# Resp failure ift pt



## mrhunt (Feb 9, 2020)

Hey so had a kinda interesting call today where i second guessed myself and wanted to share i guess.

80 something yo f, A&0X4 GCS15 transfer for +Flu, CHF new onset, NSTEMI , Pneumonia. pt came in originallly for difficulty breathing, transfer for higher level of care. in er pt decomps on NRB @ 15lpm and placed on bipap at like 7mm/h20.

Placed pt on cpap at 10lpm or about 8mm/h20, She tolerates fine. BP maintains in 130's roughly. Sinus in 80's to 90's.sp02 ranges from 94 to 96% at best. pt is just chilling with no pain, resp complaints. Skins pink/warm/dry with cap refill about 2 seconds, No labored breathing. She IS tachypnic in high 20's to low 30's but this is baseline since picking her up. Pt has NO complaints of breathing while on mask.....When pt has to transfer off mask she'll immediately decomp to Low 80's SP02 but aside from this she's FINE. 

I check an ETC02 and she's acidotic from the get go at around 15 to 20 the whole time......
So i treated the pt and not the monitor.....she maintained find at the rate of cpap she was on and checked her frequently, all vitals maintained and she has no complaints. Even though she's tachypnic theres no accessory muscle use and she even starts sleeping near end of transport. 

Who here would have increased cpap to a max setting? Or done something differently to try to lower her resp rate and hopefully her acidotic nature? Or would increasing the cpap rate of even DONE anything except possibly tank her bp? guess im just looking for some reassurance. Lol.


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## Tigger (Feb 9, 2020)

Is the patient's EtCO2 low because there is some sort of metabolic issue causing tachypnea or is the tachypnea from a respiratory etiology? If the patient does have some sort of metabolic acidosis, is the tachypnea a normal compensatory response?


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## DesertMedic66 (Feb 10, 2020)

I would imagine your patient probably has some metabolic acidosis going on and is breathing fast to cause respiratory alkalosis (EtCO2 <35 is alkalotic) to offset it. If she is tolerating the CPAP well and has a SpO2 >93% I am not going to change much at all. CPAP helps with oxygenation much more than ventilation. BPAP helps with both oxygenation and ventilation.


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## mrhunt (Feb 10, 2020)

the pt had MULTIPLE respiratory etiologys, Sending hospital stated pt was speaking in 3 to 4 word sentences at baseline and that was an improvement for her apparently.   So yes the tachypnea was a normal compensatory response


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## mrhunt (Feb 10, 2020)

Oops. I Knew <35 was alkalotic. My bad mixing them up. ..... *sheepish grin*


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## E tank (Feb 10, 2020)

ETCO2 from a bipap set up wouldn't be as reliable as an ETT tube, so I wouldn't be too surprised at your readings. That said, she's in respiratory failure which in part means she isn't eliminating her CO2 where it would be detected by your monitor.

There could be a diffusion barrier defect caused by fluid or her pneumonia (atelectasis, bronchospasm, mucous plugs, etc) that is preventing her CO2 from leaving her blood and entering her lungs to be exhaled. Probably a  contributor to your low ETCO2 as well.

So you're right, I'd expect that someone like this would have a respiratory acidosis with her attendant tachypnea...a rising PaCO2 with a low ETC02.


...all this assuming her blood pressure isn't in the tank....


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## VFlutter (Feb 10, 2020)

mrhunt said:


> Or done something differently to try to lower her resp rate and hopefully her acidotic nature? Or would increasing the cpap rate of even DONE anything except possibly tank her bp? guess im just looking for some reassurance. Lol.



How did you get an ETC02? Probe between the mask and tubing or a ETC02 NC under the mask? I have found the latter to be more reliable depending on vented vs non-vented mask and leak.  

Would lowering her RR be helpful for her acidosis? 

Unfortunately only so much you can do with a pneumatic CPAP. A transport Ventilator with Bi-Level would have probably been ideal. 

Rate of CPAP? Did you have a baseline respiratory rate on? What would maxing out PEEP have done for her ETC02 and RR?


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## mrhunt (Feb 10, 2020)

So i just used the Intubation style ETC02 monitor which fits nicely into our type of cpap and doesnt interfere with the mask seal at all. We dont have ventilators on our units so thats not an option. Also her bp was perfectly fine the whole transport. Lowest it got was 110 systolic and was typically in 130's.


