Prehospital Sedation of the Combative Patient in the presence of a TBI

[Handsome Robb]

I'm not trying to be a jerk, but you stated that there were firefighters and another ALS unit on scene, how it that you don't have time to call but you have time to get 2 IVs? RSI would have taken much more time than calling. I've worked urban with short transport times and have been in nearly exact situations... still had time to call (it was required where I worked). Let the firefighters and other ALS crew members wrestle while a call is made (shouldn't take more than 1 minute).

I know it can be a pain in the *** to call, but it is something to consider when there is no protocol. Instead of thinking about creative writing it might be better to think, "I'll just make a quick call."

Not being a jerk, I asked for opinions. Our engines are 4 man engines with 3 basics and an intermediate so all they can really do is BLS and start a line if they can actually hit it. We had two very sick patients and the other ALS crew was tied up with their also altered patient.

I got both IVs en route, had RSI been an option it would've been performed on scene but I knew from the get go it wasn't and this guy needed it so I didn't want to spend a ton of time doinking around on scene. I got on scene and he was already boarded, we pulled our gurney out walked it over put him on it and moved to the truck and started going. I wish it was "just a quick call" but unfortunately we routinely have to wait a few minutes before a doc can even come to the phone after the charge nurse answers and pages them overhead.

 

[RocketMedic]

Sounds like you did the best you could in a bad situation.

 

[triemal04]

As easy as it would be, I actually don't mean this in a completely derogatory way.

If the reporting of the call, including times are accurate, this to me screams "very new, very inexperienced paramedic who is very new to working alone and panicked." You had a patient with a pretty clear TBI who was combative to the point you couldn't really assess, let alone treat. While you weren't allowed to intubate, you were allowed to mask-ventilate, but were/would have been unable to do so due to the patient fighting. You had a patient with trismus (or at least a clenched jaw due to them being highly agitated and combative) which mixes very poorly with vomitting, something they are definetly at risk for. To say nothing about how increased ICP doesn't go well with being combative. Yet, despite apparently knowing all this you elected to spend less than 4 minutes on scene and essentially run for the hospital while doing nothing. Let's think this through:

Which is better:
1- Deliver a patient who needs to be assessed and intubated to the ER in a very combative state where nothing can be done until the patient is calmed. This may cause the ER to "ramp up" more than they need to and potentially make mistakes/miss things that they wouldn't otherwise. While this will depend on the ER, it should be a concern.
2- Take a couple extra minutes, get orders for sedation, and give them the same patient but in a very CALM setting (both the patient and yourself), and in a state that is more benefical to their health, and who you now know more about.
3- Go outside your protocols, knowing that, because no protocol can be written to cover every situation, and you are acting appropriately and in the patient's best interest and will immedietly inform your supe and medical director you will not face discipline. Of course this only works in a good system. And then give them the patient from #2.

Which do you think would be more appropriate?

Would this guy have been intubated right away no matter what? Almost certainly. Do you think that maybe if he had been properly sedated prior to arrival there wouldn't have been as much of a rush (percieved by you or not)? Perhaps if that was the case he would have been better prepped for intubation and the doc would have been successful on the first pass. Perhaps knowing that taking a little extra time can make things go better for the patient and run smoother for the ER would be good, and knowing that dumping every patient on the ER is bad.

To continue. What makes you so certain you wouldn't have been able to intubate this patient? Because 3 doc's using the Glidescope had trouble? Really? How profiecent are each of them at using the Glidescope? How often do they do it? How many times did they use it while learning? How often do they intubate period and how good are they? The Glidescope is not the same as DL and takes practice. Were they in a rush due to the patient's state? Was the patient in an optimal conditon to intubate (full sedation and paralysis)? Making the immediate assumption that because a ER doctor is unable to intubate means that you wouldn't be able to either is wrong. IF you are truly profiecent at intubation of course. If not all bets are off.

And to close:

Let me ask you this, I spent an extra two minutes on scene of a nasty 100 mph motorcycle accident so my partner and I could drop bilateral large bore lines because I wouldn't have had time to do both en route. Total scene time was 14 minutes. Did I do it wrong?

So you are unwilling to spend extra time doing something that will be beneficial to the patient in both the short and long term, but are willing to waste time doing something that is likely unneccasary, not helpful, and possible harmful? You were willing to spend 14 minutes with that patient to start IV's but only 4 for another who actually needed something?

