# NRB Flow Rate



## medichopeful

Hi all,

I was reviewing PCRs for my colleges EMS unit, and I have a quick question.  It may be a stupid one, but I figure I'll ask anyways.

I was reviewing a case where a student approached a member of our student security stating that he had had too much to drink.  The student security officer called it into dispatch, and EMS was dispatched.

I wasn't on the call, so all I have to go by was what was on the report (which was seriously lacking, which is something that I'm going to work on improving in future training session).  The patient stated that he was having difficulty breathing and numbness and tingling in his extremities, so he was placed on a NRB @ 5lpm (his SpO2 was 99%, respirations 12).  Again, this is pretty much all I have to go on, besides that he was vomiting when EMS was on scene and had a BP of 118/76.  

The big thing that stuck out to me when I was reviewing this was the oxygen therapy.  In the textbook, it says that a flow rate of 12-15lpm is the correct flow rate for a NRB.  Of course, this is the textbook and therefore not gospel, as lower flow rates and higher ones can be used as well.  I'm not arguing that the flow rate should have been between 12-15 because "that's what the book says."  I am, however, a little concerned about the flow rate that was used:  5lpm seems a little low.  

I figured I'd ask here before I talked to the club about this, because I want to make sure that I'm not insane (at least, when it comes to this).  Does anybody have any thoughts or comments?

Thanks!
Eric


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## nakenyon

Yes. The textbook says 12-15 lpm when using a NRB. As you said though, the textbook is not gospel. However the lowest I've ever seen a NRB used is 10 lpm. Not sure if you guys carry nasal canulas. Seems that might have made more sense in this situation. Just my .02. Not criticizing anyone. Just making a suggestion.


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## medichopeful

EMSJunkie91 said:


> Yes. The textbook says 12-15 lpm when using a NRB. As you said though, the textbook is not gospel. However the lowest I've ever seen a NRB used is 10 lpm. Not sure if you guys carry nasal canulas. Seems that might have made more sense in this situation. Just my .02. Not criticizing anyone. Just making a suggestion.



Hey Junkie,
Yes we do carry NCs, and as far as I'm concerned if the flow rate is going to be that low then yes the NC would make more sense.  It would seem that otherwise, there could either be a buildup of CO2 or a lack of O2.


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## JPINFV

10-15 is the magic number. However in my experience, and for multiple reasons, the seal between the face and the side of the mask is normally non-existant, which is going to limit the effectiveness of both the oxygen delivery (if you can't draw a suction, you won't draw oxygen from the reservoir bag) as well as the dangers of not using a proper flow rate. Essentially if the bag is not collapsing to any significant consent (a little is fine), then it's more of a treatment faux pas than anything else. Kinda of like recording odd number blood pressures.


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## dmc2007

I've always been taught 10-15.  You are absolutely right in this regard.  Did you maybe consider that the reporting individual meant to type 15 and merely left off the one?


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## medicdan

Here's the deal-- the reason the book says 10-12-15 is because an NRB has the capacity, if reservoir bag is empty, to asphyxiate a patient. The seal around the mouth and exhalation ports are never perfect, the opportunity still exist. If you are trying to be stingy, you could theoretically titrate the flow to respiratory rate and tidal volume, but that's a risky game, and not likely achievable at 5lpm. It was most likely a mistake on your corps member's part. 

I have this endless rant about giving O2 to an intoxicated soul-- especially NRBs. I have more problem with the fact your EMT gave an NRB than the flow rate, simply because the patient was vomiting, and if poorly monitored, is much easier to asphyxiate them with vomit in the mask. 
Why were they giving oxygen? Was it simply a textbook response for "AMS"? 

What other causes can/could you rule out, even with no additional equipment? What additional history could you collect? 

-- Rule out fall/head trauma with physical exam, history and friend's reports?
-- Rule out diabetic with physical exam (skin, etc), history? Any other medical history (Alert Tags?) AEIOUTIPS?
-- Rule out other drugs/meds (prescribed and non-prescribed) with history from patient, friends, scene, etc.
-- Does drinking history match level of consciousness/AMS? How many drinks? What kind? WHen did they start? end? When did they last eat? History of drinking? When did they last vomit? How many times (because AMS can increase after vomiting)?  

What I'm encouraging you (and your members) is to examine other causes of AMS-- and not just provide textbook assessment and treatment. Think long and hard about the treatments you are giving (especially delivery method and dose of O2), and why you're really doing what your doing.


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## abckidsmom

It sounds like the patient was possibly hyperventilating, and I've heard of people putting low- or no-flow NRBs on people for hyperventilation, kind of for the breathe into the paper bag effect.  

If QA is your job, I might follow up with the provider to see if that's what they meant to type.  A typo for 15 seems equally likely.


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## medichopeful

emt.dan said:


> Here's the deal-- the reason the book says 10-12-15 is because an NRB has the capacity, if reservoir bag is empty, to asphyxiate a patient. The seal around the mouth and exhalation ports are never perfect, the opportunity still exist. If you are trying to be stingy, you could theoretically titrate the flow to respiratory rate and tidal volume, but that's a risky game, and not likely achievable at 5lpm. It was most likely a mistake on your corps member's part.



I'm pretty sure it was a mistake/ bad treatment choice as well.  I don't believe that it was a titrated flow for a variety of reasons, including the fact that there was absolutely no mention of titration (the report said that they put him on a NRB @ 5lpm, no mention of titration or anything of that sort.)




> I have this endless rant about giving O2 to an intoxicated soul-- especially NRBs. I have more problem with the fact your EMT gave an NRB than the flow rate, simply because the patient was vomiting, and if poorly monitored, is much easier to asphyxiate them with vomit in the mask.



This is a very good point.



> Why were they giving oxygen? Was it simply a textbook response for "AMS"?



From what the report says, it was in part because of the complaint numbness/tingling and shortness of breath.  Unfortunately, the report is not that thorough, so I'm only going by what I have.



> What other causes can/could you rule out, even with no additional equipment? What additional history could you collect?
> 
> -- Rule out fall/head trauma with physical exam, history and friend's reports?
> -- Rule out diabetic with physical exam (skin, etc), history? Any other medical history (Alert Tags?) AEIOUTIPS?
> -- Rule out other drugs/meds (prescribed and non-prescribed) with history from patient, friends, scene, etc.
> -- Does drinking history match level of consciousness/AMS? How many drinks? What kind? WHen did they start? end? When did they last eat? History of drinking? When did they last vomit? How many times (because AMS can increase after vomiting)?



I didn't mention it originally, but the patient didn't have any known past medical history.  Due to the fact that the report isn't very thorough (at all), I don't know what else was done.



> What I'm encouraging you (and your members) is to examine other causes of AMS-- and not just provide textbook assessment and treatment. Think long and hard about the treatments you are giving (especially delivery method and dose of O2), and why you're really doing what your doing.



If the members in the unit would do this, that would be great.  However, I don't see it happening very soon (for reasons I'll PM you).  

Thanks Dan!


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## Veneficus

or if you put somebody on highflow o2 and it is more than they can tolerate you might be reducing the flow until they can.

People were not meant to breath 100% o2.


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## medichopeful

abckidsmom said:


> It sounds like the patient was possibly hyperventilating, and I've heard of people putting low- or no-flow NRBs on people for hyperventilation, kind of for the breathe into the paper bag effect.
> 
> If QA is your job, I might follow up with the provider to see if that's what they meant to type.  A typo for 15 seems equally likely.



I'll talk to them when I get back to school after break, but I don't believe it's a typo (it was written in 2 different places by hand as "5 lpm."

If the patient was hyperventilating, this might have been acceptable (as it could cut down on respiratory alkalosis by increasing the amount of CO2 in the blood).  However, the patient was placed on the 5lpm after his respirations were counted to be at 12 rpm, so I'm pretty sure it wasn't for that reason.  

When I talk to them I'll ask about it though!
Eric


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## medichopeful

dmc2007 said:


> I've always been taught 10-15.  You are absolutely right in this regard.  Did you maybe consider that the reporting individual meant to type 15 and merely left off the one?



A typo is possible, but they would have had to do it twice (see post above).


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## medichopeful

Veneficus said:


> or if you put somebody on highflow o2 and it is more than they can tolerate you might be reducing the flow until they can.
> 
> People were not meant to breath 100% o2.



I'll be following up with those on the call, but as I understand it they just put them straight on 5lpm


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## Hockey

Brown bag idea is dangerous just FYI 

Asthma and heart attacks, can be confused with hyperventilation. In such cases reducing oxygen and increasing carbon dioxide can be deadly.