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## mrhunt (Feb 10, 2020)

Cpap was at around 7 to 8 mm/h20 which was what the sending facility had it at as well. She maintained fine on that and i didnt want to max it out and risk dumping her pressure or something just to have a 99% Sp02 or something dumb. 

She had nearly every resp issue there was without throwing in asthma or copd as well....So there was alot working against her.


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## VFlutter (Feb 10, 2020)

When talking about NPPV it is important to be specific. The first sentence says in the ER the patient was placed on BiPAP at 7, which is probably the EPAP.  Were they on CPAP the whole time or started on BiPAP in the ER then transported on CPAP?

Did they get an ABG?

 There is a lot working against her but also a lot of potential interventions to improve the situation if you have the right treatment path


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## mrhunt (Feb 13, 2020)

They were on bipap in sending hospital. Im honestly Not sure what Epap is. 

Sending facility didnt specify an Abg. Receiving hospital did one but i dont have info on that result.


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## DesertMedic66 (Feb 13, 2020)

mrhunt said:


> They were on bipap in sending hospital. Im honestly Not sure what Epap is.
> 
> Sending facility didnt specify an Abg. Receiving hospital did one but i dont have info on that result.


BiPAP is made up of 2 components, IPAP and EPAP. IPAP is the inspiratory pressure the patient receives when they take a breath in. EPAP is the continuous pressure the patient gets, which is PEEP.


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## mrhunt (Feb 13, 2020)

learn something everyday! I know PEEP, Just never heard it called EPAP....


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## Carlos Danger (Feb 15, 2020)

mrhunt said:


> learn something everyday! I know PEEP, Just never heard it called EPAP....


The two really aren't synonymous. At least they never used to be, but folks are starting to use them interchangeably.

EPAP was originally a proprietary term used to described the airway pressure during the expiratory phase of "Bi-Level Ventilation", which was a proprietary mode found on specific ventilators made by a specific company (can't recall at the moment which one - the Maquet Servo-i? Not sure).

Since then, bi-level ventilatory modes have become much more common and some people refer to expiratory pressure as EPAP.


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## Akulahawk (Feb 16, 2020)

mrhunt said:


> she maintained find at the rate of cpap she was on and checked her frequently, all vitals maintained and she has no complaints. Even though she's tachypnic theres no accessory muscle use and she even *starts sleeping near end of transport*.





E tank said:


> I'd expect that someone like this would have a respiratory acidosis with her attendant tachypnea...*a rising PaCO2* with a low ETC02.


When I read the initial post, I saw something that made me think of a rising PaCO2... This patient is on CPAP during transport. As stated above, it improves oxygenation but doesn't help as much as BiPAP does with ventilation. I'm sure her SpO2 was just fine during transport but I suspect her CO2 level was climbing and was probably starting to make her somnolent. If getting her back on BiPAP upon arrival at the destination didn't turn her back around...


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## hometownmedic5 (Feb 16, 2020)

Wait, was this patient transferred on a machine or a crash CPAP mask running straight off an O2 tank? It sounds like you did a CPAP transfer with a boussignac or pulmodyne type mask, and I honestly didn't think there was a system in existence that would allow such a thing.


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## DesertMedic66 (Feb 16, 2020)

hometownmedic5 said:


> Wait, was this patient transferred on a machine or a crash CPAP mask running straight off an O2 tank? It sounds like you did a CPAP transfer with a boussignac or pulmodyne type mask, and I honestly didn't think there was a system in existence that would allow such a thing.


Pulmodyne offers CPAPs that have a treaded fitting that connects to threaded ports on portable tanks and ambulance regulators.


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## VFlutter (Feb 16, 2020)

You do the best with what you have however I think this patient would have been better served being transferred with an actual ventilator.


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## hometownmedic5 (Feb 17, 2020)

DesertMedic66 said:


> Pulmodyne offers CPAPs that have a treaded fitting that connects to threaded ports on portable tanks and ambulance regulators.



I'm well aware. It's still a poorly regulated crash CPAP designed for emergency use, not long term use.


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## mrhunt (Feb 17, 2020)

Yeah i 100% agree with the above posts.  She should have stayed on bipap, not an emergency CPAP mask for a 2 hour 30 minute transport. She was supposed to be a CCT Air Transport and they were grounded due to weather in area which happens pretty frequently.....

me and my partner wern't super happy about taking her by ground but we did what we had to do....with what we had. It would have been GREAT to keep her on BIPAP and take an RT with us or something but thats just not a reality in our area.

