Just finished my training at a new job as an EMT-B. I'm still nervous about pt. care, but I'm learning. On my 3rd shift I got to see a gun shot wound, 2 IO's, an attempted RSI, Air Care, bagging a pt., cpr, a needle decomp, and then how the ME handles a fatality. Sounds bad but it was pretty awesome to finally be in a position to provide pt. care to someone who needed it. I did very little we had 2 ambulances, a ton of very well trained fire fighters, and at least 3 paramedics. At one point I think there was 8 people in the back of that truck. No real point to this thread, it's just awesome to finally have a real job at a service.
I frigging love this job
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An attempted RSI? That's disturbing. By the ground or flight team? Air Care?
Was this all one patient?
8 people in the back of a truck?
Was there not anyone in charge of this scene?
It sounds more like you witnessed something from the Keystone Cops' lost episodes rather than a rescue.
It also sounds like the only person this patient needed was the ME.
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As for the attempted RSI. We pushed the drugs and the pt. clenched his teeth so hard we couldn't get the tube in. Turned out the pt. was about to return to rehab so they thought he might have been using. I don't know if that caused a reaction or not. Yeah it was chaotic and there was a ton of stuff going on. We called aircare, but decided to wave it off cause the pt. had been down for so long we were about to call it. Yes this was one pt. Yes someone was in charge of the scene, but at the time we had a ton of extra help and we weren't about to turn it down.
Let me know the next time you have a traumatic arrest that goes perfectly.
Let me know the next time you have a traumatic arrest that goes perfectly.
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That's exciting!
My best days in EMS were during my clinical shifts. Working in a Level 1 trauma center, and riding on a busy ALS ambulance, I got to do all of the fun stuff with no pressure or expectations.
Learn a lot, ask a lot of questions, and never lose your excitement for EMS.
My best days in EMS were during my clinical shifts. Working in a Level 1 trauma center, and riding on a busy ALS ambulance, I got to do all of the fun stuff with no pressure or expectations.
Learn a lot, ask a lot of questions, and never lose your excitement for EMS.
I don't fly traumatic arrests in my helicopter.
When I do RSI for intubation, I have enough protocols with "guidelines" to hopefully get the job done correctly.
When I worked ground, I did not need 8 people in my truck regardless of how many FFs responded with me.
I see traumas everyday, both in the helicopter and in the ED, that go very well.
I hope you can get past the excitement of a "trauma" to see what patient care is all about. And remember, that is a human being who may have a family that will mourn his death so control your excited joy from the adrenaline rush when one scene or at the ED because you never know who might be present.
Good luck to you and continue with your education.
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ResTech
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I totally understand your excitement with being in the field for the first time and seeing all that... Don't let ne one kid ya... that is what we live and train for! You just have to be careful with how you present it so its not taken the wrong way. From a clinical stand point you got some good experience just from observing... The clinical, patient care element of EMS is the most important... dont ever lose sight of that and always strive to excel. All the "auxiliary" parts of EMS like the big shiny Medic units, the lights and sirens, the public reputation of EMS, etc are non-essential to the real mission.
I don't understand how if the Medic RSI'd and administered a paralytic the pt's. teeth were still clinched. Is this possible with RSI in some pt's? To my knowledge it is not.
I don't understand how if the Medic RSI'd and administered a paralytic the pt's. teeth were still clinched. Is this possible with RSI in some pt's? To my knowledge it is not.
medic417
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If he administered wrong med or wrong dose. Also seen some patients require additional dose to take affect but sadly some protocols are rigid and do not allow the medics to do what needs done, they give the minimum and if that doesn't work so sorry no more can be done. I hate cookbook EMS.
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Gotcha... I thought so but just wanted to make sure there are no special cases that may render the paralytic ineffective. Thanks!
As Medic417 stated, cookbook medicine is not always a good thing. As well, there is probably not enough education done to know what will and will not work in certain situations. Sometimes it is best to stick with what you can do without making a situation worse by doing a procedure that may not work because you have limitied set protocols.
There are situations that a paralytic should not be used especially if you don't have guidelines in your protocol. If you have a heavy drug user of certain drugs, that patient is not going down easy. There are also other situations where a paralytic is not advised. If you score the airway as being difficult from other anatomy characteristics, a paralytic is not advised.
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Not to hijack the thread... but just curious what came about with the patients airway since they couldn't get an ETT in?
Agitation and pain will cause one's teeth to clinch as will some injuries to CNS.
With the teeth clenched they could have tried NTI. However, after a botched RSI with a patient who may not be breathing that could be more difficult.
An NPA could have been used with the good ol' BVM until they got med control to allow them another RSI attempt with more meds.
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I was meaning to ask what did the crew on the call do for airway management after the failed RSI? sorry.
It was a trauma arrest if Im not mistaken... so nasal intubation is a no-go. If you got good compliance and tidal volume with a BVM and NPA... I agree an option.
Maybe consider a surgical airway as well.
One thing I was taught in airway class and am finding out first hand is.... its not knowing how to do a skill but knowing WHEN! We had a 5 month old in arrest and the Medics tried 3 attempts at intubation and with each attempt breath sounds were ausculated as were epigastric sounds simultaneously. There was a EtCO2 detector onboard the unit... but in the heat of it all the one Medic had it and forgot so we couldnt verify with EtCO2...
