OP airway or not

[Lozenger19]

Just been doing my annual assessment for St John Ambulance. The scenario I had was:

You are alone with a basic first aid kit and no radio,

You hear someone calling for help, so you head over.

You find a male who is complaining of chest pain and is nauseous.

You give aspirin for the pain, but he collapses - unconscious, NOT breathing (no defib or airway aids present)

You start Chest compressions and mouth-mouth. Casualty vomits (manual suction is in first aid kit).

Casualty is still not breathing. This continues for 10 mins with vomiting every 2 mins.

• would you insert an OP air way (which has appeared out of nowhere)?

I decided NOT to OP, as casualty vomiting & as a result, I have FAILED my assessment.


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[WolfmanHarris]

I would have considered "mouth to mouth" to be the major error. Especially given the increased emphasis on good compressions, not taking proper BSI and exposing yourself in that way would be more of a problem to me.

 

[Cup of Joe]

I would have considered "mouth to mouth" to be the major error. Especially given the increased emphasis on good compressions, not taking proper BSI and exposing yourself in that way would be more of a problem to me.

Agree.

I would have done compressions, first and foremost.

If I had a cpr mask or BVM, I would use the airway. I could see getting away without it if you're getting good chest rise though.


Took me a while to find a legit source that still has the story but:
http://abcnews.go.com/Health/video/deputy-dies-after-performing-cpr-on-infant-13156295

 

[BEorP]

I would suggest that really it doesn't matter whether we think you were right or wrong (or whether the scenario is even at all realistic). In your situation, in terms of passing, all that matters is what your St. John evaluator says.

Now, if we want to just try to use the scenario as a learning experience, I think there are a few points that should come out of it (some already raised by other responders).

To start with a few operations comments:
- A first aid kit (at least in a setting like St. John or other event medical) should always have a pocket mask in it. As an instructor, I would want to test my people the way they will actually practice in real life so I would not ask someone to do a scenario without that.
- In a setting like St. John, you will always have some way to communicate with the outside world (i.e. radio or cell phone). Again, it is unrealistic to be in the situation you were in and I personally wouldn't test someone like this.
- Given that you had no communication though, one of my biggest concerns would be to get 911 (or the local emergency number, not sure where you're located) called. Without getting that started, you're never going to get a defib to him and without that his chance of survival shifts from slim towards none. Figuring out some way to get help on the way would have been one of my top priorities if I were doing the scenario you describe.

Looking more at the actual medical treatment part of things:
- Mouth to mouth (especially if someone is vomiting) puts you at risk. Is that risk really worth it knowing that their change of survival regardless is so slow?
- What exactly was the vomiting like? Did they claim that it was shooting out at you or a more realistic scenario of it appearing in the mouth? Would you have been able to suction with the OPA in?
- If he was only vomiting every two minutes, could the OPA have gone in and been taken out if suction was needed?
- Were you able to ventilate the patient effectively? How do you know that your ventilation was effective?
- You mentioned giving ASA for the pain. What did you hope that the ASA would do to help this patient?


My final comment is in regards to doing any kind of practical testing in first aid/first responder/paramedicine. If there is an assessor there watching you do everything, it is often important to justify your decisions in the scenario. So for your scenario, it may have helped to have said during the scenario, "I'm electing not to use an OPA for this patient because I am able to effectively ventilate with manual manoeuvres and the persistent vomiting may be more difficult to clear with the OPA in." Saying this during the scenario shows that you have thought it through and not simply forgotten about the OPA (and then come up with the justification afterwards).

Again though, don't stress over the failing assessment. Instead, use the scenario as a learning experience to become a better provider. Think about some of the questions I've raised (no need to respond to them here) and hopefully that can help to prompt further learning. Good luck!

 

[Lozenger19]

The first aid kit I was using didn't have one in, but I would have used it if present

- In a setting like St. John, you will always have some way to communicate with the outside world (i.e. radio or cell phone). Again, it is unrealistic to be in the situation you were in and I personally wouldn't test someone like this.