Also, Someone was stating pt probally became somnolent....She did not and maintained her mental status and was alert and awake throughout transport, never becoming somnolent as i was reassessing her pretty damn frequently (every 5 mins to 10 max)


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## mrhunt (Feb 17, 2020)

We use Flow-safe 2 EZ Cpap masks here.   Its the type that plugs directly into the Main 02 tank and is....like the name......very easy.


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## Akulahawk (Feb 18, 2020)

mrhunt said:


> Also, Someone was stating pt probally became somnolent....She did not and maintained her mental status and was alert and awake throughout transport, *never becoming somnolent* as i was reassessing her pretty damn frequently (every 5 mins to 10 max)





mrhunt said:


> Even though she's tachypnic theres no accessory muscle use and *she even starts sleeping near end of transport.*


Someone that starts sleeping isn't becoming somnolent? This patient is tachypnic, and that's a variation of labored breathing. People can stay awake and alert all while going well down the respiratory failure pathway and becoming hypercapnic. They then just start feeling tired, they want to sleep and sometimes start nodding off. When that happens, these patients can be very close to needing significant support... like intubation and a ventilator... I've seen this more than once in patients on BiPAP. Our community uses CPAP in the field and when we get those patients, we transition them to BiPAP very quickly because we know this improves ventilation, not just oxygenation. If we see those patients starting to tire out, that's when we seriously consider RSI, before things get really bad and require an emergent RSI because they're within minutes of a respiratory code.

Clearly and obviously I wasn't there looking at the patient myself but when I saw what you wrote above, that made me VERY concerned.

ETA: One of the reasons I get concerned is that when patients like this start getting tired/somnolent, their respiratory rate can slow down a little bit and appear to be a more normal rate. At a glance, this looks like the patient is simply "just" tired and improving when what's happening is that the patient's CO2 level is climbing, the patient is physically tiring from breathing so fast for a while, and is likely fast approaching ventilatory failure. It's a very deceptive thing, one that you have to be acutely aware of and once you see it and realize it for what it is, you start seeing it as it occurs and take appropriate action.


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## mrhunt (Feb 19, 2020)

Your totally correct and i totally contradicted myself. My apologies.

I would more correctly state it as not really "sleeping" but her entire baseline being a just "responsive to verbal stimuli" from the get go sorta deal. Which still sounds bad.....and your 100% correct...She very well COULD have been going the exact route you stated and more than likely was as she really shouldnt have been on CPAP for a transfer that long. To me i didnt see a REAL mental decline or anything but more of just her being calm and having eyes closed for pretty much the duration of transport. Soon as i spoke to pt or did anything she'd aknowledge me immediately and appear fine & A&0X4, tracking etc.

And again, sorry to contradict myself or change stories. I guess hindsight is always 20/20 sorta thing.

Anyways. im the first one to say that id LOVE to know ALOT more and be way more comfortable with advanced resp such as differences in CPAP vs bipap Etc etc.....So i greatly appreciate yours and everyones input and knowledge on the subject sir.


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## mrhunt (Feb 19, 2020)

Its also worth noting we dont have bipap Or RSI within our scope and As stated before, Taking an RT wasnt an option So this was quite unfortunately for the pt....The best option that anyone had.


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## Tigger (Feb 19, 2020)

mrhunt said:


> Its also worth noting we dont have bipap Or RSI within our scope and As stated before, Taking an RT wasnt an option So this was quite unfortunately for the pt....The best option that anyone had.


A word to the wise, don't seek feedback for calls and then say "we did the best we could." Maybe, maybe not. Perhaps it would have been better for the patient to remain at the facility on BiPap until a CCT team could have transferred the patient. Don't take patients that are not appropriate just because "we do what we have to do." If you are not well versed in the management of these patients, don't take them. It's a common pitfall of the newer paramedic to say "well we have to get them out of here." For the most part, you do not. The local facility in many cases can still provide more care than an ambulance can. 

If you are going to take these patients when you know you don't have the resources to manage them, at least ask yourself "do I understand what is going on with this patient fully? Do I grasp the physiology and understand how it will change and how I might alter things?" If not, well you can guess what to do.