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## medichopeful

Hockey said:


> Brown bag idea is dangerous just FYI
> 
> Asthma and heart attacks, can be confused with hyperventilation. In such cases reducing oxygen and increasing carbon dioxide can be deadly.



Good to know Hockey.  Thanks!


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## usafmedic45

> The patient stated that he was having difficulty breathing and numbness and tingling in his extremities, so he was placed on a NRB @ 5lpm



Welcome to a good excuse to suspend the EMT responsible for that move.  In fact, I've fired someone for that exact action before.  If they are that stupid, they have no business ever touching a patient.


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## EMSLaw

medichopeful said:


> I'll talk to them when I get back to school after break, but I don't believe it's a typo (it was written in 2 different places by hand as "5 lpm."
> 
> If the patient was hyperventilating, this might have been acceptable (as it could cut down on respiratory alkalosis by increasing the amount of CO2 in the blood).  However, the patient was placed on the 5lpm after his respirations were counted to be at 12 rpm, so I'm pretty sure it wasn't for that reason.
> 
> When I talk to them I'll ask about it though!
> Eric



Even if the patient were hyperventilating, putting them on a NRBM that's either not hooked up or is hooked up at a very low flow (the equivalent of a brown paper bag) is the sort of field expedient that can get you in a lot of trouble.  I'm not saying I've never seen it done - heck, I've seen medics do it on numerous occasions - but it's a violation of the standard of care.  

I would be more inclined to believe that the patient had numbness and tingling in his fingers because he's drunk.  However, I didn't see or evaluate the patient, and ETOH tends to mask lots of possibly really bad stuff.  

If the patient is on 5lpm, then a NC is the correct tool for the job.


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## 18G

The standard is 10-15lpm with NRB as already stated. If you need to flow less than 10lpm then use a simple face mask or nasal cannula. 

A report of dyspnea and numbness/tingling, SpO2:99% + ETOH = hyperventilation.


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## usafmedic45

> A report of dyspnea and numbness/tingling, SpO2:99% + ETOH = hyperventilation.



....or hypercapnia (hypoventilation) can induce much the same sensation as hyperventilation (hyperventilation).


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## medichopeful

*Update*

So here's an update.  I talked to the EMT involved, and he said that they did it as a sort of placebo effect because "he was not in apparent resp. distress but was breathing at a 'normal' rate."

I'm not really that informed about the legality of placebos in EMS (I'll be looking it up in a few), but does anybody have any thoughts on this?  Could the low flow rate in the NRB cause an excess of inhaled CO2?


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## usafmedic45

> Could the low flow rate in the NRB cause an excess of inhaled CO2?



Yes, along with hypoxia. 



> I'm not really that informed about the legality of placebos in EMS (I'll be looking it up in a few), but does anybody have any thoughts on this?



Most ethicists would view this as clinical experimentation without informed consent.  



> So here's an update. I talked to the EMT involved, and he said that they did it as a sort of placebo effect because "he was not in apparent resp. distress but was breathing at a 'normal' rate."



Is the ink dry on this idiot's termination paperwork yet?  Also, this needs to be reported to the state EMS board.


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## spike91

Like mentioned above, if he were hyperventilating I'd do the same. And if that were the case, no real issue there in my opinion. However, in New York, the EMS Gods in Albany make it very clear that O2 should never be withheld from a patient, so if you're going to put him on a mask might as well do it at a standard flow rate. 

However, if the patient was vomiting as stated in the OP, why would they use an NRB? Unless he had stopped doing so for some period of time, I would've used an NC. Would've saved a lot of trouble.


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## usafmedic45

> And if that were the case, no real issue there in my opinion.



You know...except using a medical device in an inappropriate manner just because you can and that rebreathing is not an accepted treatment for hyperventilation anymore in most first world nations.  



The level of frank stupidity and cowboy tactics in EMS sometimes makes me even more misanthropic than I already am.


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## medichopeful

usafmedic45 said:


> Is the ink dry on this idiot's termination paperwork yet?  Also, this needs to be reported to the state EMS board.



As of now, not yet.  I'll be meeting with both him and the other EMT involved (who is, scarily enough, a state examiner), and we'll be discussing this in-depth.  If necessary, I'll go from there.  If he pulls anything again, I'll be writing to the state.


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## jjesusfreak01

I don't understand how people have so many problems with O2 flow rates...pick a saturation level you are looking for depending on the patient, and then choose a method of oxygen delivery that can get them there. NCs can go from ~0.5-4/5 lpm with no problems. Higher than that and you're blowing out their nostrils. NRBs have one golden rule, they should be getting enough oxygen to keep the bag inflated. Theoretically, there isn't a hard minimum, but if you have it on 5lpm and you aren't emptying the bag, then your patient might not be moving enough air.


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## usafmedic45

> If he pulls anything again, I'll be writing to the state.



I'm considering alerting them myself.



> NCs can go from ~0.5-4/5 lpm with no problems. Higher than that and you're blowing out their nostrils.



Actually you can go much higher if you have a way to humidify the flow sufficiently.  That's the major limiting factor. 



> NRBs have one golden rule, they should be getting enough oxygen to keep the bag inflated. Theoretically, there isn't a hard minimum, but if you have it on 5lpm and you aren't emptying the bag, then your patient might not be moving enough air.



That's not a "golden rule" because that's actually a very poor way to judge if they are getting sufficient flow unless you're already pushing at least a normal minute ventilation through there.  If they are getting 15 L/min or more and are sucking the bag in with each breath, you've got a major problem on your hands.  Judging the adequacy of a flow rate based on the performance of a stiff plastic bag on a disposable mask likely assembed by a child in a third world factory is not something I would choose to admit to in court or in front of my medical director.


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## MasterIntubator

Most all "NRB" are technically partial-rebreathers.  Unless your service has true "NRB" masks.  The partial rebreathers we carry, can support lower LPM as long as the TV and RR and usually do not cause any harm what-so-ever do to all the leaks and safety measures in the partial rebreathers.  Am I supporting doing it?   Helll no.  Have I done it? Maybe...  but my hyperventilation suspects are ALWAYS on EtCO2 and assessment makes all other metabolic probs low on the totem pole.  Then.... its a judgement call based on sound decision making by excellent assessment skills and recent history.  In which, most all have done fine on ambient air and were calmed down with about 10-20 minutes of coaching and caring.  
Plus.. non of my flow regulators have 5 as a selection. 6 would follow..... and thats way better than 2 lpm via mask that we have seen placed at nursing homes due to "COPD" :wacko:


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## usafmedic45

> Most all "NRB" are technically partial-rebreathers. Unless your service has true "NRB" masks. The partial rebreathers we carry, can support lower LPM as long as the TV and RR and usually do not cause any harm what-so-ever do to all the leaks and safety measures in the partial rebreathers.



Ever tried breathing through those little ports?  It's not easy.



> and thats way better than 2 lpm via mask that we have seen placed at nursing homes due to "COPD"



You'd be amazed how quick a nurse gets fired from a nursing home when you document your butt off and forward it to the state board of nursing and send a copy of it all to the nursing home.


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## jjesusfreak01

usafmedic45 said:


> That's not a "golden rule" because that's actually a very poor way to judge if they are getting sufficient flow unless you're already pushing at least a normal minute ventilation through there.  If they are getting 15 L/min or more and are sucking the bag in with each breath, you've got a major problem on your hands.  Judging the adequacy of a flow rate based on the performance of a stiff plastic bag on a disposable mask likely assembed by a child in a third world factory is not something I would choose to admit to in court or in front of my medical director.



True dat, but if we're sucking the bag dry we're probably past the point of simply using NCs and NRBs, which was the original focus of this thread.


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## usafmedic45

Point taken.  I was just cautioning people that they should not be using that "golden rule" in clinical practice.  To be quite honest, if you have the bag moving much when the flow is at 15L and the patient is still in frank distress with crap saturations, you need to strongly start considering the use of CPAP or BiPAP.


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## Shishkabob

usafmedic45 said:


> You know...except using a medical device in an inappropriate manner just because you can and that rebreathing is not an accepted treatment for hyperventilation anymore in most first world nations.
> 
> 
> 
> The level of frank stupidity and cowboy tactics in EMS sometimes makes me even more misanthropic than I already am.



It's not just EMS, thank you.

We were once called to the Dallas jail for someone with "neck pain" (ended up being an MI).  I walk in to the room to find the pt on an NRB... at a flow rate of 2lpm.  You read that right, 2, as in two.

I tore the mask off the pt so fast I could have caused whiplash.  The "RN" got angry that I, a lowly medic, cancelled her treatment...  ha.   She got hers.


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## usafmedic45

Oh, I know....trust me....I know.


