Knowing When To Hold ‘Em

On last week’s episode of EMS Office Hours, Jim Hoffman, Josh Knapp, and Tim Noonan discussed “Zebra Hunting.” Among other topics, when a patient with a suspected pnumothorax should have their chest decompressed.

If I understand Josh correctly, he stated that chest decompression is a relatively benign procedure.  He believes that the harm from not doing it on someone with a possible tension pneumothorax was less than the harm caused by the procedure on a patient who did not ultimately have one.  I believe he also stated that a needle decompression should be attempted on a patient with decreased breath sounds on one side before their vital signs or mentation worsen.

I gained a new perspective on this a few years ago I was precepting paramedic students during an ED rotation, when a 30-something male walked in with difficulty breathing. He appeared healthy, had no medical problems, and his breathing had been getting progressively worse for a few days.  His breath sounds on one side were noticeably decreased.  A breathing treatment was started, but did not provide any relief.  Then his chest X-ray came back, and he had a pnumothorax large enough for me to recognize on it.

So I asked my students what they would do with this new information.  One said they would decompress his chest, “just in case” his simple pneumothorax progresses to a tension pneumothorax.  Let’s see how they handle it, I replied.  The breathing treatment was discontinued and he was placed on a non-rebreather mask.  He was also given pain medication and some Versed.  A chest tube tray was brought to the patient’s side, but not opened.  We were at a teaching hospital, so there was a discussion about which resident would get to do it.  The patient’s condition did not change.  Approximately 30 minutes after the diagnosis was made, more pain medication and Versed were given, and the tube was placed without incident.  Then we all listened to equal breath sounds.

“Unless it’s an emergency, a chest tube should be a painless procedure,” the attending said afterwords.  They did not consider this an emergency, nor did they see any benefit from causing pain during a procedure.  A needle chest decompression from EMS would have been inappropriate for this patient.

On another occasion, a patient came in with angioedema.  She could not close her mouth around her toungue, sat in a tripod position, and had stridor.  This was a true emergency, and I asked my students what they would do if that was their patient.  They both said they did not know, which was the answer I hoped for at  that point in class.  Her pulse ox-remained above 95% with a nonrebreather mask applied, and as bad as she looked she did not appear to get worse.  Anethesia was called, and attempted a nasal intubation with a bronchoscope after she was sedated.  The patient swung her arm at them, and appeared to get more agitated even after getting Versed.  After about a half hour, a crich kit was brought to one side of the bed, a video laryngoscope was brought to the other, her neck was prepped, and she was given a paralytic.  An anethesiologist was able to intubate her with the video scope.

My students asked what I would have done.  I told them I would have given her oxygen, transported to the closest hospital, and notify them as quickly as possible.  I would have our crich kit out, but would only have used it if she could no longer  be oxygenated.  Would it have been wrong to crich her?  It could have been justified, but if the patient fought with the ED staff when they put a tube near her nose, imagine what she would have done if someone tried to put a hole in her neck.  A bad situation would have been much worse.

As EMS educators, we teach much more about when to do procedure than when not to.  In lab scenarios, this patient with decreased breath sounds would get their chest decompressed.  Patients with upper airway obstructions get criched.  Tachycardic patients gets an antiarrhythmic or cardioverted.  Bradycardic patients get Atropine or paced.  Head injured patients get intubated, and so on.  We teach less about when it is wise to wait.

In paramedic school, I worked as an ED tech at a busy urban hospital.  I not only learned the difference between sick and not sick, but also when sick patients need immediate treatment and when it is okay to get more information before treating.  Lots of patients who I thought looked bad, did not get any worse in the hours it took for lab results, old ECG’s, X-rays, or CT scans to come back.

All of our procedures are potentially dangerous.  Before we do anything, we should ask if the risk outweighs the benefit given the distance to the hospital, our comfort level with the procedure, and how much better prepared the hospital is than we are.  The more experience I get, the more I find myself holding back.



  1. […] [1] Knowing When To Hold ‘Em August 31, 2012 EMS Patient Perspective Bob Sullivan Article […]

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