Oxygen Administration Skills- Did I miss something (like demand valves comin' back?)

[medic_diver45]

Not really trying to flame you. The problem lies with the fact that SO MANY people come here to Florida with stories about how they were emt's/paramedics/firefighters/whatever "up north" and they do things better/faster/cheaper where they are from. They are chuck full of helpful suggestions on how you should be operating your scene. Of course, after talking to them, you quickly realize that they are either wanna-be's or that they have no idea what they are talking about. It makes you sensative after awhile.

If you read what I say, I have no problems, and I never malign the professional rescuers in Florida or anywhere else for that matter. Actually I've stopped to help at several wrecks in Florida while visiting friends and relatives and I was quite impressed by the professionalism of the medics I encountered (they didn't get rude with me when I offered to stay and help and even thanked me for taking care of the patients before the arrived. It's one of the few times that has ever happened). It would be highly unprofessional of me to trash talk services and providers with whom I have no idea of their skills.

The problem that I have is with persons with 7 (SEVEN) hours of education (the basic and advanced O2 courses from DAN) being handing a potentially dangerous device, after being misinformed about its risks and told "have fun". And that doesn't just go for in Florida, I don't care if they are in Timbuktu when they use it- THE MTV-100 resuscitator is a risky device, even in the hands of a professional rescuer with copious amounts of experience- placed in the hands of a scared, inexperienced diver who has never tended to a medical emergency before is tantamount to asking for trouble. I take issue not with the students or those who have taken the class (you should be applauded for wanting to be as prepared as possible to tend to the needs of your fellow injured diver), but rather with those who designed the class around a device that is by and large considered unsafe by those who really know about it. Not only have they gone about touting this device as safe, they have grossly misinformed everyone about it's oxygen delivery capabilities (or at least never shown any proof that these claims are valid) and discounted medical evidence that shows the much safer bag-valve-mask mask device can deliver adequate, high flow concentrations of oxygen to a patient.

Everyone seems to forget that in the rush to get the patient as much O2 to the patient as possible that one must also weigh the risks as well as the potential benefits of a particular therapeutic modality. Is it worth risking massive barotrauma (which is very likely when place in the hands of a rookie first aider) which could make things much worse, just to get oxygen to a patient a few minutes sooner? Not in my book, not when you get give the same therapy through a BVM and be much less likely to hurt the patient. This is also not to mention that a BVM is less likely to fail when you need them: we all know what salt air does to metal, this is why our regs need serviced frequently. Most people stow their O2 away and forget about it- until something happens. Why risk it? As I've sad before: it's safer, just as effective, less likely to fail, and cheaper to utilize a bag-valve-mask instead of a pressure resuscitator. These are just my words but the sentiment is carried by many medical professionals. I have begun writing an article for a respiratory therapy trade magazine about this device's use in this course so that perhaps changes can be brought about and care for ill and injured divers can be improved; the facts will be presented in an open and honest fashion, with everyone's side given equal chance to argue their point (I've already sent a list of questions to DAN requesting responses and further information on this topic). Once everything is out in the open then perhaps improvements can be made.

-Steve

 

[GoBlue!]

The books say to hyperventilate, but it's usually not feasible.

I don't recall "the book" saying to hyperventilate anyone except in some cases with head injuries but that the practice was no longer recomended.

I agree with Avatar. The recent Circulation article, while a very small study, suggests that hyperventilation (of apneic/agonal victims) by first responders is not a good idea.

If it were me, I'd want a non-rebreather and if I am treating the patient they will get a non-rebreather; As I've said before, there are many ways to do something in medicine, but some of them are just more effective.

I appreciate your desire for wanting to practice evidence-based medicine, and so I'm wondering if you have any evidence to support the claim that a non-rebreather is better than a demand valve? I'm neither advocating nor condemning the use of demand valves; just curious what the data show.

If you would like, contact me off list and I will photocopy the pages out of the book I am referencing on barotrauma (it specifically referenced damage to the alveolar-capillary membrane; the mechanism behind air embolism) and send them to you. Most medical libraries don't carry copies of Egan's for some reason.....but most hospital's respiratory therapy departments have a copy.

Better yet, what is the reference that Egan's gives for the barotrauma-induced alveolar-capillary interface damage?

And you are right that many just take guesses at RR. I don't know why. Can't they do simple mental math to ge the #? Sometimes it can be hard to see/hear but still its such a vital vital.

