# One rescuer ventilation question



## RebelAngel (Feb 8, 2014)

What is more common for you all to see/do for one rescuer: one rescuer BVM or something else?

According to book and Instructor one rescuer BVM is least efficient way to ventilate, but that's what people in our [very small] squad do. It's been bugging the crap out of me because *I* don't want to do that if it's not going to be the most efficient way. Since we're so small I need to plan on being the only EMT/rescuer running calls (besides driver of course). Be that as it may, I'd rather carry my own pocket masks around with me to use for mouth to mask since that is more efficient than one rescuer BVM. Ironically they're not part of the 800 (a list of supplies and equipment NYS says has to be on our ambulances).

Thoughts?


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## LACoGurneyjockey (Feb 8, 2014)

I've never had a problem using a BVM. Even if there's two of you, only one person is using the BVM at once. Plus, as far as I know a pocket mask can't flow O2. 
Hint: not everything the outdated textbook says is right...


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## NomadicMedic (Feb 8, 2014)

Many pocket masks have an o2 port on them. Trust me, first time you work a pukey code, you'll be half you're using a BVM.


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## RebelAngel (Feb 8, 2014)

LACoGurneyjockey said:


> I've never had a problem using a BVM. Even if there's two of you, only one person is using the BVM at once. Plus, as far as I know a pocket mask can't flow O2.
> Hint: not everything the outdated textbook says is right...



Yep, many masks have the O2 inlet and I will definitely buy those types of pocket resuscitators. 

As far as the textbook being right, I understand that. However, I had a problem keeping a good seal with my manikin today doing one rescuer BVM. I don't want that on my shoulders, if I can be better and more efficient with mouth to mask, you know?


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## Tigger (Feb 8, 2014)

I have no interest in using a pocket mask in any capacity. If I am alone with a cardiac arrest, hands only CPR all the way. All alone with a respiratory arrest, I'm probably just going to use it. It's rare to be truly alone, and you can get anyone to squeeze the bag when you say so.

I don't carry a pocket mask with me and we don't have any on the ambulances. I know many AEDs have them attached, but I'll be concentrating on what works, compressions and electricity.


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## NomadicMedic (Feb 8, 2014)

In sure you've heard plenty of people say there's a difference between textbook and real life... This is one of them. BVM. Every time. 

You're new and sparky. Good for you to want to do the best for your patients.

However. In the real world, it's a BVM.


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## Carlos Danger (Feb 8, 2014)

RebelAngel said:


> According to book and Instructor one rescuer BVM is least efficient way to ventilate, but that's what people in our [very small] squad do. It's been bugging the crap out of me because *I* don't want to do that if it's not going to be the most efficient way. Since we're so small I need to plan on being the only EMT/rescuer running calls (besides driver of course). Be that as it may, I'd rather carry my own pocket masks around with me to use for mouth to mask since that is more efficient than one rescuer BVM. Ironically they're not part of the 800 (a list of supplies and equipment NYS says has to be on our ambulances).



Single-person ventilation is perfectly adequate as long as you are doing it correctly. If you are getting good gas exchange (i.e. good chest rise and misting in the mask), then a second set of hands will add nothing.

Mask ventilation is a surprisingly difficult skill to master, however. Real proficiency takes a lot more practice than most of us get as EMT's or Paramedics. In fact, quite a few patients (I'd say 1-2% or so?) are very difficult or impossible to mask ventilate adequately, even in the OR by two anesthesia providers. A much larger percentage (at least 25%, perhaps much more, I'd guesstimate) are not adequately mask ventilated by field personnel, due to a combination of positioning problems and lack of skill. This is why 2-person is considered more efficient, although a second rescuer doesn't guarantee success, if neither are well-practiced in it.

