Russ, over at EMS Outside Agitator writes Guess I’ll Just Jump On In!
Go read what he wrote first. I will have my comments here. There is a lot to comment on, but just to give you an idea – this is the first sentence –
Here’s a doozy!
He is not exaggerating.
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Now that you have read that – From the original discussion forum –
His blood pressure is slightly elevated at 142/90, heart rate is 110 and he is breathing at 24 times a minute. He is showing a sinus tachycardia with no ectopy, and his SpO2 is 97% on room air.
His only complaint is pain to the face at the time of your initial exam, pain score 10/10. He denies any respiratory distress, and his lungs sound clear. When you open his mouth to examine his throat you note that he is a Mallampati Class 3 airway, with the soft & hard palate clearly visible. You note no soot, redness or irritation to the muscosa in the throat when he opens his mouth for you to inspect it.
. . . .
5-10 minutes into transport he begins to complain of shortness of breath, and you notice he is coughing quite a bit. You note his Sp02 is now 95% on room air, and when he coughs he has a slight barking quality to it. His respirations are now 28, and he does appear to have some mild difficulty breathing. He is becoming anxious, but has no history of anxiety, and states he is scared because he cannot breathe.
The medic later mentions that he had already given fentanyl, no idea what dose, and it only brought the pain down from 10/10 to 7/10. Starting with fentanyl is good. Continuing with fentanyl might be better. Maybe add some midazolam to calm the patient if not able to talk the patient into calming down.
If the problem is hyperventilation, why do we want to intubate?
I have never intubated a patient for rapid breathing and anxiety. I do not think that this patient would be one I would start with. For hyperventilation, I usually calm the patient down and get a refusal – an extensively documented, well informed refusal, after a thorough assessment and history.
I would reassess lung sounds, because what does a written description of a cough with a slight barking quality mean?
I would reassess the airway. Assuming that things have changed, or that things have not changed, is not an assessment. Intubating this awake and alert and talking patient without further assessment is not a good idea.
When has it ever been appropriate for anyone to intubate a patient for the SpO2 dropping from 95% to 97%?
W T F ?
An agitated hyperventilating patient probably not keeping his hands still.
More from the original forum, a later post –
After initial contact, the patient was medicated with fentanyl for pain, prior to complaint of shortness of breath, which initially only brought the pain level to a 7/10. The patient was checked for signs of allergic reaction to the fentanyl and ruled out as a cause, just FYI
During laryngoscopy some mild redness was noted to the area above the glottic opening. the cords did not appear swollen or burned. There was some slight swelling of the airway.
Intubation was performed on the first attempt with minor difficulty. The patient was adequately preoxygenated with a NRB mask for 5 minutes prior to induction, and was ventilated via BVM post induction for approx 2 minutes.
And then Clark takes off his glasses, steps into a nearby phone booth (he is old enough to remember them), and –
In his mind, he’s got the backing of his EMS peers. In my mind, 14 out of 17 responders are nuts and the only three who get away with it were those who didn’t make a call!
Amen!
However, there are a few things that I view a bit differently.
#1. Mechanism of injury; blast of steam to the face from a radiator of a car that had ALREADY COOLED DOWN for 1/2 hour.
What does time mean in EMS?
Did that seizure last 15 seconds or 15 minutes? Reports of time should generally not be considered reliable.
If the radiator discharged steam onto his face, then there may still have been some boiling going on. And, does this guy decide to wait 30 minutes, because somebody told him to wait 30 minutes? In which case, he might be as patient as kids on a car ride – Are we there, yet? 5 seconds later. How about, now? 5 seconds later. Are we there, yet?
#4. Alert, conscious, talking 1/2 hour AFTER the fact,
This is where I get to harp on one of my favorite targets.
Mechanism Of Injury vs. patient assessment.
This appears to be a case of intubation due to Mechanism Of Injury.
If you think that destination decisions based solely on MOI are acceptable, how about invasive airways? Where do we draw the line?
#5. Minimal visible signs of injury,
#6. Only complaint of pain…AROUND THE EYES!
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No. I did not give up a promising career as an artist to work in EMS.
Pain around the eyes – there is an I in airway, even if there isn’t in team, he is treating the eye in airway! A new addition to the ABCs.
#7. Time elapsed w/o incident; at least 40 minutes from time of incident until medic feels need to take action
The golden titanium 40 minutes.
#8. Complaint prompting action; “states he is scared because he cannot breathe”
WHERE ON GOD’S GOOD EARTH DOES PROTOCOL SAY “INTUBATE FOR FEAR”?
