Call Review Please: High RR --> Assisted Ventilations

[EMS49393]

Anthony,

Cap refill is a poor indicator of perfusion in any patient other then a kiddo. Distal pulses and skin temperature/color are you best indicators in an adult or geriatric patient. Dark skinned persons will have a dusky appearance if they are perfusing poorly. It's also referred to as an ashy appearance. The skin will actually look as though it is lightly dusted in powder.

I hope this helps you.

[AnthonyM83]

Yes, we were given paperwork, but never got a chance to look at it, since trying to package pt quicklyish...was going to wait until ambulance, then things started happening. In future, I should ask the attendent while package patient so at least I have something if I don't get to the packet. Also, yeah, I could have taken more time to do more assessments and look through papers before beginning to bag. There was panic involved...I knew I was there, too...that's what reverted me to cookbook.

I actually look forward to more IFTs now, though.

[Dustdevil]

If you feel you are in over your head, call ALS. A good paramedic will not beat you up over calling them because you feel you are unable to handle a patient.

If you call me to respond from across town, and you could have been at the ER faster than I was at your patient's side, then yes, I will beat you up over that decision.

There is a common misconception that if you cannot give somebody a drug to fix them, you aren't doing anything for them, and you need to call somebody who can. BS. Transporting them to definitive care IS doing something for them. Calling for this "ALS intercept" thing does nothing for the patient, except delay his care and transportation.

Doesn't sound to me like he seriously needed anything that a medic could have provided that was worth waiting for. And, in that case, your assessment is over. It's time to roll.

[actualparamedic]

BTW, how best do I judge distal perfusion on a dark skinned person? Nails were too tough/crusty for cap refill, skin dark...pulse thready anyway, so I'd assume pedal pulse would be same...warmth of extremities? Do I just have to go with facial signs? (eyes, lips)

That's a good question, and I scoured the both internet and some textbooks collecting dust here at the office for a good answer. Finding nothing, and since you brought up tough and crusty, my mentor from all those years back always taught me to look in an African American's mouth under the tongue as a sign of adequate perfusion (beefy red/dark pink as the norm). Poor perfusion and you get that grey/white pallor inside the mouth as well.

I still think of using the inside of the mouth as 'core circulation', I guess, and that's a late sign that you're circling the drain. Too many large vessels running nearby and close proximity to the brain to be considered 'distal' IMHO.

I wouldn't use temperature of the extremities as a reliable indicator of perfusion, either. Too many environmental, BMI, co-morbidities (PVD, HTN, ID/NIDDM, etc), wiring/plumbing factors could play into that.

Other thoughts, anyone?

[jmac]

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.

If i may say something here, Anthony asked when and why would he start PPV and if he made the right decision "at his level",

well and good making all the points about DKA, and recognising ALL underlying problems but he was the man on the ground, it was not a fear of the man dieing that should have made him go code three it was the actual physical presentation.

There is an old saying "a little bit of knowledge can be a bad thing", anthony did what he had to do, its all well and good thinking in a clinical enviornment, but on a supposedly stable transport you look at the Pt, the first thing you are supposed to learn at any level is that if anything goes tits up you go back to "A" airway, the physical presentation that anthony gave would make me treat the Pt the same as he did, it was the only intervention that he could do, why would he bother looking for any differential diagnosis that he did not have the tools to look for or the tools to treat.

He treated what he had in front of him, if this is supposed to be a learning process why are we filling him up with all these interventions or overthinking what you may do in your level......in my opinion anthony did a good job and presented a somewhat more stable Pt to the ED , job done...well done...every Pt is different.

I think the problem that anthony has is a worlwide problem, if we do something on the ground that reverses a problem and then bring the Pt into the ED it is hard for the nurses or staff to be in our position, thats the luck of the draw, its what we do, thats why i follow up where i can on my Pts and try to build a rapport with the staff in the ED so when they see me coming or i radio ahead they know i have a problem, though you are not right all the time with your diagnosis...you treat what you see,

again well done anthony.

[akflightmedic]

Sorry Jmac, have to respectfully disagree with you. Yes, when in doubt you should fall back on your basics, such as airway and that is what he did, however he fell back on it why???Because he was responding to a set of numbers that were taught to him. His pt fell out of the range and he thought something needed to be done. Do you have something against teaching or trying to instill critical thinking skills in an EMT. This is why I presented him with so many options and scenarios, not so that he may learn them and then try to treat them(which is out of his scope) but merely to show him there are many different reasons for why his pt responded the way he did. I also wanted him to realize he need not react or over react just because numbers don't match what he was taught. A very wise EMT once told me, "Yes we read the textbook and know how the pts is supposed to react, but did the pt read the same textbook?"

[jmac]

AK,

sorry you disagree with me but i thought my post actuall said some of the same things your last one did.

I am going on anthonys original post, I am not in any way shape or form ageinst teaching or showing what may or may not happen but if it leads to someone spending more time looking for things that they heard about or were informed about on a website in posts rather then dealing with the Pt in front of them "at their level" the teaching nad points of reference go out the window.

A lot of the information being given here take a lot of learning time, a lot of people read this, i am just saying deal with the question, who is to say some person of a lower level then the poster decides to go with what he read here and not understand the processes and ignores the job he or she is supposed to be doing, its all well and good you or someone at your level understanding the posts, its when it is misinturpreted that is the problem, i thought teaching was for direction and these type of threads were to instill the urge to find more education...not to show what the end product of that education was or by how much some have learned.

"a little bit of knowlege can be a bad thing"....in the wrong hands and no amount of posts on a website is going to fill in for education.

thats my opinion, no insult intended just like to see things r3emain at the level they started off at.

[akflightmedic]

No insult taken. Its a professional forum, we can disagree and argue points without taking offense.

If you said the same as I, I apologize. SOmetimes the way you word things leaves me at a loss of what you truly mean. Sorry, my Irish translating/understanding skills wore off when we left a couple hundred years ago...lol.

[jmac]

no prob AK,

i have had a newbie 1 1/2 mins from the ED and an anastesiest working on a Pt with hypoxic seizures because someone had told him that hyperventilation will always ease the clenching,.........sometimes commen sense can go out the window.

remind me to send Irish/American dictionary to Admin