Jumat, 05 Mei 2017

brown inhaler for asthma name

brown inhaler for asthma name

so we're going to talk aboutthe utilization of critical care paramedics in theair medical industry. this talk was originally madefor respiratory therapists, so there are someminor deviations. as far as my style of teaching,ask questions all you want. if you have to gosmoke, go smoke. go pee, whatever. pretty laid back, so. i guarantee you, this is inevery one of my presentations.

and what you're going tofind out through today is, i only have one presentation. i just rearranged the slides andtell it in a different order. you guys are goingto be working side by side with paramedics, nurses,firefighters, physicians, respiratory therapists. they're going tosay, you know what? i've been doing this five years,10 years, 15 years, 20 years, 30 years.

i have seen it all;i have done it all. is that true? october 1 is my 17th yearwith flight for life-- somewhere around 2,200 flights. i guarantee you, every timethat phone rings, every time that pager goes off, i stillget the heebie-jeebies. you have no idea in the world. much like your lineof work right now, when that pagergoes off, you have

no idea what you're going into. and the coolest thingabout this profession is, you guys get reminded everyday how much you don't know. medicine changes every day. you're never goingto know it all. this was from when we justput out a bunch of new nursing recruits throughour transport team. this is one of the guys said is,welcome to transport nursing. 90% boredom, 10% sheer terror.

if you ever have thatattitude, go sell shoes. for me, it's 100% sheerterror all the time. like i said, thingschange constantly. hopefully today aftermy talks, you guys won't be in this situation. i've been awake for like, goingon i think, three days now, so maybe i will be. but as far as transportmedicine goes, again, you always want to bethe one giving the patient off.

you don't want to be onthe receiving end of it. so probably the mostcommon question that i get is, do you have to goto school to do that? it's like, no. the funny thing is, iwas walking to taco bell to do my driving shift,and some guy said, hey you want to go fly ina helicopter all day? and i'm like, sure. yeah.

so as far as education, yeah. yeah, you do haveto go to school. my initial dreamwas actually to be a guitarist out inl.a. and wound up going to work with mysister one day, who is a pediatricrespiratory therapist, and she was working specificallywith the cystic fibrosis patients at that time. so as far as forpulmonary clearance,

you would go in there, andyou'd beat on these kids to knock the secretions loose. so i'm thinking, howcool a job is that? going and beat up kids andlisten to ozzie all day? i'm hooked. so that was my truelove is actually-- my original love is respiratorycare, respiratory therapy. and then wound up--and at same time, i wound up going to rtschool and emt basic school

at the same time. loved them both. i absolutely lovedthe icu, but i also love the pre-hospitalsection of it. wound up going back toparamedics school and getting hired by flight for life. but again, startedthe emt basic. and then, i met this guy here. this was the medical directorof our pediatric icu,

a guy by the name of billperloff, which everybody thinks that the p in pediatricicu stands for pediatric. in all honesty, itstands for perloff. this guy was anaeronautical engineer for a company that dabbledhand in hand with nasa. so i mean literally, you've gota rocket scientist right there. then in his mid 40s,decides, you know what? i'm going to go backto medical school. and in a very shortperiod of time,

became a professorof anesthesiology, professor ofpediatrics, as well as director of pediatric criticalcare, pediatric transport, all of this stuff. this guy-- i am still eatingpaste compared to this guy. but this was my mentor. i've got countless storiesabout him that, like i said, just an unbelievable guy. and then my dream-- istarted at uw back in '88.

my dream was always to have adesignated pediatric transport team. it wasn't until 2000, the year2000 when this goofball here started-- a guy by thename of tom brazelton. and if you want tobe a purist, he's actually t. barrybrazelton the third. so if you've ever heard oft. barry brazelton, the pope of pediatrics, that is his son. and anyway, we're-- at like3:00 in the morning once--

we're talking aboutpeds transport. and i'm like, you know, i'vealways wanted to do a team. and he's like, let's do it. it took us fouryears, but we wound up getting the pediatric transportteam up and running there. and administration said, wellif you guys want to so bad, tom, you've got to be themedical director. stu, you have to bethe office monkey. so i get to be the day to daycoordinator for the past eight

years. but it's formally known ascheta-- children's hospital emergency transportambulance or aircraft. and then like i said,up until last year, i was working full timedown the road at flight for life, except i wasdown at the mchenry base-- unless i was in troubleand they sent me to lockshore or fond-du-lac. and then just recently,last year, i switched back.

and now i'm doing a full timepediatric transport at madison. so as far as transport goes,couple different modes-- ground, air. and as far as air,that can be broken down into fixed wing aswell as rotor wing. probably by far, themost common is ground. the reason being,it's the cheapest. as far as criticalcare transport goes, one thing thatunfortunately we got

to get out of that mindsetof is pre-hospital care versus critical care transport. pre-hospital care, we'retaught, get in there and get them from point a topoint b as soon as possible. critical care transport, youwant to get them from point a to point b improved. so you just got to gointo with the mindset of, we are going tohave extremely prolonged the bedside times.

if you wind up going in thereand spending upwards of-- there are times where we sit atthe bedside for two hours making sure that ourpatient is stabilized. the last thing in theworld i want to do is just come and grab and go. and all of a sudden, i'mat 1,500 feet in the air with some kidsthat's crashing on me or an adult that'scrashing on me with something that could havebeen prevented at the bedside.

so like i said, wekind of have to get out of that mindset of this comingin there, grabbing, and going. or scoop and go, or whatever. it's more or less astay and play attitude. as far as air goes,again, this is one that everybody wants to do. like da vinci said the best,once you've tasted flight, you will walk the earth withyour eyes turned skyward, for there you havebeen in there,

you will always want to be. i fly down in the chicagoarea, so very routinely, we wind up headingup and down the coast of-- even over thegood old bears stadium. which if it wouldn't beillegal to urinate out of the helicopter,i probably would. and then there isfixed wing transfer. and generally, as far asrotor wing goes, generally, you've got abouta 250 mile radius.

once you exceed-- as far as theutilization of the helicopter-- once you exceed 250miles, generally, it's a lot cheaperto go by fixed wing. and as far as fixedwing goes, there's no-- you have no idea whereyou're going to wind up. at any given time, there arecountless fixed wing aircraft flying patient flightsthroughout the united states. a couple years ago, i wascalled to do a flight-- or asked if i'dassist on a flight.

well, come to find out, it wasfrom dubai to san francisco. and i've got afriend that works, and she said, yeah,in one 24-hour shift, she wound up seeing both theatlantic and the pacific ocean. that she wound up going coast tocoast for two different patient flights. so again, there's no tellingwhere you're going to wind up. but again, rotor wing, like isaid, probably the most common. it first start in the koreanwar and then vietnam era war.

again, it is whenthey really noticed the benefits of air medicaltransport-- utilizing helicopters. first state program was outin denver, colorado in 1972. when they had theolympics out there, they had to figure out the wayto get people off the mountain. and so on the firstoriginal flight for life was out of denver, colorado. and that's where we actuallystole our name from.

as well as thereare many transports, where in the courseof one transport, you might do two or threedifferent modes of transport. where you might go pickup a patient by ambulance, take them to anairport, go by airplane now to some other airport,and then go by helicopter to a hospital. so just need to throwin a boat and you'll have all fourdifferent modes there.

as well as there arespecialty transports, which we'll talka little bit also. as far as neonatalpediatric transports, again, this is acompletely different world. and this has been outthere for decades. you know, we just startedour pediatric transport team in, like i said,2000, 2004 in madison. and we think, well, we're onthe cutting edge of technology. again, this has beengoing on for decades.

there's nothing newabout any of this. and again, as far as pedstransport goes, again, it's getting moreand more specialized as well as it'sbasically a moving billboard for a lot ofthese children's hospitals. as first transportteams, this is something that you've reallygot to think about. if this is something thatyou truly want to do, you have got to do your homeworkon where you want to work.

do i want to get abusy program where i'm siting thereflying all day long? i would love that. but what's more importantthan being busy? being safe. definitely do yourhomework on those programs. a couple different typesof ways to fly out there. there's what is calledvfr, which is visual flight rules, which means you haveto be able to see where you're

going in order to fly. and that's currently where--flight for life-- that's we're at. we are a vfr program,meaning we have to see the ground ifwe're going to go flying. and then there's also ifr, whichis instrument rated flight, which means if itis cloudy out, you can fly by the instrumentsof your aircraft. so fly above the clouds.

and this is kind of whatthis is depicting here is hey, what's a mountain goatdoing way up here in the cloud bank? what's going to happenhere two seconds? yeah, they're goingto hit a mountain. anyway, and we're in the infancyof going ifr with that program. that does not mean that justbecause we're an instrument program, we can goflying in every weather, all types of weather.

again, we're stillextremely limited, and it's basically forinter-facility flights only. it's not like you guys can giveus gps coordinates to a scene flight in bad weather,and we're going to sit there, pop up,and come over, and fly to your scene in bad weather. again, is pretty muchinter-facility facility only. there is what it'scalled camts, which is like the joint commission'sversion of the good

housekeeping seal of approvalfor air medical programs. that this is pretty muchwhat we would like to see, is that every programout there is accredited, meaning that they've got--they dot all their i's, cross all their t's when it comesto safety stuff, as well as protocols, as well asall of their faa stuff. that being said,unfortunately these days, it's getting to the pointwhere the industry is getting somewhat diluted now.

more and more andmore and more programs are becoming certified, that youreally wonder the value of it anymore. unfortunately, this was alsoone of the early attitudes in this field, is you know what? you guys areself-loading baggage. get in, sit down,shut up, and hold on. these days, again, if you'repart of that air crew, you are definitelypart of that air crew.

you have got just as much ofan equal say as the pilot. and we'll talk aboutthat a little bit too. it's called crewresource management, where if something is wrong,you've got to say something. so as far as the whole camtsrequirements and stuff, unfortunately these dayswith critical care transport, specifically rotorring transport, it's becoming a business. we are seeing more and moreand more and more and more

programs out there. several-- in themid '80s, there were 275 air medical helicoptersin the united states alone. today, any ideahow many there are? a hair under 1,000. what about here in wisconsin? so in '80, '84, the first airmedical program into wisconsin was flight forlife in milwaukee, followed shortly thereafterby med-flight in 1985.

today, i think we've got10 air medical helicopters in wisconsin. you go down themissouri or arizona, there's upwards of 30 or 40. and the joke was, they're goingto be running into each other. what happened about threeyears ago, down in phoenix? they ran into each other. two air medical helicoptersgoing to the same helipad at the same hospitalat the same time.

phoenix, where they gotcrappy weather, what? one day a year? they wind up, literally,crashing into each other, killing everybody on board. and unfortunately,like i said, these days the downfall is, if you don'tfly, you go out of business. there was a very well knowncall several years ago, down in the southcarolina area, where there was a ground crew thatcalled for a helicopter.

they had a pedestrianstruck by a motor vehicle-- had a isolated tib-fib fracture. called for the helicopter. first helicopter said, we'renot doing it because of weather. they call anotherprogram, we're not doing it because of weather. they call a thirdprogram, we're not they call a fourth programwhose numbers are kind of low. what do they say?

we'll do it. so they fly outthere, they pick up the patient in crappyweather, they take off. shortly thereafter,crash, kill everybody. where again, you don't fly,you go out of business. i would much rathergo out of business than wind up like this. so this is what i wastalking about-- crew resource management.

this-- and again, this issomething that's nothing new. we stole this fromthe airline industry. where again, we'vegot what we say as three to go, one to say no. so you've get the pilot,you got the nurse, and you've got the flightmedic, the flight paramedic, or the flight rt, theflight physician, whoever. everybody has got an equal say. if you don't likesomething, speak up.

if you don't want to goon that flight-- well, i shouldn't say if youdon't want to go on flight. if it's 10 minutes beforethe end of your shift and you've got a hot date,you can't sit there and say, we're not going. but if something bothers youabout that call, speak up. no questions asked. and that's something,again, when you go and apply for a program, ask them, howmuch is my opinion worth?

if we wind up takingoff and i don't like what the weather lookslike, if i sit there and say, you know what? i don't like this, turn around. am i going to get fired? or are you going to sitthere and turn around? and we even expanded it tofour to go, one to say no. we included our dispatchers. at our dispatch center, they'vegot the big animated weather.

and if the dispatcher is lookingand saying, you know what? you're taking a flightout to western illinois. they're having thundershowers out there and tornadoes on radar. you know what? don't go. turnaround. we're not even goingto dispatch this. so again, one to go--three to go, one to say no.

and again, if youdon't like something, again, you've got to speak up. and it might besomething as simple as, where are we landing? if i was on thathelicopter there, landing on a dustyball field, you think i'd want to sitthere and say, oh yeah. go ahead. keep on landing.

hell no. no. turn around. weather-- same thing, especiallyin this neck of the woods. where in good oldwisconsin winter, we say wisconsin's got what? 11 months of winter and onereally shitty month of skiing. it changes constantly. and again, something like this.

we can fly in the snow, butif it's a real blizzard, again, we don't wantto be out there. where we fly outof in mchenry base, we're kind of downin a little bowl, kind of in a valleywhere we get fogged in. and same thing-- how welldo helicopters fly in fog? asks stevie rayvaughan about that. not too good. so again, you'vegot to speak up.

on the door going out to thehanger, out to the helicopter, it's something that i stolefrom the program over in london. it says, the leastexperienced press on, while the moreexperienced turn back to join the mostexperienced, who didn't take off inthe first place. again. and any time we accept aflight-- i shouldn't say, we accept a flight-- any timethe pilot accepts a flight--

and that's something thatalso, you need to know. is that, when a flightrequest comes in, we only tell the pilot, hey, canwe get from point a to point b? we don't tell them,him or her, that hey, a little childgot hit by a bike. and if we don't fly them,they're going to die. all they know is, can wego from point a to point b? that's all they look at. generally, we like to get offthe ground within 10 minutes.

however, if the pilotis still checking the weather, if it takes them10 minutes to check the weather, again, should thatbe a big red flag? again, landing zone security. these things are idiot magnets. if you land a helicopter,how many people come running? same thing with landingon a scene-- and this was actually taken fromdown by las vegas, where they wound uplanding at a scene.

and while they were justabout ready to touchdown, somebody drover around thepolice cars and the barricades. and the pilot triedto react and wound up rolling the aircrafton the side. so again, it's attitudeof trust in no one, which we'll talk about later. this is a fixed wingairplane that hit a deer, and somebody said,was that in the air? it happened on thenight of december 25.

we're like, no. the plane was takingoff and wound up creaming a deer on the runway. so as far as crewconfiguration-- by far, the most common isnurse, paramedic. probably about 2/3 of theprograms are nurse, paramedic. why paramedic? they are cheap. and i hate to say it,but they are cheap.

with flight, wheni first started, i was the onlynon-firefighter paramedic. every one of ourother paramedics were all full timefirefighter paramedics, where they would sit there. you know, they would get alltheir benefits and everything from the municipality. and hey, now once,twice a month, i can come fly in a helicopter?

i'm game. so as far as our stack ofapplications for paramedics, how thick is it? it is huge. because like i said,everybody and their brother wants to do it. nurse, nurse, again somewhatof a common configuration, depending on where you are. and again, also, i shouldsay the configurations also

are somewhat determined by whattype of flight that base does. if you go out tophoenix or tampa, where they do in excessof 90%, 95% scene flights, do you want aparamedic on board? oh, hell yeah. whereas, if i go downto central chicago, the program down there,ucan, out of the university where they do 95% inter-facilityflights, 5% scene flights. do i want that nurse thatjust came out of an icu,

or do i want that paramedicthat, you know-- and again, that makes a huge difference. and then, nurse, physician. only about 2% or3% of the programs out there utilize a physician. and then, nurse, other. again, there are someprograms out there that fly nurse,rt for everything. as well as, there's alsothe state of maryland.

maryland state patrol-- probablythe busiest air medical program in the nation. trooper two is actually thebusiest air medical aircraft they fly single paramedic. that is a cross-trainedstate trooper. laryngoscope in onehand, nine millimeter beretta in the other. that is the busiestprogram in the nation. so and again, thy alsoutilize-- if they've

got a sick patientfrom a scene flight, they'll grab somebody offthe ground and say, you. come on. get in. you're helping me takecare of that patient, which again, take it or leave it. so as far as, again, theutilization of paramedics, this is something that we're seeingmore and more and more and more and more in the criticalcare transport environment,

either by ground or air. and again, you guys-- you'resitting in this class. you know exactlywhat it's all about. just don't turn into thisguy, i am begging you. just because you gothrough this class, again, you've got to staycompetent in this stuff. if you look at thislist of stuff on there, you are talking about, insome cases, years and years and years and yearsand years of study.

as well as not only studyingit, but doing it and staying competent on it. and that's one ofthe huge things. and again, keep inmind, i said that we've got a stack ofapplications a foot thick. everybody has got aclsbehind their name, everybody has got palsbehind their name, everybody's got nrp behind theirname, pap, stable, blah, blah, blah.

what makes you different? why should they hireyou over anybody else? and again, if i'vegot somebody that's got three years experiencestraight out of school, versus somebody that's got 20years experience out of school, they might have theexact same initials behind their background. and it is what is calledyour competitive advantage. why should i hire you over thisguy or this girl or whatever?

with me, it was pretty easy. i had a physician actually,that made me his name tag several years ago. and i'd be sittingin the elevator and have people sitting there,looking down at my chest going, what the hell? so yeah. being a rocket scientistreally, really helped me. so as far as what type of persondo these programs look for?

what makes you agood team member? who's this guy? stuart smalley. what would stuartsmalley always say? i'm good enough, i'm smartenough, and doggone it, people like me. again, you have got tobelieve in yourself. keep in mind, you guys aregoing to be transporting the sickest of the sickpatients, in many occasions.

and a lot of times, you walkinto that outlying facility, and they sit here and say, oh! flight's here. what they do? see ya! it's like turning on a light,and all the cockroaches just take off. and they hand you thissteaming plate of turd and say, there you go.

it's yours. again, you've got to, likei said, believe in yourself. what about this guy? you know who he is unlessyou live in a shoe, right? what would he always say? my daddy always used tosay you can't expect a dog to use a screwdriverin the rain. it's like, what? well, he doesn't tell you, yeah.

daddy was a ragingalcoholic, but-- but you have got to getalong with each other. and, keep in mind, you'regoing to be working side by side with a partner,and it's much like wherever you guys come from-- theambulance, the fire department. now, correct me ifi'm wrong, but there's that person at thefire department or at the ambulance servicethat you absolutely hate. correct?

now imagine being 2000 feetin the air with somebody with a patient that's crashing. at flight, my partner incrime-- she was actually my-- believe it or not,she was actually my best man in my wedding. that's how close we are. and we've gotten intothe back an ambulance, at each other's throats,and the fire department will sit there andsay, so how long

have you guys been married? otherwise, we will sitthere and run a code without saying a singleword to each other, just because we knoweach other so well. but again, now keep in mind,being stuck in the back that aircraft with some jagthat you cannot stand. and you've got a patientthat is crashing, and you have to work together. probably one the worstfeelings in the world.

but you will find thatperson that you wind up, like i said, working with. who's the old guy? the old guy over hereis my dad, so i'm not talking about him,but this old guy. lord baden-powell, founderof boy scouts took his name, the initial terms name, bp,coined the phrase, be prepared. again, in your line of work,we try to be prepared, correct? but this picturehere, which you're

going to see it,probably in pretty much, every one of mypresentations today. being prepared. what is wrong with this picture? eye protection. again, susie save-a-life, here,just gets off some $6 million helicopter, but she is way,way, way, way, way, way, way too cool towear eye protection. long before you sit there and--

ok. what is this? are you doing charades? it's a left-handed tool. so, since you justderailed the train, why is it a left-handed tool? how many lefties in here? that is exactly why it isa left-handed tool, because of you.

what's your name? rachel. rachel screwed itup for all of us. the reason-- no, no, no. i'm dead serious. the reason the laryngoscopeis a left-handed tool is because ofpeople like rachel. i don't know how manypeople are in this class, 15, 16, whatever.

it doesn't matter. to one. the majority of theworld is a right-handed. that being said, going inthere, sweeping the tongue out of the way, that'sthe easy part. what requires thecoordination and the dexterity is going down therewith a yankauer, going down with theendotracheal tube, or going down there with thosegod-awful mcgill forceps.

