# BLS transport of ALS emergency???



## Shock (Aug 16, 2015)

I need a second and a third opinion on this. We received a call to an urgent care center for a 19 YOM with a confirmed spontaneous pneumothorax (did not appear to be tension). His chief complaint was chest pain, and was accompanied with SOB. It was dispatched by county as an ALS lights and siren response. My supervisor (EMT-P) sent out a BLS unit, and followed us in a sprint unit. However, he told us to respond non-emergency. So, we get there, and the patient appears ok. He's a little pale, no cyanosis, pulse ox reading at 93, and is on 15L non-rebreather. BP was elevated a bit, but looking at him, he pretty much looked and acted fine.

The supervisor then tells us to transport BLS, again, no lights or sirens. According to the urgent care, about 40% of the lung had collapsed. I strongly disagree with this decision, mainly to transport BLS. BLS in my state (and most as I understand) CANNOT decompress had the patient started to tension. It freaked me out a little.

Was the supervisor in the wrong? How should I handle this? How would you have handled it?


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## MonkeyArrow (Aug 16, 2015)

How far away is the hospital?


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## Shock (Aug 16, 2015)

About 6 miles, medium traffic.


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## MonkeyArrow (Aug 16, 2015)

So you said that the supervisor, who is a paramedic, followed you in a sprint car. To help clarify, was he actually on scene with you guys and the patient?


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## Shock (Aug 16, 2015)

He was on scene. He did not follow us to the hospital, however.


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## MonkeyArrow (Aug 16, 2015)

With the hospital so close, I wouldn't say the supervisor was _wrong_. As you said, the patient appeared fine and his sats are borderline acceptable. Since assuming that there was no accessory muscle usage, hyperventilation, or diaphoresis, there is probably little chance of him deteriorating in the 10-15 minutes that you are with him, especially because it was a spontaneous pneumo and not one of traumatic etiology. The fact that the patient presented to an urgent care as opposed to an ED tells me that he probably isn't in life-threatening amounts of distress, and that the condition has progressively developed over time (a few hours maybe) and will probably not culminate in him going into respiratory arrest in the back of the ambulance. Also, the medic saw the patient as stable enough to go without lights and sirens, furthering my opinion that I have outlined above. *As I did not see the patient, I'm making some broad generalizations here.
*
If I was the medic intercept, would I have accompanied? Probably, but unless the unlikely event of him crashing occurred, I would not have provided any more treatment than you.


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## SeeNoMore (Aug 16, 2015)

I would have stayed. Generally I also always make sure BLS is comfortable before I triage a patient.


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## NomadicMedic (Aug 16, 2015)

Sounds like a good use of a BLS non emergent ride to the hospital.


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## Shock (Aug 16, 2015)

The xray in the ED showed a 10% further collapse. SOB was worse at arrival, but not terrible. We didn't stick around too much longer but they were prepping him to be tubed stat as soon as we transferred him. The surgeon was paged when we called it in and they were xraying him while I was giving report. The ED was a lot more urgent than we were. It reminded me of a trauma alert.


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## cprted (Aug 16, 2015)

From where I am in my career (very early), in that situation I would have ridden in with you. That being said, I know a lot of others that wouldn't have, especially with the hospital being very nearby.  The picture you've painted (and like everyone else, I wasn't there) is of someone that, while they have a serious problem, are fairly stable and are probably going to stay stable for time it will take you to get them to higher level care.

Other things to consider, is your supervisor the only ALS resource available in your area?  If he is it for ALS, then that also changes the criteria for who he rides with.  If he ties himself up with a stable patient who doesn't require ALS treatment, what happens to the BLS crew that has to respond to the obstructed airway call without ALS backup?  That isn't really fair to the other crew or the patient.


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## Shock (Aug 16, 2015)

We had a total of 3 medics (including him) in station at the time. Supervisors, particularly this one, seldom respond to calls unless it is serious (bad MVA, arrest, juicy calls). I respect his decision to send it BLS, but I honestly think it should have been ALS. In the event that he did crash, we all would have been a whole lot of trouble.

