Did I cause barotrauma to a pt?

[DragonClaw]

Okay well I'm a little freaking out right now.

I .. I was thinking about that call where the DOA was worked and that's the first field code I've worked.

80+ YOM with unknown down time, I think they're was blood somewhere, he might have fallen due to something medical or maybe just balance and old people falling.

We get there and his wife with dementia is losing is. She's shrieking and wailing. She found him down but went to the neighbor after an undetermined amount of time who had to figure out why she was freaking out. He went and found the husband and called 911.

They were doing compressions when we got there, LE too over. We had a medic, advanced, me, a flycar of firemen , several LE, a medic sup.

We got him switched over to the LUCAS and moved to the truck ASAP. We put defib pads on him before moving him and he was asystole.

They intubated him so fast, I didn't even see. Like I saw them getting the mc grath and was spiking a bag or something. Er, no I was setting up the 4 and then maybe 12. I look back and he's already got the tube tamer and he's being bagged.

But everything happened so fast. I know there's a lot to do, so I need to take over the BLS skills ASAP to free up ALS. They get the capno test. They're dropping lines and I'm getting the epi ready. We used 2 epi, a bicarb.

I take over for the sup on bagging and we roll out pretty quickly.

I don't remember if there was head trauma to the pt.

I'm not lost in the sauce but I'm pretty like...overwhelmed. not to the point I'm not doing anything but that there's just a lot going on. I just do my tasks as quickly and efficiently as I can, and do it correctly. I ask about how to set up the epi because I've never used the Luer jet.

I'm every so slightly shaky as all this is going on, but I'm able to focus and keep my fine motor function.

I'm bagging at the correct rate, but now I'm really wondering if I did the right depth. There was a PEEP, but like, at one point blood starts coming up the tube and I've got to suction.

I've never had to do any of this before. It was interesting, but I didn't have time to really think on it. I had to get the suction ready and do it myself because the medic was on the other side of the truck.

I was really worried about bagging wrong, but even though the waveform was Shark fins, looked like it to me anyway, the medic said that was expected. I've only bagged once before and that was on a respiratory arrest who I dropped an igel in and she started breathing again after a bit.

But there was quite a bit of blood in the tube and after I suctioned once, it seemed to clear things right up. I continued bagging and then it came back. Suction. And again.

I asked the medic if this might be from a PE. She said maybe, but couldn't be sure.

We got to the hospital and he still had blood in the tube, but we were going in.

They called it soon after.

I let most of it go, just not as freaked out as I thought. Kind of rolling with the punches.

A few minutes ago I was thinking of it and the blood and even with a PEEP did I cause barotrauma? Did I blow a lobe or something? I didn't notice a change in compliance or a difference in chest rise/falk, but did I bag wrong?

They said I did decently, but what if they're just not wanting to put that on me because I'm new and gave it my best?

I think they're professional enough to tell me if I did, but I guess I'm just going over it in my head now and did I hurt this pt? I know he was dead and asystole the whole time, there was a next to nothing chance of getting him back, but even so, did I do that to him?

 

[GMCmedic]

Blood is a byproduct of CPR.

 

[DragonClaw]

Blood is a byproduct of CPR.

Oh. I thought I like ****ed up big time

 

[Akulahawk]

One of the problems with CPR is that it causes a LOT of trauma to the chest. It's not a benign treatment, though it's difficult to make someone more dead when they're already dead. Because of that chest trauma that's being caused by the CPR, you can burst capillaries in the lungs and you can then get blood coming back up the tube. Circulation isn't all that good so you could also have (effectively) a CHF-like situation develop resulting in high pressure developing in the pulmonary circuit and you could have the edema products coming up the tube. Either way, once you're doing CPR, the chances of recovery (if ROSC doesn't happen VERY SOON) is pretty darned low.

I had a patient tonight that passed on and while we did achieve ROSC, it didn't last long. We had blood coming back up the tube too. You very likely didn't do anything wrong at all. You'll remember this one because it's your first. It won't be your last. The next code you work, remember that while things need to be done quickly, you don't have to rush. Slow down, observe the scene, get going on your assignment and calmly do your work while paying attention to what's going on around you. It's absolutely OK to think back about what you did (or didn't do) and try to figure out what you could have done better. Then next time, try to implement those things you thought about or discussed with your FTO or partner(s) and do better. I have already done some reflection about my role in my code tonight and I have some ideas about how to improve upon my own practice, hopefully I'll be able to implement them the next code I'm involved in.