Things to be thinking very hard about right now.

 

[Veneficus]

Which is better:
1- Deliver a patient who needs to be assessed and intubated to the ER in a very combative state where nothing can be done until the patient is calmed. This may cause the ER to "ramp up" more than they need to and potentially make mistakes/miss things that they wouldn't otherwise. While this will depend on the ER, it should be a concern.

What?

If the ER is making mistakes and missing things because they have a patient who is agitated and needs intubated, they are certainly not following the ATLS guidlines and are likely not capable enough to receive such a patient anyway.

Past selecting the proper facility to drive to, this is not a concern of the paramedic.

2- Take a couple extra minutes, get orders for sedation, and give them the same patient but in a very CALM setting (both the patient and yourself), and in a state that is more benefical to their health, and who you now know more about..

While it is nice, it is a luxury, not a requirement. In the suspected TBI patient, with a short transport, just bringing them in is not a bad solution. Not the best, but local protocol will dictate that, not the most appropriate medical practice.

3- Go outside your protocols, knowing that, because no protocol can be written to cover every situation, and you are acting appropriately and in the patient's best interest and will immedietly inform your supe and medical director you will not face discipline. Of course this only works in a good system. And then give them the patient from #2...

What if something goes wrong and instead of pt #2, you have pt #4, in cardio-respiratory arrest?

I don't think it is a good idea to suggest to people to go outside of their protocol. If they work in a system where it is accepted even if not permissible, if something goes wrong, they could be the one who gets all the blame.

Which do you think would be more appropriate?

Do you think that maybe if he had been properly sedated prior to arrival there wouldn't have been as much of a rush (percieved by you or not)? Perhaps if that was the case he would have been better prepped for intubation and the doc would have been successful on the first pass..

Pure speculation.

This patient could easily have been a difficult airway prior to facial trauma.

Also if he required OMFS reconstruction, they prefer nasal tracheal tubes or trachs. Which unless things have changed, are not indicated for paramedics in patients with facial trauma?

I support the use of sedation in this case, but I think this post is getting a little off the map and not all of the conclusions are accurate.

Perhaps knowing that taking a little extra time can make things go better for the patient and run smoother for the ER would be good, and knowing that dumping every patient on the ER is bad..

I do not see bringing a trauma patient to the ER in no worse condition than found as bad. Certainly I would not call it dumping. If this patient truly had a TBI, then treatment is at the hospital.

The purpose of prehospital airway intervention is not to make things go smoother in the ED, it is to make sure the airway is secure and protected so the patient doesn't die.

Nobody ever died from not having a plastic tube in their trachea. They die from not having the ability to get air in and out.

In this case, the airway was controlled and the patient ventilated. Perhaps not in the most effective way, but the goal had been met.

To continue. What makes you so certain you wouldn't have been able to intubate this patient? Because 3 doc's using the Glidescope had trouble? Really? How profiecent are each of them at using the Glidescope? How often do they do it? How many times did they use it while learning? How often do they intubate period and how good are they? The Glidescope is not the same as DL and takes practice. Were they in a rush due to the patient's state? Was the patient in an optimal conditon to intubate (full sedation and paralysis)? Making the immediate assumption that because a ER doctor is unable to intubate means that you wouldn't be able to either is wrong. IF you are truly profiecent at intubation of course. If not all bets are off

Is this some sort of a joke?

I will concede that in many places ERs are staffed with any doc they can find, who may or may not be proficent at intubating with the equipment available. But many ofthe assumptions you have made here are bordering on hubris, not logic.

How do you know these docs were not board ceritfied EMs who spend far more time on intubation than medics? How do you know one or more was not an anesthesiologist, who probably puts more tubes in a shift than 99% of paramedics in a month?

There is a lot you are assuming and most of it is around an incapable doctor and a more capable medic or a medic exceeding their role.

I mentioned it in PM, but I will put it here. On a TBI patient with facial trauma, with a predetermined difficult airway, surgical cric would be my first choice and it would take a considerable amount of things going right to deter that decision.

And to close:

So you are unwilling to spend extra time doing something that will be beneficial to the patient in both the short and long term, but are willing to waste time doing something that is likely unneccasary, not helpful, and possible harmful?

Like sitting on a street corner with a trauma patient deciding to deviate from protocol while trying to prove he can intubate somebody better than the doctors in the ER because they might not be proficent?