like i said, that is the easypart-- sweeping the tongue. most of us are right-handed. thank you verymuch, rachel but-- but whoever said eyeprotection, that is it. like i said, long before youtake care of these patients, you've got to takecare of yourself first. and i cannot stress that enough. you ever catch me on a transportwithout my eye protection, i'll give you $1,000.

guarantee it. i'll give you $10,000, justbecause i know you won't do it. like i said, we areso far ahead the rest of the world in technology,but this idiot here is too cool to wearsafety glasses. go to the otherside of the world-- you've got this guy, whoat least has enough sense to sit there and takecare of his eyes. so like i said, takecare of yourself first.

going back, andagain, like i said, i've got-- a lot of mypresentations are, like i said, somewhat the same. so as far asmedications, again, we'll talk about this alittle bit later. sedation, paralytics, you guysare going to be using them. but keep in mind, whenit comes to drugs, which i know you guyshave talked about, with the sedation aswell as the paralytics.

keep in mind, as faras the paralytics go, there is no betterway in the world to get that christmascard from habish, habish, and davis saying, hey, thankyou very much for sedating and paralyzing my spontaneouslybreathing grandpa, grandma, aunt, uncle. and then failing to realize thatyou intubated the esophagus. again, just becauseyou've got the ability to use these things, you alwayshave to go back to your basics.

and i can't stress that enough. this is one of ourtransport nurses that put this onhis facebook page-- jumped over an eightfoot wall-- and this is when he was doing a medicalmission-- jumped over an eight foot wall to get tointubation equipment. when is it ever soincredibly emergent that you have to jumpover an eight foot wall to get intubation equipment.

why could you not sitthere and bag that patient, then sit there andgo find a doorway to get through that wall,go have a cup of coffee, sit down for a couplehours, and then come back with your intubation equipment? i asked one of our transportrespiratory therapists, when we were doing ouroral rotations, i said, would you sedate andparalyze your own daughter and maintain her airway?

and she said, oh, hell no. and i'm like, ok. then why would you doit to somebody else? i would love to sit thereand say, you know what? in order to get signed off onutilization of paralytics-- and keep in mind that you are--as far as the paralytics go, pancuronium, pavulon, somewhatof a common paralytic, that is the drug that they givein lethal injection in some of the states that do allowthem to put inmates to death.

in all essence,with paralytics, you are literallykilling that patient and then promisingthem an airway. for those patients thatalready have an airway that you paralyze, you're promisingthem, you know what? i'm going to takecare your airway. if it comes out, i'mgoing to take care of it. what happens if you can'tfulfill your promise? you ought to fightfor the driver's seat,

unless you'reflying, then you've got to fight for the pilot seat. and again, withthe transport team, i always told theones in madison, i said, you know, i'm goingto sound like a real jag for saying this, but at leastone time in your career, you have got to feelabsolutely helpless. and so i had one ofour transport nurses who, she's like, you know, cani come fly with you someday?

and i'm like, yeah. no problem. all she wanted to dowere scene flights. i cannot stand scene flights. give me an inter-facilityflight any day of the week. i'll gladly do that. so she came down, lovedit-- absolutely loved it. she wound up getting a flightposition at another program. they wound up goingout on a scene flight.

had a motorcyclist withan isolated head injury. neurologically did needhis airway protected. and this guy's spontaneouslybreathing, but like i said, needed his airway protected. they sedated him. they paralyzed him. then, if you can read bythe email, got my scene, got my intubation,got my cric, got my two-needledecompressions, had

my first moment of helplessness. please call me when you wake up. need to talk. they have a spontaneouslybreathing patient. they sedate him. they paralyze him. they suspectedbilateral pneumothorax. they wound up decompressinghim bilaterally. they couldn't get him intubated.

they couldn't get him criced. they had this spontaneouslybreathing patient that they literally watcheddye in front of her. think that has screwed her up? think she's got a newrespect for paralytics? oh, yeah. and like i said,i hate to say it, but you all haveto go through it. and it's one the worst feelingsin the world, but just like i

said. and this sums it upbetter than anything. this is going toend in a disaster, and you've got nobody elseto blame but yourself. we started a sundaymorning off, years ago, with this goofball that gets ina verbal argument with his wife and say, well fine. i'm just going toblow my head off. so, ladies in the room,what does she say?

you know, honey, wejust painted the walls. so if you could gooutside and do it, i'd really appreciate it. so this dude takesa shotgun outside, goes out there,blows his face off, gets all pissed off,comes storming back in. he lays down on the coach. his wife calls 911. the police officer getsthere, assumes he is dead.

the police officer takesthe shotgun outside to secure the scene. meanwhile, zombie boygets up off the coach. cop turns around, this thingis standing on the porch stoop. i would have shot him again. we get in the backof the ambulance. this guy is sittingup on the striker. this guy is self-suctioninghimself with the yankauer. and they're like, oh my god!

sedate him. paralyze him. tube him, tube him, tube him. i'm like, wait a second. we're going to go about100 yards that way, my partner and i, and we'regoing to talk for a little bit. if we did sedate himand paralyze him, and we couldn't getan airway in him, can you do bag-val mask to that?

this was in the daysof the combitube. can you do a combitube on that? let's throw in a king or an lma. can you do that? and then we'rethinking, you know what? this guy, if he could talk,and he was attempting to talk, he would have hada glasgow of 15. the trauma center was aboutsix minutes away by air. and i'm thinking, whatif we just go for it?

and then i'm thinking,you know what? i'm scared to look at thisdude sitting on the ground. what happens at2000 feet in the air when neurologically, hedeteriorates to the point that he can'tmaintain its airway? so our plan was, ifand only if both of us can palpate hiscricothyroid membrane, we will give it one shot orally. and then we'll go straightto a surgical airway.

this guy, in all honesty,was the easiest intubation i've ever done in my career. everything was gone. i could have sat therewith my index finger and my thumb, picked up--with my left hand-- picked up his epiglottis,threw the tube in. and we wound upgetting him intubated. we're all happy, doingthe snoopy dance. we get down tothe trauma center.

after they took overthe patient care, surgeon pulls us asideand says, do you guys know that you didn't do cspinal immobilization on him? and i'm thinking, you know what? wow. he is right. in a shotgun wound to the chin,is there a potential c spine injury? but we were so tunnelvisioned on this-- this--

that we forgot abouteverything else. and a couple yearslater, my partner was down at a traumaconference in chicago. and they had aplastic surgeon talk. he did a case presentation ona self-inflicted shotgun wound to the face who happenedto be zombie boy. in his presentation,he had pictures of what he looked like whenyou hit the or-- or the er-- as well as the or,as well as what

he looks like today aftermultiple facial fractures. so sharon went up to thedoctor, and she's like, hey man, i flew him. and the surgeon said,well he signed off on all images foreducational purposes. so if you wantthem, here you go. so somewhere on myexternal hard drive, i've got a picture of whathumpty dumpty looks like again. but this is the stuffthat you walk into.

again, they will sitthere and say, oh. here you go. hey, oh yeah, by the way, wejust pushed the [? succs. ?] so here you go. again, just be prepared. every intubation i go into,in the back of my mind, it is going to be amissed intubation. when plan a doesn'twork, that's why you've got 25 other letters.

and make sure,whoever you're working with, make sure they knowthat if this doesn't work, we're going to go right toplan b, right to c, right to d, et cetera. and make sure they knowwhat those plans are. don't sit there and look at eachother and say, well now what? so as far as theutilization of again, critical care transport,on my motor-- like i said, live right outside madison.

and then drive to mchenry. i pass by four or five differenthospitals on my way to work. what's the licenseplate on my motorcycle? my biggest fear iswaking up in the middle of the road with some raccoonlicking the csf out of my nose, and then getting takento some fisher price er. and then havingsome doc say, well i remember placing a chesttube back in residency. get me to someplace-- thesetertiary care facilities--

where they do thisstuff every day. you've got totreat every patient that you deal with-- again,think of them as your own kids. and these are mylittle turd nieces. this is my little monster. again, treat every patientlike they're your own child. and again as criticalcare transport goes, again, there are some programsthat transport everything. so again, one call, you mightbe taking that 99 year old stemi

flight. the next patientmight be some newborn. again, as far as theadmin stuff goes, we'll talk about that later. who's this dude? macgyver. and again, youguys have seen it. going from hospital tohospital to hospital. and as far as thecompatibility of your equipment

that you've got on yourambulance or whatever, compared to what the hospitalhas, how many times does everything fittogether perfectly? never. so you have got to have a littlebit of macgyver in you, were on the fly, you've gotto figure out how can i make this square pegfit in this round hole in a very, very, veryshort period of time. so again, you've got tohave some macgyver in you.

not as advertised. how many times do you getsent on a call-- patient sounds like they're stable. and all of a sudden,you get there and they're thismulti-system trauma patient. and they're readyto code on you. again, this happenscountless-- especially in critical care transport. you've got that patientthat is supposedly stable,

and all of a sudden, youjust walk in on this mess. we went out on onethat they said, yeah. it's a friday night, 2o'clock in the morning. your patient's 17. they were ejected. they are unresponsive. so we get out there. 17, unresponsive, bartime-- what are we thinking? we get in the back ofthe rig, and there's

this little, unresponsive17-month-old. think we'd like to know17 months versus 17 years? is there a difference? so again, get as muchinformation as you can. and again, if you're doingmultiple different types of transports-- we tookoff a couple months ago. and med com-- orflight com said, wow. really surprisedyou guys got off the ground that fast fora balloon pump flight.

we're already in the air. do you think theytold us originally that it was aballoon pump flight? where do you thinkour balloon pump was? so again, get asmuch info as you can. assassins. i hate to say this, and iprobably shouldn't say this, but i'm going to say this. as far as going out to somethese outlying facilities,

in your mind, you've got tothink of them as assassins. their sole purpose isto kill that patient. again, you have noidea what you're going to be walking into. how many times have you walkedinto something like this? and again, like isaid, it's going to be right when theysit there and say, yeah. we just pushed the[? succs. ?] good. flight is here.

there you go. or worse off, we just pushedthe [? vec. ?] there you go. now you've got 40 minutes. again, you just walkin the absolute messes. just expect the unexpected. every time i walk in, ifwe're doing a patient that is intubated-- aninter-facility flight or even a scene flight wherethe patient is already intubated-- first thing i lookfor is, where is that mask?

in my mind, that is anesophageal intubation until proven otherwise. until we can assess capnographywaveform, bilateral breath sounds, negative epigastricsounds, where is that mask? and again, right up therewith my safety glasses, that is a very, very,very close number two, as far as where is that? and is it coming with me? and again, you've got no ideawhat you're walking into.

the past couple years,i was over in ethiopia doing medical stuff, and theneonatologist-- oh, you've got to come into my icu. i've got to show youour new cpap setup. so he drags me all theway to the eighth floor at their hospital. this is their anasal cpap setup. it is a discarded waterbottle that this guy dug out of the garbage.

on the side here-- youcan just barely see it-- but it's a littlepiece of medical tape, and in incrementsof one centimeter, the further downyou stick the tube in the water, whathappens to the cpap level? it goes up. and this was theirnew cpap setup. and i'm thinking, what the hell? then i was like,well, wait a second.

this absolute-- right backto bare bones medicine. this is absolutely perfect. we carry this $30,000ventilator that does cpap, and they're doing the exact samething with a discarded water bottle. but again, you'vegot no idea what you're going to be walking into. and again, you'vegot to figure out how you can make yourstuff on the ambulance,

or the helicopter, or theairplane, configure to that. and again, you walk into somethings where-- in the back your mind, justsay, you know what? we are walking into a codeuntil proven otherwise. and again, 80%, 90% of yourrespiratory assessment, as you guys know, is done justby looking at that patient. this dude here-- does helook like he's in distress? is this the patientthat you have to go throw the pulseox on right away?

what's it going to tell you? he looks like keith richardshere, shooting up with heroin. what about the cyanotic lady? again, both of thesepatients, make sure that you know whereyour bag and mask is, make sure you've gotvascular access, because this is a patient you'regoing to want to be, like i said, protecting theirairway long before getting them in your ambulance,helicopter, airplane.

this little monsterhere-- how's he doing? he's doing fine. he's holding his littlewinnie the pooh thing. the only issue here is if hetakes a header over the side and he's got a head injury. otherwise, he's fine. what about this guy here? again, that floppyfish appearance. he's getting tired, he'sflaring, he's gasping,

he's got retractions everywhere. is it possible totell if somebody's in respiratory distress justby looking at their eyes? and again, you're goingto walk into that kid that just hit a tree at thebottom of the sled hill. you get to that er, and heis still all bundled up. all you can see are his eyes. or you go to that scene flight. you're down on your hands andknees with your mag light.

you look in the back,and all you can see are some kid's eyes. once you get himin the ambulance and you startundressing him further and further and further, thatkid look like he's in distress? and you would not believe howoften they won't tell us-- as far as our patientreport-- they won't tell us about the flaring, the gasping,the retractions everywhere. they'll tell us he's got anoxygen saturation of 93%,

and his respiratory rate is 26. what does that tell me? would i want to hearthat, or would i want to hear, you know what? he is flaring. he is gasping,he's grunting, he's got suprasternal, subcostal,intercostal retractions everywhere. but so many times, people willwithhold information from you

because, oh my god. i don't want to sound likean idiot over the radio and say the wrong terminology. if you can't rememberthe proper terminology, what are you seeing? if i sit there andsay, hey, quick. go get me the fire putter outer. do you know whati'm talking about? so again, if i can'tremember all these-- say

when this kid takesa breath in, i can count-- i could eatsoup out of his chest, it sucks in that much. or i can count every one of hisribs when he takes a breath in. that tells me muchmore than a pulse ox and a respiratory rate. so again, right backto just basic words. again, this littlemunchkin's fine. this one, again, same thing--floppy fish appearance.

poor muscle tone, gasping,retracting, flaring. what's this little guy doing? what the nebulizer doing? nothing. again, that's the equivalent ofwalking down the street to lake michigan and peeingin it and expecting to see the water rise. it's doing absolutely nothing. instead, you've gotvascular access.

where's your bag and mask? because you'regoing to have a kid that's crashing onyou, real quick. who remembers these things? why are they illegal? much like she ruined it forall of us, being a lefty, she ruined it for all of us. that is why they are illegal. but how's she doing?

she is fine. she's a pissed offlittle six-year-old, because she's gota dart in her head. she is pink, andshe is pissed off. that is absolutely perfect. pink and pissedoff, with attitude. especially in thepediatric population, that is one thing you love. she's pissed becauseyou know what?

she's got a dart in her head. again, we've gotto break this down into awareness,recognition, and management. anything that can gowrong, will go wrong. again, get in the attitudethat during this transport, that endotrachealtube is coming out. that iv is coming out. that being said, whatare we going to do? so again, awareness,recognition, and management.

we are aware whathappens when somebody's intracranial pressures go up. we're going to beable to recognize it, and then, most importantly,we're going to manage it. so again, right now,she is doing fine. but just in the back of yourmind-- in this 20, 30, 40, one hour, two hour, threehour long transport-- she is going to arrest on us. have that in theback of your mind.

have a plan. so when it happens,you guys just kind of shrug your shouldersand say, you know what? we expected this,so let's act on it. and matter of fact, we'vegot all our equipment ready to go right now. let's do it. and you know, he sitsthere, and he bitches, and he bitches, and hebitches at his son and all

those other idiots that workfor him about you know what? this bike is due tomorrow. get going, get going, get going. but you know what? he's offering a quality productin a very short period of time. this goes back to that attitudeof stay and play or load and go. again, just keep in mind, asfar as your bedside times go, we're going to be there fora prolonged period of time

because we want to deliver thispatient in the absolute best possible condition. if that means taking downthat iv-- how many times have you guys said,well, you know what? he's got a positional iv. or how many times haveyou've heard that? do i want to take off in ahelicopter or an ambulance with a positional iv? is there such thingas a positional iv?

it's either they work,or they don't work. if i've got a positionaliv, guess what? we're staying here, andwe're placing another iv. if i have to emergentlygive somebody a drug, what are the chances ofthat iv being positional when i want to give that drug? probably pretty high. so again, the wholepositional-- it's like, do they have a pulse or not?

it's a yes or no question. so the positional iv,again, don't trust it. so as far as, like i said--getting back to paulie, again, he's delivering aquality product, but he sitting theretrying to rush it. in the criticalcare mindset, you've got to get out of the emsmindset-- the load and go. you've got to sit there. you've got to take time.

so like i said, you aredelivering quality patient care. who's this lady? mother teresa. again, you guys aregoing to be just dealing with people that-- i don'twant to sit there and say, they're going to die. but you're going to dealwith some of these patients that, again, you'regoing to be taking

the sickest of the sick patient. and again, they might sitthere and say, you know what? you've got a surgeon holdingan or at that tertiary care facility. they want thatpatient there now. that dissecting aneurysm,get them there now. but meanwhile, i've gotthis patient's entire family sitting right here. is going to kill me if i windup and say, you know what?

everybody come on overhere and say goodbye. take your time. let the families dealwith that patient. so sharon, i always tease her. i always say that she'smother teresa in nomex. a couple years ago, this guyhere, tom, his entire family was leaving great america--the last big vacation of the season. and at about midnight, theyget creamed by a drunk driver.

his wife and his four children,plus the family dog, all die. anyway, long story short,is sharon tells this guy, if you need anything,you know what? let me know. he winds up living in theirbasement for well over a year, just because this guywas just a mental wreck. so she was actually thebest man in his wedding before she was thebest man in my wedding. but again, like i said,mother teresa in nomex

pretty much sums her up. and again, like isaid, you're going to be seeing some of theworst of the worst stuff, either by inter-facilityor scene flights. so how do we go from motherteresa to snoop dogg? this is probably themost important slide out of all of this. snoop dogg-- you're going tofind this hard to believe, but i'm not a bigsnoop dogg fan.

all right. so, yeah. snoop dogg and his mr.t starter set there. yeah, so he alwaysscreams, you know, hey. we're representing. you are representing. and like i said, i cannot to stress that enough. when you're sitting thereparading around in your flight suit, and you're coming fromthat hospital or that flight

program, you are aflying billboard. you are on the stage, and icannot stress that enough. and as far as coming and pickingup a patient for that hospital, you are the first contactthat patient has with that-- or that-- you are thefirst hospital contact that family has with that hospital,is that flight crew-- that transport team. if you leave the leavea bad impression, what are they going to think?

long before thatchild, that adult even gets to that hospital, they'regoing to sit and say, wow. the transport teamcoming from the hospital was a bunch of jags. do i want my loved onegoing that hospital? again, you are onstage all the time, and i cannot stress that enough. you've got to thinkabout this constantly. who is my audience?

so on the early part of theslide, it said, the other nca. everyone always said, well,what does nca stand for? in many people'sminds, this is what we are thought of-- isnomex covered a-holes. because there areprograms out there that will go to thatoutlying facility, and they will tellthem, oh my gosh. look at the-- whydidn't you guys do this? why didn't you do that?

why-- or they willcall report right in front of thatreferring facility. and they'll say,hey, you know what? they almost killed another one. we came here, andthey've got this running where theyshould-- and they gave this amountof a drug-- yeah. again, you get some ofthese small town hospitals-- they get one or twosick patients a month.

now they get somebody thatpushes them over the edge. is it going to do themany good if you sit there and come in and sitthere and belittle them? uh uh. so again, and there was aprogram that was out west that every day, with technology, theyput their flight crew online. this is who is flying today. and there was one nursethat was just such a biotch that people would sitthere and say, ok.

hey, we need this transport--this patient transported, but you know, nurseratchet is working. we're going to send themby a different program. we're going to send them by air. again, unfortunately, this ishow many of us are projected. so like i said, reallythink about how you are. and again, as far as thetransfer team member, how are we looked at? hey, we're the heroes, right?

you give us anything;we'll take care of them. we'll save them. the receiving staff. again, we takethese patients that are pretty much on death'sdoor and they're like, well why'd you bring them here? administration-- we'rea bunch of cry babies. we want absolutely everything. the pilot-- you areself-loading baggage.

