the 100% directionless thread

[Handsome Robb]

Vent as much as you need to, it is therapeutic (better with a beer) but make sure you also recognize that most of this is on your head, not your company. While the hospital certainly didn't do you any favors, there were plenty of things you could have done to smooth the trip.



45mcg is a pretty low dose for propofol; no wonder she was waking up. And 10mg of versed, in someone who's already having issues with their heart...no wonder her pressure dropped. That's the hospitals fault, but, what did you do to correct this? Are you allowed to adjust the drip rate or provide your own sedation? If so, with what? In the future it's worth "asking" if they want you to give something like fentanyl or ketamine (if you have it) instead of versed for some patients. It may not change things, but your job is still to be a patient advocate.



Her waking up in the cath lab goes squarely on you. Continued sedation is your responsibility; did you have your sedative of choice right there, drawn up and ready to go? If not, why? Why was your propofol drip turned off before theirs was ready? In the future you need to be willing to stand up for the patient and what they need; part of that is making sure that the hospitals equipment is ready to go, and part of that will be telling them how much of a sedative the patient is getting. The staff being pissy because you didn't know the exact drip rate is a bit of a cop-out for them; if they can't figure that out that's a problem. But...if they are using the same concentration of a drug as you that does make it go smoother. Just like bringing a patient into the ER, there will be a lag between your arrival and when the hospitals care will truly start; make sure you are prepared to bridge that gap.



If you have a vent that you are supposed to use it is inexscusable for you to not know how to use it. Doesn't matter if you got little or no official training; it's your responsibility. Find the manual, read and reread it, and go over and over the ventilator until you can use it in your sleep and know how to troubleshoot any problems that come up. Unacceptable to do anything less.



Hospitals are often in a hurry, especially with "unstable" or "critical" patients (ie the ones they aren't equipped to deal with). Make sure you take the time that's needed to find out the information you need; history of present illness, meds given prior, meds currently being given, reaction to those meds, vent settings (if applicable), current vitals (including labwork if applicable), past history, allergies, plan at the receiving hospital. If you need to be a little firm to get that then do so. But, pick your battles. Sometimes it may be easier to load the patient and then take a few minutes before leaving to find the needed info in their paperwork. Once they are in your truck they are your responsibility; if you need to know something, take the time to find it. You just found out the hard way that someone may not actually call report, if they do the report might not get to the right people, or it may not contain the right info. Be ready to fill in the details.



All to often hospitals get so focused on getting the patient out that they neglect both the patient's care, and what will happen at the receiving facility. Your job is not just to take them from point A to B, but to properly treat them in between, and make sure the transition is as smooth as possible.



So...take it as a learning experience. Maybe write down what didn't go well and what could have been done to make it better. If this is a rarer type of call for you, I'd consider having a written plan for the things you NEED to know, the things you NEED to do, and one for the things that are nice to know and do. Until you've got more experience it'll help a lot.

Very, very, very good advice.

 

[Anjel]

I cannot adjust drip rates and i have no sedation. I carry versed but her BP was 78/50 and she just received 10mg 10 minutes prior. I never said I didn't know how to work the vent. I said we didn't get training on it. I am a city 911 car. We don't have vents on our trucks. If we have to take a urgent transfer then the vent is brought to us in the hospital. And we have 3 different types of vents. 1 I have yet to use. So it's a little hard to know how to use all three in my sleep.

Also since my first post I said that I messed up. And the staff at the cath lab are the ones who switched out the IV tubing prior to turning on their pumps. But like I should of known the drip rate.

I will definitely know better for next time.

 

[Handsome Robb]

Hmm...

Inotropes anyone? seems like a great candidate for dobutamine...

Serial small versed doses + fentanyl sounds like a better sedation package for her if you don't have ketamine available.

 

[VFlutter]

Just applied for a second job in the MICU at a Level 1 Academic hospital. They are expending their unit and looking at possibly starting an ECMO trial. Sounds like a perfect job. It will probably suck trying to juggle two jobs but it should be worth it.

 

[Carlos Danger]

Venting.....