I asked my preceptors after the call about the tube placement and hearing the lung sounds and epigastric sounds at the same time... I concluded it was from the ETT being to small to seal off the trachea and air was coming back up (rebreathing) around the tube and into the pt's. stomach. They agreed thats prob what was happening... Vent, is this accurate?
The point of this story is... I wish they would have just took the tube out since there was doubt about proper placement and just bagged with an OPA and an NG tube in place. Least then u are sure the pt. is being oxygentated and well ventilated. Nothing wrong with falling back to sound BLS. Opinions on if this would have been a good call for management?
It was a trauma arrest if Im not mistaken... so nasal intubation is a no-go. If you got good compliance and tidal volume with a BVM and NPA... I agree an option.
Maybe consider a surgical airway as well.
One thing I was taught in airway class and am finding out first hand is.... its not knowing how to do a skill but knowing WHEN! We had a 5 month old in arrest and the Medics tried 3 attempts at intubation and with each attempt breath sounds were ausculated as were epigastric sounds simultaneously. There was a EtCO2 detector onboard the unit... but in the heat of it all the one Medic had it and forgot so we couldnt verify with EtCO2...
I asked my preceptors after the call about the tube placement and hearing the lung sounds and epigastric sounds at the same time... I concluded it was from the ETT being to small to seal off the trachea and air was coming back up (rebreathing) around the tube and into the pt's. stomach. They agreed thats prob what was happening... Vent, is this accurate?
The point of this story is... I wish they would have just took the tube out since there was doubt about proper placement and just bagged with an OPA and an NG tube in place. Least then u are sure the pt. is being oxygentated and well ventilated. Nothing wrong with falling back to sound BLS. Opinions on if this would have been a good call for management?
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It sounds like this patient was in need of CPR on arrival which you are correct about the NTI although that still is not impossible.
Air sounds can be produced throughout the abdomen especially after bagging. As you move the diaphragm, you move the contents of the abdominal cavity which is why vomiting is also a side affect. As gas moves you get sounds everywhere.
There should be just enough air placed in the cuff of the ETT to seal the trachea. So, it is not the tube since that will be the same one, or similar, used on a mechanical ventilator.
However, there is the possibility of the tube be placed to high where the cuff lies above the cords and not below them. In other words you have inadvertently used the ETT as a supraglottic device. I see this alot when some use a 5.5 or 6.0 ETT for NTI on a tall long necked patient. The cuff doesn't even come close to the glottic opening. There are also a couple of commercial ETT holders that don't secure well or it is difficult to judge where the markings are and the distance from the gum line.
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ResTech
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I know in a pediatric pt. a cuffless tube is indicated since the anatomy of the pediatric trachea serves as a "functional" cuff. They tried with a 2.5 cuffless tube and then went with a 3 that was also cuffless. So that is why I was thinking that the tube was not sealing off the trachea like it is supposed to without a cuff.
I get what your saying about air being in the stomach and the diaphragm being pulled downward causing the air to be moved around the stomach producing gastric sounds even through a tube is properly placed... I never thought of that...
I get what your saying about air being in the stomach and the diaphragm being pulled downward causing the air to be moved around the stomach producing gastric sounds even through a tube is properly placed... I never thought of that...
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My apologies, I missed the part about the pedi intubation.
Both the 2.5 and the 3.0 would be inappropriate for a 5 month old unless the baby was less then 2000 grams.
When listening for breath sounds on an intubated infant, you listen in the axillary region. You also note color and HR change.
Since Paramedics get very little training or education in pediatrics, this is probably a good example as to why pedi intubation is no longer allowed in some services.
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Why is it preferred to listen in the axillary fields versus the usual anterior fields on an infant? I did not have PALS or even ACLS yet so I'm full of questions for clarification sake.
When the Paramedic measured for ETT size, he used the pt's. little finger. Is this a good practice for determining ETT size for a infant?
When the Paramedic measured for ETT size, he used the pt's. little finger. Is this a good practice for determining ETT size for a infant?
My other question would be about the needle decompression. How was the determination made? Were ventilations by pt or assisted adequate equate enough without intubation to hear a difference in breath sounds? Tracheal deviation? Was the needle decompression done on the same side as the bullet? Was it more hemo than peumothorax which would have required a chest tube which possibly the Air Care team could have done...if the patient wasn't dead already?
This is actually a very good scenario to review for someone new to EMS. There should also be a role review of who does what. Too many cooks using cookbook medicine in the back of a truck is not always a good thing. While some might see it as "lots of help", I see it as more to get under foot or heightened an adrenaline rush situation and mistakes can be made.
This is actually a very good scenario to review for someone new to EMS. There should also be a role review of who does what. Too many cooks using cookbook medicine in the back of a truck is not always a good thing. While some might see it as "lots of help", I see it as more to get under foot or heightened an adrenaline rush situation and mistakes can be made.
LOL! He should have taken PALS or even NRP or have some idea about the concept of what a Broselow Pedi setup is even if his truck doesn't have one.
http://www.colorcodingkids.com/
We use an estimation of weight for tube size...not fingers of babies.
Due to the chest size and the disportions of the head, chest, adomen and organs within each region, listening towards the axillary region pretty much isolates the lungs.
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