# BVM mishap. Did I do something wrong?



## jshal (Jul 21, 2016)

I'm new, so when hiccups like this happen, I get kinda agitated and don't know wether it's my fault, or just something that happens from time to time. 

This happened to me last week and idk why. I'm not quite sure how to make it never happen again. I was ventilating an OD pt via BVM. (Very slow respirations) it seemed like my seal was totally fine. I squeezed the bag and instead of ALL the air going down the trachea/throat, some got stuck in the patients cheeks, making their cheeks blow out and blow the some of the air back kinda. When it did, I changed my hand position and actually squeezed the bag a little harder, and then it was fine. I had to squeeze it harder than I'm comfortable doing. it was  frustrating and scary when it occurred. The pt was not in full respiratory arrest, so maybe they happened to breath out at the exact moment I squeezed? (This was the first ventilation I gave them and we were synced yet ) Could that have been it?  

Nothing came of it so I didn't reach out to anyone afterwards. 

Advice?


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## jshal (Jul 21, 2016)

It also could have been the position of the airway, but that seemed totally fine too. No OPA was used. (Rejected)


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## cprted (Jul 21, 2016)

Sounds like the airway was partially obstructed.  In the future, consider an NPA and watch your positioning.  Make sure you're getting a good jaw lift when you're bagging.  If at all possible, use a two person technique. Always think about pulling the patient's face up into the mask instead of pressing the mask down onto the face.


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## WolfmanHarris (Jul 21, 2016)

Watch head positioning and don't be afraid to use two people to ventilate. Without an advanced airway lots of patients are difficult to bag with a one handed seal. From there you run into a problem where to maintain seal you're sacrificing positioning or to maintain positioning you're losing too much volume to leakage. 

In the spontaneously breathing bradypneic patient watch for their inherent respiratory rate and attempt to ventilate in time with it. 

Other things to consider include watching their stomach carefully for gastric inflation, especially if you're having poor compliance and need to increase bag pressures. You may not be able to eliminate gastric inflation but you can take steps to limit it and be prepared to clear the airway. 

Other than that, keep reflecting, reading and trying to improve. Avoid the pitfalls and only learning from more experienced providers who may have developed bad habits. Listen but evaluate for yourself and ask follow-up questions. The acceptable answer for "why did you do that?" is never "Because that's the way we've always done it." or "Bill told me to."


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## Carlos Danger (Jul 22, 2016)

Mask ventilation is very often not easy. As a skill it is highly under-appreciated in EMS for both its importance and difficulty. It actually takes a lot of practice to get really good at. 

So dont stress about it. Just use all the tips you've been taught and practice every chance you get.


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## OCemt86 (Jul 22, 2016)

Was there an airway obstruction? Did patient need suctioning? Since OPA was rejected, assuming no contraindications pop an NPA in next time. Lube that sucker up and patent the **** outta that airway. Make sure you're checking for gastric distention.


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## OCemt86 (Jul 22, 2016)

Also since I can't edit for some reason, try to match the patients Respitory rhythm and increase their total volume. Don't squeeze harder, good way to cause barotrauma.


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## RobertAlfanoNJEMT (Jul 23, 2016)

Always insert in airway in an OD pt.. They lose control of their tongue and it blocks their airway..


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## chaz90 (Jul 23, 2016)

RobertAlfanoNJEMT said:


> Always insert in airway in an OD pt.. They lose control of their tongue and it blocks their airway..


I actually very rarely use an OPA on my apneic opioid ODs. Most seem to have some level of gag reflex present, or will very soon after I begin treatment. Unless I'm unable to ventilate effectively with a BVM, they don't respond to Narcan, or their tongue is actively becoming an issue, I place an NPA alone and call it good. The last thing I want to do is induce vomiting in these people.


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## RobertAlfanoNJEMT (Jul 23, 2016)

chaz90 said:


> I actually very rarely use an OPA on my apneic opioid ODs. Most seem to have some level of gag reflex present, or will very soon after I begin treatment. Unless I'm unable to ventilate effectively with a BVM, they don't respond to Narcan, or their tongue is actively becoming an issue, I place an NPA alone and call it good. The last thing I want to do is induce vomiting in these people.


