One rescuer ventilation question

[Brandon O]

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.

I love that you've thought about it (which is really my main point, not the details). But to keep kicking this can along: how about if your patient tanks while you're alone in back? Or a confined space (e.g. MVA entrapment) where there's no room for another rescuer (and maybe no space to properly use the BVM)?

 

[NomadicMedic]

What if? What if? What if? We can what if this forever. Either they are able to be bagged, or they're not. If you've got another solution, you use it. If not, you just reposition and try again.

 

[mycrofft]

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.

Yeah, the BVM mask has a pneumatic seal (poofy) and the pocket mask is not. Poofy can go flat.

The deal is that their fitting to the valve or to the BVM is identical.

 

[Brandon O]

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.

I'm not really trying to elevate the stupid pocket mask as the holy grail of BLS ventilation, I'm just trying to point out that airway algorithms are only reliable if they have layers, and the single-person BVM is just one pretty crappy layer.

But yeah, I'd say it's probably among the more reliable tools. Since you have two hands and you're at a cozy distance, it's dead easy to make a seal; and generating air with your own lungs makes it reaaaaally easy to control the pressure you use (and feel the compliance as a constant quality check). I'd guess the only situation where the BVM would be easier is one where you can't get closer than arm's length for some reason.

(As a caveat, no, I haven't pocket masked a human being. But I have played with this stuff quite a bit.)

 

[mycrofft]

What if? What if? What if? We can what if this forever. Either they are able to be bagged, or they're not. If you've got another solution, you use it. If not, you just reposition and try again.

And be good at both so you have the option.

I think this is a case of we mostly thinking alike, but the leisure and detachment afforded by a keyboard and a monitor make quibbling attractive. In a pinch, most would do their best and not flub it.

 

[Brandon O]

What if? What if? What if? We can what if this forever. Either they are able to be bagged, or they're not. If you've got another solution, you use it. If not, you just reposition and try again.

The number of solutions you have is determined by how many you've come up with (and properly analyzed, planned out, and trained for) beforehand.

Eventually, the next step in any algorithm is "failed? well... keep trying until they're dead." But you want to make space before you hit that point.

With due respect, I'm not sure how understandable this is for the medics. Managing a difficult airway with nothing but a BVM and your wits is a uniquely BLS experience. Our typical airway algorithm is "1. BVM with OPA -- if failed --> 2. Soil self, call ALS, run screaming"

 

[mycrofft]

The number of solutions you have is determined by how many you've come up with (and properly analyzed, planned out, and trained for) beforehand.

Eventually, the next step in any algorithm is "failed? well... keep trying until they're dead." But you want to make space before you hit that point.

With due respect, I'm not sure how understandable this is for the medics. Managing a difficult airway with nothing but a BVM and your wits is a uniquely BLS experience. Our typical airway algorithm is "1. BVM with OPA -- if failed --> 2. Soil self, call ALS, run screaming"

BVM with OPA -- if failed --> start compressions because you spent to much time on airway and failed .

 

[RebelAngel]

Someone commented about 90% of the time there is someone else there. We're all volunteer and we're very small. There are only two active EMTs in our squad and only one of those runs calls regularly, the other is just sort of back-up (because he really doesn't want to do it anymore) for when first EMT is out of town. When me and the other woman taking the course pass that brings us up to four. 90% (probably more) there will only be me and my driver responding to calls, unless there's an EMR. My oldest is currently taking the EMR course, so that's more of a possibility now than it was before we joined the FD.

 

[chaz90]

Someone commented about 90% of the time there is someone else there. We're all volunteer and we're very small. There are only two active EMTs in our squad and only one of those runs calls regularly, the other is just sort of back-up (because he really doesn't want to do it anymore) for when first EMT is out of town. When me and the other woman taking the course pass that brings us up to four. 90% (probably more) there will only be me and my driver responding to calls, unless there's an EMR. My oldest is currently taking the EMR course, so that's more of a possibility now than it was before we joined the FD.

