One rescuer ventilation question

[RebelAngel]

What is more common for you all to see/do for one rescuer: one rescuer BVM or something else?

According to book and Instructor one rescuer BVM is least efficient way to ventilate, but that's what people in our [very small] squad do. It's been bugging the crap out of me because *I* don't want to do that if it's not going to be the most efficient way. Since we're so small I need to plan on being the only EMT/rescuer running calls (besides driver of course). Be that as it may, I'd rather carry my own pocket masks around with me to use for mouth to mask since that is more efficient than one rescuer BVM. Ironically they're not part of the 800 (a list of supplies and equipment NYS says has to be on our ambulances).

Thoughts?

 

[LACoGurneyjockey]

I've never had a problem using a BVM. Even if there's two of you, only one person is using the BVM at once. Plus, as far as I know a pocket mask can't flow O2.
Hint: not everything the outdated textbook says is right...

 

[NomadicMedic]

Many pocket masks have an o2 port on them. Trust me, first time you work a pukey code, you'll be half you're using a BVM.

 

[RebelAngel]

I've never had a problem using a BVM. Even if there's two of you, only one person is using the BVM at once. Plus, as far as I know a pocket mask can't flow O2.
Hint: not everything the outdated textbook says is right...

Yep, many masks have the O2 inlet and I will definitely buy those types of pocket resuscitators.

As far as the textbook being right, I understand that. However, I had a problem keeping a good seal with my manikin today doing one rescuer BVM. I don't want that on my shoulders, if I can be better and more efficient with mouth to mask, you know?

 

[Tigger]

I have no interest in using a pocket mask in any capacity. If I am alone with a cardiac arrest, hands only CPR all the way. All alone with a respiratory arrest, I'm probably just going to use it. It's rare to be truly alone, and you can get anyone to squeeze the bag when you say so.

I don't carry a pocket mask with me and we don't have any on the ambulances. I know many AEDs have them attached, but I'll be concentrating on what works, compressions and electricity.

 

[NomadicMedic]

In sure you've heard plenty of people say there's a difference between textbook and real life... This is one of them. BVM. Every time.

You're new and sparky. Good for you to want to do the best for your patients.

However. In the real world, it's a BVM.

 

[Carlos Danger]

According to book and Instructor one rescuer BVM is least efficient way to ventilate, but that's what people in our [very small] squad do. It's been bugging the crap out of me because *I* don't want to do that if it's not going to be the most efficient way. Since we're so small I need to plan on being the only EMT/rescuer running calls (besides driver of course). Be that as it may, I'd rather carry my own pocket masks around with me to use for mouth to mask since that is more efficient than one rescuer BVM. Ironically they're not part of the 800 (a list of supplies and equipment NYS says has to be on our ambulances).

Single-person ventilation is perfectly adequate as long as you are doing it correctly. If you are getting good gas exchange (i.e. good chest rise and misting in the mask), then a second set of hands will add nothing.

Mask ventilation is a surprisingly difficult skill to master, however. Real proficiency takes a lot more practice than most of us get as EMT's or Paramedics. In fact, quite a few patients (I'd say 1-2% or so?) are very difficult or impossible to mask ventilate adequately, even in the OR by two anesthesia providers. A much larger percentage (at least 25%, perhaps much more, I'd guesstimate) are not adequately mask ventilated by field personnel, due to a combination of positioning problems and lack of skill. This is why 2-person is considered more efficient, although a second rescuer doesn't guarantee success, if neither are well-practiced in it.

All that said, there will certainly be times where single-person ventilation needs to be done, and you just do the best that you can do. Take the skill seriously (which it sounds like you are) and practice it every chance you get. Be very quick to use an OPA and/or NPA, and pay close attention to your mask seal and your neck flexion. Using a single hand to lift the chin the right way while maintaining a good seal takes practice - especially in obese patients or those with beards - but really is the whole crux of the skill in most cases.

And as others have said, use a BVM instead of a pocket mask. A pocket mask is fine to use when you simply don't have anything else, but if you are going to keep a BLS bag in your car, a BVM should be your most important piece of equipment, and always use it (rather than a pocket mask) if you have access to it.

