NPA in an "Unresponsive" Pt? Right or Wrong?

lightsandsirens5

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So, what is y'alls take on placing an NPA in a pt you believe is "faking it?" I have a story I want to tell here, but I want some viewpoints first.

Is is ok because if they really are unresponsive the need all the airway help the can get, so an NPA helps protect the airway in case they really are out.

Or is it cruel because if you suspect they are not truly unresponsive then why are you putting an NPA in? To be mean?

When is an NPA contraindicated in a pt you suspect is faking? Or do you use the NPA to find out if pt is faking?

I look forward to your answers. And thank you.
 
I don't work as an EMT and I have zero experience other than in the fast food business so take what I say with a grain of salt, but I'd say don't use it. For the same reason(s) you suspect they are faking it, I'd not use it and document why you chose not to use it. I don't think you should write "I think they are faking it", but rather what are the clues that are hinting to you "This guy is faking it" like maybe calculating GCS, movements you observed if any, maybe go as far as trying to open his eyes to see if his pupils are looking forward or doing something less dramatic than an NPA like doing the arm test (and catch the arm), put together what bystanders say (if any), etc, and link that to your treatment. This just makes me think of the A and P in SOAP. What do I think is wrong with this patient? What is my treatment/plan? JP always talks about making a diagnosis and treating off that so I am thinking that route as long as it doesn't contradict with your protocols/policies or whatever you go by and the whole CYA thing going on. I'm just afraid that the NPA could cause complications (even if not much like a nose bleed) in a mostly healthy patient that you suspect doesn't need it. If you are unsure, I'd use it, but I wouldn't be doing it because I am testing them.
 
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Ive seen/heard of people drop them in drunks just to check responsiveness, its not right but it happens!
 
I put them in. If your patient wants to lie to you that's their business. But Murphy's law says if you decide a patient is faking/lying you'll get burned. They will really be unresponsive, or their BS chest pain will be them having a heart attack or whatever. Your protocols say unresponsive people get airway control if you are worried about their airway, person not responding to pain gets an NPA.

You can always level with them. Tell your patient "if you can hear me I need you to squeeze my hand, otherwise I have to stick this uncomfortable thing up your nose to help you breath." No response, they can't really complain.

With drunks it's a win win. Either the NPA wakes them up and you can pull it out. If it doesn't they needed it. And let's be honest, NPAs aren't super comfortable but it's not like you are putting in a chest tube or doing surgery without anesthesia.
 
Go for it. NPA wont harm the person and if they arent faking it you can say you put in a NPA. If they are faking it then they will just "wake" up instantly.
 
If they appear to be unresponsive after a little bit of stimuli, why not use it as a test of how unresponsive they are.

If they don't respond to the rubber hose in their nose, you could forgo the muscle pinches I think.
 
Use it, no reason not to. NPAs are used in the concious all the time.

Heck, if we can do nasal intubations on someone fully awake and alert, NPA is fine.
 
I wish I had the option. They're considered an ALS skill in my area. :blink:
 
Nonsense. BVM is BLS and BVM /S an airway adjunct is bad medicine. You should take this up with your medical director.

Its like peripheral dopamine with no aline.
 
Nonsense. BVM is BLS and BVM /S an airway adjunct is bad medicine. You should take this up with your medical director.

Its like peripheral dopamine with no aline.

You don't need an A line for dopamine.

It is used all the time without one and should continue to be.
 
You don't need an A line for dopamine.

It is used all the time without one and should continue to be.

I didn't even think of him meaning an A line. I thought he just left the "s" off of saline. It made sense to me, because we have to give the pt a fluid bolus to see if it increases BP before starting dopamine in the field.
 
Well, here is why I ask.

Las night I was paged to a 13 YOF who had fallen earlier in the day and now was unresponsive with a rapid thready pulse and rapid shallow respirations with bruising at the base of the skull.

