Frustrations with the dreaded OSH

On 3/26/2019 at 12:18 AM, LilPeanut said:

Just needed to vent where people understand

so what were your vent settings? JK....interesting read from a NON flight RN. Cheers my friends breathe and you are there to fight another day.

4 hours ago, antsrt4 said:

so what were your vent settings? JK....interesting read from a NON flight RN. Cheers my friends breathe and you are there to fight another day.

?

They were not awesome, but not horrific. R 45, PIP 30 PEEP 8 (of course 100% FiO2 and 20 ppm iNO)

And thankfully, PPHN has resolved, baby is off ECMO and looks like may not have any brain damage! (all exciting!)

If you can rationally defend your care point by point when another stakeholder has a question, I don't see where this would be anything other than an opportunity to educate. Where does the annoying let down emotion come in?

I get that there is a culture of 'if I don't understand it, there's something wrong'. Get that a lot. But with confident instruction and reorientation to priorities, people tend to back off and understand.

I'm not saying the to comment on your particular call, but a lot of staff have transport experience who have given it up for some reason or another.

I guess I'm one of those dreaded email writers, although mostly for the way care was given on patient brought to us. Sometimes it is because of the crews care, often is is the medical direction that allowed for so much deviance from the standard of care.

We try very hard to send out our own transport team, but unfortunately the sending facility gets to choose who and how the patient is actually transported.

On 3/26/2019 at 1:18 AM, LilPeanut said:

We were on scene for much longer than normal, over three hours. But there was setting up therapeutic hypothermia, iNO (and resulting technical issues with both, of course!), patient instability requiring multiple saline boluses, ventilator management, starting pressors, struggling to get the pt. sedated enough, getting the ETT secure enough for transport, getting peripheral access. We ran our asses off. ...Ended up needing ECMO, but that was not on the table at all when we left. The biggest complaint it seemed was the length of time on scene.

On 4/3/2019 at 1:58 AM, LilPeanut said:

?

They were not awesome, but not horrific. R 45, PIP 30 PEEP 8 (of course 100% FiO2 and 20 ppm iNO)

And thankfully, PPHN has resolved, baby is off ECMO and looks like may not have any brain damage! (all exciting!)

Again I don't know anything about the call, but some of this does strike me as odd. Why did you struggle with securing the ET tube? Why did you struggle with sedation, did you give vec? Why did you struggle with access, why not just place a low line and call it good until you get to the hospital?

I'm not commenting on whether the care given was appropriate or not, but I can definitely see where the case presentation seems a bit odd.

Didn't struggle with the ETT (except finding the right tape) but struggled with sedation. Vec isn't sedation, it's a paralytic and often not going to solve your problems, especially if your PVR is too high. Struggling to get sedated is just that - you want to sedate without oversedating and the resultant side effects. We didn't end up having any true hypotension, but it did drop our SVR, which is why we ended up needing to start dopamine. Baby had a low-lying UVC already, we needed *more* access. It wasn't that I struggled with getting access, it went it easily, but all these things just add up in time, especially when you only have two people doing them.

This is a IIIB NICU sending to a IV. It's not that we aren't the ones doing the standards of care *chuckle*

11 hours ago, LilPeanut said:

This is a IIIB NICU sending to a IV. It's not that we aren't the ones doing the standards of care *chuckle*

The fact that you automatically assume that you are the standard of care since you work at a level IV says enough about your interest in quality improvement and personal insight. Medicine evolves and is ever changing, you cannot simply beleive that what you are doing is right because you work in an academic hospital, level I trauma center, level IV NICU, or whatever else someone wants to label as being the best; as an aside our NICU is a level IV.

11 hours ago, LilPeanut said:

Didn't struggle with the ETT (except finding the right tape) but struggled with sedation. Vec isn't sedation, it's a paralytic and often not going to solve your problems, especially if your PVR is too high. Struggling to get sedated is just that - you want to sedate without oversedating and the resultant side effects. We didn't end up having any true hypotension, but it did drop our SVR, which is why we ended up needing to start dopamine. Baby had a low-lying UVC already, we needed *more* access. It wasn't that I struggled with getting access, it went it easily, but all these things just add up in time, especially when you only have two people doing them.

Vecuronium can absolutely be used in the management of pulmonary hypertension, though it does nothing to address catecholamine cascade for which the current recommendation is treatment with morphine or fentanyl. Both vec and roc have been shown to have some benefit to relaxing the vascular tone of the pulmonary arteries.

If I saw someone attempt to tube without all of their confirmation and securement supplies I'd be writing an email too, I've never intubated without having all of my supplies immediately available.

You emphasize how you only have two people, did the staff leave you with the patient? Did they offer to help and you refused? If there was nobody else present how did they manage to figure out every small detail to complain about?

