Time to vent

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Guardian

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Still waiting to see an emt save a paramedic but we can chalk up another save for the paramedics. I ran a bad MVC earlier today with my volly fire department (as an basic provider, we don't do ALS). We had a pt who was ejected from her car, awake but not completely oriented and in pretty bad shape with suspected cervical spine injury (later confirmed at the hospital). For some reason, I was the only paramedic that responded although I couldn't use my skills (I've been dreading this). A basic ambulance from the rescue squad shows up. At this point I had already called the helicopter. I'm sitting in the back of the ambulance waiting for the helicopter with two emt-basics I don't know. One of them goes to insert a NPA. I go to stop her and she gives me a nasty look like who the hell does he think he is!!! I tell her that the pts airway is fine and inserting a NPA is probably not a good idea. It was later confirmed that the pt had a cervical fracture. Sometimes emt-bs scare me. The pt was awake with a gag reflex for goodness sake.
 
bloody hell.......puts a shame to emt-b.......sorry mate. What was she thinking! some people really need to learn/understand the basics. :wacko:
 
just remember, it's easy to know when to do something but really hard sometimes to know when not to do something. This is what separates the mediocre providers from the really good ones.
 
yeah your right! but i just dont understand....you said that her airway was good and she was conscious
 
"Awake but not completely oriented and in pretty bad shape".... with ejection as a MOI. I wasnt there but just to specualte on what you provided, maybe she was just being aggresive with her airway management.

I cant honestly say if I would have in this situation or not - if she was semi-responsive and in the shape u describe, yeah she prob would have got the NPA. Surely isnt going to hurt the pt right? Try to insert it, if the pt resists the attempt to much then dont worry about it at that point. The providers actions dont jump out at me as being blatantly wrong.

So was the NPA inserted?
 
ResTech said:
"Awake but not completely oriented and in pretty bad shape".... with ejection as a MOI. I wasnt there but just to specualte on what you provided, maybe she was just being aggresive with her airway management.

I cant honestly say if I would have in this situation or not - if she was semi-responsive and in the shape u describe, yeah she prob would have got the NPA. Surely isnt going to hurt the pt right? Try to insert it, if the pt resists the attempt to much then dont worry about it at that point. The providers actions dont jump out at me as being blatantly wrong.

So was the NPA inserted?
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The NPA wasn't inserted because I stopped her. The pt is breathing ok. If she inserted the NPA, the pt could have resisted it and paralyzed herself or gagged, vomited, and we would have had to turn her on her side which again could cause paralysis. Instead we waited 2 mins for the helicopter to arrive and the pt got properly RSI'ed. This all goes back to what I said before, knowing when not to do something is harder and more important than know when or how to do something.
 
think risks vs benefits and consequences people, not just "what skill can I perform today?"
 
Guardian said:
The NPA wasn't inserted because I stopped her. The pt is breathing ok. If she inserted the NPA, the pt could have resisted it and paralyzed herself or gagged, vomited, and we would have had to turn her on her side which again could cause paralysis. Instead we waited 2 mins for the helicopter to arrive and the pt got properly RSI'ed. This all goes back to what I said before, knowing when not to do something is harder and more important than know when or how to do something.
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Now, correct me if I'm wrong, but I thought we had NPAs to get around the whole gagging and vomiting thing. I.E., if you can't drop an OPA because the pt. has an intact gag reflex, you drop an NPA. Now, that being said, I'm certainly not going to be dropping anything if the medic present hasn't done so already, and also because there is a risk of having some sort of nasal or basilar skull fracture.
 
It makes sense what Guardian is saying and his rationale for not wanting to emplace the NPA however, if the pt. was properly secured to the board, the pt. should not have posed any type of threat or compromise to herself with the suspected spinal cord injury. If a pt. needs an airway they need an airway. If all u got to work with is the NPA then use it cautiously. Dont fight the pt. but if you can insert it with relative ease then do it.. or at least attempt it. This is called being aggressive to me. To many BLS providers underuse NPA's and arent as aggressive with airway management as they should be.

I can see both sides here... Guardian's and the BLS provider and dont think either one was wrong. If I was the BLS provider I would have inserted it if I felt it was indicated cause it would have been my pt. with no "functioning" ALS provider present to overrule my judgement.