All that said, there will certainly be times where single-person ventilation needs to be done, and you just do the best that you can do. Take the skill seriously (which it sounds like you are) and practice it every chance you get. Be very quick to use an OPA and/or NPA, and pay close attention to your mask seal and your neck flexion. Using a single hand to lift the chin the right way while maintaining a good seal takes practice - especially in obese patients or those with beards - but really is the whole crux of the skill in most cases.

And as others have said, use a BVM instead of a pocket mask. A pocket mask is fine to use when you simply don't have anything else, but if you are going to keep a BLS bag in your car, a BVM should be your most important piece of equipment, and always use it (rather than a pocket mask) if you have access to it.


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## medicsb (Feb 8, 2014)

Halothane said:


> Mask ventilation is a surprisingly difficult skill to master, however. Real proficiency takes a lot more practice than most of us get as EMT's or Paramedics. In fact, quite a few patients (I'd say 1-2% or so?) are very difficult or impossible to mask ventilate adequately, even in the OR by two anesthesia providers. A much larger percentage (at least 25%, perhaps much more, I'd guesstimate) are not adequately mask ventilated by field personnel, due to a combination of positioning problems and lack of skill. This is why 2-person is considered more efficient, although a second rescuer doesn't guarantee success, if neither are well-practiced in it.



Truth.  Apparently a great way to get experience with a BVM is to attend electro-convulsive (shock-treatment) therapy, but only so many places actually do it.  Realistically, it'd be ideal to have all EMT students go to the OR to practice bagging, but it is likely not practical.


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## mycrofft (Feb 9, 2014)

One person BVM is very difficult to do without it being attached to an endotracheal device. And then not easy but do-able. At least have some sort of airway so you are not trying to hyperextend the neck AND seal the mask.

BTW, take the mask off a BVM and you have: _*a pocket mask without the valve*_. BTST (by the same token ) a bad or missing BVM mask can USUALLLLY be replaced by a pocket mask in a pinch.

Tigger has a valid point. If pt needs CPR and you are all alone, make sure the compressions are going very well and not  being interrupted by dinking around with a balky BVM.

PS: Oxygen into pocket masks? If the mask straps on, it's a sort-of oxygen mask. Find me an unbiased study where they find it makes a difference. And the ones with O2 nipples can become very stiff, enough to be unable to open them out


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## Carlos Danger (Feb 9, 2014)

medicsb said:


> Truth.  Apparently a great way to get experience with a BVM is to attend electro-convulsive (shock-treatment) therapy, but only so many places actually do it.  Realistically, it'd be ideal to have all EMT students go to the OR to practice bagging, but it is likely not practical.



YES. I work in ECT regularly and there is probably is no better way to learn mask skills. In an hour you'll mask ~5 patients or so for about 5 minutes each.

Anyone who has the chance to spend some time in ECT should absolutely do it.


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## NomadicMedic (Feb 9, 2014)

My paramedic program did a skill session called "bag a buddy". It was a great way to get a feel for bagging and BEING bagged. http://emsworld.com/article/10319947/assisting-ventilations


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## RebelAngel (Feb 9, 2014)

I have a manikin and BVM sitting in my living room. The Chief offered it to me so I could practice. The mask with BVM is completely different than the pocket resuscitator I have. The BVM mask seals much, much easier.


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## Tigger (Feb 9, 2014)

RebelAngel said:


> Yep, many masks have the O2 inlet and I will definitely buy those types of pocket resuscitators.
> 
> As far as the textbook being right, I understand that. However, I had a problem keeping a good seal with my manikin today doing one rescuer BVM. I don't want that on my shoulders, if I can be better and more efficient with mouth to mask, you know?



There is no reason to purchase your own equipment for use at your agency. Doing so sets a dangerous precedent for future department purchases.


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## Brandon O (Feb 9, 2014)

In recognition of the challenges of one-person BVM, most of the textbooks have discouraged it for many years. In the field everyone promptly ignores this, because Real EMTs have no interest in using a pocket mask, and two-person BVM use is considered weak or something.

