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

[DFIB]

this is easy:

Mike is a newbie working for a crappy transport company doing the granny shuffle and is terrified by every stiff he hauls.

Wow island, There are just to many negative things that I can read into your post.

I think that since Mike could not get an adequate operational debriefing from his partner he came to a forum where he knows there are professional people who will at least give him an unbiased professional opinion about his scenario, interventions both performed and omitted.

I bet you could offer some good advice for him as well as the others.

[chbare]

I wouldn't call a trached patient on vasoactive infusions a "granny shuffle."

[DwayneEMTP]

That post seemed very 'un-island' like...

I'm wondering if someone left their computer logged on and got spanked...

Dwayne

[DFIB]

That post seemed very 'un-island' like...

I'm wondering if someone left their computer logged on and got spanked...

Dwayne

You might be right. Very uncharacteristic.

[usalsfyre]

I am. Second semester out of 3. Already completed advanced airway managment COVERING VENTS!! Why the hell didnt I think it was the PEEP indicator!!! UGH whata bloddy brainfart from hell.

Than again. That BVM sure looked real shiny at that moment.

Actually not a PEEP indicator, it's a high pressure relief valve. The squealing and red is to let you know something is wrong. I believe these are set to activate at 55cm H20 on the AV series. What this likely meant is that the rather crude breath delivery of the Autovent was injuring your patient at that moment.

BVM would have been likely as inappropriate. What this guy needed was a provider with the equipment and knowledge to move critically ill patients from facility to facility, even if it is only 0.6 miles. You'd be surprised how fast you can cause acute lung injury.

There's a reason CCT has developed into a separate, subdiscipline within transport medicine, it's about far more than cool flightsuits and expensive toys.

Not your fault, but when you become a medic don't be afraid to say "we can't do this safely" on IFTs like this.

[chbare]

Actually, I would argue bagging would be appropriate. You should immediately dissconnect the ventilator and attempt to bag. My suspicion is that in this case, using a BVM would have been difficult, but you would know what was going on rather quickly. If I had to guess (only a guess) there was an obstruction of the trach. Perhaps a mucous plug. Also, we do not know what type of trach we were dealing with in this scenario.

Unfortunately, you cannot easily identify issues with a crude ATV like the autovent. A proper ventilator with a graphics package is your best bet; however, few providers have a great deal of knowledge when it comes to ventilator waveforms and I would still disconnect the patient and manually ventilate while getting the necessary equipment to clear the obstruction and/or trouble shoot.

[Paramagic]

I agree with usalsfyre and also with systemet. Quite aside from any errors that were made by the providers, there are some systemic issues that need to be addressed. It is really not appropriate to expect crews to transport sedated, ventilated patients without proper equipment. That means waveform capnography and proper ventilators. I'm not a fan of having to use a BVM in these situations, but I'm equally unhappy with having bullshit, cheap, nasty ventilators.

BVM's have their place, both as an initial option when we just need to get air in and out urgently, and as part of a "failed ventilator" plan, but we really need to be more cognisant of the importance of proper lung protective ventilation strategies, both on 911 calls, and most certainly on IFT calls.

[HERBIE1]

I am not an RT or Critical Care medic, just someone who has been around the block for more years than I care to admit. One of my closely held truisms is the KISS principle- Keep it simple, stupid. When it all goes to hell, as a couple people have mentioned, the first thing you do is take a deep breath and go back to the basics- ABC's. Since I have no clue about vent settings or troubleshooting vent issues, my first thought was about a mucous plug- based on the patient's PMH. Horrible things- especially if you cannot get at them. Suction is certainly a good idea at this point. They can completely occlude an airway, may be too deep to remove quickly, and they can easily prevent you from using a BVM. That said- what other choice do you have? The issues here had nothing to do with ALS skills. Yes, the person was on a piece of equipment you were not familiar with, but you know what a pulse ox is and what it means. You do have the knowledge to address the problem.