*The receiving hospital also has a sprint medic (usually available) and physician (sometimes available).


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## FlashingLights (Aug 16, 2015)

Shock said:


> I need a second and a third opinion on this. We received a call to an urgent care center for a 19 YOM with a confirmed spontaneous pneumothorax (did not appear to be tension). His chief complaint was chest pain, and was accompanied with SOB. It was dispatched by county as an ALS lights and siren response. My supervisor (EMT-P) sent out a BLS unit, and followed us in a sprint unit. However, he told us to respond non-emergency. So, we get there, and the patient appears ok. He's a little pale, no cyanosis, pulse ox reading at 93, and is on 15L non-rebreather. BP was elevated a bit, but looking at him, he pretty much looked and acted fine.
> 
> The supervisor then tells us to transport BLS, again, no lights or sirens. According to the urgent care, about 40% of the lung had collapsed. I strongly disagree with this decision, mainly to transport BLS. BLS in my state (and most as I understand) CANNOT decompress had the patient started to tension. It freaked me out a little.
> 
> Was the supervisor in the wrong? How should I handle this? How would you have handled it?



Hm. Isn't it best practice for sirens / lights? Let's start there...


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## Shock (Aug 16, 2015)

Lights and sirens, in my opinion, was indicated. It was dispatched as an ALS highly urgent emergency. We couldn't really predict how fast he was crashing. We just knew that without treatment at a hospital, or by a medic, he would have inevitably. I don't really like taking those kinds of bets with patient care. If he did crash, it would have been a disaster. Oxygen would have been useless, bagging him would have made it worse (and would probably not be possible), and CPR would be the only chance to circulate past the impinged vein or artery. A medic decompressing is a HIGHLY dangerous procedure, because the medic is blindly playing darts with a vital organ. But it would have been his best chance if he crashed. BLS is useless in that instance.


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## Flying (Aug 16, 2015)

Shock said:


> Lights and sirens, in my opinion, was indicated. It was dispatched as an ALS highly urgent emergency. We couldn't really predict how fast he was crashing.


Young guy showing compensatory signs that aren't grossly out of normal limits.
Looks and acts fairly normal at the time of arrival.
Decent transport time/distance.
Treatment of condition is guided by current clinical picture, rather than the predicted size of pneumo.

I wouldn't go so far as to say your supervisor was making a bet.


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## cprted (Aug 16, 2015)

Shock said:


> Lights and sirens, in my opinion, was indicated. It was dispatched as an ALS highly urgent emergency. We couldn't really predict how fast he was crashing. We just knew that without treatment at a hospital, or by a medic, he would have inevitably. I don't really like taking those kinds of bets with patient care. If he did crash, it would have been a disaster. Oxygen would have been useless, bagging him would have made it worse (and would probably not be possible), and CPR would be the only chance to circulate past the impinged vein or artery. A medic decompressing is a HIGHLY dangerous procedure, because the medic is blindly playing darts with a vital organ. But it would have been his best chance if he crashed. BLS is useless in that instance.


How much time would have going lights and sirens 6 miles in moderate traffic saved you?  30 seconds? 40 seconds?  

I go to lots of calls that are dispatched as ALS high acuity, but assessment of the patient determines which car takes them to the hospital and whether routine or emergency.  

You should do some more reading on tension pneumos and needle thoracentesis ... you're over stating the "HIGHLY dangerous" nature of it ... are there risks, of course, but I wouldn't consider it "HIGHLY dangerous."


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## Shock (Aug 16, 2015)

I don't take it you have ever blindly inserted a 10g needle into the dermis, all intercostal muscles (they get thicker and tougher as you go deeper), and both pleura layers without even bumping the intercostal vein, intercostal artery (shout out to the ic nerve, for the sake of your patient jolting in pain), or the lung? It's dangerous for a surgeon to do in the OR, let alone a medic on a truck. Tension pneumos are killers, there is no question about that.