That was just a comment about my situation. Even in your case, as mentioned, you can have your driver squeeze a BVM for you as you create the seal with two hands. I agree with Brandon though in saying it's more a hypothetical situation than a realistic "I expect this to happen tomorrow." Specifics aren't overly important IMO. I do like this thread as something to at least think about and remind people of the common ineffectiveness of one person BVM.

 

[broken stretcher]

throw them on a NRB. Effective CPR is your first priority.

 

[CFal]

Turns out BVM s don't work too well in single digit temperatures

 

[Handsome Robb]

throw them on a NRB. Effective CPR is your first priority.

While I agree in most cases there are patients who we need to focus on oxygenation and ventilation along with good CPR. Cardiocerebral Resuscitation (CCR) has shown some promising stuff but we will have to wait and see.

We do CCR and submit to the CARES registry.

CCR is contraindicated in a cardiac arrest with a respiratory etiology. The exact verbiage of our CCR protocol is: "Nontraumatic cardiopulmonary arrest patients without a primary respiratory etiology (ie drowning or drug overdose)."

 

[Handsome Robb]

Turns out BVM s don't work too well in single digit temperatures

Why do you say that? Is your box not temperature controlled when you're posted or in quarters?

 

[CFal]

Why do you say that? Is your box not temperature controlled when you're posted or in quarters?

Ski Patrol, wasn't in a box

 

[Handsome Robb]

Ski Patrol, wasn't in a box

Ah gotcha.

Not sure where you keep your stuff, if it's in the sled consider pulling it and taking it into the hut. We put our trauma kit inside the hut. Also used to stuff the plastic bag the BVM was in with crumpled up newspapers and that kept it decently warm. If its really cold add a blanket wrap around the whole thing.

Tricks of the trade

 

[CFal]

Ah gotcha.

Not sure where you keep your stuff, if it's in the sled consider pulling it and taking it into the hut. We put our trauma kit inside the hut. Also used to stuff the plastic bag the BVM was in with crumpled up newspapers and that kept it decently warm. If its really cold add a blanket wrap around the whole thing.

Tricks of the trade

We have an airway bag that is inside the hut, it has O2 tank, BVMs, NRBs, OPAs, NPAs etc...

 

[Tigger]

Never had a problem bagging in cold temperatures here...

 

[mycrofft]

turns out bvm s don't work too well in single digit temperatures

yep!

 

[mycrofft]

While I agree in most cases there are patients who we need to focus on oxygenation and ventilation along with good CPR. Cardiocerebral Resuscitation (CCR) has shown some promising stuff but we will have to wait and see.

We do CCR and submit to the CARES registry.

CCR is contraindicated in a cardiac arrest with a respiratory etiology. The exact verbiage of our CCR protocol is: "Nontraumatic cardiopulmonary arrest patients without a primary respiratory etiology (ie drowning or drug overdose)."

There's a shelf life for respiratory etiology codes after which you're doing CPR because the heart isn't going to restart otherwise. However...

One of the big lies of omission we perpetrate for the patients' sake; a code due to respiratory failure may initially reflect cardiac irritability related to cardiomyopathic anoxia, but after five minutes or so the brain starts going. A defib might, might bring back a damaged heart for a bit, but it won't do a thing for arrest secondary to cerebral anoxia, i.e., biological death.

 

[Handsome Robb]

We have an airway bag that is inside the hut, it has O2 tank, BVMs, NRBs, OPAs, NPAs etc...

So I'm confused as to why you had troubles with the BVM then? If they're frozen they're a pain in the butt absolutely. I guess maybe we don't get as cold here? I never had issues with a BVM on the hill. Sorry wasn't trying to be condescending...

Never had a problem bagging in cold temperatures here...

See above

There's a shelf life for respiratory etiology codes after which you're doing CPR because the heart isn't going to restart otherwise. However...

One of the big lies of omission we perpetrate for the patients' sake; a code due to respiratory failure may initially reflect cardiac irritability related to cardiomyopathic anoxia, but after five minutes or so the brain starts going. A defib might, might bring back a damaged heart for a bit, but it won't do a thing for arrest secondary to cerebral anoxia, i.e., biological death.

I might just be too tired but I didn't understand what you were trying to get at with that.