Call Review Please: High RR --> Assisted Ventilations

[akflightmedic]

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.

Your welcome. I like you. You have taken a very proactive approach to recognizing your weaknesses and trying to correct them. I will be extra critical of you from here on out since you can handle it

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?

This is what medicine is all about my friend. It varies from patient to patient. There is NO magic number and depends on a myriad of things, most importantly, how the pt presents and the history. Basically, you "cookbooked" this call cause that is what you were taught. Quite honestly we have done the best critique we possibly can for you at this time because without answers to all the questions we asked of you, we can not respond properly as we were not there. Since you were unable to get the answers (BP, O2) we just will never know. However, you have learned a lot from this call, so good job!

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.

You said you do not know the original RR, because you neglected to do one of the most important steps and that is perform your own assessment before going anywhere and establishing baseline vital signs. Without a baseline, what good are the vitals you do as you have nothing to compare them to, nor did you acquire this information from the staff.

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

Pulse was different?? Perhaps he had Afib and this is what threw you off(very common in elderly).

-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.

Arm slightly bent and turned in is called contracture. If you force it, you will break it. The muscles are atrophied, you will not defeat mother nature I promise you. I do not understand the neck description, seems like it would have been easier. Sticking to radial is another thing that may have hindered you. The elderly have weak or dimished radials as their BPs are not as strong for some, especially ones that are almost 100 years old and bed bound. Stick to carotids when in doubt.

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.

You did it cause you followed a recipe for a certain number. The question remains...DId he need it? I am thinking probably not but whats done is done. Consider the physiology of rapid breathing. Why is he breathing fast? What could it be and what can you fix? Was he hyperventiliating from anxiety?(highly unlikely and these pts are easy to fix, talk them down and coach/slow their breathing) or was he breathing fast because of a medical condition that you can do nothing for but transport(DKA, sepsis,etc.)

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

I believe I answered this already. There is no magic number and it varies from pt to pt. However, do not ventilate 12-20. Average accepatable ventilations are 12 a minute---more than this and YOU are still hyperventilating the pt. Sucks not having clear cut answers eh? But with time and experience you will learn all this and become an excellent provider. Just keep doing what you are doing?

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

[fiznat]

Like everyone else said, excellent post and big time kudos for your willingness to be completely honest about your capabilities.

First I'd like to respond to something another poster said:

DONT ever try and obtain a 12 lead ECG and "read the interpretation at the top" like someone suggested. Not to be rude, but this is an absolutely awful idea. Not only are those interpretations often completely incorrect, but even if they are correct it is silly to assume that a BLS provider would have the knowledge or means to treat such a rhythm. Not to mention that SNFs NEVER perform acute 12 lead ECGs (so what you are looking at is likely old), and an ECG is probably the absolute least important clue for you to consider at this point in the game.

Okay, sorry... had to get that off my chest...

Here is something to consider that I think might help. EMTs are trained (or at least I felt I was) to recgonize specific patterns and make treatment decisions based on that. Like you said, his resp rate was "too high" so you were taught to bag him. The problem with this manner of assessment is that you are not considering your whole patient. ALS providers are trained to recgonize certain peramaters, no doubt, but more importantly they are instructed on the difference between "stable" and "not stable."

A good example of this is with heart rate. In general, bradycardia is defined as a heart rate of less than 60 beats per minute. Presented with a patient who's heart is beating at 45 beats per minute, a newbie medic or EMT might think "his heart is going too slow, I need to do something about that!" ...But that isnt correct. What medics (and good EMTs) need to do is to assess the entire patient. Is the patient mentating properly (or at least to his baseline)? Is the blood pressure good? Is the patient perfusing his organs with this heart rate and blood pressure? All these questions-- and really you're just asking-- "Is 45 beats per minute too slow for THIS PATIENT?"

Transposed to your patient, you need to ask questions and do an assessment surrounding the question "is this patient stable?" Given the clues you found on your assessment, I'll help you make that decision:

1) The patient was unresponsive to pain. This is generally a very bad sign -- but again, if this is his baseline, it may be a completely insignificant finding. You need to find out about baseline mental status on every patient, every time. If this patient is not normally unresponsive to pain, this patient is UNSTABLE.

2) The patient had respirations in the 40's. The question you need to ask is, "is he achieving proper oxygenation at this resp rate?" Look at his skin color temperature and condition (specifically for cyanosis), check his O2 sat if you can, listen to his lung sounds. Given the rest of the patient's presentation, your decision to increase the O2 to 15 lpm by NRB was a good one, and your decision to ventilate was also probably correct.

3) The patient had a thready pulse and you were unable to get a blood pressure. Again, is this patient perfusing? The answer is probably not, but you need to look for other clues as well. Mental status is a big predictor of perfusion (and this guy is unresponsive), blood pressure another (you cant get it), skin color/temp/condition, capillary refill, etc etc. Given what you said, this patient is most likely, again, UNSTABLE.

