From the “Where did you get that tidbit of nonsense from?” file comes this gem.
We were dispatched for a lady with dyspnea at an address I’d never been to before. Which is often a bad sign since it means that the patient is not a frequent flyer valued repeat customer. Which often means that it’s someone who is really ill, not just calling for a convenient ride to the hospital. To add to the odds of this being a legitimate patient, the apartment was on a the third floor of a building with no elevator. As we got out of the ambulance I looked at the building and thought to myself “This is going to be a sick person.”
Like gazelles my partner and I sprinted up the stairs. OK, we walked up the stairs if you insist on being prosaic. We beat the BLS crew in by a couple of minutes so we found the 67 year old patient sitting by herself using all of her energy to breath and it was a losing battle. A quick listen to her breathing revealed rales to the apecies of her lungs. Plus she was extremely diaphoretic. Nor could she speak more than one word at a time. Did I mention that she also had chest pain?
Her vital signs were as follows; BP 260/140, Pulse 130, respiratory rate 32, O2 saturation (when we got that on her) 90% on 100% O2. We wasted no time in loading her up with NTG spray, getting her on the stair chair, and getting her to the ambulance. Actually while my partner and the BLS crew was doing that, I ran down the stairs (really) set up the CPAP in the ambulance and pulled the stretcher.
As soon as we got her in the ambulance we put the CPAP on, did a 12 lead, started an IV and went to the hospital. A quick radio notification was made so that the ED staff could get their resources ready for the patient. Said resources including CPAP because of course our CPAP device isn’t compatible with their CPAP device. Why would the manufacturers want to do something silly like that? It might cut into sales of consumable supplies, which is where the real money is. But I digress.
During the 8 or so minute ride to the hospital, the patient improved markedly. Her skin dried up, she was able to speak full sentences, she wasn’t gurgling, and her respiratory effort was decreased. She still had chest pain, but since the 12 lead ECGs showed absolutely nothing amiss, we decided it was most likely due to the hypoxia. For the record, she had diabetes, hypertension, previous stents, congestive heart failure, and other diseases of the mostly elderly in her history. And the medications to match.
We rolled into the ED and were directed immediately to an acute care room, no waiting for triage nurses or other stupid hospital games.
As we tranferred the patient over to the hospital bed I gave a more detailed report to the staff and handed over the two 12 leads my partner had done on the way in. The doctor thanked us, asked the patient a couple of questions and started on a treatment plan. As I walked out to start my report, I saw a respiratory tech wheeling their CPAP machine in. All was well in the world of the patient. Who, I might add, would have ended up intubated and likely dead a few years ago before we had CPAP in the field. Nice work, if I do say so myself.
I went out to the ambulance to write my report and upload my ECG data back to what Ambulance Driver
would refer to as Borg headquarters, only I don’t work for the Borg so I just call it “The Puzzle Palace” because I rarely can figure out what the geniuses that run my service are thinking when they issue mysterious memos. Again I digress.
I finished the report while my partner cleaned and restocked the ambulance. When that was done we cleared and headed back for the station. That’s when my partner told me about the clown show he had witnessed while I was busy doing the report. I think he waited until we had left the hospital because he feared I might go back and ask the attending physician WTF he was thinking. Or maybe just “Which Caribbean island medical school did you graduate from?”. Which probably would have resulted in a phone call, an incident report, and an addition to the things I can’t say or do. Probably a wise move on my partner’s part.
Here is what transpired, as related by my partner, who is not given to flights of fancy.
As the respiratory technician got ready to put the patient on the hospitals CPAP, the attending physician walked in and told him to put the patient on a non rebreather mask instead. Let my digress to mention that this is not a fly by night community hospital whose ED is staffed by moon lighting dermatologists and gynecologists. This is a well known hospital affiliated with a world famous medical school. Not a lot of medical lightweights here, but apparently they do slip up now and then.
My partner inquired (nicely) why the doctor wasn’t going to continue with the CPAP that had worked so well.
The answer made my partner’s jaw drop.
“Well, she’s in CHF, but if you put a non rebreather on with a tight fit and set the Oxygen regulator to flush, it approximates CPAP at 5cm of H2O. She doesn’t seem to tolerate the CPAP well (which was BS) and this will be sufficient.”
Huh?
For those of you not familiar with non rebreather masks “tight fit” is not one of their characteristics. There are essentially two sized of mask, one for pediatrics, one for adults. Getting a tight fit is not next to impossible, it’s impossible. Getting them to stay on many patients at all is a challenge, a tight fit is, as I think I mentioned, impossible.
Later on we saw the shift supervisor, who knows this hospital well because his wife works there. I related the story to him and his jaw dropped. At first he thought I was making the story up, but I assured him that it was the truth, nothing but the truth. Which is when he told me it was probably better we hadn’t told him the story earlier because he would have asked the doctor “Where did you get that tidbit of nonsense from?”.
Maybe Rogue Medic can find a study to support that, but I’d still be pretty skeptical. That’s almost as bizarre as the EMT who assured me that he didn’t need ALS for CHF patients because some Oxygen and calming the patient down worked just as well as medications and CPAP.
Every once in a while something still leaves me scratching my head.
Maybe from here: http://emcrit.org/misc/bvm-preoxygenation-and-reoxygenation/. It’s not the exact same situation, but close.
You might be interested – or bewildered – to learn that pediatric intensivists often use “high-flow” nasal cannulas in the ICU (http://pediatrics.aappublications.org/content/121/1/82). I think it’s hogwash, but since I don’t work in the PICU, it doesn’t matter!
Good job with the patient, but perhaps you committed the error of treating the CHF too well! As a result, the ED team thought that a less aggressive approach would work at that point.
Another example of EMS doing too good a job is described at http://millhillavecommand.blogspot.com/2012/01/just-little-burning-and-ton-of-bricks.html.
Sure, high flow O2 through a nasal cannula. Talk about causing nasal flaring!
Consider yourself linked.
Your story gives further credence to something I’ve been saying for a long time:
“EVERY hospital has a ‘B’ team.”
Sadly, at all too many hospitals the “B” team is the best they have. This joint isn’t one of them, but even the best hospitals have a dud now and then.
Good grief. Believe it or not, we’re still YEARS off using CPAP in the field here in Ye Olde Englande… In the meantime, GTN (or NTG as you guys prefer to call it), O2 and diesel are the preferred method of treatment.
Not long ago, I was gently informed (aka reprimanded) by a ‘B Team’ doc for giving a very similar patient too much GTN whilst on route to hospital, and was upset when I suggested in the radio report that they will probably need CPAP when they got to hospital.
Minutes later they put the patient on a GTN infusion and CPAP. Frustrating ain’t the word…. Good job sir!
Both this patient and one that we treated last week would have been intubated in the pre CPAP days. In fact, I think that this patient would have likely died despite intubation. That’s how dramatic the turn around is with CPAP. I’d think they’d be all over CPAP in Ye Olde Englande because it decreases intubations which means fewer ICU days, which means lower costs. Also it eliminates the incidence of VAP because the patient isn’t on a vent. I know that health care is “free” to the patients over there, but that doesn’t mean it’s free, it costs a lot of money. CPAP is simple to implement and not very expensive. It saves the patient a lot of discomfort and can save the NHS a lot of money.
Probably makes too much sense.
Amen Brother. Too much sense is an oft seen problem of any large organization… Especially government run