And before I forget: your first few codes will likely be a blur of activity until your brain settles down and starts taking it all in and allows you to do things smoothly at the same time.

 

[DragonClaw]

One of the problems with CPR is that it causes a LOT of trauma to the chest. It's not a benign treatment, though it's difficult to make someone more dead when they're already dead. Because of that chest trauma that's being caused by the CPR, you can burst capillaries in the lungs and you can then get blood coming back up the tube. Circulation isn't all that good so you could also have (effectively) a CHF-like situation develop resulting in high pressure developing in the pulmonary circuit and you could have the edema products coming up the tube. Either way, once you're doing CPR, the chances of recovery (if ROSC doesn't happen VERY SOON) is pretty darned low.

I had a patient tonight that passed on and while we did achieve ROSC, it didn't last long. We had blood coming back up the tube too. You very likely didn't do anything wrong at all. You'll remember this one because it's your first. It won't be your last. The next code you work, remember that while things need to be done quickly, you don't have to rush. Slow down, observe the scene, get going on your assignment and calmly do your work while paying attention to what's going on around you. It's absolutely OK to think back about what you did (or didn't do) and try to figure out what you could have done better. Then next time, try to implement those things you thought about or discussed with your FTO or partner(s) and do better. I have already done some reflection about my role in my code tonight and I have some ideas about how to improve upon my own practice, hopefully I'll be able to implement them the next code I'm involved in.

And before I forget: your first few codes will likely be a blur of activity until your brain settles down and starts taking it all in and allows you to do things smoothly at the same time.

I know CPR was rough, especiallyon old people, and ribs, like any bones bled, but I guess I really wasn't expecting the Red Gushing ET Tube of Panic.

I know he had a snowball's chance, I just thought I pulled out the oxy-acetylene torch instead of a some ice.

I got a little more shaky and tachy as time went on, but I forgot to do my "Tactical Breathing" that supposed to cause a Vagal response and get you to calm down. It works for me when I remember.

If there a PEEP, what's the chances of hyperinflating the lungs? How hard or how much would you have to squeeze? Or is that variable based on pt normal tidal volume?

Then you for the time to write the long reply. I appreciate it.

 

[silver]

I know CPR was rough, especiallyon old people, and ribs, like any bones bled, but I guess I really wasn't expecting the Red Gushing ET Tube of Panic.

I know he had a snowball's chance, I just thought I pulled out the oxy-acetylene torch instead of a some ice.

I got a little more shaky and tachy as time went on, but I forgot to do my "Tactical Breathing" that supposed to cause a Vagal response and get you to calm down. It works for me when I remember.

If there a PEEP, what's the chances of hyperinflating the lungs? How hard or how much would you have to squeeze? Or is that variable based on pt normal tidal volume?

Then you for the time to write the long reply. I appreciate it.

This all depends on the patient's compliance and resistance with each breath. Many BVMs have pressure gauges on them. Would recommend when you see one to take a look at the pressure gauge as you give a breath to get a good understanding of the feel and associated pressure.

 

[DragonClaw]

This all depends on the patient's compliance and resistance with each breath. Many BVMs have pressure gauges on them. Would recommend when you see one to take a look at the pressure gauge as you give a breath to get a good understanding of the feel and associated pressure.

I mean, I didn't notice any major change in compliance. Maybe a little something but not like that feeling when you've intubated into only one lung (the training dummy at least)

 

[VentMonkey]

On viable patients, with the potential for suitable neurological outcomes, this would be an example of my opinion on properly training (ALS) providers on basic ventilator management, as well as outfitting their rigs with them.

 

[DragonClaw]

On viable patients, with the potential for suitable neurological outcomes, this would be an example of my opinion on properly training (ALS) providers on basic ventilator management, as well as outfitting their rigs with them.