Ah, the joke of many doctors on rounds. I don't even know why most nurses bother writing down the RR, as they seem to never check it anyway. My question: if you're going to make up a number, why make all your patients tachypneic?! Maybe they teach that "20" is the normal RR in nursing school....seems like just about every patient on every hospital floor I've seen has a RR of "20."

To clarify i've been a first responder since 1997, an EMT since 1998, an Intermediate EMT since 1999 and a respiratory therapist since 2001. I'm not a newbie, and I don't mean to rub my certifications in anyone's face.

Many would still consider you a newbie, at least as an RT. Sorry. Glad to see you're diving into the field, though.

Jim

 

[Wildcard]

RR20, B/P 120/80, Pulse 80 RED ALERT RED ALERT!!!!They can't do basic vitals. I have an ongoing battle right now over the use of automatic V/S monitors. The new EMTs, and old, need all the practice they can get and should not learn to depend on machines.

"The problem that I have is with persons with 7 (SEVEN) hours of education (the basic and advanced O2 courses from DAN) being handing a potentially dangerous device, after being misinformed about its risks and told "have fun". And that doesn't just go for in Florida, I don't care if they are in Timbuktu when they use it- THE MTV-100 resuscitator is a risky device, even in the hands of a professional rescuer with copious amounts of experience- placed in the hands of a scared, inexperienced diver who has never tended to a medical emergency before is tantamount to asking for trouble. I take issue not with the students or those who have taken the class"
Kind of like an intermediate? Medicine yes or medicine no, no medicine sorta.

 

[cmay]

While I respect your passion for your profession, I believe you are missing the true point of the matter.

I agree that the only true way to deliver 100% O2 to a patient is by means of intubation. But what we are trying to do in the event of a diving injury is provide as high concentration of oxygen as possible. You may disagree, but I have read many sources that state that with a NRB it is not uncommon to only deliver 60-75% O2 do to a poor fit. With a demand valve it is common to achieve a 85, 90, 95, or higher % delivery.

This extra 5,10,15,20%, or more increase in O2 makes offgassing of N2 go that much faster due to the steaper pressure gradient. Not to mention the higher PO2 in the bloodstream that is helping oxygenate tissues that have reduced, or blocked blood flow due to bubbles. In these cases, every extra % of O2 you can deliver to a person might make the difference in their recovery.

As far as the argument between oxygen consumption between NRBs and Demand Valves, I truly don't understand. How can you argue that you will not use proportionately more O2 with a constant flow system than you would with a system that only delivers the amount you consume.

I do not dispute the fact that you are knowledgeable with the delivery of oxygen in a pre-hospital, and hospital setting. But when you involve diving there are a few more pieces to the puzzle, and after reading through your posts you have quite a bit to learn about diving medicine. I sincerely suggest you take a course in hyperbarics sometime. If you would like any recommendations I would be happy to provide them.

For the record, I am in no way associated with DAN nor do agree with allot of their business practices. I am just a NREMT-B, and a certified Diver Medical Technician that believes in providing the best care available to any injuried diver in my care.

 

[HammerNoMore]

As far as the argument between oxygen consumption between NRBs and Demand Valves, I truly don't understand. How can you argue that you will not use proportionately more O2 with a constant flow system than you would with a system that only delivers the amount you consume.

This is one part of MD's arugment I understand somewhat. Being an EMT he is used to people being somewhat panicked. While this is the case with some rare cases of advanced DCI, most of the cases invlove simple joint aches, etc. Most of the hits that are taken are comparitvly mild and the patient is not panicked. If someone takes a major hit and is panicked, he could easily breath down a bottle of O2 faster than the rate delivered by the NRB mask.

However, if he is outbreathing the NRB mask, the 02 level has dropped significantly, greatly reducing the effectiveness of the O2 in the first place.

James

 

[TheAvatar]

After reviewing a lot of the information here and outside sources, I agree with medicdiver that the MTV-100 demand system is a bad idea for DAN to be training and selling people on when a safer and effective alternative like a BVM is available.

To clarify, the MTV-100 demand valve is a Limited Flow Oxygen Powered Ventilation Device (positive pressure).

Studies have repeatedly shown that EMTs ventilate too fast even with BVMs a significant percentage of the time. EMTs are no longer trained to use the MTV in most places and thats with programs with 120 hours of training! What will a lay person with 7 hours of training do with an adrenaline rush and a button to press on a much more dangerous device than a BVM? These devices are so poorly regarded that instruction on how to use them is no longer taught to most EMTs and the EMT manual has only a (very negative) paragraph and bullet list on the subject (vs pages on the BVM). A BVM is going to deliver 90-95 %O2 and seems like a much safer and more reliable tool in the hands of all but the most exprienced.

