Trach Problems

[daedalus]

I can remember how horrified I was the first time I had to do it. Then the patient took the suction from my hand and did it himself. It sounded like I was killing the guy.

I got some laughs out of that! My partner was absolutely HORRIFIED when she called me to the back of the rig to do it when she lost breathing on an emergency fire evacuation patient. She was like your killing him your killing him!

Oh, an why should we not sound mean? I think we as EMTs should take a very tough position on education and incompetence.

 

[KEVD18]

Oh, an why should we not sound mean? I think we as EMTs should take a very tough position on education and incompetence.

thats pretty much me in a nutshell.

 

[JPINFV]

This is probably a question I should know the answer to but it has slipped my mind. What would be BLS care for a patient experiencing a problem with home equipment such as a respirator or other piece of equipment that can't be moved into the ambulance and is causing a serious issue (e.g. airway compromise)?

Why would a ventilator call be BLS to begin with? When I was working in Southern California this would be a RT call by sole fact that the patient was on a vent.

 

[jrm818]

Probably a regional difference. In PA the protocols just changed so long as the equipment is the sort that is normally operated and maintained by the pt. the call can be BLS, unless the problem is with the equipment. So vent pt. with a broken arm is BLS - vent problem would still be ALS. It would only be an ALS call, no RT.

Only similar thing here I've seen as the inclusion of an RTs the use of a flight crew with a biomedical engineer for an LVAD issue. One of the stupidest things I've yet seen - took over an hour just to get all these people into the BLS ambulance (engineer from hospital, flight crew from base, ambulance from somewhere else) and en route to the residence. Pt. lived maybe 20 minutes from the hospital...

likely the reason this would be BLS is a two tiered system. In many places BLS provides primary 911 coverage and calls for ALS intercept. Where I work in MA, even though ALS would hopefully have been dispatched at the same time as us, our BLS ambulance would probably be on scene at least 5 minutes prior to ALS, quite possibly more.

 

[VentMedic]

Where to begin.......

Patient on ventilator and distressed:

Remove from ventilator.
Hook BVM to O2
Bag patient
Listen for breath sounds
If you as an EMT can not suction, ask the parents to suction
Watch pt's response with color change, chest rise.
Assess breath sounds
If good results; continue ventilations, assess the rest of the patient

Leave vent if can not be moved although most homecare ventilators are very portable. The O2 concentrator usually is not but does not have to be taken. Hospitals have their own O2. They also have their own ventilators. The family can bring the vent later.

Read the hypoxic drive link. Do not withhold O2 on a patient in distress. Bag if they quit breathing. Chances are they would quit breathing anyway as it is commonly called RESPIRATORY FAILURE.
A patient that is in respiratory failure is already retaining CO2 regardless of whether they are a retainer or not. It is just a matter of time to when they reach the point of no return. They are fatiqued. You may later have the satisfaction of knowing the heart, brain and gut didn't take a hypoxic hit.

These patients will usually have some disease process in addition to COPD that is creating the problem. This could be PNA, metabolic disorders, cardiac problems etc.

If you or a ventilator is doing the ventilating, regardless of how much O2 used, YOU OR THE MACHINE IS BREATHING FOR THE PATIENT. Often a pt in ICU will be on an FiO2 of 1.0 and due to shunting or V/Q mismatching will barely have a PaO2 of someone on 0.21 or room air.

If the patient is not in distress, you can titrate the O2 to comfort or SpO2. No, not all patients need high concentrations of oxygen.

The one patient that you can KILL with O2 is a baby with an uncorrected cyanotic heart defect that is ductal dependent.

 

[VentMedic]

Why would a ventilator call be BLS to begin with? When I was working in Southern California this would be a RT call by sole fact that the patient was on a vent.

Going home, we will send a ventilator patient via BLS truck if accompanied by a parent or other caregiver. An ALS truck with a Paramedic is not guarantee that the Paramedic is very familiar with trachs and definitely not that particular homecare ventilator. Endotracheal suctioning is not a skill that is practiced by many EMTs or Paramedics. I will put my trust to the parents since they have been thoroughly trained/educated on the equipment. Different companies have different rules and many parents will invest in a mini-van or SUV and bypass the ambulance transport rather than deal with situations like initially described.