Things to be thinking very hard about right now.

I agree.

 

[the_negro_puppy]

Our ICP's here can use Midazolam for "agitated head injuries to facilitate assessment and treatment"

IV 1-2.5mg repeated at 1-2mg increments every 5 minutes until pt is cooperative or allows O2 + spinal immobilisation. Should be avoided in cases of hypovolemia.

 

[triemal04]

If the ER is making mistakes and missing things because they have a patient who is agitated and needs intubated, they are certainly not following the ATLS guidlines and are likely not capable enough to receive such a patient anyway.

Past selecting the proper facility to drive to, this is not a concern of the paramedic.

I'm glad that you've never seen an ER, even one staffed by very competant providers get thrown for a loop so to speak, for however brief a time when a patient in extremis is thrown into their lap. Like I said, how much of a concern this is will depend on the ER, and on the local EMS service(s). If they are used to a patient being delivered with little to nothing being done then I'd hope it wouldn't be as much of a concern. If they are used to a well treated patient being delivered it may be something to consider.

While it is nice, it is a luxury, not a requirement. In the suspected TBI patient, with a short transport, just bringing them in is not a bad solution. Not the best, but local protocol will dictate that, not the most appropriate medical practice.

Yes, and again, this will depend on the ER and is where knowing their capabilities comes into play. And this is where knowing when to pick up the phone comes into play.

What if something goes wrong and instead of pt #2, you have pt #4, in cardio-respiratory arrest?

If done correctly you diminish this possibility, though it is absolutely still there. But a apneic or hypoventilating patient who is sedated is much easier to handle than one who is combative. Add in that the "trismus" seen very well may have been the patient clenching their jaw due to the agitation, and leaning towards sedation in the field would be appropriate.

I don't think it is a good idea to suggest to people to go outside of their protocol. If they work in a system where it is accepted even if not permissible, if something goes wrong, they could be the one who gets all the blame.

That's correct. That wasn't written in the best way. Regardless, it would appear that his own protocol's did allow him to give a sedative, but he didn't.

Which do you think would be more appropriate?

Without having been there and knowing anything about the system I think #2 is what should have happened. It's in the patient's best interest, and adding even 2 minutes of extra time on scene to start the process of obtaining orders would likely not have been harmful, but probably beneficial.

Pure speculation.

Of course it is! Only one person on this forum was actually there, and it wasn't either of us. I could be wrong. I could be right. Wether or not you are willing to admit it to yourself, it is something that should be thought about.

This patient could easily have been a difficult airway prior to facial trauma.

Also if he required OMFS reconstruction, they prefer nasal tracheal tubes or trachs. Which unless things have changed, are not indicated for paramedics in patients with facial trauma?

Sure. Or an easier one. Going off incomplete info makes it hard to know what happened. And I will gaurentee that with the patient presented nothing other than an orotracheal tube or crich would have been initially placed. My point with this is that there are a lot of variables in this case, and what was done/not done prehospital may have affected what happened during the initial treatement in the ER.

I do not see bringing a trauma patient to the ER in no worse condition than found as bad. Certainly I would not call it dumping. If this patient truly had a TBI, then treatment is at the hospital.

I would call not making any effort to treat the patient, in however small a way dumping. You have a patient who is hypoventilating and who you are unable to mask ventilate due to the patient's state. But no steps where taken to correct this.

The purpose of prehospital airway intervention is not to make things go smoother in the ED, it is to make sure the airway is secure and protected so the patient doesn't die.

Nobody ever died from not having a plastic tube in their trachea. They die from not having the ability to get air in and out.

In this case, the airway was controlled and the patient ventilated. Perhaps not in the most effective way, but the goal had been met.

This airway was unsecured and not controlled. Completely. Maybe 8 spontaneous breathes a minute...irregularly...snoring...clenched jaw...unable to mask ventilate due to the patient fighting...and nothing was done.

Is this some sort of a joke?

I will concede that in many places ERs are staffed with any doc they can find, who may or may not be proficent at intubating with the equipment available. But many ofthe assumptions you have made here are bordering on hubris, not logic.

How do you know these docs were not board ceritfied EMs who spend far more time on intubation than medics? How do you know one or more was not an anesthesiologist, who probably puts more tubes in a shift than 99% of paramedics in a month?