The thing I'd be the most concerned about is that you take feedback as a 'let down' rather than a point of improvement. Even if you did everything perfectly there was a perception that you didn't. Perhaps that means that you need to do education with the sending facility or the manner in which you explain your process while packaging the patient for transport.

3 hours ago, PeakRN said:

The fact that you automatically assume that you are the standard of care since you work at a level IV says enough about your interest in quality improvement and personal insight. Medicine evolves and is ever changing, you cannot simply beleive that what you are doing is right because you work in an academic hospital, level I trauma center, level IV NICU, or whatever else someone wants to label as being the best; as an aside our NICU is a level IV.

Vecuronium can absolutely be used in the management of pulmonary hypertension, though it does nothing to address catecholamine cascade for which the current recommendation is treatment with morphine or fentanyl. Both vec and roc have been shown to have some benefit to relaxing the vascular tone of the pulmonary arteries.

If I saw someone attempt to tube without all of their confirmation and securement supplies I'd be writing an email too, I've never intubated without having all of my supplies immediately available.

You emphasize how you only have two people, did the staff leave you with the patient? Did they offer to help and you refused? If there was nobody else present how did they manage to figure out every small detail to complain about?

The thing I'd be the most concerned about is that you take feedback as a 'let down' rather than a point of improvement. Even if you did everything perfectly there was a perception that you didn't. Perhaps that means that you need to do education with the sending facility or the manner in which you explain your process while packaging the patient for transport.

Holy jebus. Talk about nitpicking on a post when I came to vent, not coming to have to defend myself again.

First, I was joking, hence the "chuckle", I was trying to keep it lighthearted. My hospital doesn't do a lot of things right and I'm actively working to change it but what we were doing was absolutely the standard of care. This hospital did not have iNO, so they could not care for the child. They did not do therapeutic hypothermia so they could not care for the child. They did not have ECMO, so they could not care for the child.

Vec can be used, but it is not always the best thing, and in this case, we had not optimized our other sedation. Again, it just takes time to sedate without over sedation.

Way to assume I'm incompetent. I didn't start re-taping a freaking ETT without the supplies, it was difficult to obtain the supplies prior to starting. Child was already intubated and the ETT was loose, needed retaped, I had to get appropriate tape to do so. and then do it. Not a big deal, but takes time.

When we go out on transport, there is often not much the OSH can do for us, because they do not know our equipment or supplies. It's just the way it is. They sat and watched us, which is frequently what happens. When we needed help, we asked for it.

I came here to freaking vent because I went on a difficult call and did some great work with a great nurse to get an incredibly ill child back to our home hospital stably, and a person, who has a history of complaining about every transport team that comes into the unit, complained.

I made this very clear it was a post to vent. Not a post where I wanted you to nitpick too, because I intentionally left a lot very vague because of HIPAA. You don't have the full information. I did not come here asking "What could I have done better"? I came here with a rough sketch of what happened asking for a little empathy for a rough day.

Clearly asking too much of some.

19 hours ago, PeakRN said:

Vecuronium can absolutely be used in the management of pulmonary hypertension...

To the extent that it facilitates mechanical ventilation and doesn't make PH worse, but the suggestion that it in itself is meaningfully therapeutic is ludicrous.

As far as rocuronium goes, from the package insert:

5.11 Increase in Pulmonary Vascular Resistance Rocuronium bromide may be associated with increased pulmonary vascular resistance, so caution is appropriate in patients with pulmonary hypertension or valvular heart disease [see Clinical Studies (14.1)].

I use both liberally in PH patients but it surely isn't because I think they'll help in any other way than muscle relaxation.

Quote

The fact that you automatically assume that you are the standard of care since you work at a level IV says enough about your interest in quality improvement and personal insight.

...as long as we're talking about quality improvement and personal insight...?

Quote

I guess I'm one of those dreaded email writers...

I am getting that, yes...

13 hours ago, offlabel said:

To the extent that it facilitates mechanical ventilation and doesn't make PH worse, but the suggestion that it in itself is meaningfully therapeutic is ludicrous.

As far as rocuronium goes, from the package insert:

5.11 Increase in Pulmonary Vascular Resistance Rocuronium bromide may be associated with increased pulmonary vascular resistance, so caution is appropriate in patients with pulmonary hypertension or valvular heart disease [see Clinical Studies (14.1)].

I use both liberally in PH patients but it surely isn't because I think they'll help in any other way than muscle relaxation.

...as long as we're talking about quality improvement and personal insight...?

I am getting that, yes...

I'm so glad we are using the package insert, I'll remember that the next time I'm giving sildenafil to one of our pulmonary hypertension kids who has been on it for more than two years.

