# Trach Problems



## KB1MZR (Nov 11, 2008)

This is probably a question I should know the answer to but it has slipped my mind.  What would be BLS care for a patient experiencing a problem with home equipment such as a respirator or other piece of equipment that can't be moved into the ambulance and is causing a serious issue (e.g. airway compromise)?


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## MMiz (Nov 11, 2008)

I'm confused, what are you asking?  What kind of problem is the patient experiencing?  If it comes down to ventilating a patient then you would use a BVM.  A BVM is the simplest form of manual ventilation.


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## KB1MZR (Nov 11, 2008)

I guess I'm asking how we are supposed to handle the equipment.  Scenario: Dispatched to a respiratory problem, upon arrival pt. is on artificial ventilation at home via ventilator (pt. in an ICU type setting in the home), nurse is not on scene and other caregivers aren't sure about use of the equipment but it is now causing the pt. a respiratory problem.  What would be BLS care for that scenario?  Can we disconnect the vent and switch to a BVM without being trained to operate the vent.?  What about other types of equipment?


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## Vizior (Nov 11, 2008)

Make the call for ALS to begin with.  Secondly, consider your ABCs and contact medical control.  Between your basic assessment skills and talking to the doc, hopefully you can come up with a successful plan for either fixing the problem, or a solution for transport.


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## KB1MZR (Nov 11, 2008)

That's what I was thinking, can't go wrong with ABC, ALS, and when all else fails call med control.  I was just wondering if I missed something and there was something I should do because I'm not going to mess with equipment a pt. is relying on even to take over with a BVM because who knows at that point what is the actual problem and what is worse.


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## KEVD18 (Nov 11, 2008)

your thinking is like a scatter plot. make it linear.

is the ventilator they are on currently working? no? then disconnect it and go with what works, a bvm. you dont need to know how to work the vent. your not using the vent. quite the opposite in fact, so the operation of the vent is irrelevant.

id say als is a given.

unless your required to do so by state/county/municipality or service rules, why call med control? you dont need a doctors permission to ventilate a patient. they cant breathe, you breath for them. we dont carry any advanced airways or respiratory drugs. we dont do advanced procedures. we ventilate and screw for the H. let the medics worry about the rest of it.


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## Jersey (Nov 11, 2008)

Ok, well let me give you a case study of one of the frequent flyers for my BLS service before I became ALS.

We would regularly get dispatched to an elderly gentleman who was on a very advanced home ventilator. The man was fully with it, but was vent dependent through a tracheostomy. The patient would regularly develop lung infections which would require an ED visit due to respiratory difficulty.

Due to a slight language barrier with the patients wife, sometimes the call would come in as an undefined medical emergency which only gets a BLS response in New Jersey (BLS transport with ALS flycar). Often, we would get there and realize that the patient needed to be transported to the hospital. Our procedure was as follows:

1) Crank up the O2 settings from 4LPM to 10LPM through the vent. (usually there is a hospital style oxygen controller on many commercial vents, and it is obvious in many home vents). 

2) Call for an Advanced Life Support unit.

3) Prepare a BVM with 10LPM of oxygen (Remember, with COPDrs you don't want to blast them with oxygen)

4) Manually disconnect the vent from the patients trach tube and bag WITH THE PATIENT. This is the most difficult part as many ventilator patients you will find at home have a fairly significant respiratory drive of their own and are merely "assisted" by the vent. The vent is set either at a predictable and consistent rate (that you as a human will never be able to provide!) or on a negative-pressure sensor which senses when the patient starts to breath in and thus assists the breath by firing off. A neat trick that I use is to have the patient tap me, or whomever is bagging, on the leg or arm whenever he wants a breath. Presto!

If the reason that you have to transport the patient is NON respiratory related, I would argue that transporting a patient that uses a vent with no acute respiratory distress is a BLS call. At a BLS level, ventilations are no biggie, and as long as you keep providing ventilations for the patient, ALS should not be needed. Just make sure to call the ER and let them know to have a vent ready! Otherwise you'll have some pissed off nurses at two in the morning (when this stuff ALWAYS seems to happen). All the best,

Jersey


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## KEVD18 (Nov 11, 2008)

Jersey said:


> Remember, with COPDrs you don't want to blast them with oxygen
> 
> Jersey


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## Jersey (Nov 11, 2008)

As informative as that graphic was, I'm not sure as to what point you are making.

10LPM is more than adequate for a COPD patient in respiratory distress, and using an additional 5LPM over a long transport time of up to an hour is something that can have a significant impact on the patients respiratory drive.

If you have an issue with a post, for all means say it! None of us are experts, and I love hearing different opinions as they consistently add to my knowledge. Posting a stick figure banging his head against the wall however does not add to my, the original poster, or any other readers knowledge.


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## reaper (Nov 11, 2008)

Hehe, I caught that too!


