Final school scenario

[Shishkabob]

While the airway is not compromised by a FBAO, it is compromised. Going with the FBAO protocol, sans checking for obstructions to remove, seems like more of a PUHA situation according to your protocols. I think the thing to look at here is what is causing the Cardiac Arrest? In this situation, it's presumably a compromised airway so without fixing that you could shock him all day and not get a spontaneous return of circulation worth anything. I don't know if you can drop a combi-tube or any other airways in your area but it seems like if he would accept one it would be prudent. Obviously you want to hook him up and see i he is shockable but you need an airway ASAP. Just my 2 cents.

Errr...

CA secondary to allergic reaction. You *typically* aren't going to go in to arrest that quickly secondary to a FBAO. If they are getting non-compliance through BVM and oral adjuncts / airways, that most likely means laryngeal edema. A combi won't bypass that. A surgical / needle cric can. But that's still not treating the cause of the arrest, but merely a side-effect (a rather important one, but still a side effect)

But even on top of that, when working an arrest you treat reversible causes, which here it would be treated by giving Epi, which is a drug given in the algorithm anyhow. Shock ASAP, give the Epi IV, and work from there.



2 birds, meet 1 stone.

 

[Frozennoodle]

Huh, The more you know.

*cue music*

---------*

 

[BEorP]

Airway was clear. As I was drawing up my 0.3mg Epi the patient went VSA. I quickly gave my Epi as per protocol, started CPR to circulate it until defib could be hooked up and went from there. Once I put in my oral airway, I got no compliance on bagging, patient was still in VF so I treated this as a General Arrest Medical NOT Foreign Body.

I still don't understand how I was wrong? I wonder if I can contact my local Base Hospital to figure out what they would have done and then try and fight the exam.

What college is this?

I'm sorry to get in on this late (I don't think there has been a lot of Ontario input), but DO NOT contact the base hospital. You can read the directives as well as anyone and you know that this patient does not fit the FBAO cardiac arrest directive since there was no foreign body involved. Contacting the base hospital will be seen as trying to "go over the heads" of the college faculty ("above" them to a body that is completely independent of them). The base hospital will also not likely be receptive to this.

What is the consequence of having failed this scenario? Did you fail the semester or just lose some marks? If it is just lost marks, you should seriously consider how far you want to go with this since you've got at least one semester left with this program. And even after that, EMS people talk so much that you don't want to end up with a reputation before even getting on the road. I know it sucks needing to suck it up when you know you're right, but sometimes you need to play the game (take it from someone who has been there).

Have you seen the paperwork that says this is the reason you failed and the only reason you failed? Sometimes after scenarios students do not always hear all of the feedback that the instructor is giving them and they might focus in on just a certain area. Get the paperwork and see how they thought the entire scenario went.

The other consideration is that your college is sort of your base hospital right now. By this I mean that if they really want this type of arrest treated as FBAO and they taught you this then that is sort of what you've got to run with. I'm not trying to defend them, but the reality is that you're stuck with their rules until you graduate, get a job, and get certified by a base hospital. Even with the standard provincial directives there are still differences between the base hospitals even on things that seem clear on paper. For example, some base hospitals would not want epi 1:1000 administered to this patient if they went VSA before you could give it. As a keen student, you would reply by saying that the BLS Standards say we should though. That doesn't change the fact that some base hospitals have their medics not doing this even though it is clear on paper from the outside. If this type of scenario had been discussed before, you need to follow your base hospital, or in this case you need to follow what your college says.

Bottom line is that you're are correct and an arrest from anaphylaxis should be treated under the general arrest directive. The question is what you want to do about it. Your college should have a formal appeal process, which is what you will need to use if you want to formally challenge the mark. Timelines for this are very important and you may only have a week or less from receiving the grade to formally appeal it so act fact if you want to pursue that.

 

[Fraz]

What college is this?

I'm sorry to get in on this late (I don't think there has been a lot of Ontario input), but DO NOT contact the base hospital. You can read the directives as well as anyone and you know that this patient does not fit the FBAO cardiac arrest directive since there was no foreign body involved. Contacting the base hospital will be seen as trying to "go over the heads" of the college faculty ("above" them to a body that is completely independent of them). The base hospital will also not likely be receptive to this.

What is the consequence of having failed this scenario? Did you fail the semester or just lose some marks? If it is just lost marks, you should seriously consider how far you want to go with this since you've got at least one semester left with this program. And even after that, EMS people talk so much that you don't want to end up with a reputation before even getting on the road. I know it sucks needing to suck it up when you know you're right, but sometimes you need to play the game (take it from someone who has been there).

Have you seen the paperwork that says this is the reason you failed and the only reason you failed? Sometimes after scenarios students do not always hear all of the feedback that the instructor is giving them and they might focus in on just a certain area. Get the paperwork and see how they thought the entire scenario went.

