I Can't Breathe! Help Me!

[MSDeltaFlt]

The way to stop this lady from struggling is to initiate therapy toward alleviating the problems.

If you sedate the drive that is maintaining her oxygenation, you better have a great airway alternative. She will go down fighting even if you do have the ability to RSI. Sedating may or may not alleviate the combativeness but may present with other problems.

CPAP does NOT ventilate. You may end up bagging and still have a lot more of your protocols to run through to maintain stable BP, assess and continue treatment.

Remember these patients aren't fighting YOU. They are fighting a body that is failing them. Just from her COPD, she has very limited oxygenation and ventilation abilities. Any disease process be it CHF or PNA that can cause just a little more hypoxemia with may cause her PaO2 to fall from 55 mmHg where she probably lives to 40 mmHg where her other organs start to feel the effects.

Very true, Vent. Remember, They say she started to really complain ~10 min before you showed up. Time is relative. The amount of time you feel elapsing and the amount of time actually occuring might not necessarily be the same amount.

Therefore, don't be surprised if you can't fix the problem enroute. Most times you can't. But you can get the fixing of the problem started.

 

[zzyzx]

Vent wrote, "If you sedate the drive that is maintaining her oxygenation, you better have a great airway alternative."

Yes, that's what I'm afraid off. Say you have a combative 400 lb CHF'er and you sedate them, but then they loose their respiratory drive and now you've got a difficult intubation.

The problem is, what if they are just so combative that you can't to any treatment, i.e. they are throwing the mask off, won't let you do a nasal intubation, are fighting you as you try to move them downstairs, etc.

I guess I already know the answer--that it's just a tough call as to what to do. I'd like to just hear people relate their experiences with nightmare calls like this. Besides, I love hearing war stories from you guys.

 

[Sasha]

vent, how would you have treated her stast to finish?

Sorry, I was typing ^that^ on my phone. Didn't mean it to come out disrespectfully or anything in case it was taken that way but:

Since you and Rid are basically the EMS Gurus and you and MSDelta are certainly the source for all things respiratory, and I've already failed miserably at the scenario, I'd like to know how you, as a Paramedic, would treat this patient so I can learn from you?

 

[colafdp]

Canadians and those of other countries;
Are they still giving Salbutamol by IV in EMS and the ED?

Pardon the off track question.

I can't speak for the rest of the country, but here in Saskatchewan, Salbutamol isn't given via IV anymore. Just good ol' nebulized.

Also, Outbac, Atrovent is really an ACP skill out there? hmmm...crazy. Learn something new every day.

 

[Outbac1]

Here in NS atrovent is for ACP use only. There is no reason why it couldn't be given by PCPs. as could IVs, D50 and benedryl. But that's the way the MD wants it.
I have never seen ventolin given iv.

 

[MSDeltaFlt]

Sorry, I was typing ^that^ on my phone. Didn't mean it to come out disrespectfully or anything in case it was taken that way but:

Since you and Rid are basically the EMS Gurus and you and MSDelta are certainly the source for all things respiratory, and I've already failed miserably at the scenario, I'd like to know how you, as a Paramedic, would treat this patient so I can learn from you?

Sasha,

You're a student. You didn't fail miserably. The only way you could possibly fail in any shape, form, or fashion is if you didn't do what students are supposed to do... which is learn.

Your preceptor, on the other hand, ...well. I'll leave that alone for now.

 

[VentMedic]

Sasha,

As I said, start at the beginning and write out this scenario. There are some things that you will do for all medical calls at an ALS level as part of your assessment while you are taking care of the obvious A,B,Cs. As well there will be common therapies initiated reguardless of what path you decide to call your working dx. You also must be aware there will be a little of everything going on. Become methodical in your assessment so that you don't miss anything that is a necessary part of your assessment. Ex. an EKG rhythm strip might have shown a HR of 220 even if the pulse was only 130. A BGL might have been expected to be elevated but could also have been low. COPD pts that can't breathe don't always eat..

You will also have a partner. In this scenario it seemed that you as a student had no one. Multiple things should be happening at one time. I usually prefer to establish the O2 and/or neb tx myself because that gives me direct eye contact with the patient and from there I will have an idea of the difficulty this patient will present and the eyes can tell volumes. If there is a calm family member, I have no problem having them assist with getting some O2 and neb closer to the patient. Sometimes if the patient knows the mask can be removed easily they are okay with it.

Many here have given you good directions but you need to start at the beginning. That is in your text book and protocols. I am not going to rewrite what is already in print. Sorry but you are the one who should know where to find the answers for some of your questions. As I asked before, type out your treatment plan with your protocols. You can call this lady COPD exacerbation and CHF for working dxs if you feel that is what your assessment indicated.

