# To bag or not to bag?!?!?!?!



## trauma1534 (Jan 19, 2006)

Hello again!   I thought you may enjoy another call I recently ran.  What would you do?

This past weekend, we recieved a call to a local nursing home "unresponsive patient after seizure like activity".

Upon our arrival, found a 78 year old female patient lying in bed, eyes rolled back in her head, upper extremities shaking, resp. 38, shallow, B/P 210/p, HR 100.  02 sats:  84 on 15lpm/nrb.  We got her loaded into the truck, got in route,  we started to notice her lips and finger tips turning blue.  She is at this point comming around and getting combative, altered loc's.  The husband and nurse stated that none of this was normal for the patient.  We then started to bag her.  Oh yeah... her lungs were clear, but she was breathing shallow and not moving much air.  So we're bagging right along by now, and my partner tells me to drop a nasal airway in her...I did.. finally her sats came up to 99%.  Upon arrival at the ER, the doctor tells us to stop bagging so that he can get a room air 02 sat.  She maintains at 99%.  He pulls the Npa,She goes home two hours latter,, they never found anything wrong with her.  Her color had return about 5 min. out from the hospital.  Talk about feeling stupid when we got her there... and more stupid when she was released... but the question is...
WHAT WOULD YOU DO?  
Do you agree with what we did, why or why not?
What would be the alternate plan of action/  Why?

Have fun!


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## ffemt8978 (Jan 19, 2006)

I would have done the same thing you did, except maybe put the NPA in sooner.

Other than that, I can't see where you could have done anything different.  After all, we're supposed to treat what we see and if it means the patient is better by the time we get them to the hospital then we did our job.


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## TTLWHKR (Jan 19, 2006)

Why feel stupid?

Patient recovery and release is the whole ball game.

The ER see's it one way, you see it through how you have been taught. You did what any other tech, in their right mind would have done.

Consider the patient is in the condition due to Hypoxia, with proper documentation of how you found the patient, what you witnessed, and what you did to treat/correct the findings.. There is no question that the treatment may have saved the patients life.  

I probably would have started a line, KVO, begged the OMC and kissed his *** to give a little valium to calm the patient, have my partner place a nasal with Lido Jelly and bag. If the rapid resps weren't the problem, I'd go w/ the CPAP. Of course all the other stuff, monitor, bglc, labs, etc.. But I don't feel like getting that indepth. 

Now we have a new system... I call it "A-ALS for ALS" Advanced ALS for ALS. We have NREMT-P/PHRN's now, which we can call on to assist ALS. Too confusing. Thier rig is like a helicopter with wheels, critical care equipment, etc. Of course we only have one, and I'm not sure of their schedule.


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## Recruiting (Jan 19, 2006)

Past med History, Meds?, Allergies??? Confined to bed? What was her baseline AOX3?, warm and dry? Diaphertic? I know it's tough to remember EVERY darn call and the details but it would help out a bit 

Alright, she was in a Nursing home (did they give her something just before this happened, med's or food?) Allergic reaction. What did her airway look like? any swelling?

She was a hypoxic, cyanotic, nursing home pt. She was not having a Seizure but Seizure type movement, could it have been a purposeful type movement, thrashing maybe?  The patient became combative after the "Sz like activity" Postictal maybe? How long did the SZ like activity take place, what made you think it was not a Sz? Was it because the staff said this was "not like her"? Was it a Seizure?

I agree with TTLWHKR on his treatment. BUT I don't think MC would have had a problem with the Vailum at all.. 

For me I think she was seizing, history or not. All patient histories start somewhere, aye 

With out the pt's hist, meds & allergies this is where I go with it.

You said here the the pt had Sz type activity (duration??) then she became cyanotic/hypoxic you placed a nasal airway & Bagged her, then soon after she  became combative the then came out of it (where? Amb, Hosp?) what was her mental status when she was calming down? Did she know her name or where she was? Did she know what happened?

AIRWAY, drop the Nasal Airway, Ambu if needed otherwise HIFLO O2 via NRM, EKG, IV, Bag "O" Ringers-TKO, Valium (Maybe, you did not say how long the pt was having Sz activity), check GLY, whack with Dex if needed, recovery position call the Doc on the way.. :beerchug:

Your treatment was fine as well. You treated what you saw.. never say you feel stupid for saving someone life which is exactly what you did


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## emtff376 (Jan 19, 2006)

As a BLS provider, I would have done what you did.  I may have called for a medic intercept, since our tx time is so long.

I wouldn't feel stupid at all because nothing I did resulted in further harm to the pt.


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## SmokinGun911 (Jan 19, 2006)

*'CURIOUS', perhaps. 'STOOPID', no. With the rate and quality of respirations along with cyanosis? What are we taught to do as BLS providers?

You got your pt to the hospital. You did your job and did it properly. Go home and have a beer.*


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## Recruiting (Jan 19, 2006)

Is Trauma1534 a BLS or ALS provider? From an old post it would appear he/she is ALS, but i dunno.

At any rate I am down for that Beer! :beerchug:


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## TTLWHKR (Jan 19, 2006)

Recruiting said:
			
		

> BUT I don't think MC would have had a problem with the Vailum at all..