I agree. This was unrealistic as I was told that I had forgotten my mobile, so there was no way I could call/ get help

- Mouth to mouth (especially if someone is vomiting) puts you at risk. Is that risk really worth it knowing that their change of survival regardless is so slow?
- What exactly was the vomiting like? Did they claim that it was shooting out at you or a more realistic scenario of it appearing in the mouth? Would you have been able to suction with the OPA in?

- Were you able to ventilate the patient effectively? How do you know that your ventilation was effective?

ok- maybe mouth to mouth wasn't the best Thing to do, but I had no BVM. I have not been tought how to suction with OPA in place, so couldn't do that.

The assessor told me that ventilations were affective.

My final comment is in regards to doing any kind of practical testing in first aid/first responder/paramedicine. If there is an assessor there watching you do everything, it is often important to justify your decisions in the scenario. So for your scenario, it may have helped to have said during the scenario, "I'm electing not to use an OPA for this patient because I am able to effectively ventilate with manual manoeuvres and the persistent vomiting may be more difficult to clear with the OPA in." Saying this during the scenario shows that you have thought it through and not simply forgotten about the OPA (and then come up with the justification afterwards).

Again though, don't stress over the failing assessment. Instead, use the scenario as a learning experience to become a better provider. Think about some of the questions I've raised (no need to respond to them here) and hopefully that can help to prompt further learning. Good luck!

I did mention all of the above, but my assessor said "that's no excuse for not using OPA, I would have still placed one in".

I am going to challenge their decision and ask if there is any chance I can re-do my assessment



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[mycrofft]

By all means, challenge.

However, if the pt has trismus, which coupled with vomiting occludes the airway and prevents successful oropharyngeal suctioning, if the OPA doesn't go in quickly, you lose the opportunity to suction and ventilate.

Many places would not allow folks to administer aspirin. In fact, the aspirin could cause the vomiting.

 

[Lozenger19]

We are allowed to administer aspirin in St John.


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[Melclin]

Hey Lozenger,

I'm a Johno as well as a paramedic, and I've both sat and administered a few of these scenarios.

I always told my johnos that I wanted them to understand the reasons behind what they were doing so they could make an educated decision on whether or not to do it. If they came up with a reason that was well thought out but ultimately wrong, I would prefer that and correct whatever underlying knowledge deficit caused the issue, to them regurgitating some dot points from one of those ridiculous power point presentations, that just happened to be right. The dot points always work well in scenarios but rarely in real life. If you can reason things out on the spot and reason well, its far better tool, even for a first aider, than proficiency in scenarios.

Its sounds like a disjointed scenario. An OP wasn't ganna fix this guys situation. If you can ventilate without one, then you don't need one. Some of the trainers are obsessed with them because they were taught that they had to use them and its as simple as that. There is not a lot of grey in those people's minds when it comes to first aid, which is of course absurd because is pretty much all grey.

That said. From having held these scenarios, there is a check list of things you're supposed to do. Just memorise it for the scenario and leave it at that.

The out on patrol scenario is a common one. You call for help, or have a bystander do that, start basic CPR 30:2. When the "advanced resus" gear arrives you transition to that. Defib first, then BVM/OPA. Its supposed to show that you are proficient in both basic and advanced resus. Just do what you're told in your re-acred and use you brain later.

I don't know why you would have manual suction but not airway adjuncts or defib in a basic kit. Whats the go there?

 

[mycrofft]

No one restocked the kit?

And no one stole the V-Vac suction because it is worthless.

 

[DV_EMT]

ABC.... if the patient is unresponsive but tollerates the OPA then keep it in. if he start to vomit or is vomiting for reasons unrelated to the OPA, pull it out so that he doesnt aspirate.... then reinsert another?

 

[socalmedic]

And no one stole the V-Vac suction because it is worthless.

lies, the v-vac works great if you know how to use it. I have used it many times, just makes your hand tired...

 

[Bosco836]

Just been doing my annual assessment for St John Ambulance. The scenario I had was:

You are alone with a basic first aid kit and no radio,

You hear someone calling for help, so you head over.

You find a male who is complaining of chest pain and is nauseous.

You give aspirin for the pain, but he collapses - unconscious, NOT breathing (no defib or airway aids present)

You start Chest compressions and mouth-mouth. Casualty vomits (manual suction is in first aid kit).