When I said "an airway" I wasn't specifying OPA over NPA... I generally use an NPA as well


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## NomadicMedic (Jul 23, 2016)

RobertAlfanoNJEMT said:


> When I said "an airway" I wasn't specifying OPA over NPA... I generally use an NPA as well



 I hope you understand why one would think that you meant an OPA, Making a statement like "They lose control of their tongue and it blocks their airway" would make one think that you were attempting to control that tongue. Which, as I'm sure you're well aware, you do not do with a nasal trumpet.


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## RobertAlfanoNJEMT (Jul 24, 2016)

DEmedic said:


> I hope you understand why one would think that you meant an OPA, Making a statement like "They lose control of their tongue and it blocks their airway" would make one think that you were attempting to control that tongue. Which, as I'm sure you're well aware, you do not do with a nasal trumpet.


Does an NPA not go behind the pts tongue?


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## RobertAlfanoNJEMT (Jul 24, 2016)

They lose control of their tongue which blocks their airway, insert a nasal airway which snakes behind the tongue and allows them to breath.. So no I do not understand why you would make that assumption


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## DesertMedic66 (Jul 24, 2016)

RobertAlfanoNJEMT said:


> Does an NPA not go behind the pts tongue?


An NPA does not lift the patients tongue out of their airway like an OPA does


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## RobertAlfanoNJEMT (Jul 24, 2016)

DesertMedic66 said:


> An NPA does not lift the patients tongue out of their airway like an OPA does


I didn't say anything about lifting the tongue... Just clearing the airway of the tongue.. You can admit that you misinterpreted me at any time


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## Carlos Danger (Jul 24, 2016)

Every OD doesn't need an airway. Passive airway obstruction is common, but certainly not universal. Treat your patients as they present.


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## RobertAlfanoNJEMT (Jul 24, 2016)

Remi said:


> Every OD doesn't need an airway. Passive airway obstruction is common, but certainly not universal. Treat your patients as they present.


Does it hurt them to insert an NPA? No. And if I do it I know their airway is secure and I can focus on treating their other presenting life threats and ailments..


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## Carlos Danger (Jul 24, 2016)

RobertAlfanoNJEMT said:


> Does it hurt them to insert an NPA? No. And if I do it I know their airway is secure and I can focus on treating their other presenting life threats and ailments..



Does it hurt? Probably not. Unless it does. Every intervention has risks, even simple BLS ones.  

The point is that it just isn't necessary if they are moving air just fine without it. We shouldn't make a habit of doing things just because they probably won't hurt.


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## NomadicMedic (Jul 24, 2016)

RobertAlfanoNJEMT said:


> I didn't say anything about lifting the tongue... Just clearing the airway of the tongue.. You can admit that you misinterpreted me at any time


 
An NPA doesn't "clear the airway of the tongue."


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## DesertMedic66 (Jul 24, 2016)

RobertAlfanoNJEMT said:


> I didn't say anything about lifting the tongue... Just clearing the airway of the tongue.. You can admit that you misinterpreted me at any time


The way you stated "they lose control of their tongue and it blocks the airway" is going to make the majority of people think you are referring to a OPA being the best airway option.

Also for my post I was just stating the difference between an OPA and NPA as far as what they do.

Edit: since when does placing a NPA mean the airway is secured?


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## RobertAlfanoNJEMT (Jul 24, 2016)

Remi: the way I see it it is better to take the risk with an OD patient because sometimes it can appear that they are addiquatly profusing when they are not.. You can't measure how much air they are moving and someone with an AMS is at risk for an airway obstruction with their tongue.

DEmedic: it certainly does! Do you not know how an NPA works? It goes through the nasal passage and if measured correctly will go to the end of the pharynx, just behind the tongue which would cover the epiglottis..


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## Carlos Danger (Jul 24, 2016)

RobertAlfanoNJEMT said:


> Remi: the way I see it it is better to take the risk with an OD patient because sometimes it can appear that they are addiquatly profusing when they are not.. *You can't measure how much air they are moving and someone with an AMS is at risk for an airway obstruction with their tongue.*


Perfusion (I think that it what you meant) is an entirely different thing from ventilation. 