Then most of these Real EMTs promptly proceed to utterly fail to successfully ventilate people.

IMO everyone who says they'd never use a pocket mask should be forced to demonstrate the ability to obtain a one-handed BVM seal on every patient and ventilate them without gastric distention. On any patient, 100% of the time. Because if you can't, and you still maintain you'd never use the pocket mask, then theoretically there is a hypoxic patient out there you'd allow to die because you're so convinced that Real EMTs Don't Need Backup Plans.

But that never happens, right? We've never seen somebody "managing the airway" who's really just squeezing oxygen near somebody's face.

Hopefully we all remember this little factoid, but if somebody's not breathing and you can't ventilate them, they will die. This is a kinda important thing. It behooves you to have as many tools, options, solutions, and backups as you can wedge between a hypoventilatory patient and hypoxia.

Here's one example of having options. Everyone's different, so you should have your own toolbox. But the guy with only one option is gonna kill someone eventually.

(By the way, the medics have a lot more pieces of plastic, but if they can't competently use them all or don't have a mental process for when to do so, they don't have any more options than you.)


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## RebelAngel (Feb 9, 2014)

Thanks to the Manikin and being able to practice I think I figured out what my issue was. I am going to give it a little bit and then rush in there to save my manikin with one person BVM. :rofl:


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## Tigger (Feb 9, 2014)

Brandon O said:


> In recognition of the challenges of one-person BVM, most of the textbooks have discouraged it for many years. In the field everyone promptly ignores this, because Real EMTs have no interest in using a pocket mask, and two-person BVM use is considered weak or something.
> 
> Then most of these Real EMTs promptly proceed to utterly fail to successfully ventilate people.
> 
> ...



I have no interest in getting puke on my face frankly. If a BVM mask is not going to stop vomit (and it doesn't), I don't really want my face there either. Can't wear a mask and use a pocket mask...


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## Brandon O (Feb 9, 2014)

Tigger said:


> I have no interest in getting puke on my face frankly. If a BVM mask is not going to stop vomit (and it doesn't), I don't really want my face there either. Can't wear a mask and use a pocket mask...



Fair enough. And I'm not necessarily saying you should. Certainly, with BSI in mind, nobody would fault you for passing on that option.

But it's smart to unpack the ramifications of your decisions when things are calm. In the hypothetical situation where you absolutely cannot ventilate the patient with the BVM but possibly could with the pocket mask, would you let that person die?


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## NomadicMedic (Feb 9, 2014)

I'm certainly not to proud to ask for help with an extra set of hands in a difficult to bag patient. Practice does make it easier. I also have BIG hands and use several adjuncts when I bag a patient, so I usually don't have issues on patients with "normal" facial anatomy.  Knowing the predictors for a difficult to mask ventilate patient (BONES anyone?) is also a smart way to know if you're going to have to move to another option when you can't bag. However,,it's not really an issue for me. In the "can't ventilate/can't intubate" situation, they just get cut.


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## chaz90 (Feb 9, 2014)

Brandon O said:


> Fair enough. And I'm not necessarily saying you should. Certainly, with BSI in mind, nobody would fault you for passing on that option.
> 
> But it's smart to unpack the ramifications of your decisions when things are calm. In the hypothetical situation where you absolutely cannot ventilate the patient with the BVM but possibly could with the pocket mask, would you let that person die?



Someone else is going to be on scene. For one, where I am we have a partner that is with us as we arrive at a call ~90% of the time. Secondly, the BLS ambulance often beats us there or is very close behind. Thirdly, who called EMS? If I'm single medic and alone for a brief time on a profound respiratory failure patient who is difficult to ventilate alone with the use of airway adjuncts, the caller is going to be squeezing the BVM for me as I use two hands to create a seal.


