NRB Flow Rate

[spike91]

Like mentioned above, if he were hyperventilating I'd do the same. And if that were the case, no real issue there in my opinion. However, in New York, the EMS Gods in Albany make it very clear that O2 should never be withheld from a patient, so if you're going to put him on a mask might as well do it at a standard flow rate.

However, if the patient was vomiting as stated in the OP, why would they use an NRB? Unless he had stopped doing so for some period of time, I would've used an NC. Would've saved a lot of trouble.

 

[usafmedic45]

And if that were the case, no real issue there in my opinion.

You know...except using a medical device in an inappropriate manner just because you can and that rebreathing is not an accepted treatment for hyperventilation anymore in most first world nations.



The level of frank stupidity and cowboy tactics in EMS sometimes makes me even more misanthropic than I already am.

 

[medichopeful]

Is the ink dry on this idiot's termination paperwork yet? Also, this needs to be reported to the state EMS board.

As of now, not yet. I'll be meeting with both him and the other EMT involved (who is, scarily enough, a state examiner), and we'll be discussing this in-depth. If necessary, I'll go from there. If he pulls anything again, I'll be writing to the state.

 

[jjesusfreak01]

I don't understand how people have so many problems with O2 flow rates...pick a saturation level you are looking for depending on the patient, and then choose a method of oxygen delivery that can get them there. NCs can go from ~0.5-4/5 lpm with no problems. Higher than that and you're blowing out their nostrils. NRBs have one golden rule, they should be getting enough oxygen to keep the bag inflated. Theoretically, there isn't a hard minimum, but if you have it on 5lpm and you aren't emptying the bag, then your patient might not be moving enough air.

 

[usafmedic45]

If he pulls anything again, I'll be writing to the state.

I'm considering alerting them myself.

NCs can go from ~0.5-4/5 lpm with no problems. Higher than that and you're blowing out their nostrils.

Actually you can go much higher if you have a way to humidify the flow sufficiently. That's the major limiting factor.

NRBs have one golden rule, they should be getting enough oxygen to keep the bag inflated. Theoretically, there isn't a hard minimum, but if you have it on 5lpm and you aren't emptying the bag, then your patient might not be moving enough air.

That's not a "golden rule" because that's actually a very poor way to judge if they are getting sufficient flow unless you're already pushing at least a normal minute ventilation through there. If they are getting 15 L/min or more and are sucking the bag in with each breath, you've got a major problem on your hands. Judging the adequacy of a flow rate based on the performance of a stiff plastic bag on a disposable mask likely assembed by a child in a third world factory is not something I would choose to admit to in court or in front of my medical director.

 

[MasterIntubator]

Most all "NRB" are technically partial-rebreathers. Unless your service has true "NRB" masks. The partial rebreathers we carry, can support lower LPM as long as the TV and RR and usually do not cause any harm what-so-ever do to all the leaks and safety measures in the partial rebreathers. Am I supporting doing it? Helll no. Have I done it? Maybe... but my hyperventilation suspects are ALWAYS on EtCO2 and assessment makes all other metabolic probs low on the totem pole. Then.... its a judgement call based on sound decision making by excellent assessment skills and recent history. In which, most all have done fine on ambient air and were calmed down with about 10-20 minutes of coaching and caring.
Plus.. non of my flow regulators have 5 as a selection. 6 would follow..... and thats way better than 2 lpm via mask that we have seen placed at nursing homes due to "COPD" :wacko:

 

[usafmedic45]

Most all "NRB" are technically partial-rebreathers. Unless your service has true "NRB" masks. The partial rebreathers we carry, can support lower LPM as long as the TV and RR and usually do not cause any harm what-so-ever do to all the leaks and safety measures in the partial rebreathers.

Ever tried breathing through those little ports? It's not easy.

and thats way better than 2 lpm via mask that we have seen placed at nursing homes due to "COPD"

You'd be amazed how quick a nurse gets fired from a nursing home when you document your butt off and forward it to the state board of nursing and send a copy of it all to the nursing home.