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## mrhunt (Feb 19, 2020)

Very true tigger and i appreciate the advice.  i wasnt trying to come off like that after asking for feedback / advice so my apologies. 

While there HAVE been a few pt transfers denied by medics....The unfortunate general consensus is that unless the Transfer is SO unsafe and the pt is SO critical that denying a transfer will be a quick way to not have employment anymore. Ive witnessed it multiple times and its just a beginning to an end. 

Pt care comes first. But obviously so does someones livelyhood. 

Again, not making excuses. Just trying to make a clear picture.


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## hometownmedic5 (Feb 20, 2020)

You are making excuses, step for step. I get it, "do the wrong thing or you're fired" is a systemic ems problem, but the solution isn't complicity, it's defiance. Which is worth more, your current employment, or your license? The state won't care that your company "made you do it". You do it, you own it. Make your choices from that starting point from here going forward.


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## MonkeyArrow (Feb 20, 2020)

hometownmedic5 said:


> You are making excuses, step for step. I get it, "do the wrong thing or you're fired" is a systemic ems problem, but the solution isn't complicity, it's defiance. Which is worth more, your current employment, or your license? The state won't care that your company "made you do it". You do it, you own it. Make your choices from that starting point from here going forward.


That is such an overblown line. The state will not be coming for anyone's license because they transported a respiratory distress patient on CPAP and the patient deteriorated en route.


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## hometownmedic5 (Feb 20, 2020)

MonkeyArrow said:


> That is such an overblown line. The state will not be coming for anyone's license because they transported a respiratory distress patient on CPAP and the patient deteriorated en route.



Ok. You do you. I know two former paramedics who “did what they had to do to get the call done” and lost their licenses because of it, directly. There was no long line of clinical failures and remediation on either records. They took a transfer for a stroke patient on a CCB infusion to control their hypertension. That truck didnt have a pump, which had been reported previously but was not reported that day. That hospital doesn’t allow ems to borrow pumps. They decided to eyeball it(which they did poorly), and failed to correct the rising blood pressure during the transfer, caused by the inadequate medication delivery. The patient suffered what could charitably be described as a negative outcome. The family, who had been at the sending facility to see the patient immediately before the transfer and was waiting at the receiving facility so they could see the result of “getting the call done” at all costs, inquired of the state ems dept if this call was handled appropriately. The state ems dept felt it was not, and there are now two less paramedics. The company was issued a stern warning, but was not directly damaged, since the pump was not reported as missing that day.

I don’t carry water for my employers. They either give me the tools to do the jobs they ask me to do, and I do them; or they don’t, and I don’t. I’m not going down for them. You can choose to do it whatever way you want, but the sympathy tank is going to start running dry for people who get burned faking their way through called. The idea here is to increase professionalism, not stagnate at the duct tape and BS phase we’ve been at for so many years.


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## Tigger (Feb 20, 2020)

hometownmedic5 said:


> Ok. You do you. I know two former paramedics who “did what they had to do to get the call done” and lost their licenses because of it, directly. There was no long line of clinical failures and remediation on either records. They took a transfer for a stroke patient on a CCB infusion to control their hypertension. That truck didnt have a pump, which had been reported previously but was not reported that day. That hospital doesn’t allow ems to borrow pumps. They decided to eyeball it(which they did poorly), and failed to correct the rising blood pressure during the transfer, caused by the inadequate medication delivery. The patient suffered what could charitably be described as a negative outcome. The family, who had been at the sending facility to see the patient immediately before the transfer and was waiting at the receiving facility so they could see the result of “getting the call done” at all costs, inquired of the state ems dept if this call was handled appropriately. The state ems dept felt it was not, and there are now two less paramedics. The company was issued a stern warning, but was not directly damaged, since the pump was not reported as missing that day.
> 
> I don’t carry water for my employers. They either give me the tools to do the jobs they ask me to do, and I do them; or they don’t, and I don’t. I’m not going down for them. You can choose to do it whatever way you want, but the sympathy tank is going to start running dry for people who get burned faking their way through called. The idea here is to increase professionalism, not stagnate at the duct tape and BS phase we’ve been at for so many years.


Oof. That’s awful.

Perhaps these are not the most comparable cases, but the more you ride the edge, the more likely you are to take a bigger chance.