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## Carlos Danger (Feb 9, 2014)

Brandon O said:


> In recognition of the challenges of one-person BVM, most of the textbooks have discouraged it for many years. In the field everyone promptly ignores this, because Real EMTs have no interest in using a pocket mask, and two-person BVM use is considered weak or something.
> 
> Then most of these Real EMTs promptly proceed to utterly fail to successfully ventilate people.
> 
> *IMO everyone who says they'd never use a pocket mask should be forced to demonstrate the ability to obtain a one-handed BVM seal on every patient and ventilate them without gastric distention. On any patient, 100% of the time.* Because if you can't, and you still maintain you'd never use the pocket mask, then theoretically there is a hypoxic patient out there you'd allow to die because you're so convinced that Real EMTs Don't Need Backup Plans.



This presupposes that most patients who are difficult to ventilate with a BVM will not be equally difficult to ventilate with a pocket mask.

Are pocket masks that much easier to ventilate with? 

I've never used one so I honestly don't know, but the physics are the same no matter what you are using to generate pressure, so I'd imagine that someone who isn't skilled with a BVM is probably not going to do great with a pocket mask either. 

I know a pocket mask allows for use of both hands on the mask which should theoretically make it easier to maintain a seal, but keeping a seal is only part of the battle, and I can envision other challenges that are unique to pocket masks. Primarily, it would seem to be more difficult to maintain proper jaw thrust and neck flexion while leaning down at an awkward angle and moving your mouth onto and off of the mouthpiece. You'd also probably get tired quicker, at which point form tends to get sloppy.


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## Brandon O (Feb 9, 2014)

chaz90 said:


> Someone else is going to be on scene. For one, where I am we have a partner that is with us as we arrive at a call ~90% of the time. Secondly, the BLS ambulance often beats us there or is very close behind. Thirdly, who called EMS? If I'm single medic and alone for a brief time on a profound respiratory failure patient who is difficult to ventilate alone with the use of airway adjuncts, the caller is going to be squeezing the BVM for me as I use two hands to create a seal.



I love that you've thought about it (which is really my main point, not the details). But to keep kicking this can along: how about if your patient tanks while you're alone in back? Or a confined space (e.g. MVA entrapment) where there's no room for another rescuer (and maybe no space to properly use the BVM)?


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## NomadicMedic (Feb 9, 2014)

What if? What if? What if? We can what if this forever. Either they are able to be bagged, or they're not. If you've got another solution, you use it. If not, you just reposition and try again.


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## mycrofft (Feb 9, 2014)

RebelAngel said:


> I have a manikin and BVM sitting in my living room. The Chief offered it to me so I could practice. The mask with BVM is completely different than the pocket resuscitator I have. The BVM mask seals much, much easier.



Yeah, the BVM mask has a pneumatic seal (poofy) and the pocket mask is not.   Poofy can go flat.

The deal is that their fitting to the valve or to the BVM is identical.


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## Brandon O (Feb 9, 2014)

Halothane said:


> This presupposes that most patients who are difficult to ventilate with a BVM will not be equally difficult to ventilate with a pocket mask.
> 
> Are pocket masks that much easier to ventilate with?
> 
> ...



I'm not really trying to elevate the stupid pocket mask as the holy grail of BLS ventilation, I'm just trying to point out that airway algorithms are only reliable if they have layers, and the single-person BVM is just one pretty crappy layer.

But yeah, I'd say it's probably among the more reliable tools. Since you have two hands and you're at a cozy distance, it's dead easy to make a seal; and generating air with your own lungs makes it reaaaaally easy to control the pressure you use (and feel the compliance as a constant quality check). I'd guess the only situation where the BVM would be easier is one where you can't get closer than arm's length for some reason.

(As a caveat, no, I haven't pocket masked a human being. But I have played with this stuff quite a bit.)


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## mycrofft (Feb 9, 2014)

DEmedic said:


> What if? What if? What if? We can what if this forever. Either they are able to be bagged, or they're not. If you've got another solution, you use it. If not, you just reposition and try again.



And be good at both so you have the option.