Notice that the things you are looking at follow the initial assessment that every EMT should learn:

1) Mental Status

2) Airway

3) Breathing

4) Circulation

Check and do your best to treat those things, every patient, every time and you will always do the right thing. Err on the side of caution for your patient, and dont be afraid to call for ALS if you think your patient is unstable.

Good luck man, hope some of this overly lengthy response was helpful haha

[JPINFV]

Like everyone else said, excellent post and big time kudos for your willingness to be completely honest about your capabilities.

First I'd like to respond to something another poster said:

DONT ever try and obtain a 12 lead ECG and "read the interpretation at the top" like someone suggested. Not to be rude, but this is an absolutely awful idea. Not only are those interpretations often completely incorrect, but even if they are correct it is silly to assume that a BLS provider would have the knowledge or means to treat such a rhythm. Not to mention that SNFs NEVER perform acute 12 lead ECGs (so what you are looking at is likely old), and an ECG is probably the absolute least important clue for you to consider at this point in the game.

Okay, sorry... had to get that off my chest...

1. The 12 lead in question wasn't from a SNF

2. Umm, how exactly do you plan a basic to "treat a rythum?" High flow o2 and transport? It's about trying to get as much background information as possible. Is this patient different from yesterday? Is this patient different from 2 weeks ago? Not, "Hmm, should I hot wire my AED to shock this rythum from 5 days ago, I think it's still there."

3. Each case is different. The hard choices are those borderline cases. A/Ox2, normally A/Ox4, elevated irregular pulse, so on and so forth. Nothing that yells out "patient is going to crash in 4 seconds" but not a patient that is completely healthy. Are you going to say that the treatment decisions for these patients (which BLS wise, is basically a call 911/rapid transport to the hosiptal, or BLS transport), espeically when trying to determine if a condition is acute or chronic?

[becksdad]

Hey AKFlightmedic, you've got me thinking about something. I never thought of myself as a "ccokbook" EMT, but some of the things you stated earlier have me wondering. I immediately thought this patient need ventilatory assistance because of RR and initial SPO2 @91%. Plus unresponsive. You stated that he quite possibly didn't need the bag. Yep, his sat went to 96% on NRB, and thats not too bad. But I still would have bagged him. Do you think this is just a knee-jerk response to numbers drilled into our heads? I'm thinking of the physiology here, and I'm almost getting it, but something still resists not working on his resps. Can you explain a little more? And, yes, I intend to do some research here too, but I'm very interested in what you (or anyone else) has to say about this. Thanks

[fiznat]

1. The 12 lead in question wasn't from a SNF

2. Umm, how exactly do you plan a basic to "treat a rythum?" High flow o2 and transport? It's about trying to get as much background information as possible. Is this patient different from yesterday? Is this patient different from 2 weeks ago? Not, "Hmm, should I hot wire my AED to shock this rythum from 5 days ago, I think it's still there."

3. Each case is different. The hard choices are those borderline cases. A/Ox2, normally A/Ox4, elevated irregular pulse, so on and so forth. Nothing that yells out "patient is going to crash in 4 seconds" but not a patient that is completely healthy. Are you going to say that the treatment decisions for these patients (which BLS wise, is basically a call 911/rapid transport to the hosiptal, or BLS transport), espeically when trying to determine if a condition is acute or chronic?

1) Doesnt really matter, but ok

2) Exactly my point. EMTs dont treat cardiac arhythmias unless it is a code-- and even then they dont treat, they support. Looking at the ECG really does nothing for your BLS assessment except bring factors into the mix that will have no bearing on your treatment. By all means, bring the ECG along with the rest of the paperwork so someone else can have a look - but please dont ask the question "is this heart rate more irregular than the one thats on 5 day's ago ECG" because that really is immaterial. Ironically enough, your "real story" included an ECG that had frequent PVCs, for which the first line treatment actually IS BLS (supplimental oxygen)... but you should be giving O2 anyways, not because you think the patient's pulse is irregular.

3) I'm having a hard time understanding what you're trying to say here. Yes every patient is different, yes sometimes acutely ill patients are not obviously acutely ill. ...My point stands, though. Reading the computer-generated analysis off the top of an old ECG is probably one of the worst diagnostic tools you (as an EMT) could possibly employ to assess your patient.

[fiznat]

I immediately thought this patient need ventilatory assistance because of RR and initial SPO2 @91%. Plus unresponsive. You stated that he quite possibly didn't need the bag. Yep, his sat went to 96% on NRB, and thats not too bad. But I still would have bagged him. Do you think this is just a knee-jerk response to numbers drilled into our heads? I'm thinking of the physiology here, and I'm almost getting it, but something still resists not working on his resps. Can you explain a little more? And, yes, I intend to do some research here too, but I'm very interested in what you (or anyone else) has to say about this. Thanks

I dont think anyone on the forum can really make an accurate determination whether this patient needed to be bagged or didnt... Its a matter of seeing the patient and really taking in his full presentation that would help lead good providers to that kind of a decision.