We get on scene and I find this girl lying on the couch apparently not responsive. No response to muscle pinch, no reflex when I run the back of a pen up the sole of her foot. Eyes staring strait ahead and not moving. I started a line in her hand and she didn't flinch, not a bit, even though I didn't say a thing before I stuck her. Vitals all stable and WNL, pupils PERRL, no bruising to the base of her skull. She just didn't LOOK comatose to me. I can't say why, she just didn't.

Well, I know this pt has a past hx with out service of being a complete faker, but she always responds to majorly painful stimuli, Ie, a needle in her hand. Now as we were loading her into the amb, I thought I saw her blink slightly when I flipped the dome lights on, but I wasn't sure. I of course decided to treat her as if she really was critical instead of falling back into the frequent flyer treatment mode because you never know when one will be critical, right.

Anyhow, we began transport, and I started going through the treatment and all. I decided to use a nasal instead of an oral because I wasn't 100% certain she was faking. Maybe 95%, but not quite sure. Now I feel like crap because of that.

As I was lubing the tube up, I told her I am going to have to put this tube in your nose to help you breathe since you are not responsive and I want to make sure you can still breathe well. No response. So I started to insert it, still talking all the time to her. As I felt the tube reach the end of it's run, the pt grimaced very slightly and she got tears in her eyes. Now I hate to see people cry, so that is part of the problem here, but anyhow. Here is where I think I messed up and why I feel so bad. I told her, I could take the tube out when she woke up, cause I needed a good airway for her to breathe. That poor girl tolerated that NPA for almost the entire hour long transport. But about 20 minutes from the hospital I started thinking. On scene, which was the neighbors house, her stepdad was higher than a freaking kite, here mom is one of those people who when you look in their eyes, nothing looks back. The neighbors were drunk. Maybe she is trying to tell us something with these "episodes." She is way behind in school. We NEVER pick her up at her home, always the neighbors. And I just had this feeling something isn't right.

So I started talking to her and rubbing her forehead (as best I could with her fully c-spined) and just talking trying to reassure her and make her feel comfortable with me. I told her she was doing really good and how she looked like she was starting to wake up and she could talk to me if she wanted, that it was safe in the ambulance with me, and so on and so forth. Well, she started crying (again, I hate that, I am such a softie. :-S), the first thing I asked was if she wanted that thing out of her nose, she nodded, so I removed the NPA. She was very very reserved for a while, but I just kept holding her hand and talking to her. Eventually she starting talking more openly, but I couldn't make sense of some of it. She claimed she was home alone when she fell (she did fall, or something. She had a good goose egg on the back of her head). But school is in right now. She claimed to have missed the bus. I asked if both her parents worked. She said the thinks her stepdad works and she said her mom might be going to school "or something." (if that woman can study at an undergraduate level, then I should be on my second doctorate degree by now). I know I am not really authorized to, but I kind of asked how she felt at home, did she enjoy living where she did, did she have any friends, etc. She answered them all appropriately, but it seemed forced to me. (Albeit I have no training in that stuff whatsoever.) When we got to the hospital, I accidentally left her bracelet in the rig. I had taken it off to do the IV. I walk into her ER bay with it and tell her that I had to take it off to work on her. Before she could answer, before I could even start to hand it to her, both her parents were all like, oh thank you just put it over on the counter well get it later. Both talking at the same time, over each other. The pt seemed happy around them, but again, it seemed forced. (to my untrained mind). I guess I suspect some kind of emotional or verbal abuse and/or general neglect.

So I pulled the nurse aside and told her all my thoughts. Fortunately she was familiar with this pt and was starting to feel the same way I was. She told the doctor and even he thought the same thing, but said that there were no apparent signs of physical abuse, and that mental abuse was something really touchy to get into. I helped get her to CT to clear her head and the doc came and talked to here without the parents there really briefly. She denied any problems, but I still have this bad feeling.