I just do not believe that this should not have been transported BLS. The doctor at the urgent care had also requested an ALS transport, I should mention.


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## MonkeyArrow (Aug 16, 2015)

On the topic of danger of inserting a needle, while probably more risky and bearing a higher rate of complications than most other procedures, if done right, needle thoracentesis is still relatively safe. The reason it is drilled to go along the top of rib is to avoid the neurovascular bundle. The military trains soldiers in its CLS class to do needle thoracentesis within a few hours (on that specific skill). They do a large number of them, as tension pneumo was at one time responsible for killing 33% of soldiers dying of preventable causes. And yet, we haven't heard of a massive number of complications for such a high reward procedure. 

From your posts on here, it seems as though you were not looking for others opinions, but rather affirmation of your thoughts, and trying to dismiss any dissenting opinions.


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## Smitty213 (Aug 16, 2015)

In my protocols, and most that I'm aware of, the patient being conscious/alert is a contraindication for needle decompression (though medical control can override based on transport time). The contraindication comes not so much from the potential danger, but more of the shock caused by someone inserting a very large needle (or two) into your chest. With a six minute transport time and a fairly stable patient, no MC doc would have given the override; therefore the best intervention that could be provided if the patients SOB was truly severe would be positive pressure ventilation, which is a BLS skill.


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## Ewok Jerky (Aug 16, 2015)

1. If you aren't comfortable with taking a patient then you need to speak up.

2. Thoracentesis is not done blind and is not that difficult if you have the training, you just need the balls to do it, and hen done correctly is not HIGHLY dangerous.

3. I vote No supervisor was not wrong, but if BLS wasn't comfortable he (or she) should have done a more thorough handoff.


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## SandpitMedic (Aug 17, 2015)

Shock said:


> The xray in the ED showed a 10% further collapse. SOB was worse at arrival, but not terrible. We didn't stick around too much longer but they were prepping him to be tubed stat as soon as we transferred him. The surgeon was paged when we called it in and they were xraying him while I was giving report. The ED was a lot more urgent than we were. It reminded me of a trauma alert.



I think everyone else missed this part...
Are you sure you're using the term tube the way we use the term tube? You mean chest tube?
A 50% pnuemo is an ALS emergency. Clinical outcome should have been taken into consideration prior to transport.


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## medichopeful (Aug 17, 2015)

FlashingLights said:


> Hm. Isn't it best practice for sirens / lights? Let's start there...



No.  This is a myth that must disappear, and soon, before it takes more lives.

http://www.emsworld.com/article/103...a-significant-amount-of-travel-time-and-lives
http://www.aapsus.org/articles/1.pdf


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## medichopeful (Aug 17, 2015)

SandpitMedic said:


> I think everyone else missed this part...
> Are you sure you're using the term tube the way we use the term tube? You mean chest tube?
> A 50% pnuemo is an ALS emergency. Clinical outcome should have been taken into consideration prior to transport.



I'm with you.  Even with only a 6 mile transport distance, I'd be pretty uncomfortable transferring this call as a basic.  93% SpO2 is fine, but requiring a NRB at 15lpm to maintain this is concerning.  93% on RA would be a completely different story.

It's true that ALS might not be able to do much for this patient, but in the event they degrade further there's even less that a BLS crew could do.  In addition, I would like to see this patient transferred on a monitor.  I'm usually pretty liberal when it comes to use of BLS for short transfers, but I don't think this call is BLS appropriate.


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## Akulahawk (Aug 17, 2015)

For a 6 mile transport, I'd rather send the patient with a BLS crew that I have on hand than wait a while for an ALS crew, but I'd also not downgrade to BLS and ride in with this patient if I were the medic on this call. I wouldn't call this patient "stable" but he's not crump right now unstable either. He'll need a chest tube very soon though.