There is a lot you are assuming and most of it is around an incapable doctor and a more capable medic or a medic exceeding their role.

I'm not assuming anything. I'm not saying that is what happened. I'm saying that to make the immediate assumption that "the MD couldn't do it so neither could I" is not always accurate. It very well may be, or it may not be. How do you know that these were board certified EM's who spent much more time on intubation than medic's? If they are, how do you know how often they intubate a patient? How do you know how profiecent there are at it? How do you know how well they use a glidescope? It would appear that someone else is making assumptions.

I'm not saying anything I've said is exactly what happened; what I am saying is that these are all things that should be thought about before coming to a conclusion.

Like sitting on a street corner with a trauma patient deciding to deviate from protocol while trying to prove he can intubate somebody better than the doctors in the ER because they might not be proficent?

Don't misquote me, I know how much you dislike it. I'm not saying that he should have tried to intubate this patient; the capability isn't there. But this patient should have been sedated in the field. Not overly sedated, and done very cautiously, but it still should have been done. If that would have meant that a couple extra minutes would have been spent on the scene to start the process, it would have been appropriate. After all, it would appear that he is proud to spend extra time doing something that is likely not needed...so why not do the same for something that could help?

I'm not suggesting to take what I say as gospel or that I'm completely right in all that I've said; hard to be without knowing everything that happened. What I am saying is that this case, as presented by a very new and relatively inexperienced paramedic raises several red flags. They may be justified or not in this specific instance, but all are worth considering for the future.

 

[RocketMedic]

The Army answer would be "load and go", with Versed and a crike tossed in for good measure, at best.

EDIT: Sometimes, it's better to undertreat a patient and have a job than to overtreat and have a lawsuit. It's not the best medicine, but we are not emergency physicians and we do not have the tools or educations to be assuming that risk. Yes, Rob, in this case, Versed was indicated (I think we've beaten that horse to death, and it's taught me too). However, triemal04, there's nothing wrong with grabbing an unstable patient and bolting L/S if we don't know what else to do.

I'd rather take an ***-chewing than get fired, and I'd rather get canned than to avoidably kill someone through inaction or malpractice on my behalf. A lawsuit is the nightmare scenario, and is a lot less likely to result from "load and go, didn't quite know what to do so I brought them here, I'm young and this was scary; I need to see Education" than "I, Paragod, Defender of Life and Airways, sat with a difficult airway and tried to do a half-assed RSI because my service carries just enough midazolam to tempt me. Protocol? THIS IS A LIFE WE'RE TALKING ABOUT!

I'd rather be Johnny & Roy calling for Dr. Brackett than Chicago Fire, in popular terms.

 

[Handsome Robb]

Triemal04, if you want to say you think I'm a :censored::censored::censored::censored:ty medic just come out and say it. Yes I am young, and inexperienced only having about 3 months under my belt being out on my own as an ALS provider. Panicked is not the word I would use to describe me in this situation but if that's what you think then there isn't much that's going to change your mind.

Hindsight is 20/20, it's real easy to sit here and monday morning quarterback my call and tell my I'm an idiot. The whole reason I started this thread was because I had a question and wanted to learn from this, I know it wasn't handled as well as it could have been and I know what I would do differently this time.

I've been told by multiple medics, including my FTO, at the company that I work for that using the "Combative Patients" protocol or sedating in the presence of an altered TBI pt was a no-no per QA/QI and I like my job and am still in my probationary period so no, I will not deviate from protocol and risk my livelihood for a complete stranger.

Two attempts were made in the ER with direct laryngoscopy before the glidescope came out. A couple ER physicians and a Trauma Surgeon at the only Trauma Center in my area, I'd say they are pretty competent but I'm just a snot nosed new paramedic so take it for what it's worth.

The fact that I asked the Trauma Surgeon what more I could have done as they were wheeling my guy out of the trauma room and into CT and he said "Nothing, you got him here quickly with IV access and he was oxygenated with an acceptable SpO2%" makes me think that I hardly "dumped" this patient on the ER. So you're advocating I sit on scene while I call and wait anywhere from 2-4 minutes to get a doc on the phone to get sedation orders while my patient continues to further his journey down herniation road with an unsecured airway rather than recognizing there was nothing I could do within my protocols for this man and taking him to somewhere that could do something about it. But then I'm wrong for taking the extra minute to get a second line started on scene with a guy who had a lot of potential to end up going to surgery and receiving blood products during it?


