Death By BVM






Over at Street Watch: Notes of a Paramedic, there is an excellent post about airway management. Beach Ball Bellies. The discussion is about the common problem of stomach inflation. Stomach inflation is almost always followed by vomiting. One solution proposed is to allow BLS (Basic Life Support) to use the LMA (Laryngeal Mask Airway) to ventilate cardiac arrest patients.

First I want to comment on one other skill change Peter mentions. CPAP (Continuous Positive Airway Pressure). I do not see any problem with adding this to the BLS scope of practice. If the dividing line between BLS and ALS (Advanced Life Support) is seen as BLS cannot perform invasive procedures, then CPAP is certainly not invasive. CPAP is only to be used for patients who can control their own airways. The airway is in the control of the patient, not in the control of the basic EMT, not in the control of the medic, not in the control of respiratory, not in the control of the nurse, not in the control of the doctor. So, where is the objection to CPAP use by BLS?

Back to the main problem.

In medicine, there is a lack of airway management skill.

Not just first responders. Not just basic EMTs. Not just intermediate level EMTs. Not just paramedics. Not just nurses. Not just doctors. Everybody.

There are some people with excellent airway management skills, but there are plenty with such pathetic skills that they should wear this patch.



Why do we tolerate incompetence?

We are no different from the rest of the world in overdosing on Cognitive DissonanceTM.

In paramedic schools, do we require that paramedics demonstrate excellence in BVM (Bag Valve Mask) use? Some places do, but many do not. It is usually just a quick demonstration of inflating the lungs on Fred the Head (an intubation mannequin - the head in the picture on the right in the link is Fred, or a relative). The person evaluating the future medics probably isn't even interested, because it is not an effective evaluation and it is not considered important.

It used to be that paramedic candidates had to use a BVM to ventilate a patient through an entire surgical procedure, but that kind of attention to BVM skill does not seem to be important any more. After all, if the NR (National Registry of EMTs) can certify medics for you, why worry about skill? If NR says they have what it takes, they must have what it takes. Too bad what it takes is only the ability to memorize and regurgitate material with no understanding of relevance to patient care. Patients are still regurgitating, because of NR certified airway mismanagement.

There is a demand for people with patches that end with a P, as in EMT-P, P for Paramedic. In order to provide those patch wearers, we need to lower the standards? Maybe. Maybe not.

Fire departments, private ambulance companies, volunteer organizations, hospitals, . . . all demand more employees. The public demands paramedics. The school administrators demand high pass rates. The standards get lowered to satisfy these customers.

We have a problem with the instructors, too. Do they have the ability to perform the skills? Do they understand when the skills are indicated? Do they understand how to teach? Are they being pressured to just run them through the program, because the NR will weed out the bad ones? The last reason was the main one for me, when I stopped teaching paramedic school.

Too many clueless medics being passed, because the final exam is a test that we think will weed out the ones who never learned. But we have been spending more time on test preparation. Test preparation is just how to make it seem that you know what you are doing, even though you do not. We spend a lot of time on test preparation, because the students are not being educated. The less prepared the students are, the more time we spend on gaming the system.

Maybe we should hand out ruby slippers and teach the medics to say, There's no place like trachea. There's no place like trachea. There's no place like trachea.

At the end of paramedic school, there is the NR exam. This is the equivalent of Professor Marvel handing out diplomas. Suddenly, the possession of the paramedic card is expected to produce the competence that the paramedic school could not in all of the hours of training they provided? Sounds reasonable.

There is an excellent article[1] by Kelly Grayson at EMS1.com. This should be read by everyone involved in airway management. In hospital (respiratory, nurses, doctors), out of hospital (first responders, basic EMTs, medics, flight crews), everywhere (if you have anything to do with airway management, you should read this article).

If we do not begin insisting on BVM excellence at the first responder level, we need to teach it over again at the basic EMT level. It is hard to get people to stop using bad habits. If we do not begin insisting on BVM excellence at the basic EMT level, we need to teach it over again at the paramedic level. It is even harder, by then, to get people to stop using bad habits.

I do not have a problem with putting LMAs, King LTs, CombiTubes, . . . in the hands of first responders and basic EMTs. I do have a problem with substituting one form of misunderstanding for another. If they are not competent with the BVM, will they be competent with any alternative airway?

We thought the solution to the problem was insistence on OPA (OroPharyngeal Airway)and NPA (NasoPharyngeal Airway) use. We demand that these devices be used in airway management. But why do we really need them? Sometimes the tongue will continue to obstruct the airway, even with good head positioning. OK, then use these, when they are indicated. They are not indicated for every use of the BVM.

