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RocketMedic

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I had my first one *ever* today, pretty psyched, but I made a few mistakes.
1. I tunnel-visioned. My FTO said he needed to see me tube, which I then missed. Not good. (As an aside, I'm having a tough time finding initial anatomy/landmarks, and I'm having an even harder time aligning axis. Any tips?
2. As a direct result of tunnel vision, my scene control sucked sort of- fire did a great job on compressions, but I should have asked my partner to get either the tube or the IO instead of me trying both.
3. Patient kept converting from perfusing rhythms to VF/VT and back with defibrillation, and thus my medication times are odd. I'm sure eyebrows will be raised.
4. Defibrillations were good and aggressive, with 8 defibrillations in all, with 210mg amiodarone total and only 1 epi. I'm fairly certain that the epi didn't mean a thing, but the amiodarone *may* have helped.

Sustains: IO access, great compressions by fire, good ventilations, and aggressive electrical therapy.
Improves: Better intubation technique- be more aggressive with moving the patient's head/body to align axis.
2. Delegation.
I'm sure there's an argument for timely medication in there, but I don't think that medication influenced this one way or another as-is, and I don't know if we would have had similar results with epi. With our patient's constant changes in perfusion and rearrests, I was reluctant to start with the epi cascade.

All in all, I think the credit should go to the BLS fire guys. Great compressions and Edison did the miracle-working on this one.

Now I just have to hope I pass my internship...patient is apparently still alive and talking as of EoS.
 
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Well don't feel bad I have trouble with delegating tasks and not bring aggressive enough. However I am still a medic student, I am hoping to get hired on with a local EMS agency as a basic I'll know Friday, and hoping that will help me. Keep at it!!!
 
Oh and on my first code I went on in the field I pulled out and used a NRB, on the pt instead of a bvm, my though process was pt needed O2, I was doing compressions, one preceptor was hooking up monitor/defib, and getting intubation equipment ready, other one was getting meds, and FD hadn't arrive on scene yet, so the NRB made since at the time
 
Pt. was talking? Not bad at all.

Ultimately, it takes practice to get things "right" on codes. I think simulation can help with prioritizing what you're going to do and coordinating it. It's really easy for codes to be worked haphazardly, which is why this whole "pit crew" thing (aka good CPR) is becoming so popular.

Learn to intubate during compressions if you're going to intubate. To get good alignment, you will usually need to raise the occiput. Towels, pillow, or saline bag will work (hell, I knew of a medic that'd use a box of D50). NEVER forget bimanual manipulation (https://www.youtube.com/watch?v=LgSrtspeONg). If the compressor's hands are hindering smooth insertion of the blade because the handle hits their hands, wait for a rhythm check to place the blade.

Don't forget EJs. Even if you go for an IO early, it is my opinion that an IV should still be sought. You need the practice and also fluids will move much quicker through an IV.
 
Pt. was talking? Not bad at all.

Ultimately, it takes practice to get things "right" on codes. I think simulation can help with prioritizing what you're going to do and coordinating it. It's really easy for codes to be worked haphazardly, which is why this whole "pit crew" thing (aka good CPR) is becoming so popular.

Learn to intubate during compressions if you're going to intubate. To get good alignment, you will usually need to raise the occiput. Towels, pillow, or saline bag will work (hell, I knew of a medic that'd use a box of D50). NEVER forget bimanual manipulation (https://www.youtube.com/watch?v=LgSrtspeONg). If the compressor's hands are hindering smooth insertion of the blade because the handle hits their hands, wait for a rhythm check to place the blade.

Don't forget EJs. Even if you go for an IO early, it is my opinion that an IV should still be sought. You need the practice and also fluids will move much quicker through an IV.

I like using an HID to prop the head... At least it is useful for something
 
I'm lucky in that we always have 2 medics. I like to camp out by the feet with the monitor turned toward me. I drill an IO, can watch the monitor and push drugs. My partner can manage the airway and the Lucas. That helps to keep things smooth.
 
Oh and on my first code I went on in the field I pulled out and used a NRB, on the pt instead of a bvm, my though process was pt needed O2, I was doing compressions, one preceptor was hooking up monitor/defib, and getting intubation equipment ready, other one was getting meds, and FD hadn't arrive on scene yet, so the NRB made since at the time

Some services, mainly in AZ are starting to use passive ventilation during cardiac arrest calls w/ vasopressin. So far it's been working pretty well...AZ has about a 40% prehospital cardiac survival rate compared to the national 10%.
 