I posted this thread because I knew I had a lot to learn from this call and I've learned a lot from the responses. With that said, I didn't create this topic to have my competency questioned. I'd be more worried about the medics that had a call similar to this and never went out and asked for help to learn from it. I was under the impression I could reach out to my peers here with questions when I ran into something I didn't understand and needed help learning about it but since me looking for help causes people to question my competency and statements such as "no effort was made to treat this patient" I guess I wont be asking anymore. Constructive criticism is helpful, "you suck at your job nOoBiE" is not.

You've made it pretty clear in previous threads that you don't like me, Triemal04, not sure what I did to you. Were you never a new medic? Have you never had a call that you were unsure what to do so you just transported to patient to the ER or are you that good that you always know what to do for every single patient you see no matter what is going on? If that's the case congratulations because you're the only one at that party.

 

[Sharky]

Right on, thank you!

I know Vene makes us all look dumb but I'd like to hear from others as well

Speak for yourself.

 

[Veneficus]

I'm glad that you've never seen an ER, even one staffed by very competant providers get thrown for a loop so to speak, for however brief a time when a patient in extremis is thrown into their lap. Like I said, how much of a concern this is will depend on the ER, and on the local EMS service(s). If they are used to a patient being delivered with little to nothing being done then I'd hope it wouldn't be as much of a concern. If they are used to a well treated patient being delivered it may be something to consider.

Truthfully, the only EDs I have seen anywhere in my travels that get thrown for aloop on a patient like this are community hospitals that shoul not be recieving these types of patients anyway.

Some of the same community hospitals also have level III trauma center designations. Because if is financially beneficial.

In the trauma centers I have worked at in the past and in the the one I am currently at, this type of patient is an everyday occurance, it wouldn't even get anyone excited enough to take out their phone and snap a couple of pictures.

Yes, and again, this will depend on the ER and is where knowing their capabilities comes into play. And this is where knowing when to pick up the phone comes into play.

Agreed.

If done correctly you diminish this possibility, though it is absolutely still there. But a apneic or hypoventilating patient who is sedated is much easier to handle than one who is combative. Add in that the "trismus" seen very well may have been the patient clenching their jaw due to the agitation, and leaning towards sedation in the field would be appropriate.

I already agreed to that.

Without having been there and knowing anything about the system I think #2 is what should have happened. It's in the patient's best interest, and adding even 2 minutes of extra time on scene to start the process of obtaining orders would likely not have been harmful, but probably beneficial.

I am very cautious between what should happen. I agree that versed in this situation would have been a good idea. I think if you are going to start with 2mg on anything except an elderly patient it will likely be 2 or more doses before and effect. However, in a facial trauma patient, combative, where ventilation is difficult, with trismus, "can't intubate, can't ventilate" is a real possibility, and I think a greater focus should be the discussion of maintaining the airway and not whether or not simply sedating the patient was a good idea.

For sure a combative patient will have to be sedated and sooner is better than later. But I think it is erroneous to attribute successful sedation with successful intubation.

Of course it is! Only one person on this forum was actually there, and it wasn't either of us. I could be wrong. I could be right. Wether or not you are willing to admit it to yourself, it is something that should be thought about.

I think you are right in the expected outcome. I admit I would be very surprised by any other outcome. But when I read your response it look like direction to "do what you need to and apologize later" and I do not think that is good advice.

Sure. Or an easier one. Going off incomplete info makes it hard to know what happened. And I will gaurentee that with the patient presented nothing other than an orotracheal tube or crich would have been initially placed. My point with this is that there are a lot of variables in this case, and what was done/not done prehospital may have affected what happened during the initial treatement in the ER.

I think we will just have to agree to disagree on how much.

I would call not making any effort to treat the patient, in however small a way dumping. You have a patient who is hypoventilating and who you are unable to mask ventilate due to the patient's state. But no steps where taken to correct this. .

Sometimes discretion is the better part of valor.

When I am unsure of myself I seek another opinion or more skilled of a provider. Before I attempt something I think is outside of my ability.

I don't see any dfference here. A relatively new provider taking a conservative approach.

Just because I would sedate somebody and reach for a knofe doesn't mean everyone should. There was also a time where it wasn't the best idea for me to do it either.