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## medichopeful

*Update*

I just thought that I would give an update on the situation.  I will be talking to the president of the club about this incident, as well as our faculty advisor to fill them in.  After that, I will be talking to the two EMTs and the first responder involved, where I will get their side of the story.  If their actions were intentional, I'll be having a serious talk with all of them about the dangers, recklessness, and legality of their actions.  If they were not intentional, and were a mistake (everybody makes them), I'll give them an educational talking to about placebos, doing things without having a knowledge of their consequences, and the irresponsibility and legality of their actions.  Either way, they will dealt with.  The president of the club and the faculty advisor will both be filled in about everything.

I will also be keeping an eye on their patient care and their reports for the rest of the school year.  If any similar incidents occur, I will be going through the process again, and will be going to the state OEMS as well.

Any thoughts or comments are welcome.


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## AnthonyM83

usafmedic45 said:


> Is the ink dry on this idiot's termination paperwork yet?  Also, this needs to be reported to the state EMS board.


 Out of all the things to be reported to an EMS board, you would choose putting a low flow rate on an NRB? I would imagine EMS boards expect you to be able triage these things and take something like this internally with some training. But I suppose I really can't speak for them.





18G said:


> The standard is 10-15lpm with NRB as already stated. If you need to flow less than 10lpm then use a simple face mask or nasal cannula.
> 
> A report of dyspnea and numbness/tingling, SpO2:99% + ETOH = hyperventilation.


We don't use simple face masks in my system, so I'm less knowledgeable about these. But wouldn't reducing the flow rate on an NRB be similar to turning it into a simple face mask? 

If a simple mask isn't dangerous at lower flow rates, how would an NRB mask be dangerous? (At least dangerous enough to go prosecute a college EMT to the state EMS board.)


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## AnthonyM83

usafmedic45 said:


> That's not a "golden rule" because that's actually a very poor way to judge if they are getting sufficient flow unless you're already pushing at least a normal minute ventilation through there.  If they are getting 15 L/min or more and are sucking the bag in with each breath, you've got a major problem on your hands.  Judging the adequacy of a flow rate based on the performance of a stiff plastic bag on a disposable mask likely assembed by a child in a third world factory is not something I would choose to admit to in court or in front of my medical director.


Maybe that's why some systems have it written into their educational guidelines, so people don't have to be embarrassed by it. We have that rule here, THOUGH, you ALSO, have to adhere to minimum flow rates for the device.

I feel a bit uncomfortable that you're jumping on people so quickly. The previous poster didn't say that rule is used for all situations. Whether you're using an NRB or BVM is judged separately. The monitoring of bag inflation is a guideline to determining whether you want 10, 12, or 15 liters per minute, since all 3 are within range (depending on the source). Within his post, he acknowledged 5 LPM seems low.


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## medichopeful

medichopeful said:


> I just thought that I would give an update on the situation.  I will be talking to the president of the club about this incident, as well as our faculty advisor to fill them in.  After that, I will be talking to the two EMTs and the first responder involved, where I will get their side of the story.  If their actions were intentional, I'll be having a serious talk with all of them about the dangers, recklessness, and legality of their actions.  If they were not intentional, and were a mistake (everybody makes them), I'll give them an educational talking to about placebos, doing things without having a knowledge of their consequences, and the irresponsibility and legality of their actions.  Either way, they will dealt with.  The president of the club and the faculty advisor will both be filled in about everything.
> 
> I will also be keeping an eye on their patient care and their reports for the rest of the school year.  If any similar incidents occur, I will be going through the process again, and will be going to the state OEMS as well.
> 
> Any thoughts or comments are welcome.



After talking to a member of this site, I'm actually going to be taking a much more educational approach to this, and not an accusatory approach.  This is something I'm new at (being in charge of QA/QI), so any comment would really be greatly appreciated.

Thanks all!
Eric


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## Veneficus

I think we need to keep this in perspective.

Was a mistake made? Yes.

Does it need to be corrected? Yes.

Is it the life altering permanant disability or death? No.

These people are volunteer college students with probably the same 120 hours of training as Ricky Rescue Volunteer Fire Department. Only they are basically acting as glorified first responders who will in all likelyhood never have a patient who needs 100% oxygen.

They are not a "professional" agency of care providers, the primary purpose is likely educational. 

Like the treatments of most EMTs, it is very hard to mess up in a really bad way. 

They are not the sole agency responding and transporting. As I understand there is a ALS agency that serves as the primary responsible agency.

Some remediation and move on.


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## Shishkabob

AnthonyM83 said:


> We don't use simple face masks in my system, so I'm less knowledgeable about these. But wouldn't reducing the flow rate on an NRB be similar to turning it into a simple face mask?



A simple facemask essentially has an open port in the mask allowing room air to get mixed in.

Take an NRB, pop off one of the valves, and viola, simple face mask.


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## Journey

> Originally Posted by AnthonyM83
> We don't use simple face masks in my system, so I'm less knowledgeable about these. But wouldn't reducing the flow rate on an NRB be similar to turning it into a simple face mask?





> Originally Posted by AnthonyM83
> If a simple mask isn't dangerous at lower flow rates, how would an NRB mask be dangerous? (At least dangerous enough to go prosecute a college EMT to the state EMS board.)






Linuss said:


> A simple facemask essentially has an open port in the mask allowing room air to get mixed in.
> 
> Take an NRB, pop off one of the valves, and viola, simple face mask.



Is this what you were taught in EMT or Paramedic school?  I guess RNs will have to start checking the O2 masks on patients coming or going on IFTs to ensure the correct flow is going for patient safety.  I find it hard to believe that some EMTs would criticize RNs for something when it seems some in EMS make the same mistakes.  Any RN who does not know the proper use of these devices can expect a write up and some education from their manager. Where is the oversight for EMTs and Paramedics to see that they know what they are doing or that they understand these very simple but important devices?  

Usafmedic45 has given  good explanations for the whys and hows. If you don't believe him maybe you should be finding a credible source to confirm what he has posted.


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## Shishkabob

Next, you'll be telling me a Capno-cannula is NOTHING like a nasal-cannula....


My bad for giving a simple explanation.


Get it?  "Simple"?  HA!


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## Journey

Linuss said:


> Next, you'll be telling me a Capno-cannula is NOTHING like a nasal-cannula....
> 
> 
> My bad for giving a simple explanation.



What you are giving as a "Simple" or an attempt at a dumbed down explanation is not necessarily the correct one but rather just your own interpretation and not understanding all the factors.  It is much like the quote I used from an EMT on another forum which a couple of people on this forum seemed to also take offense and probably because someone like you might have told them this was what high flow oxygen was.



> Quote:
> High flow Oxygen is any flow rate where you can hear the oxygen flow from the tubing.



To understand some oxygen devices you must also understand deadspace ventilation which is taught in college anatomy and physiology classes. 

Knowing the correct explanation will save you or someone else on this forum some embarrassment and may even keep you from doing harm to your patients.


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## Shishkabob

So, tell me then, aside from the lack of an Oxygen reservoir, and one way valves, what the physical difference is between an NRB and SFM, just so everyone can understand.  Because clearly I'm missing something quite obvious that every Paramedic should know and learn back in medic school for you to make the hub-bub.


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## Journey

Linuss said:


> So, tell me then, aside from the lack of an Oxygen reservoir, and one way valves, what the physical difference is between an NRB and SFM, just so everyone can understand.  Because clearly I'm missing something quite obvious that every Paramedic should know and learn back in medic school for you to make the hub-bub.



Linuss, that reservoir bag is there for a reason just as the reservoir bag or tail on a BVM.    

A simple mask can be ran at as low as 6 liters because it does not have the reservoir mask. The reservoir bag has a capacity of 600 - 1000 ml.  I think you might also have been attempting to describe is a partial rebreathing mask.  A partial rebreathing mask allows gas exhaled in the initial phase of exhalation to return to the reservoir bag. As exhalation proceeds, the expiratory flow rate declines, and when the expiratory flow rate falls below the oxygen flow rate, exhaled gas can no longer return to the reservoir bag.  The initial part of expiration contains gas from the upper airways (anatomic dead space) so  the gas rebreathed is still rich in oxygen and contains very little CO2. So, maintaining adequate flow because of that bag is still important.

The one way valve on a nonrebreather prevents any exhaled air from returning to the reservoir bag. 

You can check the accuracy of my description of these two masks with just about any nursing, critical care or respiratory therapy book if you can not the info in a Paramedic book. The manufacturers willl also have a description and instructions on the proper use of these masks.  This is not something that is difficult to look up and you should learn the proper use of each device on your truck regardless of what it is.   

