The Patient

Imagine if you will a patient with difficulty breathing is laying on the stretcher in the back of the ambulance. Their shortness of breath is turning into an inability to speak and the patient has a scared look in their eyes that tells you that they need serious help. The medics can see their pulse oximetry drop as sweat pours off the patient’s skin. They can see with their own eyes the patient is failing to ventilate and oxygenate. What are the medics to do? Do they just wait for the patient to become unconscious?

Let’s start with what they shouldn’t do. They shouldn’t lay the patient flat. Laying a patient flat while they have marked respiratory distress is a recipe for cardiac arrest. The patient can be managed in the supine position.

The medics can assist the patient’s breathing by assisting ventilations.

Indication

These patients start out conscious but decline during transport. There is not a more dynamic patient than a patient with respiratory distress. As the patient begins to decline the following symptoms should appear:

• Altered Mental Status
• Inadequate Minute Ventilation – this can be seen by observing shallow chest rise despite being tachypneic.
• Fatigue

Complications

As the patient approaches losing consciousness, the patient may become combative. Combativeness is a sign of hypoxia. The patient probably doesn’t really have enough strength to hurt the medics, but the patient may not be very cooperative. There is always the risk of over pressure causing damage to the lung and gastric inflation anytime the patient is being ventilated.

Ride The Wave

The first thing to do is explain the procedure to the patient. Place the mask of a bag valve mask over the patient’s nose and mouth. Initially assist at the rate at which the patient has been breathing. Wait for the patient to inhale, then squeeze the bag to increase the tidal volume of the patients inspiration. Over the next 5 – 10 breaths, adjust the rate and tidal volume to fit the patient’s needs. When ventilating, just ventilate enough to get chest rise.