You can adequately measure the amount of air movement simply by placing your hand in front of their nose and mouth. If you can feel air movement.....they are not obstructing. At least not to a point that needs to be addressed immediately. If they are obstructing, often turning their head to one side will alleviate it. 

OPA's are a great tool to use when indicated. But if air exchange is good, they are not indicated and placing one would therefore be a practice error.


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## RobertAlfanoNJEMT (Jul 24, 2016)

Oh that's genius! Why didn't I think of that! I could just turn the physically agitated patients head to the side! Because they'll leave it like that right? You do what you've got to do and I'll use my own discretion to keep people livin


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## NomadicMedic (Jul 24, 2016)

RobertAlfanoNJEMT said:


> Oh that's genius! Why didn't I think of that! I could just turn the physically agitated patients head to the side! Because they'll leave it like that right? You do what you've got to do and I'll use my own discretion to keep people livin



Just keep racin' the reaper.


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## gotbeerz001 (Jul 24, 2016)

RobertAlfanoNJEMT said:


> Remi: the way I see it it is better to take the risk with an OD patient because sometimes it can appear that they are addiquatly profusing when they are not.. You can't measure how much air they are moving and someone with an AMS is at risk for an airway obstruction with their tongue..



You can adequately measure the effectiveness of their ventilations; it's called ETCO2.


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## DesertMedic66 (Jul 24, 2016)

RobertAlfanoNJEMT said:


> Oh that's genius! Why didn't I think of that! I could just turn the physically agitated patients head to the side! Because they'll leave it like that right? You do what you've got to do and I'll use my own discretion to keep people livin


So you can't turn a physically agitated patients head to the side because they may move it back but yet an OPA or NPA they will tolerate with no problems?


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## Carlos Danger (Jul 24, 2016)

RobertAlfanoNJEMT said:


> Oh that's genius! Why didn't I think of that! I could just turn the physically agitated patients head to the side! Because they'll leave it like that right? You do what you've got to do and I'll use my own discretion to keep people livin


Oh so now they are agitated. But they still need an OPA?

You are either a great troll or have absolutely no idea what you are talking about.


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## RobertAlfanoNJEMT (Jul 24, 2016)

gotshirtz001 said:


> You can adequately measure the effectiveness of their ventilations; it's called ETCO2.
> 
> 
> Sent from my iPhone using Tapatalk


We don't carry ETCO2.. I don't think anyone does!


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## RobertAlfanoNJEMT (Jul 24, 2016)

DesertMedic66 said:


> So you can't turn a physically agitated patients head to the side because they may move it back but yet an OPA or NPA they will tolerate with no problems?


Yes they will because their agitation and discomfort  supersede that of the NPA.. I'm not talking out the *** this is something I have seen more than once in the heroin rich area I live in


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## RobertAlfanoNJEMT (Jul 24, 2016)

Remi said:


> Oh so now they are agitated. But they still need an OPA?
> 
> You are either a great troll or have absolutely no idea what you are talking about.


The need an NPA not an OPA.. Which is what I've been saying! Have you really never seen an overdose parient who squirms around moaning with an AMS that isn't cognitively alert enough to maintain their airway?? I know what I'm talking about I see a lot of ODs in my area!


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## NomadicMedic (Jul 24, 2016)

Remi said:


> Oh so now they are agitated. But they still need an OPA?
> 
> You are either a great troll or have absolutely no idea what you are talking about.



I think it's the latter.


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## Carlos Danger (Jul 24, 2016)

RobertAlfanoNJEMT said:


> The need an NPA not an OPA.. Which is what I've been saying! Have you really never seen an overdose parient who squirms around moaning with an AMS that isn't cognitively alert enough to maintain their airway?? I know what I'm talking about I see a lot of ODs in my area!



I've managed a few airways, too. To each his own.


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## gotbeerz001 (Jul 24, 2016)

Why is a BLS unit on an OD?


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## Flying (Jul 24, 2016)

gotshirtz001 said:


> Why is a BLS unit on an OD?


New Jersey! Where we have the two tier system in many places, thus letting fresh, barely-off the press EMTs gain enough "experience" within a few years time to trump even the knowledge of practitioners with decades of understanding!