Yeah, I wish we had vents

 

[DragonClaw]

On viable patients, with the potential for suitable neurological outcomes, this would be an example of my opinion on properly training (ALS) providers on basic ventilator management, as well as outfitting their rigs with them.

Also. Username checks out

 

[SandpitMedic]

Lol. Read the first paragraph and thought- no. That’s a lot of words for something that had about <1% chance.

 

[DragonClaw]

Lol. Read the first paragraph and thought- no. That’s a lot of words for something that had about <1% chance.

I mean, they made it a big deal in school and on the truck not to hyperinflate their lungs.

 

[DrParasite]

I mean, they made it a big deal in school and on the truck not to hyperinflate their lungs.

back in the day, we used to squeeze all of the adult bag out when ventilating the patient. if you had small hands, you could press it against your thigh. While I totally agree, don't hyper inflate the lungs, I wouldn't stress it too much; IIRC, if you do squeeze too much air into the mouth, it tends to go somewhere (usually the stomach, which leads to gastric distention, which can cause a huge mess)

It's not a benign treatment, though it's difficult to make someone more dead when they're already dead...Either way, once you're doing CPR, the chances of recovery (if ROSC doesn't happen VERY SOON) is pretty darned low.

exactly. it's difficult to make someone much worse than dead. I'll take it one step further: you likely did cause barotrauma to the patient, but it had zero impact on the patient's condition. as was previously mentioned, CPR causes a lot of trauma to the body, but when the alternative is death, well, you do what you can. Don't stress it.

Just going by the description provided, I'm surprised they transported the patient at all. asystole, unknown downtime, oldish, I would think they would work him there, and if they don't see any improvements (ETco2 between 35 and 45, shockable rythym, or some other fixable H or T, etc), call it right there.

on my first arrest when I was the lead on, old person, unknown downtime, in a SNF, the paramedic crew wanted to prounouce, so we packed up our stuff and left... only to be called back 5 minutes later, because the doc wouldn't let them pronounce, so we worked this dead body for 20 minutes until he was pronounced 2 minutes after we made it to the ER.

things will run smoother for you the more you do it. don't stress it.

 

[RedBlanketRunner]

While I totally agree, don't hyper inflate the lungs, I wouldn't stress it too much; IIRC, if you do squeeze too much air into the mouth, it tends to go somewhere (usually the stomach, which leads to gastric distention, which can cause a huge mess)

it's difficult to make someone much worse than dead. I'll take it one step further: you likely did cause barotrauma to the patient, but it had zero impact on the patient's condition. as was previously mentioned, CPR causes a lot of trauma to the body, but when the alternative is death, well, you do what you can. Don't stress it.

Words of wisdom and experience.

We had a new EMT on the chest bringing in the patient. ER sup took one glance at the compressions and bumped her. Her first blue, feeling like she was responsible the code was called. Took a lot of pep talks but she came around.

Bottom line as others have said, your patient is already dead. Take your best shot, pay attention, and learn.

PS And it can't be said enough, pay attention to your patient! Don't just lock in on the motions. Looking el preggo means you might be about to get their last meal in your face. The extremities for twitching. Eyes. Face color. Effective CPR can pink up anyone except some aneurysms, even if they are long gone. And BTW, some venous blood is no big deal. People leak, especially the elderly. And bleeding indicates your compressions are working.

 

[dutemplar]

Contrary to TV, most codes arent successful. CPR breaks bones and contuses stuff inside. Bagging patients while CPR is being done does cause damage to the lungs.. But, not doing that and dead is dead and not just "mostly dead."

Decades ago, we had a frequent flier. Woman who would brady down and pass out. Towards the end, we saw her at least once a month. Usually it was super easy, just shout and that frequently got her perky. Other times a bit of atropine and she's perky, fine, goes to the hospital and gets sent back home fast. I dont remember what the underlying problem was, or why they never dropped a pacemaker. Well, our last visit she did pass out, but she had taken the ultimate brady challenge. Husband was all "just fix her up like you always do." Well,... a few seconds later there was a very broken voice from the other side of the room saying "Maybe I shouldn't be here anymore." He passed away maybe a month later. I can still hear his voice though...