The literature that shows paralytics associating with increased PVR were with extended infusions, not in the bridge to rescue whether that be to an oscillator, ECMO, or other therapies. Certainly you would agree that maintaining lower vent pressures by reducing dyssynchrony and increasing chest/diaphram compliance during transport is better than a trivial amount of increased PVR which was not demonstrated with vec or roc in short interval studies (and was in fact demonstrated only when stopping the paralyti. Yes paralytics can (not that they always will) decrease the vascular tone of arteries and (to a lesser degree) arterioles, and if this is a cause or contributory to the patient's pulmonary hypertension then it would be therapeutic.

The literature in neonates is very limited and therapy is largely based on expert opinion which varies among facilities. The UpToDate recommendations acknowledge the 1988 and 2000 studies (the first of which was specifically on pancuronium and the latter showed neither risk nor benefit to paralytics and does not specify the paralytics used), but still recognize the place of paralytics in combination with morphine or fentanyl for those who continue to be dyssynchronous.

It is also important to recognize that these neonates are having their pressures estimated with an echo and not by catheter measurement, and that we are very aware the differences in accuracy between echos and measurements in the cath lab.

In an adult study vec was show to have no effect or decreased pulmonary artery pressure. Naturally we need to view this with skepticism since adults and neonates have different physiology, but we still both have smooth muscle. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5914209/

There is no way to determine the etiology of pulmonary hypertension at the bedside in the acutely decompensating neonate who is being prepared for transport, nor should it be the priority. Bridge to therapy is the goal, I'd rather have the kid on my circuit an hour sooner and have gotten vec than later and even more decompensated. Especially since the longer you are on circuit the higher risk you are for stroke, kidney injury, and so on not to mention the release of cytokines on circuit which can contribute to pulmonary hypertension. This is not to say that extended scene times don't happen, but we should be conscious to minimize them.

Yes, I write emails. I also welcome those to audit my care. Not because I think I'm infallible but rather that I'm always open to improving my care and recognize that I can make mistakes. I come from the days of MAST pants back when I started in EMS and avoiding tourniquets because of course we knew that if it was on for more than an hour you would need an amputation. I've called STEMI alerts on patients who under the sgarbossa criteria were actually normal and missed the brugada criteria in which the patient ended up getting (and needing) a cath. I came from the days when video laryngoscopy was was for the weak and the larger the tube the better the clinician you were.

I actually had a chart pulled recently on a code I ran, and though my care was deemed appropriate we also talked about some better medication choices as a system and what we could have done to prevent the code in the first place. I used to get questioned about my vascular access choices a lot because I tend to lean towards some unconventional approaches (I love to straight stick an IJ, it turns out that EJs can be safe access even in infants, and brachial A-lines are safe), and as annoying as it was I'm glad that we had a good quality assurance program that kept our patient's best interests in line.

On 4/8/2019 at 11:10 PM, LilPeanut said:

Holy jebus. Talk about nitpicking on a post when I came to vent, not coming to have to defend myself again.

...

I made this very clear it was a post to vent. Not a post where I wanted you to nitpick too, because I intentionally left a lot very vague because of HIPAA. You don't have the full information. I did not come here asking "What could I have done better"? I came here with a rough sketch of what happened asking for a little empathy for a rough day.

Clearly asking too much of some.

Allow me to add some clarity to my posts. I don't think that you are a bad clinician. I've never met you and even if you didn't give the 100% best care (not that I'm saying that) we all make mistakes and all have room to improve.

I want to provide some outside view on the situation. Every time a get a parent complaint, complaint from an sending hospital, or from an EMS service there will always be some degree of validity to it. Maybe we need to do more education on why we discharged a patient that they referred in, maybe why their priority transport got a small room in the back, maybe why we were so hands off with cares. Maybe we did make a mistake. Often the problem is in communication and not in care, but that isn't to say that everyone have room for improvement in their practice.

I do think that EMS has a poor reputation among hospitals and the general public. It is a bit of a sore spot for me because I think a lot has nothing to do with the care that is provided but rather the public image we put on. This is a social media site, and I don't like when EMS talks poorly of other in public, it rarely makes you service look better and usually makes everyone look worse.

I commiserate with your experience. I've had plenty of calls that I thought went well and then later got pulled into the office. I'm sorry that you had so much frustration, but I don't support complaining in public about it. If you were one of my nurses we would have gone out to have mimosas to celebrate the complaints away after shift.

10 hours ago, PeakRN said:

In an adult study vec was show to have no effect or decreased pulmonary artery pressure. Naturally we need to view this with skepticism since adults and neonates have different physiology, but we still both have smooth muscle. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5914209/

Wrong study link, although still a great read on cardiac anesthesia.

https://www.ncbi.nlm.nih.gov/pubmed/6137982