Trach Problems

[KEVD18]

anybody still want to question my head banging against the wall graphic at this point?

R/r, vent? how many times have you been down this road on this board?

im going to go render myself unconcious now.

 

[MSDeltaFlt]

anybody still want to question my head banging against the wall graphic at this point?

R/r, vent? how many times have you been down this road on this board?

im going to go render myself unconcious now.

I got why. Funny.

 

[BossyCow]

In that case, the COPD pt's primary issue is DIB, so that in my system would make it an automatic ALS, if ALS was available. If the pt is already having difficulty breathing, it really shouldn't matter in a bls response what the pt's respiratory drive issues are specifically. We treat the symptoms. We would manage the airway. Assist with BVM if necessary, O2 at a level that improves perfussion and eases the distress. ALS to cover our butts in case the pt goes south on the way to the ER.

The knowledge is good for understanding of respiratory systems so we can be a bit more aware of when ALS is going to be needed, but in this case, its pretty clearly an ALS call.

 

[daedalus]

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.

I am prepared to ventilate with a 15 mm connector, or use the ol' infant mask over the airway trick. I will do what I have to. I also understand patients who will not have a pulse because of VADs. But Vent, your right. Lets teach paramedics and EMTs more about this stuff before sending them into special populations around tertiary hospitals.

 

[VentMedic]

Lets teach paramedics and EMTs more about this stuff before sending them into special populations around tertiary hospitals.

Too few take advantage of what they can learn in their hospital clinicals. Just because it isn't dripping blood doesn't mean there is not something to learn. The same with routine BLS transports. Dialysis or chemo patients are great to find various devices of access. Observe what various access ports patients have even if you as an EMT-B can not do much with them yet. You might gain some respect when you mention that to the RN or MD in the ED. You can then take notes or get formally instructed later.

At far as airways, remember a trach is not always the trach pictured in the text book.

Here's a thread for last year.
http://www.emtlife.com/showthread.php?t=4606

For the links not working:
http://www.tracheostomy.com/faq/types.htm

Trach buttons and rings (Olympic)
http://www.natus.com/index.cfm?page=products_1&crid=124&contentid=219

Examples of various ETTs used in the hospital.
http://www.aarc.org/marketplace/reference_articles/06.99.0661.pdf

Speaking valves you may see:
http://www.passy-muir.com/

voice restoration
http://blomsinger.com/

http://blomsinger.com/voicerestorationwhatsalary.htm

 

[daedalus]

I understand what your saying "do not cop the you called us attitude". I was always taught to have a calm and in control affect and turn chaos into calm. We are supposed to be cool and in charge, so how can we reconcile this training with responding to a scene and than handing control of the situation to those who called us? Thats backwards for most of us non hospital types.

 

[Sasha]

Got it - mis-interpreted what you meant.

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

The right answer was to not withhold O2. I got 100% on the test. Answer any questions on my stance on the issue?

 

[VentMedic]

I understand what your saying "do not cop the you called us attitude". I was always taught to have a calm and in control affect and turn chaos into calm. We are supposed to be cool and in charge, so how can we reconcile this training with responding to a scene and than handing control of the situation to those who called us? Thats backwards for most of us non hospital types.

Non hospital types? This is about medicine and patient care regardless of where it is practiced. It is about respect for the knowledge of the caregivers and their ability to assist in a situation that you are not well prepared for. It will of course depend on the emergency but don't kick the family to the curb so that you can "be cool and in charge".

The patient and/or parents still have some rights and still know the devices and medical condition better than an EMT-B or even a Paramedic. If you rush in and not listen to what they have to say or let them direct you through procedures you are not accustomed to doing, you may do more harm than good. The families have also spent many hundreds if not thousands of hours training and educating themselves on how to take care of their child or loved one. You have spent 110 hours on first-aid. They have the same concerns about handing their child over to your care. They are not stupid and have probably been informed on what abilities EMS systems have and don't have. You have to learn some interaction skills to communicate with parent and patient to gain confidence. Depending on the situation, you may be the one that is overwhelmed and need calming with a very technology dependent medical needs patient. The parents may have been through rough times before and will be okay but still need to get their child to the hospital. If you get into a peeing match with the family, no one wins. Calm yourself and listen to the family. Again, they can be reasoned with if they see you are not going to do something to cause harm to their child or family member.

As I said before, most would have hoped for a smoother way to the hospital then deal with the drama of EMS especially in areas that run 3 trucks/engines/ladders to every call.

 

[VentMedic]

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?

I went from Paramedic to RRT; a big educational and learning process.

In EMT or paramedic school, we were taught recipes for devices by way of memorization. The higher the flow the higher......... Luckily college A&P were prerequisites at the time I took my Paramedic 30 years ago.

I didn't understand how many of the O2 devices worked until I started in the respiratory program. The same with intubation. I rarely if ever missed a tube on Rescue as a Paramedic but I definitely learned how to intubate proficiently and efficiently as a Respiratory Therapist.