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## hometownmedic5 (Feb 20, 2020)

Tigger said:


> Oof. That’s awful.
> 
> Perhaps these are not the most comparable cases, but the more you ride the edge, the more likely you are to take a bigger chance.



I respectfully disagree. Both are pretty standard calls, easily done most of the time with the proper equipment, but nearly impossible to do correctly without. Both of these patient could have been managed by a competent, properly equipped non CC paramedic; but both calls went pear shaped because both crews were inadequately equipped for the call they were on, knew it, decided to press on regardless, and both patients had a poorer than expected outcome that, on the surface appears to have been preventable in both cases.

i don’t see much more than an inch of daylight between these calls, but I’d be curious to hear where you feel they differ(aside from the ultimate outcome, of course).


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## Carlos Danger (Feb 20, 2020)

hometownmedic5 said:


> i don’t see much more than an inch of daylight between these calls, but I’d be curious to hear where you feel they differ(aside from the ultimate outcome, of course).



Where they differ is that in the OP's scenario, he was using FDA-approved, company-supplied equipment in accordance with protocols approved by his medical director and in a manner consistent with his training and the instructions provided by the manufacturer of the equipment. Maybe it wasn't the best equipment to use for that particular patient, but it's an approved device and what he was supplied with, and it would probably be difficult to argue that he deviated from his training or from the standard of care. 

Eyeballing a CCB infusion however in a critical patient, however…..is a non-starter all day long, no matter who you ask. It's clearly not the standard of care, not the way they were trained, not in their protocols, and good luck finding anyone who will admit on the record that they'd do the same thing.


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## hometownmedic5 (Feb 20, 2020)

I’m not certain you’re wrong that the manufacturer intended and approved this device for use in the IFT world, but I’m not certain you’re correct, so I will investigate that point further. 

Moving on from that, my original point was that any system(so paramedic, company, affiliate hospital medical direction, and county/region/state ems agency) that feels that transferring patients on an crash cpap mask, whether to save time, to save money on a vent, to circumvent CC requirements, etc is a system to run sideways away from, screaming.  Whether the medics themselves were negligent(criminally or civilly) I guess would come down to the details, but regardless of the rules and regulations we’ve arrived at the Nuremberg Bifurcation. you can go left, do what you know is wrong and when it all goes haywire, hide in the folds of your employers skirt and say “I was just doing what I was told to do”; or you can go to the right and do what’s right for the patient(and you, really), which may cost you the job(ultimately or immediately), but A) wont kill anybody and B) lets you keep your license and go in search of a better job.


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## mrhunt (Feb 20, 2020)

I'd have to agree with BOTH of the above posters opinions.also, if you find more information regarding if that type of mask ISN'T meant for long term ifts I'd very much like to know along with the article.


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## VFlutter (Feb 20, 2020)

I do not envy EMS crews that work in areas without available ground CCT. A lot of this falls back on the sending facilities whom push to transfer patients out at any cost. These smaller facilities may not have all the specialties available that a patient needs however they are still can provide appropriate care until true critical care transport can be arranged, weather clears for HEMS, etc more so then throwing them in the back of an business and hoping for the best. And unfortunately I have seen many ER providers not know, or care, that there are very significant differences between standard ALS equipment and care vs CCT as long as the patient is out the door.

Although many patients may do fine being transported on a crash CPAP or CMV transport vent that does not mean it is ideal nor that there will be some whom will deteriorate when they would have been better off waiting in the ER until more appropriate arrangements could be made. Let the hospital bear that responsibility and risk.


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## Peak (Feb 20, 2020)

I think that the other piece that should be considered is the clinical urgency of the situation and the available resources at the time, neither of which I think we were actually given a good picture of. 

For example about a year and a half ago my current center had an adult patient who had been shot in the chest dropped dropped off at the front door. We are a downtown tertiary referral center but of low trauma designation. We have pediatric CT surgery but not adult coverage available overnight. 

The patient was rapidly deteriorating in the trauma room despite aggressive medical management. Typically we would have sent this patient by CCT transport to the level 1 center that is about 10 minutes away. Unfortunately due to call volume across the area the soonest we would get a HEMS unit was about 45 minutes, and ground CCT was over an hour. We already had acceptance from the level 1, the surgeon was waiting in the ED and they already had the OR getting prepped waiting for us.