 

[jjesusfreak01]

That's not a "golden rule" because that's actually a very poor way to judge if they are getting sufficient flow unless you're already pushing at least a normal minute ventilation through there. If they are getting 15 L/min or more and are sucking the bag in with each breath, you've got a major problem on your hands. Judging the adequacy of a flow rate based on the performance of a stiff plastic bag on a disposable mask likely assembed by a child in a third world factory is not something I would choose to admit to in court or in front of my medical director.

True dat, but if we're sucking the bag dry we're probably past the point of simply using NCs and NRBs, which was the original focus of this thread.

 

[usafmedic45]

Point taken. I was just cautioning people that they should not be using that "golden rule" in clinical practice. To be quite honest, if you have the bag moving much when the flow is at 15L and the patient is still in frank distress with crap saturations, you need to strongly start considering the use of CPAP or BiPAP.

 

[Shishkabob]

You know...except using a medical device in an inappropriate manner just because you can and that rebreathing is not an accepted treatment for hyperventilation anymore in most first world nations.



The level of frank stupidity and cowboy tactics in EMS sometimes makes me even more misanthropic than I already am.

It's not just EMS, thank you.

We were once called to the Dallas jail for someone with "neck pain" (ended up being an MI). I walk in to the room to find the pt on an NRB... at a flow rate of 2lpm. You read that right, 2, as in two.

I tore the mask off the pt so fast I could have caused whiplash. The "RN" got angry that I, a lowly medic, cancelled her treatment... ha. She got hers.

 

[usafmedic45]

Oh, I know....trust me....I know.

 

[medichopeful]

Update

I just thought that I would give an update on the situation. I will be talking to the president of the club about this incident, as well as our faculty advisor to fill them in. After that, I will be talking to the two EMTs and the first responder involved, where I will get their side of the story. If their actions were intentional, I'll be having a serious talk with all of them about the dangers, recklessness, and legality of their actions. If they were not intentional, and were a mistake (everybody makes them), I'll give them an educational talking to about placebos, doing things without having a knowledge of their consequences, and the irresponsibility and legality of their actions. Either way, they will dealt with. The president of the club and the faculty advisor will both be filled in about everything.

I will also be keeping an eye on their patient care and their reports for the rest of the school year. If any similar incidents occur, I will be going through the process again, and will be going to the state OEMS as well.

Any thoughts or comments are welcome.

 

[AnthonyM83]

Is the ink dry on this idiot's termination paperwork yet? Also, this needs to be reported to the state EMS board.

Out of all the things to be reported to an EMS board, you would choose putting a low flow rate on an NRB? I would imagine EMS boards expect you to be able triage these things and take something like this internally with some training. But I suppose I really can't speak for them.

The standard is 10-15lpm with NRB as already stated. If you need to flow less than 10lpm then use a simple face mask or nasal cannula.

A report of dyspnea and numbness/tingling, SpO2:99% + ETOH = hyperventilation.

We don't use simple face masks in my system, so I'm less knowledgeable about these. But wouldn't reducing the flow rate on an NRB be similar to turning it into a simple face mask?

If a simple mask isn't dangerous at lower flow rates, how would an NRB mask be dangerous? (At least dangerous enough to go prosecute a college EMT to the state EMS board.)

 

[AnthonyM83]

That's not a "golden rule" because that's actually a very poor way to judge if they are getting sufficient flow unless you're already pushing at least a normal minute ventilation through there. If they are getting 15 L/min or more and are sucking the bag in with each breath, you've got a major problem on your hands. Judging the adequacy of a flow rate based on the performance of a stiff plastic bag on a disposable mask likely assembed by a child in a third world factory is not something I would choose to admit to in court or in front of my medical director.

Maybe that's why some systems have it written into their educational guidelines, so people don't have to be embarrassed by it. We have that rule here, THOUGH, you ALSO, have to adhere to minimum flow rates for the device.

I feel a bit uncomfortable that you're jumping on people so quickly. The previous poster didn't say that rule is used for all situations. Whether you're using an NRB or BVM is judged separately. The monitoring of bag inflation is a guideline to determining whether you want 10, 12, or 15 liters per minute, since all 3 are within range (depending on the source). Within his post, he acknowledged 5 LPM seems low.