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## Shock (Aug 17, 2015)

SandpitMedic said:


> I think everyone else missed this part...
> Are you sure you're using the term tube the way we use the term tube? You mean chest tube?
> A 50% pnuemo is an ALS emergency. Clinical outcome should have been taken into consideration prior to transport.


Yes, the ED placed a chest-tube, which is pretty much what we were expecting them to do. I didn't stick around long enough to see if he was decompressed before that. So, here's the kicker. According to the patient, if he leaned forward, he would start to black out. He didn't have LOC at any point, however. As I understand, this is a sure-fire sign of a tension pneumo in the making (enough pressure to compress vena cava). We kept him in full fowlers during transport, which was effectively a position of comfort. I've been doing a bit of research on pneumo's. We're taught about traumatic instances that even BLS can treat generally, but not so much when they happen for no clear reason. There's nowhere for the pressure to go. Onset was about 30 - 40 minutes before we had arrived to the UC. I'm listening to what everyone says, but I cannot convince myself that this was appropriate for BLS.


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## ERDoc (Aug 21, 2015)

A known ptx with a sat of 93% in 15L, that seems pretty ominous to me.  Even if it is a short ride, I would rather see this guy go with a medic.  There is a potentially life threatening condition that a medic can actually do something about.  Needle decompression is not dangerous by any means as long as you know what you are doing.  If there was no ALS present on the scene then I would say diesel is the best treatment but why not have that person who can do something in the ambulance in case it is needed.

OP, keep in mind that not all pneumos become tension pneumos.  Some people can walk around for days/weeks with a ptx and be fine.


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## Tigger (Aug 22, 2015)

As said, first and foremost if you aren't comfortable accepting a patient from a medic, don't. There's not really any excuse to make there.

That said you'd think your supervisor might have raised an eyebrow at 15lpm maintaining 93% spO2. As for lights and sirens, no to both. There are few good reasons to respond to an urgent care or community ED emergent, it is after all a higher level of care than the ambulance you are about to place them in. And it really does not save a clinically significant amount of time.


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## Bullets (Aug 25, 2015)

Sounds very similar to my town, if i was the BLS crew i would have no problem transporting the 6 miles from an SNF to the ER. i would however have taken a pulse ox on room air to get an idea of how bad this kid is, then probably switch to a NC and give the ER a heads up im coming. L&S isnt needed, but i would not fault you if you did. 

If ALS was coming and on scene before i was loaded then i would expect them to hop in an treat en-route. If not, they are cancelled proximity. Nice to have, not absolutely required


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## CANMAN (Aug 25, 2015)

Bullets said:


> Sounds very similar to my town, if i was the BLS crew i would have no problem transporting the 6 miles from an SNF to the ER. i would however have taken a pulse ox on room air to get an idea of how bad this kid is, then probably switch to a NC and give the ER a heads up im coming. L&S isnt needed, but i would not fault you if you did.
> 
> If ALS was coming and on scene before i was loaded then i would expect them to hop in an treat en-route. If not, they are cancelled proximity. Nice to have, not absolutely required



Obtain a room air pulse ox, why? How will this guide your treatment of this patient? Switch to a NC, did you catch the patient is 93% on 100% 15liters non-rebreather already? If the patient is mildly hypoxic on a non-rebreather why take them off of that to obtain a room air SpO2? I can tell you what it's going to be, low..............


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## Chewy20 (Aug 27, 2015)

CANMAN said:


> Obtain a room air pulse ox, why? How will this guide your treatment of this patient? Switch to a NC, did you catch the patient is 93% on 100% 15liters non-rebreather already? If the patient is mildly hypoxic on a non-rebreather why take them off of that to obtain a room air SpO2? I can tell you what it's going to be, low..............