We had a local paramedic 911 crew who had just brought us another patient that told us that they could take the patient, but that they could not manage transfusions or the chest tubes. This system does not typically do IFTs, in fact that center contracts their IFTs out to a private ambulance company. 

I got approval from our administration to ride with them to manage transfusions and the chest tube, and the medic would take the rest of the patient; their on duty supervisor approved the same for them. Our doc approved this and specifically wrote for me by name to ride with the bus. We took the patient emergent and ultimately had a good outcome in large part due to his rapid transport. 

This ultimately got reviewed by multiple levels of quality, peer review, legal, risk management, and so on. The summary of the various opinions and findings were essentially that this did not reflect an ordinary standard of care and is not a routine what we should be using by any means. They also agreed that given the circumstances that in this case the patient was given appropriate care, and that we were covered for legal concerns like scope of practice and insurance coverage. 

These kinds of things do have a lot of gray area, and there are a lot of dynamic factors that come into play. Had this patient not been rapidly deteriorating then it would have been a much different situation.

We also would have justified to wait for HEMS/CCT to show up, although the patient would have had a high chance of dying. What is legally okay is not always in the best interests of the patient.


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## Gurby (Feb 20, 2020)

Peak said:


> I got approval from our administration to ride with them to manage transfusions and the chest tube, and the medic would take the rest of the patient; their on duty supervisor approved the same for them. Our doc approved this and specifically wrote for me by name to ride with the bus. We took the patient emergent and ultimately had a good outcome in large part due to his rapid transport.



When in doubt about whether you should take a transfer that seems over your head, IMO you should call medical control.  Push the liability onto someone higher up the food chain.  Let the MD decide whether the transfer is appropriate or not.


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## hometownmedic5 (Feb 20, 2020)

Gurby said:


> When in doubt about whether you should take a transfer that seems over your head, IMO you should call medical control.  Push the liability onto someone higher up the food chain.  Let the MD decide whether the transfer is appropriate or not.



Absolutely, but even that isn’t an infallible option. Here’s another fun tidbit from my career, tangentially. BLS discharge to home. Upon arrival, while getting the patient situated, the attendant notices the patient still has an IV in. Not a problem, a quick call to the doc should fix this wagon(this was back in the days when you needed med con for a lot more things than today). Attendant calls the doc, tells the story, doc says sure, pull the line, any problems, call me back. The attendant pulls the line, there are no complications, cue the music, right?

The attendant was a Basic, if you had not sorted that bit out yet. She neglected to mention that tidbit to the doc. Her partner had...not so much turned her in but made it clear, in the moment,  to those that cared that he was not a participant in this event. She was fired, but it never left the shop. No license stress.

So yeah, you should always call the boss when you need too; but if you gloss over or outright omit(intentionally or unintentionally) a crucial detail(like your level of licensure, or the specific type of cpap device you‘re going to use, or that you intend to drip and pray your CCB infusion etc), it then stops being the safety net it is supposed to be.

Training is good, education is better, oversight and supervision play a critical role in an efficient EMS operation; but none of it matters a tinkers damn if the system is designed in such a way as to allow and encourage recurrent institutional failure. I’ll take a patient 10 minutes to the hospital on a crash CPAP(as designed), and if I was in the same boat as the homeboy ambulance gsw I might transfer a patient the same distance on the same mask if there was truly no other option; but this isn’t that. The patient could have been knocked down and tubed if need be to secure the airway and get back to a respiratory happy place, but it sounds like they were doing pretty ok in the sending ED And it was poor clinical decision making, ignorance perhaps in EMS protocols and equipment(which is a problem if you’re an ER doc expected to give orders to ems), and straight up bad paramedicine that led to the patients deterioration. That, multi faceted, multi level, cross organizational error is, in short, an institutional failure.


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## mrhunt (Feb 21, 2020)

The other factors to mention is that our company is now owned by the sending facility and our med control is the e.r. doctor.

Our company runs all 911s as well as ifts in the area and we have complete control. There is only one cct unit owned by another company that isn't ALLOWED to enter our area.


Peak. Your story reminds me about how the transfer system worked in Hawaii in the e..r. I worked at. There was a dedicated ift company but they were usually way too slow so when we had something urgent we contacted city and county 911 to have them there in minutes and sometimes give r.n. riders. It always worked well.