Last night was absolutely horrible. I messed up on a critical care transport we took and didn't get the info that the cath lab needed. And the sending hospital didn't call report like they said.

This lady was 84 shoveling show started having chest pain and enroute to the cardiac facility she went unresponsive so the FD diverted to the smaller hospital 2 miles from the cardiac facility.

We picked her up. She was on a vent, propofol drip and heparin drip. Her dose of propofol was 45mcg/kg/min and she was still waking up trying to talk, and pull out anything she could grab on to. They gave 10mg of versed and she was finally sedated, but her pressure dropped dramatically on the way to the other hospital, and she woke up on the cath lab table.

Just a mess all around. I was exhausted, frustrated, and was made to feel like a complete idiot. Ugh can't wait to come back tonight.


/vent

Sorry to hear you had a lousy run.

FWIW, I don't think it sounds like you screwed up. Maybe there are a few things you could have done better, but there are plenty of things that both the sending and receiving could have done better, as well.

CCT is a team sport. In the big picture, you are just a small cog in a big machine.

You are a street medic, not a CCT medic. If you had more training and experience with this stuff you'd be more comfortable with it. Don't beat yourself up.


As an aside, propofol is not a good drug to transport on by itself. 45 mcg is a pretty small dose, but even if you doubled that you might not get a really quiet patient in the high-stimulus transport environment. Next time this happens, try 50-75 mcg boluses of fentanyl instead of a big slug of versed as an adjunct to the prop. Roc/vec is your friend. So is phenylephrine when (not if, but when) the pressure drops.

 

[exodus]

What I've also seen with propofol, is to have a 10ml syringe full of it, that way you can piggyback it on in a bolus if they start waking up, giving you time to fix the rate settings.

 

[Handsome Robb]

What I've also seen with propofol, is to have a 10ml syringe full of it, that way you can piggyback it on in a bolus if they start waking up, giving you time to fix the rate settings.

Definitely an idea however it doesn't sound like this patient could tolerate boluses of propfol, especially after the sending knocked her with 10 of versed.

I've heard enough stories about patients waking up during transport on prop drips to not be stoked if they ever allow us to take it.

 

[UnkiEMT]

Definitely an idea however it doesn't sound like this patient could tolerate boluses of propfol, especially after the sending knocked her with 10 of versed.

I've heard enough stories about patients waking up during transport on prop drips to not be stoked if they ever allow us to take it.

I've had a few pts start to come around on me with propofol, rather than drawing up a separate syringe on a just in case basis, if I need to knock them back down fast, I just use a flush into a high med-port, then once they're back down, disconnect the line and flush the saline back out. Depending on your tubing, you've got 3-12 mg of drug in there (between the top med pot and the end, ours has about 8). I've only had to do it once, but it worked a treat. That way I don't have to document anything if I didn't need to do it, and there's no confusion as to how much they've received when I drop the pt off.

That being said, most of the time that I take a pt on propofol, they've had appropriate adjunct meds, and are being transported on 40-60 mcg/kg/min. My protocol allows me to adjust up to 100 without med control, so if they're coming up slowly enough, I can just tweak it and put them back down without needing to add the hemodynamic complications of bolusing.

 

[Handsome Robb]

I never thought of doing it that way. Seems like it'd be difficult to give a precise dose. Although you know your concentration and know how much volume you're flushing... Still not sure how I feel about it. I guess it's a similar concept with a bolus. Seems more complicated than just having a syringe of it drawn up out of the line before you start it then just flush it once more.

I don't have any real hands on experience with propofol besides a few times in clinicals. Only sedative drip we can take is versed.

 

[Akulahawk]

I've had a few pts start to come around on me with propofol, rather than drawing up a separate syringe on a just in case basis, if I need to knock them back down fast, I just use a flush into a high med-port, then once they're back down, disconnect the line and flush the saline back out. Depending on your tubing, you've got 3-12 mg of drug in there (between the top med pot and the end, ours has about 8). I've only had to do it once, but it worked a treat. That way I don't have to document anything if I didn't need to do it, and there's no confusion as to how much they've received when I drop the pt off.