Well you see, the NC is actually INSERTED into the nostril with the two little tubes. So if you think about it, the pt has a better shot of getting that o2 in their system...or something like that. POTATO


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## medichopeful (Aug 27, 2015)

Chewy20 said:


> Well you see, the NC is actually INSERTED into the nostril with the two little tubes. So if you think about it, the pt has a better shot of getting that o2 in their system...or something like that. POTATO



Unless they're breathing through their mouth. With everything described so far, it doesn't sound like breathing through the mouth in this situation is too far-fetched.


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## CANMAN (Aug 27, 2015)

Chewy20 said:


> Well you see, the NC is actually INSERTED into the nostril with the two little tubes. So if you think about it, the pt has a better shot of getting that o2 in their system...or something like that. POTATO



So if you're trying to be sarcastic and I am not picking up on it I am sorry. But are you trying to tell me that someone in a high level of respiratory distress, and likely fairly substantial hypoxia on room air deserves a NC over a NRM? And if so is that your protocol for respiratory distress and hypoxia as an intervention prior to CPAP or intubation?


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## Chewy20 (Aug 27, 2015)

CANMAN said:


> So if you're trying to be sarcastic and I am not picking up on it I am sorry. But are you trying to tell me that someone in a high level of respiratory distress, and likely fairly substantial hypoxia on room air deserves a NC over a NRM? And if so is that your protocol for respiratory distress and hypoxia as an intervention prior to CPAP or intubation?


 
C'mon man, my reply had the word "potato" in it.


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## CANMAN (Aug 27, 2015)

Fair enough  wasn't familiar with the term being used that way lol.


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## Chewy20 (Aug 27, 2015)

Go watch the movie "The Ringer".


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## Carlos Danger (Aug 27, 2015)

Shock said:


> I need a second and a third opinion on this. We received a call to an urgent care center for a 19 YOM with a confirmed spontaneous pneumothorax (did not appear to be tension). His chief complaint was chest pain, and was accompanied with SOB. It was dispatched by county as an ALS lights and siren response. My supervisor (EMT-P) sent out a BLS unit, and followed us in a sprint unit. However, he told us to respond non-emergency. So, we get there, and the patient appears ok. He's a little pale, no cyanosis, pulse ox reading at 93, and is on 15L non-rebreather. BP was elevated a bit, but looking at him, he pretty much looked and acted fine.
> 
> The supervisor then tells us to transport BLS, again, no lights or sirens. According to the urgent care, about 40% of the lung had collapsed. I strongly disagree with this decision, mainly to transport BLS. BLS in my state (and most as I understand) CANNOT decompress had the patient started to tension. It freaked me out a little.
> 
> Was the supervisor in the wrong? How should I handle this? How would you have handled it?



If it appeared that he _required_ the 15 lpm to maintain a 93% sat, then he's pretty sick. In that case the paramedic should've rode along, because he's already on scene and even in a 10 minute ride, a patient on edge like this can change for the worse.

On the other hand, if he really is perfectly fine clinically - with a normal resp rate and effort - then my guess is that the 93% reading was errant. Or, maybe the reading was accurate, but he wasn't requiring the NRB to maintain it. The picture you paint just doesn't describe a person who is requiring high-flow oxygen to maintain a low-normal sat. 

Why did he present to the urgent care initially? 

Why did they put him on 15lpm - what was his initial Sp02 for them? 

Did you have a pleth to go along with that Sp02?


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## johnrsemt (Aug 29, 2015)

Thoracentesis is done blind quite a few times:  I transported a patient that needed it from a small ED; they refused to do it, looking at it will 2 ultrasounds at the same time.  When we got the pt to the larger ED, the staff doctor let the 1st resident stick the pt blind.


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## ERDoc (Aug 29, 2015)

johnrsemt said:


> Thoracentesis is done blind quite a few times:  I transported a patient that needed it from a small ED; they refused to do it, looking at it will 2 ultrasounds at the same time.  When we got the pt to the larger ED, the staff doctor let the 1st resident stick the pt blind.



But the pt the OP transported had a pneumothorax, not a pleural effusion.