 This isn't hearsay or street medicine or whatever you want to call it. Manufacturers design, test medical devices and print instructions for a reason which is to take the mystery out of the use of these things so patients will achieve maximum benefit and not be harmed by their use.


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## AnthonyM83

As an FYI, not all companies include instructions of any kind in the masks' wrappings. Many have only a company name and listings of parts included with patent info. No further description or images.

Also the EMT and paramedic curriculums AND textbooks seem to have a very poor coverage of how each device works. Also I believe previous poster was referring to the side valves in reply to my post, not the reservoir bag's valve.


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## usafmedic45

> A simple mask can be ran at as low as 6 liters because it does not have the reservoir mask.



Actually it can be done that because the mask is not a sealed system like an NRB (or to a lesser extent, a PNRB ) so the person can entrain atmospheric air to meet their metabolic needs beyond what the oxygen flow is delivering. 



> You can check the accuracy of my description of these two masks with just about any nursing, critical care or respiratory therapy book if you can not the info in a Paramedic book.



Didn't need to break out my RT textbooks.


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## Journey

usafmedic45 said:


> Actually it can be done that because the mask is not a sealed system like an NRB (or to a lesser extent, a PNRB ) so the person can entrain atmospheric air to meet their metabolic needs beyond what the oxygen flow is delivering.



The aerosol mask with the larger side ports would be better for entraining air and meet the definition of high flow.  At my hospital we can run a high flow system with 2 - 35 liter aerosols giving 70 liters and still allow the patient to entrain enough air to meet their flow demands and maintain some consistency in FiO2. We can utilize this system in the ICUs, tele and in the ED if there is an extended hold time and the patient is not a candidate for BiPAP/CPAP.   

There are newer masks on the market such as the OxyMask which can eliminate some of the mistakes commonly made in and out of the hospital.  We have eliminated the NRB and simple masks from the med surg floors to prevent running the masks at too low of a flow or accidental disconnects which leaves the patient  unmonitored with their face in a plastic mask especially if they are not able to call for help.  They may not be getting the oxygen they need but they may still have a chance by breathing through the large ports of the OxyMask.



> Didn't need to break out my RT textbooks.



Maybe not since you are a Respiratory Therapist. However, it seems some are going by what they've heard or probably information that may have been posted on these forums by those who have not bothered to learn why or how from credible sources.



> As an FYI, not all companies include instructions of any kind in the masks' wrappings. Many have only a company name and listings of parts included with patent info. No further description or images.



Check with the person who does your supplies. Usually there will be a spec and literature sheet in each case.  You can also request it from the manufacturer through their website if it is not already posted.


----------



## usafmedic45

> Maybe not since you are a Respiratory Therapist. However, it seems some are going by what they've heard or probably information that may have been posted on these forums by those who have not bothered to learn why or how from credible sources.



Geez...I was trying to be funny.  



> At my hospital we can run a high flow system with 2 - 35 liter aerosols giving 70 liters and still allow the patient to entrain enough air to meet their flow demands and maintain some consistency in FiO2.



A jet nebulizer system? 



> We have eliminated the NRB and simple masks from the med surg floors to prevent running the masks at too low of a flow or accidental disconnects which leaves the patient unmonitored with their face in a plastic mask especially if they are not able to call for help.



Honestly if someone needs a simple mask or NRB, they probably don't have any business being on the floor and need to be in the ICU.


----------



## Journey

usafmedic45 said:


> Geez...I was trying to be funny.



It is hard to tell on this forum.



usafmedic45 said:


> A jet nebulizer system?



Thera-mist

They've been around for many, many years. 

AquinOx for high flow NC up to 35 liters.




usafmedic45 said:


> Honestly if someone needs a simple mask or NRB, they probably don't have any business being on the floor and need to be in the ICU.



A simple mask at 6 liters is maybe 0.40 and our policy says move the patient to a higher level after 0.50 if there is not a chance of reversing the situation. The physicians can still decompress or tap a chest and insert chest tubes on the floors to alleviate some problems as well as giving diuretics. There are also some patients who are DNR with a do not transfer to ICU order but that does not mean we will not continue to treat or make comfortable at least until more medications can be given to get a handle on the air hunger feeling which may have nothing to do with the pulmonary system but whatever works for the moment until the other systems can be supported or comforted.  Microsurgery may also want some their replants or grafts hyperoxygenated for 24 hours. 

We prefer to assess each situation and allowing for a clinical decision rather the following recipes.


----------



## usafmedic45

> Thera-mist



Yeah, the nurses around here just call them "jet nebs" which I am not entirely fond of but it's the terminology they choose to use and I gave up correcting them years ago.  I'm not paid enough to do that and if they do something that harms a patient or could potentially do so, I let the administration deal with it.



> We prefer to assess each situation and allowing for a clinical decision rather the following recipes.



Same here but as a general rule, if they are sick enough to need to be on above 44% O2 (a 6 L/min cannula) they are significantly ill enough to go to an ICU or an intermediate care unit.   If you're talking about something that can be rapidly reversed, that is obviously an exception to transferring the patient, but when I say "need" higher flow O2, I'm referring to those patients with complicated pathology that is not amenable by simply doing thoracentesis or giving some furosemide.  Our hospital's policy is that if the patient has a chest tube, they have to be in an "acute care" (ICU or intermediate care) unit and not out on the floor.


----------



## Journey

usafmedic45 said:


> Our hospital's policy is that if the patient has a chest tube, they have to be in an "acute care" (ICU or intermediate care) unit and not out on the floor.



There are patients who have recurrent pleural effusions and even a recurrent pneumothorax that do not need an ICU bed.   Our med-surg RNs are capable of handling chest tubes and whatever oxygen equipment that can be used on the floors. We may also have ALS patients on BiPAP on the med-surg floors if they are not in the hospital for an acute respiratory problem other than their ALS.


----------



## usafmedic45

> There are patients who have recurrent pleural effusions and even a recurrent pneumothorax that do not need an ICU bed.



We don't get many of those out on the floor.  Most of our chest tubes are inserted in the emergency room or are in place for post-operative drainage. 



> Our med-surg RNs are capable of handling chest tubes and whatever oxygen equipment that can be used on the floors.



Likewise.  I don't fully understand the reasoning for the chest tube policy and don't pretend to.



> We may also have ALS patients on BiPAP on the med-surg floors if they are not in the hospital for an acute respiratory problem other than their ALS.



We put patients like that over in the acute care unit which is technically part of our hospital's rehabilitation arm but is used as a "step-down" from the ICU to the med/surg unit.


----------



## Melclin

@USAF







I see you didn't avail yourself of the delights of frivolous parlour conversation in your time away from the forums


----------



## Phlipper

Melclin said:


> @USAF
> 
> I see you didn't avail yourself of the delights of frivolous parlour conversation in your time away from the forums



He does seem rather wound up, doesn't he?  I generally don't pay attention to screen names and can be arguing with someone one minute and then gabbing with them one post later.  It's the internet.  No one with a real life takes it seriously.  But USAF does, indeed, seem to need a little time away somewhere quiet.  He's getting pretty wrapped around the axle on every thread.  If I noticed his screen name and all the vitriol, it's _definitely _an issue.

Now, for something of substance: since we have learned a low flow NRB is borderline criminal, what are the 'approved' methods of treating hyperventilation, in the absence of other, more significant issues?


----------



## Melclin

Phlipper said:


> He does seem rather wound up, doesn't he?  I generally don't pay attention to screen names and can be arguing with someone one minute and then gabbing with them one post later.  It's the internet.  No one with a real life takes it seriously.  But USAF does, indeed, seem to need a little time away somewhere quiet.  He's getting pretty wrapped around the axle on every thread.  If I noticed his screen name and all the vitriol, it's _definitely _an issue.
> 
> Now, for something of substance: since we have learned a low flow NRB is borderline criminal, what are the 'approved' methods of treating hyperventilation, in the absence of other, more significant issues?



Not at all what I meant.

It was taking the p*ss.


----------



## Journey

Phlipper said:


> Now, for something of substance: since we have learned a low flow NRB is borderline criminal, what are the 'approved' methods of treating hyperventilation, in the absence of other, more significant issues?



If you have a POC machine you can check an ABG (arterial blood gas - if arterial sticks are in your scope of practice) to confirm hyperventilation which is a decrease in arterial CO2 (PaCO2). You can also check other labs if you have the cartridges to check for other forms of acidosis which are not readily obvious.  

You can attempt to calm the patient but for some with a profound metabolic acidosis which you may not know about, dropping their pH can be life threatening when they slow their respiratory rate or you force them to rebreathe their CO2 or increase their work of breathing which will also add to the acidosis systemically. 