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## WolfmanHarris (Jul 24, 2016)

RobertAlfanoNJEMT said:


> We don't carry ETCO2.. I don't think anyone does!



We carry it both in line and via nasal prongs. Goes on all my altered LOC pt's, most of my respiratory patients and certainly any whose airways and ventilations I'll be managing. 

There's an excellent review package (and some others) from our medical direction at this link:
https://www.lakeridgehealth.on.ca/en/ourservices/pastcmeandselfstudy.asp

Being presented with ideas that challenge your practice is not a personal affront, it's important to know the limits of your current knowledge and always be striving to push those limits a bit further.


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## Tigger (Jul 24, 2016)

RobertAlfanoNJEMT said:


> We don't carry ETCO2.. I don't think anyone does!


An ALS ambulance would. You know, the kind of resource that should be taking care of these patients in this area apparently...


RobertAlfanoNJEMT said:


> The need an NPA not an OPA.. Which is what I've been saying! Have you really never seen an overdose parient who squirms around moaning with an AMS that isn't cognitively alert enough to maintain their airway?? I know what I'm talking about I see a lot of ODs in my area!


No, no I have not. A squirming and moaning patient is likely to not need supplemental ventilation but I'll just bow to your vast experience now. Also basic adjuncts do not maintain an airway. But yea.


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## RobertAlfanoNJEMT (Jul 24, 2016)

Tigger said:


> An ALS ambulance would. You know, the kind of resource that should be taking care of these patients in this area apparently...
> 
> No, no I have not. A squirming and moaning patient is likely to not need supplemental ventilation but I'll just bow to your vast experience now. Also basic adjuncts do not maintain an airway. But yea.


Who gets on scene first ALS or BLS? I don't understand why all of you medics can't stick to the ALS forum because you seem to have forgotten your days as a basic when there aren't a lot of skills you can utilize to care for your patients. When I get on scene and am the highest level of medical attention I get to make that call as I see fit. If ALS wants to undo what I have done or modify it so be it, but until they get there it is my call and their lives are my responsibility! To the other point I have had a number of patients who were squirming babbling and having snoring respirations, stick the NPA in and they start sucking air through it like there's no tomorrow!


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## gotbeerz001 (Jul 25, 2016)

RobertAlfanoNJEMT said:


> Who gets on scene first ALS or BLS? I don't understand why all of you medics can't stick to the ALS forum because you seem to have forgotten your days as a basic when there aren't a lot of skills you can utilize to care for your patients. When I get on scene and am the highest level of medical attention I get to make that call as I see fit. If ALS wants to undo what I have done or modify it so be it, but until they get there it is my call and their lives are my responsibility! To the other point I have had a number of patients who were squirming babbling and having snoring respirations, stick the NPA in and they start sucking air through it like there's no tomorrow!


1. ALS Fire often gets there first... Unless the ALS ambulance does. 
2. ALOC is not a BLS call. 
3. No one is saying that an NPA is a bad move... Saying to ALWAYS do (insert thing here) is a bad practice even if it's just an NPA (and they do kinda hurt). If an intervention is indicated; do it. 
4. I remember being an EMT... I have since realized I didn't know ****. 


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## Tigger (Jul 25, 2016)

RobertAlfanoNJEMT said:


> Who gets on scene first ALS or BLS? I don't understand why all of you medics can't stick to the ALS forum because you seem to have forgotten your days as a basic when there aren't a lot of skills you can utilize to care for your patients. When I get on scene and am the highest level of medical attention I get to make that call as I see fit. If ALS wants to undo what I have done or modify it so be it, but until they get there it is my call and their lives are my responsibility! To the other point I have had a number of patients who were squirming babbling and having snoring respirations, stick the NPA in and they start sucking air through it like there's no tomorrow!


You don't know what you don't know. 

Putting an NPA in is fine, though it might help to have a good idea of why it works and what the potential complications are. But you don't get to run the call as you see fit. You get to run the call as medicine sees fit, you just implement (a tiny but important) part of that.