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## daedalus (Nov 11, 2008)

Uh, what would ALS do for this patient that you cannot? And why could you not disconnect the vent? Assess the patients LOC, lung sounds, pulse oximetry, vital signs, and affect. Pull the vent off and soft cath suction the trach. Hook your BVM up with 100% O2 and reassess the patient, and transport with parents and Hx.

When you get back to station after the call, learn about the condition that put the pt on the vent, learn about home care vents, and read up on assessment and common respiratory conditions. Than next time you get a call, teach everybody what you already know and you will look like a real professional.


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## KEVD18 (Nov 11, 2008)

at least once a month, someone comes here and posts something regarding overloading copd patients with o2 and how its a guaranteed way to kill them.

then, people who actually read the data on the matter answer back with the facts regarding conversion of respiratory drive, how long it takes, how much oxygen, the real dangers etc etc.

then uninformed people try to justify their position with several versions of "well thats what i was taught".

then the informed people try to answer that with stats and so on and so on. it rapidly deteriorates into a big mess.

id rather repeatedly bang my head against the wal until im rendered unconscious than do that again. if you stick around here for any period of time, you'll see that gif pops up from time to time. thats what it means. id rather repeatedly bang my head against the wall until im rendered unconscious than do this again.


although i must say that your the first person to bring up this topic that will admit that ten lpm is ok. usually we get the standard party line of "never under any circumstances administer anything more than 4lpm".


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## Jersey (Nov 11, 2008)

Right, that's my argument. If the patient doesnt need a respiratory treatment or deep airway suctioning (not a BLS skill in my state) then he is a BLS patient! Spot on.


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## KEVD18 (Nov 11, 2008)

daedalus said:


> Uh, what would ALS do for this patient that you cannot? And why could you not disconnect the vent? Assess the patients LOC, lung sounds, pulse oximetry, vital signs, and affect. Pull the vent off and soft cath suction the trach. Hook your BVM up with 100% O2 and reassess the patient, and transport with parents and Hx.
> 
> When you get back to station after the call, learn about the condition that put the pt on the vent, learn about home care vents, and read up on assessment and common respiratory conditions. Than next time you get a call, teach everybody what you already know and you will look like a real professional.



basics in mass cant suction anything past the stoma of a strach. only medics can deep suction.


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## MMiz (Nov 11, 2008)

Wow, reading this thread you'd think that we were a community of jerks.  Even my response sounded mean.

It really all comes down to the ABCs, especially at the BLS level.  I'd go with 15 LPMs because that's what I've been taught, but I'm sure 10 LPM would work just fine.  For the record, I believe that this should be an ALS call, as all DIB should be.  In our system it would be classified as an ALS call with a BLS unit also dispatched for support.


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## daedalus (Nov 11, 2008)

KEVD18 said:


> at least once a month, someone comes here and posts something regarding overloading copd patients with o2 and how its a guaranteed way to kill them.
> 
> then, people who actually read the data on the matter answer back with the facts regarding conversion of respiratory drive, how long it takes, how much oxygen, the real dangers etc etc.
> 
> ...


I had a new EMT on my rig last month who stopped me with his hands as I went to put a mask on a patient. The patient called 911 for difficulty breathing, and was a CHFer and COPDer. He told me I would kill the patient with the oxygen.


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## daedalus (Nov 11, 2008)

KEVD18 said:


> basics in mass cant suction anything past the stoma of a strach. only medics can deep suction.



I dont think I can but I do it allllll the time. Many patients would be not breathing by the time I got to the ER if I did not.


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## MMiz (Nov 11, 2008)

daedalus said:


> I dont think I can but I do it allllll the time. Many patients would be not breathing by the time I got to the ER if I did not.


I can remember how horrified I was the first time I had to do it.  Then the patient took the suction from my hand and did it himself.  It sounded like I was killing the guy.


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## KEVD18 (Nov 11, 2008)

daedalus said:


> I dont think I can but I do it allllll the time. Many patients would be not breathing by the time I got to the ER if I did not.



i can neither confirm nor deny that i may or may not do the same.

i will say that i dont make a public record of my operations outside of scope. whenever i write something it will always be per protocols.

what happens in the back of my truck or your truck or anybody elses truck may differ slightly or greatly from the prescribed treatment algorithms.


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## jrm818 (Nov 11, 2008)

10LPM may indeed be enough for a pt. who is not compromised except for a malfunctioning vent, depending on what sort of a mix they were on when the vent was working.  

The reference to switching to hypoxic drive and inhibiting breathing, as you may have gathered, garners signifigant skepticism at this site (and among educated providers everywhere).  The notion that COPD'rs can't tolerate high flow 02 is just not supported by evidence, and basically is wrong (according to me).

That said, even if you do end up inhibiting their respiratory drive (unlikely) - if you are ventilating with a BVM: Who cares?  You are their respiratory drive now.  You're breathing for them.