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## Bullets (Aug 30, 2015)

CANMAN said:


> Obtain a room air pulse ox, why? How will this guide your treatment of this patient? Switch to a NC, did you catch the patient is 93% on 100% 15liters non-rebreather already? If the patient is mildly hypoxic on a non-rebreather why take them off of that to obtain a room air SpO2? I can tell you what it's going to be, low..............


What if you take the patient off the oxygen and hes still at 93%? Thar would guide my treatment

And if he is, then ill just crank the NC to 6lpm or 10 lpm or even GASP! 15lpm. And if the patient continues to deteriorate and i start considering RSI, i dont have to interrupt supplemental oxygenation when i attempt to place the tube.


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## ERDoc (Aug 30, 2015)

The last thing you want to do intubate this guy.  This is one of the few times when you actually need 15L NRB and diesel.  He has a confirmed pneumothorax.  There is very little you can do in the field so get him to the hospital.


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## systemet (Aug 30, 2015)

* I wonder why the sending ER didn't put one of these in?  Is there a decent reason not to? http://epmonthly.com/article/pigtail-insertion/

* Also, I'd argue that this isn't completely blind if you have a CXR.

Ultimately, isn't it the sending physician's discretion as to whether this goes ALS? I ended up backing up a BLS crew a few weeks back to watch a completely resolved high-risk TIA (known DVT, on Xarelto), because the physician wanted a CT at a non-stroke center, and wanted a paramedic because he didn't trust the EMTs to recognise if the patient's symptoms recurred and divert to a stroke center. We had a discussion about the situation (a < 15 minute trip), and how the patient was asymptomatic, but ultimately the physician is the highest medical authority, the patient's under their care until they choose to transfer care, and it's not my decision.

Regarding this situation, if they haven't addressed the PTX, and have asked for ALS, I think I'd attend. Granted, it's likely nothing's going to happen, but if it does, you've got to justify why you created a cardiac arrest in transport, by not going with the BLS crew.


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## Akulahawk (Aug 30, 2015)

Bullets said:


> What if you take the patient off the oxygen and hes still at 93%? Thar would guide my treatment
> 
> And if he is, then ill just crank the NC to 6lpm or 10 lpm or even GASP! 15lpm. And if the patient continues to deteriorate and i start considering RSI, i dont have to interrupt supplemental oxygenation when i attempt to place the tube.





ERDoc said:


> The last thing you want to do intubate this guy.  This is one of the few times when you actually need 15L NRB and diesel.  He has a confirmed pneumothorax.  There is very little you can do in the field so get him to the hospital.


I'm pretty much with ERDoc on this. While I would be okay with seriously increasing the oxygen flow through the nasal cannula, I would first want to be certain that the nasal cannula is designed to handle the higher flow. Something else that struck my mind is that if you have the ability to intubate via RSI, then you also have the ability to probably do a needle decompression. This patient has a spontaneous pneumothorax and if you switch to PPV, effectively make the problem worse faster.

To me, the fact that patient is on 15 L and only has an SPO2 of 93% means that I really don't need to get a room air saturation. He's probably also working to breathe a bit, I would probably want to check for tracheal deviation and if I find it, then this guy fits needle decompression criteria. I am, of course, approaching this from an ALS perspective. Being that the transport crew is BLS, and 6 miles away from the ED, I would rather go with the BLS crew transport that is on hand right now that wait more time for an ALS crew to arrive. The ED is already aware of the impending arrival of the patient and is probably ready to receive him and perform an immediate and emergent chest tube placement for chest decompression. Even if the patient compensates in route, the arrival time is very short and the ED is ready, they can again do an emergent chest decompression.


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## CANMAN (Aug 31, 2015)

Bullets said:


> What if you take the patient off the oxygen and hes still at 93%? Thar would guide my treatment
> 
> And if he is, then ill just crank the NC to 6lpm or 10 lpm or even GASP! 15lpm. And if the patient continues to deteriorate and i start considering RSI, i dont have to interrupt supplemental oxygenation when i attempt to place the tube.



