The internal oh s*** button. And staying calm with a quickly deteriorating vent patient.

[runswithneedles]

*Back story to this post*

We were dispatched for a 0.2 mile Inter-facility transfer from one ICU to another because this pt had a type of pneumonia that couldnt be handled at his existing location. We arrive there and we have the following

approx 65 yo male who is sedated running 3 infusions controlled by a pump

norephinephrine

fentanyl

and a antibiotic which I cant think of at this moment

His vitals at the time of arrival

Pulse 77

BP: 105/58

Spo2: 98% via 100% O2 delivered by a vent

GCS: 3 (patient was sedated)

Weight: approx 250 lbs. or 113.6 kg

We have an

auto-vent 3000

Zoll M series cardiac monitor (ETCo2 not equipped)

Which was used on the pt. We get him hooked on to our cardiac monitor and vent with no problem whatsoever.

After we load him onto the truck we switch him to the on-board 02 system.

Heres where the fun begins

Short after switching it the medic and myself hear this high pitch squeak come from the vent (more specifically the part where it connects to the trach or ET tub) I see there's a clear window on top of that piece and every time it delivers a respiration the sound comes back and a little green piece inside the window goes red. (sorry I dont know my terminology of the equipment)

We checked the monitor and SP02 normal with the 3 lead showing a NSR.

About 2 minutes this bloody squeaking is still present and driving me and my partner nuts.

I start getting this gut feeling that something is really wrong and shit is about to hit the fan. So I start checking and re-checking that monitor and I begin to see a negative trend. His spo2 is falling rapidly and his heart rate is steadily increasing.

At this point I tell the medic somethings not right here. He looks at the monitor and yells up to the driver to go.

That moment I suggested a possible displacement of the trach. This guys vitals still deteriorating and Im thinking of pulling out my stethoscope to check but something kept me from doing it. My medic was quiet and said nothing he just was occupying himself with tasks and I didnt know what.

We had no further communication. The patient began to cough and gasp and appeared to struggle for air and at this point Im about to press the internal oh shit button cause im in the captain chair watching this guy spin down the drain before my eyes and im just sitting here. I didnt want to get in the way of my medic but at the same time I was frustrated because I keep feeling their must've been something I can do.

We arrived to the hospital and I was thinking we were going to hit the ER with the way things are going with this guy. But no, we head to the elevators and begin to take this guy up. My eyes were set on that monitor fearing he was going to code right in that elevator. By now his pulse was 140 spiking at 170 and his SPo2 leveled out at 80. His skin showing it too.

Once up to the ICU he was transferred over. And it was clear with the amount of staff in the room he didnt fair too well on the way over to their facility. After he was on their bed I removed myself from the room and went back to the truck. Hands trembling.

How do you ladies and gentlemen manage to maintain composure when a perfectly uneventful transfer spirals into a oh shit run.

And does it get less creepy to transfer sedated patients that have their eyes open after a while. its not a huge bother to me but it is kinda awkward to work around when hes spinning the drain in fast circles. Can I close them?

Edited January 27, 2012 by Mike Ellis

[chbare]

You should have immediately disconnected the patient from the ventilator and manually bagged. Clearly, your paramedic had lost control of the situation and failed to intervene. Did you clearly communicate what you saw regarding the ventilator issue? The visual indicator should be green during inspiration with the Autovent 3000. If not, there is a serious problem and the patient should be disconnected and manually bagged immediately.

Unfortunately, the patient may have deteriorated in part because your partner failed to manage the patient appropriately and because you failed to be assertive when it really counted. Please do not take this personally, take this as a major learning experience. Also, both you and your partner need to discuss this situation and identify what went wrong and how to correct it. Ventilator management is serious business, but you must always be ready to manage your patient with basic techniques. Basic airway management is a fundamental part of our job description as pre-hospital professionals.

Again, this is nothing personal.

[DwayneEMTP]

I've got very little experience with vents, so I've never done an uneventful transfer of a vent patient. Though things didn't go wrong, it was a fucking event for me, I'll tell you that.

And it shouldn't need to get easier to transfer sedated patients with their eyes open, they should have been lubed and taped closed to protect them, assuming GCS of 3 and not just a snowed patient.

This is where it sucks to be a basic. You're partner was completely off in the ditch on this call if you're story is accurate. As soon as things started going south, and after checking the obvious, it was clear that he didn't know where the wheel was to turn them right again and you should have disconnected and bagged him back into the hospital. Humilating? Maybe...I don't know, my brain doesn't really run down those tracks. I try and give my very best care now, and if it's not good enough, I try and learn what I can and do better next time. No real humiliation.