If the COPD pt. is not breathing adequately or in resp. distress - give them high flow O2.  If they are being adequately oxygenated by a vent using a room air mix, it's probably OK to withold the highest flow 02. 

for more:

http://emtlife.com/showthread.php?t=4225&highlight=hypoxic+drive

Really, if I'm ventilating by BVM I'm going to crank the O2 all the way up just to make sure, COPD or not.  Even a transport time of an hour isn't going to have any major impact, and it's much worse to find out you were ventilating insufficiently.


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## daedalus (Nov 11, 2008)

MMiz said:


> I can remember how horrified I was the first time I had to do it.  Then the patient took the suction from my hand and did it himself.  It sounded like I was killing the guy.



I got some laughs out of that! My partner was absolutely HORRIFIED when she called me to the back of the rig to do it when she lost breathing on an emergency fire evacuation patient. She was like your killing him your killing him!

Oh, an why should we not sound mean? I think we as EMTs should take a very tough position on education and incompetence.


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## KEVD18 (Nov 11, 2008)

daedalus said:


> Oh, an why should we not sound mean? I think we as EMTs should take a very tough position on education and incompetence.



thats pretty much me in a nutshell.


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## JPINFV (Nov 12, 2008)

KB1MZR said:


> This is probably a question I should know the answer to but it has slipped my mind.  What would be BLS care for a patient experiencing a problem with home equipment such as a respirator or other piece of equipment that can't be moved into the ambulance and is causing a serious issue (e.g. airway compromise)?



Why would a ventilator call be BLS to begin with? When I was working in Southern California this would be a RT call by sole fact that the patient was on a vent.


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## jrm818 (Nov 12, 2008)

Probably a regional difference.  In PA the protocols just changed so long as the equipment is the sort that is normally operated and maintained by the pt. the call can be BLS, unless the problem is with the equipment.  So vent pt. with a broken arm is BLS - vent problem would still be ALS.  It would only be an ALS call, no RT.  

Only similar thing here I've seen as the inclusion of an RTs the use of a flight crew with a biomedical engineer for an LVAD issue.  One of the stupidest things I've yet seen - took over an hour just to get all these people into the BLS ambulance (engineer from hospital, flight crew from base, ambulance from somewhere else) and en route to the residence.  Pt. lived maybe 20 minutes from the hospital...

likely the reason this would be BLS is a two tiered system.  In many places BLS provides primary 911 coverage and calls for ALS intercept.  Where I work in MA, even though ALS would hopefully have been dispatched at the same time as us, our BLS ambulance would probably be on scene at least 5 minutes prior to ALS, quite possibly more.


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## VentMedic (Nov 12, 2008)

Where to begin.......

*Patient on ventilator and distressed:*

Remove from ventilator.
Hook BVM to O2 
Bag patient
Listen for breath sounds
If you as an EMT can not suction, ask the parents to suction
Watch pt's response with color change, chest rise. 
Assess breath sounds
If good results; continue ventilations, assess the rest of the patient

Leave vent if can not be moved although most homecare ventilators are very portable.  The O2 concentrator usually is not but does not have to be taken. Hospitals have their own O2. They also have their own ventilators.   The family can bring the vent later. 

Read the hypoxic drive link.  Do not withhold O2 on a *patient in distress.*  Bag if they quit breathing. Chances are they would quit breathing anyway as it is commonly called RESPIRATORY FAILURE.  
A patient that is in respiratory failure is already retaining CO2 regardless of whether they are a retainer or not. It is just a matter of time to when they reach the point of no return.  They are fatiqued.   You may later have the satisfaction of knowing the heart, brain and gut didn't take a hypoxic hit.    

These patients will usually have some disease process in addition to COPD that is creating the problem.  This could be PNA, metabolic disorders, cardiac problems etc.  

If you or a ventilator is doing the ventilating, regardless of how much O2 used, YOU OR THE MACHINE IS BREATHING FOR THE PATIENT.  Often a pt in ICU will be on an FiO2 of 1.0 and due to shunting or V/Q mismatching will barely have a PaO2 of someone on 0.21 or room air.  

If the patient is not in distress, you can titrate the O2 to comfort or SpO2.  No, not all patients need high concentrations of oxygen.

The one patient that you can KILL with O2 is a baby with an uncorrected cyanotic heart defect that is ductal dependent.


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## VentMedic (Nov 12, 2008)

JPINFV said:


> Why would a ventilator call be BLS to begin with? When I was working in Southern California this would be a RT call by sole fact that the patient was on a vent.


 
Going home, we will send a ventilator patient via BLS truck if accompanied by a parent or other caregiver. An ALS truck with a Paramedic is not guarantee that the Paramedic is very familiar with trachs and definitely not that particular homecare ventilator. Endotracheal suctioning is not a skill that is practiced by many EMTs or Paramedics. I will put my trust to the parents since they have been thoroughly trained/educated on the equipment. Different companies have different rules and many parents will invest in a mini-van or SUV and bypass the ambulance transport rather than deal with situations like initially described. 