Now our job is PT advocacy, but how far does that go? I left all my concerns with the nurse and the doc, is that all I should do? I talked to my partner, and she feels like I do. But doesn't know what to do. I mean how far do you go as a simple ambulance monkey?

You know those calls that just get to you? I dot get that very often. Maybe three in the four years I've been in EMS. The other ones were things like infant MVA fatalities. But this one just gets me. I can't stop thinking about her. I know I am letting it go too far, but I literally had nightmares about her last night. I get teary every time I think about her. I feel like there is something wrong, she is helpless, and I can't do a freaking thing about it.

So anyhow, sorry this no longer really has to do with NPAs, but that was what started the whole thing for me.

I'm sorry if it is against the rules to hijack your own thread. :-S I just have to talk about it, even if it is just to an online forum.
 
I had a patient a few months ago who had snoring respirations (stroked out 11 hours before, NH felt like waiting). Totally unresponsive to painful stimuli, no flinch with my needle pokes, blown pupil.

I did an npa, and at the end of it being in, she flinched whenever it was touched.

No doubt in my mind she wasn't faking... hemhoragic stroke upon CT.
 
I definitely would NOT have done an NPA if there was a fall with bruising at the base of a skull. Think about your contraindications. Better safe than sorry. If she was legitimately unresponsive, she probably would've tolerated an OPA which would have been more appropriate for the circumstances. Depending on her O2 stats and how inadequate the breathing was, might've just kept it simple with a BVM so long as the airway wasn't legitimately obstructed by the tongue, etc.
 
L&S5 finds his Hot Button!

Congratulations. It took you a few years but there you have it; out of nowhere, for no damned reason, you run this diddlypoop call and it's tearing your guts up!

As if, you were immune. As if you were more than human. You're just a guy (assumption) with a heart.

A heart? They don't supply that with your bootlace zippers or trauma shears. Oh, wait, wasn't that standard issue equipment from the get go? (Jeez, I remember that...it was in here somewhere!)

Almost forgot, didn't you? And where did you find it? In the tears of an abused child while you were torturing her because you thought she was a fake.

That's a pretty human thing you did there L&S5! Your Flesh Mechanic ran smack in to your heart!

She wasn't a fake. She was as real as you and that is exactly what's flipping you out. For one moment that is now echoing through your sleepless nights, you experienced what it means to be in someone else's skin. Does that ring true? You, for whatever reason, related so strongly to something living inside her that you took a bit of that pain on. That is called Compassion (from Latin: "co-suffering").

Thanks for bringing your lesson to us. Thanks for doing a bait and switch from, "Is this proper technique?" to "Help me out here, willya?"

But you've brought this to a den of wolves, don't you know? What do medics really talk about or care about? Pay, hours, calls, system discrepancies and system abusers, and the occasional pulled'emoutofthe:censored::censored::censored::censored:ter story. The "culture" of the paramedic states you really can't do your work and be a human being, with emotional impacts, doubts and fears at the same time.

But let me tell you something. Most in EMS, and myself included, pretty much were able to handle the everyday traumas that would cripple the emotional lives of typical "citizens". The problem is, every one of us hits a wall now and again, and there are very few outlets for honest expression and support.

And that is OUR fault!

Impactful moments that go unresolved add up. Without their being faced, they accumulate until they become a mass of unresolved issues covered over with layers of hard, impenetrable protection. Under that weight, suddenly, and often without warning, people crumble. And you know where that usually happens? Right at HOME!

THAT, MY FRIEND, IS CALLED BURNOUT.

REAL conversation? The truth is, you ARE on the right track. You're not the first to bring out issues like this, and, in fact, my observation is that it's more likely to happen here than at your station, so for that, congratulations are in order as well.

I suspect you're looking for support because you hit the limits of your humanity and think that someone here may have had the SAME experience.

So I'll stop here and offer everyone else a challenge: Are you willing to take what L&S5's said, translate it into your own experiences and mirror back SUPPORT?

That is, without getting too fixated on the size of the NPA, of course.