i don't-- you're sandbag. how much do you weigh, andwhere are you going to sit? that's all they care about. and probably the most importantslide of all this presentation is their family. what's missing? this is something that, again,most-- a lot of people, this is all they want todo is i want to fly, i want to fly, want to fly,want to fly, want to fly.

and unfortunately, whenthey get that chance to fly, what do they forget about? everything else. and you just get sosucked into this industry. and like i said, i cannotstress this enough. don't get stuckin that situation. i did. i'm one of those people. five minutes before i waswalking down the aisle

to get married, i wasanswering some bullshit text about a transport. two minutes before my sonwas born-- same thing. i'm on the phone talkingabout transport crap over it. again, don't getsucked into this. and again, it's somethingyou want to do so bad. and then they call youand say, you know what? hey, so and so justcall in for thursday. thursday is your only day off.

what are you going to say? i'll be there. i was just tellingmark, i said, the filter is probably going to beoff today because i'm on like 48 hoursof no sleep, just running from placeto place to place. because i'm one of thoseidiots that can't say no. i'm slowly, slowly,slowly learning, but like i said, knowwhat's important to you.

so as far as the types offlights-- inter-facility. again, taking a patientfrom a community hospital to a tertiary care facility. generally a level one traumacenter for the scene flights. however, there are specialtycenters be it ones that-- burn centers,places that do offer hyperbaric therapy likest. luke's, or wherever. scene flights-- again, dependingon where you work-- here in the waukesha area,it's probably about 20%,

25% scene flights. the rest are inter-facility. once you get a littlebit more rural, the scene flights increase. specialty flights-- again,we do balloon pump flights. as far as organs,we'll go pick up a team that just harvestedorgans on a patient. and then we're taking themto a transplant center. training flights-- again,if you don't do something,

you get rusty at it. so again, especiallywith the pilots, they do a lot oftraining flights. and especially thesedays when, like i said, we're going to be goingto instrument flight. again, it takes a lotof training in order to stay competent. and then marketing flights. as far as abcs-- again, you'vehad this drilled in your mind--

into your head since day one. i always break it down. adult abcs-- alwaysbring camera. pediatric abcs-- apnea,bradycardia, coroner. and as far as abcs on kidsgo, this little munchkin, he looks fine. isn't he cute? sit there and, oh,take a picture of him. in the back of his mind,what is he daring you to do?

look away. look outside the window. kids don't give youany advanced notice that they're going to crash. he can't sit thereand say hey, mr. it's getting harder andharder for me to breathe. when he has a respiratory issue,what happens to his heart rate? it drops like a rock. so again, pediatric abcs--apnea, bradycardia, coroner.

if you have a bradycardic kid,get right back to their airway. like i said, in a matter ofseconds, look out the window, and i guarantee you-- kidsdo really, really, really bad things in amatter of seconds. so as far as scenefights, again, you pick up some ofthe-- i don't want to say-- the dumbestof dumb, but. and the theme song fromthe dukes of hazard is supposed to be playinghere, but for whatever reason,

it's not, so. 1 that porsche had 46 miles onit when that picture was taken. when i was talking about beingon stage, i got gas once. i was heading to work--or come back from work. and i was still wearing myflight suit, and i got gas. and the lady behind the countersaid, oh, are you a pilot? and i was like, no. i said, no, i workin [inaudible].

and she goes, well,what do you do? i said, i work asa flight paramedic. well what's that? and i said, oh, we justfly around in a helicopter and pick up idiots. and she just kind ofsits there and stops. and she goes, yeah, myboyfriend was flown last year. i'm like, ok. i'll just stop there.

and so as far as prflights, marketing flights-- again, this is somethingthat-- as far as utilizing the aircraft-- this issomething, just again, going back to education. we do a lot of education withthe local fire departments, local ambulanceservices especially, as far as utilizingthe aircraft. what are some of the indicationsyou should be calling us? as well as the firedepartment, you

are the ones that areresponsible for setting up our landing zone. so every year, we go from firedepartment to fire department. and about this time of year--because we are busy season is coming up. and again, just givethem a refresher on setting up a landing zone. and especially if theydon't utilize the aircraft that often, it's goodto have a refresher.

but again, helicoptersare idiot magnets. you land a helicopter,who comes running? exactly. so again, a lot pf pr; alot of marketing stuff. and again, you get some ofthe most bizarre questions at some of these pr events. this is probably the mostcommon question we get. can i have a ride? it's like, you want a ride?

they're like, yeah. i'm like, go dosomething stupid. we'll give your a ride. or else, my cousin, myuncle, my sister, my dad, was a gunner in vietnam. that's the otherbig, common one. and as long as there are noadministrators here from flight for life-- so what--and again, what do you guys do when you're not flying?

that's exactly what we do. so no. when we're not flying-- again,depending on where you work. when i first startedat flight, we were considered part ofthe emergency room staff. so when we weren't on aflight, we were out in the er doing stuff, which wasnice because you could stay competent on ivs, you couldstay competent on intubations. you were constantly busy.

but then again, wewere their bitches. hey, flight boy. go do this. go do that. and of course, when you'reup on the sixth floor taking a patient, what happens? you wind up getting a call. so once our flightvolume exceeded-- i forgot what it was-- 600flights a year at that base,

we got pulled outof the er, and we were made a designated flight. so again, dependingon where you work, some places, you might getstuck in staffing in the icu or in the er. there's constantly rotations--going through the equipment, making sure thateverything's ready to go. as far as all your medications,all your equipment, again, making sure thatit's not expired.

training-- we areconstantly doing training. these days, with thesimulation centers. again, at uw, if we're noton a flight or on a transfer, we can go and hangout in the sim center and be a part of the simulationsif those are going on. as far as cross-training,this is something that you either loveit, or you hate it. and when i firststarted at flight, they said, well here's the deal.

we're going to be cross-trained. so i had flashbacks backfrom when i was a kid. so when i was a kid, i wasthe heavy equipment operator. that was mine,and that was mine. my brother-- he wasthe dump truck driver. that was his, and that was his. if i ever had to pee, i'djust go running back here, and i'd pee in theelderberry bush. if i came back, what wasmy brother playing with?

now, think about this. in all honesty, can you becomea heavy equipment operator in the time it takes alittle brother to pee? it takes years andyears and years and years and years of practice. so again, when they said, you'regoing to be cross-trained, coming from an icuenvironment, where we are extremely territorial. again being an rt, and then--going in-- they're saying,

well you know what? well here, the medics aregoing to be starting lines, pushing drugs. the nurses are goingto be intubating. and i walked in on a nurse witha laryngoscope in her hand. do you think i freaked out? i was like, oh. all right there, gladys. you know?

put down] the laryngoscope. you take care of the foley;i'll take care of the airway. if it's below the diaphragm,i want nothing to do with it. but pretty much every programyou're going to be working at, there is cross-training. and there is no betterfeeling in the world in knowing that, you know what? if i miss it miss anintubation-- which i will-- i want another competent careprovider to do it for me.

so as far as cross-traininggoes, it's, like i said, by far one of the bestthings in the world. multitasking-- again,this is something that you're going tohave to do constantly. continuing education--again, we're constantly doingeducation, again, in order to maintain your pals,your nrp, your acls, blah, blah, blah. you're just constantlyre-certifying in stuff.

as well as a lot oftimes, the flight crews get tapped to deliver education. this is from a couple years ago. we had a group of surgeons,pediatricians, and er docs from ethiopia come over. and we taught them ventmanagement and intubation in the pediatric population. and in reciprocation,we wound up getting to go over there andhang out in their er, as well

as their icu, which is oneof the most eye opening things i've everseen in my life. on a regular 12 hourshift, you might have six to eight pediatricfull arrests come into the er. and i was in the er one day. and we were doing rounds. and they had an adult patientwith a glasgow of three. and they said well, you know,what you want to do for him? and i'm like well, youknow, let's intubate him

and secure his airway. and they're like oh, no,no, no, no, no, no, no. he had his chance back when hewas a glasgow of six, or seven, or eight. but now that he's athree, over there, intubating somebody's prettymuch a death sentence. you had your chance whenyou were a much higher gcs. because basically, we weretying up a ventilator for, you know-- i don't knowif you can see this here.

what looks like a stiletteis actually that child's arm. but yeah, so i got to go hangout over there for a couple weeks in their icu and stuff. and again, i alreadyshowed you that. community educationagain, do a lot of stuff. be with elementary school,junior high schools, as far as injury prevention being bikehelmets, all that good stuff. patient follow-up--again part of the job is after we transporta patient, we

will wind up calling backto that referring facility, or that referringfire department and letting them know. how's that patient doing. what changes have they made. as well as this is agreat chance for us also for education. again, instead of at the bedsidetalking about their-- not their mistakes, but what theycould have done better is.

just offer that up whenyou give them a call back. say you know what? so the pediatricpatient with dka, i don't know howoften you see it, but we've gotseveral lectures here that have got several cannedpediatric dka lectures. what about if we come outat your next team meeting and give you guys a talk. speciality training--again especially

in aeromedical industry,it's pretty much mandatory that you do some formof survival training-- fire starting, howto build a shelter, how to field dress yourflight nurse in case you if you have to eat them,all that good stuff. and then again, knowyour limitations. know when to say no. just because you'renow on the flight crew doesn't mean that you cantake absolutely everything.

again, you've got to geta decent patient report. if something soundsfishy, again, you've got to say you know what,let's just take a timeout. and as far as yourresources, again, know what your resources are. know how to use them. and know how touse them correctly. never, ever, ever burn alone. i cannot stress that enough.

know what your resources are. and there's noreason in the world, if you're flying outfor something, or even on the ground, you're goingout for that five-year-old that just coughed his trach out. and they cannot get it back in. there is no reasonin the world you can't call you medical control. and say you know what,we're adding out for this.

just can you stayby the phone or stay by the radio incase we need you. that being said, who isyour medical control? and what is their level? so with us on flight,our medical control, depending on whichstate we're flying in, is the emergency room physician. that being said, if i'vegot this patient that is on a balloon pump, theyare in full blown ards,

and pressure controlledventilation, which we'll talk about later, and i've got avent question or a balloon pump question, and i callback to the er doc, what are they going to do? wrong number, wrong-- so this is truly whatit comes down to. find a job you love andnever, ever, ever work again. we don't transporttraumatic arrests. well, if somebody iscoding, we won't fly them.

if it's to a scene,again the chances of getting a traumatic arrestback is what-- less than 0.1%, 2%, something like that. whatever. so if that's the case, ifcpr is in progress before we get there, say to a scene,we'll just turn around. however, if thepatient is in our care. and we're still in the ambulanceand the patient arrests, then we'll go with thoseproviders to the local--

to the closest hospital. and then we'll have theaircraft come there. and as far as ourtraumatic arrest protocol, it's oral intubation,bilateral needle thoracentesis, and thenpericardiocentesis. and i've been ontwo flights where, after doing apericardiocentesis, we got vitals back. that being said, thepatient didn't live.

but we are able to getthem to the trauma center. and their familycould come up and say their goodbyes andall that stuff. but for inter-facilityflights, if cpr is in progress, we don't take them, so-- there is more andmore and more and more alphabet soup outthere these days. so the first one was acritical care emt paramedic. and then now there'sthe fpc, which

is the certifiedflight paramedic. and dr. perloff, the guythat i showed you many slides ago, he would alwayssit there and say-- you know, i'd ask him. i'd say well, what about pals? and he would say well,pals and a couple quarter will get you a cup of coffee. and basically whathe was saying is you know what, everybody has it.

so now going back to thatcompetitive advantage, why should we hire you? you've got theexact same alphabet soup as everybody else. you know what, since we areutilized so much in education, instead of having youracls, your pals, your nrp, your stable, go back and getyour acls, your pals, your nrp, and your stable instructor card. you'll be so much more valuable.

and especially forthese flight programs that all of thesecertifications are mandatory. we have to re-certifythem every two years. if i've got so and sothat's in the instructor, do you think they're goingto put him or her to work? get your instructorand all of that stuff. so the certifiedflight paramedic exam. i took it first in 2005 andswore i would never, ever, ever, ever, ever take it again.

that was one of-- that was thehardest exam i've ever taken. and now with caamsaccreditation, now we have to be certified. and i've just beendragging my feet, because i've gotto take it again. and i'm scared to death. so and again, many places, itis mandatory that you've got it. or you have to get it withinthe first two years of hire. there is what, it used to becalled the nfpa, the national

flight paramedicassociation, that they had two differentmembership levels. one was called theassociate member, which hey, i've got an interest inair medical transport. and then there'sthe active member, where you arecurrently doing it. and it's a professionalorganization. and i signed uplong before i was flying, because i knew thatwas a direction i wanted to go.

and back then, they wouldsend you a list saying, here's the minimumrequirements to fly. here's the preferredrequirements. i took the minimum requirements,pretty much tore it up and threw it away,and concentrated on that preferred requirement. if you go to a websitecalled flightweb-- one word, f-l-i-g-h-t-w-e-b-- soif you go to flightweb, and that's the site outthere, flightweb.com,

they do have a job center. and again, so there arepositions out there. and just go to any oneof these positions. and it'll sit there. and it'll tell you what themandatory requirement are. generally nationwide, it'sabout three to five years of pre-hospital experience. again, as well as all thatalphabet soup, your acls, your pals, all that stuff.

but i was going to say, ifyou go to the main site also, there's a section on therecalled links section. click on the links. and they've got flight programs. and they've got them for europe. they got them fromthe united states. click on the united states. they got pretty muchevery state out there. and basically in thedays of social media

and technology, pretty muchevery flight program out there has got a website. and i guarantee, onthe section there that says you want tofly for us, again, here is the minimum requirements. here is the preferredrequirements. again, do your homework. find out where you want to fly. if you want to sit there anddo scene flights all day long,

again you're probablygoing to have to go down to phoenixor something like that. but with me, i wound upliking 50-50 early on of scene versus inter-facility. and like i said, over time,that has changed significantly. now the last thing in the worldi want to do is a scene flight. gladly do inter-facilitiesall day long. but again, numerousprograms out there. they've got a ridealong program.

or again, if it's somethingthat you're interested in, sign up for a ride along. go hang out withthem for a shift. and that means pretty muchany flight they go on, you go along with them,with the exception of its, say a balloon pump, ora specialty team flight, or a long distance flight wherethey need your weight for fuel, they won't take you, but-- again, it's kindof a neat section

to hang out on there, aswell as the flight web forum. if you go to thegeneral discussion area, this is probably one of themost common threads that's out there is i want to breakinto air medical transport. what do i need to do? and again, you'vegot people that have been doing this for decadesout there that will give you numerous hints asfar as what to do. there's actually a coupleof these goofballs that

have written books on what todo in order to get into it. so like i said, you canspend hours on there, so-- flight for life doeshave a ride along program at all three bases. what the summercoming up though, we suspend itjust-- we suspend it at the waukesha baseand the mchenry base, just because of the heat. but fond-du-lac keeps itgoing i believe year around.

don't quote me on that, so-- so now let's talkmechanical ventilation. these are all fair game. these are all specificallyin this region. these are all ventilatorsthat you as critical care paramedics, you'regoing to be picking up patients on these ventilators. to you, every onelooks the same. to me, every one of theseis a different monster

that has got the ability tokill your patient quicker than you know. so i've been doing moreand more event education. these are two of theemails that i received after that is firstoff, isn't there just a ventilatorfor dummies manual? no, there's not. every patient is different. every patient istreated different,

especially when they're beingmechanically ventilated. there is no cookbookmedicine saying ok, i've gotten end-tidal of 32. what do i do? or this is exactly whati do, blah, blah, blah. and then the other oneis, nice job, asshat. now they're more afraidthan able to use the vent. which i am fine with. you know what, i would muchrather have you not use it

then completelyscrew somebody up. and again, a couple ofthe old proloff-isms. you don't know what don'tknow, acls and a quarter will get you a cup of coffee,and knowing and not doing is like not knowing at all. so this lecture was specificallymade for a flight for life after we had gone to adifferent transport ventilator. and again, with flightat all three bases, we utilize a nurse paramediccrew configuration.

and with the paramedics,everyone, pretty much everyone except me, is a fulltime firefighter medic somewhere else. and i told them,i said, today this is what i'm going to teach you. i'm going to teach you how totake that fire extinguisher and extinguish that bigold pan of whatever it is. tomorrow, this what you'regoing to be expected to manage. for the nursey types, whoremembers those things?

dial-a-flows. it's like the fisherprice iv pump. we wind up rotating that andthey got different orifice diameters in there. and basically, thatdetermined your drip rate. so today, this is whati'm going to teach you is how to use a dial-a-flow. tomorrow, this is what you'regoing to be expected to manage. as far as mechanicalventilation goes,

this is the singlemost piece of equipment on your-- fill in the blank--ambulance, helicopter, airplane, that has got thehighest probability of killing your patient. but yet, it's thatpiece of equipment that you get the leastamount of training in. so as far as vents go, portablevents, transport vents, they have been outthere for decades and decades and decades.

again, even down to theselittle single patient use fisher price ones. but like the trend, everythinggets smaller and smaller and smaller and moreand more advanced. i was at a-- coupleyears, well when i first started with flight, i wastelling our marketing person, she goes well, would you beinterested in doing education anywhere else? and i'm like yeah, i saidtell me where i have to go.

so i wound up gettingan email saying, you need to be inkansas next week to do a mechanicalventilation talk. so i wound up going down toa flight program down there. and did a vent talk down there. and i got a call about threeo'clock in the morning. and they said, hey. you deal with kids and trachsand vents all the time, don't you.

i'm like, yeah. they go, do you want togo on a flight with us? i went, sure. so it was taking a patientfrom omaha children's hospital down to oklahoma city children'shospital by fixed-wing. and anyway, duringthis transport, this child started waking up. and started begin becomingasynchronous with the vent. and the receiving facilitywas adamant we do not

want that child re-paralyzed. and so they said well,what should we do? i said, well i wouldchange the mode that you're ventilating in. and i would drop the rate. and they were like, do it. i don't know this vent. i said, if i do that, i said,does anything else change? and the flight medicsaid, i don't think so.

so that ventilatorthat we're using was very similar tothis one up here. this is an old servo 900c. so us respiratorynerdlingers, if you think about your cardiacoutput-- cardiac output is comprised of what? how do we determinecardiac output? what times what? heart rate times stroke volume.

so us respiratorynerdlingers calculate what we call our minutevolume the exact same way, our respiratory ratetimes our tidal volume gives us our minute volume. so on these old vents,what we would do is we would set a minute volume. so here it's 7.5 liters,or 7,500 milliliters. and we would setour breath rate. and between thosetwo, we would wind up

getting our tidal volume. so here we've got 7,500milliliters being delivered in one minute over thecourse of 10 breaths. that being said, whatwas our tidal volume? 750 milliliters. so again, this isvent that we're using in flight was verysimilar to this type. and i said, change themode, drop the rate, but does anything else change?

i don't think so. long story short iswe wound up dropping the rate of change and the mode. this kid's tidal volume wound upalmost quadrupling, as well as his inspiratory time. keep in mind with many of thesevents, you change one thing, you alter three, four,five, six other parameters in a very short period of time. this kid wound up bradying down.

and i'm like, thisis going to be great. we're going to kill this kid. and again, it'smy fault because i did somethingstupid on a machine that i was not familiar with. the other thingyou need to know is besides knowingyour equipment, you need to know the limitationsof your equipment. so i showed youthis slide earlier.

aerocare fixed-winginternational program out of west chicago,the program director called me andshe's like, are you familiar with theservo-i ventilator? i'm like yeah, we've gotprobably 30 or 40 of them at uw. she's like, do you wantto do a transport for us? they had a 48-year-old patientwith pulmonary fibrosis that needed to be flown out.

another fixed-wingprogram went in. and basically,pulmonary fibrosis, that's one foot in the grave,extremely difficult population to mechanicallyventilate and oxygenate. and this other programwent in with, again, one of these littletransport vents. and this patient wasmaxed out on what the icu ventilator could do. and they tried to matchit on a transport vent.

she didn't even make it outof the icu before she crumped. and they took her back. didn't even makeit out the door. and the husband said, she'snot leaving this facility unless she is on a servo-i. so she called. and she's like, can you do it? and then she tellsme, yeah, it's from dubai to san francisco.