Put an OPA in your mouth. Some of you may not have a gag reflex, but for those of you, who do have intact gag reflexes, didn't it make you want to vomit? For the patients with bad airway management, the OPA really just helps the stomach fill up with air even faster, while stimulating any gag reflex that is present. If I were to write a recipe for vomiting, a recipe that does not include ipecac, this would be it. Fill the stomach, while stimulating the gag reflex. That should not be our goal. Good airway management means using what is appropriate to manage the airway. It does not mean using everything, just because it is in the bag.

Some instructors will tell you that you need to use an OPA (NPA when you cannot open the mouth) whenever you are using a BVM. Airway management is about continual reassessment of the airway. If you cannot tell where the air is going, it does not matter what device you are using. OPA, NPA, LMA, endotracheal tube, . . . it does not matter what the device is. The skill of continual reassessment of the airway is the only essential in airway management.

Airway management is about being able to outsmart the airway. Why are we constantly losing this battle of wits?

It appears that the solution to the problem of Beach Ball Bellies will really come from the elimination of ventilation from the initial management of cardiac arrest. This is something that is overdue, but it is not the solution to airway management problems. This just hides the problem a bit. This just decreases the incidence of the problem.

Removing ventilation from the initial management of cardiac arrest is good for the patient. The AHA (American Heart Association) and ARC (American Red Cross) should be as aggressive in promoting this important change to CPR as they were in promoting fibrinolytics for stroke.[2]

We do not need to lower any standards. We need to raise standards. We have too many paramedics. When there are more paramedics than patients, we usually have too many paramedics. Only in very busy systems do we need to have two medics on a call. Two medics in busy systems, only so they can alternate being in charge of patient care. To minimize burn out. We need to oppose these attempts to make everyone a paramedic, because this leads to a dilution of skills and a lowering of standards. The standards are already too low in too many places. Or are your medics intubating over 95% of patients successfully and managing the airway adequately by alternative means in the rest of cases?


Footnotes:


^ TM Cognitive Dissonance
Wikipedia
How to harm people with a clear conscience. Fool yourself.
Article


^ 1 The Airway Management Continuum
Kelly Grayson
EMS1.com
Article


^ 2 EMS mythology. EMS myth #2. Thombolytic therapy is the standard of care for acute ischemic stroke.
Bledsoe BE.
Emerg Med Serv. 2003 Apr;32(4):63-5. No abstract available.
PMID: 12705219 [PubMed - indexed for MEDLINE]
Free PDF

.

10 comments:

Adam Thompson, EMT-P said...

Does that patch come in blue?

The art of the BVM. I have never heard of the OR test, but that sounds like an amazing way to teach the skill properly.

With EMTs using combi & king tubes, should they acquire ETCO2 monitoring as well.

If we are going to continue expanding the scope for EMTs as well as medics, the class should be longer than a single semester. I have actually taught a half-semester class, 8 weeks long.

As for CPAP, I think EMTs would have to be taught the physiological effects and how to recognize a patient who needs it. This is easy for you and me, and I am sure this skill could be adopted into their scope. I think that they should call for ALS transport depending on where they are though.

Yet another good read!

Rogue Medic said...

Adam Thompson, EMT-P,

Does that patch come in blue?Maybe, but in this case, the patients are the ones that are blue. Sad and cyanotic.

The art of the BVM. I have never heard of the OR test, but that sounds like an amazing way to teach the skill properly.It isn't as if an anesthesiologist, or CRNA, is going to let you get away with bad BVM use. This is not a mannequin that can be abused without evidence.

With EMTs using combi & king tubes, should they acquire ETCO2 monitoring as well.Waveform capnography is something that would be much better in the hands of BLS, than pulse oximetry. It is more useful and less dangerous.

If we are going to continue expanding the scope for EMTs as well as medics, the class should be longer than a single semester. I have actually taught a half-semester class, 8 weeks long.The length of the class should be appropriate to teach the material. It should not be based on what other college course lengths are. It should only be based on what is needed to educate. We need to spend more time on making sure we have instructors who actually can educate students.

As for CPAP, I think EMTs would have to be taught the physiological effects and how to recognize a patient who needs it. This is easy for you and me, and I am sure this skill could be adopted into their scope. I think that they should call for ALS transport depending on where they are though.I think the physiology can be explained pretty easily. This is only used with conscious alert patients. If the patient is not able to protect his own airway - no CPAP.

I agree with ALS transport - as long as the hospital is not the closest ALS.

