Resp failure ift pt

[Lemur]

Oops. I Knew <35 was alkalotic. My bad mixing them up. ..... *sheepish grin*

End-tidal CO2 is really good for monitoring tube placement and also good as a rough look at ventilation- but often it doesn’t correlate well with the blood gasses. Without those, you don’t really know the patient’s underlying acid-base status. A good guess would be she is tachypneic from a primary respiratory process. Another would be she was acidotic and compensating with her breathing. Or as someone else mentioned, a diffusion defect or shunting. Hard to know. But from your perspective transporting her, honestly just keeping her sats and in an acceptable range is fine- especially if her mentation intact. Sounds like you handled the situation just fine within your training.

 

[Lemur]

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.

Wait really? We don’t know their scope of practice and if their license would actually be in any real danger. What we probably all know too well is that there isn’t much choice when I comes to turning down calls while working for a private ambulance service. I care for patients that I don’t fully understand all the time, and it doesn’t put my license in danger. As long as I operate without my training and experience and do the best I can while getting more help, that’s often all we can do. What might not be ok in this situation is refusing to transfer, delaying definitive care for the patient, and getting internally disciplined all at once.

 

[VFlutter]

End-tidal CO2 is really good for monitoring tube placement and also good as a rough look at ventilation- but often it doesn’t correlate well with the blood gasses. Without those, you don’t really know the patient’s underlying acid-base status. A good guess would be she is tachypneic from a primary respiratory process. Another would be she was acidotic and compensating with her breathing. Or as someone else mentioned, a diffusion defect or shunting. Hard to know. But from your perspective transporting her, honestly just keeping her sats and in an acceptable range is fine- especially if her mentation intact. Sounds like you handled the situation just fine within your training.

PaC02 - ETC02 gradient is often overlooked. With shock, pulmonary disease, V/Q mismatch etc the less reliable an absolute ETC02 value becomes. Still beneficial to trend in response to treatment.

 

[hometownmedic5]

Wait really? We don’t know their scope of practice and if their license would actually be in any real danger. What we probably all know too well is that there isn’t much choice when I comes to turning down calls while working for a private ambulance service. I care for patients that I don’t fully understand all the time, and it doesn’t put my license in danger. As long as I operate without my training and experience and do the best I can while getting more help, that’s often all we can do. What might not be ok in this situation is refusing to transfer, delaying definitive care for the patient, and getting internally disciplined all at once.

No. Just no. You are incorrect, and this is the problem we need to fix.

You always have a choice. You may not like one or more of the options, and thus feel as if you don’t have a choice, but you always have a choice and when the piper sticks his hand out, he doesn’t give a hoot whether you followed your companys bad management practices into the ground. You’re still the guy that was in the back of the truck, treated the patient, and signed the form.

Now, if it turns out that they(the medics in that system) have been duly authorized by their medical control doc to use crash CPAP for an IFT patient on BiPAP, then they(the medics) are absolved of their responsibility(for that single part of the equation), but being complicit in a bad system you don’t have the authority to change doesn’t mitigate the fact that you chose to work there, and you chose to do a call you were ill equipped to manage. Both of those are choices.

I have refused several IFTs while working for privates because they exceeded my capacity to manage them and it would have placed the criminal and civil liability on my head had I undertaken them. I have been fired zero times for it because I don’t play that particular card when I just don’t want to do the call. That card only comes out when, imho, the patient is truly better off waiting at the sending facility for CC/HEMS, and I always have my OLMC doc onboard before I refuse the call. Ive also spent over two hours anchored at the ED getting a patient ready to travel.

You don’t have to do the job in a hacky way just because you work for a private, and if you work for a private that’s going to put you in those kinds of boxes as a matter of routine business, you have the choice to seek employment elsewhere. Your safety and ability to make a living far exceeds the value in any one job, or any one patient, and until that is the anthem of EMS, we’re going to keep getting **** on by our bosses and just saying “well, thats life in the privates I guess”.

 

[Lemur]

No. Just no. You are incorrect, and this is the problem we need to fix.

You always have a choice. You may not like one or more of the options, and thus feel as if you don’t have a choice, but you always have a choice and when the piper sticks his hand out, he doesn’t give a hoot whether you followed your companys bad management practices into the ground. You’re still the guy that was in the back of the truck, treated the patient, and signed the form.