Adults are at the mercy of the ambulance crews unless they have an S.O. or caregiver to accompany them who is knowledgeable. Many ventilator patients like the late Christopher Reeve do not want to be parted from their wheel chair and will find alternate transportation if at all possible. Thus, these are a few reasons you don't transport many homecare patients in the back of your ambulance.


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## daedalus (Nov 12, 2008)

> If you as an EMT can not suction, ask the parents to suction


That would never ever happen on my crew. Ever.

My EMT will suction the patient. Also, parents always ride in front in non emergency situations. Company policy.


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## VentMedic (Nov 12, 2008)

daedalus said:


> That would never ever happen on my crew. Ever.
> 
> My EMT will suction the patient. Also, parents always ride in front in non emergency situations. Company policy.


 
With over 300  different airways and at least 60 different makes and models of homecare ventilators as well as textbooks full of thousands of different diseases or disorders, there may be a time you will have to listen to the parents.  If you lose an airway that had to be surgically placed due to abnormal anatomy because of your over inflated "I am EMT" ego, that child will die.   If the parents try to tell you something, LISTEN.  Do not rely on the very few pages of an EMT text to get you through every situation.


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## daedalus (Nov 12, 2008)

I have no ego. I push for better and freely admit to the lack of education EMTs receive. However, airway management, including suctioning, positive pressure ventilation, oxygen, pulse oximetry, and lung sounds are all well within an EMT's knowledge base. The parents called us, not the other way around. That said, the parents knowledge of the ventilator and their particular situation with their child is invaluable. It does not take a genius EMT to figure out the management for difficulty breathing or intolerance to a ventilator.


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## VentMedic (Nov 12, 2008)

Daedalus said:


> I have no ego. I push for better and freely admit to the lack of education EMTs receive. However, *airway management,* including suctioning, positive pressure ventilation, oxygen, pulse oximetry, and lung sounds are all well within an EMT's knowledge base. *The parents called us, not the other way around.* That said, the parents knowledge of the ventilator and their particular situation with their child is invaluable. *It does not take a genius EMT to figure out the* *management for difficulty breathing* or intolerance to a ventilator.


 
Yes, as you stated the parents' knowledge is invaluable in these situations. But, please do not cop the "you called us" attitude with parents who do call you for a way to get to the hospital. Parents may have no choice but to call due to the immobility of the child or a sudden emergency that needs quick attention. The parents are probably already feeling they have let their child or loved one down in some way or their care was inadequate which may totally not be the case but they are the primary caregivers. 

Most are very protective of their child or loved ones and want people who are well educated/trained to do the care or at least someone who will not haphazardly fumble around causing great harm. That is why we have hospitals that specialize in certain populations such as children or various cardiac disorders. You also shouldn't take this attitude with someone who might have a LVAD or some other VAD if the S.O.s try to explain "continuous flow" when you check the pulse and want transport to where their doctor is. 

These patients and their families go through enough without being made to feel like they are indebted to the EMT because they can not carry their own loved one to the car themselves. Many would prefer to stay in control of their loved one's care after being witness to others misunderstand the pt's disease or muddle through the care as well as and taking their own to the hospital . Even in the hospital we respect that as much as possible. Afterall, we trained them to do almost all or total care for their loved one. They will relax if you do not shove them aside and listen to what they have to say. 

Some of the airways used in children or adults with various disorders take a while for even the most experienced RT to figure out and they don't mind getting educated by a parent in an emergency as well as consulting an ENT physician who is familiar with these devices. When it comes to airways, those with more education don't assume they know it all because they have enough education to know there is much more. 

How familiar are you with false tracked trachs or fistulas? Decannulation? Are you prepared to attach to an airway device that is not the standard 15 mm? As an EMT, do you know how to ventilate a laryngectomy patient with a BVM? Various speaking valves including those internal? Ventilate a fenestrated trach? Uncuffed? 

I have also seen Paramedics destroy the only venous access a patient has because of "assuming a line is a line". Many have failed to take advantage of more education that is often offered for free or minimal charge at various hospitals and colleges that offer CEUs for healthcare. Too many associate trachs and various venous access devices to be "nursing or nursing home stuff" and if it has nothing to do with trauma, they don't bother. These are relatively simple devices to master if only a little time was taken to expand one's knowledge of patient care.


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## Sasha (Nov 12, 2008)

jrm818 said:


> 10LPM may indeed be enough for a pt. who is not compromised except for a malfunctioning vent, depending on what sort of a mix they were on when the vent was working.
> 
> The reference to switching to hypoxic drive and inhibiting breathing, as you may have gathered, garners signifigant skepticism at this site (and among educated providers everywhere).  The notion that COPD'rs can't tolerate high flow 02 is just not supported by evidence, and basically is wrong (according to me).
> 
> ...




