Resp failure ift pt
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Someone that starts sleeping isn't becoming somnolent? This patient is tachypnic, and that's a variation of labored breathing. People can stay awake and alert all while going well down the respiratory failure pathway and becoming hypercapnic. They then just start feeling tired, they want to sleep and sometimes start nodding off. When that happens, these patients can be very close to needing significant support... like intubation and a ventilator... I've seen this more than once in patients on BiPAP. Our community uses CPAP in the field and when we get those patients, we transition them to BiPAP very quickly because we know this improves ventilation, not just oxygenation. If we see those patients starting to tire out, that's when we seriously consider RSI, before things get really bad and require an emergent RSI because they're within minutes of a respiratory code.
Clearly and obviously I wasn't there looking at the patient myself but when I saw what you wrote above, that made me VERY concerned.
ETA: One of the reasons I get concerned is that when patients like this start getting tired/somnolent, their respiratory rate can slow down a little bit and appear to be a more normal rate. At a glance, this looks like the patient is simply "just" tired and improving when what's happening is that the patient's CO2 level is climbing, the patient is physically tiring from breathing so fast for a while, and is likely fast approaching ventilatory failure. It's a very deceptive thing, one that you have to be acutely aware of and once you see it and realize it for what it is, you start seeing it as it occurs and take appropriate action.
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Your totally correct and i totally contradicted myself. My apologies.
I would more correctly state it as not really "sleeping" but her entire baseline being a just "responsive to verbal stimuli" from the get go sorta deal. Which still sounds bad.....and your 100% correct...She very well COULD have been going the exact route you stated and more than likely was as she really shouldnt have been on CPAP for a transfer that long. To me i didnt see a REAL mental decline or anything but more of just her being calm and having eyes closed for pretty much the duration of transport. Soon as i spoke to pt or did anything she'd aknowledge me immediately and appear fine & A&0X4, tracking etc.
And again, sorry to contradict myself or change stories. I guess hindsight is always 20/20 sorta thing.
Anyways. im the first one to say that id LOVE to know ALOT more and be way more comfortable with advanced resp such as differences in CPAP vs bipap Etc etc.....So i greatly appreciate yours and everyones input and knowledge on the subject sir.
I would more correctly state it as not really "sleeping" but her entire baseline being a just "responsive to verbal stimuli" from the get go sorta deal. Which still sounds bad.....and your 100% correct...She very well COULD have been going the exact route you stated and more than likely was as she really shouldnt have been on CPAP for a transfer that long. To me i didnt see a REAL mental decline or anything but more of just her being calm and having eyes closed for pretty much the duration of transport. Soon as i spoke to pt or did anything she'd aknowledge me immediately and appear fine & A&0X4, tracking etc.
And again, sorry to contradict myself or change stories. I guess hindsight is always 20/20 sorta thing.
Anyways. im the first one to say that id LOVE to know ALOT more and be way more comfortable with advanced resp such as differences in CPAP vs bipap Etc etc.....So i greatly appreciate yours and everyones input and knowledge on the subject sir.
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A word to the wise, don't seek feedback for calls and then say "we did the best we could." Maybe, maybe not. Perhaps it would have been better for the patient to remain at the facility on BiPap until a CCT team could have transferred the patient. Don't take patients that are not appropriate just because "we do what we have to do." If you are not well versed in the management of these patients, don't take them. It's a common pitfall of the newer paramedic to say "well we have to get them out of here." For the most part, you do not. The local facility in many cases can still provide more care than an ambulance can.
If you are going to take these patients when you know you don't have the resources to manage them, at least ask yourself "do I understand what is going on with this patient fully? Do I grasp the physiology and understand how it will change and how I might alter things?" If not, well you can guess what to do.
Very true tigger and i appreciate the advice. i wasnt trying to come off like that after asking for feedback / advice so my apologies.
While there HAVE been a few pt transfers denied by medics....The unfortunate general consensus is that unless the Transfer is SO unsafe and the pt is SO critical that denying a transfer will be a quick way to not have employment anymore. Ive witnessed it multiple times and its just a beginning to an end.
Pt care comes first. But obviously so does someones livelyhood.
Again, not making excuses. Just trying to make a clear picture.
While there HAVE been a few pt transfers denied by medics....The unfortunate general consensus is that unless the Transfer is SO unsafe and the pt is SO critical that denying a transfer will be a quick way to not have employment anymore. Ive witnessed it multiple times and its just a beginning to an end.