Adults are at the mercy of the ambulance crews unless they have an S.O. or caregiver to accompany them who is knowledgeable. Many ventilator patients like the late Christopher Reeve do not want to be parted from their wheel chair and will find alternate transportation if at all possible. Thus, these are a few reasons you don't transport many homecare patients in the back of your ambulance.

 

[daedalus]

If you as an EMT can not suction, ask the parents to suction

That would never ever happen on my crew. Ever.

My EMT will suction the patient. Also, parents always ride in front in non emergency situations. Company policy.

 

[VentMedic]

That would never ever happen on my crew. Ever.

My EMT will suction the patient. Also, parents always ride in front in non emergency situations. Company policy.

With over 300 different airways and at least 60 different makes and models of homecare ventilators as well as textbooks full of thousands of different diseases or disorders, there may be a time you will have to listen to the parents. If you lose an airway that had to be surgically placed due to abnormal anatomy because of your over inflated "I am EMT" ego, that child will die. If the parents try to tell you something, LISTEN. Do not rely on the very few pages of an EMT text to get you through every situation.

 

[daedalus]

I have no ego. I push for better and freely admit to the lack of education EMTs receive. However, airway management, including suctioning, positive pressure ventilation, oxygen, pulse oximetry, and lung sounds are all well within an EMT's knowledge base. The parents called us, not the other way around. That said, the parents knowledge of the ventilator and their particular situation with their child is invaluable. It does not take a genius EMT to figure out the management for difficulty breathing or intolerance to a ventilator.

 

[VentMedic]

I have no ego. I push for better and freely admit to the lack of education EMTs receive. However, airway management, including suctioning, positive pressure ventilation, oxygen, pulse oximetry, and lung sounds are all well within an EMT's knowledge base. The parents called us, not the other way around. That said, the parents knowledge of the ventilator and their particular situation with their child is invaluable. It does not take a genius EMT to figure out the management for difficulty breathing or intolerance to a ventilator.

Yes, as you stated the parents' knowledge is invaluable in these situations. But, please do not cop the "you called us" attitude with parents who do call you for a way to get to the hospital. Parents may have no choice but to call due to the immobility of the child or a sudden emergency that needs quick attention. The parents are probably already feeling they have let their child or loved one down in some way or their care was inadequate which may totally not be the case but they are the primary caregivers.

Most are very protective of their child or loved ones and want people who are well educated/trained to do the care or at least someone who will not haphazardly fumble around causing great harm. That is why we have hospitals that specialize in certain populations such as children or various cardiac disorders. You also shouldn't take this attitude with someone who might have a LVAD or some other VAD if the S.O.s try to explain "continuous flow" when you check the pulse and want transport to where their doctor is.

These patients and their families go through enough without being made to feel like they are indebted to the EMT because they can not carry their own loved one to the car themselves. Many would prefer to stay in control of their loved one's care after being witness to others misunderstand the pt's disease or muddle through the care as well as and taking their own to the hospital . Even in the hospital we respect that as much as possible. Afterall, we trained them to do almost all or total care for their loved one. They will relax if you do not shove them aside and listen to what they have to say.

Some of the airways used in children or adults with various disorders take a while for even the most experienced RT to figure out and they don't mind getting educated by a parent in an emergency as well as consulting an ENT physician who is familiar with these devices. When it comes to airways, those with more education don't assume they know it all because they have enough education to know there is much more.

How familiar are you with false tracked trachs or fistulas? Decannulation? Are you prepared to attach to an airway device that is not the standard 15 mm? As an EMT, do you know how to ventilate a laryngectomy patient with a BVM? Various speaking valves including those internal? Ventilate a fenestrated trach? Uncuffed?

I have also seen Paramedics destroy the only venous access a patient has because of "assuming a line is a line". Many have failed to take advantage of more education that is often offered for free or minimal charge at various hospitals and colleges that offer CEUs for healthcare. Too many associate trachs and various venous access devices to be "nursing or nursing home stuff" and if it has nothing to do with trauma, they don't bother. These are relatively simple devices to master if only a little time was taken to expand one's knowledge of patient care.

 

[Sasha]

10LPM may indeed be enough for a pt. who is not compromised except for a malfunctioning vent, depending on what sort of a mix they were on when the vent was working.