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## Carlos Danger (Feb 21, 2020)

hometownmedic5 said:


> I’m not certain you’re wrong that the manufacturer intended and approved this device for use in the IFT world, but I’m not certain you’re correct, so I will investigate that point further.


I very highly doubt that the manufacturer specifies whether or not this device is appropriate for use in the IFT setting. They may though, who knows? We use devices and drugs for off-label uses all the time. As long as it’s a common practice and a generally accepted use and for paramedics, if it is authorized by your protocols, no one is going to accuse you a breach of duty and therefore there’s probably no increased individual liability risk.

The point is, you asked what the differences were between the OP’s  scenario and the one you described, and there are really big differences from a medico-legal perspective.

The two scenarios would be much more analogous if the OP had taken the patient off CPAP altogether and substituted a NC, or if the paramedics on the stroke transport had at least used a dial-a-drip.


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## Lemur (Feb 22, 2020)

mrhunt said:


> Oops. I Knew <35 was alkalotic. My bad mixing them up. ..... *sheepish grin*


End-tidal CO2 is really good for monitoring tube placement and also good as a rough look at ventilation- but often it doesn’t correlate well with the blood gasses. Without those, you don’t really know the patient’s underlying acid-base status. A good guess would be she is tachypneic from a primary respiratory process. Another would be she was acidotic and compensating with her breathing. Or as someone else mentioned, a diffusion defect or shunting. Hard to know. But from your perspective transporting her, honestly just keeping her sats and in an acceptable range is fine- especially if her mentation intact. Sounds like you handled the situation just fine within your training.


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## Lemur (Feb 22, 2020)

hometownmedic5 said:


> You are making excuses, step for step. I get it, "do the wrong thing or you're fired" is a systemic ems problem, but the solution isn't complicity, it's defiance. Which is worth more, your current employment, or your license? The state won't care that your company "made you do it". You do it, you own it. Make your choices from that starting point from here going forward.


Wait really? We don’t know their scope of practice and if their license would actually be in any real danger. What we probably all know too well is that there isn’t much choice when I comes to turning down calls while working for a private ambulance service. I care for patients that I don’t fully understand all the time, and it doesn’t put my license in danger. As long as I operate without my training and experience and do the best I can while getting more help, that’s often all we can do. What might not be ok in this situation is refusing to transfer, delaying definitive care for the patient, and getting internally disciplined all at once.


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## VFlutter (Feb 22, 2020)

Lemur said:


> End-tidal CO2 is really good for monitoring tube placement and also good as a rough look at ventilation- but often it doesn’t correlate well with the blood gasses. Without those, you don’t really know the patient’s underlying acid-base status. A good guess would be she is tachypneic from a primary respiratory process. Another would be she was acidotic and compensating with her breathing. Or as someone else mentioned, a diffusion defect or shunting. Hard to know. But from your perspective transporting her, honestly just keeping her sats and in an acceptable range is fine- especially if her mentation intact. Sounds like you handled the situation just fine within your training.


 
PaC02 - ETC02 gradient is often overlooked. With shock, pulmonary disease, V/Q mismatch etc the less reliable an absolute ETC02 value becomes. Still beneficial to trend in response to treatment.


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## hometownmedic5 (Feb 22, 2020)

Lemur said:


> Wait really? We don’t know their scope of practice and if their license would actually be in any real danger. What we probably all know too well is that there isn’t much choice when I comes to turning down calls while working for a private ambulance service. I care for patients that I don’t fully understand all the time, and it doesn’t put my license in danger. As long as I operate without my training and experience and do the best I can while getting more help, that’s often all we can do. What might not be ok in this situation is refusing to transfer, delaying definitive care for the patient, and getting internally disciplined all at once.



No. Just no. You are incorrect, and this is the problem we need to fix.

You always have a choice. You may not like one or more of the options, and thus feel as if you don’t have a choice, but you always have a choice and when the piper sticks his hand out, he doesn’t give a hoot whether you followed your companys bad management practices into the ground. You’re still the guy that was in the back of the truck, treated the patient, and signed the form.

Now, if it turns out that they(the medics in that system) have been duly authorized by their medical control doc to use crash CPAP for an IFT patient on BiPAP, then they(the medics) are absolved of their responsibility(for that single part of the equation), but being complicit in a bad system you don’t have the authority to change doesn’t mitigate the fact that you chose to work there, and you chose to do a call you were ill equipped to manage. Both of those are choices.