There are several young people, 14 - 24, that are coming to the ED with a new onset of DKA.  They had no idea they were diabetic and are in a panic when they feel they have lost control of their breathing. It is probably  a very weird feeling and they probably don't feel well or the tingling sensation doesn't help. The first thing some want to do is write them off an a psych case or anxious teenager and stick their face into a plastic mask with little or no flow or tell them to get a ride with a friend.  

You also have to remember a person who is breathing fast may not be hyperventilating at all and their CO2 might be rising. This is true for infants, peds and patients with chronic lung diseases as well as metabolic disorders.

Any terms and information I have provided can easily be looked up in any nursing or critical care book and may also be found on credible websites.


----------



## Phlipper

Journey said:


> If you have a POC machine you can check an ABG (arterial blood gas - if arterial sticks are in your scope of practice) to confirm hyperventilation which is a decrease in arterial CO2 (PaCO2). You can also check other labs if you have the cartridges to check for other forms of acidosis which are not readily obvious.
> 
> You can attempt to calm the patient but for some with a profound metabolic acidosis which you may not know about, dropping their pH can be life threatening when they slow their respiratory rate or you force them to rebreathe their CO2 or increase their work of breathing which will also add to the acidosis systemically.
> 
> There are several young people, 14 - 24, that are coming to the ED with a new onset of DKA.  They had no idea they were diabetic and are in a panic when they feel they have lost control of their breathing. It is probably  a very weird feeling and they probably don't feel well or the tingling sensation doesn't help. The first thing some want to do is write them off an a psych case or anxious teenager and stick their face into a plastic mask with little or no flow or tell them to get a ride with a friend.
> 
> You also have to remember a person who is breathing fast may not be hyperventilating at all and their CO2 might be rising. This is true for infants, peds and patients with chronic lung diseases as well as metabolic disorders.
> 
> Any terms and information I have provided can easily be looked up in any nursing or critical care book and may also be found on credible websites.



That's why I wrote "in the absence of other, more significant issues".  Interesting info on DKA.  I have noticed even in my small town service we are checking bg more and more and I am trying to understand all the different ways db issues present.  Good info to know.  Thanks.

Let me try it this way:  pt presents with what looks like hyperventilation and medic has ruled out more serious issues - checked BG, they're on a monitor w/capno, etc. and medic says "You can take this one."  At this point he wants me to jump in the back, document as much info as I can, and treat the pt for hyperventilation on the way to the ER.  What can/should I, working as a Basic only, do for the pt?  Grab a plastic bag/brown paper bag?  Do nothing and let ER handle it when we get there?  What do you guys (experienced medics) suggest?  What would you want to see a basic do?


----------



## Journey

Phlipper said:


> That's why I wrote "in the absence of other, more significant issues".  Interesting info on DKA.  I have noticed even in my small town service we are checking bg more and more and I am trying to understand all the different ways db issues present.  Good info to know.  Thanks.
> 
> Let me try it this way:  pt presents with what looks like hyperventilation and medic has ruled out more serious issues - checked BG, they're on a monitor w/capno, etc. and medic says "You can take this one."  At this point he wants me to jump in the back, document as much info as I can, and treat the pt for hyperventilation on the way to the ER.  What can/should I, working as a Basic only, do for the pt?  Grab a plastic bag/brown paper bag?  Do nothing and let ER handle it when we get there?  What do you guys (experienced medics) suggest?  What would you want to see a basic do?



ABG means Arterial Blood Gas, not blood glucose. You can not actually confirm a true hyperventilation without knowing a PaCO2. (arterial measurement of CO2).  Even an ETCO2 might not be accurate depending on the mismatching and gradient of the arterial to End Tidal measurements. 

I would not advise using a paper bag but that might still be in your protocols.


----------



## jrm818

Phlipper said:


> Let me try it this way:  pt presents with what looks like hyperventilation and medic has ruled out more serious issues - checked BG, they're on a monitor w/capno, etc. and medic says "You can take this one."  At this point he wants me to jump in the back, document as much info as I can, and treat the pt for hyperventilation on the way to the ER.  What can/should I, working as a Basic only, do for the pt?  Grab a plastic bag/brown paper bag?  Do nothing and let ER handle it when we get there?  What do you guys (experienced medics) suggest?  What would you want to see a basic do?



Just as a note not at all relevant to the original scenario, but I wouldn't think that end tidal capnography is sufficient to exclude the possibility of arterial hypercapnia as the cause of tachypnea (I presume the reasoning behind including ETCO2 as part of the assessment is that if "ETCO2 is normal/low, there must be arterial hypocapnia and thus we are seeing maladaptive hyperventilation and not adaptive tachypnea due to arterial hypercapnia).  In patients with lung disease ETCO2 may not represent arterial CO2 due to poor ventilatory function.  Of course if our pt. has a low ETCO2 because they are inadequately ventilating, they are probably actually hypercapniac due to inability to shed CO2.  I would consider reducing such a patient's minute ventilation or forcing them to re breathe CO2 would be in rather poor form.

I don't know how common this presentation is, and I have no data to support my supposition, but I would think that treating tachypnea as hyperventilation on the basis of ETCO2 readings is fraught with peril.  It seems to me that the primary use would be in confirming hypercapnia with observation of high ETCO2, rather than ruling out disease with observation of low/normal ETCO2.


----------



## Veneficus

usafmedic45 said:


> Likewise.  I don't fully understand the reasoning for the chest tube policy and don't pretend to.



Sure you do, for the money of course. Why bill for a standard bed when you could bill for an ICU stay. 

Of course the other answer may be that the nurses get all bothered about somebody needing something as "complicated" as a chest tube so they have an excuse to turf the pt. to somebody else. 

You know the medical playbook, punt on first down to remove yourself from responsibility and doing any more work than the absolutely minimum required to stay employed while professing to be a superhero healthcare provider.


----------



## Journey

Veneficus said:


> Sure you do, for the money of course. Why bill for a standard bed when you could bill for an ICU stay.
> 
> Of course the other answer may be that the nurses get all bothered about somebody needing something as "complicated" as a chest tube so they have an excuse to turf the pt. to somebody else.
> 
> You know the medical playbook, punt on first down to remove yourself from responsibility and doing any more work than the absolutely minimum required to stay employed while professing to be a superhero healthcare provider.



If you need an ICU bed, we will try to get you one even if it means transferring patients to another hospital if necessary. If a patient is critical and needs an ICU bed, you should not consider that turfing.  If a policy says a patient with a chest tube must go to the ED, that also should not be considered as turfing. It might be different in EMS where you can only take to the nearest ED and have the hospital sort out the appropriate level of care.  The wallet biopsy also seems to be a concern for some in EMS on this forum and is used to decide what level of care the patient deserves or if they even deserve care. 

While sometimes it seems we can't do as much as we would like in the hospital, just doing the minimum should not be a standard. EMS really needs to get beyond this minimum thing.


----------



## Veneficus

Journey said:


> If you need an ICU bed, we will try to get you one even if it means transferring patients to another hospital if necessary. If a patient is critical and needs an ICU bed, you should not consider that turfing.  If a policy says a patient with a chest tube must go to the ED, that also should not be considered as turfing. It might be different in EMS where you can only take to the nearest ED and have the hospital sort out the appropriate level of care.  The wallet biopsy also seems to be a concern for some in EMS on this forum and is used to decide what level of care the patient deserves or if they even deserve care.
> 
> While sometimes it seems we can't do as much as we would like in the hospital, just doing the minimum should not be a standard. EMS really needs to get beyond this minimum thing.



I am not talking about EMS. 

Wallet biopsy is alive and well in hospitals too. Many times inacted as policy by administrators. 

My favorite is a private hospital that removed all of it's inner city OB resources to wealthy suburbs so that those needing immediate OB care (like delivery) could meet the transfer criteria for services not available onsite. Very clever. Not very altruistic.

"Needs" are often relative and policy as a form of fixed rule rarely takes that into account.

"critical" is also one of those relative terms that means different things to different people. So while I agree if the patient needs the ability and resources of an ICU, they should have it.

Rules, are mearly guidlines.

There are few conditions that are not served better from a medical standpoint in the ICU. Figure, more resources, highly skilled providers, extremely small provider/patient ratio.

In referencing USAFs comment, a chest tube shouldn't always and automatically mean an ICU. A policy requiring such is not based on a medical standpoint. The comfort or ability of nursing staff is not a medical issue, nor are the economics of billing.


----------



## usafmedic45

> He's getting pretty wrapped around the axle on every thread.