if you could just calculateoxygen consumption for a servo-i going from dubaito san francisco, which just to get you from dubai to theeast coast of the united states to refuel and get on more oxygenwas in excess of 15,000 liters. anyway, patient wound up dyingbefore we did the transport. i'm like, we're still going togo to dubai though, aren't we? but anyway, so much ofthe transport vents, again, they arethe ferrari vents. all the bells, all thewhistles, that's what we want.

that being said,giving you folks in ems or transport medicineanything expensive, what are you goingto do with it? it's like takinggrandma kickboxing. so yeah, ok. like vents, do you needall the bells and whistles, blah, blah, blah. not really. so this is what we windup giving you, something

a little bit moreand more durable. it's going to getyou from point a to point b with thechest going up and down. that being said,you guys really are transporting patientsthat are healthy. many times their pulmonarystatus is in the toilet. and again, is your alittle fisher price vent going to be able to manage that? probably not.

so when we pulled the triggerand got transport vents at flight, they hadasked, well you know, what do you recommend? and at that time,the ltv series, which i was very familiarwith, i said you know, this would be myventilator of choice. so who's this guy here? sully from monsters,inc. so i asked one of our pediatricpulmonologist, dr. mary

schroth, she's a world-renownedpediatric pulmonologist. she uses that model. that not only thatvent, but there's a whole series of ltv vents. she uses those numeroustimes every week invasively, as well as a non-invasively. and i said, what do youthink about the ltv 1,000? quote, unquote, it'sa "f-ing" monster. she said, it took me six monthsjust to get the basics of it.

and again, now they tell me, ok. if you could justteach our staff how to use this in one hour. is that going to happen? one of my biggestpet peeves as far as why we don't usethe vents-- well, it's only an eightminute flight. is there such a thing asan eight minute flight? you know, ok, maybe flight timeis eight minutes from the skids

up to skids down. but the bedside tobedside time, that's what we need to think about. one of the absoluteworst things in the world you can do for somebody thathas been mechanically ventilated is take them off and bag them. reason being, as soon asyou disconnect that circuit, what happens? basically everything that thatoutlying facility has gained

as far as their oxygenationand their ventilation status goes, you just pissed awayin a matter of seconds as far as disconnectingthat vent. disconnecting,even disconnecting them to suction them if they'reon a high level of peep, which we'll talk about here prettysoon, we'll see if this plays. so these are rats lungs. and what they're going to dois, and so currently they're deflated.

they're at what is calleda zeep, zero end expiratory pressure. what they're goingto do is slowly increase the peep, the positiveend expiratory pressure by five centimetersof water pressure. and what we will watch is youwatch alveolar recruitment, where these slowly get moreand more and more expanded. so here we've got bigbands of atelectasis right here, which is justall collapsed alveoli.

so then you can watchthe recruitment. again, you've got justliterally millions and millions and millions of alveolithat they're opening up. and then watch what happenswhen they disconnect it. so here we're atfull recruitment. and again, you can seethose bands of atelectasis have been popped open withthe positive pressure. like i said, in amatter of seconds, you go from basically completelyinflated lungs all the way down

to nothing. and on that patientthat is in ards, again, that is one of theworst things you can do is disconnectthem or suction them. because everythingyou had gained, oxygenation andventilation-wise, you just ruined. you just lost in amatter of seconds. then you've got to think aboutwho's bagging that patient?

so in the courseof a transport, you might have the pilot--again if you're sitting there watching the linesand everything, or the monitor, or trying to getsomething secured, you might say thepilot, well give the bag a couples squeezes. the security guard-- hey, justgive him a couple breaths. or that nurse fromthat outlying facility that wants to comeout and see the bird,

they might wind up doing it. that being said, oneof the nice things about the mechanicalventilator is it gives you a consistent rate. it gives you aconsistent volume. do you think allthree of these people are going to bebagging consistently? that patient's minute volume isgoing to be all over the board. so this was taken directlyfrom one of our charts.

this is going fromkenosha up to froedtert. at 10:17, will manuallyventilate the patient with the bag due to a short eta. when they rolled into theneuro icu, it was 10:58. quick math-- how long wasthat patient being bagged? 41 minutes. is that a quick--is that a short eta? in 41 minutes, they did theydid no justice to that patient. this is a balloon pump flight.

again, so our crew windsup getting down there, determines-- they questionthe vent settings. and the outlyingfacility says, well this patient isbasically pre-ards. so what we're going to dois a high rate and lower tidal volume to decreasethe chance of what's called barotrauma, insteadof hurting the lungs. so now you've got apatient that's pre-ards. again, they're on the fence.

you've got a sick patient. and then in the nextsentence it says, ok. now we hook himup to the oxygen. we're going to bag him. what good did we justdo for that patient? absolutely nothing. and again, knowing and not doingis like not knowing at all. the ultimate sin-- so again,we've got this $30,000 ventilator that, whenwe told the people that

work on ourhelicopters, yeah, we need some type ofbracket for it. they literally boltedit to the wall. so again, we've gotthis transport vent. when the first time thatpatient is on the vent is when they'rein the helicopter. is that going to do any good? with transport vents,the best you can do is take your ventto the bedside.

while you're gettingreport, get your ventilator on that patient. see how well that patientis tolerating your vent. see how wellthey're oxygenating. see how wellthey're ventilating. make any changes you need todo at that patient's bedside prior getting out to thataircraft or ambulance. because i would much ratherdo the troubleshooting at the patient's bedsidebefore getting in the air.

as far as it types ofventilation, invasive of versus non-invasive,again, invasive ventilation, we're talking about endotrachealtubes, combitubes, kings, lmas tracheostomy tubes. non-invasiveventilation-- we are doing more and more andmore and more non-invasive ventilation these days. we teach you hours andhours and hours and hours how to intubate somebody.

you're going to spendyour entire career trying to figure out how to keepthem from getting intubated. given the choice thesedays, i would much rather do a non-invasive ventilation. and as far as thislecture goes, it's somewhat specific to theltd mechanical ventilator. so a lot of the stuff doesn't--and when i used to teach the critical care class,the one in madison, i would bring in six or sevendifferent mechanical vents that

we used in our icus. and we had a littleheydey where everybody could sit there and go aroundfrom ventilator to ventilator and sit there andplay with them. and the more and morei got to think of it, you know what, you guys don'tneed to know our ventilators. you don't need to know howto run our ventilators. whose ventilatordo you need to know how to run like theback of your hand?

yours. so it's not going to do anygood to sit there and bring all of ours in and say, ok. this is how they work. you need to know your ventilatorup, down, in, and out. so again, as far as anon-invasive ventilation goes, multipledifferent ways to do it. you can do it via nasalmask, as well as adults also. as far as the volume ventilationversus pressure ventilation,

again these are thetwo biggest animals. again, we talked aboutinvasive versus non-invasive. breaking it down alittle bit further, we're going to be doinga volume versus pressure. in volume ventilation,your volume is always goingto stay the same. it's your pressure thatis going to change. so if i've got a trachea,if i've got lungs. if i've got a patient thatis perfectly intubated,

endotracheal tube is twocentimeters below the carina. and we are volumeventilating that patient, i am putting in--i'm going to say if i'm putting in a tidalvolume of 500 milliliters, i'm getting greatchest expansion. and in order to getthat 500 milliliters in, it's taking a pressurereading of about, i am going to 20 centimetersof water pressure, or you can usemillimeters of mercury.

they're pretty muchinterchangeable. so i'm volume ventilatingat a tidal volume of 500 milliliters. and i'm looking at what'scalled my pressure manometer, my pressure gauge. it's taking a pressure of 20centimeters of water pressure. now let's say that thestretcher stops or jerks, or the ambulanceor aircraft jerks. and now i get a rightmainstem intubation.

what's going tohappen to my volume? and we're in volume ventilation. what's going tohappen to my pressure? so now we've got a big, nastyleft-sided pneumothorax, exact same settings. and volume ventilation? stay the same. again, we're putting a largervolume in a smaller area. it's going to gothrough the roof.

so again, volume ventilation,volume always stays the same. the pressure changes. pressure ventilation. so in volume ventilation,we are dialing in a specific tidal volume. and we'll get into that a littlebit later, as far as what size. we are dialing ina pressure in order to get a specificvolume in return. so if i am pressureventilating a patient,

that pressure always, always,always stays the same. and the volume changes. so same thing-- now i'mpressure ventilating a patient. and i'm going to saythat i'm ventilating them at a pressure of 20centimeters of water pressure. and in return, i'm gettingback an exhaled tidal volume same scenario. now i get a bigright-sided-- or now i get a right mainstem intubation.

what's my pressure going to do? what's my volume going to do? it's going to decrease. other scenario-- bigold left-sided tension pnuemothorax. what's going to happento my exhaled volume? so as far as alarms go,besides the vent setting, we're also going to besetting appropriate alarms. if i am volume ventilatingletting somebody,

it's going to be thehigh pressure alarm. that's the one that i'mgoing to kind of key in on. because any timethere's a change, in my patient's volumes, ortrying to get that pressure on, this the one that iwant to keep an eye on. if i am pressure ventilatingsomebody, where my volumes are changing, it's going to bemy low minute volume alarm. that's the one thati want to key in on. whereas, if i geta change in that,

i want to knowsomething's wrong. you know, do i have--and we'll talk about that here in a second. so a couple years ago, wewere at a national convention. and i got dragged overto one of the vendors. it was impact, who makesmechanical ventilators. and at the chiefflight nurse for flight as well as the programdirector for uw dragged me over differentoccasions and said,

you've got to comeand look at this vent. it is so, so, so cool. any time you get an alarm,on this little screen here, it lists off the topfive or 10 reasons that alarm could be happening. and i'm thinking,are they serious? so imagine-- and we'llsee if this plays or not-- imagine if i'm takingoff with the pilot. so if we have analarm in-flight,

do i want my pilot to sit therewith a manual and say, hey, could you tell mewhat that alarm means? if you're going to hang theshingle that you are this fill-in-the-blank critical careparamedic, critical care nurse, critical care physician,critical care rt, i should be able to go toany one of you and say, give me five causes for ahigh pqr pressure alarm. you should be ableto rattle those off, bing, bing,bing, bing, bing.

give me five causes of alow minute volume alarm, you should be ableto rattle those off. you should not have to sitthere and look at a book. again, we're talking aboutthis patient's airway, this patient's pulmonary status. should you have to sit thereand read something off a screen? high causes of peakairway pressure alarm on the mechanical ventilatorin a transport setting. what do you think one ofthe most common causes is?

baby elephants. no, it's that patientcoming out of their sedation and they're paralytic. last thing i rememberis i just saw, you know, skynard at summer fest. now all of a sudden i'mwaking up in some helicopter. do you think that patient'sgoing to freak out if they've got sometube in their mouth and they're trying to breatheagainst some machine that's

trying to breathe againstthem and they can't talk? they freak out. lot of times when your patientcomes out of their sedation and they're paralytic,they freak out. who said secretions or coughing? again, where you getthese patients-- again, these patients that havesevere pneumonia or something like that-- this is a sizeeight endotracheal tube. this is a patient thatwas emergently extubated

in the trauma center overon madison because we couldn't-- basically,we couldn't ventilate. we couldn't suction. so again, that beingsaid, a size eight. how big a chunkof lung butter is that to completely occlude asize eight endotracheal tube? so secretions. again, that's why thepatient's high hydration status is extremely important.

again, when we're mechanicallyventilating somebody, we are bypassingthat upper airway. so remember the purposeof the upper airway is going to be to heat,humidify, and filter that inspired air. when i was a kid, i'd goout running in the winter and my mom wouldsay, well, you idiot, you're going tofreeze your lungs. are you going tofreeze your lungs?

do you know within25/1000 of a second, your inhaled air is heatedup to body temperature? so it's going to heat it. it's going to humidify it. in the course of 24 hours, youlose about one liter of fluid just by breathing. so again, withouthumidifying these secretions, what's going to happen to it? it becomes just like that.

and then it's going to filter. same thing. well when i was a kid i'dbe downstairs spray painting my guitars schwinncandy apple red paint. two days later, i'd windup picking my boogers. what color were my boogers? specifically, what color red? schwinn candy apple red. so heat, humidifier, filter.

so again, a lot oftimes, prior to departing that outlying facility icu er,one of the things i always ask, have you suctionedthem recently? if so, what were yousuctioning out of them? if they have beensuctioning them and they've been suctioned recently, good. if they haven't,prior to departure i'm going to suctionthem because i don't want to bedoing it in transport

unless i absolutely have to. trauma patient, bilateralpulmonary contusion, big old occluded endotrachealtube again, due to a big old blood clot. who's that? [inaudible] mm-hm. so again, severe chf. again, we're trying to put avolume in a space that that

volume just cannot go becauseit is so filled up with fluid, and in this case,just severe chf. is that going to cause thehpqr pressure alarm to go off? probably. again, secretion. that's just a bigold tracheal casting. what's going on here? we don't know. the best place in the world toassess somebody's chest rise

is at their feet. and at this point,we don't know. it might be something as simpleas a mainstem intubation. it might be atension pneumothorax. we don't know, until theywind up getting an x-ray. but again, somethingis not right there. and again, now we'retrying to put a set volume in a much smaller space whichmight create a higher pqr pressure.

we can be the causeof high pqr pressures. let's go back to this one. basically, everything medicalthat's put on a patient or in a patient has got someform of radio- opaque line on it. so again, here we'vegot the trachea. we've got the rightmainstem bronchus, the left mainstem bronchus. the arrow here isgoing to be depicting

the carina, or the bifurcation. you can just barely see avery faint white line here, which is the radio opaque lineon that endotracheal tube. that being said,what's going on here? you've got a right mainstemintubation, which is something that we see all too often. and there have beentimes we've gotten in the back of anambulance where you've got johnny save-a-lifewith a 14-gauge angio

over that left chest,ready to decompress that chest for thesuspected tension pneumo. first thing youwant to do is look at the depth of thatendotracheal tube. a good rule of thumbfor absolutely everybody is three times thetube diameter is where it should wind upat the teeth or gums. so if i have a sizeseven, if i get in the back of theambulance, they've

got that patient intubatedwith a size seven. and it's at 28 atthe teeth, and they want to decompressthe left chest. what's the problem? it's probably too deep. and you want to use aanatomical landmark that does not change position. so some people willsay lip to tip. that being said, when you guyswind up pulling somebody out

of a house fire orpull somebody out of the car that just bitthe steering wheel, what's going to happen to their lips? they're going to swell. so again, use theteeth or the gums. that being said, unlessyou live or work way up in northern wisconsinwhere they don't have that front set ofteeth then use the gums. big old tension pneumo.

and they always say that a chestx-ray of a tension pneumothorax should be a sin. why? you should have caught it longbefore they snap that chest x-ray. and my guess is, the doc willprobably say, you know what? we can't look at the x-ray nowbecause we're coding this kid. so again, we're trying toput a large volume in an area where it just can't go.

again, you're going toget high pqr pressures. restrictive lung disease. so you can breakdown lung disease into restrictiveverses obstructive. restrictive lung disease,you've seen these patients that have got the severescoliosis kyphosis, lordosis, where theirspine is like a question mark or a pretzel. again, no matter how much volumewe put in that patient's chest,

are we going tostraighten out his spine? or in the winter,when it's really, really, really, really,really cold out, we wind up sittingthere throwing them under our cot and thatbig old sleeping bag. and we sit there and wecinch the straps down really, really tight. what happens totheir pqr pressures? they wind up going up.

years ago, we had onethese little teeny boppers with the big push up bra. her pqr-- and she hadnormal pulmonary status-- but her pqr pressureswere through the roof. it wasn't until theywound up cutting her bra that all of a suddenher pqr pressures dropped by like 20millimeters of mercury. so again, if they have any formof restrictive clothing on, take it off.

obesity. again, in order toget that 500, 600, 700 milliliters intothe chest, we've got to move those--all of that tissue. another thing that can causehigh pqr pressures-- this is something thatwe see quite often in the pediatricpopulation, especially if we go to a smallcommunity hospital that doesn't deal withkids all that often.

the size of the tube. anytime you decrease thediameter of anything-- doesn't matter if it's a firehose, endotracheal tube, iv catheter, garden hose. what happens the resistance? it goes through the roof. now you go to somesmall town hospital that doesn't deal withkids that often and they've got a four-year-oldthat just arrests.

and they say well,hey, give me a tube. give me a pediatric tube. and they hand thema size 3 and 1/2. what do you think thepressures are going to be like? they're going to bepretty darn high. causes of low volume. and for extra credit credit,what movie is this from? spinal tap. thank you, thank you.

you're wasting your time readingthe brady textbook and all that other crap. you should bewatching spinal tap. so if you've got a lowminute volume alarm, the first thing you wantto do is you know what? get right back tothat patient's airway. there's a possibility thatthe airway might be out. and again, looking at thesekids here, both trach. do you think this kid herehas any clue in his mind

that his trach is out? do you think he cares? same thing here. but again, go rightback to that airway. make sure thatyour airway hasn't become displaced inthe transport setting. and again, justget in the mindset. if you're going to betransporting somebody that is intubated, have it in yourmind that during this transport

that tube is coming out. i can't stress that enough. same thing with your iv. it's coming out. the circuit itselfpossibly leaking, if there's a smallhole in the circuit. again, air is going to takethe path of least resistance which is probably goingto be out that hole. in the [? ltv ?]series, the circuit

hooks up in four differentplaces, the main circuit area as well as these threelittle connections here. these are notorious for becomingloose and creating a leak. as far as the differentmodes of ventilation, multiple different modes. cmv, which is called controlmechanical ventilation. this like the first two modeof mechanical ventilation ever. then from thereit was broken down into assist control,both volume and pressure.

simv, both volume and pressure. non invasive positivepressure ventilation or bipap. pressure support, cpap. and we'll discuss prettymuch all of these here. so controlledmechanical ventilation. we rarely see itanymore however there are some dinosaurs outthere that still use it. and again, you might do atransport from some small town hospital that-- you know, theer doc, from back in residency

this is what we always usedso this is what we're using. basically it's going todeliver a preset tidal volume at a preset rate overa preset inspiratory time for every breath. preferably that patient's goingto be sedated and paralyzed. so if i've gotsomebody, we're going to say on a-- there's abetter color marker here, instead of this pea soup green. and again, besides thinkingabout the vent settings,

we also want to do some math. if i've got somebodyon a rate of 12, how often is thatpatient going to be getting a breath in a minute? every five seconds. so every five-- so everyfive seconds this patient is going to be getting a breath. a breath-- in this case,tidal volume of 1/500 and our inspiratory time we'lltalk about a little bit later.

but this sectionhere, this is what we call-- thatfive seconds-- that is what we call ourrespiratory cycle time. in that respiratory cycle time,that patient has got to inhale and that patient has gotto exhale every time. and if that patient winds uptaking any additional breaths, now let's say they windup going from a rate of 12 up to a rate of 15. what happens to ourrespiratory cycle time?

now we go from a respiratorycycle time of five seconds down to four seconds. now what happens if they'reclipping along at a rate of 20? drops down to three seconds. rate of 30 dropsdown to two seconds. rate of 40, 1.5. where they have to inhale,they have to exhale. but in controlledmechanical ventilation, they get that breathevery five seconds.

what happens if that patientcomes out of their sedation, they're paralytic, and theywant an additional breath? in controlledmechanical ventilation? you're not getting it. so the next generation ofmodes was assist control. and that can be broken downinto assist control volume and assist control pressure. however, in this regionof the united states it's more commonlycalled pressure control.

and the way thatworks is again, we've got the-- the machineis going to deliver a breath every whatever-- again,if we've got a rate of 12, every five seconds they'regoing to get that breath. however, if they wanta breath in between, the machine will sense itin couple different ways. they will trigger that machine. in this case here it iswhat is called pressure triggering where thatpatient 's got to inhale,

create the negative pressure. the machine senses itand delivers a breath. and in the assistcontrol mode, it's going to give theman additional breath at the exact same tidalvolume that you've got dialed in at as well as theexact same inspiratory time. and your inspiratory time is howfast is that breath delivered. so again, on oneof our flights-- this patient is on assistcontrol, rate of 16,

tidal volume of 500 milliliters. so that being said, are theyin assist control volume or are they in assistcontrol pressure? they're in assistcontrol pressure-- sorry, you're right-- assistcontrol volume. 60% oxygen, 5% of peep--plus 5 centimeters of water pressure of peep. that's what's charted. the patient assists the ventwith shallow respirations.