I think this is a case of we mostly thinking alike, but the leisure and detachment afforded by a keyboard and a monitor make quibbling attractive. In a pinch, most would do their best and not flub it.


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## Brandon O (Feb 9, 2014)

DEmedic said:


> What if? What if? What if? We can what if this forever. Either they are able to be bagged, or they're not. If you've got another solution, you use it. If not, you just reposition and try again.



The number of solutions you have is determined by how many you've come up with (and properly analyzed, planned out, and trained for) beforehand.

Eventually, the next step in any algorithm is "failed? well... keep trying until they're dead." But you want to make space before you hit that point.

With due respect, I'm not sure how understandable this is for the medics. Managing a difficult airway with nothing but a BVM and your wits is a uniquely BLS experience. Our typical airway algorithm is "1. BVM with OPA -- if failed --> 2. Soil self, call ALS, run screaming"


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## mycrofft (Feb 9, 2014)

Brandon O said:


> The number of solutions you have is determined by how many you've come up with (and properly analyzed, planned out, and trained for) beforehand.
> 
> Eventually, the next step in any algorithm is "failed? well... keep trying until they're dead." But you want to make space before you hit that point.
> 
> With due respect, I'm not sure how understandable this is for the medics. Managing a difficult airway with nothing but a BVM and your wits is a uniquely BLS experience. Our typical airway algorithm is "1. BVM with OPA -- if failed --> 2. Soil self, call ALS, run screaming"




BVM with OPA -- if failed --> start compressions because you spent to much time on airway and failed .


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## RebelAngel (Feb 10, 2014)

Someone commented about 90% of the time there is someone else there. We're all volunteer and we're very small. There are only two active EMTs in our squad and only one of those runs calls regularly, the other is just sort of back-up (because he really doesn't want to do it anymore) for when first EMT is out of town. When me and the other woman taking the course pass that brings us up to four. 90% (probably more) there will only be me and my driver responding to calls, unless there's an EMR. My oldest is currently taking the EMR course, so that's more of a possibility now than it was before we joined the FD.


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## chaz90 (Feb 10, 2014)

RebelAngel said:


> Someone commented about 90% of the time there is someone else there. We're all volunteer and we're very small. There are only two active EMTs in our squad and only one of those runs calls regularly, the other is just sort of back-up (because he really doesn't want to do it anymore) for when first EMT is out of town. When me and the other woman taking the course pass that brings us up to four. 90% (probably more) there will only be me and my driver responding to calls, unless there's an EMR. My oldest is currently taking the EMR course, so that's more of a possibility now than it was before we joined the FD.



That was just a comment about my situation. Even in your case, as mentioned, you can have your driver squeeze a BVM for you as you create the seal with two hands. I agree with Brandon though in saying it's more a hypothetical situation than a realistic "I expect this to happen tomorrow." Specifics aren't overly important IMO. I do like this thread as something to at least think about and remind people of the common ineffectiveness of one person BVM.


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## broken stretcher (Feb 10, 2014)

throw them on a NRB. Effective CPR is your first priority.


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## CFal (Feb 26, 2014)

Turns out BVM s don't work too well in single digit temperatures


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## Handsome Robb (Feb 26, 2014)

broken stretcher said:


> throw them on a NRB. Effective CPR is your first priority.




While I agree in most cases there are patients who we need to focus on oxygenation and ventilation along with good CPR. Cardiocerebral Resuscitation (CCR) has shown some promising stuff but we will have to wait and see. 

We do CCR and submit to the CARES registry. 

CCR is contraindicated in a cardiac arrest with a respiratory etiology. The exact verbiage of our CCR protocol is: "Nontraumatic cardiopulmonary arrest patients without a primary respiratory etiology (ie drowning or drug overdose)."


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## Handsome Robb (Feb 26, 2014)

CFal said:


> Turns out BVM s don't work too well in single digit temperatures




Why do you say that? Is your box not temperature controlled when you're posted or in quarters?