Now, if it turns out that they(the medics in that system) have been duly authorized by their medical control doc to use crash CPAP for an IFT patient on BiPAP, then they(the medics) are absolved of their responsibility(for that single part of the equation), but being complicit in a bad system you don’t have the authority to change doesn’t mitigate the fact that you chose to work there, and you chose to do a call you were ill equipped to manage. Both of those are choices.

I have refused several IFTs while working for privates because they exceeded my capacity to manage them and it would have placed the criminal and civil liability on my head had I undertaken them. I have been fired zero times for it because I don’t play that particular card when I just don’t want to do the call. That card only comes out when, imho, the patient is truly better off waiting at the sending facility for CC/HEMS, and I always have my OLMC doc onboard before I refuse the call. Ive also spent over two hours anchored at the ED getting a patient ready to travel.

You don’t have to do the job in a hacky way just because you work for a private, and if you work for a private that’s going to put you in those kinds of boxes as a matter of routine business, you have the choice to seek employment elsewhere. Your safety and ability to make a living far exceeds the value in any one job, or any one patient, and until that is the anthem of EMS, we’re going to keep getting **** on by our bosses and just saying “well, thats life in the privates I guess”.

I am resisting the urge to ignore this out of hand because I think there is some value in having a discussion.

I’m not talking about an hypothetical scenario where a paramedic is facing the decision to transport a patient that is definitively outside of their scope of practice (by the way, a wiser medical ethics still demand analysis here, imagine a disaster scenario). I’m talking about quite a different thing- a potentially unstable patient that needs to go somewhere else for definitive care, where during transport you may have less than ideal equipment at your disposal but are still wholly capable of managing the patient within your scope of practice for a limited period of time.

Very often, when transferring patients to another hospital for higher level of care, we have incomplete information and can only make a snap judgment as to if transfer is safe given the circumstances and in the best interest of the patient. Most of the time it is, and we always accept a small risk of deterioration during transport that is out-balances by potential benefit the patient can receive wherever they are going. If you are routinely refusing to transport these people because you have a different form of non-invasive ventilation that is not likely to result in harm, that’s unfortunate. And your service be correct in attempting to dissuade making this call.

The longer I’ve been around and the further I get in my training, the less absolutist and black or white my thinking has become. Especially in a scenario like the OP’s. Your comparison to “eyeballing” some cardene on a head bleed is not equivalent in any ethically salient way.

 

[hometownmedic5]

It would appear we have reached an impasse, as you and others want to make excuses for hacky practice for the sake of profitably and I will not. Yes, I see things as black and white most of the time, because most shades of grey distill down to BS. I simply am not willing to risk my personal safety, or that of those in my charge, or my capacity to make a living because my employer won’t cough up a buck. If others want to “take one for the team”, well, I hope theres still a chair for them when the music stops.

 

[RocketMedic]

Wait, was this patient transferred on a machine or a crash CPAP mask running straight off an O2 tank? It sounds like you did a CPAP transfer with a boussignac or pulmodyne type mask, and I honestly didn't think there was a system in existence that would allow such a thing.

That’s how we’re stuck doing it here thanks to the way it’s always been.

life is grey and I think you’re horribly wrong Hometownmedic.

 

[Carlos Danger]

It would appear we have reached an impasse, as you and others want to make excuses for hacky practice for the sake of profitably and I will not. Yes, I see things as black and white most of the time, because most shades of grey distill down to BS. I simply am not willing to risk my personal safety, or that of those in my charge, or my capacity to make a living because my employer won’t cough up a buck. If others want to “take one for the team”, well, I hope theres still a chair for them when the music stops.

No one here has made excuses for hacky practice, or advocated for "taking one for the team" in a way that jeopardizes anyone's safety. The fact that you interpret any of these posts that way supports your explanation that you do indeed choose to view things as black or white.

That is certainly your prerogative, but insisting on viewing things through that lens at every turn is going to make it difficult for you to come to grips with and communicate about many of the realities of the world that we live in, especially (though certainly not only) in medicine, where almost nothing is black and white.