Once those alarms begin, and you cannot figure out what they are, what they mean, or how to correct them, remove the vent and try to manually ventilate the patient. Clearly the person is decompensating and it's time to earn your money. Better to pop a bleb or push a plug distally then have a patient become anoxic.

Anyway- this medic sounds like he has no business doing critical care transports. He screwed the pooch on this one.

Next time if your medic isn't willing to step up, you need to be your patient's advocate. After the call you can discuss what went wrong.

I'll echo the statements about you having big nuts for putting yourself out there like this. On the plus side, I promise you will learn more from this incident than you would listening to a lecture from a doc from the Mayo Clinic. These are the calls we never forget, and always vow to never repeat.

[Aussieaid]

There is a Mnemomic for situations just like this (trouble shooting deteriorating ventilated patients):

DOPE

D- Disconnection (Can add displacement)

The circuit is disconnected somewhere either at the tube or somewhere along the ventilator circuit. In the case of displacement the

ETT/Trach has displaced and the patient has extubated accidently (or self extubated).

O- Obstruction

Either the ETT/Trach is plugged with a mucous plug (or cockroach, etc) or the tube or circuit is kinked somewhere.

P-Pneumothorax

Pt has blown a lung or two causing a pneumothorax which can quickly progress to a tension pneumothorax.

E- Equipment

The equipment has failed. Either something is wrong with the tube (leaking cuff), the ventilator or the ambubag (not connected to oxygen for

example)

Your first action with a ventilated patient should always be to disconnect them from the ventilator and bag them. By the simple act of doing this it will narrow down the possible causes faster than anything else.

If you start bagging and the immediately improve then you know the problem is with the equipment. You stabilize the patient and then you can trouble shoot the equipment.

If you start bagging and they are hard to bag you can narrow it down to an obstruction or pneumothorax and know that the problem is with the patient not the ventilator.

If you start bagging the patient and they are easy enough to bag but don't improve then you check your oxygen source, tube placement and cuff pressure.

If you are in doubt that the tube is in the correct place then you immediately pull the tube and revert to BLS airway until the patient is improved or stable enough to reintubate.

One of the most valuable tools that you can use is some form of capnometry. If you can't afford a proper piece of equipment with a waveform that can tell you so much more than you can imagine, then you can use a simple ETCO2 detector that just changes color. If you have confirmation that the tube is in place quickly then you can save pulling the tube and focus on an alternative cause of the deterioration.

I have to say that I would run as far from that program as I could if they think it is ok to send an obviously untrained (in CCT for sure), single paramedic provider to transfer a septic, intubated, ventilated patient on pressors.

[runswithneedles]

this is easy:

Mike is a newbie working for a crappy transport company doing the granny shuffle and is terrified by every stiff he hauls.

I am not afraid of any damn stiff. I shit myself because IT wasn't my damn patient and I let this guy spin down the drain quietly instead of doing what I should've done.....Pulling out a BVM and bagging his ass and when my medic got into an up roar I shouldve told him to fly a kite. Hell I could've deep suctioned him, did a chest decompression if needed, or re-intubated BUT I didn't have the damn patch to do it. Because of his lack of action it makes me look like an incompetent fuck.And yes I am concerned what people think about me. Wouldn't you if you were "some kid". People judge me because of my date of birth. Not my ability to care. And I feel like if I can acquire the knowledge and ability to care they will overlook my age. Am I off key to think this way?

Im not afraid to act. Im scared of the consequences of due to my LACK of action.

Also on a different note. I came to the ICU a few days ago. He was no longer there. He died. So I am wondering if Ill be appearing in court a few months from now because my partner and myself let this guys brain fry due to hypoxia?

And im not doing no damn granny shuffle. Just last weekend we took a critical pedi. We are a ITFT that is under trained and underequipped. whatever drugs we need but dont have. we get the docs to write the orders (our protocols are the generic J-RAC and even than we dont carry all the drugs we are supposed to. so whatever we need we have get from the transferring doc) Hell the company is so damn cheap they are training all basics to give EPI IM instead of buying the damn EPI-pens.