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## CFal (Feb 26, 2014)

Robb said:


> Why do you say that? Is your box not temperature controlled when you're posted or in quarters?



Ski Patrol, wasn't in a box


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## Handsome Robb (Feb 26, 2014)

CFal said:


> Ski Patrol, wasn't in a box



Ah gotcha. 

Not sure where you keep your stuff, if it's in the sled consider pulling it and taking it into the hut. We put our trauma kit inside the hut. Also used to stuff the plastic bag the BVM was in with crumpled up newspapers and that kept it decently warm. If its really cold add a blanket wrap around the whole thing. 

Tricks of the trade


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## CFal (Feb 26, 2014)

Robb said:


> Ah gotcha.
> 
> Not sure where you keep your stuff, if it's in the sled consider pulling it and taking it into the hut. We put our trauma kit inside the hut. Also used to stuff the plastic bag the BVM was in with crumpled up newspapers and that kept it decently warm. If its really cold add a blanket wrap around the whole thing.
> 
> Tricks of the trade



We have an airway bag that is inside the hut, it has O2 tank, BVMs, NRBs, OPAs, NPAs etc...


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## Tigger (Feb 26, 2014)

Never had a problem bagging in cold temperatures here...


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## mycrofft (Feb 27, 2014)

cfal said:


> turns out bvm s don't work too well in single digit temperatures



yep!


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## mycrofft (Feb 27, 2014)

Robb said:


> While I agree in most cases there are patients who we need to focus on oxygenation and ventilation along with good CPR. Cardiocerebral Resuscitation (CCR) has shown some promising stuff but we will have to wait and see.
> 
> We do CCR and submit to the CARES registry.
> 
> CCR is contraindicated in a cardiac arrest with a respiratory etiology. The exact verbiage of our CCR protocol is: "Nontraumatic cardiopulmonary arrest patients without a primary respiratory etiology (ie drowning or drug overdose)."


There's a shelf life for respiratory etiology codes after which you're doing CPR because the heart isn't going to restart otherwise. However...

One of the big lies of omission we perpetrate for the patients' sake; a code due to respiratory failure may initially reflect cardiac irritability related to cardiomyopathic anoxia, but after five minutes or so the brain starts going. A defib might, might bring back a damaged heart for a bit, but it won't do a thing for arrest secondary to_* cerebral*_ anoxia, i.e., biological death.


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## Handsome Robb (Feb 27, 2014)

CFal said:


> We have an airway bag that is inside the hut, it has O2 tank, BVMs, NRBs, OPAs, NPAs etc...



So I'm confused as to why you had troubles with the BVM then? If they're frozen they're a pain in the butt absolutely. I guess maybe we don't get as cold here? I never had issues with a BVM on the hill. Sorry wasn't trying to be condescending...



Tigger said:


> Never had a problem bagging in cold temperatures here...



See above 



mycrofft said:


> There's a shelf life for respiratory etiology codes after which you're doing CPR because the heart isn't going to restart otherwise. However...
> 
> One of the big lies of omission we perpetrate for the patients' sake; a code due to respiratory failure may initially reflect cardiac irritability related to cardiomyopathic anoxia, but after five minutes or so the brain starts going. A defib might, might bring back a damaged heart for a bit, but it won't do a thing for arrest secondary to_* cerebral*_ anoxia, i.e., biological death.



I might just be too tired but I didn't understand what you were trying to get at with that.


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## mycrofft (Feb 27, 2014)

Some BVM's don't re-expand very quickly when they are too cold, limiting the amount of air per stroke.

Also ( remember we are talking under 10 deg F right?), exhalation can freeze in the duckbill valve making it "sticky" (resists opening, then POPs open).

Friction joints where female tubing or whatnot is jammed onto a male receptor don't work when the tubing is stiff like cement. Without care, the male connector can even snap.