 

[medicsb]

Mask ventilation is a surprisingly difficult skill to master, however. Real proficiency takes a lot more practice than most of us get as EMT's or Paramedics. In fact, quite a few patients (I'd say 1-2% or so?) are very difficult or impossible to mask ventilate adequately, even in the OR by two anesthesia providers. A much larger percentage (at least 25%, perhaps much more, I'd guesstimate) are not adequately mask ventilated by field personnel, due to a combination of positioning problems and lack of skill. This is why 2-person is considered more efficient, although a second rescuer doesn't guarantee success, if neither are well-practiced in it.

Truth. Apparently a great way to get experience with a BVM is to attend electro-convulsive (shock-treatment) therapy, but only so many places actually do it. Realistically, it'd be ideal to have all EMT students go to the OR to practice bagging, but it is likely not practical.

 

[mycrofft]

One person BVM is very difficult to do without it being attached to an endotracheal device. And then not easy but do-able. At least have some sort of airway so you are not trying to hyperextend the neck AND seal the mask.

BTW, take the mask off a BVM and you have: a pocket mask without the valve. BTST (by the same token ) a bad or missing BVM mask can USUALLLLY be replaced by a pocket mask in a pinch.

Tigger has a valid point. If pt needs CPR and you are all alone, make sure the compressions are going very well and not being interrupted by dinking around with a balky BVM.

PS: Oxygen into pocket masks? If the mask straps on, it's a sort-of oxygen mask. Find me an unbiased study where they find it makes a difference. And the ones with O2 nipples can become very stiff, enough to be unable to open them out

 

[Carlos Danger]

Truth. Apparently a great way to get experience with a BVM is to attend electro-convulsive (shock-treatment) therapy, but only so many places actually do it. Realistically, it'd be ideal to have all EMT students go to the OR to practice bagging, but it is likely not practical.

YES. I work in ECT regularly and there is probably is no better way to learn mask skills. In an hour you'll mask ~5 patients or so for about 5 minutes each.

Anyone who has the chance to spend some time in ECT should absolutely do it.

 

[NomadicMedic]

My paramedic program did a skill session called "bag a buddy". It was a great way to get a feel for bagging and BEING bagged. http://emsworld.com/article/10319947/assisting-ventilations

 

[RebelAngel]

I have a manikin and BVM sitting in my living room. The Chief offered it to me so I could practice. The mask with BVM is completely different than the pocket resuscitator I have. The BVM mask seals much, much easier.

 

[Tigger]

Yep, many masks have the O2 inlet and I will definitely buy those types of pocket resuscitators.

As far as the textbook being right, I understand that. However, I had a problem keeping a good seal with my manikin today doing one rescuer BVM. I don't want that on my shoulders, if I can be better and more efficient with mouth to mask, you know?

There is no reason to purchase your own equipment for use at your agency. Doing so sets a dangerous precedent for future department purchases.

 

[Brandon O]

In recognition of the challenges of one-person BVM, most of the textbooks have discouraged it for many years. In the field everyone promptly ignores this, because Real EMTs have no interest in using a pocket mask, and two-person BVM use is considered weak or something.

Then most of these Real EMTs promptly proceed to utterly fail to successfully ventilate people.

IMO everyone who says they'd never use a pocket mask should be forced to demonstrate the ability to obtain a one-handed BVM seal on every patient and ventilate them without gastric distention. On any patient, 100% of the time. Because if you can't, and you still maintain you'd never use the pocket mask, then theoretically there is a hypoxic patient out there you'd allow to die because you're so convinced that Real EMTs Don't Need Backup Plans.

But that never happens, right? We've never seen somebody "managing the airway" who's really just squeezing oxygen near somebody's face.

Hopefully we all remember this little factoid, but if somebody's not breathing and you can't ventilate them, they will die. This is a kinda important thing. It behooves you to have as many tools, options, solutions, and backups as you can wedge between a hypoventilatory patient and hypoxia.

Here's one example of having options. Everyone's different, so you should have your own toolbox. But the guy with only one option is gonna kill someone eventually.

(By the way, the medics have a lot more pieces of plastic, but if they can't competently use them all or don't have a mental process for when to do so, they don't have any more options than you.)

 

[RebelAngel]

Thanks to the Manikin and being able to practice I think I figured out what my issue was. I am going to give it a little bit and then rush in there to save my manikin with one person BVM. :rofl:

 

[Tigger]

In recognition of the challenges of one-person BVM, most of the textbooks have discouraged it for many years. In the field everyone promptly ignores this, because Real EMTs have no interest in using a pocket mask, and two-person BVM use is considered weak or something.

Then most of these Real EMTs promptly proceed to utterly fail to successfully ventilate people.