are they going to be takingshallow respirations? how big should everyone of their breaths be? 500. so again, as far as thatpatient wanting a breath. a couple differentways to do it here. either the patient--either the machine will sense it bypressure triggering. again, where the patient hasto create a negative pressure. these days though,many of the vents

have what is called flowtriggering, where floor triggering, anydisruption in the flow going through the circuitof that ventilator, the machine assumesit is that-- it's that patient thatwants a breath. that being said, anydisruption in flow which might be assimple as shaking that tubing, the machine isgoing to assume it's a breath. in the transport setting, doyou guys move around a lot?

you guys ever go on bumpy roads? so when we got thosenew ventilators, we had a patient on anorcuron-- actually, we didn't. the fond-du-lac crew had apatient on a norcuron drip. and the vent wasset at a rate of 12. but yet, throughoutthe entire transport, this patient wasbreathing at a rate of 22. so can you over breathe the ventif you're on a paralytic drip? and what it came down to isthe sensitivity of the vent

was set too sensitive,that any little vibration in that tubing,the machine assumed it was that patientwanting a breath. so again, make sure you knowwhat type of sensitivity your vent has. and on the ltvs that we use,you can do pressure triggering or you can do flow triggeringand the flow triggering is-- anyway, make sure ifit's flow triggering make sure it's notset too sensitive.

and like i said,on the ltv that's kind of backwards to therest of the ventilator world where it's less is more. and that's an insidejoke here because that's our mechanic called les. anyway, blah, blah, blah. anyway, so going back, if thepatient is over-triggering the vent, where youdon't want them to, again, you're going to just haveto adjust their sensitivity.

or again, look at that patient. if it looks like they want abreath and they can't get it, chances are you have toadjust your sensitivity to make it easierfor them to breathe. so again, assist control. there are some downfallsof assist control. so again, this was takenfrom another transport that they had done where thepatient was on a rate of 12. that being said, what'smy respiratory cycle time?

five seconds. five secondrespiratory cycle time. we're going to say thatagain to make easy math. we're going tosay that we've got a tidal volume of500 milliliters. and we have a 1.0second inspiratory time. so that 500 milliliters isdelivered over one second. so one second of my fivesecond respiratory cycle time is chewed up by inspiration.

how much time does thispatient have to exhale? four seconds. and on many of theventilators out there you have to setyour rate by what is called your ideratio, your inspiratory to expiratory ratio. so if we've got-- if we have afive second respiratory cycle time. we've got one second ofthat is for inspiration.

what's my ide ratio? one to four. one part inspiration,four parts exhalation. and again, thisis things that you need to think of everytime you change the rate or you change yourinspiratory time because your ide ratio changes. so on this call. this was a patientthat a old copder

that they wound up flying out. this patient wasmechanically ventilated. they were on a rateof 12, giving us a five secondrespiratory cycle time. and when they got there, thepatient's exhaled carbon-- or their capnography was 63. so, you know, normal,35 to 45, as they say. so there were 63. so are we breathing enough oris our patient breathing enough?

so ok. now what they wind updoing is they wind up changing him to arespiratory rate of 15. so now we just went from a fivesecond respiratory cycle time to a four secondrespiratory cycle time. they didn't change theinspiratory time at all so we still have aone second i time. what's our e time now? three.

so now we're at a one to three. and so this patient is a copder. so they wind up jackingup the rate to 15 because we had anend tidal of 63. so they jack up the rateto 15 and now his end tidal goes to 74. is that normal? so ok, now let's checkup the rate to 20. so now we're up to a rate of 20.

we didn't change anything else. so we still-- so ourrespiratory cycle time that started at five secondsnow went down to four seconds at a rate of 20. what is ourrespiratory cycle time? three seconds. we didn't change ourinspiratory time. so we went from a one to fouride ratio to a one to three ide ratio.

what are we at now? a one to two. what are those copdersasthmatics notorious for? air trapping. so now all of a suddenour end tidal is 80. so now we jack upour rate to 30. what's our ide ratio now? so now we've got a two secondrespiratory cycle time. one second of that isburned up by inhalation.

you are at a one to one. our next end tidal will probablycome back in the triple digits. so again, these arethe patients that you want to drop their respiratoryrate because these patients are air trapping. they are hyper inflated. so again, we startedon a rate of 12. what if i wound up dropping myrespiratory rate down to 10? what would that do to myrespiratory cycle time?

it's going to increase to six. and we got a one point-- whatdid i say, one second i time? now a five second e time. now all of a sudden,our end tidal co2 drops. and we think, wellthat doesn't make sense because in order for somebodyto drop somebody's end tidal we think that we haveto increase their minute volume either byincreasing their rate or increasingtheir title volume.

but yet i just dropped myrate, and now their n title goes down. why is that? longer expiratory time,and now these patients are able to finally exhale. so this population of patients--first off, the best thing to do is not even intubatethem in the first place. do non-invasiveventilation, your bipapp which we'll talk abouta little bit later.

one of the worstthings you can do is intubate anasthmatic or copder. and let me obnoxiouslyrepeat that. is intubate anasthmatic or a copder. but by dropping the rate, weincrease their expiratory time. and now these patients finallyare able to truly exhale. and again, many of these ventshave got graphics packages on them where you canactually look and see that they are truly notexhaling down to baseline.

where if they'reautopaping, they wind up getting a breath beforeexhaling all the way down and they wind up breathstacking over and over and over time they wind upbecoming so incredibly hyper inflated. with simv-- and the firstsimv was actually called imv, which stands forintermittent mechanical ventilation, where basically youwould get machine size breaths. however, in between the patientcould spontaneously breathe.

the difference is-- and we'llbe looking at the volume down here on the bottom. so your machine size breathes. if i've got a title volumedialed in at 500 milliliters, every machine size breath isgoing to be 500 milliliters. in imv, in between thepatient can spontaneously breathe however thesize volume of breaths that they take isdependent on them. they're the onesthat set the volume.

one of the downfallsof imv, though, is if that this patientwas spontaneously breathing and if they wereat end inspiration, and it was time for thatmachine breath to be delivered, what would happen? they would wind upbreath stacking. they would wind up getting yetanother breath on top of that. so then they cameout with simv which stands for synchronizedintermittent mechanical

ventilation. so the machine basicallymonitors that patient's spontaneous breathing and itwon't deliver that machine breath until they exhaletheir spontaneous breath. again, can be used in acouple different modes. a lot of times wewind up using it when we wean a patient, whenthat patient is waking up, and we like them to do a littlemore breathing on their own. in the transport settingthough, how often

are we weaning patients? the only time i everreally changed to simv in the transport setting is wheni want to lower somebody's co2. whereas if they'rewaking up and they're in assist control eithervolume or pressure, where every time they take anadditional breath on their own it's that exact same size breaththat you've got dialed in. and if they'rehyperventilating, you can take them outof the equation

by sedating them orparalyzing them but if i don't want to i can change them simv. and by them taking afew spontaneous breaths on their own, it's generallya lower tidal volume. and by being alower tidal volume, it's going to be alower minute volume. by being a lowerminute volume, it's going to be raisingtheir co2 a little bit. but like i said, we really don'tdo it that much in transport.

if you ever have anybody on simvor imv, many of the ventilators also have what iscalled pressure support. and what pressuresupport does is it gives them a littlebit of assistance to overcome the resistance ofnot only the endotracheal tube but the circuit ofthe ventilator itself to give them a littlebit of a boost. and again, we'll talk aboutwe'll talk about breath size here pretty quick.

but again, if you watchsomebody that's spontaneously breathing while they'rebeing mechanically ventilated and they're takingspontaneous breaths in between thosemachine breaths, again, we have to think aboutnot only their machine breaths but now are they gettingan adequate chest rise with the spontaneous breaths? and if they'renot, we might have to add a little bitof pressure support.

and we'll talk about thevolumes here pretty soon. so as far as bipap goes. again, this issomething that we are doing more and moreand more and more of. it is non invasive, positivepressure ventilation. and again, in all honestyit's a pain in the butt. you get to thatoutlying facility, and you get this patient thatwould be much easier for us to just sedate her,paralyze her, and intubate

here, and transporther intubated but is that the right thing to do? so again, if we can maintainnon invasive ventilation throughout thetransport, and again, by far one of the bestthings in the world you can do these patients. if you do work for a programthat does use a ltv series ventilator it's got tobe a non-vented mask. so again, for the initialvent settings i always ask.

first off, ifthey're ventilated, what's the firstthing i'm looking for? where is that mask? that manual resusitator mask? so again, ask whatsettings were you using? and again, was thepatient oxygenating and were they ventilating? again, apples and oranges. in with the good air,out with the bad air.

don't just ask, youknow, what's her sat? think about the entire picture. how were they oxygenating? how were they ventilating? that being said,again, remember what we talked aboutthese people here? who are they? again, you go to some pumpkinhollow community hospital that don't deal with ventilatedpatients all that

often in the er, there is notelling what type of settings you're going to walk into. there's a small communityhospital northwest of madison that they have no need fora ventilator in the er. they have one that's leased. it sits out inthe ambulance bay. it is literally shrink wrapped. as soon as they cut thatshrink wrap on there and break the seal, theystart to get charged for it.

that being said, whatis the last thing they want to do in the er? ventilate a patient. so, you know, we'llbe there in 40 minutes and they are therefor 40 minutes handbagging that patient. and on the rare occasionthat they are on the vent, it is some of the most bizarresettings you've ever seen. and again, how many timeshave you walked into this?

we already talked about that. where is your mask? already talked about that. so as far as dependingon the facility, there's a possibility that theymight still be handbagging. now we're going to be thinkingabout some appropriate ventilator settings. and again, this comes into--there's no cookbook on this. again, we've got to be thinkingabout what type of patient

are we ventilating? do they have some type ofdestructive process going on? some type of restrictedprocess going on? so then initialsettings, we want to know what mode, what rate? are we going to be volumeventilating or are we going to be pressureventilating? is it going to be a mode thatpressure support is an option? how much oxygen, how much peep?

what's appropriateinspiratory time? it's a whole lot of math ina very short period of time. so exactly what is normal? so for machine-sizedbreaths, we like to see six to eightmilliliters per kilo. early on, straightacross the board it was 10 millimeters per kilo. so if i had a 70 kilo patient,how big a tidal volume would they get?

700. if i have an 80 kilopatient how big? what we had found out ishistorically over time, we were beating upthese patients lungs by what's called barreltrauma, giving them too big-- or volume trauma, by givingthem too big a breath. so then we said, we've got todecrease these tidal volumes. so now for machine sizebreaths, we like to six to eight milliliters per kilo.

if they're in a modeof ventilation that offers pressuresupport-- so on the ltv the simv modes-- if that patientcan spontaneously breathe then we like to see four tosix milliliters per kilo for their pressuresupport breaths. and ultimately,what it comes down to though is we like tosee-- we use the ideal body weight, which we'll talkabout here in a second. and then the correctedversus uncorrected.

which again, thisis where you need to know your ventas well as you also need to know kind ofthat patient's vent on the outlying facility. when you push thosetwo milligrams of midaz to quiet your patient down,what do you follow it up with? a flush? why's that? to make sure that themedication actually

gets into thepatient's circulation. so as far as correctedversus uncorrected, there are still a large amountof ventilators out there-- i've got my patient over here. if i've got atidal volume-- if i want to give my patient a tidalvolume of 500 milliliters, i might actually set thevent at 600 milliliters. and all of usrespiratory nerdlingers, every ventilator circuitthere has got what is called--

and don't write this down,because you're never, ever going to need it again. yes, i'll take worthlessventilator facts for 200, stu. it is what is called your tubingcompressibility factor, where us respiratorynerdlingers, we would have to calculate howmuch volume of that 500 milliliters that thatventilator-- and keep in mind that it is putting out500 milliliters right here, when it exits the vent.

we would calculate how muchvolume is lost in that tubing, and then calculate,make up there for the differencein the tidal volume. so if i wanted my patientto get 500 milliliters, i would set it to 550, 570,or something like that. now, again, where itcomes into play with you guys is, you might be pickingup a patient at an old line facility that they're usingthe uncorrected tidal volumes. maybe the new transportvents that you guys

are going to be using iswhat is called a corrected tidal volume, whereit's actually measured at the patient at theendotracheal tube. how much volume thatpatient is getting. that being said, if i wind usingthat old line facilities tidal volume, are yougoing to be giving a breath that's toobig or too small? too big. if i take theirtidal volume of 550

and throw it on myventilator, keep in mind that their ventilatorstidal volume is measured way out here, whereas alot of the transport vents, they measured right at thepatient's endotracheal tube. and they are compensating. they are over inflatingtheir tidal volume to make up for all of thisvolume lost in the circuit, whereas many of thetransport ventilators these days, that patient'stidal volume is measured at what

is called the patient's wye--w-y-e-- at where it connects to the endotracheal tube. and again, this iswhere it comes down to you need to knowwhat type of ventilator you're going to be using. is it going to becorrected tidal volumes or uncorrected tidal volumes? but ultimately, all of thisstuff, what it comes down to do is, do we really careabout all of these numbers

in our line of work? what happens if i get out thereand my patient is being maxed out, if they're going byprotocol and they're saying, we are delivering eightmilliliters per kilo, and you look at that patient andthey've got minimal chest rise. what are we going to do? what if they're at sixmilliliters per kilo they're getting ahuge chest rise? so again, these arejust recommendations.

just numbers. and i absolutely numbers. again, it's just agood reference point on where to start. but again, keep in mind. ultimately what's goingto come down for you folks in the transport settingis, whatever we are dialing it in, be it six mils perkilo, eight mils per kilo, are we getting anadequate chest rise?

if not, what are wegoing to do about it? if we're getting toomuch of a chest rise, what are we goingto do about it? so again, look at your patient. so, ideal body weight. again, what are we going to usefor a tidal volume on this guy here? what's that? i've seen it.

i've seen 400 [inaudible]. and again, here you go. i'm just big boned. look at the size of lungvolume on both those people. they would have prettymuch the same tidal volume. so again, ideal body weight. and there are a littlecharts out there where you can guesstimate thepatient's ideal body weight, but again, ultimately what it'sgoing to come down to you guys

in the transport setting isenough to get an adequate chest rise. and this is one of the olduncorrected tidal volume vents, blah, blah, blah. and again, we wantto look at-- here we've got a tidal volumeof 250 milliliters dialed in for a tidal volume. what we also want to look atis besides an adequate chest rise is your ventilatorhas the ability

to give you what is calledan exhaled tidal volume, where we're putting in at 250--this stands for tidal volume exhaled, vte. we're putting in 250,what are we getting back? one fifth of our volume. is there a problem? we're leaking somewhere, so, again, if you can compareinspiratory tidal volume to expiratory tidal volumeon your vents, by all means,

also do it. but, again,ultimately it's going to come down to gettingthat adequate chest rise. and then your peakinspiratory pressure, if you're pressureventilating somebody. again, the vents willhave a pressure manometer on there, which will giveyou an idea how much pressure it takes in order toan adequate chest rise. as well as when you'revolume ventilating somebody,

besides just writing down howmuch volume they're getting, write down how much pressureit takes to get that volume. and again, that'sall good information. for me, being on the receivingend, if you guys come to me and say, we're on arespiratory rate of 10, tidal volume of 500, it'staking pressures of about 25 in order to get that, andi put them on my machine and i'm getting pressuresof 40, something changed. but again, this should all bepart of your documentation.

if you're volumeventilating, also tell us how much pressure it'staking in order to get that in. and again on the pressuremanometer, some of them are a little dial witha little needle on it. some of the digitalone these days will have a littlebar graph on there. if you wind up getting ahigh peak airway pressure alarm on your vent,it does three things. first off, it givesyou an audible alarm,

it gives you a visual alarm,and most importantly, it aborts that breath so it doesn'tsubject the patient's lungs to that high pressure. if you choose to pressureventilate somebody, again, we have noidea how much pressure to start ventilatingthese people with. they do have portable pressuremanometers where basically you will hook it up in linewith the main resuscitator and start bagging that patient.

and just take goodlook on the dial there how much pressure it takes toget an adequate chest rise. and if it looks like it takesabout 20 millimeters of mercury or centimeters of water pressurein order to get adequate chest rise, i'm probably going tostart ventilating that patient with a pressureof about 15 or so, and then to slowlywork my way up in order to get anadequate chest rise. and just because themanometer says 20,

i'll always start lowerand work my way up. so, as far pressure ventilationgoes, 300 million alveoli, all the thicknessof a soap bubble. how much pressure does ittake to pop a soap bubble? not much at all. as far as peep, positive endexpiratory pressure, again, much like the tidal volume,compensated and corrected verses uncorrectedpeep, we also have compensated versesuncompensated.

again, somethingimportant to think about. any time you've got a patientthat you're transporting on peep, on the ventilator, oneof the first things you should also do is, eventhough i had said, don't bag that patient,but pretty much every main resuscitatorthat's out there, you can put a externalpeep valve on it. if you've got somebodythat's on peep on the vent, you should automaticallyhave a peep valve

on your main resuscitator. reason being is, if i'mon a high level of people peep on the vent andnow i have to bag that patient for whateverreason, that same level of peep is maintained throughoutthe entire time. if they're on a reallyhigh level of peep, down on the bottomhere, we've got what are called inlinesuction catheters. where generally in orderto suction somebody,

i've got a disconnect themfrom the endotracheal tube, and like what i said earlier,everything that you just gained you just ruined,because you disconnected them. by using an inlinesuction catheter , you're able to suction thosepatients while they're still connected, while they'restill maintaining their peep and maintaining theirpressures and their volumes. so if they have one inline, to keep it in line, take it with you.

again, it's an airway item, soif you've never used it before, ask how to use it. but going back tothe peep, is anybody in here using an lvtseries vent in transport? you are. ok, so as you can see, thereare multiple different ltvs out there. they all look the same. you have an 800, 850, 900, 950,1000, 1100, 1200, and a 1200mr.

everything below an 1150 is whatis called non-peep compensated. and what that means, verysimilar to your tidal volume, is when we are pressureventilating a patient, we wind up making alterationsto our pressure level to take into accountfor the peep. and i'm not going to get thattoo much because, again, you need to knowwhatever type of vent you're going to wind up using. test lungs, whichare nothing more

than a darn expensiverubber glove. prior to putting yourtransport vent on a patient, preferably put it onsome form of test lung to make sure that itis working adequately. but keep in mind thecompliance of a test lung is much different thanthat of your patient. so if you're pressureventilating somebody, or volume ventilating somebody, it's goingto be a little bit different. and again, know whatyour resources are.

and preferably, thatreceiving intensivists. icu intensivists. somebody that's used todealing with mechanically ventilated patients. so, the problem children. if anybody knows where i canget one of those t shirts, by all means,please let me know. thoracic trauma. again, just looking at thispatient's chest area x-ray,

you've got rightsided white out. left is starting toget a little bit hazy. again, multiple broken ribsover there on the right side. so besides brokenribs, you might have a pulmonary contusion,might be leading to hemothorax, pneumothorax, we don't know. but that in mind, again, thewhole awareness recognition management, they tell youthis patient's chest x-ray is horrible.

so we can just thinkabout, if we're going to be volumeventilating somebody that's got all of thisschmutz in there, plus a bunch of brokenbones, we can just expect high peakairway pressures, poor oxidation,poor ventilation. little critters. preemies, neonates. who's this guy here?

that is doc baker from littlehouse on the prarie, where pa ingalls wouldcall him up and say, i need helpdelivering this calf. so doc baker would comeon, and meanwhile, he's heading back to his buggy,and pa ingalls says, well wait a sec. you know, half pint'sgot another std, can you come take a look at her? so you got this guy taking alook at farm animals to people.

basically, again, asfar as these kids go, these preemies, micropreemies, again, it is a completely different world. again, there is evidencebased medicine out there-- and this is now myshameless plug-- but evidence basedmedicine out there as far as utilizingspecialty transport teams. where again, i don't want tobe on one of those teams that takes a 90-year-oldmyocardial infarction

and then the next flightis some 700 gram patient. that is a completelydifferent world. asthmatics. copd. we already talked aboutthis, don't intubate them in the first place. that's that hyperinflationphase that we see on these asthmaticsand the copders, where they don't fully exhale.