My understanding is too much oxygen will knock down a COPDers respiratory drive. That being said, that is something that can be managed at a hospital and re-learned. Thats what I was taught in basic class. Not breathing is 100% fatal, hypoxia is bad juju. I think LPM should be set to their patients need, read the pulse ox, skin color, etc and if theyre awake ask them if they feel like theyre getting enough O2. (Though I guess with COPDers they never feel like theyre getting enough O2.) If not, crank it up, if yes, leave it alone.


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## Ridryder911 (Nov 12, 2008)

True too much oxygen can knock down the respiratory drive since they are on a opposite mechanism but remember how long and how much is required as well as what can one do if it occurs? 

R/r 911


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## VentMedic (Nov 12, 2008)

Ridryder911 said:


> True too much oxygen can knock down the respiratory drive since they are on a opposite mechanism but remember how long and how much is required as well as what can one do if it occurs?
> 
> R/r 911


 
Not all COPDers are CO2 retainers and not all CO2 retainers are COPDers.

A brief article on the the controllers of breathing:

http://www.rtmagazine.com/issues/articles/2000-02_17.asp

One must also consider the etiology of the C02 retention. Hypoventilation caused CO2 retention with either Central, physical characteristics or disease based orgins can be a different process. There are also many COPD pts that have other disease processes such as pulmonary hypertension that must be taken into consideration. Rarely is there a well defined blanket statement to fit all patients. 



> *Summary
> The neurological drive to breathe is complicated and is not fully understood. From a clinical standpoint, the injudicious and uncontrolled administration of supplemental oxygen to patients with compensated respiratory acidosis, although probably less risky than implied in the clinical literature, is not a good idea. The deliberate under-oxygenation of a patient with compensated respiratory acidosis (or a diagnosis of COPD) because of fear of hypoventilation or apnea, however, creates the greater risk of inducing prolonged tissue hypoxia.*


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## jrm818 (Nov 12, 2008)

In rare cases it may "knock down" their drive, but its uncommon and unlikely in the short time you see the patient. I was told the same thing in basic class about their drive - it didn't make much sense to me then, it doesn't now.  

Even in the population of CO2 retainers, the changes in chemoreceptor function and pathophysiology of the disease in general is a lot more complicated than the common explination of "they switch to a hypoxic drive, so O2 reduces the drive to breathe and they die (of hypoxia presumably?)" .  That makes little sense if you think critically about it. 

Don't make VentMedic re-write what she's already written - read that thread!  Make sure you actually "understand" rather than "were told."

As for not breathing being "100% fatal"...well it would be...if the person giving them O2 didn't have a way of ventilating them.....

As for titrating the O2, as suggested in that thread, that's not something easily done prehospitally in this patient population.  O2 sat readings tend to be highly variable among COPD'rs, most are smokers which throws off the reading more, skin color is an OK indicator as long as it isn't hot, cold, they aren't sick, they aren't anemic, they don't have increased H&H, etc.  I'm not going to stake my patient on that as an indicator. If they called you chances are they feel like they are SOB or having difficulty breathing.  If they called for a broken arm sure, leave them on their home setting, but if they called for a breathing issue, 100% O2 and monitor breathing.


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## VentMedic (Nov 12, 2008)

jrm818 said:


> As for titrating the O2, as suggested in that thread, that's not something easily done prehospitally in this patient population. O2 sat readings tend to be highly variable among COPD'rs, most are smokers which throws off the reading more, skin color is an OK indicator as long as it isn't hot, cold, they aren't sick, they aren't anemic,


 
In the Pulmonary Lab, we will call the primary physician who sends us a smoker to titrate on home O2 with a "forget it" message. Even with a carboxyhemoglobin level, their smoking will cause it to fluctuate and they will probably adjust their O2 anyway accordingly as their SaO2 drop is felt.

However, we will be more than happy to spend the hour doing a smoking cessation lesson which is still a reimbursed item.


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## Sasha (Nov 12, 2008)

jrm818 said:


> In rare cases it may "knock down" their drive, but its uncommon and unlikely in the short time you see the patient. I was told the same thing in basic class about their drive - it didn't make much sense to me then, it doesn't now.
> 
> Even in the population of CO2 retainers, the changes in chemoreceptor function and pathophysiology of the disease in general is a lot more complicated than the common explination of "they switch to a hypoxic drive, so O2 reduces the drive to breathe and they die (of hypoxia presumably?)" .  That makes little sense if you think critically about it.
> 
> ...




Re-read my post. I wasnt disagreeing with giving COPDers lots of O2. As I said, if by some chance you knock out their drive, then that can be fixed at the hospital, until then you bag them. That was actually a question on my pre-hire test, would you give a COPDer high flow O2. Interesting thread.


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## MSDeltaFlt (Nov 12, 2008)

KB1MZR said:


> That's what I was thinking, can't go wrong with ABC, ALS, and when all else fails call med control.  I was just wondering if I missed something and there was something I should do because I'm not going to mess with equipment a pt. is relying on even to take over with a BVM because who knows at that point what is the actual problem and what is worse.