Wow... Do you honestly believe that given the scenario you can take this guy off 100% NRM and his sats might stay at 93% ?


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## systemet (Aug 31, 2015)

That would be some awesome shunt physiology.


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## Bullets (Aug 31, 2015)

Akulahawk said:


> I'm pretty much with ERDoc on this. While I would be okay with seriously increasing the oxygen flow through the nasal cannula, I would first want to be certain that the nasal cannula is designed to handle the higher flow. Something else that struck my mind is that if you have the ability to intubate via RSI, then you also have the ability to probably do a needle decompression. This patient has a spontaneous pneumothorax and if you switch to PPV, effectively make the problem worse faster.


True, i forgot what subforum im in. 



CANMAN said:


> Wow... Do you honestly believe that given the scenario you can take this guy off 100% NRM and his sats might stay at 93% ?


Ive seen functional hypoxics at like 84%, so ill believe anything at this point.


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## ERDoc (Aug 31, 2015)

Bullets said:


> Ive seen functional hypoxics at like 84%, so ill believe anything at this point.



They have probably lived there for a while and their body has adapted.  In this scenario we have someone with a relatively acute onset so their body will not like the situation and will not be able to compensate for very long.


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## Akulahawk (Sep 1, 2015)

Bullets said:


> Ive seen functional hypoxics at like 84%, so ill believe anything at this point.





ERDoc said:


> They have probably lived there for a while and their body has adapted.  In this scenario we have someone with a relatively acute onset so their body will not like the situation and will not be able to compensate for very long.



If you've been in healthcare for any appreciable amount of time, you'll see those people that are well-adapted to living with their SpO2 level in the mid-80's and doing quite well. I've seen them too, not many, but I've seen them. However, I have yet to see a relatively young person do all that well when their SpO2 is in the mid-80's and they're not acclimated to being so hypoxic. I suspect that ERDoc has seen more of these than I have.


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## ERDoc (Sep 1, 2015)

Other than kids with congenital issues, I can't think of anyone of a relatively young age I have ever seen that has tolerated a pulse ox in the 80s very well.


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## Akulahawk (Sep 1, 2015)

ERDoc said:


> Other than kids with congenital issues, I can't think of anyone of a relatively young age I have ever seen that has tolerated a pulse ox in the 80s very well.


There ya have it folks... ERDoc, thanks for posting that. I suspected that was the case.


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## evantheEMT (Oct 24, 2015)

So you were nervous about the call and wanted als? Sometimes you do calls out of your comfort zones. Monitor the pts vitals and abc's atleast the hospital wasn't too far away. Also, if you're in the back with the pt you have the right to either have the emt respond or not unless the medic/supervisor is with you.


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## MackTheKnife (Oct 24, 2015)

MonkeyArrow said:


> On the topic of danger of inserting a needle, while probably more risky and bearing a higher rate of complications than most other procedures, if done right, needle thoracentesis is still relatively safe. The reason it is drilled to go along the top of rib is to avoid the neurovascular bundle. The military trains soldiers in its CLS class to do needle thoracentesis within a few hours (on that specific skill). They do a large number of them, as tension pneumo was at one time responsible for killing 33% of soldiers dying of preventable causes. And yet, we haven't heard of a massive number of complications for such a high reward procedure.
> 
> From your posts on here, it seems as though you were not looking for others opinions, but rather affirmation of your thoughts, and trying to dismiss any dissenting opinions.


We teach TP can develop within 10-20 minutes in the military. We also teach that a needle decompression, even done inadvertently, does little to no harm. And yes, you go over the rib, not under. We carry 14ga needles for chest taps in our blowout kits.


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## NYBLS (Nov 21, 2015)

evantheEMT said:


> So you were nervous about the call and wanted als? Sometimes you do calls out of your comfort zones. Monitor the pts vitals and abc's atleast the hospital wasn't too far away. Also, if you're in the back with the pt you have the right to either have the emt respond or not unless the medic/supervisor is with you.



