Full Arrest

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emtwacker710

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ok, we were hanging out at the FD after a call on saturday night (4/20/08) and we are dispatched with the squad for a P1 ALS response to the ******* nursing home 87 y/o female full arrest, CPR is in progress, (at exactly 2300)(witnessed arrest we found out upon arrival) we jump in the rescue and respond on the scene 1 minute after dispatch, we grab our green bag, suction and AED, we get in there..our manpower consists of myself (EMT-Basic), 2 firefighters with no medical training at all, and another FF who used to be an EMT. Well there are 3 nurses present one bagging, the other doing compressions, and the other working with their AED, I get in there and take over compressions (at that time the ambulance is on the street) the ex-emt I tell her to suction as there is a very large amount of vomit coming up, I guess what I am really trying to say here with all the other useless info I provided is, I am pretty sure that the nurses were doing CPR wrong, I have ridden 5-6 other full arrests before and I have never seen that amount of vomit before and when the nurse was bagging you could hear resistance and the stomach was rising a bit, what my main concer is...I'm not entirely sure the air was going to the lungs.....what do you guys think??

(sorry about all the other most likly useless background info)
 
I agree, the chest should be rising shouldn't it? Do the FF"s have CPR training if so i would have had 1 of them take over breaths.
 
If the patient was aspirating, air was probably not going into the lungs. Vomit is not a sign CPR is being done wrong. Not maintaining an airway is wrong. Removing vomit with suctioning and using an OPA, NPA and preferrly intubating a patient is necessary. Of course intubating is probably out of the scope of nurses and EMT-Bs.
 
This is a common problem with hyperventilation and overventilation. Providers get excited during these situations and what you see is providers squeezing the bag as soon as it fills up with air, or you'll see people squeezing the entire bag into the patient - I was taught in my original EMT class that 800ml of air was the standard...we now know you want to ventilate enough to see chest rise. The lungs can only hold so much air; the remainder goes into the stomach. As the stomach fills up with air, it eventually has only one way to go - and the contents go with it. Sellicks maneuver will help tremendously with this problem while you're crew is bagging the patient.
 
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most patients need about 500cc of air per breath... most BVM's hold about 1600, so do the math...

at JEMS, laerdal had a simulator hooked up to measure peoples ventilations and compressions...

regarding the ventilations, they had a monitor, that displayed the optimal range, and basically the only way to be in that graphic range was to slowly and smoothly squeeze the bad with one hand... you won't empty the bag that way, but you don't need to...

they saw a high number of incidents of emt's just busting through that optimal range, and they knew what they were being evaluated for, so what do you think happens in the field...

yes, many post that CPR is taught and performed correctly, and there are no problems...

makes me say, hmmm....
 
as opposed to a half arrest?? three quarters arrest?

i bet they were doing it wrong. id also bet you've done it wrong. i can tell you ive done it wrong. everybody has. its a skill, like anything else. the more you practice it, the better you get at it. if you work one code a year; do you cpr class once every other year; your skills are going to suck too.
 
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well we had a limited amount of personel that were actually cool under pressure (the 4 of us that responded on the rescue) the nurses although trying to act professional were starting to freak out, they do not get full arrests there often and the nurses that are there have been at that home for a while, i did get an OPA in but her head kept moving around so that may have contributed to the lack of an airway, I was trying to keep my own guys (and girl) in check while also telling the BVM nurse to keep adjusting the pt.'s head...by the way I can't remember if I mentioned it in the 1st post but the pt. was worked on in the hospital for about 5-7 minutes then pronounced there...
 
Thank You! Exactly for painting the reason for ALS need on all emergency responses. Unfortunately, vomiting is a general occurrence for multiple reasons as stated and remember, AMI symptamology (nerve) is vomiting as well.

Yes, one can perform BVM and good airway control without air entering the esophagus. While being taught airway control, I had to work several codes before I was allowed to intubate, we had to demonstrate that we had mastered the basics first. So yes, it can be done. It takes lots of practice.. and I mean lots of practice, not five or ten or fifteen codes, but up to enough were one masters it.

It sounds like it was a cluster **** and glad I was not there, sorry for the patient. The patient deserved better care than that. I am sorry, I don't see any reason for an excuse of not placing and cleaning out an airway! Just because a group apparently does not know how to handle an emergency is not an valid excuse. Four rescuers and no one knew what to do? Just how many rescuers does it take to provide care for one patient?