Oh and on my first code I went on in the field I pulled out and used a NRB, on the pt instead of a bvm, my though process was pt needed O2, I was doing compressions, one preceptor was hooking up monitor/defib, and getting intubation equipment ready, other one was getting meds, and FD hadn't arrive on scene yet, so the NRB made since at the time

Believe it or not putting a nrb on an arrest patient and leaving them without a secured airway is becoming the new thing to do.

The negative pressure in the thoracic cavity created by chest compressions in combination with an OPA and NRB are enough to cause "passive" ventilation.

Here is a study showing improved outcomes over positive pressure ventilation. I believe this study is why some services are moving to this method.

http://www.azdhs.gov/azshare/documents/Passive Oxygen Insufflation is Superior.pdf

And congrats to the OP for the save, sounds like you did pretty good.
 
Pt. was talking? Not bad at all.

Ultimately, it takes practice to get things "right" on codes. I think simulation can help with prioritizing what you're going to do and coordinating it. It's really easy for codes to be worked haphazardly, which is why this whole "pit crew" thing (aka good CPR) is becoming so popular.

Learn to intubate during compressions if you're going to intubate. To get good alignment, you will usually need to raise the occiput. Towels, pillow, or saline bag will work (hell, I knew of a medic that'd use a box of D50). NEVER forget bimanual manipulation (https://www.youtube.com/watch?v=LgSrtspeONg). If the compressor's hands are hindering smooth insertion of the blade because the handle hits their hands, wait for a rhythm check to place the blade.

Don't forget EJs. Even if you go for an IO early, it is my opinion that an IV should still be sought. You need the practice and also fluids will move much quicker through an IV.

Fact,

and drips are sure hard to properly calculate through an IO without a pump
 
Believe it or not putting a nrb on an arrest patient and leaving them without a secured airway is becoming the new thing to do.

The negative pressure in the thoracic cavity created by chest compressions in combination with an OPA and NRB are enough to cause "passive" ventilation.

Here is a study showing improved outcomes over positive pressure ventilation. I believe this study is why some services are moving to this method.

http://www.azdhs.gov/azshare/documents/Passive Oxygen Insufflation is Superior.pdf

And congrats to the OP for the save, sounds like you did pretty good.

That's what the FTO riding in place of my preceptor that day told the other medic who was about to rip me a new one lol.
 
Strong work, it is a great feeling isn't it?

Advise for the tube?

Relax and be calm. Many times when people are new or new at an agency and are under scrutiny their skills degrade a bit. Let it go or your next tube will be worse.

Otherwise, think of it like sniping. Take a breath, tak your time, get the best position, pull the trigger when you decide, do not be forced until you are ready.

If all you see is a big black hole, the is the esophagus.

I have found that if I take my time setting up the intubation equipment and assessing the difficulty of the airway, it takes a little bit of the edge off. Sort of like taking a minute to walk to the truck before driving lights and sirens.

Scene control.

I can recall the number of times I had a second paramedic working a code when I was on a truck. (it wasso few) I got into the role of being the one- man-band and still haven't gotten out of it. (drives the nurses crazy)

Delegation comes with comfort. one of the hardest things to do is to step back and let other people do things you know you can do. Especially if you know you are good at it.

It is better to not delegate and get the job done than to be able to delegate and not do the job. Consider it a minor point.

I also have noticed "lack of delegation" is a common thing to say when there is nothing to say. An experienced team member can look at any situation and step in where needed, they don't have to be told what to do. They don't even have to ask what has been done. It is obvious.

With a few more codes, you will be on the internet telling people to calm down.

I had my first one *ever* today, pretty psyched, but I made a few mistakes.
1. I tunnel-visioned. My FTO said he needed to see me tube, which I then missed. Not good. (As an aside, I'm having a tough time finding initial anatomy/landmarks, and I'm having an even harder time aligning axis. Any tips?
2. As a direct result of tunnel vision, my scene control sucked sort of- fire did a great job on compressions, but I should have asked my partner to get either the tube or the IO instead of me trying both.
3. Patient kept converting from perfusing rhythms to VF/VT and back with defibrillation, and thus my medication times are odd. I'm sure eyebrows will be raised.
4. Defibrillations were good and aggressive, with 8 defibrillations in all, with 210mg amiodarone total and only 1 epi. I'm fairly certain that the epi didn't mean a thing, but the amiodarone *may* have helped.

Sustains: IO access, great compressions by fire, good ventilations, and aggressive electrical therapy.
Improves: Better intubation technique- be more aggressive with moving the patient's head/body to align axis.
2. Delegation.
I'm sure there's an argument for timely medication in there, but I don't think that medication influenced this one way or another as-is, and I don't know if we would have had similar results with epi. With our patient's constant changes in perfusion and rearrests, I was reluctant to start with the epi cascade.