Here's the really funny thing.  What you are seeing as me being "wound up" is my being thorough and blunt.  My blood isn't boiling over anything on this forum.  In fact, most of it just amuses the hell out of me.  I'm actually to the point in my career where a guy with a self-inflicted stab wound to the neck (the last case I handled at work) that required me to do a surgical airway and then to help the doc get the bleeding under control bothered me only because it delayed my going home by almost an hour. 



> since we have learned a low flow NRB is borderline criminal, what are the 'approved' methods of treating hyperventilation, in the absence of other, more significant issues?



Treat the underlying problem (i.e., panic attack) even if it requires sedating the patient.  That, however, is a step that should not be taken in the field under most circumstances. 

If you consider someone not being all warm and fuzzy when trying to explain something as vitriole, you need to lighten the heck up more than I do.  LOL



> Sure you do, for the money of course. Why bill for a standard bed when you could bill for an ICU stay.



Of course.  I was just trying not to turn this into one of those debates.  



> The wallet biopsy also seems to be a concern for some in EMS on this forum and is used to decide what level of care the patient deserves or if they even deserve care.


Even as the reigning misanthrope on this forum, I don't think I would go so far as to say someone doesn't deserve lifesaving care just because they can't afford it.  Now, I sure as heck don't think we owe them any more than that but you'd have to be a pretty cold SOB to abandon your duty to care for someone just because they can't pay. 



> You also have to remember a person who is breathing fast may not be hyperventilating at all and their CO2 might be rising. This is true for infants, peds and patients with chronic lung diseases as well as metabolic disorders.



Excellent point:  tachypnea (faster than normal respirations) and hyperventilation (increased minute ventilation) are not the same thing.  Technically you don't even have to have the former to have the latter.  Probably the best example of why fast respirations does not equal hyperventilation is the severe asthmatic exacerbation.  To famously quote a post I made on another forum:


			
				DropkickMurphy said:
			
		

> That's breathing about as much as a dog humping your leg counts as sex....it's going through the motions but it doesn't do a whole hell of a lot for you". The patient was trying like hell but had such severe bronchospasm (and probably mucus plugging) that he was moving next to no air and was crashing.



Source: http://forums.studentdoctor.net/showthread.php?p=5499105&highlight=dog+humping+your+leg#post5499105


----------



## Phlipper

Journey said:


> ABG means Arterial Blood Gas, not blood glucose. You can not actually confirm a true hyperventilation without knowing a PaCO2. (arterial measurement of CO2).  Even an ETCO2 might not be accurate depending on the mismatching and gradient of the arterial to End Tidal measurements.
> 
> I would not advise using a paper bag but that might still be in your protocols.



I know what ABG is, I'm a basic and can't do them, and IIRC our medics can't either in the field.  Some of us aren't reading the posts.

I'll try one more time before giving up :  *What would YOU, as a medic, expect your Basic grunt to do for a hyperventilating pt if you've been able to rule out anything worse than anxiety?*

And as I mentioned already, the answer may be "Nothing, get them to the hospital asap." and that's cool too.  But inquiring minds want to know.


----------



## usalsfyre

Phlipper said:


> *What would YOU, as a medic, expect your Basic grunt to do for a hyperventilating pt if you've been able to rule out anything worse than anxiety?*



I think the point being made is that you can't do this. And nothing is a great option sometimes.


----------



## Shishkabob

If it IS 'just' hyperventilation and no possibility of anything else, they'll pass out eventually, and the problem will fix itself. h34r:


----------



## Phlipper

So then the answer is "Don't do anything, just get them to the hospital."

Correct?  Someone say "Yes" or "No".


----------



## Phlipper

usalsfyre said:


> I think the point being made is that you can't do this. And nothing is a great option sometimes.



I have maintained all along that might what was called for, but I kept getting explanations for things I never asked or made clear are above my paygrade.  I just needed a clarification that you guys feel nothing should be done.  It was already made clear why, and I validated this info in my Para texts.

Trust me ... there is a reason I ask this.  I periodically see things done in the field that contradict what I was taught, but I went to the worst EMT-B program on the East coast so there's plenty I don't know.  Then I later read here that this or that treatment should never ever be done that way, or done at all. So I like to clarify before I go back to the station and ask why something was done.


----------



## usalsfyre

Phlipper said:


> So then the answer is "Don't do anything, just get them to the hospital."
> 
> Correct?  Someone say "Yes" or "No".



Nothing if you think everything is ok, O2 if there is ANY concern they are hypoxic.


----------



## Phlipper

usalsfyre said:


> Nothing if you think everything is ok, O2 if there is ANY concern they are hypoxic.



Excellent.  Thanks!


----------



## JPINFV

usalsfyre said:


> I think the point being made is that you can't do this. And nothing is a great option sometimes.



"The delivery of good medical care is to do as much nothing as possible."

Rule 13.
The House of God.


----------



## usalsfyre

JPINFV said:


> "The delivery of good medical care is to do as much nothing as possible."
> 
> Rule 13.
> The House of God.



If more people took this to heart, we'd be better off.


----------



## JPINFV

usalsfyre said:


> If more people took this to heart, we'd be better off.



The House of God should be required reading for anyone entering the health care field.


----------



## usalsfyre

JPINFV said:


> The House of God should be required reading for anyone entering the health care field.



Just think, in a couple of years you'll be eligible for call room nookie too 

And yes, even if the medicine is a little old, the message in that book rings clearer than ever.


----------



## usafmedic45

> And as I mentioned already, the answer may be "Nothing, get them to the hospital asap." and that's cool too. But inquiring minds want to know.



BTW, if you think they are having a panic attack and no other clinical signs or symptoms to warrant emergency treatment, going by lights and sirens might be a bad idea.  Discuss.



> The House of God should be required reading for anyone entering the health care field.



Although it seems like more people are reading "The Spirit Catches You and You Fall Down", especially in the premed crowd.


----------



## Sasha

> BTW, if you think they are having a panic attack and no other clinical signs or symptoms to warrant emergency treatment, going by lights and sirens might be a bad idea. Discuss.



Let's give them something else to make them anxious and panicy. Loud sirens and a fast, bumpy ride to the hospital


----------



## Veneficus

Sasha said:


> Let's give them something else to make them anxious and panicy. Loud sirens and a fast, bumpy ride to the hospital



perhaps the same line of thought as:

"i'll give you something to cry about?"


----------



## Journey

Linuss said:


> If it IS 'just' hyperventilation and no possibility of anything else, they'll pass out eventually, and the problem will fix itself. h34r:



Define "just hyperventilation".

A patient can be "hyperventilating" from a variety of causes that you can not diagnose in the field. If they pass out does that mean your job is done and your diagnosis of "just hyperventilation" is correct?  A patient can also "pass out" from acidosis, hypoxia, hypercapnia and cardiac issues.  I don't think your advice is very sound.


----------



## Shishkabob

Reading comprehension.


Does wonderful things, doesn't it?


----------



## Journey

Linuss said:


> Reading comprehension.
> 
> 
> Does wonderful things, doesn't it?



Do you carry any POC testing equipment on your truck Linuss? Have you even seen a patient with Chronic Hyperventilation Syndrome?  I seriously hope you didn't take them to be a joke. 

This article might give you some idea about hyperventilation.

http://emedicine.medscape.com/article/807277-overview


----------



## usafmedic45

Journey said:


> Do you carry any POC testing equipment on your truck Linuss? Have you even seen a patient with Chronic Hyperventilation Syndrome?  I seriously hope you didn't take them to be a joke.
> 
> This article might give you some idea about hyperventilation.
> 
> http://emedicine.medscape.com/article/807277-overview


I wouldn't pick a fight with him too staunchly on this.  He's one of the sharper paramedics on this forum. 

You know the chronic hyperventilation syndrome is viewed by a lot of docs as simply an indication of poorly treated anxiety disorders in over 70-90 percent of cases (depending on the source you want to rely upon)?  They are not a "joke" but it's not a medical condition in the strict sense in the vast majority of cases. 

From the link you posted: 


> "Current thinking suggests that the syndrome might better be termed behavioral breathlessness or psychogenic dyspnea with hyperventilation as a consequence rather than as a cause of the condition. It is also recognized that some patients may be physiologically at risk of developing psychogenic dyspnea."


----------



## Journey

usafmedic45 said:


> I wouldn't pick a fight with him too staunchly on this.  He's one of the sharper paramedics on this forum.