That being said, most of the time that I take a pt on propofol, they've had appropriate adjunct meds, and are being transported on 40-60 mcg/kg/min. My protocol allows me to adjust up to 100 without med control, so if they're coming up slowly enough, I can just tweak it and put them back down without needing to add the hemodynamic complications of bolusing.

I would say that with a patient that unstable as what Anjel had, I suspect I would be quite reluctant to bolus the patient with more propofol. Personally, I think that she got stuck with a patient that was forced on her and was basically dumped on the receiving facility. After all, the sending facility apparently did not call report over to the receiving facility. This is just my opinion, I think the sending facility was so desperate to get rid of the patient that they did what ever they could to get the patient sent out, regardless of exactly how legal or safe it was...

 

[Akulahawk]

I never thought of doing it that way. Seems like it'd be difficult to give a precise dose. Although you know your concentration and know how much volume you're flushing... Still not sure how I feel about it. I guess it's a similar concept with a bolus. Seems more complicated than just having a syringe of it drawn up out of the line before you start it then just flush it once more.

I don't have any real hands on experience with propofol besides a few times in clinicals. Only sedative drip we can take is versed.

I think I would have to agree that using the propofol that is in the line already to bolus the patient with what sounds like a saline flush just sounds more complicated than it needs to be. If I suspected that I needed to bolus the patient with some more propofol, I think I would probably draw up a small amount of propofol in a syringe and then have that available for an immediate bolus, drawn from the same bag as the drip, so the concentration is the same but I can have a lot more control over the bolus amount and I don't have to worry about having to effectively re-prime the line with propofol. If I don't end up needing to use the bolus, I can simply put it right back in the bag. That way there's no question about how much was infused and the total amount of drug never changes... except for what goes in the patient.

And no, I don't have any hands-on experience with propofol, but given what I know of the stuff, I'd probably prefer to bolus a patient this way... unless I can somehow program the pump with a bolus pre-set.

 

[Handsome Robb]

I think I would have to agree that using the propofol that is in the line already to bolus the patient with what sounds like a saline flush just sounds more complicated than it needs to be. If I suspected that I needed to bolus the patient with some more propofol, I think I would probably draw up a small amount of propofol in a syringe and then have that available for an immediate bolus, drawn from the same bag as the drip, so the concentration is the same but I can have a lot more control over the bolus amount and I don't have to worry about having to effectively re-prime the line with propofol. If I don't end up needing to use the bolus, I can simply put it right back in the bag. That way there's no question about how much was infused and the total amount of drug never changes... except for what goes in the patient.

And no, I don't have any hands-on experience with propofol, but given what I know of the stuff, I'd probably prefer to bolus a patient this way... unless I can somehow program the pump with a bolus pre-set.

Our pumps can do a bolus.


Well.. I thought they could but now I'm looking at the manual and can't find how to do it.

Edit: Found it. Pretty easy, set your volume hit start and away it goes then goes back to the program. From looking at it it seems like you could preset the volume and even if you couldn't as long as you've done your math ahead of time it wouldn't take more than a few seconds to punch it in.

We use the BodyGuard 121 Twins pump. Pretty darn easy to use.

 

[UnkiEMT]

I never thought of doing it that way. Seems like it'd be difficult to give a precise dose. Although you know your concentration and know how much volume you're flushing... Still not sure how I feel about it. I guess it's a similar concept with a bolus. Seems more complicated than just having a syringe of it drawn up out of the line before you start it then just flush it once more.

As far as knowing how much you're bolusing goes, it's exactly the same as using a syringe full of propofol, up to the limit of the volume of the tubing (Actually not quite, you're going to have some turbulent mixing at the head of the saline, but the engineer in me says that's ignorable.), and when you have to do it, it's more work, but it saves work when you don't have to do it, and I figure that it balances out. It's rare that a pt starts coming up fast enough from propofol that you can't adjust the infusion to keep them down.

I would say that with a patient that unstable as what Anjel had, I suspect I would be quite reluctant to bolus the patient with more propofol. Personally, I think that she got stuck with a patient that was forced on her and was basically dumped on the receiving facility. After all, the sending facility apparently did not call report over to the receiving facility. This is just my opinion, I think the sending facility was so desperate to get rid of the patient that they did what ever they could to get the patient sent out, regardless of exactly how legal or safe it was...