 

[KEVD18]

I understand what your saying "do not cop the you called us attitude". I was always taught to have a calm and in control affect and turn chaos into calm. We are supposed to be cool and in charge, so how can we reconcile this training with responding to a scene and than handing control of the situation to those who called us? Thats backwards for most of us non hospital types.

because in some cases, as vent is trying to demonstrate, they called us as a mode of conveyance.

i know its tough to accept that someone who isnt even an emt(admittedly the godliest of medical training levels) might just happen to know more about the disease process and the treatment for it; but sometimes its true. i'll take any help i cant get. if the parent/wife/child etc knows how to do something the patient needs better than you becuase they have been trianed in it and do it x times a day(v. you having had 8 minutes of training 5 years ago and maybe used said skill twice in your entire career), why wouldnt you take that help?

 

[daedalus]

I had Law Enforcement Officers who were also paramedics run my EMT program. They subscribed to the Dr Bledsoe ideology, that EMS was a fusion of public safety and medicine. I am the first to say that medicine is medicine, and that we should move beyond levels of care or silly titles to provide it, but I cannot ignore how I was trained. I was taught that the EMS and Fire crews were to take absolute control of all aspects of the scene. I am now asking for your views on the matter and criticism on how these ideologies might be wrong. Just remember I did not come up with these viewpoints personally.

 

[KEVD18]

I had Law Enforcement Officers who were also paramedics run my EMT program. They subscribed to the Dr Bledsoe ideology, that EMS was a fusion of public safety and medicine. I am the first to say that medicine is medicine, and that we should move beyond levels of care or silly titles to provide it, but I cannot ignore how I was trained. I was taught that the EMS and Fire crews were to take absolute control of all aspects of the scene. I am now asking for your views on the matter and criticism on how these ideologies might be wrong. Just remember I did not come up with these viewpoints personally.

well my view is as above

 

[VentMedic]

I had Law Enforcement Officers who were also paramedics run my EMT program. They subscribed to the Dr Bledsoe ideology, that EMS was a fusion of public safety and medicine. I am the first to say that medicine is medicine, and that we should move beyond levels of care or silly titles to provide it, but I cannot ignore how I was trained. I was taught that the EMS and Fire crews were to take absolute control of all aspects of the scene. I am now asking for your views on the matter and criticism on how these ideologies might be wrong. Just remember I did not come up with these viewpoints personally.

Once you become educated about medicine, you will find that there are few absolutes in medicine. Recipes are good only to a certain point. Every situation must be with patient care and your personal safety in mind.

Allowing a parent or family member to assist you in some aspect of care you are not familiar with is not giving up control. If you fumble through a situation because you did not allow the family to educate you on how to properly take care of the patient, then you are truly not in control.

If a nurse just told you to pick up a medically complex patient with a bunch of equipment at a LTC facility or hospital without report or assistance, I am sure you would be upset. This is no different. It is just that the LTC facility is the patient's home.

 

[MSDeltaFlt]

I went from Paramedic to RRT; a big educational and learning process.

In EMT or paramedic school, we were taught recipes for devices by way of memorization. The higher the flow the higher......... Luckily college A&P were prerequisites at the time I took my Paramedic 30 years ago.

I didn't understand how many of the O2 devices worked until I started in the respiratory program. The same with intubation. I rarely if ever missed a tube on Rescue as a Paramedic but I definitely learned how to intubate proficiently and efficiently as a Respiratory Therapist.

That's what I thought. Thanks.

 

[Ridryder911]

Actually if you were to talk to Dr. Bledsoe I believe his thinking is we should be more medicine than to ever be considered public safety. Sorry, I don't want to wear a badge nor be unionized, and at least be expected to read above a 10'th grade level.

Vent's point is many times for some reason many of those in EMS fail to see the whole picture. EMS is not always alone with this attitude but I have to admit they are the ones with the least education and training that usually expose it so well.

Remember, the family and yes.. (gulp!) the patient is the one that deals with, works around, etc. every second, every minute of everyday and your whopping 20 to 50 minute exposure. Listen to the family, talk to the patient and the chances are they usually have a solution or a way that is better.


Don't make things any more complicated than necessary.

R/r 911

 

[VentMedic]

Actually if you were to talk to Dr. Bledsoe I believe his thinking is we should be more medicine than to ever be considered public safety.

Here's the article for everyone's viewing pleasure.
http://www.jems.com/news_and_articles/columns/Bledsoe/Should_EMS_Be_a_Part_of_Public_Safety.html

Should EMS Be a Part of Public Safety?

Another Perspective

• <LI class=author>Bryan E. Bledsoe, DO, FACEP
• 2007 Aug 2

Thus, we have a conundrum. Public safety, especially law enforcement, requires employees to adhere to Kohlberg’s “Maintaining Social Order” stage (Stage 4) for much of their work. In fact, this reasoning is reinforced in law enforcement academies. In this stage of moral reasoning, adhering to the letter of the law trumps all other concerns. An example of this, of which I’m acutely aware, is a local Texas Highway Patrolman who wrote his wife a ticket for speeding. His moral reasoning was “she broke the law and the law must be enforced — no matter who the offender.”

Such a priority can conflict with the role of EMS. In our textbooks, and in education classes, we teach that the patient always comes first (after scene and personal safety). We emphasize that EMS personnel are advocates for the patient.Thus, in EMS education, we ask that EMTs and paramedics function, at a minimum, in Kohlberg’s “Social Contracts and Individual Rights” stage (Stage 5).

 

[Ridryder911]

Yes, but he was discussing it as in a profile of sociology not professional stature, in which Bryan and I have had discussions. Definitely an advocate for EMS to be more in-depth in medical adaptation than to be regarded as a "public servant" type employee.

R/r 911