Casualty is still not breathing. This continues for 10 mins with vomiting every 2 mins.

• would you insert an OP air way (which has appeared out of nowhere)?

I decided NOT to OP, as casualty vomiting & as a result, I have FAILED my assessment.


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As a unit training officer for SJA (Canada), perhaps I can offer a bit more insight into this scenario.

An OPA is, under the AMFR curriculum, a critical intervention, to be done within the primary survey if a casualty is unconscious (and is able to tolerate the OPA/has no gag reflex).

Even if the casualty is vomiting, the OPA can be suctioned, or even removed (temporary and quickly suctioned/cleaned if need be) and reinserted. I see that you have not been trained how to suction around an OPA/with an OPA in place. I suggest that you bring this issue to the attention of your unit training officer who can hopefully provide more insight with respect to this skill.

In your scenario, the casualty was vomiting every two minutes...this still leaves another 1.8-1.9 minutes where the casualty was not vomiting where the OPA would have been able to provide assistance with better maintaining an airway.

Although the OPA certainly is not the be all and end all in the real world (and likely would not have benefited this casualty without access to early defib and early advanced care), it is still part of the protocol, and as such, must be followed - especially on a scenario when every move is being evaluated. Moreover, I'm a bit concerned that your instructor/evaluator never raised an issue with providing mouth to mouth without any sort of barrier device. I can't imagine a SJA kit that has a v-vac in it, OPAs, etc. but no pocket mask/BVM?

It sounds like that the scenario has some critical faults in it (as others have already identified - i.e. no radio? no cell phone?). With that said, chalk it up to a learning experience and move on. I'm sure that virtually everyone has failed a scenario at one time or another. The important thing is to learn from the mistake in the future, and realize that you are human - mistakes are going to happen.

 

[Lozenger19]

Thanks bosco836

I know you were trying to help, but I actually feel worse after reading your post. (hard to explain)

I have challenged the decision and am waiting for my CHQ to finish their investigation


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[Bosco836]

Thanks bosco836

I know you were trying to help, but I actually feel worse after reading your post. (hard to explain)

I have challenged the decision and am waiting for my CHQ to finish their investigation


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Terribly sorry to hear that. That was certainly not my intention.

One of the biggest issues I have with scenarios is that - its so hard to replicate real world conditions, and as a result, account for real world judgment. I'm sure you're likely a fine and competent provider - but even the best can make decisions that don't necessarily satisfy the evaluator. Even amongst evaluators, there tends to be some inconsistencies.

Hang in there! I'm sure things will work out in the end.

 

[mycrofft]

Not lie, V-Vac has some significant problems

1. The thin rubber one way flutter valve in receiver will rot or get stiff, causing air to go in and out, not in and in. The material is like that of a rubber glove. I threw out twenty of the receivers that had sat in kits for five years, every single one was defective.
2. None of the females I worked with could get their hands around it to work it properly.
3. The little red safety cap on the end of each suction "tip" is not attached (or didn't used to be) so if it is accidentally left on in the heat of the action it comes off in the airway, as was cited here some years ago (happened to the then-Sarpy County Nebraska EMS director if I recall).

 

[mycrofft]

To add to Bosco's comment

Make sure you can use the (Berman) "I-Beam" shaped airways instead of the closed (Hudson) type. To clear a Hudson you either have to remove it and blow it out somehow, somehow establish a seal with the suction tubing and suck it out, or have those little thin flexible suction handpieces you can snake in, a tonsil (Yankauer) tip won't do it.

If the OP is the right size, chances are it won't be aspirated or ingested. If it is causing vomitting/gagging, maybe the OPA is no longer needed, put pt on his/her side.

 

[Lozenger19]

Sorry to bring this to life again.

I have had the results from the challenge.

I WON.

This means I now have my med gases qualification back


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[Bosco836]

Sorry to bring this to life again.

I have had the results from the challenge.

I WON.

This means I now have my med gases qualification back


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Congrats. I'm glad you were able to get your qualification back, especially given the (very poor) scenario you were given to test in.

Hopefully you gained some new insight and were able to take some positive learning experience away from this whole mess.

Best of luck in the future!