Pt care comes first. But obviously so does someones livelyhood.
Again, not making excuses. Just trying to make a clear picture.
hometownmedic5
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You are making excuses, step for step. I get it, "do the wrong thing or you're fired" is a systemic ems problem, but the solution isn't complicity, it's defiance. Which is worth more, your current employment, or your license? The state won't care that your company "made you do it". You do it, you own it. Make your choices from that starting point from here going forward.
MonkeyArrow
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That is such an overblown line. The state will not be coming for anyone's license because they transported a respiratory distress patient on CPAP and the patient deteriorated en route.
hometownmedic5
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Ok. You do you. I know two former paramedics who “did what they had to do to get the call done” and lost their licenses because of it, directly. There was no long line of clinical failures and remediation on either records. They took a transfer for a stroke patient on a CCB infusion to control their hypertension. That truck didnt have a pump, which had been reported previously but was not reported that day. That hospital doesn’t allow ems to borrow pumps. They decided to eyeball it(which they did poorly), and failed to correct the rising blood pressure during the transfer, caused by the inadequate medication delivery. The patient suffered what could charitably be described as a negative outcome. The family, who had been at the sending facility to see the patient immediately before the transfer and was waiting at the receiving facility so they could see the result of “getting the call done” at all costs, inquired of the state ems dept if this call was handled appropriately. The state ems dept felt it was not, and there are now two less paramedics. The company was issued a stern warning, but was not directly damaged, since the pump was not reported as missing that day.
I don’t carry water for my employers. They either give me the tools to do the jobs they ask me to do, and I do them; or they don’t, and I don’t. I’m not going down for them. You can choose to do it whatever way you want, but the sympathy tank is going to start running dry for people who get burned faking their way through called. The idea here is to increase professionalism, not stagnate at the duct tape and BS phase we’ve been at for so many years.
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Oof. That’s awful.
Perhaps these are not the most comparable cases, but the more you ride the edge, the more likely you are to take a bigger chance.
hometownmedic5
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I respectfully disagree. Both are pretty standard calls, easily done most of the time with the proper equipment, but nearly impossible to do correctly without. Both of these patient could have been managed by a competent, properly equipped non CC paramedic; but both calls went pear shaped because both crews were inadequately equipped for the call they were on, knew it, decided to press on regardless, and both patients had a poorer than expected outcome that, on the surface appears to have been preventable in both cases.
i don’t see much more than an inch of daylight between these calls, but I’d be curious to hear where you feel they differ(aside from the ultimate outcome, of course).
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Where they differ is that in the OP's scenario, he was using FDA-approved, company-supplied equipment in accordance with protocols approved by his medical director and in a manner consistent with his training and the instructions provided by the manufacturer of the equipment. Maybe it wasn't the best equipment to use for that particular patient, but it's an approved device and what he was supplied with, and it would probably be difficult to argue that he deviated from his training or from the standard of care.
Eyeballing a CCB infusion however in a critical patient, however…..is a non-starter all day long, no matter who you ask. It's clearly not the standard of care, not the way they were trained, not in their protocols, and good luck finding anyone who will admit on the record that they'd do the same thing.
hometownmedic5
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I’m not certain you’re wrong that the manufacturer intended and approved this device for use in the IFT world, but I’m not certain you’re correct, so I will investigate that point further.
Moving on from that, my original point was that any system(so paramedic, company, affiliate hospital medical direction, and county/region/state ems agency) that feels that transferring patients on an crash cpap mask, whether to save time, to save money on a vent, to circumvent CC requirements, etc is a system to run sideways away from, screaming. Whether the medics themselves were negligent(criminally or civilly) I guess would come down to the details, but regardless of the rules and regulations we’ve arrived at the Nuremberg Bifurcation. you can go left, do what you know is wrong and when it all goes haywire, hide in the folds of your employers skirt and say “I was just doing what I was told to do”; or you can go to the right and do what’s right for the patient(and you, really), which may cost you the job(ultimately or immediately), but A) wont kill anybody and B) lets you keep your license and go in search of a better job.