The other consideration is that your college is sort of your base hospital right now. By this I mean that if they really want this type of arrest treated as FBAO and they taught you this then that is sort of what you've got to run with. I'm not trying to defend them, but the reality is that you're stuck with their rules until you graduate, get a job, and get certified by a base hospital. Even with the standard provincial directives there are still differences between the base hospitals even on things that seem clear on paper. For example, some base hospitals would not want epi 1:1000 administered to this patient if they went VSA before you could give it. As a keen student, you would reply by saying that the BLS Standards say we should though. That doesn't change the fact that some base hospitals have their medics not doing this even though it is clear on paper from the outside. If this type of scenario had been discussed before, you need to follow your base hospital, or in this case you need to follow what your college says.

Bottom line is that you're are correct and an arrest from anaphylaxis should be treated under the general arrest directive. The question is what you want to do about it. Your college should have a formal appeal process, which is what you will need to use if you want to formally challenge the mark. Timelines for this are very important and you may only have a week or less from receiving the grade to formally appeal it so act fact if you want to pursue that.

Thanks for the reply!

I have checked the paper and discussed with the teacher, and he classed it as I couldn't secure an airway after the two minutes so I had to treat it with the FBAO protocol.

What happens now that I failed this for apparently using the wrong protocol? I have to stay back an extra three months, go for a 'review' course (more $ obviously) and then if I pass that I have my final consolidation afterwards.

On the paper after my first initial shock he had written and highlighted;
"Protocol should have stopped here, and went to FBAO"

Everything else was perfect, CPR intervals, Epi dose, Route given and treatment. The college (I would prefer not to disclose at this moment in time) is a private college, and they don't really have an appeal process (not that I am aware of).

I had contacts that knew a BHP physician that over looks these protocols, and he even told me over the phone that being a PCP I was in the right for choosing such protocol. As I went to the dean and admissions (ex. medic) I was told that I needed to take it up with my instructor.

Hopefully this week I can get something going, this whole situation is just one giant piss off.

 

[BEorP]

Even a private college should have an appeals process if they are a real educational institution. I would encourage you to find it quickly since as I mentioned the timelines are critical. Even with you being right, if you miss the deadline to formally appeal you will not have a leg to stand on.

If this is going to cost you three months of time and a lot of money then I would encourage you to formally appeal.

If you feel comfortable doing so, please PM me with what college you're at. I may be able to offer further advice by PM once I know a bit more.

 

[Fraz]

^ You have a PM. Thank you.

 

[Outbac1]

Even a private college should have an appeals process if they are a real educational institution. I would encourage you to find it quickly since as I mentioned the timelines are critical. Even with you being right, if you miss the deadline to formally appeal you will not have a leg to stand on.

If this is going to cost you three months of time and a lot of money then I would encourage you to formally appeal.

I think I have to agree with BEorP on this. I believe you did it right. You can't not shock vfib, do compressions while putting all you energy into correcting a blocked airway. Did your examiner ding you for not calling for ALS when the pt arrested? Are your scenarios filmed? If so get it played back to you. I have the suspicion your instructor and I,(and a few others here), would probably have to agree to disagree on this. Is this the only scenario you failed? Can you do another scenario? I know of several students here who failed a scenario first time. They did a retest a week or so later, passed it and moved on. I suggest you investigate an appeal. Ultimatly it is not about the right protocol to follow but did you do what was best for the patient, in my opinion.

 

[Fraz]

Thanks everyone for the support. I am waiting to hear back about the appeal process.

 

[Melclin]

I had some trouble in third year with an examiner when I gave adrenaline to a severely anaphylactic pt. He had exposure to a known trigger agent, self administered his epi pen, had obvious angioedema and was severely SOB. The examiner contended that I should have done a complete assessment first, but I maintained that there was no piece of information I was going to find that would stop me from giving adrenaline and that I was administering it essentially as part of the primary survey.

We just had a good discussion about it and it was clear that I understood the subject matter well. We simply disagreed about the extent of assessment required before adrenaline in this case, which the examiner was happy to accept, and I passed.

You really shouldn't fail over one interpretation of what looks like a pretty stupid protocol. Just as in my case, if you can make an argument for it, show you get what you're talking about and that it could be reasonably argued that it was best for the pt then you should be fine.

 

[jjesusfreak01]

I had some trouble in third year with an examiner when I gave adrenaline to a severely anaphylactic pt. He had exposure to a known trigger agent, self administered his epi pen, had obvious angioedema and was severely SOB. The examiner contended that I should have done a complete assessment first, but I maintained that there was no piece of information I was going to find that would stop me from giving adrenaline and that I was administering it essentially as part of the primary survey.

We just had a good discussion about it and it was clear that I understood the subject matter well. We simply disagreed about the extent of assessment required before adrenaline in this case, which the examiner was happy to accept, and I passed.

I got dinged in a scenario once for waiting way too long to give epi. Have hives? Have difficulty breathing? You give epi, no contraindications, you can give it to people alive, dead, and mostly dead.

 

[BEorP]

Any update on this?