then again, we've got to bethinking about that copder that has a co2 level of 63. should we get all bentout of shape about that? then we've got tothink about what is called permissive hypoxia. what is their normaloxidation status? what is their normalventilation status? are we going to sit thereand some old lunger that has a normal baseline co2in the mid 50s, mid 60s.

are we going to cure thatin a 20 minute transport? what about circumferentialthoracic burns? over time, what's going tohappen that patient's chest? it's going to get tight. and if i'm volumeventilating somebody where i'm trying to put that 500milliliters in that chest for every breath,over time, what's going to happen to my volume? not a trick question.

volume ventilation, what'sgoing to happen to my volume? it's going to wind up going up. and again, over timeit's going to be like trying to ventilatea leather shoe. it's just impossible to getadequate chest expansion. and in the burn unit,where they wind up doing these escharotomies,we'll get these patients that we just get no chestrise, because the skin is just so taught.

and they wind up doing theseelective escharotomies. and you watch somebody'speak airway pressures go from the 80s, 90s down tothe 40s just by cutting them. then all of a sudden,their oxidation, their ventilationstatus goes up . severe chf. again, where we've gotthis fluid in the alveoli where we want air. it's just not goingto happen, not

until we get that fluid out. mr. farley, we talked about him. again, ards. severe ards, where we'vegot a bilateral white out. again, you can just expect pooroxidation and poor ventilation. and again, this isone that you want to fight for that driver's seat. little, micro preemies. again, you're talk aboutthese little 400, 500, 600

gram-ers that are intubated witha size two endotracheal tube. completely different world. the red flags. again, if your dispatchcenter tells you about any of these things, iwould kind of perk up my ears. pressure control ventilation. again, if they're atpressure control ventilation, there's a chance, dependingon the population, that they already exhausted all of theirmeans of volume ventilation.

and keep in mind withvolume ventilation, i'm going to stress it timeand time and time again. your volume stays the same,your pressure goes up. once your pressurecontinues to go up and you wind up blowing pneumoafter pneumo after pneumo, then we wind up switchingover to pressure ventilation. so if there's somebodythat's already on pressure ventilation,chances are they already exhausted all of their optionswith volume ventilation.

and again, when you'retransporting somebody, get their ventilation history. if they can sitthere and tell you, we started volume ventilatingand our peak airway pressure was in the 20s, thenthe 30s. then the 40s, then we blew a right-sidedpneumo, blah, blah, blah, then we switched overto pressure ventilation. nitric oxide. early on it wasjust fda approved

for the preemies due topulmonary hypertension. these days it's alsoused for adult patients. but again, it shouldbe a red flag, because you'regoing to be dealing with a sick, sick, sick patient. prone positioning. has anybody everheard about this? so, how often haveyou seen somebody in the hospitallaying on their belly?

why does everybody lay supine? easier for the healthcare providers. the only mammal in the worldthat sleeps prone is the sloth. and so as far asprone ventilation goes, basically what's happeningis, for whatever reason, we're not oxygenating,we're not ventilating. basically we are,in a way, shunting. we've got perfusionwithout ventilation or we've got ventilationwithout perfusion.

so somebody thought,you know what? this patient's been layingsupine for several weeks. let's flip him overto see if we can recruit some new areas of lung. and believe it or not, and againdepending on the physician's, something, it's voodoo,and some others buy it. or you can tell whenthe attendings change at some of the icus becauseone attending gets on and says, prone everybody.

another attending comes outand says, flip them back over. but again, ifyou've got somebody that you're goingto be transporting and they tell you in thereport they are being prone ventilated, thatshould be a red flag. because chances are, they spoketo somebody a tertiary care facility and said,you know what, you're pretty much atthe end of your rope. try flipping them over, seeif that makes a difference.

what about ecmo? basically, the heartlung bypass machine. and again, there aretransport programs throughout the nation thatactually do this, where you've got a patient thatis being transported on ecmo, either byground or fixed wing. there are also some rotowingprograms that also do it. ultimately though, whatit comes down to is know what your limitationsare, especially with the vent.

like i said, i cannotstress it enough. it a piece of equipment youdon't get anywhere near enough training on, but it's the onethat will kill your patient. continuing on. if you do we aventilator problem, again, get the ventout of the equation. the best thing todo and is don't just get tunnel vision on that vent. take it out of the equation.

look at the whole picture. when in doubt,even though i told you don't disconnectthe vent, if you're having a problemwith that patient, disconnect and goright back to bagging. make sure that you'rebagging with 100% oxygen. this is going to eliminatethe ventilator as the problem. as far as baggingby hand, some people will say you're ableto gauge the patient's

compliance, again,that's hit or miss. that only comesdown to if you've bagged that patient before. whereas if you have a problemand now you're bagging them, they're much harderto bag, and you're not getting an adequatechest rise, there might be a possibilitythat tube has changed, now its a main stem intubation,or a possible pneumo, or something like that.

but if they get easier to bag,again, it's the vent problem. if they get hard to bag withno problem or no improvement, might be a tube problem, acuterespiratory problem, again, like a pneumo, orsomething like that. if it's a rapidonset, chances are there's an acute blockage,be it a tracheal tube plug of secretions orsomething, equipment problem, maybe the tubing iskinked or disconnected, or the settings changed.

and again, chances are we're notgoing to-- if the settings were changed, we're goingto the ones that do it. years ago, we used to have asection of the hospital that was nothing butchronic vent patients. and one of the kids, hewould get all the attention when his parents would come. well, his sibling reached upand turned the tidal volume on the vent. so now all of a sudden,his tidal volume

was 80, now all of asudden it's up to 400. so, again, if it'sa slower onset, chances are it's thatpatient's respiratory status is getting worse. and then if youtruly have a problem, and if and only if you canconfirm the tube placement, take the patientout of the equation. sedate them and paralyze them. many times you canimprove their oxygenation

and their ventilation status somuch better by paralyzing them. and again, i cannotstress that enough, make sure that your tubeis in the right place. where's your mask? and again, this isfrom the physician that i showed you earlier. again, this was theway that he wanted you to think aboutmechanical ventilation. and if you truly thinkabout this, and this

actually breaking it down,breaking that tidal volume down to the breaking that minutevolume down to a tidal volume, and breaking thattidal volume down to milliliters per second-- if i gave you a concentrationof a drug that was however many milligrams per milliliter,and you were running it at however manymilligrams per minute, you would be ableto break that down into micrograms persecond, correct?

by basic math. you can do the exact same thingwith mechanical ventilation with your minute volume,your tidal volume, and your inspiratory time. so one of the other thingsi've been dabbling with in all of my spare time is withmechanical ventilation, since we are seeing this moreand more and more and more in the transport environment. what else do you thinkwe're seeing more and more

and more of? going back to saying that thatventilator has got the highest probability of killingyour patient, but yet is that piece of equipmenton your ambulance, helicopter, airplanethat you get the least amount of training on. we are seeing more andmore and more and more patients getting killedor significantly injured with mechanical vents.

so over the pastcouple years, i've been dealing with these twogoofballs, medical malpractice lawyers, that have had issueswith transfer teams severely injuring or killing a patient. so the things thati tell them to do is many of the newerventilators these days have some form of data card. subpoena that cardand downloaded it. one of the first casesthat i looked at,

in a 32 minute bedsideto bedside transport time, how many ventchanges do think were made? 28. let's just turn the knob, pressbuttons, and see what happens. do you think if they did 28vent changes in a 32 minutes transfer time, they knewwhat they were doing? then the other thing, the good,the bad, the ugly, and then i don't know if you canread that on the bottom. it says, "are youf'ing kidding me?"

so the other thing besidessubpoenaing that data card if it's available, whoeveris running that vent, or managing that vent, yousubpoena their training records. so there is a classout there that's put on by a couple rtsout of north carolina. they do a four day,4,000 slide two day hands on class on amechanical ventilation. that's the book.

one of our flightparamedics and in mchenry went through this class. loved it, was very confidentdealing with the vent. then he went through thatfour day class, brought this textbook back, and isaid, so, what did you think? he said, if ricardo was smart--our medical director-- he said, he would take the ventilatoroff of all the helicopters before we kill somebody. he goes, we have got nobusiness managing these things.

that's a four day class. this is down in thestate of tennessee. if you're going to be doinginter-facility transports with a intubatedpatient utilizing a mechanical ventilator,this is 16 hours of training. 16 hours of classroom, and thenfour to eight hours of hands on every year. this is from down inflorida, two different air medical programs.

the first one isself-directed learning. you get on there,and the first one is an 11 pagepowerpoint presentation. you watch it, yousign off on it. the other one is six pages. you read about the ventilator,you sign off on it. that makes you competent. this is one that i was supposedto teach ventilator theory and oxygen therapyin 10 minutes.

i had emailed them back,and i said, you know what? i'm going to be able to tellthem how to turn the vent and turn the vent off. in the other eight minutes,i'll tell them some good places to buy clothes so theylook really, really good on the witness stand. i said, dude, 10minutes, i'm going to have to respectfully decline. there's no way i canteach this in 10 minutes.

so we talked about cmv. we talked what assistcontrol pressure, assist control volume. simv volume, simv pressure,non-invasive positive pressure ventilation, pressuressupport, and cpap. that being said, medicineis changing every day. i don't know ifyou can read that, but every one of those,these are all new modes of mechanical ventilationthat came out, probably,

within the past two years. and now when yousit there with-- you said you use an ltv 1200. now when you go out andpick up that patient, and they sit there andthey say, yeah, ok, well, what mode are you on? well, they're onlfppv ventilation. what is that? and again, we are themedical professionals.

we are the critical caretransport professionals. you are expected to takeover this patient's care. and this is where you have tosit there and raise your hand and say, you know want? we don't have 90%of what is on here. however, we've got these modes. one of the nice thingsabout all this crap up here is it is synonymouswith exactly what you already have on your vent.

like the one down here, apressure regulated volume control-- i can't evenfind it on here-- prvc. very common in this area. does the ltv have prvc? we have a [inaudible] valve too. so in all honesty, pressureregulated volume control is nothing more thanassist control volume. it's just a different name. and again, you're going tohave to sit there and ask

these outlyingfacilities, this is what we can offer you, what isthe closest vent setting that's like that? and again, i can't stressthis enough either. get your either medicalcontrol involved or that receiving facility. their intensivist involved. the downfall ofthat is now you've got somebody that's notyour medical control

physician giving yousuggestions or orders. but like i said, never,never, never, burn alone. i'm going to skip that. the masks again. right up there withsafety glasses. when i started ems, wecarried that mask and we carried this mask. 99% of the time, whichmask did we need? that yellow one.

the green one. sometimes even that white one. and as a volunteer program,when it came down to, well, we got extramoney in the kitty, should we buy decentresuscitation equipment, or should we buy chrome wheelcovers for the ambulance? what did we buy? oh, chrome wheel covers. we take these very,very, very dead patients

to the hospital in a reallycool looking ambulance. as far as teachingthis, i'm kind of stuck in between arock and a hard place. i mean, i want to tell you guysabout mechanical ventilation, but it is impossible to teachit in one hour, two hours, four hours, six hours. and then there's the thoughtabout, you know what? maybe if we had an rt from alocal hospital coming to us and teaching us,which, in all honesty,

we've done that in-flight. but we had an icu rt comewho was extremely brilliant. but now we've got somebodyfrom a hospital icu setting trying to teach us how to dothings in a transport setting. how well does that work? and as far as mechanicalventilation goes, in order to actually understandit, you have to sit at that patient'sbedside for hours, if not days to actuallysee what happens.

so it is absolutely impossibleto teach this stuff. and then plus, so muchof it is region specific. do you think there's apissing match between madison and milwaukee asfar as how patients are managed ventilation wise? oh yeah. and then they're goingto be pulmonologists-- and i've seen it. i've seen pulmonologists andcritical care intensivists butt

heads. you know the little colormetric end tidal co2 devices that change from purple to gold? i had one guy almostin a fist fight saying, well, that's not really gold. that's more of a sandalwood. i'm like, what? again, nobody agrees onanything, especially when it comes to mechanicalventilation.

the nice thing is, everythingthat you learned today will be obsolete ina matter of months. so what it's ultimatelygoing to come down to is, you, guys and girls, whenyou go back to your facility or whatever programyou're working with, and they say, we're goingto do vent teaching, you're going to have tospeak up and say either i'm familiar with this, or i'mnot familiar with this. and let them knowthat it's probably not

enough education on it. so, any questions at all? and one of the reasons thatwhen i was talking about all of this legal stuff, whenmark had emailed me and said, are you ok with thisbeing videotaped? reason being isbecause the day will come when somebody doessomething bad with a vent and they subpoenatheir training record. and they say, well, this dudethat with long, red hair taught

me how to use it, and theni get dragged into the mix. i have got a papertrail, decades, years long that i cansit there and say, i've been bitching aboutventilator training for years and years and yearsand years, that it is no way near adequate enough. so, you're going to haveto go back to your training director, your medicaldirector, whoever, and say, what else can we do inorder to truly understand this?

this was takenstraight from the er directly to the operating room. so in the operating room, he hasbeen cleaned up a little bit. as you can see, they didcollectively trach him, which-- how familiaryou guys with trachs? again, this is oneof those things. my first question, if ihad to transport this guy is, where was thattrach performed? in the er versus the or.

reason being is, ifthat trach comes out during transport, whichagain, in the back of my mind, that is coming out,what are the chances of me doing direct laryngoscopyand intubating him from above? probably not so good. so the reason i want to knowis, where was that trig placed? er versus or? if it was in the or, andit was electively trached, or electively placed,there's a darn good chance

it was placed in between thesecond and third or third and fourth tracheal ring. generally that'sfor cosmetic reasons as well as so they can secureit a little bit better. if that trach comesout, and i can't get that or an endotrachealtube back through that stoma, what anatomical landmark isleft relatively untouched? your cricothyroid membrane. that is going tobe your lifeline.

that being said,you're probably going to have to use anendotracheal tube, a cuffed endotracheal tube,and insert it past-- down the trachea, pastthat surgical site. because if it'snot, air is going to take the path ofleast resistance, which is going to beright out that hole or out into thesubcutaneous tissue. so the best thing, just burythat tube as far as you can,

even if it's a right ora mainstem intubation. so that is what helooked like early on. that says three day-- 3d. and then this is whathe looks like today. well, actually not today,but-- because he's had actually more surgeries in between. but get rid of thisexternal fixation device. get rid of thattrach site there. you have your choice ormanaging either the airway

on the left orairway on the right. which one would you want to do? left. take the left, and run. again, long before youguys push sedation, long before youguys push paralytic, you have got to sit there andstudy that patient's face. this is a setup for disaster asfar as airway management goes. i mean, what's basicallyscreaming at you?

there's a couple things. grizzly adams here. he doesn't have much ofa duck dynasty beard, but is that going to[? scrip ?] your seal? possibly. small mouth, large tongue. however, justlooking at his face, you can look at somepeople, and you can know. you've had some type of-- at onetime, you've had a burn injury,

or you've had a skin graft. as far as the elasticityof a skin graft, how stretchy is that? do you think you're going tobe able to adequately open up this guy's mouth fordirect laryngoscopy? nuh-uh. so now what happens if wesedate him, and we paralyze him, and we can't even do bagvalve mask ventilation? now we're screwed.

and again, are we going to beable to even open up his mouth? i don't know how muchthat's going to stretch. again, given the choicebetween these two, i'd be fighting forthat driver's seat. i would want nothing to do witheither one of these airways. but now even more so, iswhere was that trach placed? and as far as supraglotticairways, king's combitubes, lmas, which again, your airwaytoolbox should be bottomless. again, the chances of him evenopening up as mouth in order

to get one of those inmight be slim to none, but. i don't know. like i said, themore and more i do this, the more and more airwaysjust scare me to death, so. wisdom comes from experience,and experience unfortunately comes from mistakes. all i can say is just sitback, and listen, and watch everything you can. in the er, when you guys doyour clinicals, rotations,

and stuff, just be a sponge. and if you guys, ifyou have the ability to go through patient rounds,when the critical care team is going bedside tobedside to bedside, if you can get involved inthat, by all means do so. and then also, if you canadd your two cents worth, do so, becauseagain, you're talking to a bunch ofhospital monkeys that have no idea what you guysdo in the pre-hospital

or in the transport setting. and if you sit thereand tell them that yeah, this is what we do inthe pre-hospital setting, many times they arejust blown away. they have no ideathat-- you guys start ivs outside of a building? it's like, well,yeah, all the time. no matter how much weprepare again, in this field you guys have no ideawhat you're walking into.

this is from a nursinghome out in idaho. and like it says, good thingthey've got all these fire extinguishers. they got one there, they gotone there, they got one there. who would think that a bearis going to come walking in? and again, in your line of work,you have no idea, especially in the transportenvironment, what you're going to go outfor your next call. no clue in the world.

talked about all of this. as far as kids go,again, you either love them or you hate them. i hate them. can't stand them. there's nothingworse than having-- we're talking about apopulation of people that eat their boogers. now they want to getin your helicopter.

they want to try on your helmet. they want to talkon the microphone. they want to pressall the buttons. there's not enoughpurell in the world. and i had one of my coworkerssit there and say, well, how do you deal with kids? i can't stand kids. and he goes mypediatric jump bag should consist of somesimilac in a funnel.

that way i can guarantee theyat least get a last meal. otherwise i have no ideawhat to do for kids. awareness, recognition,man-- we already talked about all this stuff. blah, blah, blah. again 90% of yourassessment is done just looking at that patient. that's not going to play. talk about-- see, this is goingto be a quick presentation.

because you've alreadyseen all of this stuff. but this is one of mybiggest pet peeves. not snot. but we sit there,and this is something that, unfortunately,we overlook. once we have the ability tointubate somebody, or cric them, that's all we want to do. and unfortunately, we forgetabout all of the basic stuff. we forget about suctioning.

we forget about positioning. and many times, we'll beheading out to a facility, and they say, yeah,we're preparing to intubate this child. we get out there, do someaggressive airway management, be it by suctioningor positioning, and all of a suddenthat child doesn't need to be intubated anymore. as far as anatomy again,i don't want to sit there

and-- this is stuffthat you all know, but again, we're talking abouta little bobble head here. and when i was makingthis presentation, i had the pilot looking overmy shoulder going, oh, yeah, i see. you've got the pilot,you've got the flight nurse, and you got the flight medic. and i'm going, uh, actually,dude, you got the flight medic. you got the pilot, andthen you got the nurse

with that yippy little jaw thatjust doesn't shut the f up. as far as the tongue,again, large loss of tone with sleep sedation,cns dysfunction. again, you know all of this. frequent, if not the most commoncause of airway obstruction. as far as pediatricairways, again, extremely high, very anterior. as far as in relationshipto the cervical spine, the infant is extremely highat about, located about c 1.

six months of age, about c 3. a little bit, once theyget older, c 5, c 6. very, very, veryanterior to the point that you might have to actuallyget down and look up in order to visualize thatglottic opening. and again there's just arelationship to the c-spine. the epiglottis-- floppy. there's not much cartilagethere, relatively large in children, and it'somega-shaped, basically

like an upside down horseshoe. kids are just onemassive design flaw. they are built for failure,designed for failure. again, they've got thisbig, old occiput there, so if we lay them downon a flat surface, what happens to their airway? they're like, how wellcan you breathe like that? again, tiny little nares. we talked aboutdecreasing the diameter

of anything increasesthe resistance. big old tongue, high glotticopening, very anterior, very high, slanting vocal cordsin that narrow cricoid ring. narrowest portion, andagain, the upper airway of that pediatricpatient is very similar to that of a funnelwhere it decreases in diameter, versus that of an adult, prettymuch uniform in diameter. narrowest portion ofa pediatric airway-- going to be that ofthe cricoid cartilage.

the adult, it's goingto be the vocal cords. they say the averagesize foreign body that they pull out of anadult, that completely occludes their upper airway is how big? say about the size ofa pack of cigarettes. what's even moreamazing is they say normally alcohol is involved. but where we windup getting burned is with this pediatricairway, is if i'm

doing direct laryngoscopy,that looks absolutely normal. but again, what isthe narrowest portion? so this was from asix-year-old, years ago, that was intubated inthe pre-hospital setting. they watched the tube go throughthe cords, they went to bag, and they just couldnot squeeze that bag. they extubated the kid. here the entire distal endof that endotracheal tube is occluded with bubble gum.

