Today, I ran into an Ambulance Driver. I had literally worked with a team of professional paramedics and EMTs (OCFD and my partner) to stabilize and start to correct a fairly acute COPD exacerbation. As you could imagine, I elected to use our ventilator. BiPap, albuterol, atrovent, methylprednisone (fairly generic COPD call). Afterwards, as we were packing up, another medic came in. I expressed my pleasure at the success of our therapy and the surprising success I have had with our vents- by my conservative count, I have avoided a dozen or so intubations and really helped twenty or so patients with early, aggressive application of BiPAP. I also use it on my arive rests- it is more reliable, more accurate and more effective than a BVM, especially when in motion. Anyways, this guy flat-out says that he refuses to use it, no matter the circumstance. His rationale was that it had "strangled" two of his patients, and he attributed their deaths to the ventilator. One was apparently a full arrest, the other was unknown. His attribution of their deaths to the vent boiled down to user error within a few seconds of listening to him; or he was making it up. Either way, he simply refuses to use them in any case. "You can bag them better always, that's what I do."
Now, there's lots of flaws to the ventilators we use. They're sensitive, they're not terribly rugged, the cases suck and their hoses and masks are pretty universal in size. They have a lot of very useful alarms and a few that are less than useful, and they're not exactly as idiot-simple as the ParaPacks that their replaced. With that being said, they offer us some much, much better therapy options and are quite a bit more versatile than any simple CPAP device. We can both effectively ventilate and transport patients who are really vent-dependent without setting their therapy back by weeks and provide emergent, clinically-significant therapies in a 911 setting. The ventilators take training and knowledge to use- knowledge that is not exactly NR-paramedic standard, but is far from unavailable or incomprehensible. Learning how to use the vents is literally a matter of reading a handout or playing with the thing for a few minutes.
After this medic left, the charge RN looked at me and told me "That's why you make $15 an hour. It's because of people like that, who ignore tools that you're given because they're too lazy, dumb and stupid to learn. That guy's an idiot." He is literally leaving a lifesaving tool on the shelf because he is more comfortable thinking that a BVM provides PEEP or that it's preferable to intubate a patient than it is to simply BiPap them.
Ambulance drivers can be found at all cert levels.
If a patient is in cardiac arrest with CPR being performed, you probably should bag because the ventilator will end the cycle with a chest compression and will be out of sync during chest compressions. This means the patient will not be ventilated even with the ETT. Yes, that will not help with achieving ROSC and might prevent it from happening.
A "BIPAP" mode is also not to be used on someone who is not spontaneously breathing (agonal is not) and who can not maintain their airway.
You do not need to worry about "setting back" their therapy with a short transport or even a long one. Chances are these patients will change modes for sleeping and procedures all the time. If the patient is having an acute breathing problem you must place them on the appropriate ventilator mode and settings rather than worry about "setting them back". Being dead will set them back more.
If you don't have the appropriate meds which might even include giving a paralytic along with lots of sedation and pain relievers you might not be able to ventilate a patient effectively. Every time the machine cycles off due to high pressure, the patient is not getting effectively ventilated. This can also lead to arrhythmias and death.
The patient might just feel like they are being suffocated by the ventilator. Some ventilators do not have a high demand flow rate which could be because of generic settings or by machine design. EMS medical directors are usually not CCMs or Pulmonologists so their knowledge of ventilators are limited. They will have to write for generic protocols.
All alarms on a ventilator serve a purpose. If something is alarming you have either set if inappropriately or something needs to be addressed with the patient. I have yet to see a transport ventilator which has too many alarms and most do not have enough.
Most of the transport ventilators function with single limb technology and an external PEEP valve rather than a continuous end flow. Most do not have a compressible volume feature so you do not know don't know how much tidal volume they are getting. Most transport ventilators do not give a Plateau Pressure. There might be a way to achieve it for the experience practitioner but for the inexperienced it is not advised.
Your transport ventilator might have a lot of "knobs to turn" but that does not always make it the appropriate ventilator for all patients especially in acute situations.
You will also seen in the ER an RT or experienced RN kicking the usual standby portable vent into a corner and having the ICU ventilator wheeled over because they noticed something by bagging which will require a better ventilator. They already know it would be stupid of them and probably harmful to the patient to place them on an inadequate machine. In some cases bagging is definitely better than placing them on a machine that won't adequately ventilator the patient. If those transport ventilators would do the job the ICUs would probably use them instead of the big vents which take up a lot of room.
That being said, hospital staff will try to use transport ventilators to move patients from one area to another. A couple of the ICU machines can be switched to being mobile. But, hospital staff will have known values for ABGs and a CXR. The RNs and RTs work with many ventilators everyday and all day. With a few known values and the appropriate medications which also are often not available in EMS, they have the expertise to manipulate the transport ventilators to get through a short transport.
Not knowing the limitations of your ventilator, using it inappropriately like BIPAP to "ventilate" a nonbreathing patient and believing your transport ventilator is life saving in all situations would make you look more like a lessor provider to those with experience and expertise with ventilators. Notice I also said expertise since some do what they believe to be a lot of ventilator transports on an ambulance but keep making the same mistakes over and over.
How much training did you get for the the ventilator you are using AND how much education and training did you get for ventilation, oxygenation and disease processes as it applies to ventilator principles?
