Woman collapsed on the roadside CPR in progress. We arrive and when I get out of the ambulance, I can barely see the woman’s face her stomach is so large — it looks like a beach ball and getting bigger with each squeeze by the first responder of the bag valve mask.
“I think the air is going in her stomach,” the responder says.
“Stop doing that,” I say.
Green vomit is coming out of her nose and mouth.
So we work the code, get her intubated, get a line, try to do CPR on the small little bit of sternum not on the beach ball. We get her from asystole to PEA to vfib to PEA to vfib to asystole.
You sure the tube’s not in the belly one of the staff says at the hospital as we wheel the patient in.
No, it’s good. I show the capnography. Good wave form. Numbers in the 30’s with CPR. Equal lung sounds. Nothing in the belly. The doctor confirms its good.
First responder bagging, we say.
The patient is called dead shortly later.
This story is fairly typical. Not that it would have changed the outcome. First responders get there. Apply bag valve mask, stomach inflates.
We all complain about how nobody knows how to bag, but it continues. Maybe no one knows how to teach it properly. Teaching it properly goes beyond teacher demonstrating how to tilt the head back to open the airway and hold a good seal — it goes to the system. We can teach it, but Johnny still can’t bag. The stomachs keep blowing up. Maybe we need a new way to teach it or maybe we need another way altogether. It isn’t the easiest thing to do or else everyone would be doing right.
One of the principles in Medicine is to do no harm. While there are many first responders out there who do know how to properly ventilate with a bag valve mask, there are so many who don’t that I wonder if it might not be easier to give first responders LMAs and let them slip those in the mouth and then ventilate with the LMA.
This, of course, raises the whole drug and gadget debate about what level of service can do what.
On one side there is the argument that letting first responders or basics do things such as give ASA for chest pain, epi for anaphylaxis, nebs for wheezing, narcan for opiate overdoses, or with this suggestion, insert LMAs in cardiac arrests, you may run the risk of keeping communities from upgrading to the paramedic level, thus harming other potential patients who could benefit from quicker access to the higher level of care.
And each time we add another drug or skill to the basic scope, the question is what’s next? IOs and epi for first responders to use in cardiac arrests?
And what about the increased educational burden on basics?
I am in my job as a clinical coordinator, working on a proposal to let basics use CPAP. Similar proposals have been approved in many states where CPAP is now considered within the basics scope of practice. One of the towns I oversee is covered by an intermediate service and is some distance from the hospital, requiring lengthy paramedic intercepts. Some like I mentioned argue giving a basic or intermediate service more tools makes the town less likely to upgrade to the higher level, and some would say, needed level of paramedic service. Others would say, if a basic or intermediate can do it safely and the risk outweighs the benefit, let them do it. I tend to fall toward this side.
Once defibrillators were the province of physicians only. Now the lay public has access to them because they save lives.
I don’t know what the future holds. I just know I am tired of seeing beach ball bellies.