This airway was unsecured and not controlled. Completely. Maybe 8 spontaneous breathes a minute...irregularly...snoring...clenched jaw...unable to mask ventilate due to the patient fighting...and nothing was done.

That does appear to be a statement of fact. But as I said, sometimes a conservative approach is better than a overzealous approach when experience and skill is in question.

I'm not assuming anything. I'm not saying that is what happened. I'm saying that to make the immediate assumption that "the MD couldn't do it so neither could I" is not always accurate. It very well may be, or it may not be. How do you know that these were board certified EM's who spent much more time on intubation than medic's? If they are, how do you know how often they intubate a patient? How do you know how profiecent there are at it? How do you know how well they use a glidescope? It would appear that someone else is making assumptions.

I live the life of being able to do things when others fail. But that is not my point in that statement.

My point is, we do not know the qualifications of these doctors and there are requirements for ongoing skill usage and training. That is not something that is common in EMS. It means they have a better chance of success. I am not saying they will always be or that nobody else can. But I think it is a good indicator it was a difficult airway.

I'm not saying that he should have tried to intubate this patient; the capability isn't there. But this patient should have been sedated in the field. Not overly sedated, and done very cautiously, but it still should have been done. If that would have meant that a couple extra minutes would have been spent on the scene to start the process, it would have been appropriate. After all, it would appear that he is proud to spend extra time doing something that is likely not needed...so why not do the same for something that could help?.

I again agree he should have been sedated. In my experience working with versed, I think it would have taken longer to sedate him on scene because of the dose incriments.

I think this patient, based on limited description was likely going to be a very difficult airway. I think it was a prudent decision for a new provider to defer to the ED rather than get into a situation beyond his ability to manage. (can't intubate, can't ventilate, on an apnic patient.) Because if the sedation caused apnea and there was no ability to intubate ad difficulty ventilating, we are looking at a new and likely scared provider holding a knife in his hand without experienced oversight.

The first time I ever did a cric was in an OR, with an extremely respected surgeon looking over my shoulder. I was scared. (I am not sure more by which, the "helpeful" advice I was getting in the form of some ball busting, or actually cutting somebody)

I could only imagine being a new unsupervised paramedic trying that in the street. It probably wouldn't go well.

I'm not suggesting to take what I say as gospel or that I'm completely right in all that I've said; hard to be without knowing everything that happened. What I am saying is that this case, as presented by a very new and relatively inexperienced paramedic raises several red flags. They may be justified or not in this specific instance, but all are worth considering for the future.

I agree.

Not only from the point of the provider, but from the system.

 

[Veneficus]

Two attempts were made in the ER with direct laryngoscopy before the glidescope came out. A couple ER physicians and a Trauma Surgeon at the only Trauma Center in my area, I'd say they are pretty competent but I'm just a snot nosed new paramedic so take it for what it's worth.

Failed intubation of a surgeon does not count towards the total

Most surgeons are not very good at it because they hardly ever do it. In most training programs they aren't even permitted to RSI.

But he probably could have willed the trach in using the force

 

[triemal04]

Truthfully, the only EDs I have seen anywhere in my travels that get thrown for aloop on a patient like this are community hospitals that shoul not be recieving these types of patients anyway.

And I've seen it happen at hospitals that have been a level 1 or 2. With attendings and residents both. It shouldn't be happening often, no matter what type of patient is brought in; if it is then there is a problem. But to think that it can't/won't/doesn't, or that what we do/don't do in the field won't potentially have an effect isn't a good idea. If people in EMS should be thinking about what the long-term outcome and care for the patient will be and considering how what we do initially may effect their care in the ICU (or in whatever unit they end up in) then this is a valid concern. Whether or not it is acted on will vary, but to say that it should not be considered is wrong.

I am very cautious between what should happen. I agree that versed in this situation would have been a good idea. I think if you are going to start with 2mg on anything except an elderly patient it will likely be 2 or more doses before and effect. However, in a facial trauma patient, combative, where ventilation is difficult, with trismus, "can't intubate, can't ventilate" is a real possibility, and I think a greater focus should be the discussion of maintaining the airway and not whether or not simply sedating the patient was a good idea.

Yes, but in this specific case the ability to maintain an airway was not there because, as presented, mask-ventilation was impossible due to the patient's combative state.

For sure a combative patient will have to be sedated and sooner is better than later. But I think it is erroneous to attribute successful sedation with successful intubation.