IMO everyone who says they'd never use a pocket mask should be forced to demonstrate the ability to obtain a one-handed BVM seal on every patient and ventilate them without gastric distention. On any patient, 100% of the time. Because if you can't, and you still maintain you'd never use the pocket mask, then theoretically there is a hypoxic patient out there you'd allow to die because you're so convinced that Real EMTs Don't Need Backup Plans.

But that never happens, right? We've never seen somebody "managing the airway" who's really just squeezing oxygen near somebody's face.

Hopefully we all remember this little factoid, but if somebody's not breathing and you can't ventilate them, they will die. This is a kinda important thing. It behooves you to have as many tools, options, solutions, and backups as you can wedge between a hypoventilatory patient and hypoxia.

Here's one example of having options. Everyone's different, so you should have your own toolbox. But the guy with only one option is gonna kill someone eventually.

(By the way, the medics have a lot more pieces of plastic, but if they can't competently use them all or don't have a mental process for when to do so, they don't have any more options than you.)

I have no interest in getting puke on my face frankly. If a BVM mask is not going to stop vomit (and it doesn't), I don't really want my face there either. Can't wear a mask and use a pocket mask...

 

[Brandon O]

I have no interest in getting puke on my face frankly. If a BVM mask is not going to stop vomit (and it doesn't), I don't really want my face there either. Can't wear a mask and use a pocket mask...

Fair enough. And I'm not necessarily saying you should. Certainly, with BSI in mind, nobody would fault you for passing on that option.

But it's smart to unpack the ramifications of your decisions when things are calm. In the hypothetical situation where you absolutely cannot ventilate the patient with the BVM but possibly could with the pocket mask, would you let that person die?

 

[NomadicMedic]

I'm certainly not to proud to ask for help with an extra set of hands in a difficult to bag patient. Practice does make it easier. I also have BIG hands and use several adjuncts when I bag a patient, so I usually don't have issues on patients with "normal" facial anatomy. Knowing the predictors for a difficult to mask ventilate patient (BONES anyone?) is also a smart way to know if you're going to have to move to another option when you can't bag. However,,it's not really an issue for me. In the "can't ventilate/can't intubate" situation, they just get cut.

 

[chaz90]

Fair enough. And I'm not necessarily saying you should. Certainly, with BSI in mind, nobody would fault you for passing on that option.

But it's smart to unpack the ramifications of your decisions when things are calm. In the hypothetical situation where you absolutely cannot ventilate the patient with the BVM but possibly could with the pocket mask, would you let that person die?

Someone else is going to be on scene. For one, where I am we have a partner that is with us as we arrive at a call ~90% of the time. Secondly, the BLS ambulance often beats us there or is very close behind. Thirdly, who called EMS? If I'm single medic and alone for a brief time on a profound respiratory failure patient who is difficult to ventilate alone with the use of airway adjuncts, the caller is going to be squeezing the BVM for me as I use two hands to create a seal.

 

[Carlos Danger]

In recognition of the challenges of one-person BVM, most of the textbooks have discouraged it for many years. In the field everyone promptly ignores this, because Real EMTs have no interest in using a pocket mask, and two-person BVM use is considered weak or something.

Then most of these Real EMTs promptly proceed to utterly fail to successfully ventilate people.

IMO everyone who says they'd never use a pocket mask should be forced to demonstrate the ability to obtain a one-handed BVM seal on every patient and ventilate them without gastric distention. On any patient, 100% of the time. Because if you can't, and you still maintain you'd never use the pocket mask, then theoretically there is a hypoxic patient out there you'd allow to die because you're so convinced that Real EMTs Don't Need Backup Plans.

This presupposes that most patients who are difficult to ventilate with a BVM will not be equally difficult to ventilate with a pocket mask.

Are pocket masks that much easier to ventilate with?

I've never used one so I honestly don't know, but the physics are the same no matter what you are using to generate pressure, so I'd imagine that someone who isn't skilled with a BVM is probably not going to do great with a pocket mask either.

I know a pocket mask allows for use of both hands on the mask which should theoretically make it easier to maintain a seal, but keeping a seal is only part of the battle, and I can envision other challenges that are unique to pocket masks. Primarily, it would seem to be more difficult to maintain proper jaw thrust and neck flexion while leaning down at an awkward angle and moving your mouth onto and off of the mouthpiece. You'd also probably get tired quicker, at which point form tends to get sloppy.