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## WolfmanHarris (Jul 25, 2016)

RobertAlfanoNJEMT said:


> Who gets on scene first ALS or BLS? I don't understand why all of you medics can't stick to the ALS forum because you seem to have forgotten your days as a basic when there aren't a lot of skills you can utilize to care for your patients. When I get on scene and am the highest level of medical attention I get to make that call as I see fit. If ALS wants to undo what I have done or modify it so be it, but until they get there it is my call and their lives are my responsibility! To the other point I have had a number of patients who were squirming babbling and having snoring respirations, stick the NPA in and they start sucking air through it like there's no tomorrow!



A little bit of knowledge is a dangerous thing.

Anecdotal evidence, that is what you learn from direct experience, is dangerous because it has a greater impact then knowledge gained from data. This is a common pitfall for providers who begin to make decisions based on past experience (good/bad) and pattern matching. Take a step back let your hackles down and realize there is good I for here from knowledgable clinicians that you can learn from. You seem to be taking disagreement very personally. 

As far as ALS providers staying out of BLS forum, well in my system I am a BLS provider so I think I'll stick around. 

Let's take a few steps back and consider the OD patient requiring ventilatory and airway management.

First toxidromes. What drug has been taken and how is it effecting their respirations? Opiates and benzos are going to suppress respiratory drive as well as being sedative. Assume this patient is presenting w/ bradypnea, decreased O2 sats, hypercapnea and decreased LOC. 

You begin to assist ventilations and insert an airway adjunct. As you're bagging them they begin to moan and move about as you've described. Consider at this point that the patient's condition despite not being reversed via narcan may have improved due to improved oxygenation and ventilation. So yes, your OD patient is demonstrating the behaviour you described, but I would argue that at this point reassessment is indicated which may find that their inherent respiratory rate and depth as well as improved LOC may make continued used of an airway adjunct unnecessary.


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## StCEMT (Jul 25, 2016)

RobertAlfanoNJEMT said:


> Does it hurt them to insert an NPA? No. And if I do it I know their airway is secure and I can focus on treating their other presenting life threats and ailments..


You do realize you or your partner can position the airway and assist ventilations right? Do that til ALS gets Narcan going. Especially if they are breathing on their own somewhat well.


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## RobertAlfanoNJEMT (Jul 25, 2016)

gotshirtz001 said:


> 1. ALS Fire often gets there first... Unless the ALS ambulance does.
> 2. ALOC is not a BLS call.
> 3. No one is saying that an NPA is a bad move... Saying to ALWAYS do (insert thing here) is a bad practice even if it's just an NPA (and they do kinda hurt). If an intervention is indicated; do it.
> 4. I remember being an EMT... I have since realized I didn't know ****.
> ...


Not in Jersey! PD is first on scene then BLS second and third ALS. So until ALS gets there it is a BLS call.. Just because you didn't know **** as a basic doesn't mean the rest of us don't..


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## RobertAlfanoNJEMT (Jul 25, 2016)

WolfmanHarris said:


> A little bit of knowledge is a dangerous thing.
> 
> Anecdotal evidence, that is what you learn from direct experience, is dangerous because it has a greater impact then knowledge gained from data. This is a common pitfall for providers who begin to make decisions based on past experience (good/bad) and pattern matching. Take a step back let your hackles down and realize there is good I for here from knowledgable clinicians that you can learn from. You seem to be taking disagreement very personally.
> 
> ...


I agree and I believe we are saying pretty much the same thing


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## RobertAlfanoNJEMT (Jul 25, 2016)

StCEMT said:


> You do realize you or your partner can position the airway and assist ventilations right? Do that til ALS gets Narcan going. Especially if they are breathing on their own somewhat well.


1) my partner may very well just be a driver depending on what time of the day the call comes in
2)Narcan is a BLS medication that we now carry
3)it's a soft tube that goes up their nose
I don't know why everyone is up in arms about it! You can do more damage by not inserting one when it is needed than inserting one when it is not needed. You are lashing out against my attitude not my choice of patient care management


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## TransportJockey (Jul 25, 2016)

RobertAlfanoNJEMT said:


> Not in Jersey! PD is first on scene then BLS second and third ALS. So until ALS gets there it is a BLS call.. Just because you didn't know **** as a basic doesn't mean the rest of us don't..