All in all, I think the credit should go to the BLS fire guys. Great compressions and Edison did the miracle-working on this one.

Now I just have to hope I pass my internship...patient is apparently still alive and talking as of EoS.
 
To the OP, engaging in that sort of self-critique is almost as impressive as your save. Sounds to me like you've already passed your internship.
 
2. Delegation.

I think delegation is an issue that everyone has, even when they have a lot of experience. I still have issues telling people what to do without feeling like I'm a freight train running everyone over.
 
in a town near me, the town protocol is to work the code on scene for 30 mins maximum. if patient makes no improvement on scene in those 30 mins, it is a no transport- pt is dead. that has raised their survival rates quite a bit!
 
Congrats on the save Rocket! That's awesome, good on ya! I was part of one when I was working as an Intermediate a couple shifts before my medic FTO started. It's crazy to talk to someone who you were doing CPR on a couple days before. Cool feeling.

Delegation is tough, I still haven't figured it out. Like Aidey said, I feel like I'm being an *** telling people to do stuff while I stand around, especially being one of, if not the youngest person on scene.

Sounds like things are going better at the new gig!


Oh and on my first code I went on in the field I pulled out and used a NRB, on the pt instead of a bvm, my though process was pt needed O2, I was doing compressions, one preceptor was hooking up monitor/defib, and getting intubation equipment ready, other one was getting meds, and FD hadn't arrive on scene yet, so the NRB made since at the time

Google "Cardiocerebral Resuscitation". Like others said, it's becoming more common but like everything it has indications and contraindications.
 
I had my first one *ever* today...

Well done.

1. I tunnel-visioned. My FTO said he needed to see me tube, which I then missed. Not good. (As an aside, I'm having a tough time finding initial anatomy/landmarks, and I'm having an even harder time aligning axis. Any tips?

Airwaycam.com. Learn it. Know it. Love it.

I already heard the call for bimanual laryngoscopy (i.e. external laryngeal manipulation by you) and head elevation.

I can't stress enough to ensure you raise the head to put the external auditory meatus and the sternal notch in line.

Try not to be an intimate intubator, give yourself some room for your vision to work as designed.

Make intubation a search for the epiglottis and not a search for the glottic opening.

I talk down through the mouth as I go--yep, everyone stares--"lips, teeth, tongue, uvula, you know the floppy punching bag thing, tip of the epiglottis..."

Once you find it, you now position the tip of your blade such that you maximize control over it. Gently advance via rotation. This is where you'll use ELM.

When you have maximal control, e.g. you can make the epiglottis wave, start your lifting in search of the aretynoids. Now if your worst case is a POGO of 0%, it shouldn't matter. You have your superior and inferior (really anterior and posterior) borders of your target. A properly shaped tube or a bougie will solve the problem from there.
 
Make intubation a search for the epiglottis and not a search for the glottic opening.

I personally think this is a key point and something that helped me when I was first learning.

With new interns learning to intubate I commonly see a rush to insert the scope and just hunt around for the vocal cords.

I remember being absolute horrible with my first several intubations and felt like I just couldn't get the hang of it. I then took a step back and re-evaluated my technique, slowed down a bit, and went step by step like was mentioned above identifying the anatomy as I went. For me once the epiglottis flopped down into the picture I was good, from there I knew where everything was and just had to make a few small adjustments to view the cords.
 
Congrats on the save Rocket! That's awesome, good on ya! I was part of one when I was working as an Intermediate a couple shifts before my medic FTO started. It's crazy to talk to someone who you were doing CPR on a couple days before. Cool feeling.

Delegation is tough, I still haven't figured it out. Like Aidey said, I feel like I'm being an *** telling people to do stuff while I stand around, especially being one of, if not the youngest person on scene.

Sounds like things are going better at the new gig!

-Yep, mostly better. It's not a career place, but I like it. There's a lot of calls, and a lot of experience to be had.
 
To the OP, engaging in that sort of self-critique is almost as impressive as your save. Sounds to me like you've already passed your internship.

Today was my last "FTO" day, ghost ride is Monday, then we finish out the week driving. The important part's done.

EDIT: Patient's still alive too, reportedly being discharged soon.
 
Congrats on the save. It's a nice feeling knowing you made a difference.

Delegation will come with time. We do the CCR broken down into 2 minute increments of tasks. The other night FD was doing compressions, bagging etc so I had nothing to do but start the IO, push meds then intubate. It was really odd to sit and watch most of the time.

Put everybody onscene on a task and codes are easy.
 
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