If the head was moving around, then either the patient was alert enough to secure their airway, or the rescuer failed to take action. The patient requires you to perform what is needed, hold the head, suction the airway, place the airway in, and ventilate the patient. No excuses is allowed ethically or legally!

I suggest that before your service or group is allowed to respond to another emergency without a supervising licensed or trained experienced professional, that you practice, rehearse scenarious, practice skills.

I am sure your intentions are honorable, but truthfully that is irrelevant. The patient apparantly obtained aspiration (the gurgling you heard) and if the patient was able to ever survive the AMI, would probably have died of chemical pneumonia. Again, part of the problem and consequence of sole BLS responses, it is dangerous.

I do hope your group will increase your studies, practice, and are able to get a member with valid good experience.

R/r 911
 
Rid... not to nitpick, but the OP was with the FD's first responders... not on the ambulance. For all we know, the ambulance had 2 EMT-P's :). I agree that ALS is good... but BLS is better than nothing... and usually a little better than some nursing home LPN's.

Additionally.... how about the BLS side using a King LTD or combitube to secure the airway?

And yes.. the code sounds like a big CF... as they usually are.
 
I've been to few nursing homes (we call them Old Age Homes OAH) where the nurses treating the patient is often older, was sleeping harder than the patient self. So you don't have to guess the medical care that they provide in case of emergency is out of date and not on par.

Untrained hands on a scene, specially a resus, is a hinderence, more than a help. You should also be able to tell if their CPR is incorrect, as you know what is correct. If you find this to be the case, you need to diplomatically take over and pick up the peices where they left off. Sometimes one connot undo the complications of what has been done, and it may be better to just call it.

If the cardiac arrest did not kill her, the aspiration sure would have. It sounds like copious amounts, in which case pretty much nothing would have reversed the damage done (or still to occur). PS- We resuscitated a patient and post intubation, we used the Esophageal Detector Device to confirm (or tried to at least, looking at the result we obtained) placement, and upon releasing the pressure off the EDD, it fill up with vomitus (From the lungs)!! We called it shortly there after.
 
Aspiration alone brings along with it approximately a 50% mortality rate. That requires not just good airway skills, but also good breathing skills.

I believe it only takes around 30cmH2O pressure to open up the sphincter at the stomach. So even if you have a proper BLS airway but still squeeze the %$#@ out of that bag, you will still inevitably inflate the stomach. Slow and easy. That's the way to go.

I am saying all of this only to echo Rid et al. Education is key in more ways than one.

Because if you add the 50% mortality rate of aspiration to her age, the reason she was admitted to the nursing home in the first place, and to the reason for her loss of vital signs, you end up delivering the ER a cadaver.
 
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I have only a few things to offer after Rid and MSDeltaFlt.

Review the BVM threads that have been posted on this forum.

Shut the feeding tube off when you are bagging the patient.

Master the art of clearing the airway by both yankuer and NT suctioning.

Don't apply CPAP on a spontaneously breathing patient that has aspirated. That is an intubation for sure when you reach the ED.

Regardless of the professional credentials, if you don't perform a skill enough to keep up competency, you are going to be ineffective when the opportunity calls. This is across the board in all professions. We've heard many on this forum asking for advice on things that many think should be second nature. Although they should, not all services and facilities are the same when it comes to expectations and competencies as well as medical oversight.

Not everybody gets the same training when it comes to the BVM. It is rarely brought out in BLS CPR classes. In past ACLS classes, a lot of time was spent playing with the laryngoscope and intubating a dummy head even though it was known most of the nurses in that class would never intubate. The BVM was not emphasized appropriately which is the device they would be responsible for. In essence, the nurses could be ACLS certified and have no idea how to use a BVM if that is what their employer considered to be "training". I even found that to be true with new ED and ICU RNs. Now, the BVM has finally found its place in ACLS.
 
2-person, double-handed, head-tilt chin-lift bag valve mask with cricoid pressure!

that was the saying in my medic class....and we had to say it out loud every time we had to bag a person..........that's of course for medical no trauma, if trauma it was modified jaw thrust BVM.....
 
Jon said:
Rid... not to nitpick, but the OP was with the FD's first responders... not on the ambulance. For all we know, the ambulance had 2 EMT-P's :). I agree that ALS is good... but BLS is better than nothing... and usually a little better than some nursing home LPN's.