Getting back on topic, you didn't miss anything.  And I wouldn't worry about the actual vent either.  Like Vent said, the family can take care of that.  They can turn it off and/or bring with them in the truck or later on if they choose to do so.


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## jrm818 (Nov 12, 2008)

Sasha said:


> Re-read my post. I wasnt disagreeing with giving COPDers lots of O2. As I said, if by some chance you knock out their drive, then that can be fixed at the hospital, until then you bag them. That was actually a question on my pre-hire test, would you give a COPDer high flow O2. Interesting thread.



Got it - mis-interpreted what you meant.

Outta curiosity - what was the "right" answer on the test?


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## VentMedic (Nov 12, 2008)

> Originally Posted by *Sasha*
> 
> 
> _Re-read my post. I wasnt disagreeing with giving COPDers lots of O2. As I said, if by some chance you knock out their drive, then that can be fixed at the hospital, until then you bag them. That was actually a question on my pre-hire test, would you give a COPDer *high flow O2*. Interesting thread._


 


jrm818 said:


> Got it - mis-interpreted what you meant.
> 
> Outta curiosity - what was the "right" answer on the test?


 
That is an interesting question and as worded "high flow O2" it can be interpreted very differently.

EMT(P)s consider a NRBM to be high flow but it is actually not but can give a higher FiO2 of O2.

A venturi or other entrainment mask or system is high flow and can deliver as little as an FiO2 of 0.24. Thus, for an RT exam a high flow device would be the correct answer to deliver a controlled low O2% while it might mean a NRBM on an EMT exam.


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## MSDeltaFlt (Nov 12, 2008)

VentMedic said:


> That is an interesting question and as worded "high flow O2" it can be interpreted very differently.
> 
> EMT(P)s consider a NRBM to be high flow but it is actually not but can give a higher FiO2 of O2.
> 
> A venturi or other entrainment mask or system is high flow and can deliver as little as an FiO2 of 0.24. *Thus, for an RT exam a high flow device would be the correct answer to deliver a controlled low O2% while it might mean a NRBM on an EMT exam*.



Why were we taught that in EMT and paramedic school, Vent?  Going from resp to the street I could never really understand why.  The only reason I can come up with is that, at 15 L/M, it *sounds* high flow.  Is it that simple or do the books have some outdated emperical data that they're going by?


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## KEVD18 (Nov 12, 2008)

anybody still want to question my head banging against the wall graphic at this point?

R/r, vent? how many times have you been down this road on this board?

im going to go render myself unconcious now.


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## MSDeltaFlt (Nov 12, 2008)

KEVD18 said:


> anybody still want to question my head banging against the wall graphic at this point?
> 
> R/r, vent? how many times have you been down this road on this board?
> 
> im going to go render myself unconcious now.



I got why.  Funny.


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## BossyCow (Nov 12, 2008)

In that case, the COPD pt's primary issue is DIB, so that in my system would make it an automatic ALS, if ALS was available. If the pt is already having difficulty breathing, it really shouldn't matter in a bls response what the pt's respiratory drive issues are specifically. We treat the symptoms. We would manage the airway. Assist with BVM if necessary, O2 at a level that improves perfussion and eases the distress. ALS to cover our butts in case the pt goes south on the way to the ER.

The knowledge is good for understanding of respiratory systems so we can be a bit more aware of when ALS is going to be needed, but in this case, its pretty clearly an ALS call.


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## daedalus (Nov 12, 2008)

VentMedic said:


> Yes, as you stated the parents' knowledge is invaluable in these situations. But, please do not cop the "you called us" attitude with parents who do call you for a way to get to the hospital. Parents may have no choice but to call due to the immobility of the child or a sudden emergency that needs quick attention. The parents are probably already feeling they have let their child or loved one down in some way or their care was inadequate which may totally not be the case but they are the primary caregivers.
> 
> Most are very protective of their child or loved ones and want people who are well educated/trained to do the care or at least someone who will not haphazardly fumble around causing great harm. That is why we have hospitals that specialize in certain populations such as children or various cardiac disorders. You also shouldn't take this attitude with someone who might have a LVAD or some other VAD if the S.O.s try to explain "continuous flow" when you check the pulse and want transport to where their doctor is.
> 
> ...



I am prepared to ventilate with a 15 mm connector, or use the ol' infant mask over the airway trick. I will do what I have to. I also understand patients who will not have a pulse because of VADs. But Vent, your right. Lets teach paramedics and EMTs more about this stuff before sending them into special populations around tertiary hospitals.


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## VentMedic (Nov 12, 2008)

daedalus said:


> Lets teach paramedics and EMTs more about this stuff before sending them into special populations around tertiary hospitals.


 
Too few take advantage of what they can learn in their hospital clinicals. Just because it isn't dripping blood doesn't mean there is not something to learn. The same with routine BLS transports. Dialysis or chemo patients are great to find various devices of access. Observe what various access ports patients have even if you as an EMT-B can not do much with them yet. You might gain some respect when you mention that to the RN or MD in the ED. You can then take notes or get formally instructed later. 