Moving on from that, my original point was that any system(so paramedic, company, affiliate hospital medical direction, and county/region/state ems agency) that feels that transferring patients on an crash cpap mask, whether to save time, to save money on a vent, to circumvent CC requirements, etc is a system to run sideways away from, screaming. Whether the medics themselves were negligent(criminally or civilly) I guess would come down to the details, but regardless of the rules and regulations we’ve arrived at the Nuremberg Bifurcation. you can go left, do what you know is wrong and when it all goes haywire, hide in the folds of your employers skirt and say “I was just doing what I was told to do”; or you can go to the right and do what’s right for the patient(and you, really), which may cost you the job(ultimately or immediately), but A) wont kill anybody and B) lets you keep your license and go in search of a better job.
VFlutter
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I do not envy EMS crews that work in areas without available ground CCT. A lot of this falls back on the sending facilities whom push to transfer patients out at any cost. These smaller facilities may not have all the specialties available that a patient needs however they are still can provide appropriate care until true critical care transport can be arranged, weather clears for HEMS, etc more so then throwing them in the back of an business and hoping for the best. And unfortunately I have seen many ER providers not know, or care, that there are very significant differences between standard ALS equipment and care vs CCT as long as the patient is out the door.
Although many patients may do fine being transported on a crash CPAP or CMV transport vent that does not mean it is ideal nor that there will be some whom will deteriorate when they would have been better off waiting in the ER until more appropriate arrangements could be made. Let the hospital bear that responsibility and risk.
Although many patients may do fine being transported on a crash CPAP or CMV transport vent that does not mean it is ideal nor that there will be some whom will deteriorate when they would have been better off waiting in the ER until more appropriate arrangements could be made. Let the hospital bear that responsibility and risk.
I think that the other piece that should be considered is the clinical urgency of the situation and the available resources at the time, neither of which I think we were actually given a good picture of.
For example about a year and a half ago my current center had an adult patient who had been shot in the chest dropped dropped off at the front door. We are a downtown tertiary referral center but of low trauma designation. We have pediatric CT surgery but not adult coverage available overnight.
The patient was rapidly deteriorating in the trauma room despite aggressive medical management. Typically we would have sent this patient by CCT transport to the level 1 center that is about 10 minutes away. Unfortunately due to call volume across the area the soonest we would get a HEMS unit was about 45 minutes, and ground CCT was over an hour. We already had acceptance from the level 1, the surgeon was waiting in the ED and they already had the OR getting prepped waiting for us.
We had a local paramedic 911 crew who had just brought us another patient that told us that they could take the patient, but that they could not manage transfusions or the chest tubes. This system does not typically do IFTs, in fact that center contracts their IFTs out to a private ambulance company.
I got approval from our administration to ride with them to manage transfusions and the chest tube, and the medic would take the rest of the patient; their on duty supervisor approved the same for them. Our doc approved this and specifically wrote for me by name to ride with the bus. We took the patient emergent and ultimately had a good outcome in large part due to his rapid transport.
This ultimately got reviewed by multiple levels of quality, peer review, legal, risk management, and so on. The summary of the various opinions and findings were essentially that this did not reflect an ordinary standard of care and is not a routine what we should be using by any means. They also agreed that given the circumstances that in this case the patient was given appropriate care, and that we were covered for legal concerns like scope of practice and insurance coverage.
These kinds of things do have a lot of gray area, and there are a lot of dynamic factors that come into play. Had this patient not been rapidly deteriorating then it would have been a much different situation.
We also would have justified to wait for HEMS/CCT to show up, although the patient would have had a high chance of dying. What is legally okay is not always in the best interests of the patient.
For example about a year and a half ago my current center had an adult patient who had been shot in the chest dropped dropped off at the front door. We are a downtown tertiary referral center but of low trauma designation. We have pediatric CT surgery but not adult coverage available overnight.
The patient was rapidly deteriorating in the trauma room despite aggressive medical management. Typically we would have sent this patient by CCT transport to the level 1 center that is about 10 minutes away. Unfortunately due to call volume across the area the soonest we would get a HEMS unit was about 45 minutes, and ground CCT was over an hour. We already had acceptance from the level 1, the surgeon was waiting in the ED and they already had the OR getting prepped waiting for us.
We had a local paramedic 911 crew who had just brought us another patient that told us that they could take the patient, but that they could not manage transfusions or the chest tubes. This system does not typically do IFTs, in fact that center contracts their IFTs out to a private ambulance company.