And yes.. the code sounds like a big CF... as they usually are.
Click to expand...

actually there was 3 probie members on the rig along with a level 3 tek, after we got the pt. secured on the stretcher a medic, and 2 more basics finally made it there
 
Ridryder911 said:



It sounds like it was a cluster **** and glad I was not there, sorry for the patient. The patient deserved better care than that. I am sorry, I don't see any reason for an excuse of not placing and cleaning out an airway! Just because a group apparently does not know how to handle an emergency is not an valid excuse. Four rescuers and no one knew what to do? Just how many rescuers does it take to provide care for one patient?

If the head was moving around, then either the patient was alert enough to secure their airway, or the rescuer failed to take action. The patient requires you to perform what is needed, hold the head, suction the airway, place the airway in, and ventilate the patient. No excuses is allowed ethically or legally!


R/r 911
Click to expand...


ok, as I said in one of my posts on this thread, we went in and suctioned and I did put an OPA in place, and the way that the head was moving around looked like there was no muscle control whatsoever, it looked..well...dead, and I did tell the BVM nurse to keep adjusting the head, because I took over compressions because when I got there the nurse that was doing them looked like she was going to be our next pt.
 
hahaha i was one of the probies on scene that night and i definetly think that the nurses were doing cpr wrong, pushing on the stomach and not the chest would explain all of the vomit
 
bassman1490 said:
hahaha i was one of the probies on scene that night and i definetly think that the nurses were doing cpr wrong, pushing on the stomach and not the chest would explain all of the vomit
Click to expand...

they were not pushing on the stomach
 
emtwacker710 said:
they were not pushing on the stomach
Click to expand...

Thank you for clarifying that.

emtwacker710 said:
well we had a limited amount of personel that were actually cool under pressure (the 4 of us that responded on the rescue) the nurses although trying to act professional were starting to freak out, ...
Click to expand...

4 rescue personnel respond to a scene and only one seems to be doing anything to help the situation.

If there are 4 people that show up to "rescue", the nurses should be assisting if you need to hook up to some of their equipment, ie O2, suction and gathering the necessary information, paperwork and med list that you need for transport. The CPR bit is what the 4 of you were called for.

bassman1490 said:
hahaha i was one of the probies on scene that night and i definetly think that the nurses were doing cpr wrong, pushing on the stomach and not the chest would explain all of the vomit
Click to expand...

Do you have a CPR card? If so, why did you not take over for the nurses? If one nurse was doing CPR by the new standards, a 4 minute response time can seem like an enternity. That alone will make what might have been excellent CPR for the first 2 minutes look like crap the last two minutes. And, that doesn't include the time you may have just stood there doing nothing.

You are supposed to be the CPR masters. The nurses at nursing home called 911 for your assistance.

What's with the criticizing of other professionals when you yourself is listed as a student or probie? How many times have you done CPR in your vast career?

People vomit for many reasons and not just bad CPR. The vomiting may have come before the arrest.

You got distracted by one thing and let it interfere with what needed to get done. Focus on the job at hand and your own effectiveness in a code.
 
i will say that by the looks of it the nurses had it going good at first, but by the time we got there they were getting tired and starting to freak out, also the two firefighters that responded that were not medically trained, one was the driver and the other came along for lifting assist just in case, and yes one of the firefighters started getting info (BLS PCR) from the "charge nurse" that was at the desk..also I didn't mean for this thread to get this out of control, lol, all I really wanted to know was some reasons as to why the pt. was vomiting as much as she was (which was a lot!!)
 
The thread got out of control because of the care or should I say lack of care the presentation was presented. Your an EMT, there were other EMT's that was supposed to know what to do and did not. There is a legal term for that. Sorry, I would assume an EMT would know there is no muscle control on a cardiac arrest, and yes they look dead because they are dead....hence the reason for attempting resuscitation.

Sorry, but like it or not, I am glad I do not have to depend upon your EMS services, if this is representation of the type of care delivered. First responder, transport, or even passer by can be proficient.. patients deserve better care by so called health care professionals.

Harsh maybe, but I realize that you probably do care. Now, take my criticism and apply it by studying, practising all EMS skills, so the next time (yes, it will occur again, if you ever work another cardiac arrest) and be better prepared. Chalk this up to experience as a learning tool on not what to do again. As others have described on techniques to prevent or reduce vomiting (which you should had been taught in Basic CPR). We all have been through such events on various levels and learned off our mistakes, that is how we grow and become better practitioners.

I hope you can convince others to learn as well and perform as a team, and again provide optimal care you can provide.

R/r 911
 
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