At far as airways, remember a trach is not always the trach pictured in the text book. 

Here's a thread for last year.
http://www.emtlife.com/showthread.php?t=4606

For the links not working:
http://www.tracheostomy.com/faq/types.htm

Trach buttons and rings (Olympic)
http://www.natus.com/index.cfm?page=products_1&crid=124&contentid=219

Examples of various ETTs used in the hospital.
http://www.aarc.org/marketplace/reference_articles/06.99.0661.pdf

Speaking valves you may see:
http://www.passy-muir.com/

voice restoration
http://blomsinger.com/

http://blomsinger.com/voicerestorationwhatsalary.htm


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## daedalus (Nov 12, 2008)

I understand what your saying "do not cop the you called us attitude". I was always taught to have a calm and in control affect and turn chaos into calm. We are supposed to be cool and in charge, so how can we reconcile this training with responding to a scene and than handing control of the situation to those who called us? Thats backwards for most of us non hospital types.


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## Sasha (Nov 12, 2008)

jrm818 said:


> Got it - mis-interpreted what you meant.
> 
> Outta curiosity - what was the "right" answer on the test?



The right answer was to not withhold O2. I got 100% on the test. Answer any questions on my stance on the issue?


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## VentMedic (Nov 12, 2008)

daedalus said:


> I understand what your saying "do not cop the you called us attitude". I was always taught to have a calm and in control affect and turn chaos into calm. We are supposed to be cool and in charge, so how can we reconcile this training with responding to a scene and than handing control of the situation to those who called us? Thats backwards for most of us non hospital types.


 
Non hospital types? This is about medicine and patient care regardless of where it is practiced. It is about respect for the knowledge of the caregivers and their ability to assist in a situation that you are not well prepared for. It will of course depend on the emergency but don't kick the family to the curb so that you can "be cool and in charge". 

The patient and/or parents still have some rights and still know the devices and medical condition better than an EMT-B or even a Paramedic. If you rush in and not listen to what they have to say or let them direct you through procedures you are not accustomed to doing, you may do more harm than good. The families have also spent many hundreds if not thousands of hours training and educating themselves on how to take care of their child or loved one. You have spent 110 hours on first-aid. They have the same concerns about handing their child over to your care. They are not stupid and have probably been informed on what abilities EMS systems have and don't have. You have to learn some interaction skills to communicate with parent and patient to gain confidence. Depending on the situation, you may be the one that is overwhelmed and need calming with a very technology dependent medical needs patient. The parents may have been through rough times before and will be okay but still need to get their child to the hospital. If you get into a peeing match with the family, no one wins. Calm yourself and listen to the family. Again, they can be reasoned with if they see you are not going to do something to cause harm to their child or family member.

As I said before, most would have hoped for a smoother way to the hospital then deal with the drama of EMS especially in areas that run 3 trucks/engines/ladders to every call.


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## VentMedic (Nov 12, 2008)

MSDeltaFlt said:


> Why were we taught that in EMT and paramedic school, Vent? Going from resp to the street I could never really understand why. The only reason I can come up with is that, at 15 L/M, it *sounds* high flow. Is it that simple or do the books have some outdated emperical data that they're going by?


 
I went from Paramedic to RRT; a big educational and learning process.

In EMT or paramedic school, we were taught recipes for devices by way of memorization. The higher the flow the higher.........  Luckily college A&P were prerequisites at the time I took my Paramedic 30 years ago.

I didn't understand how many of the O2 devices worked until I started in the respiratory program. The same with intubation. I rarely if ever missed a tube on Rescue as a Paramedic but I definitely learned how to intubate proficiently and efficiently as a Respiratory Therapist.


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## KEVD18 (Nov 12, 2008)

daedalus said:


> I understand what your saying "do not cop the you called us attitude". I was always taught to have a calm and in control affect and turn chaos into calm. We are supposed to be cool and in charge, so how can we reconcile this training with responding to a scene and than handing control of the situation to those who called us? Thats backwards for most of us non hospital types.



because in some cases, as vent is trying to demonstrate, they called us as a mode of conveyance.

i know its tough to accept that someone who isnt even an emt(admittedly the godliest of medical training levels) might just happen to know more about the disease process and the treatment for it; but sometimes its true. i'll take any help i cant get. if the parent/wife/child etc knows how to do something the patient needs better than you becuase they have been trianed in it and do it x times a day(v. you having had 8 minutes of training 5 years ago and maybe used said skill twice in your entire career), why *wouldnt* you take that help?


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## daedalus (Nov 12, 2008)

I had Law Enforcement Officers who were also paramedics run my EMT program. They subscribed to the Dr Bledsoe ideology, that EMS was a fusion of public safety and medicine. I am the first to say that medicine is medicine, and that we should move beyond levels of care or silly titles to provide it, but I cannot ignore how I was trained. I was taught that the EMS and Fire crews were to take absolute control of all aspects of the scene. I am now asking for your views on the matter and criticism on how these ideologies might be wrong. Just remember I did not come up with these viewpoints personally.