Okay....I guess "on this forum" are the key words here. 



usafmedic45 said:


> You know the chronic hyperventilation syndrome is viewed by a lot of docs as simply an indication of poorly treated anxiety disorders in over 70-90 percent of cases (depending on the source you want to rely upon)?  They are not a "joke" but it's not a medical condition in the strict sense in the vast majority of cases.
> 
> From the link you posted:



There are many pyschogenic disorders that require hospitalization and medication.  Too many patients do get blown off because of the "psych" stigma and sometimes even the EDs are easily influenced by something the paramedics have said. We've already seen what has happened to women, the elderly and diabetics when it comes to heart disease and what some "diagnosed" as anxiety or some pyschogenic pain if it doesn't present as the textbook states.


----------



## usalsfyre

Journey said:


> A patient can also "pass out" from acidosis, hypoxia, hypercapnia and cardiac issues.  I don't think your advice is very sound.



All of which can be somewhat reasonably removed from consideration of being the presenting emergent condition by careful and complete history and physical exam. Which from talking with Linuss himself and his educators is not an area in which he lacks knowledge or is careless.

One does not always need labs to diagnose a serious medical condition.


----------



## usalsfyre

Journey said:


> Okay....I guess "on this forum" are the key words here.



Glad to see you think so highly of us.  





Journey said:


> There are many pyschogenic disorders that require hospitalization and medication.  Too many patients do get blown off because of the "psych" stigma and sometimes even the EDs are easily influenced by something the paramedics have said. We've already seen what has happened to women, the elderly and diabetics when it comes to heart disease and what some "diagnosed" as anxiety or some pyschogenic pain if it doesn't present as the textbook states.



Absolutely, which is why a careful medical provider will assess patients completely. Laying the blame for an ED's failings on paramedics assessments (which we have established are not always reliable) is unfair. Both parties share equal responsibility. 

Only the truly ignorant allow the ignorance of those before them to influence their decision making. There's a lot of idiot medics out there, but apparently a lot of idiot ED staff as well.


----------



## Veneficus

Inadequete exams are not limited to EMS. 

They are not even limited to any particular field of healthcare.

Around the world I have witnessed providers, some MDs, who are lax in their exams, histories, and even diagnostics, who write off patients they feel are unworthy or uninteresting in some way.

In my experience and it seems to be shared by many of my associates at all levels, nonacademic medical centers are notorious for harboring these types of providers. 

I have seen some of these facilities and by extension their providers who are so bad, they should be closed down, the building bulldozed, and the ground salted. The employees forever banished from the healthcare realm in shame.

Many of these providers see nothing at all wrong with their practices. 

In some instances a paramedic like Linuss in the back of a rig will be considerably better care then a fair amount of these providers.

I think it is important to remember that not every patient is hovering on the brink of death by some obscure disease. That it is both economically and practically impossible to run every test on every patient. 

There is merit in epidemiology as well as clinical usefulness in using it as part of forming a dx. 

Specialized providers should not get too caught up in their ability to point out obscure pathology relating to their field as a measure of superiority. For some providers are required to be generalists and provide supportive care until specialists can be engaged.


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## Journey

usalsfyre said:


> All of which can be somewhat reasonably removed from consideration of being the presenting emergent condition by careful and complete history and physical exam. Which from talking with Linuss himself and his educators is not an area in which he lacks knowledge or is careless.
> 
> *One does not always need labs to diagnose a serious medical condition*.



A serious medical condition does not always have to present with a lot of blood on the ground, no breathing or tombstone T waves.  There are many disease processes that can be recognized early, and yes with labs, to prevent them from cascading into a situation that is life threatening.


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## Journey

Veneficus said:


> Inadequete exams are not limited to EMS.
> 
> They are not even limited to any particular field of healthcare.
> 
> Around the world I have witnessed providers, some MDs, who are lax in their exams, histories, and even diagnostics, who write off patients they feel are unworthy or uninteresting in some way.
> 
> In my experience and it seems to be shared by many of my associates at all levels, nonacademic medical centers are notorious for harboring these types of providers.
> 
> I have seen some of these facilities and by extension their providers who are so bad, they should be closed down, the building bulldozed, and the ground salted. The employees forever banished from the healthcare realm in shame.
> 
> Many of these providers see nothing at all wrong with their practices.
> 
> In some instances a paramedic like Linuss in the back of a rig will be considerably better care then a fair amount of these providers.
> 
> I think it is important to remember that not every patient is hovering on the brink of death by some obscure disease. That it is both economically and practically impossible to run every test on every patient.
> 
> There is merit in epidemiology as well as clinical usefulness in using it as part of forming a dx.
> 
> Specialized providers should not get too caught up in their ability to point out obscure pathology relating to their field as a measure of superiority. For some providers are required to be generalists and provide supportive care until specialists can be engaged.



You don't seem to have a good opinion of doctors, hospitals or anybody associated with them.  EMS is not the end all for all medicine.  Linuss who has a certificate as a Paramedic and a few months of experience on a BLS transfer truck is not the highest standard of medicine. From some of the talk on this forum you would think a few would want to get past that level. 

In my remark I was referring to the hospital ED staff actually trusting what  a Paramedic might have assessed and put the patient in a back hall unmonitored for awhile. True, it is the ED staff's fault by not doing an assessment themselves to make their own determination. Just taking the word of a Paramedic could get them into serious trouble.  As licensed health care providers they should be aware of their responsibility and liability.  Sometimes we just need reminding of that responsibility and not all who are not EMTs or Paramedics should be banished. There are many , many good doctors, nurses and hospitals that do enforce a higher standard of care.  Again, medicine doesn't just stop with EMS.


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## usalsfyre

Journey said:


> A serious medical condition does not always have to present with a lot of blood on the ground, no breathing or tombstone T waves.  There are many disease processes that can be recognized early, and yes with labs, to prevent them from cascading into a situation that is life threatening.



If you'd payed attention to my post on this and many other subjects you'd realize I'm very aware of this. However, MOST of these conditions also have accompanying signs and symptoms, however stubtle they may be. How do you think medicine is practiced in underdeveloped areas or was practiced prior to diagnostic testing? 

Overreliance on technology is poor form.


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## Journey

usalsfyre said:


> Absolutely, which is why a careful medical provider will assess patients completely. Laying the blame for an ED's failings on paramedics assessments (which we have established are not always reliable) is unfair. Both parties share equal responsibility.
> 
> Only the truly ignorant allow the ignorance of those before them to influence their decision making. There's a lot of idiot medics out there, but apparently a lot of idiot ED staff as well.



See my above post and my previous posts. I actually gave Paramedics credit that the ED staff did trust them. You have obviously proved me wrong  for that trust by acknowledging we are idiots if we do trust the Paramedics' assessments.


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## usalsfyre

Journey said:


> You don't seem to have a good opinion of doctors, hospitals or anybody associated with them.  EMS is not the end all for all medicine.  Linuss who has a certificate as a Paramedic and a few months of experience on a BLS transfer truck is not the highest standard of medicine. From some of the talk on this forum you would think a few would want to get past that level.
> 
> In my remark I was referring to the hospital ED staff actually trusting what  a Paramedic might have assessed and put the patient in a back hall unmonitored for awhile. True, it is the ED staff's fault by not doing an assessment themselves to make their own determination. Just taking the word of a Paramedic could get them into serious trouble.  As licensed health care providers they should be aware of their responsibility and liability.  Sometimes we just need reminding of that responsibility and not all who are not EMTs or Paramedics should be banished. There are many , many good doctors, nurses and hospitals that do enforce a higher standard of care.  Again, medicine doesn't just stop with EMS.





This is just funny.


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## JPINFV

usalsfyre said:


> This is just funny.



I was thinking the same thing.


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## usalsfyre

Journey said:


> See my above post and my previous posts. I actually gave Paramedics credit that the ED staff did trust them. You have obviously proved me wrong  for that trust by acknowledging we are idiots if we do trust the Paramedics' assessments.



Don't put words in my mouth. 

I trust many of my first responders implicitly, doesn't mean a patient doesn't get a full assesment upon my arrival. Doubly so if I'm not familiar with the medical provider in question, including IFTs from the floor in which approprite care hasn't been started/care can be improved. If EDs are not willing to reassess a patient appropritely, especially if the paramedic in question doesn't have a proven track record, then they share as much blame as the EMS unit.


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## Journey

usalsfyre said:


> If you'd payed attention to my post on this and many other subjects you'd realize I'm very aware of this. However, MOST of these conditions also have accompanying signs and symptoms, however stubtle they may be. How do you think medicine is practiced in underdeveloped areas or was practiced prior to diagnostic testing?
> 
> *Overreliance on technology is poor form*.



Mortality rate in an underdeveloped country or even in parts of the U.S.? 

I would say there are some but I would not say most diseases. I would say you might have been lucky enough to catch something before it developed into something serious.

What would you say is overreliance on technology?  Labs should confirm what you suspect.  