You haven't failed at anything yet. You just haven't been able to pull all the info together probably more from the lack of proper guidance. But, if your preceptor wants to behave more like an ambulance driver....

 

[brice]

how interesting

 

[Ridryder911]

Hence why we had and still continue to urge you to obtain more clinical exposure and increasing your didactic knowledge. Those of us that may appear to have wise knowledge do so because of continuous studying, having the privilege of our clients to allow gaining more experience and learning off them.

You are learning more than you may realize. Your now are asking questions instead of just responding spontaneously which is a very positive sign that your increasing your knowledge and wisdom. Remember, when one graduates through the program it only means the just started learning.

R/r 911

 

[Outbac1]

Sasha your preceptor may have failed you but you haven't failed yourself.
How many pts like this have you seen since you got your EMT-B? If you have, were you working with someone who could do something for this type of pt? As Rid said try to get as much clinical experience as you can. The more pts you see the more you will learn.

There is a reason they call it the PRACTICE of medicine. I have met two Dr.s this week who have just returned or are going to conferences or sessions/courses to learn more. The learning never stops unless we want it to. Don't let this incident get you down. Pick yourself up and push on.

 

[Sasha]

Hence why we had and still continue to urge you to obtain more clinical exposure and increasing your didactic knowledge.

I'm working on that! I'm studying constantly, and am taking as much clinical time as I possibly can. It's coming along slowly, surely, but it doesn't happen over night. Ok, so things aren't really coming together very well but a lot of it has been self teaching and it's taking some time!

You're a student.

A student, yes, but according to instructors and preceptors I should be able to function out in the field by myself. March 18th is it. That's all she wrote for Paramedic class. Yes, I realize that it's only the start of education and knowledge, etc, And I understand some of it is inexperience, and some of it's lack of education because of a crappy "school" and some not so great preceptors, but damnit I need to stop making huge mistakes and freezing up like that!

Do you understand my frustration now? I've never been so behind in something, and I've never been working so hard to catch up!

 

[Sasha]

Retracted.

 

[Aidey]

Sasha, take a deep breath.

The patient lived. You learned something. It's ok. Even medics who have been doing this for 10, 15, 20 years spin on occasion and feel like they buggered up a call.

The only time you should freak out is if you have a call like this and you DON"T feel like you messed up and need practice. That is a bad bad sign.



P.S. I'm not trying to be patronizing, I've just been where you are.

 

[Jon]

That's not so shocking. My entire experience with paramedic school has been "sad". Nothing has promoted learning but rather a "pass the test, get out there, then you'll learn" mentality. The nowhere near ready is a culmination of things, and not soley the preceptor. I've learned a lot from his preceptorship, though. Probably more than I've learned in class.

Sounds like the EMT-B program


Seriously - my program is going through a lot of growing pains... we are year 4, and the biggest class, double the size of last years. Our lead instructor is now realizing that he dropped the ball a time or two and is going back over stuff.

Some of our preceptors are really good. Some of the folks who precept couldn't find their butt with two hands and a road map... one of them didn't even realize that we carry lidocane as a drip. :facepalm:

And some of our preceptors have been removed from precepting - like when they had/allowed their student to intubate a dog on a fire scene.


All in all, now that we are in Stage 2 of clinicals, the preceptors are EXPECTED to allow us and MAKE US run things, and give us enough rope to learn, but not enough rope to hurt ourselves or the patient.


I feel as if I have enough experience that I'll be adequately prepared for life once I pass my NREMT-P :hope: :Big, Obama-Style Hope: Sure, I'll be new and green, and won't know everything. But I know 20-year medics that don't know everything. That said, I worry about some of my classmates. Today we were told that as a class, we aren't allowed to push drugs anymore in the local ED, becase at least one student couldn't adequatly answer questions on why a med was being given and what it was.... and it is ON the state Medic Drug list, AND a VERY commonly pushed drug in the ED. Add that to at least 1 student being unable to preform the psychmotor skill of drawing up a drug... and the ED director has pulled the plug until we get signed off again and she's comfortable we aren't going to make errors for her nurses.... they have enough work already!

 

[Jon]

The way to stop this lady from struggling is to initiate therapy toward alleviating the problems.

If you sedate the drive that is maintaining her oxygenation, you better have a great airway alternative. She will go down fighting even if you do have the ability to RSI. Sedating may or may not alleviate the combativeness but may present with other problems.

CPAP does NOT ventilate. You may end up bagging and still have a lot more of your protocols to run through to maintain stable BP, assess and continue treatment.

