't put being scared of liability (like code 3 upgrade decision) over patient health

-I did get into the right mindset on this call...but not right off the bat...so gotta push self in future.

And final thought:

It's damn hard to not be a dumbtard when you get that little field training. If you're with a medic, it's fine b/c they'll teach you. But when you have two new EMTs, there's no one to show you stuff...critique you after a call...you learn from trial and error...no one of higher title to emulate....and thus you look like a Gomer to the medics that ride with you and ER staff. Trying hard not too, but damn. And that's why I'm posting this here.

[DwayneEMTP]

AnthonyM83,

Sorry I can't help on the call...it sounds like you're in an impossible situation in your job.

But I did want to say this may be the best post I have ever seen!

Even those that don't share your question can learn much about posting, linear logic and self examination....Outstanding.

Good luck in your new job!

Dwayne

[Dustdevil]

Dittos on the kudos. Excellent post! Self-criticism and self-evaluation are very powerful educational tools. I really like the way you presented this. It reminds me of an excellent, well laid out PCR or SOAP note. It also reminds me of what we teach our new medics which is, "always have a plan." Don't come to me asking what to do. Tell me what you think is wrong and what your plan is. If it is appropriate, well then there you go. You worked the patient out all by yourself. If there is something more appropriate, then we'll talk it out. But you will learn better from it because now you have done your own assessment and plan, and can compare and contrast it with the other plan. You don't get this point of reference if you never formulated your own plan.

That was a long winded way of saying you did very well, both in your ultimate plan for the patient, and in your case presentation.

-Get rid of old reminents of police explorer, where I was never to make the decisions except for minor stuff or exigent circumstances.

This also reminds me of something I strongly believe. Those with law enforcement backgrounds tend to make excellent medics, if they actually put their minds too it. The practise of medicine is very much like being a detective. It is about conducting an investigation, finding and interpreting clues, arriving at a conclusion, and acting upon it in a thorough and methodical manner. That is police work! Unlike pulling hose and squirting water, there are many parallels in police work that make it analogous and compatible with medicine. I urge you to maintain that outlook and utilise those instincts and skills that you honed in your Explorer experience to benefit you in EMS. It is obvious that you learned some very fine documentary skills somewhere along the line.

It's my job to do this...don't put being scared of liability (like code 3 upgrade decision) over patient health

I agree. I would only caution you to remember that the decision to run "code 3" is just like any medical decision you may make. You don't do it just because you can, or just because the cookbook says so. You only do it if it holds very convincing promise to benefit your patient so much that it will outweigh the risks it poses to him, you, your partner, and every other person on the road. That means, quite honestly, that there really aren't that many cases that justify it. From your narrative, I would say this one was borderline. No fault. No foul. But don't fall into that cookbook mentality of turning on lights and sirens for every difficult patient when in reality it won't save you any time and may get you killed. Especially if the nimrod behind the wheel has a month of experience!

[akflightmedic]

[MikeJ]

Good post.

My opinion is that you were sort of screwed from the beginning - this really wasn't a BLS transport. Old guy, SOB like that, he could have been in the midst of heart failure, and he really needed ALS care from the outset. (I'm guessing that your boss may have frowned on you calling for ALS support for a call like this, and it's up to you to decide what you want to do about that).

When his respirations became inadequate during transport, you supported them successfully. Other than calling for ALS intercept or preparing for CPR, there isn't much more you can do at a BLS level. I would have told my driver to light up and go at that point, too - once you are bagging somebody, you have every right to hurry to the ER.

I've learned not to expect much from nursing home staff. Sometimes they can be quite good, but they often make poor patient care decisions. You are probably correct when you say you should be more assertive, but it's hard to be assertive when you are new to the job and unsure what to do, especially when your opinion differs from that of more experienced people.

The really important thing was noticing the life threat as it developed, and correctly addressing it.

I think you did all right, considering your situation, and I applaud your effort to learn as much from this experience as you can. That's the right way to get good at this job.

[becksdad]

Hey Anthony! Nothing like trial by fire, huh? Listen, I have never worked a purely BLS truck, but this would have been my take based on the info you provided (which was quite thorough by the way).