The reference to switching to hypoxic drive and inhibiting breathing, as you may have gathered, garners signifigant skepticism at this site (and among educated providers everywhere). The notion that COPD'rs can't tolerate high flow 02 is just not supported by evidence, and basically is wrong (according to me).

That said, even if you do end up inhibiting their respiratory drive (unlikely) - if you are ventilating with a BVM: Who cares? You are their respiratory drive now. You're breathing for them.

If the COPD pt. is not breathing adequately or in resp. distress - give them high flow O2. If they are being adequately oxygenated by a vent using a room air mix, it's probably OK to withold the highest flow 02.

for more:

http://emtlife.com/showthread.php?t=4225&highlight=hypoxic+drive

Really, if I'm ventilating by BVM I'm going to crank the O2 all the way up just to make sure, COPD or not. Even a transport time of an hour isn't going to have any major impact, and it's much worse to find out you were ventilating insufficiently.

My understanding is too much oxygen will knock down a COPDers respiratory drive. That being said, that is something that can be managed at a hospital and re-learned. Thats what I was taught in basic class. Not breathing is 100% fatal, hypoxia is bad juju. I think LPM should be set to their patients need, read the pulse ox, skin color, etc and if theyre awake ask them if they feel like theyre getting enough O2. (Though I guess with COPDers they never feel like theyre getting enough O2.) If not, crank it up, if yes, leave it alone.

 

[Ridryder911]

True too much oxygen can knock down the respiratory drive since they are on a opposite mechanism but remember how long and how much is required as well as what can one do if it occurs?

R/r 911

 

[VentMedic]

True too much oxygen can knock down the respiratory drive since they are on a opposite mechanism but remember how long and how much is required as well as what can one do if it occurs?

R/r 911

Not all COPDers are CO2 retainers and not all CO2 retainers are COPDers.

A brief article on the the controllers of breathing:

http://www.rtmagazine.com/issues/articles/2000-02_17.asp

One must also consider the etiology of the C02 retention. Hypoventilation caused CO2 retention with either Central, physical characteristics or disease based orgins can be a different process. There are also many COPD pts that have other disease processes such as pulmonary hypertension that must be taken into consideration. Rarely is there a well defined blanket statement to fit all patients.

Summary
The neurological drive to breathe is complicated and is not fully understood. From a clinical standpoint, the injudicious and uncontrolled administration of supplemental oxygen to patients with compensated respiratory acidosis, although probably less risky than implied in the clinical literature, is not a good idea. The deliberate under-oxygenation of a patient with compensated respiratory acidosis (or a diagnosis of COPD) because of fear of hypoventilation or apnea, however, creates the greater risk of inducing prolonged tissue hypoxia.

 

[jrm818]

In rare cases it may "knock down" their drive, but its uncommon and unlikely in the short time you see the patient. I was told the same thing in basic class about their drive - it didn't make much sense to me then, it doesn't now.

Even in the population of CO2 retainers, the changes in chemoreceptor function and pathophysiology of the disease in general is a lot more complicated than the common explination of "they switch to a hypoxic drive, so O2 reduces the drive to breathe and they die (of hypoxia presumably?)" . That makes little sense if you think critically about it.

Don't make VentMedic re-write what she's already written - read that thread! Make sure you actually "understand" rather than "were told."

As for not breathing being "100% fatal"...well it would be...if the person giving them O2 didn't have a way of ventilating them.....

As for titrating the O2, as suggested in that thread, that's not something easily done prehospitally in this patient population. O2 sat readings tend to be highly variable among COPD'rs, most are smokers which throws off the reading more, skin color is an OK indicator as long as it isn't hot, cold, they aren't sick, they aren't anemic, they don't have increased H&H, etc. I'm not going to stake my patient on that as an indicator. If they called you chances are they feel like they are SOB or having difficulty breathing. If they called for a broken arm sure, leave them on their home setting, but if they called for a breathing issue, 100% O2 and monitor breathing.

 

[VentMedic]

As for titrating the O2, as suggested in that thread, that's not something easily done prehospitally in this patient population. O2 sat readings tend to be highly variable among COPD'rs, most are smokers which throws off the reading more, skin color is an OK indicator as long as it isn't hot, cold, they aren't sick, they aren't anemic,

In the Pulmonary Lab, we will call the primary physician who sends us a smoker to titrate on home O2 with a "forget it" message. Even with a carboxyhemoglobin level, their smoking will cause it to fluctuate and they will probably adjust their O2 anyway accordingly as their SaO2 drop is felt.