Your partner obviously didn't have the education and training to be putting his hands on a vent patient, and maybe not any other critical patients either. Want me to prove it? At the minimum he should have pulled the plug and started bagging when he couldn't quickly correct the problem, in fact couldn't even seem to identify any problems to fix, but instead chose to run. And that is a terrible, terrible, terrible choice when you make it just to try and prevent having egg on your face. Maybe there were other reasons, but I can't see them, at the very least you should have bagged him to the next hospital, there were two of you after all.

But, as a basic and near medic, you're supposed to advocate for your patient against EVERYTHING, right? Disease, trauma, cops, bad med orders, and yeah, even your partner. So you pull the tube and begin to bag...and any add'l deficits are going to land on your head because you're partner is gonna burn you down. You don't pull the tube and you've allowed an incredibly sick person that was intrusted to you to be harmed so that you can cover your ass...and that's shitty.

Really bad situation Brother. I'd really, really love to read your partners run report.

But I will tell you this..if you know for a fact that he related the call details inaccurately and you let it pass? Well...there are very few unforgiveable things in EMS, but in my opinion that is one of them....

Good call review! But watch your presentation, ok? Type, proof, correct, post, proof, correct...etc.

Of course having said that, it took me two days to figure out that my spell check stopped working, so as I didn't see the little Christmas lights telling me I had typos my posts for the last several days appear to have been written by an even bigger halfwit than me...So there's that...

Dwayne

[runswithneedles]

Blasted typos. Gotta love having a netbook with tiny keys and be blessed with large fingers. Dwayne you nailed it directly on the head as to why I didnt intervene. If I had intervened I wouldve have opened myself up to liability if I was wrong and the pt continued to get worse and only being certified as a basic I cant re-intubate a trach patient My partner would've ripped my ass a new one as I was taking control of a patient that wasn't mine. I didnt want to point fingers to my partner in any way shape or form as I have learned from previous posts pointing fingers at fellow healthcare professionals only makes me look unprofessional and just a general know it all asshole. I tried very hard not to present my partner in a negative light in any way shape or form until I had a few comments from you guys because like previous posts their mightve been a reason of why he didnt just disconnect the vent and bagged him.

And to Chbare, I dont take it offensively in the slightest. I froze and fucked up when this couldve been my opportunity to shine. This was a call that couldve been probably uneventful had I said piss on covering my ass and took the reins. I firmly believe it was a displaced trach. But I knew my partner. I touched his patient or took the reins my ass would be grass and because of my certification and level of experience in comparison to him (EMT-B of 11 months vs EMT-P of 25 years).

I dont know maybe I just need to grow a pair.

[Just Plain Ruff]

Blasted typos. Gotta love having a netbook with tiny keys and be blessed with large fingers. Dwayne you nailed it directly on the head as to why I didnt intervene. If I had intervened I wouldve have opened myself up to liability if I was wrong and the pt continued to get worse and only being certified as a basic I cant re-intubate a trach patient My partner would've ripped my ass a new one as I was taking control of a patient that wasn't mine. I didnt want to point fingers to my partner in any way shape or form as I have learned from previous posts pointing fingers at fellow healthcare professionals only makes me look unprofessional and just a general know it all asshole. I tried very hard not to present my partner in a negative light in any way shape or form until I had a few comments from you guys because like previous posts their mightve been a reason of why he didnt just disconnect the vent and bagged him.

And to Chbare, I dont take it offensively in the slightest. I froze and fucked up when this couldve been my opportunity to shine. This was a call that couldve been probably uneventful had I said piss on covering my ass and took the reins. I firmly believe it was a displaced trach. But I knew my partner. I touched his patient or took the reins my ass would be grass and because of my certification and level of experience in comparison to him (EMT-B of 11 months vs EMT-P of 25 years).

I dont know maybe I just need to grow a pair.

Yeah I hear you on the experience but if the patient died then you would be just as liable as the medic.

Think about it this way, think about it in a coutroom

Witness - you - plaintiff's attorney "When did you realize that something was wrong with the patients airway"

You 'about two minutes after the patient was loaded into the ambulance"

Plaintiff "Why did you not intervene with this patient?"

You - "I didn't because I thought my medic had it covered"

Plaintiff "but when you realized that your medic did not have it covered, why didn't you intervene"

You - "I didn't intevene because I was afraid of what my medic partner would do to me, because he has so much more experience than me and my certification is less than his"

Plaintiff "so you were afraid of what your partner woudl do to you for touching his patient yet you let this patient suffer and in the end this patient suffered real irreparable harm. *Insert whatever long term medical effects the patient might have suffered* "

You "Well when you put it that way, I should have grown a pair and intervened (your words not mine) "

Plaintiff "Ladies and gentlemen of the jury, please find for my client in the amount of $XXXXXXX.00"

And the jury would have done just that.