The main problem is that there are a number of pathologies that could be the cause of this presentation BESIDES hypoxia. The fact that the SpO2 reads at 96% and the patient was not cyanotic are points against hypoxia as the cause, and raise suspicions about other possible causes. Given an extra set of hands that are otherwise doing nothing during transport-- sure why not, bag him. Given only myself in the back? I think I'd probably spend that time trying to do a more complete assessment, first.

[EMS49393]

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!!

I have to point this out as a "teaching" point for BLS providers. If you are capable of starting an IV, and you start one or two large bore IV's on this type of patient, you had better make sure you do a full assessment before loading up a patient of this age (or any age) with liters of fluid. You contradicted yourself in the end with your comment about "wet lungs" in regards to circulatory support. Do not load a patient up with fluid if they have crackles in their lungs. Assume they are in heart failure. They do not need fluid, they need an inotrope. Chances are good they are already in or beginning renal failure as well, which is contributing to their inability to get rid of excess fluid. It is perfectly acceptable to maintain a systolic blood pressure between 90-100 on this type of patient for transport.

Now, to the matter at hand.

I feel your assessment and history taking skills may need some work. Do not assume care of a patient you seemingly know nothing about. I saw no mention of this particular gentlemen's medical history. Did the facility fail to provide you with paperwork and a report on this patient? Did you fail to require they give you a report prior to transfer of patient care?

A big part of the problem with a BLS education is that you do not understand the pathology of disease processes. Because of this lack of education, you are often unable to do anything but "panic" and follow what you were taught in class. 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. A good paramedic will teach you, not bash you when you want to learn and do the best for your patients. IMHO, this is an ALS patient, unless they have a palliative care only order.

Take advantage of being on a routine transfer car as a BLS provider. I'll be the first to admit that running dialysis transfers over and over can become monotonous. Many new EMTs fail to take advantage of the wealth of knowledge you can gain running transfers. There is no law that says you can't come home and google a medical condition or medication your 80 year old nursing home patient has in her history. You will be surprised at how much better you are at getting a good comprehensive history from a patient if you can associate certain medications with disease processes. You'll always have a patient that will tell you "No, I don't have high blood pressure" only to find they are Atenolol. You can alter your line of questioning with this information. "I see you're on Atenolol. What do you take that for?" You'd be surprised how often I've been told by a patient that they don't have hypertension anymore because they take medication.

Assess your patients each and every transfer. Things can change from day to day in the chronically ill. You might see Mary Renalfailure three to six times a week. One day Mary might seem a little "off" to you. Be alert for those changes as you may be the only one that notices. Besides, you're a new EMT, and you need practice!

I think you did a good job with the understanding that you are not going to perform the type of assessment that an experienced provider might perform. One thing we must remember... just because you passed a test doesn't mean you know it all. You passed a test that stated you know the bare minimum. It's up to you to become experienced. Be the type of provider you want to be. Your ability to critique yourself speaks absolute volumes about your character. Your ability to handle constructive criticism will elevate you above most providers. Don't be afraid to ask, and we won't be afraid to answer.

As for inotrope, :wink: Look it up, it's the best way to learn!

=D>

[becksdad]

Hey EMS49393, of course you are absolutely right about the caution with fluids. The way I put it did sound pretty contradictory, but I wasn't suggesting to start running bags into him, I just thought it would be good to have the locks there if needed. Probably even went overboard by saying "large bore".

[JPINFV]

1) Doesnt really matter, but ok

2) Exactly my point. EMTs dont treat cardiac arhythmias unless it is a code-- and even then they dont treat, they support. Looking at the ECG really does nothing for your BLS assessment except bring factors into the mix that will have no bearing on your treatment. By all means, bring the ECG along with the rest of the paperwork so someone else can have a look - but please dont ask the question "is this heart rate more irregular than the one thats on 5 day's ago ECG" because that really is immaterial. Ironically enough, your "real story" included an ECG that had frequent PVCs, for which the first line treatment actually IS BLS (supplimental oxygen)... but you should be giving O2 anyways, not because you think the patient's pulse is irregular.

3) I'm having a hard time understanding what you're trying to say here. Yes every patient is different, yes sometimes acutely ill patients are not obviously acutely ill. ...My point stands, though. Reading the computer-generated analysis off the top of an old ECG is probably one of the worst diagnostic tools you (as an EMT) could possibly employ to assess your patient.

You've got a patient with an irregular pulse. You've got a hospital discharge packet as your "report" because the staff knows nothing. Patient is altered slightly. Now the question is do you call ALS/transport code 3, or do you transport BLS. So, exactly how much of this patient's condition is acute and how much is chronic. Charging down the street code 3 for an irregular pulse is kinda of stupid if the patient has it as a chronic condition.

[AnthonyM83]

Good responses guys. Very helpful.

Looking back, I realize I was doing cookbookish medicine. And I even felt it at the time...my overall sense of urgency and danger for the patient wasn't bad...but I felt compelled to step it up to code 3, because of the different vitals...the data...rather than looking beneath the data.

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)