Your arm might appear to be broken and it might be quite obvious. Would you profer no X-Ray be done and just take your chances on setting the bone to see if it grows back together okay. 

I guess if your wife finds a lump in a breast exam you would advise her to wait and see what happens next instead of getting it check out.  Would you tell your wife a mammogram is a waste of time since you could diagnose what is wrong without relying on diagnostic tests? Would you be willing to gamble with her life just to prove your point? 

If you child appears with seizure like activity but stops after a few minutes, you probably would not want to take the child to a doctor and a CT Scan or MRI would not be something you would ever want since that would be relying on technology. You already diagnosed "a seizure" and that is all you  need to know just as you would in the field as a Paramedic.  I could rattle off a long list of things that could cause a seizure but to confirm them, some diagnostic tests would have to be done and you wouldn't want to be thought of as relying on technology. It's only a seizure. 

I guess if you tore up your back lifting a patient you would just want the surgeon to cut into it  without any idea of what the problem might be from a preliminary work up. Definitely wouldn't want any lab work. 

Again, some of the most common life threatening injuries or diseases are not always the most obvious.


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## Journey

usalsfyre said:


> If EDs are not willing to reassess a patient appropritely, especially if the paramedic in question doesn't have a proven track record, then they share as much blame as the EMS unit.



I definitely agree. But then you'll get post after post on this forum that the ED staff "assessed" the patient again after they were just told something and didn't seem to trust what was given in report.  However, it shouldn't matter to the ED staff if they hurt your feelings by doing their own assessment.


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## usalsfyre

Journey said:


> Mortality rate in an underdeveloped country or even in parts of the U.S.?
> 
> I would say there are some but I would not say most diseases. I would say you might have been lucky enough to catch something before it developed into something serious.
> 
> What would you say is overreliance on technology?  Labs should confirm what you suspect.
> 
> Your arm might appear to be broken and it might be quite obvious. Would you profer no X-Ray be done and just take your chances on setting the bone to see if it grows back together okay.
> 
> I guess if your wife finds a lump in a breast exam you would advise her to wait and see what happens next instead of getting it check out.  Would you tell your wife a mammogram is a waste of time since you could diagnose what is wrong without relying on diagnostic tests? Would you be willing to gamble with her life just to prove your point?
> 
> If you child appears with seizure like activity but stops after a few minutes, you probably would not want to take the child to a doctor and a CT Scan or MRI would not be something you would ever want since that would be relying on technology. You already diagnosed "a seizure" and that is all you  need to know just as you would in the field as a Paramedic.  I could rattle off a long list of things that could cause a seizure but to confirm them, some diagnostic tests would have to be done and you wouldn't want to be thought of as relying on technology. It's only a seizure.
> 
> I guess if you tore up your back lifting a patient you would just want the surgeon to cut into it  without any idea of what the problem might be from a preliminary work up. Definitely wouldn't want any lab work.
> 
> Again, some of the most common life threatening injuries or diseases are not always the most obvious.



All of the examples you gave were initally found by physical exam. So you defeated your entire argument about occult disease being found by lab test. 

Do you really believe this stuff? Your advising a full ED workup for EVERY, FREAKIN PATIENT. If you hear hoofbeats, think horses...


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## usalsfyre

Journey said:


> I definitely agree. But then you'll get post after post on this forum that the ED staff "assessed" the patient again after they were just told something and didn't seem to trust what was given in report.  However, it shouldn't matter to the ED staff if they hurt your feelings by doing their own assessment.



My feelings are not hurt by this, it's their job.


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## usafmedic45

> Okay....I guess "on this forum" are the key words here.



Actually he's one of the sharper medics that I've talked to regardless of setting.  Maybe not the best, but he certainly is on the upper side of the curve.



> There are many pyschogenic disorders that require hospitalization and medication.



Right.  Never said that was not the case.



> Too many patients do get blown off because of the "psych" stigma and sometimes even the EDs are easily influenced by something the paramedics have said.



Too many people simply continue to beat dead horses when shown that the defense they put up was not necessarily incorrect, but at least incorrectly applied.  



> some pyschogenic pain if it doesn't present as the textbook states.



Let's not turn this into a discussion about "fibromyalgia".  LOL  Besides, we are talking about something presenting exactly as the textbook states in this particular case.  The only issue was the improper dosing of a drug until it was turned into a debate about differential diagnosis.


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## Melclin

Veneficus said:


> I think it is important to remember that not every patient is hovering on the brink of death by some obscure disease. That it is both economically and practically impossible to run every test on every patient.



Beat me to the obvious point.

Journey, mate, are you really suggesting that every person who bumps their head needs to go to CT, every person whose resp rate rise above 20 when they're upset needs to be worked up for a million metabolic disorder etc?

At some stage you've gotta start saying well there is a decent enough probability that ______ has happened to this person and it would be unreasonable to spend ten thousand dollars on testing it.


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## DesertMedic66

thats weird. trouble breathing but resp at 12 per min and spo2 at 99% with vomiting. seems weird they would use a nrb. i think the better choice would have been a nc at 4lpm if not lower. just my opinion.


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## jjesusfreak01

firefite said:


> thats weird. trouble breathing but resp at 12 per min and spo2 at 99% with vomiting. seems weird they would use a nrb. i think the better choice would have been a nc at 4lpm if not lower. just my opinion.



Emergencies are often only what the patients make them. I'll grant that if the pt is happy with a NC that (and an emesis basin) wouldn't be a bad idea.


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## cmetalbend

usalsfyre said:


> Don't put words in my mouth.
> 
> I trust many of my first responders implicitly, doesn't mean a patient doesn't get a full assesment upon my arrival. Doubly so if I'm not familiar with the medical provider in question, including IFTs from the floor in which approprite care hasn't been started/care can be improved. If EDs are not willing to reassess a patient appropritely, especially if the paramedic in question doesn't have a proven track record, then they share as much blame as the EMS unit.



In my opnion they should assume more of it actualy. (the ED) due to the fact patient vitals will and can change in a Heart beat, so to speak. Once I transfer care to the ed, it's now their' patient and my oral report is a STARTING point not the diagnosis and treatment. I get them there ALIVE and thats My job. If an ED doesn't do another assesment then thats on them not me. Now if it is discovered I missed a life threat that could have saved a patient, well thats somthing I have to live with. Sorry if any of this sounds rude, but passing the Buck, or trying to distribute it is not a good practice.


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## usafmedic45

firefite said:


> thats weird. trouble breathing but resp at 12 per min and spo2 at 99% with vomiting. seems weird they would use a nrb. i think the better choice would have been a nc at 4lpm if not lower. just my opinion.



Yeah, the choice of device and flow rate were the major problems here.


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## Veneficus

Journey said:


> You don't seem to have a good opinion of doctors, hospitals or anybody associated with them..



I am not really sure where such an extreme statement comes from. Are you really naive enough to think that Doctors or any other healthcare career doesn't have substandard providers?

That everyone is equal in their attitude and ability?

I am actually rather fond of doctors, but I know enough about medicine to realize that it is not the promised land. Many people (and especially you) might be surprised that the limits and faults of medicine are as much a part of medical education as chemistry or any other subject we study.  



Journey said:


> EMS is not the end all for all medicine.  Linuss who has a certificate as a Paramedic and a few months of experience on a BLS transfer truck is not the highest standard of medicine. From some of the talk on this forum you would think a few would want to get past that level.



I never suggested EMS was the end all for medicine. What I was trying to state was that a competent provider in their environment is superior to an incompetent or apathetic provider in the same.

You maybe surprised to discover that a paramedic with the tools and technology available to them can make less grevious errors than somebody with an unlimited license to practice medicine. Unless you consider home propofol treatment a standard of care beneficial for the late Michael Jackson.

I do not have a high opinion of any provider or institution that engages in substandard care and feels comfortble with it or even finds it acceptable.

In regards to community hospitals, I have seen a definite pattern of such behavior. It was also pointed out in one of my classes about 4 years ago that doctors outside of the academic setting are less likely to change their practices as medicine advances and that we as new physicians should be constantly aware of that and seek to not fall into the same complacency in order to better serve patients.    



Journey said:


> Sometimes we just need reminding of that responsibility and not all who are not EMTs or Paramedics should be banished..



It is still my opinion poor or apathetic providers should be banished. It doesn't matter if it is a doctor or a the most minimally trained aid.



Journey said:


> There are many , many good doctors, nurses and hospitals that do enforce a higher standard of care.  Again, medicine doesn't just stop with EMS.



Nor does it start or stop with the hospital or a docotor or any other overzealous ancillary provider. Medicine starts with the patient. Before he/she gets sick and ends with the same.


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