By definition, with the curriculum, basics are under educated in every aspect of emergency medicine. And the fact als is last on scene is one of many reasons I would never move there


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## gotbeerz001 (Jul 25, 2016)

RobertAlfanoNJEMT said:


> Just because you didn't know **** as a basic doesn't mean the rest of us don't..


Clearly. 



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## RobertAlfanoNJEMT (Jul 25, 2016)

TransportJockey said:


> By definition, with the curriculum, basics are under educated in every aspect of emergency medicine. And the fact als is last on scene is one of many reasons I would never move there


That is fine with me, stay in Texas! Most 911 calls in Jersey are answered by volunteers.. People who care about their patients and community. You guys could learn from us!


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## luke_31 (Jul 25, 2016)

RobertAlfanoNJEMT said:


> That is fine with me, stay in Texas! Most 911 calls in Jersey are answered by volunteers.. People who care about their patients and community. You guys could learn from us!


Did you ever think that what you just said here is the reason your state is so backwards with its EMS system.


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## chaz90 (Jul 25, 2016)

Let's stay on topic folks. The volunteer vs. career debate has been done to death.


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## DesertMedic66 (Jul 25, 2016)

RobertAlfanoNJEMT said:


> That is fine with me, stay in Texas! Most 911 calls in Jersey are answered by volunteers.. People who care about their patients and community. You guys could learn from us!


You're joking right?


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## StCEMT (Jul 25, 2016)

DesertMedic66 said:


> You're joking right?


I think not.


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## RedAirplane (Jul 27, 2016)

I'm now getting very confused on what an NPA can and cannot do. For some reason I thought it wouldn't help with the tongue problem.


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## luke_31 (Jul 27, 2016)

RedAirplane said:


> I'm now getting very confused on what an NPA can and cannot do. For some reason I thought it wouldn't help with the tongue problem.


It doesn't. If the tongue is blocking the airway an OPA can keep it out of the way. The NPA doesn't reach far enough to reach the trachea.


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## TransportJockey (Jul 27, 2016)

RobertAlfanoNJEMT said:


> That is fine with me, stay in Texas! Most 911 calls in Jersey are answered by volunteers.. People who care about their patients and community. You guys could learn from us!


I don't mind volunteers. Provided they are held to the same standard as professional EMS providers. In NJ, that often is not the case thanks to the efforts of your <sarcasm>wonderful</sarcasm> first aid council. And as to me being paid detract from my care of patients and the desire to help my community, you need to take a good hard look at why you do this. I live and work in the same community. My neighbors are my patients. It's an island, so everyone is in everyone else's business. If I didn't care for my patients like I would care for my family, I wouldn't last here. Just because I do it as my chosen profession and make money, have great benefits, and will get a quite good pension from it, should not detract in any way from the fact that I've invested almost ten years of blood, sweat, and tears to make myself into the provider that I am. Now, if a maggot like you would like me to stay out of Jersey, fine. My GF is FROM Jersey, and she keeps saying how backwards and screwed up it is, so I wouldn't ever want to go there anyway, even if I was paid and able to live at the same level I do here.


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## NomadicMedic (Jul 27, 2016)

RedAirplane said:


> I'm now getting very confused on what an NPA can and cannot do. For some reason I thought it wouldn't help with the tongue problem.



Here's a decent little overview. http://lifeinthefastlane.com/ccc/nasopharyngeal-airway/

http://theemtspot.com/2009/12/08/the-art-of-the-nasopharyngeal-airway/


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## Carlos Danger (Jul 27, 2016)

RedAirplane said:


> I'm now getting very confused on what an NPA can and cannot do. For some reason I thought it wouldn't help with the tongue problem.



Usually, either one will work. An OPA directly displaces the base of the tongue anteriorly, which will hopefully lift the soft tissue out of the hypopharynx and alleviate the obstruction. An NPA snakes around the superior part of the pharynx behind the tonque to create a route around the obstruction. 

IME, a properly placed OPA will usually work better, but an NPA will often do the trick just fine and is usually better tolerated. In reality, you just use whichever one works. 

For whatever its worth, the best way to fix passive airway obstruction is to get them off their back. Put them in the "recovery" or "sidelying" (for the nurses) position and the obstruction will very often alleviate.


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