Remember these patients aren't fighting YOU. They are fighting a body that is failing them. Just from her COPD, she has very limited oxygenation and ventilation abilities. Any disease process be it CHF or PNA that can cause just a little more hypoxemia with may cause her PaO2 to fall from 55 mmHg where she probably lives to 40 mmHg where her other organs start to feel the effects.

Hey Vent - refresh my memory - what's the healthy PaO2 in a young, nonsmoker?



Great points, all. I saw a PE a few weeks ago - in a 15-minute timespan, between the bedroom and while we were transporting, Pt. went from CAO and in SEVERE respritory distress to Apniec... to DEAD. We worked that for a while, no luck.


Sasha - do you guys HAVE CPAP? given the patient's history, it might have been worth a shot. I've seen it work miricles... and I've seen it fail.

 

[MSDeltaFlt]

Hey Vent - refresh my memory - what's the healthy PaO2 in a young, nonsmoker?



Great points, all. I saw a PE a few weeks ago - in a 15-minute timespan, between the bedroom and while we were transporting, Pt. went from CAO and in SEVERE respritory distress to Apniec... to DEAD. We worked that for a while, no luck.


Sasha - do you guys HAVE CPAP? given the patient's history, it might have been worth a shot. I've seen it work miricles... and I've seen it fail.

Normal PaO2 is 80-100 torr, or mmHg depending on your point of view.

 

[Sasha]

Sounds like the EMT-B program


Seriously - my program is going through a lot of growing pains... we are year 4, and the biggest class, double the size of last years. Our lead instructor is now realizing that he dropped the ball a time or two and is going back over stuff.

Some of our preceptors are really good. Some of the folks who precept couldn't find their butt with two hands and a road map... one of them didn't even realize that we carry lidocane as a drip. :facepalm:

And some of our preceptors have been removed from precepting - like when they had/allowed their student to intubate a dog on a fire scene.


All in all, now that we are in Stage 2 of clinicals, the preceptors are EXPECTED to allow us and MAKE US run things, and give us enough rope to learn, but not enough rope to hurt ourselves or the patient.


I feel as if I have enough experience that I'll be adequately prepared for life once I pass my NREMT-P :hope: :Big, Obama-Style Hope: Sure, I'll be new and green, and won't know everything. But I know 20-year medics that don't know everything. That said, I worry about some of my classmates. Today we were told that as a class, we aren't allowed to push drugs anymore in the local ED, becase at least one student couldn't adequatly answer questions on why a med was being given and what it was.... and it is ON the state Medic Drug list, AND a VERY commonly pushed drug in the ED. Add that to at least 1 student being unable to preform the psychmotor skill of drawing up a drug... and the ED director has pulled the plug until we get signed off again and she's comfortable we aren't going to make errors for her nurses.... they have enough work already!

Here on clinicals we are allowed to push drugs in the ER, but they must be drawn up by the nurse, first and pushed under a nurse's supervision. One of my favorite nurses would draw up the drug, take a saline flush and inject it into the now empty drug vial, and make the student draw up the saline, to make sure the student knows how to, but you're expected to know the whys, hows, why nots, what to expect, etc if the drug is considered a "prehospital drug".

We, however, are no longer allowed to start IVs after a student who had never used a spring loaded IV needle, never thought to ask about it, just started an IV and assumed that the button to "spring" the needle back, shot the needle into the vein. Well, it doesn't, but it does make a big mess of the patient's arm, bedding, floor, etc. The patient complained, the nurse complained, and we are no longer able to start IVs in the hospital. Personally I hate the spring loaded IVs, they like to fling blood while they "spring".

My program is "new" too, but it doesn't give the program an excuse to suck so bad. I could kick myself for staying, but before I had floated around here, I thought we were doing okay. Come to realize the school is basically breeding mill medics, and that's not something I want to be. It's hard to ask questions because my instructors don't even know why or how a treatment works, just that if you have this, you give that, etc. It makes it difficult and frustrating to learn.

And yes, we have CPAP, but I kind of froze and forgot about it, and no one felt compelled to remind me.

 

[medic417]

Sasha sounds like you are going to be OK not because of the school or the preceptors but because you refuse to settle for the bottom.

A good preceptor lets you run the show then if its critical says we need to do this or that if your not quick enough. If not critical but should be done the preceptor will initially ask you a question to help you think about what you need to do. And at no time will they allow a patient to suffer. If the patient is in bad shape and someone is not addressing patients needs they take over and then educate later so that you do better next time. Honestly I wonder if you preceptor actually knew what to do.