Yet another good read!Thank you.

Anonymous said...

CPAP/CO2 - we dont get it in my region in australia due to one factor - $cost$....hmm same for IO actually $180 a pop...much cheaper to get an IV.
Nick G

Adam Thompson, EMT-P said...

Anonymous Aussie,

Do your hospitals have MRIs? Do you have heart monitors?

They are expensive as well.

I understand the cost issue, but the benefit of CPAP outweighs the cost for sure! If I were you, I would be pushing CPAP on everyone. I would cary the research around with me. Imagine not having to wait and watch your next CHF patient flood and become unresponsive so you can tube them. Usually, from what I have read, Austrailia EMS organizations are pretty progressive.

The IV vs IO debate doesn't make much sense to me. An IO could be used in those instances where IV access is too difficult. An IO is not a substitute for an IV, just a contingency plan. It has also become quite useful in pediatric emergencies.

Adam

Rogue Medic said...

Nick G.,

As Adam mentions, CPAP is one of those treatments that is inexpensive, when you consider how effective it is and what the alternatives are. How cheap is it to run a code on a patient, in stead of transporting them alive to the ED.

Many of these patients have dramatically decreased hospital bills after CPAP vs conventional EMS treatment. They may be discharged the next day, rather than spending a week in the ICU. It is only expensive if you do not use it.

IO vs IV. IO needles can be expensive, but they are really only supposed to be for when you cannot get an IV and the patient is not going to feel it due to being unconscious or unstable (not always the same thing).

Walt Trachim said...

I don't disagree with the premise of raising the standards of pre-hospital providers. Far from it, in fact; I believe it would be a welcome wake-up call if that somehow could be achieved. Question is how, though.

RM, you advocate "the OR test." So do I. It is a very strong lesson to teach someone who is learning to manage an airway properly, from someone who is well-qualified to do so. An anesthesiologist or a CRNA is a great resource for teaching this skill. I know that when I was in the position of being precepted by an anesthesiologist in the OR myself I learned - quickly - how to do it right. If I didn't, there was no way I'd be allowed to intubate patients. And there is nothing that I know of, other than the limits set by the facilities themselves, that says an EMT-B or EMT-I student can't learn the skill of ventilation from one who knows it as well as either one of the practicioners mentioned.

This was an excellent post. Thank you for sharing it - as usual, you done good... :)

Rogue Medic said...

Walt Trachim,

I don't disagree with the premise of raising the standards of pre-hospital providers. Far from it, in fact; I believe it would be a welcome wake-up call if that somehow could be achieved. Question is how, though.
One way would be the elimination of the farcical goal of providing each candidate with the same testing experience. It isn't about avoiding any possible perception of bias. It is about assessing competence.

RM, you advocate "the OR test." So do I. It is a very strong lesson to teach someone who is learning to manage an airway properly, from someone who is well-qualified to do so. An anesthesiologist or a CRNA is a great resource for teaching this skill. I know that when I was in the position of being precepted by an anesthesiologist in the OR myself I learned - quickly - how to do it right. If I didn't, there was no way I'd be allowed to intubate patients. And there is nothing that I know of, other than the limits set by the facilities themselves, that says an EMT-B or EMT-I student can't learn the skill of ventilation from one who knows it as well as either one of the practicioners mentioned.
I completely agree.

This was an excellent post. Thank you for sharing it - as usual, you done good... :)
Thank you.

Kevin said...

Thank you for the insightful post. I am a Paramedic student working towards my degree and information like this is invaluable. Oh and I do apologize for attempting to breach the ranks and put one more Paramedic on the streets since there seems to be an abundance of them, this is something I've dreamt of doing since I was a kid. Standards should most definitely be higher for acheiving the certification, it should be something held in high regard and less common.

Kevin said...

Sorry about that just re-read your paragraph about the abundance of P's and I'm in complete agreement with you. I took it the wrong way.

Rogue Medic said...

Kevin,

Thank you for the insightful post.


Thank you.


I am a Paramedic student working towards my degree and information like this is invaluable. Oh and I do apologize for attempting to breach the ranks and put one more Paramedic on the streets since there seems to be an abundance of them, this is something I've dreamt of doing since I was a kid. Standards should most definitely be higher for acheiving the certification, it should be something held in high regard and less common.


We will always need more medics. I just want them to be good medics. One way is to have fewer of them responding to more serious calls.


Sorry about that just re-read your paragraph about the abundance of P's and I'm in complete agreement with you. I took it the wrong way.


It is my fault, if I do not make myself clear.