On that call, you were merely a BLS provider working under the primary BLS crew on the ambulance. I know its so hard as a medic to not be in control isnt it :)

On a side note in reference to the EMT's reaction to your telling her not to insert it. Could it have had something to do with the way you stated your opinion? If your actual demeanor and personality is anything like your online demeanor and personality its no wonder she gave you the look and attitude.
 
Awake and breathing ok, would not have bought her an NPA in my service either. From any of us, and we have a few who are known in the 3 counties we transport to for being VERY aggressive in airway management. Not from our BLS departments either. If she's breathing fine, we'd have waited the couple minutes for the helo.

Being properly secured and collared will not necessarily completely prevent further aggravating a cervical spine injury. She could still raise her head a little bit, she could start pushing with her feet and rocking her entire body, her arms are probably free so she could start fighting with them and those headbeds don't glue the head to the stretcher. Once they start fighting they get free of that too. And you can bet all of that would happen to a conscious patient once you turn them on their side while vomitting.
 
As was said earlier - the risk of a basilar skull fracture is present with trauma to the head/neck. Putting chunks of plastic into the brain through the basilar plate (???) is a ad thing to do, and that is why nasal intubation is "not reccomended" with head inuries.

If the patient had a patent airway and was breathing on his own, then yes, there isn't a real need for an airway adjunct initially. Once aeromedical arrives, they will probably RSI the patient.
 
I too can see it both ways. If the patient is unable to maintain a patent airway, then at the BLS level (if a combitube is not available) a NPA is appropriate. The key tem here is that nasal airways are not recommended, they are not contraindicated. If you don't have an airway, then nothing else matters. On the other hand though, if the patient is maintaining, then there is no need for a NPA nor is there any need for RSI. Soooooooooo, if the helicopter crew RSI'd the patient, then either a) they needed it and a NPA would have been appropriate or b) the helicopter crew is needlessly 'playing' with their toys!
 
Flight-LP said:
Soooooooooo, if the helicopter crew RSI'd the patient, then either a) they needed it and a NPA would have been appropriate or b) the helicopter crew is needlessly 'playing' with their toys!
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Good point...
 
I agree with Guardian on this. If the patient is adequately maintaining her own airway, and has no respiratory compromise, there is no benefit to inserting an NPA. The insertion could very well damage the inside of the nose resulting in bleeding, and that is going to run down the back of the patients throat, not out of the nare. The first indication things went wrong would be the bloody vomit covering you and everything else in your truck. Supplemental oxygen would have been sufficient for this patient 12-15 liters through a NRB would have been fine, especially with a short ETA from the helicopter.

Jon hits contraindication number one squarely on the head, DO NOT stick anything in the nose of a suspected head injury. Immobilize them, oxygenate them, keep 'em warm, infuse fluids, and apply lots of diesel.

As far as the flight crew "playing" with their toys, their orders are as stringent as anyone else's about justifying treatments performed. I would have probably done the same as them with a suspected head/spinal injury, because it is easy for a patient to go south on you quickly, and hard to maneuver around in the bird. You don't want a head bleed becoming combative at 2,000 feet, that can ruin your whole day.

To those riding Guardian for possibly being too strident, we weren't there. Some people do not want to take advice no matter who gives it. And as far as acting only as a first responder, well, when the attorneys ask Guardian on the stand why he allowed harm to come to the patient because an overzealous EMT stuck a tube into the patient's brain and caused them irrepairable damage, how is he going to answer? "Uhhhh, I wasn't in charge?" That dog won't hunt, because ultimately he knows better. I guarantee you the EMT involved would be the first one to point the finger and say, "Well he's a paramedic he should have said something..."
 
Thank goodness for my wonderful Paramedic partner. In my 20 + years of Emergency Medicine, I was blessed with a few wonderful teachers that when I rode on a BLS unit, I knew when to or not do things and to look at the whole picture before reacting. Sounds like these BLS people need a wonderful teacher to help them. I hope they are open to your knowledge that you have to offer to them. Man what a wonderful experience that will be for them and for you.
 
Pardon me, I'm new here!

So, to sum up the EMT-B vs EMT-P debate... . we.. like our patients are human? We are all combinations of angels, sinners, heroes and victims depending on our audience, current emotional state, sleep level and caffeine level.

I'm an EMT-B married for many years to an EMT-P. He's a career FF and I volunteer at a local rural Fire Department. So I see this from both sides. I have found though.. that aside from those days when our tolerance factor is a bit depleted for whatever reason.... if you have skills and you are confident in those skills, you are better able to appreciate skills in others.
 
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