I got approval from our administration to ride with them to manage transfusions and the chest tube, and the medic would take the rest of the patient; their on duty supervisor approved the same for them. Our doc approved this and specifically wrote for me by name to ride with the bus. We took the patient emergent and ultimately had a good outcome in large part due to his rapid transport.
This ultimately got reviewed by multiple levels of quality, peer review, legal, risk management, and so on. The summary of the various opinions and findings were essentially that this did not reflect an ordinary standard of care and is not a routine what we should be using by any means. They also agreed that given the circumstances that in this case the patient was given appropriate care, and that we were covered for legal concerns like scope of practice and insurance coverage.
These kinds of things do have a lot of gray area, and there are a lot of dynamic factors that come into play. Had this patient not been rapidly deteriorating then it would have been a much different situation.
We also would have justified to wait for HEMS/CCT to show up, although the patient would have had a high chance of dying. What is legally okay is not always in the best interests of the patient.
Gurby
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When in doubt about whether you should take a transfer that seems over your head, IMO you should call medical control. Push the liability onto someone higher up the food chain. Let the MD decide whether the transfer is appropriate or not.
hometownmedic5
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Absolutely, but even that isn’t an infallible option. Here’s another fun tidbit from my career, tangentially. BLS discharge to home. Upon arrival, while getting the patient situated, the attendant notices the patient still has an IV in. Not a problem, a quick call to the doc should fix this wagon(this was back in the days when you needed med con for a lot more things than today). Attendant calls the doc, tells the story, doc says sure, pull the line, any problems, call me back. The attendant pulls the line, there are no complications, cue the music, right?
The attendant was a Basic, if you had not sorted that bit out yet. She neglected to mention that tidbit to the doc. Her partner had...not so much turned her in but made it clear, in the moment, to those that cared that he was not a participant in this event. She was fired, but it never left the shop. No license stress.
So yeah, you should always call the boss when you need too; but if you gloss over or outright omit(intentionally or unintentionally) a crucial detail(like your level of licensure, or the specific type of cpap device you‘re going to use, or that you intend to drip and pray your CCB infusion etc), it then stops being the safety net it is supposed to be.
Training is good, education is better, oversight and supervision play a critical role in an efficient EMS operation; but none of it matters a tinkers damn if the system is designed in such a way as to allow and encourage recurrent institutional failure. I’ll take a patient 10 minutes to the hospital on a crash CPAP(as designed), and if I was in the same boat as the homeboy ambulance gsw I might transfer a patient the same distance on the same mask if there was truly no other option; but this isn’t that. The patient could have been knocked down and tubed if need be to secure the airway and get back to a respiratory happy place, but it sounds like they were doing pretty ok in the sending ED And it was poor clinical decision making, ignorance perhaps in EMS protocols and equipment(which is a problem if you’re an ER doc expected to give orders to ems), and straight up bad paramedicine that led to the patients deterioration. That, multi faceted, multi level, cross organizational error is, in short, an institutional failure.
The other factors to mention is that our company is now owned by the sending facility and our med control is the e.r. doctor.
Our company runs all 911s as well as ifts in the area and we have complete control. There is only one cct unit owned by another company that isn't ALLOWED to enter our area.
Peak. Your story reminds me about how the transfer system worked in Hawaii in the e..r. I worked at. There was a dedicated ift company but they were usually way too slow so when we had something urgent we contacted city and county 911 to have them there in minutes and sometimes give r.n. riders. It always worked well.
Our company runs all 911s as well as ifts in the area and we have complete control. There is only one cct unit owned by another company that isn't ALLOWED to enter our area.
Peak. Your story reminds me about how the transfer system worked in Hawaii in the e..r. I worked at. There was a dedicated ift company but they were usually way too slow so when we had something urgent we contacted city and county 911 to have them there in minutes and sometimes give r.n. riders. It always worked well.
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I very highly doubt that the manufacturer specifies whether or not this device is appropriate for use in the IFT setting. They may though, who knows? We use devices and drugs for off-label uses all the time. As long as it’s a common practice and a generally accepted use and for paramedics, if it is authorized by your protocols, no one is going to accuse you a breach of duty and therefore there’s probably no increased individual liability risk.
The point is, you asked what the differences were between the OP’s scenario and the one you described, and there are really big differences from a medico-legal perspective.
The two scenarios would be much more analogous if the OP had taken the patient off CPAP altogether and substituted a NC, or if the paramedics on the stroke transport had at least used a dial-a-drip.