 

Well, I wouldn't know until I obtained permission to administer per protocol.


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## trauma1534 (Jan 20, 2006)

I am ALS, and I did start an IV @ KVO, .9NSL.  We don't carry ringers.  Ran a strip, sinus rythem, slightly tacky at times, nothing major... only the HTN and 02 sats stuck out at me.  The duration of the episode was throughout the transport except for the last 5 min.  She started pinking up.  I have reason to believe that she was not having a SZ.  She never lost controle of herself.  She never did come to verbaly though.  She was just combative, cyanotic and just acting wierd!  Mumbling as her upper extremities trembled, or jerked.  She tried to fight everything we did.  I thought she would pull her line, but she didn't.  The reason I did not enclude the ALS skills is because I posted this in the BLS forum.  It was just a very strange call!


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## Recruiting (Jan 20, 2006)

Well now we know!  

That bit of "newly released" info would infact change the treatment, no.

That's why I asked for more info, just as in MM rounds (or online) this important information is needed to evaluate and treat a patient. 

I for one think it's great that TRAUMA takes the time to put some runs up here. I would only request a bit more info though.


* TTLWHKR:Well, I wouldn't know until I obtained permission to administer per protocol. * 

That's easy, Standing Orders .....h34r:


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## Ridryder911 (Jan 20, 2006)

I agree with your basic of increasing oxygenation. However what is her normal L.O.C. ? Is this patient with dementia, senility, normal combatitive as well, hx. of seizures ?.. I also agree withthe physicians treatment. If the patient is able to protect her airway, I probaly would pull the npa if she "grabbing" at things, and you do need to get a baseline room sats... 

If she as able to have sats maintain> 90-92%, I doubt then she could be dx. with room air hypoxia for admission. He probably found out that this was normal for the patient and had experienced some hypoxic episode wither related to either medication (behavior meds, anxiety, or even seizure med level down) appearantly didn't make the ciriteria for admission or PCP was aware of her condition and was not concerned of change. 

Be safe,
R/R 911


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## TTLWHKR (Jan 20, 2006)

Recruiting said:
			
		

> *TTLWHKR:Well, I wouldn't know until I obtained permission to administer per protocol. *
> 
> That's easy, Standing Orders .....h34r:


 

My protocol is: Call medical command. I believe that's what I said. Not hard to comprehend.

:angry:


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## Recruiting (Jan 20, 2006)

It appears all systems and providers are not created equal, that is a reality that I comprehend.


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## Stevo (Jan 20, 2006)

well this is true

especially of med control

in the mountain here out reception is inversley proportional to our need to communicate with them

~S~


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## Recruiting (Jan 20, 2006)

I can see where that could be a problem on a call up there.

Do your system use standing orders for situations like that? I find that SO come in quite handy.  


B)


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## Recruiting (Jan 20, 2006)

I can see where that could be a problem on a call up there.

Do your system use standing orders for situations like that? I find that SO come in quite handy.  

Apply appropriate protocol and standing order based on assessment, simple, 

It appears not all use them...

B)


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## nyc.ems (Jan 20, 2006)

never feel like you did something wrong....were out there trying to help with what we have presented.the hospital staff are not out there.maybe re-evaluate the pts. breathing after been combative,but bagging with that kind of r/r is standard protocols.good job


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## firegal920 (Jan 21, 2006)

I agree, you did the right thing. Airway, Breathing are always first. Another one saved by the "whackers".


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## coloradoemt (Jan 22, 2006)

firegal920 said:
			
		

> I agree, you did the right thing. Airway, Breathing are always first. Another one saved by the "whackers".


 
Ouch!!!! :unsure:


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## Jon (Jan 22, 2006)

BLS - I would have done the same as you.

Your quick actions probably saved the patient, and DEFINATLY saved the patient from deteroriating further... needing a vent, brain damage from hypoxia, etc..

My one Med. Command doc is of the opionion that we, as field providers, have it easy - we can diagnose and treat very quickly. He wants to see medics agressivly managing pain, and also giving IM steroids for moderate asthma (to stop the asthma attack, so it dosen't get any worse).... very good guy.


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## EMTK005 (Jan 23, 2006)

I'd say based on the given information you are right on. Resp. rate above 30 definately qualifies as inadequate respirations and warrants a BVM. However, we all need to remember to be careful to treat the patient and not the machine. Even if the SpO2 reads 84%, look at the patient, their color, general appearance, etc. I've had perfectly healthy, non resp-distress pt's who's sat has been read on the maching as 80%....not likely.


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## TTLWHKR (Jan 23, 2006)

EMTK005 said:
			
		

> Even if the SpO2 reads 84%, look at the patient, their color,


 


> lips and finger tips turning blue


 
Pretty good indication that the machine is correct.


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## Ecnalubma (Jan 31, 2006)

trauma1534 said:
			
		

> She was just combative, cyanotic and just acting wierd!  Mumbling as her upper extremities trembled, or jerked.  She tried to fight everything we did.



Sounds like hypoxia to me. As far as bagging a pt with tachypnea and low O2 sats, you did the right thing.


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