I quite agree, once the pt starts tanking, I would be very unlikely to bolus more propofol.

Further, I think you're right, the sending facility was doing a dump. They likely either were panicking because the pt was significantly above their usual cardiac acuity (Probable, given that they're only 2 miles from a cardiac center.), or were too busy to take the time to treat the pt appropriately. (As you said, they didn't bother calling report...). Or both.

 

[UnkiEMT]

Our pumps can do a bolus.

Damn you and your fancy equipment having ways.

 

[exodus]

Damn you and your fancy equipment having ways.

Cant all pumps bolus if you program them to?

 

[UnkiEMT]

Cant all pumps bolus if you program them to?

Mine can, but it's not an easy system, I'd have to set a new drip with the desire bolus and a rate of 999 ml/hr, which unfortunately involved tabbing through a few screens, and would erase the settings and info of my previous drip.

 

[Carlos Danger]

In transport of the intubated patient, I think it is much better to use a NMB than to mess with bolusing propofol, slugging versed on top of propofol, etc.

You can get into hemodynamic trouble pretty quick with propofol boluses. It's one thing if you have a way to treat that quickly, but in certain patients it can be a real problem if you don't.

 

[CALEMT]

8 hour drive up to Nor Cal for a interview. See y'all later!

 

[unleashedfury]

True Story: While I was working in Maine as a basic, I couldn't activate the helicopter. Bystanders could, but I had to have med control do it.

Fire Chiefs are God's gift to mankind. When they deem a helicopter is necessary (IE, their department needs some snazzy PR pics; It's been a long boring winter; They like the sounds whirly birds make; That wreck sure sounds scary on the radio), the helicopter will be landing and will be transporting. Advice of the paramedic caring for the patient is often nothing more than an asterisk to be ignored.

Were in the same boat we need medical direction to activate a helo,, but a fire chief with no medical background can fly one just cause he wants to.. I tend to use it to my advantage sometimes. When I know a patient is going to need to be flown, which rarely happens since I'm on average 30 minutes from a Level 1 Trauma center. I just call the fire chief and say he can you send me a helicopter.. Sure.

I cannot adjust drip rates and i have no sedation. I carry versed but her BP was 78/50 and she just received 10mg 10 minutes prior. I never said I didn't know how to work the vent. I said we didn't get training on it. I am a city 911 car. We don't have vents on our trucks. If we have to take a urgent transfer then the vent is brought to us in the hospital. And we have 3 different types of vents. 1 I have yet to use. So it's a little hard to know how to use all three in my sleep.

Also since my first post I said that I messed up. And the staff at the cath lab are the ones who switched out the IV tubing prior to turning on their pumps. But like I should of known the drip rate.

I will definitely know better for next time.

I would definitely put my foot down. and get every bit of info on that patient prior to even loading him/her up. It wasn't your fault and I don't think you screwed up. Its more of the Band Aid Shop just wanted to get them out of there as quickly and as fast as possible. Which is poor continuum of care on their behalf.

8 hour drive up to Nor Cal for a interview. See y'all later!

Good luck and have a safe trip

 

[UnkiEMT]

I would definitely put my foot down. and get every bit of info on that patient prior to even loading him/her up. It wasn't your fault and I don't think you screwed up. Its more of the Band Aid Shop just wanted to get them out of there as quickly and as fast as possible. Which is poor continuum of care on their behalf.

The biggest trick for people with 911 experience but relatively little IFT experience to learn is to be comfortable pinning RNs to the wall to get the information you need, and be skilled enough at it that only the worst of them complain. (The difference between a good shop and a bad shop is easily seen by whether they back you up or not when those complaints come in.)

I can, have, and almost certainly will again, straight up told nurses that I won't accept the pt until I know everything I want to know. Being on that side of that particular power play is something that almost never happens in 911, and indeed, is somewhat anathematic to the 911 mentality of taking control of the scene when you walk in, and thus automatically "accepting" the patient.