Immediately (at bedside), call for ALS intercept, priority 1. Immediate ventilatory support, which you did. If no gag reflex, place an OPA (or LMA if you can use). NPA's suck- I wouldn't even bother unless I encountered resistance and couldn't place anything else. Immediate and rapid transport to ALS rendevous.

This guy desperately needs respiratory and circulatory support. If you are certified to do it - place at least 1 (2 would be better) large bore IV. Kidnap the most competent appearing person there as a rider - they can grab equipment for you, bag if they're competent enough to do it, etc. Rendevous ALS, or continue rapid transport to closest facility if ALS delayed.

It sounds like you did everything you could do, though. I heartily applaud your self evaluation! That is a VERY, VERY good sign of a professional provider. Just a word of caution for future, similar situations: I know EMT school is big on Trendelenberg for hypotension, and my first immpression of this patient is decompensated septic shock. Be VERY careful with Trendelenberg. It may or may not have some limited benefit, but I bet this guy's lungs were pretty wet and that is an ABSOLUTE CONTRAINDICATION for that positioning. Listen to lung sounds on everybody. We EMT's forget that a lot.

GOOD JOB!!

[JPINFV]

[nbsp]

Since I didn't see it when I skimmed this thread, I hope it hasn't been mentioned before, but...

In my emt class, we were taught to "track" or "bag down" when the patient is breathing abnormally slow or fast. Tracking is to bag the patient every breath, and bag him again between breaths. Bagging down is to bag the patient with his/her breaths, but not every breath. We would supposedly do it in a manner as to be bagging the patient bewteen 12-20 times a minute. In this way we could "multiply" or "divide" the RPM so as to place it between 12 and 20.

i.e., if the patient was breathing at 5 RPM, you would bag him twice between each breath as well as with each breath, to "raise his RPM" to 15. Or if the patient was breathing at 30 RPM, you would bag with him every other breath, to "lower his RPM" to 15.

Is this valid or is this another medical myth along with trendelenburg and the platinum 10?

[becksdad]

I have not actually heard it described that way, but I guess "tracking" would work. It sounds like a "formula" to achieve 12-20 RPM. Either way, if you bag every 5 seconds, you're gonna get 12. If you can get that to coincide with a patients own respiratory effort, great. I just try to bag a patient how a normal, healthy person breathes. We breathe like that because it works real good.

Personally, I think it much more important to just get rhythm down with the rate, a good tidal volume, and allow for full exhalation. With supplemental O2 @ 15lpm, you just need decent chest rise. So many people seem to be trying to blow up a balloon. Just from what I've seen, the biggest mistakes made in PPV are too much, too fast. Just breathe for them. Nice easy ventilation, pause for good exhalation.

No matter what anybody says, though, do in class as your instructors teach, and test to the book. Either me or anybody else could be full of crap.

[AnthonyM83]

Thanks for the feedback guys, especially akflightmedic and JPINFV.

I was specifically looking for technical criticism, as well as mindset/big picture perspective direction (since I have no one at work to get it from...least on the rig), so thank you AK. Appreciated.

As for the call:

If you guys had to say when you would start either bagging or tracking for rapid breathing, at what RR would it be and under what circumstances?

I don't know original RR. The 1 IFT I did with my FTO, we didn't setup like a real call. We did everything in the ambulance...I kept thinking back to it as my only point of reference. Again, that was a main mistake and will now treat all IFTs differently.

Order of Events

-Take pulse

-Take BP (since I already knew RR was fast)

-Trouble getting BP

-Attempt to palpate, instead...I notice the pulse is much different (perhaps like AK said, it was stress...or a combination...but I think it was different)...

-Move on to RR...I see that as most immediate problem I can address, so start using the BVM

-And we can't do BG (or O2 sat)L...but good suggestion on utilizing nursing home staff who can.

-His arm was slightly bent and turned in...couldn't get it open without putting extreme force...

-His neck was outstretched and stiff and scruffy, so hard time getting carotid pulse...I stuck to radial pulse.

I started bagging, basically, because I was taught you do that if respirations are high. I was told from 25 to 30s is when you'd start...He was 44, so while I didn't think was absolutely dying, I should be bagging/tracking...I ended up dong a combination of the two.

So my question now is, as a general rule, when would you guys start tracking or full on bagging (1 every 5) for tachypnea?

BTW, thanks Dust...it's all those police forms that taught me to document thoroughly...protecting against all the defendent attorneys.