Monitor the ABCs? This patient already has a failure right in B that has a high potential for required correction in the next few minutes.


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## Doczilla (Nov 22, 2015)

ERDoc said:


> A known ptx with a sat of 93% in 15L, that seems pretty ominous to me.  Even if it is a short ride, I would rather see this guy go with a medic.  There is a potentially life threatening condition that a medic can actually do something about.  Needle decompression is not dangerous by any means as long as you know what you are doing.  If there was no ALS present on the scene then I would say diesel is the best treatment but why not have that person who can do something in the ambulance in case it is needed.
> 
> OP, keep in mind that not all pneumos become tension pneumos.  Some people can walk around for days/weeks with a ptx and be fine.



This. This may not be the most popular opinion here, but _shortness of breath  that _worsens in the presence of a known or suspected (ANY chest trauma, including blunt, penetrating, or barotrauma) pneumothorax is enough to buy a decompression.  

Too often I see people rationalizing that the patient needs to be in extremis to pop someone's chest; (JVD, tracheal deviation or other signs of mediastinal shift), and this is downright wrong. That's like witholding treatment for a STEMI until they code the first time. 

If he's symptomatic, he needs to be treated. This isn't any different than treating an arrhythmia, heat illness, or sepsis; but since it involves putting a hole in someone, people freak out.


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## Doczilla (Nov 22, 2015)

Ewok Jerky said:


> 1. If you aren't comfortable with taking a patient then you need to speak up.
> 
> 2. Thoracentesis is not done blind and is not that difficult if you have the training, you just need the balls to do it, and hen done correctly is not HIGHLY dangerous.
> 
> 3. I vote No supervisor was not wrong, but if BLS wasn't comfortable he (or she) should have done a more thorough handoff.



Thoracentesis isn't done blind? God, don't tell me they're using ultrasounds for that too nowadays. They're practically using them for digital blocks anymore. 

Which is funny, because every time I see a chest tube done, (including the ones I've performed), that was pretty much as blind as a procedure can get. How ironic that a (comparatively) little needle needs guidance. I'm calling risk adversity on this one.


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## TransportJockey (Nov 22, 2015)

Doczilla said:


> Thoracentesis isn't done blind? God, don't tell me they're using ultrasounds for that too nowadays. They're practically using them for digital blocks anymore.
> 
> Which is funny, because every time I see a chest tube done, (including the ones I've performed), that was pretty much as blind as a procedure can get. How ironic that a (comparatively) little needle needs guidance. I'm calling risk adversity on this one.


I wonder if he's confusing it with pericardiocentesis? Although the one of those I've done in the field was landmark only, no ultrasound guided.


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## Doczilla (Nov 22, 2015)

TransportJockey said:


> I wonder if he's confusing it with pericardiocentesis? Although the one of those I've done in the field was landmark only, no ultrasound guided.



Yeah, even in tintinalli, blind pericardiocentesis is still a thing, just not a very "popular" thing. But then again, they've got surgeons to do a cardiac window and stuff like that at the hospital.

Whenever it comes up in the field, it always seems like a hail mary, so the risk/reward on a trauma arrest isnt thst big of a deal.

The only time I can think of as far as not popping someone's chest "blind", is using a portable US to confirm a pneumo before I made the decision to do it, but that's about it.


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## Carlos Danger (Nov 22, 2015)

Doczilla said:


> Which is funny, because every time I see a chest tube done, (including the ones I've performed), that was pretty much as blind as a procedure can get. How ironic that a (comparatively) little needle needs guidance. *I'm calling risk adversity on this one.*



Reducing risk isn't a bad thing.


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## Doczilla (Nov 22, 2015)

Remi said:


> Reducing risk isn't a bad thing.


Sure, but reducing risk for the sake of reducing risk can interfere with good clinical decision making. There is literally nothing that we do that is risk free.


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