Right there. You just wrote it. 😉
I always wonder about this part – “states he is scared because he cannot breathe”
How do you know the patient could not breathe?
He told me so.
While I have had patients gasp out similar statements and some of them have been close to respiratory arrest:
This is a young, otherwise healthy guy (no meds, no hx, no allergies) breathing at 28 times a minute and the worst part is that his sat just dropped from 97% to 95%.
I’ve been out of the field for twenty-five years. I do not understand what capnography is and don’t know how wave forms are related to it. I never used Albuterol or Solu-medrol, and never administered anything other than IV Valium or Morphine to sedate. The idea of using or even needing to use paralytics in the field to intubate gives me the Screaming Willies because I know (humbly) if I couldn’t intubate, paralytics wouldn’t help.
Things have changed a lot. RSI may be the thing that allows you to be more successful intubating, or it may be the thing that allows us to be more harmful.
The most common thread amongst the responses; “Sedate, paralyze, intubate.”
If our OP doesn’t realize WHY everybody is watching and waiting for medics to screw up and is ready to pounce when they do, he’s going to learn Damn Fast!!
Maybe I’M the one who’s nuts!?
You do not provide sufficient information for anyone to make an informed statement about that..
How the hell did the OP talk a conscious patient into getting intubated? That makes me wonder now if any consent was obtained and what the patient’s experience of the whole thing was?
This is EMS.
We don’t do informed consent.
In order to obtain informed consent, we would have to provide accurate information about the known risks and benefits of treatments.
I have never observed patients provided with information about spinal immobilization other than – If you don’t get on the board, you’re going to be paralyzed!
Sometimes it is not as adamant as that, but this coercion is based on what?
According to the narrative of the OP, the only treatment the patient needed at the time the OP chose to go for the throat was a reassuring hand and a few moments of connection.
I should have been doing that all along.
Here’s where you get to really learn. This suggests to me you need to take a real good look at what you know, what you don’t and why you jump to extreme paramedic/Doctor when being a humble EMT would suffice.
Here is my opinion.
Every intubation should be treated as a sentinel event. There should be review with the doctor in the ED. There should be review with the medical director. This does not mean punitive review, but a review of whether intubation was appropriate.
If I cannot justify to a doctor why I intubated a patient, is there any reason to believe that intubation was appropriate?
The same should be true for every other aggressive treatment. This is where oversight takes place, not some magic phone call, where you paint the picture you want the doctor to see. That is a pure fantasy.
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(I welcome feedback in how I’m communicating with you. If I’m sounding like an old, used-up war veteran with nothing but inaccurate memories based on an infant’s experience of a profession, tell me. Otherwise, I’m open to suggestions as my intent is to build bridges of understanding, while still staying true to my animal nature!)
You seem to have overcome that introversion problem. I am having trouble believing that you ever worked in EMS. We are usually so hesitant to speak write our minds.
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Simply put, this is why I avoid EMS forums like the plague. This is also why we can’t have nice things, like more leeway in patient treatment and the ability to actually PRACTICE medicine. We are stuck in the dark ages because of the lowest common denominator. This has to stop.
510medic,
There is some promising work on a plague vaccine. Maybe the EMS forum vaccine insanity will be next.
Amen!
As an FNG (again!) who’s an FOG, I can’t tell you how much I appreciate you explaining the intricacies of medical intervention these days so I don’t have to!
Truth is, the best I can do is spot inconsistencies in rhythm, approach, utilizing basics, and patient connection. After so long, I get to look at things from the long-view (not worrying about my certs being pulled!) and comment.
I enjoy http://www.EMTlife.com particularly because it’s all about the words, without distractions, and though there is a lot of the other BS and squabbling as on all Forums, there are still a lot of medics there willing to explore what has formerly been neglected territory.
If you think that was speaking my mind, stay tuned!
And thanks for your good work keeping the kiddies in line while I took a snooze!
firetender,
Most people seem to avoid looking at the details, but I like to get into the details.
That is most of what we still do in EMS. We have more drugs, some even supported by good research. These tend to be the ones that require the magical Mother-May-I? phone call, while the ones without evidence tend to be on standing orders and mandatory.
How much has really changed?
Anybody willing to intelligently discuss what is best for the patient is worth communicating with. A forum will sometimes deviate from that goal.
Maybe we will develop a new motto – EMS Blogs – The S is not for Subtle.
I don’t keep anybody in line. I hope to sometimes point out things in a way to convince people that their poorly considered position is not worth maintaining – such as intubation for an eye injury. 😉
Keep up the great work.
thanks for the post