However, we will be more than happy to spend the hour doing a smoking cessation lesson which is still a reimbursed item.

 

[Sasha]

In rare cases it may "knock down" their drive, but its uncommon and unlikely in the short time you see the patient. I was told the same thing in basic class about their drive - it didn't make much sense to me then, it doesn't now.

Even in the population of CO2 retainers, the changes in chemoreceptor function and pathophysiology of the disease in general is a lot more complicated than the common explination of "they switch to a hypoxic drive, so O2 reduces the drive to breathe and they die (of hypoxia presumably?)" . That makes little sense if you think critically about it.

Don't make VentMedic re-write what she's already written - read that thread! Make sure you actually "understand" rather than "were told."

As for not breathing being "100% fatal"...well it would be...if the person giving them O2 didn't have a way of ventilating them.....

As for titrating the O2, as suggested in that thread, that's not something easily done prehospitally in this patient population. O2 sat readings tend to be highly variable among COPD'rs, most are smokers which throws off the reading more, skin color is an OK indicator as long as it isn't hot, cold, they aren't sick, they aren't anemic, they don't have increased H&H, etc. I'm not going to stake my patient on that as an indicator. If they called you chances are they feel like they are SOB or having difficulty breathing. If they called for a broken arm sure, leave them on their home setting, but if they called for a breathing issue, 100% O2 and monitor breathing.

Re-read my post. I wasnt disagreeing with giving COPDers lots of O2. As I said, if by some chance you knock out their drive, then that can be fixed at the hospital, until then you bag them. That was actually a question on my pre-hire test, would you give a COPDer high flow O2. Interesting thread.

 

[MSDeltaFlt]

That's what I was thinking, can't go wrong with ABC, ALS, and when all else fails call med control. I was just wondering if I missed something and there was something I should do because I'm not going to mess with equipment a pt. is relying on even to take over with a BVM because who knows at that point what is the actual problem and what is worse.

Getting back on topic, you didn't miss anything. And I wouldn't worry about the actual vent either. Like Vent said, the family can take care of that. They can turn it off and/or bring with them in the truck or later on if they choose to do so.

 

[jrm818]

Re-read my post. I wasnt disagreeing with giving COPDers lots of O2. As I said, if by some chance you knock out their drive, then that can be fixed at the hospital, until then you bag them. That was actually a question on my pre-hire test, would you give a COPDer high flow O2. Interesting thread.

Got it - mis-interpreted what you meant.

Outta curiosity - what was the "right" answer on the test?

 

[VentMedic]

Originally Posted by Sasha
Re-read my post. I wasnt disagreeing with giving COPDers lots of O2. As I said, if by some chance you knock out their drive, then that can be fixed at the hospital, until then you bag them. That was actually a question on my pre-hire test, would you give a COPDer high flow O2. Interesting thread.

Got it - mis-interpreted what you meant.

Outta curiosity - what was the "right" answer on the test?

That is an interesting question and as worded "high flow O2" it can be interpreted very differently.

EMT(P)s consider a NRBM to be high flow but it is actually not but can give a higher FiO2 of O2.

A venturi or other entrainment mask or system is high flow and can deliver as little as an FiO2 of 0.24. Thus, for an RT exam a high flow device would be the correct answer to deliver a controlled low O2% while it might mean a NRBM on an EMT exam.

 

[MSDeltaFlt]

That is an interesting question and as worded "high flow O2" it can be interpreted very differently.

EMT(P)s consider a NRBM to be high flow but it is actually not but can give a higher FiO2 of O2.

A venturi or other entrainment mask or system is high flow and can deliver as little as an FiO2 of 0.24. Thus, for an RT exam a high flow device would be the correct answer to deliver a controlled low O2% while it might mean a NRBM on an EMT exam.

Why were we taught that in EMT and paramedic school, Vent? Going from resp to the street I could never really understand why. The only reason I can come up with is that, at 15 L/M, it sounds high flow. Is it that simple or do the books have some outdated emperical data that they're going by?