 

[medichopeful]

I just thought that I would give an update on the situation. I will be talking to the president of the club about this incident, as well as our faculty advisor to fill them in. After that, I will be talking to the two EMTs and the first responder involved, where I will get their side of the story. If their actions were intentional, I'll be having a serious talk with all of them about the dangers, recklessness, and legality of their actions. If they were not intentional, and were a mistake (everybody makes them), I'll give them an educational talking to about placebos, doing things without having a knowledge of their consequences, and the irresponsibility and legality of their actions. Either way, they will dealt with. The president of the club and the faculty advisor will both be filled in about everything.

I will also be keeping an eye on their patient care and their reports for the rest of the school year. If any similar incidents occur, I will be going through the process again, and will be going to the state OEMS as well.

Any thoughts or comments are welcome.

After talking to a member of this site, I'm actually going to be taking a much more educational approach to this, and not an accusatory approach. This is something I'm new at (being in charge of QA/QI), so any comment would really be greatly appreciated.

Thanks all!
Eric

 

[Veneficus]

I think we need to keep this in perspective.

Was a mistake made? Yes.

Does it need to be corrected? Yes.

Is it the life altering permanant disability or death? No.

These people are volunteer college students with probably the same 120 hours of training as Ricky Rescue Volunteer Fire Department. Only they are basically acting as glorified first responders who will in all likelyhood never have a patient who needs 100% oxygen.

They are not a "professional" agency of care providers, the primary purpose is likely educational.

Like the treatments of most EMTs, it is very hard to mess up in a really bad way.

They are not the sole agency responding and transporting. As I understand there is a ALS agency that serves as the primary responsible agency.

Some remediation and move on.

 

[Shishkabob]

We don't use simple face masks in my system, so I'm less knowledgeable about these. But wouldn't reducing the flow rate on an NRB be similar to turning it into a simple face mask?

A simple facemask essentially has an open port in the mask allowing room air to get mixed in.

Take an NRB, pop off one of the valves, and viola, simple face mask.

 

[Journey]

Originally Posted by AnthonyM83
We don't use simple face masks in my system, so I'm less knowledgeable about these. But wouldn't reducing the flow rate on an NRB be similar to turning it into a simple face mask?

Originally Posted by AnthonyM83
If a simple mask isn't dangerous at lower flow rates, how would an NRB mask be dangerous? (At least dangerous enough to go prosecute a college EMT to the state EMS board.)

A simple facemask essentially has an open port in the mask allowing room air to get mixed in.

Take an NRB, pop off one of the valves, and viola, simple face mask.

Is this what you were taught in EMT or Paramedic school? I guess RNs will have to start checking the O2 masks on patients coming or going on IFTs to ensure the correct flow is going for patient safety. I find it hard to believe that some EMTs would criticize RNs for something when it seems some in EMS make the same mistakes. Any RN who does not know the proper use of these devices can expect a write up and some education from their manager. Where is the oversight for EMTs and Paramedics to see that they know what they are doing or that they understand these very simple but important devices?

Usafmedic45 has given good explanations for the whys and hows. If you don't believe him maybe you should be finding a credible source to confirm what he has posted.

 

[Shishkabob]

Next, you'll be telling me a Capno-cannula is NOTHING like a nasal-cannula....


My bad for giving a simple explanation.


Get it? "Simple"? HA!

 

[Journey]

Next, you'll be telling me a Capno-cannula is NOTHING like a nasal-cannula....


My bad for giving a simple explanation.

What you are giving as a "Simple" or an attempt at a dumbed down explanation is not necessarily the correct one but rather just your own interpretation and not understanding all the factors. It is much like the quote I used from an EMT on another forum which a couple of people on this forum seemed to also take offense and probably because someone like you might have told them this was what high flow oxygen was.

Quote:
High flow Oxygen is any flow rate where you can hear the oxygen flow from the tubing.

To understand some oxygen devices you must also understand deadspace ventilation which is taught in college anatomy and physiology classes.

Knowing the correct explanation will save you or someone else on this forum some embarrassment and may even keep you from doing harm to your patients.