And, anyone practice working a BVM with gloves on? Snow gloves? Can't get a good grip on the pt's facial bones for a seal I bet.

We lacked covered heated storage for every unit, in Nebraska where I worked. In the winter sometimes we'd jump start them and park them in the garage to thaw out while the other units were out. Grab an armful of warm blankets before going out for the pts.


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## Summit (Feb 27, 2014)

Numask is a nice alternative to the pocket mask... unless there is extreme trauma...


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## mycrofft (Feb 27, 2014)

Quote:
Originally Posted by mycrofft View Post 
There's a shelf life for respiratory etiology codes after which you're doing CPR because the heart isn't going to restart otherwise. However...

One of the big lies of omission we perpetrate for the patients' sake; a code due to respiratory failure may initially reflect cardiac irritability related to cardiomyopathic anoxia, but after five minutes or so the brain starts going. A defib might, might bring back a damaged heart for a bit, but it won't do a thing for arrest secondary to cerebral anoxia, i.e., biological death. 

I might just be too tired but I didn't understand what you were trying to get at with that. ENDQUOTE  Robb



Hands only CPR was mentioned, and that in codes initiated by respiratory failure ventilation is paramount.

My input: in respiratory arrests, some will revive if they are temporary (glottis closed due to water in airway, electrical shock, airway embarrassment) but if electrical activity in the heart is ineffective (no pulse, unconscious due to myocardial infarction, intoxication or anoxia ) you will need full CPR because that oxygenated blood will stay in the lungs and not get to where it is needed...the brain and heart. That needs to start promptly,not after dithering.

I nominate a change in CPR training: No pulse and no breathing, full CPR. (Radical, right?).


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## Brandon O (Feb 27, 2014)

mycrofft said:


> I nominate a change in CPR training: No pulse and no breathing, full CPR. (Radical, right?).



Research suggests more people tend to die this way.

Lots of things make sense but aren't true.


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## Bullets (Feb 27, 2014)

The answer to this:


Brandon O said:


> Eventually, the next step in any algorithm is "failed? well... keep trying until they're dead." But you want to make space before you hit that point.
> 
> With due respect, I'm not sure how understandable this is for the medics. Managing a difficult airway with nothing but a BVM and your wits is a uniquely BLS experience. Our typical airway algorithm is "1. BVM with OPA -- if failed --> 2. Soil self, call ALS, run screaming"



Is this:


mycrofft said:


> BVM with OPA -- if failed --> start compressions because you spent to much time on airway and failed .


and also this:


broken stretcher said:


> throw them on a NRB. Effective CPR is your first priority.



My mouth will never ever ever ever ever ever touch a patients face, nor will it come within a few inches required to use a pocket mask. I used to carry a pocket mask in my patrol bag, i have since thrown it away. BVM is the only means by which i will attempt ventilation.

Why would i ever be alone in a cardiac arrest? Where is my partner?


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## Brandon O (Feb 27, 2014)

Bullets said:


> My mouth will never ever ever ever ever ever touch a patients face, nor will it come within a few inches required to use a pocket mask. I used to carry a pocket mask in my patrol bag, i have since thrown it away. BVM is the only means by which i will attempt ventilation.



Right on -- but I hope you're very good at using it and you know alllll the tricks.



> Why would i ever be alone in a cardiac arrest? Where is my partner?



Perhaps you won't be, and your airway plan always presumes extra hands available. That's okay if it reflects your own circumstances. (I wasn't really talking about cardiac arrest though, since airway management isn't usually the priority there.)


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## Household6 (Feb 27, 2014)

Bullets said:


> Why would i ever be alone in a cardiac arrest? Where is my partner?



I have been, twice in the last month, and collectively more times than I can count.. 

Our service had us on-duty for 12 hours, and on-call for the next 12. We can leave the station when we're on-call, but we have to maintain an 8 minute response back to the garage.. Often, it's quicker for us to just show up on scene, and radio the on-call to meet us there. 