I think medicdiver is spot on about this subject whether or not you agree with how he presented it.

(On the nonrebreather, the book says 80-95 %O2)

I still think a normal demand mask (the actual demand mask, not the positive pressure one) has applicaiton for extending O2 use time.

I'd still like to hear from anyone who knows something about the DAN REMO2 system.

I'd also like to know under whose offline medical direction a DAN Adv O2 certificee woudl be operating a MTV-100 under in a state where such a device is no longer sanctioned?

I could see an EMT easily having their ticket pulled by their state (or national) registry for runing an MTV in an area where it is not in the EMT's scope of practice despite any DAN course.

 

[Scubakevdm]

Pulmonary barotrauma is a mute point though these days because the Super Deluxe O2 provider kits come with synthetic lung tissue and an easy to understand field-grafting diagram. Also, everybody knows that your dive lunch sac should contain at least a couple of bunches of small grapes, which due to their ucanny resemblance to aelvioli are interchangable with them. Duh.

 

[GoBlue!]

Pulmonary barotrauma is a mute point though these days because the Super Deluxe O2 provider kits come with synthetic lung tissue and an easy to understand field-grafting diagram. Also, everybody knows that your dive lunch sac should contain at least a couple of bunches of small grapes, which due to their ucanny resemblance to aelvioli are interchangable with them. Duh.

Love it. I'll have to pick one of these up from my local PADI LDS. (ducking & running....)

Jim

 

[medic_diver45]

This has been a most enlightening conversation.....for the most part, I have found all of those who posted to be professional in their manner of conduct (with a couple of notable exceptions). It should be stated however that, despite certain persons' best efforts to bait me into losing my temper that I REFUSE to lose my professional demeanor as this reflects badly not only on me, but upon the services with which I work, my instructors, and others in my chosen professions (respiratory therapy and emergency medical services).

A certain person on here needs to be reminded that true professionalism lies not in the credentials after one's name, but in the manner with which they conduct themselves. I know MD's who are ignored despite vast knowledge and experience simply because they conduct themselves like spoiled toddlers when things don't exactly go their way. I would suggest that this particular attitude applies to a certain allied health provider who has responded to this debate with a holier than thou attitude, seeking only to malign those with whom he does not agree.

CMAY, I am going to contact you through private messenger as I have a few questions about dive medicine training that I would like to ask you.

SCUBAKEVDM, thanks for the good laugh.....

JAMES, I appreciate the insight into how divers normally react after taking a hit- as I have only seen one diving injury in my medical career (and that was an air embolism- the guy was freaking, as I would be) I do not have a wide base of experience to base a guess on. I erred on the side of caution and presented a worse case scenario, as I am a big believer in the adage, "Hope for the best and prepare for the worst and you will never be caught unprepared."

Thank you again everyone for your input, this has been most educational for me, and I hope that some of what I presented will help you be better prepared to care for the sick or injured diver (or at least spark an interest in learning more about it.)

-Steve

 

[gazzahawkes]

Hello,

Been reading with interest the different attitudes and opinions
Like yourself i work daily with 02 provision and have used various methods in treatment of stable to unstable patients plus had o2 for countless ressus attempts particulary with drownings.all outside of a hospital setting

Im a qualified Cht, Dmt, alst, and have succesfully treated over 90 dcs cases having stabalised before evacuating to multiplace chamber.

Im also an instructor For tech diving and an instructor trainer for Dan.

I feel that some people here are takeing your stand on things as you trying to preach and prove that ye know more than most.

I simply see it that you are thinking outside the box.

Unfourtunatly as you know these international protocolls (ie demand is better)are always based on evidence based research and are deemed unarguable.
However im sure you will agree that change often takes time and the current stay of play is not always correct.

I personally introduce the MTV 100 in courses pointing out the dangers associated I also point out that in most cases Nrb is what the patient will accept and end up with.

AS you correctly state an injured patient particulary from barotrauma will find it easier to breath from an nrb.
most dcs patients are also very anxious and require the same.

Its important for people to use common sense with dive accidents to not go beyond there level of training and most importantly to not be scared to provide 02 in a dive accident.

Kind regards

Gary