Maybe. Believe me, I'd very much like to agree; I like having faith in the capabilities of an ER. My point was, and remains, that this patient was mismanaged, and, while far from a certainty, it must be asked if this mismanagement may have played a part in what happened during the initial rescucitation.

I think you are right in the expected outcome. I admit I would be very surprised by any other outcome. But when I read your response it look like direction to "do what you need to and apologize later" and I do not think that is good advice.

Yea, I'll admit that was poorly worded and not the best advice. I've been lucky to only work in places that had guidelines that contained a similar clause in them; not so with many people. As I said, calling for orders for versed, or even knowing that a "relative contraindication" is not an absolute would have been the appropriate course to take.

I think we will just have to agree to disagree on how much.

That's fine. I'm not expecting anyone to agree, especially since I could be fully wrong. What I'm expecting, or hoping, is that, in the future, it will be thought about, and taken into account before a decision is made.

Sometimes discretion is the better part of valor.

When I am unsure of myself I seek another opinion or more skilled of a provider. Before I attempt something I think is outside of my ability.

I don't see any dfference here. A relatively new provider taking a conservative approach.

Just because I would sedate somebody and reach for a knofe doesn't mean everyone should. There was also a time where it wasn't the best idea for me to do it either.

It is, and I agree with both bolded statements. Which is my issue. Despite knowing, for whatever reason, that this was someone who could benefit from a benzo, no attempt was made to take the steps neccasary to administer one. Instead, as presented, it was toss 'em in the back and beat feet for the ER.

My point is, we do not know the qualifications of these doctors and there are requirements for ongoing skill usage and training. That is not something that is common in EMS. It means they have a better chance of success. I am not saying they will always be or that nobody else can. But I think it is a good indicator it was a difficult airway.

Probably. Given how frequently the average paramedic will intubate it's very likely. But to make a blanket assumption like that is innacurate. Especially when you take into account that a trauma surgeon was one of the MD's attempting intubation. If anything, that is proving my point; in all honesty when do you think the last time that doc intubated was, and how well were they initially taught?

I again agree he should have been sedated. In my experience working with versed, I think it would have taken longer to sedate him on scene because of the dose incriments.

I never said that they should have sat on scene until the patient was completely sedated. That probably wouldn't have been a good idea. But spending a couple extra minutes to pick up the phone and at least start the process of getting orders before leaving and then administer those drugs while enroute would have been a better course of action.

I think this patient, based on limited description was likely going to be a very difficult airway. I think it was a prudent decision for a new provider to defer to the ED rather than get into a situation beyond his ability to manage. (can't intubate, can't ventilate, on an apnic patient.) Because if the sedation caused apnea and there was no ability to intubate ad difficulty ventilating, we are looking at a new and likely scared provider holding a knife in his hand without experienced oversight.

It could be. And this should have been something that went through anyone's mind who is in a similar situation. But again, as presented, the only impediment to mask-ventilation was the patient fighting.

As I said, I'm not saying that I'm right or wrong, just that, as presented and coupled with some other comments, there's some very concerning things here.

 

[Maine iac]

I've been told by multiple medics, including my FTO, at the company that I work for that using the "Combative Patients" protocol or sedating in the presence of an altered TBI pt was a no-no per QA/QI and I like my job and am still in my probationary period so no, I will not deviate from protocol and risk my livelihood for a complete stranger.

Did you ask your FTO how they would have treated this pt then?

If you think the answer might be incorrect I would talk to a doctor and inquire about what would be the right thing to do.

I find it interesting that this doesn't fall into the combative pt... because he was fighting.

In my ambulance, if you are not following my commands and pose a risk to yourself or myself you will be restrained and if need be chemically slowed.


Rob, have you personally called for orders before? The only reason I ask is because I always thought that whole process would take a while, but when I made my first call it got connected through right away. I was calling for pediatric sedation orders on a violent kid, and for me I have to call dispatch who calls the hospital then I wait on the hospital channel for them to answer. When dispatch could hear the kid screaming at us in the background things got connected through fast and I got my orders quickly.

Something else to consider is as soon as you get on scene, and think you might need sedation orders for a combative TBI pt have your partner call for them while you and the FF work on extrication and back boarding. That way by the time you are in the ambulance and maybe have a line you have the orders and can act on it.... or if it turns out you don't actually need them then oh well... the hospital at least will have a heads up that a critical pt is coming their way.