so this kid's sittingthere, chewing gum, looks out the window, sees atruck coming, and goes, [gasp]. aspirates the gumpast the vocal cords, gets hung up at thecricoid cartilage. again, direct laryngoscopy,that upper airway looks normal. so i'm going to goahead and just-- so one of my best friends isa pediatric anesthesiologist. anytime her number shows up onmy cell phone, it's just like, cool, what am i going to get?

so she calls me, andshe's like, where are you? and i'm like, in my office. she's like, stay there. i'm coming to you right now. so she's doingthis case that she goes to intubate thispatient, and she's like wait. wait a second. something is wrong. and so as far asairway management,

again, with intubating somebody,again, much like the vent, you guys are doinga procedure that has got the abilityto kill a patient. you need to knowthat upper airway like the back of your hand. i cannot stress enough. so go ahead andlook at this video. she goes to intubatethe-- just to take a look, and something just is not right.

let me know if you see somethingthat doesn't look right. so she's like, ok,halt everything. and you stop. they call an ent. they come down and look. and they say, well, you'vegot a big subglottic cyst. well, we can either push itin, retrieve it some other day, or we can just get thepediatric leatherman and we can just goahead and tear it off.

so here comes thepediatric leatherman. so it's acting likebasically a big old ball valve during inhalationand exhalation. so they abort the operation. they go down, cauterize it,and they redo the operation several days later. again, looking atthat airway, there is your perfectomega-shaped epiglottis. and again, generally, again withan extremely high very anterior

airway in little munchkinnewborns, infants, they always say thatstraight blades work better. and again, i reallycouldn't care less which blade you use, but witha straight blade, a lot of time in a newborn or aninfant, i'll actually use it similar to whatthey're doing here, and actually put it in thevallecula, like you would a curved blade or a mac andthat just works better for me as well as whoever'sdoing this intubation.

well, leanne was. it was just a big old cyst. so as far as losethem, again if i'm going to be monkeying aroundwith somebody's airway, have a plan. the mnemonic thati use is loosemm, which we'll talkabout here real quick. where again, every intubation'sgoing to be a failed attempt. what's your backup plan?

where is it? when we go on toa scene together, an intubation together,everything gets lined up, so we can just goright down the road. but the loosemmmnemonic, this is something that iuse for everybody, be it a crash intubationor a conscious sedation, laryngoscope, oxygen,oral airway, suction, endotracheal tube,combitube, king, lma,

bag and mask, medication. this is all of thestuff that i want to have readily availablewithin arm's reach if i'm going to bemanaging somebody's airway. given the choice outof this entire list to manage somebody'sairway, what would you want? so laryngoscope andthe endotracheal tube, you guys have seenbotched intubations. you've been involvedin botched intubations.

if you've nevermissed an intubation, you haven't doneenough intubation. oxygen, even overhere in waukesha, you guys have 21%room error, correct? hopefully. so if you don't havesupplemental oxygen, just start bagging them. oral airway, again, do a chinthrust, head thrust, whatever. suction-- role that patient.

endotracheal tube there's thatpopulation of patient that you just cannot intubate. kings, combitubes,lmas-- keep in mind they have their limitations. be it a superglotticrescue airway, if i've got somebody thatjust drank a gallon of drano, or got pulled outof a house fire with a significantinhalation injury, is that going to do me any good?

that bag and mask,that's the one that you don't haveto be good at that. you have to perfect it. like i said, that'sgoing to save your butt time and time andtime and time again. if you're dealingwith little munchkins, mcgill forceps, make surethey are readily available, because when you're doingdirect laryngoscopy, and you see that, oh, hey,there's a lego down there,

is it going to do any goodknowing that your mcgill forceps are in theoutside compartment? make sure you've gotthem right there. oxygen again, cannulaadult, pediatric, infant. if you can ever put aninfant cannula on an infant by yourself, dothey need a cannula? if we ever start supplementaloxygen in the ic, we normally call securityand say, yeah, send us six of your biggestgoons with a staple gun

to hold this thing on,hold this kid down. but if they just freely letyou put a cannula on them, something is wrong. is there such a thingas too much oxygen? and don't go intothis whole return a spontaneous circulationafter they've been quoted, but do we ever reallywithhold oxygen from anybody? again, the device is what youguys have used a million times. make darn sure youknow the difference

between a non-rebreatherand a partial rebreather. they look absolutely identical. however the fio2difference is 30 to 40%. there's a hospital thatwe fly into quite often to take out patients thatare actively infarcting. their entire hospital has gotnothing but partial rebreathers in there. so the first thing we dois, oh, we're going there. get a non-rebreather ready.

again oral airways,nasal pharyngeal airways, i only use theseabout 5% of the time. the reason being isthe less amount of crap you stick in somebody'sairway, the better. and again, in revcs, and youget these snot-nosed little critters that canbarely breathe, and they've got one, notone, but possibly two of these in place. is that going tohelp them breathe?

majority of the time weend up pulling them out and repositioning them. suction-- make sure you've gotthe biggest, baddest suction on readily available. this was just east ofmadison on the interstate that this guy decides to passeverybody in the construction zone, winds up runninginto that big yellow thing, kills the two front people. the guy in the backis unresponsive,

just a vomit volcano. we suction an entire 500 cccanister of vomit out of him with a little portablesuction device. and the whole time, i'mtaking the yankauer, tapping it on the groundto clear it out, go back into suction, tapit out, suction. medflight gets there. they intubate him. they take him away.

and when i'mcleaning up, i notice that the tip of theyankauer is gone. and so i'm following thisguy's progress down in tlc, the trauma center at uw. and throughouthis hospital stay, he had this right-lower lobalpacification on a chest x-ray that just would not go away. so i pull the attendingoutside, and i'm like, hey, man, somebodysaid out at the scene

they lost the tip ofthe yankauer, you know? and this whole pacification,well, you know. so they call pulmonary,and they bronch him. and they pull outa big old tooth, big old molar out of hisright, mainstem bronchus. he gets extubated. he gets discharged. six months later,calls mark hanson, who was the chief flight nurseof medflight at the time.

he's like, hey, man. i just coughed upthis chunk of plastic. is that normal after i'vebeen in the hospital? yeah, yes it is. you're going to bepooping out rubber gloves here too pretty soon. the only thing moresurprising in this whole talk is there's not an illinoislicense plate on that car. endotracheal tubes,i always have

the size i think i need,the next size larger, and the next size smallerwith the exception of if we're going to likean inhalation injury. then i'll have probably thenext two sizes smaller readily available. what do you notice aboutthat pediatric one? it's cuffed. oh my gosh. the cuffed endotracheal tubein the pediatric population

is the product of the devil. right? i've only intubatedthree kids in my career with uncuffed tubes,because cuffed ones weren't right there. we don't intubate healthy kids. we intubate the ones that justget pulled out of the lake, out of the swimming pool, outfrom underneath grandma's car tire, out from the house fire.

what are their lungsgoing to be like? are they going to getbetter any time soon? with mechanicalventilation air is going to take the path of leastresistance, which is where? right up and away. and so again, they have gotcuffed endotracheal tube all the way downto a size 2.5, that have been out there for decades. and as far as kidsgo, if you don't

deal with kidsthat often, if i'm going to be intubatinga kid, you know what? this whole age plus 16 dividedby 4, blah, blah, blah, blah, don't give me a math problem. couple years agowe did a flight up to racine for a three-year-oldand a seven-year-old. both of them burned headto toe from a house fire. 3:00 in the morning, weget toned out for this. and insurancesaid, ok, stu, what

size tube do you wantfor a three-year-old? i just crawled out of bed. she might as wellhave said, stu, a train leaves phoenix headingeast at 80 miles-- meanwhile, a bus leaves. there's multiple differentlittle cheat sheets out there. this is the one that i carry. gets me through the firstfive minutes of resuscitation till i can get the eyeboogers out of my eyes,

wake up a little bit. you guys familiar with this one? like it? love it? hate it? broselow tape. so there are some thingsi like about that. there are some thingsi hate about it. and doing a lot ofpediatric lectures,

i'm pretty vocal about it, andour medical director told me. he said, you know, withlecturing and stuff, just be careful. he said it's like hittingthat fire button on a torpedo. you have no idea wherethat's going to wind up. so i have, in all honesty,i've tossed the broselow tape under the busnumerous times. this is an email i get. the man, the myth, the legend.

and in all honesty,he is like one of the coolest guys in theworld that i've ever talked to. so somehow he heardabout yeah, so what exactly were yousaying about my tape? but being aweight-based tape, this is what we have to takeinto consideration. obesity is runningrampant nationwide. not only in theadult population, but in the pediatric population.

with baby hueyhere, do you think that epi's going to hithim a little bit different, compared to somebody that'sheight and weight proportional? as far as bags go,infant, pediatric, adult? there have been timeswe have gone out, and they have literallywithheld resuscitation efforts, because the appropriatesize bag wasn't there. meanwhile, you've got thissize bag hanging on the wall. is there any reasonin the world you

can't use that on thetiniest little infant, newborn, preemie? just tiny, tiny,tiny little puffs. yeah, not good. and again, as far asthe whole intubation. intubate, intubate,intubate, intubate, intubate. again, go back toyour basic maneuvers. again with thatbig old ox-- there is a classicalpicture as far as what

happens when you putthem on a flat surface. what you want to do is get thatexternal auditory canal in line with the shoulder blades. one of the best ways you can doit with a kid, put a tall roll or rolled up washclothunderneath the shoulder blades to take up that void. and then again, basic maneuvers,positioning, suctioning, bag, valve, mask. again it should bea two-person job.

in the hospital, being aspoiled rotten hospital brat, we press a little bluebutton on the wall. how many people come running? that's when half thestaff calls in sick. now in your environmentwhere you've got two people in the back of anambulance, one person thumping on the chest, youdon't have this luxury. macs verses millers,curved versus straight, if you want to bea purist, there's

about 300 different types oflaryngoscope blades out there. basically any timean anesthesiologist makes any alteration to ablade, what they do with it? put their name on it. so curved, straight,blah, blah, blah. again among five differentsize straight blades from a 0 to a 4. and unless you guys get calledto the milwaukee zoo every now and then to helpintubate a giraffe,

that's somewhat overkill. and again you're going tobe going down, picking up the epiglottis itself, liftingit up and out of the way. curved, there's-- upuntil several weeks ago, i thought there wasonly four sizes of macs. there's actuallya mac 5 out there. which same thing-- really,really, really big blade. and again, going to begoing down in the vallecula, lifting up and away.

that being said, if itake a mac and pick up the vallecula,who's going to know? or if i take a miller andgo in the vallecula, who's going to know? only me. and when i first startedintubating, every other patient i just went curved, straight,curved, straight, curved, straight just to get proficientat both types of blades, because the day willcome, i guarantee it,

when your favorite mac 3 isall filled with blood or vomit, and somebody hands you a miller. little munchkins, if youcan beg, borrow, steal, there is a crossblade out there. it's a combination ofa mac and a miller. it's called a robertshaw. made by? you guys are sharp as the edgeof town on your class mark. as far as intubation, again, asfar as maintaining proficiency

on it, we sit there, and wespend hours and hours and hours and hours on fredthe head learning i've never intubatedanybody that's got that nice plastic airway. a couple years ago iwas doing this lecture, and coincidentally the daybefore i gave the lecture, michael jackson died. and i said i've never intubatedsomebody with a plastic airway. and i'm thinkingthere's probably

some medic out in californiathat could say, well, i did. go to google, and up on the topit says web, it says images, it says maps, shopping, video. type in vocal cords,and hit enter. it is like rt porn. you're going to see 200, 300pictures of upper airways taken by video laryngoscopy,bronchoscopy. i will sit there forhours just looking at real airway picturesinstead of a piece of plastic.

again, you need to know whatnormal anatomy looks like before you go afterabnormal stuff. here again, there'syour vocal cords. there's your cricoidcartilage and your subsequent tracheal rings. again here's thatpediatric airway, that funnel-shaped airway. here's an infant with, again,that classic omega-shaped epiglottis.

so those were allnormal airways. this is a patient that justhad what appears to be somewhat of a significantinhalation injury. and again, in yourline of work, you've got to be thinking aboutinto the future, what is this patient's airways goingto be like five minutes, 10 minutes, 15, 20, 25minutes from now? if this is an inhalationinjury, what's going to happen? it's going to swell.

and we were always taught,less than eight, intubate. why is it eight,as far as our gcs? more important than that. that's the only numberthat rhymes with intubate. these are the patientsthat are going to have a glasgowof 12, 13, 14, 15 that are going tobe talking to you. and you say, you know what? to the closest facilityit's 20 minutes.

is this patient's airwaygoing to last 20 minutes? but do i want to be that medicin the back of the ambulance that has somebody that's gettingmore and more stridulous. and they wind uplosing their airway? these are the patients thati would much rather control their airway sooner than later. because if their airwaycompletely occludes, again, is yoursupraglottic airway going to help you at all?

that's the upper glottis. you got probablyabout a 20, 25% field of view of that glottic opening. 20 minutes from now,that's going to be gone. eschmann stylet or gum rubberbougie-- you guys using these? familiar with them? the original flight nurseis blake, from waukesha. he called me yearsago, and he goes, i had the worst, one of theworst airways of my career.

i almost thought i'dhave to use a bougie. and i went, really? i said, how many timeshave you ever used it? and he goes, never. and i said, ok, so let'sjust back up a little bit. so you got the worstairway of your career, and you're going to usea piece of equipment that you've never used before? i said, from now on, for allof your elective or emergent

intubations, i would use thebougie on absolutely everybody. just make it secondhand. that's so when you do havethat nasty intubation, it's a tool that you'veused multiple times before versus grabbing somepiece of equipment that you've never used before. and the bougie, keep in mind,it does have its hangups. where again, going backto somebody like this, we might be able topass the bougie fine.

however, we're passinga larger diameter tube through that glottic opening. what are the chance ofthat tube getting hung up? there's definitely a chance. and if it does happen,remember the rule of thumb is you want to do acounter-clockwise rotation with the tube so itdoesn't get hung up on the arytenoid cartilage. there is a bettermouse trap out there.

it's called the radlyn stylet. it's a cuffed stylet. where again it'sa tapered stylet, so it's like a hot knifegoing through butter when you use it forsomebody like that. so that is the epiglottis. this is epiglottitits. that being said, what's thattiny, tiny, tiny little dot in the middle?

so that is the glottic opening. so again, this is thefight for the dry receipt. an these are the patientsthat generally bypass the er and go directly tothe operating room. this is epiglottititis. now it's probablynot going to play. on a smoke inhalation where youcan visibly see some anatomy. however, it is dark dueto the soot on there. but again you need to know whatthat upper airway looks like,

so you have some ideaof what to go for. and as far as confirmingtube placement, we always talk about endtidal, end tidal, end tidal. the little color metric ones,the ones that change color, they are, by far,the most accurate. they're probably the mostcommonly used ones, also. but all that being said,they're used the most, because they are the cheapest. and as far as if youread all the studies,

where were all of thestudies on those done? in the or. where these patients havebeen npo since midnight. now when you guyspick up somebody off the side of the roadon one of the nights when the packers win,what's in their belly? beer. or you go to the local skatepark with little munchkin, non-helmeted, justdrank a six of red bull

and washed it downwith mountain dew. now you inadvertentlyintubate the esophagus, and you get a rush of gasback, that thing changes color. what makes carbonatedbeverages carbonated? so now that the thing changescolor, is it lying to you? is co2 present? but the downfall isas far as technology, you can either embrace it,or you can run from it. the downfall is somepeople embrace it too much.

and instead of going back toour basic patient assessment, they're sitting there looking atthis stupid little colorimetric device. they say, well, thatthing changed color. my tube is good. instead of doinga full assessment, negative epigastric sounds,high bilateral breath sounds, and then capnography,capnography waveform. and by far one of thebest things you can do

is actually just go back downand do direct laryngoscopy and visualize that tube goingthrough the vocal cords. thank you. yes. eventually, it'llbe to the point where we're not even goingto have to touch patients because we've got them on theautomatic blood pressure cuff and we've gotvideo laryngoscopy. and all this other stuff.

and it's just unbelievable. same thing with the automaticblood pressure cuffs. if you can't even take a bloodpressure manually-- again, just the basics. kids, in a nutshell, if it'snot chained to the ground, if it's not bolted to thefloor, what they do with it? so any acute onset ofrespiratory distress in a pediatric patient youcan pretty much assume it's a foreign body untilproven otherwise.

so again, if you're goingto be monkeying around with their airways,make darn sure you've got the mcgill'sreadily available. probably the most come thingwe pull out of kids is what? they're just ambulatorylittle piggy banks. a monopoly toy sittingright above the carina. again, not supposed to be there. acute onset of striata thatgoes away pretty much as soon as it came on.

getting a little bit more ofa history what they find out is well, he was playingwith a wood screw. which initially was caughtup here in his upper airway creating [inaudible]. and then he inhaled. now it's all the way down herein his right mainstem bronchus. in the kids are stupidfile, this a 13-year-old that walked into aner down in denver. he couldn't speak.

he had brown sludgecoming out of his mouth. and his friend said,well, here's the deal. we were fishing and i get himhe couldn't swallow that eight inch perch that he just caught. so fish bones are going toshow up just like human bones. so here you'vegot the fish head. here you got the tailand the posterior oral [? fernix. ?] well, thedocs like, oh, no worries. that's why they make[? mcgill ?] forceps.

well, i'm not[? babe winkleman ?] the fishermen or anything, butperch have these spiky dorsal-- so yeah, he grabs the tailand gives it a big old yank. and it embeds the--what are they called? so they wind uptaking him to the or. they [? crack ?] the kidto give him an airway. they cut the dorsal fin offthe fish and then pull it. what about somebody that'sin full [? c-spine ?] immobilization.

how easy is it to dodirect [? laryngoscopy ?] with somebody like this? it can be done,but generally it's a two or a three person job. pop that collar. pop those [? sid ?] blocks. have somebody maintain manual[? c-spine ?] stabilization from the front. this guy up here is actuallydoing [? crikoid ?] pressure

with his thumb for me. get that tube in. confirm tube placement. secure that tub. and then put the c collar backon plus the [? sid ?] blocks. again, never burn alone, blahblah blah blah blah blah. let's see, as long as i stillgot you for a couple minutes, someone made a commentabout the trach. we're going to chat justa little bit about them

just because as far asairways, as far as ventilators and stuff, there's a trend here. they make me nervous,extremely nervous. and the more prepared you canbe about some of this stuff, the better. so as far as the trach, i toldyou that's in there everyday. so when i went throughparamedic school, we sat there and we learned how tointubate people nasally, orally, digitally, allof this good stuff.

and i said to myinstructor, well, what about thepatient with a trach? because at that time,i was working as an rt and we were sending peopleout not only adults, but kids and adults, out to the communityevery week with trachs. and this is whatshe had said, you have a betterchance of picking up elvis than a sameperson with a trach. so there i was, brandnew paramedic, just off

orientation. we get toned out fora motorcycle accident. what was differentwith this patient? yeah, that's fake. so as far as kids, again,fighting for the driver's seat. rectal bleeds, childbirth,anything with a trach. you want to see abunch of grown adults fight for the driver'sseat of the ambulance. if you get toned out for anyof that stuff, i guarantee you,

the last thing i want to do isdeal with any of that stuff. and this used to be my mo. i used to sit there and ifwe had any of that stuff get toned out, i wouldbe the first person in that driver's seat. and how well did that workwhen i started flying? yeah, it went over likea fart in a phone booth. it's like, yeah, that'snot going to happen. and when i started,they said, well,

you're the medic from wisconsin. what do you guys doup there trach cows? i was like, actually ifyou do have a trachea, you can trach a cow. i talked about this again. preparing for the unexpected,talked about that. talked about that. see, very, veryshort lecture here. so as far as whatwe're going to do,

we're going to talk about thedifferent types of trach tubes, identify trach emergencies,pre-hospital management as well as transport management, andthen just basic suctioning. again, these thingshave been out there for decades anddecades and decades. anyway, we talked aboutupper and lower airway, heat, humidify, filter,blah, blah, blah. i talked about that. there's that littleclassic towel roll.