I know how hard it is to butt heads against a more seasoned and higher certified "professional" is and lord knows I've been there as well but you aren't accountable to your partner in this situation. You are accountable to the patient and you have already said that you didn't advocate for the patient in this instance so this is your chance to truly learn from this situation and try not to let it happen again.

Thanks for having the cojone's to come forward and ask for opinions on this. It's tough to do here sometimes.

[runswithneedles]

With each time I replay that run in my head and reading the posts it sickens me that I actually stood by and let it happen. This was my moment to act and correct a quickly deteriorating situation. (Which I would like to add we as a company rarely receive cases like these.) And had I jumped on it would've demonstrated my ability to handle a less than perfect patient and perhaps had me recognized within the company. Now im open to liability as much as my medic if something should come up regarding this run. But most importantly I failed a personal goal which is to protect another human being from unreasonable harm which is why I came into this profession.

[runswithneedles]

Thanks for having the cojone's to come forward and ask for opinions on this. It's tough to do here sometimes.

I should also be thanking the other users of this forum. The way you ladies and gentleman give advice and responding to posts make it alot easier for me to post cases such as these. If I would've said this within a the local fire department I would've gotten remarks like "You dumb fuck why didn't you do anything" "Yeap and that's why your a worthless transfer EMT and not a macho life saver like me" and "that's why I make you carry my shit and apply oxygen"

Im one of the worst contenders in admitting I screwed up. I'm also very young and still have alot to learn regarding professional conduct and knowing the whereabouts of legal boundaries in regards to liability. You guys allow this place to be a learning environment rather than a firehouse dick measuring contest or a house of elite paragods.

Had I have known I was just as legally liable for this patients well being as much as my medic I would've done something more or at least I would've actually spoke up.

[chbare]

Mike, we've all been there bro. A while back I was a student doing clinical rotations in a trauma ICU. A patient had arrived following a laparotomy after being stabbed. Two trauma surgeons were arguing over the current plan and it's effectiveness. One of the surgeons placed their bare fingers into the patient's abdominal wound to make a point. I began to protest verbally and was immediately silenced by everybody in the room including my instructor. I was a student and I was frightened I'd be expelled if I said anything or continued to protest.

You know what bro? I failed that day, I absolutely and utterly failed, miserably to protect a helpless patient. Never again. We all phuck up, but we can learn and vow to do better. You will always face fear over confrontation or potential consequences but you have to look at yourself in the mirror. Good on you for discussing this incident.

[Happiness]

If you take this bad experience and make it a learning one then all is good. The guy didn't die and you and your partner are not being sued "yahooo". Dont fret on it to long, everyone of us have made or not made decisions on that internal holy shit button, some turn out and some dont. The earlier you realize that it will make your career a bit more enjoyable. I dont understand why you wouldn't feel that you could ask a question at the time of all of this, as in the end it is all about learning right. So one question I have were you around when the medic was getting the nursing report ? The reason I ask is maybe this person had a DNR or something else was going on that you may not have been aware of.

As for staying calm when all is going down the drain it all comes with experience, and so you know even the ones with experience are freaking inside its just they have learned to hide it well, I know I do................

good luck in you future adventures

[paramedicmike]

I'm going to take a different approach to this just a little. I agree with the comments that have been presented so far. What bugs me, however, is that your response to this has been, at least as far as your written word goes, that you missed your opportunity to "shine and make yourself known in the company".

What kind of approach to PATIENT care is that? Are you doing this simply to be known to your boss? Or are you doing this for the recognition from your coworkers? Or are you genuinely interested in treating patients and maintaining, if not improving, their condition/status from when you met them?

I'm going to respectfully suggest you re-evaluate why you're in this business. If you're here to be a glory hound then please leave. EMS does not need any more of those. If you're here because you are genuinely interested in being the best EMS provider you can be while providing the best patient care you can then please stick around.

Weeding through your self deprecating comments leaves me to wonder why you're doing this. You have presented some good scenarios for discussion but you have left your motivations for success in doubt. That doubt, at least to me, is left in question by your desire to impress your boss over your concern for appropriate patient care.

Please think about this and let us know. I can pretty much guarantee you, though, that if you act in the best interest of your patient and make patient care the focus and goal of your professional life, your bosses and coworkers will notice you. That will be secondary, of course, to treating your patients with the level of care you'd expect for yourself or your family member.

I know you're young and new to this. I know I sound much more harsh than this is intended to be. But you do need to make up your mind on this. Do the right thing at the right time for the right reason and you will be successful. Do it to try and impress someone and it will, eventually, blow up in your face. And I hope that doesn't come at the life of a patient.