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## KEVD18 (Nov 12, 2008)

daedalus said:


> I had Law Enforcement Officers who were also paramedics run my EMT program. They subscribed to the Dr Bledsoe ideology, that EMS was a fusion of public safety and medicine. I am the first to say that medicine is medicine, and that we should move beyond levels of care or silly titles to provide it, but I cannot ignore how I was trained. I was taught that the EMS and Fire crews were to take absolute control of all aspects of the scene. I am now asking for your views on the matter and criticism on how these ideologies might be wrong. Just remember I did not come up with these viewpoints personally.



well my view is as above


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## VentMedic (Nov 12, 2008)

daedalus said:


> I had Law Enforcement Officers who were also paramedics run my EMT program. They subscribed to the Dr Bledsoe ideology, that EMS was a fusion of public safety and medicine. I am the first to say that medicine is medicine, and that we should move beyond levels of care or silly titles to provide it, but I cannot ignore *how I was trained.* I was taught that the EMS and Fire crews were to take absolute control of all aspects of the scene. I am now asking for your views on the matter and criticism on how these ideologies might be wrong. Just remember I did not come up with these viewpoints personally.


 
Once you become *educated* about medicine, you will find that there are few absolutes in medicine. Recipes are good only to a certain point. Every situation must be with patient care and your personal safety in mind. 

Allowing a parent or family member to assist you in some aspect of care you are not familiar with is not giving up control. If you fumble through a situation because you did not allow the family to educate you on how to properly take care of the patient, then you are truly not in control. 

If a nurse just told you to pick up a medically complex patient with a bunch of equipment at a LTC facility or hospital without report or assistance, I am sure you would be upset. This is no different. It is just that the LTC facility is the patient's home.


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## MSDeltaFlt (Nov 12, 2008)

VentMedic said:


> I went from Paramedic to RRT; a big educational and learning process.
> 
> In EMT or paramedic school, we were taught recipes for devices by way of memorization. The higher the flow the higher.........  Luckily college A&P were prerequisites at the time I took my Paramedic 30 years ago.
> 
> I didn't understand how many of the O2 devices worked until I started in the respiratory program. The same with intubation. I rarely if ever missed a tube on Rescue as a Paramedic but I definitely learned how to intubate proficiently and efficiently as a Respiratory Therapist.



That's what I thought.  Thanks.


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## Ridryder911 (Nov 12, 2008)

Actually if you were to talk to Dr. Bledsoe I believe his thinking is we should be more medicine than to ever be considered public safety. Sorry, I don't want to wear a badge nor be unionized, and at least be expected to read above a 10'th grade level. 

Vent's point is many times for some reason many of those in EMS fail to see the whole picture. EMS is not always alone with this attitude but I have to admit they are the ones with the least education and training that usually expose it so well. 

Remember, the family and yes.. (gulp!) the patient is the one that deals with, works around, etc. every second, every minute of everyday and your whopping 20 to 50 minute exposure. Listen to the family, talk to the patient and the chances are they usually have a solution or a way that is better. 


Don't make things any more complicated than necessary. 

R/r 911


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## VentMedic (Nov 12, 2008)

Ridryder911 said:


> Actually if you were to talk to Dr. Bledsoe I believe his thinking is we should be more medicine than to ever be considered public safety.


 
Here's the article for everyone's viewing pleasure.
http://www.jems.com/news_and_articles/columns/Bledsoe/Should_EMS_Be_a_Part_of_Public_Safety.html

*Should EMS Be a Part of Public Safety?*

*Another Perspective*


<LI class=author>Bryan E. Bledsoe, DO, FACEP
2007 Aug 2



> Thus, we have a conundrum. *Public safety, especially law enforcement, requires employees to adhere to Kohlberg’s “Maintaining Social Order”* stage (Stage 4) for much of their work. In fact, this reasoning is reinforced in law enforcement academies. In this stage of moral reasoning, adhering to the letter of the law trumps all other concerns. An example of this, of which I’m acutely aware, is a local Texas Highway Patrolman who wrote his wife a ticket for speeding. His moral reasoning was “she broke the law and the law must be enforced — no matter who the offender.”
> 
> Such a priority can conflict with the role of EMS. In our textbooks, and in education classes, we teach that the patient always comes first (after scene and personal safety). *We emphasize that EMS personnel are advocates for the patient.*Thus, in EMS education, we ask that EMTs and paramedics function, at a minimum, in Kohlberg’s “Social Contracts and Individual Rights” stage (Stage 5).


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## Ridryder911 (Nov 12, 2008)

Yes, but he was discussing it as in a profile of sociology not professional stature, in which Bryan and I have had discussions. Definitely an advocate for EMS to be more in-depth in medical adaptation than to be regarded as a "public servant" type employee. 

R/r 911


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