It actually works pretty good. The on-call personnel are scattered around town, first responders are scattered around the rural areas.


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## Carlos Danger (Feb 27, 2014)

Brandon O said:


> Managing a difficult airway with nothing but a BVM and your wits is a uniquely BLS experience. Our typical airway algorithm is "1. BVM with OPA -- if failed --> 2. Soil self, call ALS, run screaming"



This is exactly why I feel very strongly that every BLS provider should be trained on and carry a SGA of some type.

In a _perfect world_, we would all be very adept at all that BLS airway management requires: positioning, suctioning, maintaining a mask seal, placing NPA's and OPA's, generating adequate pressure, but not too much, etc.

In the _real world_ though, we don't get to practice it nearly enough. And it's not a level of care thing at all, because paramedics, on the whole, are no better at it than EMT's. 

SGA's provide an effective, safe, much-needed, rather easy-to-use tool. I cannot fathom why any medical director would not support his BLS personnel using them.


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## Handsome Robb (Feb 27, 2014)

mycrofft said:


> Quote:
> Originally Posted by mycrofft View Post
> There's a shelf life for respiratory etiology codes after which you're doing CPR because the heart isn't going to restart otherwise. However...
> 
> ...



compressions are an integral part of CPR...and CCR. There's no question about that. However, cardiocerebral resuscitation is designed for arrests with a cardiac etiology where compressions and defibrillation are the only proven things to make any difference. With a respiratory etiology you can pump away on the chest all you want with perfect compressions but if you don't optimize ventilation and oxygenation to correct the hypoxia, which caused the cardiac irritability and eventually cardiac arrest, you're signing that patient's death warrant.


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## Brandon O (Feb 27, 2014)

Halothane said:


> SGA's provide an effective, safe, much-needed, rather easy-to-use tool. I cannot fathom why any medical director would not support his BLS personnel using them.



No real arguments here. It's not elegant to use them as a substitute for imperfect bagging, but it's better than no alternative at all.


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## Carlos Danger (Feb 27, 2014)

Brandon O said:


> No real arguments here. It's not elegant to use them as a substitute for imperfect bagging, but it's better than no alternative at all.



Not elegant or ideal, for sure. But far better than the algorithm you described that most BLS providers are limited to.


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## mycrofft (Feb 28, 2014)

Robb said:


> compressions are an integral part of CPR...and CCR. There's no question about that. However, cardiocerebral resuscitation is designed for arrests with a cardiac etiology where compressions and defibrillation are the only proven things to make any difference. With a respiratory etiology you can pump away on the chest all you want with perfect compressions but if you don't optimize ventilation and oxygenation to correct the hypoxia, which caused the cardiac irritability and eventually cardiac arrest, you're signing that patient's death warrant
> .



Agreed!!
==============================================

Brandon O:

Quote:
Originally Posted by mycrofft View Post 
I nominate a change in CPR training: No pulse and no breathing, full CPR. (Radical, right?). 

Research suggests more people tend to die this way.

Lots of things make sense but aren't true. 

Please cite one. I bet there are, but I bet we can deconstruct them. Too many armchair people trying to make their living and maybe get some notoriety by publishing stuff or getting onto a bandwagon and making citations which only support their premise.

Hands-only is to spark bystanders to DO something that short window when CPR may make a difference, instead of grossing out and turning away. Just like spineboarding in the Seventies and Eighties, hands-only may get a life of its own without anyone to tell them the emperor has no clothes.

But, we digress.


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## Brandon O (Feb 28, 2014)

mycrofft said:


> Please cite one. I bet there are, but I bet we can deconstruct them.



Here's a few.

http://www.ncbi.nlm.nih.gov/pubmed/18374452
http://www.ncbi.nlm.nih.gov/pubmed/18334691
http://jama.jamanetwork.com/article.aspx?articleid=186668


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## mycrofft (Feb 28, 2014)

Thanks sir!


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