If there were a single intervention whose effectiveness I had to say impressed me nearly every time, it would have to be the power of CPAP (Continuous Positive Airway Pressure).
I've mentioned this before, but there are few things more intimidating than being a fairly new EMT and walking into a situation where your patient is clearly sick and you're faced with a 45 minute ride to the hospital. I can hear the patient's respirations from two rooms away--the loud, wet gasps that tell you "Oh crap...", and my mind jumps to envisioning exactly what sight will greet me a mere 30 feet away.
She's tripod-ing, perched on the edge of the bed, and her eyes are wide open and pleading--trying to communicate a desperation that words are failing right now. She is frightened and she knows that there is something very wrong with her right now. Her years are catching up to her, and she wonders if this is it. You can see the edema in her lower legs from 15 feet away, her swollen ankles peeking out from the modest nightgown she dons.
Your observations begin to mold into a concrete set of suspicions about what you're facing, and you start racking your brain for everything that your remember about congestive heart failure. Does she have a history? Cardiac? Respiratory? Otherwise? Medications--what's she been prescribed? Those neatly lined up pill bottles on the bedside table tell a much larger story, I'm sure. When did all of this start?
Her husband is rambling nervously at my side, and I tune into "COPD", "she takes pressure pills", and "she takes water pills". At this point, I'm at her side, and introducing myself and taking her hand. The death grip that follows is no surprise. I feel for a pulse and it's racing beneath my fingers. It takes a split second for me to make the "load and go" decision.
We apply hi flow oxygen, shift her to a rolling chair borrowed from the kitchen, and wheel her to the entryway where our stretcher sits at the opening to a narrow maze of halls in this one story home. The transfer is efficient and professional, and I am anxious to get her into the back of my truck where I have something that might relieve both the patient's and my own anxiety.
A month ago, I had spent two hours of CE preparing exactly for this situation. A month ago, our OMD had devoted two hours to educating his EMTs about an intervention that works, and works perfectly in certain circumstances: continuous positive airway pressure, or CPAP.
Positive Airway Pressure is a form of ventilation that EMTs are introduced to early on in their educations. When you are taught the "A" of ABCs, you learn the necessity of ventilating with a bag-valve mask (BVM) in certain situations where either the airway is compromised and the individual is unable to breathe adequately on their own. Ventilations with a BVM are a means for providing Positive Airway Pressure. However, the majority of my patients that have been on the receiving end of a BVM are usually no where near able to communicate with me; rather, they hover right around "unresponsive". Yet there is a whole other class of patients that are alert and able to communicate, yet could also benefit from Positive Airway Pressure with a continuous flow. Thus, CPAP was born as an intervention for a variety of conditions ranging from sleep apnea to congestive heart failure to chronic obstructive pulmonary disease (COPD).
As we transitioned the patient from house to ambulance, I quickly and mentally reviewed my indications and contraindications for CPAP. My patient hit nearly every indication for CPAP and no contraindications appeared to be present; thus began my first experiment with rigging up the CPAP and applying it to my patient.
There is no better sense of satisfaction and relief when you start out with a patient who is clearly very sick and 45 minutes out from the hospital, and 10 minutes down the road there is notable improvement in your patient's condition because not only are they tolerating your intervention, but they are also benefiting from your intervention.
What's even more satisfying is when you arrive at the hospital with a patient who is in congestive heart failure, yet due to the lack of several notable signs and symptoms the doctor has trouble telling exactly why you brought in this patient.
The great thing about CPAP is that if your patient can tolerate it, and the indications are present, CPAP can, and often will, make your patient better. More often than not, providers at the basic level are already intend to, and often do, apply hi flow oxygen to a patient who is having difficulty breathing. It is one of the most fundamental protocols that you learn as an EMT-B. In many ways, CPAP is a jacked up version of hi flow oxygen whose mechanism of operation makes it much more effective in certain situations. If OMDs around the country are already willing to let their EMTs utilize high flow oxygen, then why not expand their access to yet another tool that can make an even greater difference for patients whose symptoms are drilled into our heads, but for which there are very few things that--nationally--we, as basic level providers, are able to do to alleviate such symptoms. CPAP is a tool that can make a difference, and isn't it our goal as providers to bring our patients to the hospital in better condition than they were when we received them?
I may be over simplifying the science behind why CPAP, or I may not fully understand why it is often a skill reserved for individuals at the Advanced Life Support level due to the whole "newbie" thing, but I can tell you this. It's as frustrating as hell knowing that local protocol was the only thing preventing a BLS truck from administering an effective intervention at the pre-hospital level when my grandmother went into congestive heart failure. Even though she lives less than a mile away from a staffed rescue squad in a suburban New England town, she landed in the ICU for four days because of a lack of timely and effective interventions--interventions that she failed to receive until she arrived at the hospital. And last time I checked, that's not what EMS is all about.
There are some services that keep their EMTs on leashes with a scope of practice so narrow you could fit it on the head of pin; Small-City Service in the town where I go to school in Virginia is one of them. As a BLS provider at Small-City Service, you are rarely viewed as more than a medic chauffeur or BS (and yes I do mean BS, not BLS) transport unit. And then there are services like mine, Small-Town Service, VA where we have an OMD that understands the value in giving his providers the tools they need to do their job well and to treat their patients accordingly.
And isn't THAT what EMS is all about?
No comments:
Post a Comment