ok, let's talk trachs. what's the difference betweenthe parent of a high tech kiddo and a terrorist? you can negotiatewith a terrorist. how many people have dealt witha parent a special needs child? yeah, so when you come inthere and say, this the way we're going to do it. what does mom or dad say? no, you're not.

and there you go. so we have a frequent flyerdown in the mchenry area a little girl that'sgot what's called a spinal muscular atrophy. her mom will carry her intothe triage desk at the hospital and say, i need your helicopterto take my daughter down to children'smemorial in chicago. she will sit there and say,sharon, you're the nurse. you're going to sit there.

your jobs are going tobe this, this, and this. stu, you're the medic. your job's going to bethis, this, and this. i'm going to sit right here. my job is to bail you guys outwhen you can't figure it out. and the pilots sit thereand say, oh my gosh. i thought she was goingto tell me and you. you're the pilot. you're going to talk too'hare tower on 127.9.

but this lady dealswith that child 24/7. i see this child onceevery three years. do i know more than mom? so a couple of years ago i did alecture for an emse conference. and i took a couple of kidsfrom the children's hospital and invited their parents aswell as their home health care nurse. and we talked aboutchildren with special needs. and on one side of the table wehad the pre-hospital providers.

and on the otherside of the table we had, again,the family members plus the home healthcare provider. it was just unbelievable. because i said,ok, connor here-- who connor has got spinalmuscular atrophy type two-- i said, he coughs his trach out. these parents, thishome health care nurse who has put that trach back inemergently dozens and dozens

and dozens and dozens oftime, if they can't get it in, what are you guys going to do? and they're like, well,we're going to call 911. ok, what are they going to do? well, they'll probably come. they'll probably start an iv. it'll probably sedatehim and paralyze him. and they'll probablyorally intubate him. and these guys areso far west, they're

almost to the mississippi. and so they're out inliterally more or less pumpkin hollow, where again, wisconsinbeing 85% basic emts. now when i tell mom and dad thatthey're not starting any ivs. they're not giving any drugs. they're going to be doingbasic area managements, what you think they said? do you think they freaked out? and the thing is,they weren't freaked

out more than the peopleover on this side who are the firstresponder emt basics. they're like, wait a second. this ticking time bombis in our community and we know nothingabout him or her. so as far as tracheostomy,temporary opening into the tracheasurgically placed below the level ofthe cricoid ring. and we talked about thatdue to securing it better

as well as cosmetic purposes. stoma, again,opening into the neck created for thattracheostomy itself. and again, due tocosmetic issues there are so manythings out there where-- if you'retalking to somebody that's got a stoma, what arethe chances of you looking down at that stoma and staring at it? these days, they'vegot all sorts of things

to cover those things up with. so you might haveto go searching if you can't get an adequateseal with your bag valve mask because there's some pieceof fabric going like this underneath their chin,chances are they have a trach. so why a trach? vocal cord paralysis, inabilityto handle secretions, head and neck differences,spinal cord injuries, unable to maintaina functional airway,

laryngeal cancer, as wellas long-term mechanical and there's that spinalmuscular atrophy. and again, kids, adults,you name it, teenagers, little munchkins,all the way down to these tiny, tiny,tiny, tiny little kids. and again, it might not bean interfacility transport. it might be you guys gettingcalled out to a 911 call where, again, these days thereare more and more specialty transport teams out there.

there might be thatpossibility of one of those specialtytransport teams transporting a child or anadult with a trach. and they wind up upsidedown in the ditch. and now you've gotto take care of them as well as that patient. that's what happenedout here in arkansas. ok, frequent speedbumps with a trach. again, when you bypassthat upper airway, again,

in order to talk air has togo through my vocal cords. if i've got a trach, andi bypass the vocal cords, how do we talk to these people? and there's multipledifferent things out there, the little typewriters, you'veseen the little-- i'll probably go to hell forsaying this, but they call them the cancer kazoos,the things they talk with that vibrates their vocalcords-- as well as a couple different speaking valvesthat are out there.

in a case like this,basically the patient will inhale throughthat and then when they want to talk theywill put their finger up. they will cover up that opening. and then the air gets forced togo up through the vocal cords. and then they cango ahead and speak. they're not going to be ableto sing songs or anything, but they can speak to you inone, two word sentences or so. as well as there are also whatare called fenestrated trachs

out there that havegot a hole on the back. where again, theycan either plug that and again the air is forced togo up through the vocal cords and then out through thenose and mouth and they can go ahead and speak. speaking valves, theyattach to the trach itself simply by friction. it's a little one wayvalve that when they inhale it opens up thatvalve very similar

to-- like a little valveon a non-rebreather. and then when they exhale,it forces that valve closed. and forces the air to go up,again, through the vocal cords, so they can speak. the thing we needto keep in mind is with that speaking valveon there, what is it blocking? it's blocking our ability to bagthat patient in an emergency. so keep in mind, those areheld on there just by friction. you're going to haveto remove those.

and then you can go right backto your manual resuscitator same thing, that's goingto have to come off. so this a speakingvalve, plus he's got supplementaloxygen attached to it. other things is,again, secretions. we talked about thisa little bit earlier. we need to keep those secretionsheated and humidified. if not, they wind upturning into rocks. so generally thesepatients that have a trach,

since their upperairway is bypassed, they're on some form ofartificial heated humidity. the downfall is thislittle kid, do you think he wants to be stuck ona heated humidifier all day? no, he wants to beoutside playing around. so they take themselves off. they become dehydrated. the secretions become rock hard. there are also what arecalled artificial noses,

which they're about thediameter of a quarter. and inside there's thisalmost like expensive crepe paper that when thepatient inhales, it winds up going throughthat artificial nose. but when that patient exhales--again, when we exhale, we exhale humidity. it saturates thatpaper that's in there. and then when they inhalefor the next breath, it re-humidifies.

so it's called an artificialnose, or a heat moisture exchanger. the downfall with theseis after about 45 minutes, an hour of usage theybecome extremely soggy. and when they become soggyand saturated with secretions, what happens to the resistance? so again, theyneed to be changed. and again, just likethose speaking valves, in an emergency situationthat gets in my way

when i have to bag that patient. same thing, those are heldon there just by friction. just go ahead androtate them off. we talked about that. different types of trachs,this a whole day long lecture. up on the top, we've got someof the larger diameter trachs. down on the bottom, we'vegot the smaller trachs. one of the big differencesbetween the larger diameter trachs is generallythey have got

what is called an innercannula, which we're going to talk about,which is basically a tube within the tube. downfall of some ofthese smaller trachs, they are such a smalldiameter to begin with, if we wind up putting yetanother tube inside there, the diameter is so incrediblysmall, the resistance is so incredibly high. with the prepackagedtrach tubes you're

going to wind up gettingthe trach itself. again, these are what arecalled the inner cannula. you're going to get what iscalled the obturator, which is something that you definitelyneed to have with you. and then you also get what'scalled twill tape, which is just a darnexpensive shoelace. as far as the single cannulaswith the obturator-- and again, this is such asmall diameter tube there's no way to put yetan additional inner cannula

and again, all the way downto tiny little neonatal trachs that might have aninternal diameter of two millimeters. that being said, thesmallest amount of secretions can partially, if not fully,occlude that trach tube. which in these cases,secretions can be a problem. if you have dried out secretionsthat completely occlude that trach tube, you haveto either emergently suction or take that trach tube out.

whereas, the largerdiameter trachs that have got that innercannula, if i wind up completely occluding thatinner cannula with secretions, i can pop out thatinner cannula. my patient now can at leastspontaneously breathe. the downfall isthat inner cannula, that is going tobe your lifeline to connect to thatmanual resuscitator. that needs to go back in.

and these are thoseinner cannulas that i just spoke about. but like i said,with that taken out, you can't hook a manualresuscitator up to it. and these are held on acouple different ways. some of them havegot little claws that you have to pinchtogether in order to remove it. other ones you've got to rotateit probably about a 90 degree counter clockwise turnand they do snap in place.

some of the informationthat i would love to have beingon the receiving end if it's a trach problem, andyou don't have a backup trach, is up on the wings of thetrach-- this is a shiley. it's an uncuffed. it's a 4.5 pediatric. that's all nice to know. the need to know iswhat's over here. this is a 4.5 millimeterinternal diameter

and it's a 6.5 millimeteroutside diameter of the tube, as well as also if you canreally, really help us out, also give us the length. reason being is if i don'thave a 4.5 shiley in stock, i'm going to get thenext closest thing. this one, it's ashiley 4.0 cuffed one, 4.0 inner diameter, 5.9millimeter external diameter. and again, so you've got theinternal the outside diameter, and then you've got the length.

and if we don't have thatparticular shiley in stock, we're going to give youthe next closest thing. so assessment andintervention is no different than anendotracheal tube. if you've got aproblem, we always use the dope nmemonic, dislodge,obstructed, pneumothorax, or is it an equipment problem? again, dislodged get rightback to that patient's airway. and again, with a stomathere's two different patient

populations. there's those stomasout there that, as soon as that trach comes out,those things close pretty much immediately. then there's theones like this kid here that that stoma comesout, he doesn't even know it. so as far as why theybecome dislodged again. positioning, when thetrach ties are too loose. kids want to be kids.

they untie it. weight changes, again, ifyou've got a heavy event circuit hanging off there. our cuffed trach problems,much like an endotracheal tube, never, never, never,assume that that cuff has anything to do withsecuring that tube, or anchoring that tube in place. the only thing the cuff is therefor is to create that seal. the purpose of a cuff isnot to anchor or secure

a tube in place. so again, the questions i alwaysask is why do they have it? first off, what happensif it comes out? again, what happenswith that stoma? and if you've got that homehealth care professional, that mom or dad thatsits there and says, that stoma shuts immediately. that's good to know. and then, why do they have it?

and is it needed? if it comes out,is that stoma going to close immediately or do ihave to put a tube back in, or can i take my time? as far as insertinga trach tube, again, positioningis everything. and everybody thathas a trach also has some form of what's called ago bag, or ready to go trach set that everythingis ready to go.

and we'll show youthat here in a second. suction equipment, if youdo have a lot of secretions. bag and mask. and there's that go bag wherepretty much everything that you will ever need is in that bag. and like i said, ifthey have a trach, they should have that with them. multiple different sizetrachs, bag and mask, where again the mask-- and notso much for doing bag valve

mask ventilation over the mouthand nose, but to do bag valve mask ventilation over the stoma. unless you havesome strange fetish to do mouth tostoma ventilation. and then there'sthat classic towel roll that we'realways going to have. and then we want to lubricatewith some form of water soluble lube, be itsurg lube or ky jelly. and if you don't haveit, just go ahead,

saline water is fine as well. should be a two person job. again, use that towel roll. one person to go ahead andspread apart that stoma. lift up the chin. and there they've gotthat obturator in place. and we sit there andwe practice as well as part of thosepatients going home, the caregivers get hoursand hours and hours

and hours of changing atrach on somebody like this, on these dolls. the first person you have toemergently change a trach on, are they going tolook like this? no, it's going to this guy here. or worse off,somebody like this. where somewhere underneaththat 13th double chin, there's a stoma. and that trachneeds to go in it.

again, if you meetresistance go ahead and stop. you might have toreposition, re-lubricate. this is the daughter one ofour paramedic instructors down in illinois, whohad guillain-barre. she was electively trached. and i was talking her. so she was trached andmechanically ventilated for a prolonged period of time. and i asked her, what isit like to be trached?

tell me. if i'm going to beteaching this stuff, i don't want tobe trached, but i want to be able to discuss it. and she said one of the worstthings was trach changes. and she said theyhad some people that just put so muchpressure down on her she thought that theywere breaking her neck. so these are images takenfrom bronchoscopy of a trach.

and this is apercutaneous trach that's being placed at the bedside. but there's those cartilagerings, the c-shaped cartilage rings in the airway. here they're putting it in. and here you can see whathappens with pressure. and she said that's what it feltlike every time is that they were just completelyoccluding airway by putting downso much pressure.

if you're putting down so muchpressure, there's a problem. you need to stop. as far as thatobturator coming out. again, we're putting somethingin somebody's airway. anytime anything foreigngoes in somebody's airway, what's the body'sfirst thing to do? it coughs. so you want to make darnsure that somebody's holding that trach downbecause otherwise you're

going to have to go all the wayto the other side of the room, pick up that trachoff the floor, bring it back in, wipe itoff, and then put it back in. so that obturator, again,make sure somebody's holding the trach. you're going touse the obturator just for inserting the trach. and then go ahead and remove it. and then there they'reinserting in the inner cannula.

and keep in mind you're going toneed that inner cannula to hook up to the bag orthe vent itself. and again, much like placingan endotracheal tube, we're going to confirm breathsounds as well as capnography, much like an endotrachealtube after we go ahead and place that trach back in. if it's cuffed, go ahead,much like an endotracheal. put in just enough air tocreate a seal, securing it, use a weill tapeand tie it in place.

and again, as far as fashiongoes, kids these days here-- you've got themr. t starter set. and then you've got theenvironmentally correct hemp biodegradable ones. if you don't havetwill tape or whatever, just go ahead and steala patient's shoestring and tie it in place. that will work just as well. there are also commerciallyavailable devices,

much like the endotracheal tubeholders that are just velcro. fairly simple. if by chance you can'tget that trach back in and you have to go aheadand secure an airway again, you can do bag valvemask ventilation from above covering up thestoma with a piece of gauze for an adult, samething with a kiddo. and again, if we'vegot the trach problems we're going to getthere and we're

going to the exact samething that the parents did. we're going attempt ventilating. we're going to attemptventilating with a mask. we're going toattempt suctioning. we're going to attempt bag valvemask ventilation from above. however, if you don'thave that stoma occluded, air is going to take thepath of least resistance, which is right outthrough the stoma. and then one thingthat's really going

to throw a wrenchin the works is there's also a population ofpatients out there that have what are called complete trachs,or complete laryngectomies. these are patients thatare chronic aspirators. where everything in theirmouth, be it secretions, whatever, goes directlyinto the lungs. they've spent countlessdays in the hospital with repeat pneumoniaswhere after a while they sit there andsay, you know what,

we're going to closeoff the bridge. we're going to close off theupper airway to the lower airway. and they literally sewthe glottic opening shut. that being said, if iattempted to do this, where would my air go? right to the belly. again, this is when you're inthe dire straits mode where you can take a suctioncatheter very similar to that

of a bougie, stickit through the trach, stick the suctioncatheter through and then thread the trach over the top. the downfall is ifthey're to this point here, that stoma site isgoing to be so traumatized, so edematous already, that thechance of this passing over is probably goingto be slim to none. this probably isn'tgoing to play, but if all else failshave the child do it.

decannulation, meaningthat it comes out. again, basic life support first. go ahead bag. and then again, youcan always go ahead with an endotracheal tube. and then last resort,orally intubate. however, again, if they'vegot that complete laryngectomy you're going to go downand do direct laryngoscopy, you're going to comeacross a tissue wall.

as far as insertingthe endotracheal tube, generally, wedon't cut them off. some people will cutthem off to decrease the amount of dead space. if you just emergentlyrecannulated somebody with an endotrachealtube, are we really going to worry aboutthe small amount of dead space? and again, somebody needsto be assigned to that tube, so it doesn't come out again.

they're not going to helppush the stretcher or life or anything. they're going tobe, like i said, strictly dedicated to that. and again, no differentthan placing an endotracheal tube in somebodywith the exception of how deep you stick it. don't stick it three timesthe diameter to the stoma because where areyou going to wind up?

probably down in the main stem. again, shouldn'tbe any resistance. equal chest rise andfall, equal breath sounds. improved vital signs,capnography, as well as colometric, if needed,and pulse oximetry. we're not going togo through that. as far as suctioning,again, don't be burying thatsuction catheter. generally the ruleof thumb is only

suction to the depthof the trach itself. so again, probably about70 millimeters or so. and many the suction cathetershave got centimeter markings on there, so about sevenor eight centimeters. obstruction, again, we talkedabout this a little bit earlier. generally, if you have a trulyobstructed tube, first thing you can do withthat trach that's got that inner cannula justgo ahead and replace that.

if you've got a child that hasgot a obstructed single cannula trach tube, that's going haveto be changed immediately. then again, a goodrule of thumb as far as how deep to suctionthat patient you can also use theobturator as a guide as far as how deep to insertthat suction catheter. and again, you guysknow how to suction. i'm not going to sit thereand beat a dead horse to death here.

if you do have toremove a trach, again, this is somethingthat should be last resort, especially in thepre-hospital section, even in the transport setting. this is the absolutelast thing in the world i like doing, even ina hospital where i've got ent surgeons rightthere and ready to go. again, a several person job. get that towel roll in there.

have somebody get thatchin out of the way. lubricate. and here with a cuffed one,much like an endotracheal they're just dropping thecuff and then removing it. cutting the twill tapeand putting it back in. and there you can seethe obturator in place. and there they'resuctioning and attempting-- i should say the secondtype of obstruction is where you've definitelygot a blockage there.

and there what they'redoing it just squirting a couple drops of normalsaline down there to see if they can break that up,loosen it up a little bit. and again, if thatdoesn't work, then you're probably going tohave to emergently change that tube itself. ok, all basic suctioningstuff, which you guys know. again, pneumothorax, that'sprobably not going to play. so i'm not even goingto bother with it.

same thing there. you know that. emergency treatmentfor a pneumothorax, what you're going to do? needle them and you're goinghear this huge rush of air. and you're going to see unicornponies that fart glitter and all that other good stuff. i don't know how many timesi've decompressed a pneumo, i've never heardthat rush of air

with the exceptionof this one time. we decompressed him. and there was such arush of air as well as i looked at the ceilingof the helicopter. that's how much pressurewas in that guy's chest. and so i yelled at the pilot. i'm like, don't clean it. i need a pictureof it for class. so i did that just for you guys.

as far as equipment goes,again, multiple problems. when replacingthat trach this is why it is soincredibly important to check capnography aswell as breath sounds. because we can stick thattrach down into the stoma, and we can create anew pathway, where we assume it's in the tracheawhere in actuality, it's down in the subcutaneous tissue. and that's what'shappening here.

you've got your trachea here. and here you can see the trachtube itself has migrated off to the side where theycreated a new pathway. we talked aboutall of this stuff. anytime anybodywith special needs goes into the community, theamerican academy of pediatrics as well as the american collegeof emergency physicians came out with theselittle cheat sheets that if you've got repeatoffenders hopefully

that they have contacted theambulance service and said, my child, daughter, whatever isgoing to be in your community. this is what's wrong with her. this is where she windsup going or he goes. so if you get calledout to that address you know pretty much exactlywhat you're walking into. we talked about all of thisstuff, all of this stuff. so again, with thesespecial needs kids, especially if they've got atrach-- if they have a trach,

they should have abackup trach somewhere. there's also apopulation of patients that have got what are calledcustom made trachs, where there are generally two ofthem in the world. one of them in their neck. and the other one's usually tapeto their bed post or something. make darn sure thatcomes with you. we had one repeat offender thathe would come in constantly with trach problems.

and i would always askhim, i'd say, bernie, where's your backup trach? taped to the bed post. what good would itdo us back there? so take the backup trach. they should have the correctsize as well as one smaller. same thing withsuction catheters. take only what you need. and we already talked aboutthis a little bit earlier.

so as far as trachproblems, this is a cabbie downin the gurney area that he was robbedby his cab fare. shot the left, right,and back side of his neck and his lower lip and jaw andthe upper and middle portion of his back. so we had to take him fromwaukegan to libertyville. and anyway, when wegot there he had just had upper airway surgery.

his jaw was wired shut. his was trached. and again, being thepessimistic person i am, that trach is coming out. that being said, witha wired shut jaw, am i going to be able to dodirect laryngoscopy on him? plus if i was, he just saidrecent upper airway surgery. there's no telling whati would be looking at. so again, this iswhere you need to talk

about where was that trach done. or versus er, and wejust talked about that a little bit earlier. if it's a er, it's probablyyour cricothyroid membrane. that being said, that is nowgoing to be your lifeline.

Tidak ada komentar:

Posting Komentar