Question about a code we had last night

Kevin EMT · Jan 18, 2012

My heart goes out to the patient and his family. My username makes it obvious that my background is in emergency medical services. Over the years I've observed a less than professional relationship between prehospital care providers and nurses. I'm referring to a few of the comments regarding the EMT's intubation verification and some other subtle tones of suspicion regarding the patients bleeding. It's not blatant and I'm not implying that this site is anti EMT, just sounds like there's a pretty significant disconnect. Since I have had the fortune of having my feet in both EMS and nursing, I would love to encourage nurses and EMTs to learn about one anothers jobs. As an EMT do I know what a RN's responsibilities in a code even are, and vice versa? From the sound of some of the comments it's obvious to me that the local protocol for verifying tube placement isn't understood. Besides that, do we even know what level of care arrived when 911 was called? If you called 911 on your next shift, would you even know who would show up and what their care level would be? EMS varies greatly from state to state and even county to county or city to city, just like the title nurse can mean a million different things. Every EMS district has a a written set of protocols. Some are standing orders and some are physician orders and they cover everything from respiratory arrest to sprained ankles. I would encourage nurses to get a copy and take a look, you may be surprised at what you find. As I continue with my education I will do my best to learn things about nursing that I can share with the next EMT I hear questioning nurses... as if that ever happens.

FranEMTnurse, CNA, LPN, EMT-I · Jan 18, 2012

I had that happen to me in 2007, but I wasn't a code. Mine was from tachycardia, but was going into a code. Thankfully, even though I didn't code, I was diagnosed with pulmonary hypertension

Kittypower123, BSN, RN · Jan 18, 2012

To Kevin EMT: I certainly hope I didn't sound like I thought those in the code were not capable or doing what they were supposed to. I really don't know much about what they do, this was only my second code and with things happening so fast, I know I didn't see everything they did. I admire EMT's, they do this kind of thing daily.

The decision is make a loved one DNR is difficult, no one wants to feel as if they are saying they don't care about mom/dad/grandma living or dying (even though that's not what it's about). At the same time though, I've seen the issue addressed in such a round about way the family really doesn't have the chance to understand how traumatic that kind of end will be. My mom's a nurse and when my grandmother was going into the nursing home, my mom sat her down and explained what happens during a code and what her chances of survival would be. She wasn't crass or rude or overally graphic, but honest. Because of that conversation my grandmother chose DNR and died peacefully. I think there need to be more of these kinds of conversations so families can make informed decisions.

Pediatric Critical Care Columnist · Jan 18, 2012

Kevin, paramedics and EMTs like you are essential links in the chain of survival. When I think of the trauma patients we've admitted in the past who survived and went on to live fairly normal lives, there's only one place to put the credit and that's on superlative prehospital care. Without that, none of the things we ICU nurses do will ultimately mean much. And of course, we get these patients long AFTER the horrible events that have caused them to need us and were never on the scene with all its psychologically- and spiritually-scarring detail. We provide our care to them in a warm, clean, dry environment, not out on the side of the road in sub-Arctic temperature and perilous conditions. We aren't required to carry a fully-loaded stretcher with a 500 pound body strapped to it down four flights of stairs. There are so many aspects of your job that would send many of we nurses screaming for the exit. Thank you and your coworkers for all that you do.

commonsavage · Jan 19, 2012

Ok, so last night, a patient on the rehab unit where I work coded. The aide that was calling 911 informed me just as I was returning from lunch (he had JUST coded) so I ran to the room to assist. I took over compressions and when the paramedics arrived and took over, I ended up squeezed in the corner where I couldn't get out. When they intubated him, they had to suction and what came up was frank blood. This was only my second code, so I'm wondering - what could cause that? Is it "normal"? His nurse for the evening was in the room also and saw the same thing, she was disturbed by it too. We don't get a lot codes (thankfully - not my favorite activity) so I don't have a lot of experience with them. Any thoughts?

Normal? No. It's best, when asking a clinical question, to provide some clinical information.

GHGoonette, BSN, RN · Jan 19, 2012

I'm inclined towards the traumatic intubation theory. That is indeed the most common cause of frank blood being suctioned post intubation. Remember, too, it's very easy to damage the mouth and gums during a code. Even the insertion of a Guedal airway can cause that.

In the absence of capnography, checking for correct placement of an ET tube is done by (1) observing the bilateral movement of the chest during inspiration, (2) listening with a stethoscope for sounds of air movement through both bronchi and (3) listening for sounds of air movement in the stomach while bagging the patient.

Kevin EMT · Jan 19, 2012

Kittypower I was trying to bring up the rift between the two professions, nursing and ems. I know you must have experienced it. Maybe in the form of rude comments, unprofessional behavior, or just plain ignorance toward another facet of health care. I bring it up to combat all that negative stuff. Your reply is an example of a humble professional. I hope my first post didn't lead you to believe my opinion of you was any thing less.

Kevin EMT · Jan 19, 2012

janfrn, very kind words. I tell you what, when I think of the times I've crawled in over turned cars to tend to a patient compared to a 12 hour shift in an insane er, I'd rather be in that over turned car! Nursing is a humbling and intimidating profession. Nurses like you, with your obvious knowledge and humble spirit will make my transition a bit less intimidating. I hope I have at least one instructor with you attitude for EMS professionals. Thanks for your kind words and let's all do are part to work well with one another. This will no doubt improve our care for those under it.

TheCommuter, BSN, RN · Jan 19, 2012

Over the years I've observed a less than professional relationship between prehospital care providers and nurses.

I've noticed the unprofessional behavior at times, too. If you have time on your hands, feel free to click on the link below to read an older, enlightening discussion that I started a while back.

https://allnurses.com/geriatric-nurses-ltc/rudeness-emts-paramedics-268561.html

BelgianRN · Jan 19, 2012

From my experience if a patient codes long enough or often enough they always end up with bleeds somewhere.

We take up the majority of all OHCA's in our area and we see our share of traumatic intubations. I also see my share of fingers pointed at the prehospital care teams (in Belgium OHCA's are attended to by a ER nurse and ER doc from the hospital), but I like to start with the assumption they are capable at what they do. In the end that's the type of attitude I expect from others when they come into my ICU to respect and acknowledge my expertise in that area.

Generally these traumatic intubation bleeds are self limiting and rarely have I seen gross amounts of blood being evacuated. What we see much more often during extended codes is diffuse pulmonary bleeding. When it finally seems we are getting the patient under control the ETT starts filling up with blood and there we go again :).

In the end we musn't forget that even a little blood mixed with saliva for example will look like a massive amount of blood. It could be just something simple like that.

kickinbck · Jan 20, 2012

Was it suction from the oral cavity or deep suction? How much blood are we talking about? Is it possible that it was trauma caused by the intubation? Maybe from pulmonary edema possible, not sure, can you provide any more information?

Kittypower123, BSN, RN · Jan 20, 2012

Kickenbck - it seemed like a pretty good amount of blood, but I'm not really sure how much exactly, they used their own suction machine and the canister went with them. As BelgainRN said, it may have actually been less than it appeared. It was deep suction.