Just so it's clear, because these digits on a screen don't really convey one's attitude, I'm happy this came out and I appreciate it wasn't easy for you. In that you have my respect. You've done us all a service by your transparency and even if nothing happens here, I'm available for backup if you need it.

And one more thing...I really DO see that there are a lot of people on this site willing to step up to the plate for each other. I wouldn't invest so much if I didn't. There is much to work with here, and I am quite appreciative of you all!
 
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I definitely would NOT have done an NPA if there was a fall with bruising at the base of a skull. Think about your contraindications..

Contraindications?

Craniofacial trauma?

Nasal trauma?


Better safe than sorry. If she was legitimately unresponsive, she probably would've tolerated an OPA which would have been more appropriate for the circumstances..

That is not a factual statement. A patient can have an intact gag reflex and not be responsive. (like a person using barbiturates) As well, a patient can be responsive and have no gag. (like an extremely intoxicated person)

A person without an airway will die. So if you are banking on better safe than sorry, bet on airway.

Depending on her O2 stats and how inadequate the breathing was,

Just out of curiosity, what o2 stats would you be considering?

might've just kept it simple with a BVM so long as the airway wasn't legitimately obstructed by the tongue, etc.

If you are bagging an unresponsive patient, an airway adjunct is indicated.
 
Placing an airway adjunct in a patient because you think they're faking it?

Absolutely inappropriate.


Placing an airway adjunct in a patient who you think may have a problem managing their airway due to be altered, even if one of the reasons that they are "altered" is because they are faking it?

Absoluely appropriate.

The end result of the two ways of approaching a patient may be the same, but the underlying reason is vastly different. One line of reasoning is based on the emotions of the provider (How dare that patient try to fake being altered!), the other is based on an assessment (my assessment says that the patient is altered and might have trouble managing her airway, hence an NPA is an appropraite precautionary intervention).
 
I know I am not really authorized to, but I kind of asked how she felt at home, did she enjoy living where she did, did she have any friends, etc. She answered them all appropriately, but it seemed forced to me. (Albeit I have no training in that stuff whatsoever.)
You need authorization to do a social history?


The pt seemed happy around them, but again, it seemed forced. (to my untrained mind). I guess I suspect some kind of emotional or verbal abuse and/or general neglect.

...

Now our job is PT advocacy, but how far does that go? I left all my concerns with the nurse and the doc, is that all I should do? I talked to my partner, and she feels like I do. But doesn't know what to do. I mean how far do you go as a simple ambulance monkey?
You are a mandated reporter, aren't you, so did you report it? This is one of the reasons why I recommend both having your own clipboard (even if your company supplies one) and carrying a mandated reporter kit in it.


Edit:

Also, if you don't speak up, who will?

[youtube]http://www.youtube.com/watch?v=IpE73PvU9bk[/youtube]
 
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+1 what firetender said.

my company had a shrink (who was an ex-medic) at the HQ 9-5 m-f. no appointment needed and on call 24-7 for CISD. I took advantage of his services often, talked about home stuff too. if you have access to one USE THEM, think of it as mental maintenance. you should look into if your company/dept has an EAP program, they are free to employees and it will NOT be reported to your supervisor or management. but getting it out into the open is the first step.

secondly, I would have reported this to child protective services (or your states equivalent), mental abuse is still abuse. the doctor is wrong, it is not harder to investigate, once the social worker sees the family situation and moms 1000mile stair. just take good notes (or recording) for when you write your report.

thirdly, I try not to judge who is "faking". I may suspect it, but if they present as un-responsive 9 times out of 10 they are getting an NPA. i typically only use an OPA if i am considering intubation (stay on topic, if you want to discuss this start and OPA thread). the only protocol that i may "judge" is seizure. if i feel that they are faking i WILL use an NPA before versed. if they take the NPA like a champ versed is next.

to sum it all up, I would have treated the same as you. i would report this incident. and i would talk to a professional head doc who has experience with EMS.
 
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