I have refused several IFTs while working for privates because they exceeded my capacity to manage them and it would have placed the criminal and civil liability on my head had I undertaken them. I have been fired zero times for it because I don’t play that particular card when I just don’t want to do the call. That card only comes out when, imho, the patient is truly better off waiting at the sending facility for CC/HEMS, and I always have my OLMC doc onboard before I refuse the call. Ive also spent over two hours anchored at the ED getting a patient ready to travel. 

You don’t have to do the job in a hacky way just because you work for a private, and if you work for a private that’s going to put you in those kinds of boxes as a matter of routine business, you have the choice to seek employment elsewhere. Your safety and ability to make a living far exceeds the value in any one job, or any one patient, and until that is the anthem of EMS, we’re going to keep getting **** on by our bosses and just saying “well, thats life in the privates I guess”.


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## Lemur (Feb 22, 2020)

hometownmedic5 said:


> No. Just no. You are incorrect, and this is the problem we need to fix.
> 
> You always have a choice. You may not like one or more of the options, and thus feel as if you don’t have a choice, but you always have a choice and when the piper sticks his hand out, he doesn’t give a hoot whether you followed your companys bad management practices into the ground. You’re still the guy that was in the back of the truck, treated the patient, and signed the form.
> 
> ...


I am resisting the urge to ignore this out of hand because I think there is some value in having a discussion.

I’m not talking about an hypothetical scenario where a paramedic is facing the decision to transport a patient that is definitively outside of their scope of practice (by the way, a wiser medical ethics still demand analysis here, imagine a disaster scenario). I’m talking about quite a different thing- a potentially unstable patient that needs to go somewhere else for definitive care, where during transport you may have less than ideal equipment at your disposal but are still wholly capable of managing the patient within your scope of practice for a limited period of time.

Very often, when transferring patients to another hospital for higher level of care, we have incomplete information and can only make a snap judgment as to if transfer is safe given the circumstances and in the best interest of the patient. Most of the time it is, and we always accept a small risk of deterioration during transport that is out-balances by potential benefit the patient can receive wherever they are going. If you are routinely refusing to transport these people because you have a different form of non-invasive ventilation that is not likely to result in harm, that’s unfortunate. And your service be correct in attempting to dissuade making this call.

The longer I’ve been around and the further I get in my training, the less absolutist and black or white my thinking has become. Especially in a scenario like the OP’s. Your comparison to “eyeballing” some cardene on a head bleed is not equivalent in any ethically salient way.


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## hometownmedic5 (Feb 22, 2020)

It would appear we have reached an impasse, as you and others want to make excuses for hacky practice for the sake of profitably and I will not. Yes, I see things as black and white most of the time, because most shades of grey distill down to BS. I simply am not willing to risk my personal safety, or that of those in my charge, or my capacity to make a living because my employer won’t cough up a buck. If others want to “take one for the team”, well, I hope theres still a chair for them when the music stops.


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## RocketMedic (Feb 26, 2020)

hometownmedic5 said:


> Wait, was this patient transferred on a machine or a crash CPAP mask running straight off an O2 tank? It sounds like you did a CPAP transfer with a boussignac or pulmodyne type mask, and I honestly didn't think there was a system in existence that would allow such a thing.


That’s how we’re stuck doing it here thanks to the way it’s always been.

life is grey and I think you’re horribly wrong Hometownmedic.


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## Carlos Danger (Feb 26, 2020)

hometownmedic5 said:


> It would appear we have reached an impasse, as you and others want to make excuses for hacky practice for the sake of profitably and I will not. Yes, I see things as black and white most of the time, because most shades of grey distill down to BS. I simply am not willing to risk my personal safety, or that of those in my charge, or my capacity to make a living because my employer won’t cough up a buck. If others want to “take one for the team”, well, I hope theres still a chair for them when the music stops.



No one here has made excuses for hacky practice, or advocated for "taking one for the team" in a way that jeopardizes anyone's safety. The fact that you interpret any of these posts that way supports your explanation that you do indeed choose to view things as black or white.

That is certainly your prerogative, but insisting on viewing things through that lens at every turn is going to make it difficult for you to come to grips with and communicate about many of the realities of the world that we live in, especially (though certainly not only) in medicine, where almost nothing is black and white.


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