Many years ago, as a brand new EMT, I was driving lights and sirens to a call when the ambulance slid on a patch of ice, trapping the rear tires in a snowdrift. I was sure that I’d be fired or jailed or worse.
Thankfully, we were close enough to our destination to jog to the house with our equipment. By the time that we were ready to transport, firefighters and other first responders had pulled the ambulance from the snow. There wasn’t any damage, and I didn’t even receive a stern look from the supervisor. I was very grateful.
Most people appreciate first responders for their heavy lifting (including lifting an ambulance from a pile of snow), but it seems that many overlook the medical importance of skilled firefighters and EMRs. During a national shortage of EMTs and paramedics, it’s crucial that healthcare stands behind all first responders.
Basic skills: A dangerous, misleading term
Perhaps we should recycle the term “basic skills,” rename it “primary skills.”
Many new EMRs and EMTs (I was one of them) believe that their “basic skills” are less important than the “advanced skills.” As a result, EMRs and EMTs (and paramedics and nurses and physicians) often neglect honing these vital procedures. A quote from “The Walls Manual of Emergency Airway Management” sums this up perfectly: “In spite of its importance, there is a paucity of literature that adequately describes effective BMV [bag-mask ventilation]. Most healthcare providers mistakenly think that they are proficient at it, and it is given less attention in training for airway management than more glamorous, but less frequently applied, airway techniques. Nonetheless, BMV is among the most difficult airway skills to master …”
The text lists a study that found that it took 25 training runs to reach 80 percent efficiency using the BMV—and 80 percent isn’t good enough. The text notes that the study serves in “highlighting the necessity for frequent, scrupulous training in BMV.”
I was one of those mistaken healthcare providers. As a young EMT, I didn’t want to waste extra time on the “basics.” Rescue breathing, bleeding control, CPR: Those were nice to know, but I wanted to learn the advanced skills that actually save lives. I was too eager to impress people.
I was foolish.
Unfortunately, it took completing paramedic school and working several years on the road to realize that advanced skills don’t save lives any more than basic skills do. Further, it appeared that these basic skills were just as difficult as advanced skills.
When we denigrate fundamental skills, patients suffer. Bleeding control, CPR and airway management often are overlooked and forgotten. I’ve witnessed countless unforced errors (and made many myself) that involved these “easy” skills, all because they weren’t given the respect that they deserve.
Twelve techniques for better BMV
To increase muscle memory and improve strength, responders should practice even the most straightforward maneuvers, including tilting the head back and holding the mask on the jaw. Other helpful techniques:
- Clear the mouth before you open the airway. If the mouth is full of vomit or blood, use suction or roll the patient on his/her side first. If you perform a head tilt-chin lift while the patient’s mouth is full of vomit, you’ll contaminate the lungs.
- Align the airway axis. A towel roll under the head for adults and under the shoulders for children will align the airway axis (oral, pharyngeal and laryngeal), placing the patient in a better position to breathe. Think about smelling a flower: head foreword and chin up.
- Manage your muscles. Don’t stoop. Extend your arms and lean back. Use your body weight to keep the chin up. Also, rest between breaths. For a better seal, tighten your grip while you squeeze the bag, then relax as the patient exhales. Both techniques will reduce fatigue.
- If the jaw is clenched, try to ventilate through the nose. For clenched jaws, you still can suction around the edge of the teeth and breathe through the nose (using a nasopharyngeal airway, when appropriate).
- Use the “OK” grip, instead of the C-E. Make the “OK” symbol with your hands around the rescue mask, then lift the front of the jaw with the remaining fingers. This prevents leaks and creates more even pressure around the edges of the mask.
- Use petroleum jelly for beards. If a patient has a large beard, consider using jelly on the beard to help to create an airtight barrier between the mask and the mouth. If you have a safety razor, you could shave some hair.
- Try three fingers for babies. Many times, you only need your thumb and index finger on the mask and the middle fingers to support the jaw. Don’t place pressure on the eyes or the soft part of the neck.
- Leave dentures in place. Dentures support the mask. Leave them in place. However, if they’re dislodged or someone is about to intubate, remove them.
- Feel the lungs and avoid overventilation. Squeeze the bag carefully, as if you’re trying to inflate a fragile balloon. After practice, you’ll begin to “feel the lungs.” This is part of the art of airway management, and it takes practice.
- If something isn’t working, do something different. Don’t keep trying the same thing and expecting different results. Try a different patient head position, try a new grip, try a different airway. Patients aren’t manikins. They all are different.
- Use a modified two-handed grip (H-E grip). You probably know that it’s wise to use two people for BMV, one to hold the mask and one to squeeze the bag. You also probably know that this isn’t always practical. Try this instead: Place the bag valve mask (BVM) on the patient’s face normally. First, take your hand from the top of the BVM bag and place it palm-up under the bag. Now, pull the bag down and use the side of your palm and pinky finger to stabilize that side of the mask. Use your thumb and index finger to squeeze the bag; your other hand holds the mask as usual. This technique provides a two-handed grip by one person.
- Buy a cheap foam head and practice your airway skills. Visualize your most feared scenarios (often involving children). A foam head doesn’t have lungs, but you can use it to hone your skills. (Even MLB players use a tee for batting practice.) Note: Failing to tilt the chin back and failing to get a good mask seal are the biggest mistakes that I witnessed during BMV.
The little things matter
I’m passionate about airway management from both perspectives: responder and patient. My daughter required intense resuscitation at birth. Had it not been for the astuteness of a seasoned neonatologist, I wonder whether she would’ve lived through her first day.
This physician didn’t talk much. He was very tall and stood back and watched as the younger physicians helped my daughter. Then, breaking his stoic nature, the physician leaned over and corrected the practitioner (it was a nurse practitioner or a doctor, I can’t remember) who was using the BVM. “Careful to lean the chin back and keep your fingers clear of the neck,” he instructed.
Such a simple suggestion that could have been brushed off as insignificant, yet the physician knew the profound effect that the small change could have on successful resuscitation. I’m immensely grateful to sharp professionals, such as that neonatal specialist, who gave me more time with my daughter.
The value of a good first responder
A well-trained emergency first responder isn’t “an extra set of hands.” Such an individual is an important member of the healthcare team. I would prefer that a dedicated, well-trained EMR take care of my family much more than a poorly trained paramedic.
Albert Einstein said, “Everything should be made as simple as possible, but not simpler.” We can oversimplify things. Unfortunately, in the name of “keeping it simple,” many critically important skills are mistaken as easy and unimportant.
Remember your high school coach? Mine was basketball. He never screamed when we fumbled an extravagant play (which wasn’t particularly important anyway), but he damaged his vocal cords if we ignored the fundamentals: “Rebound! Stay low! Hustle! These skills win basketball games!”
My basketball coach sort of reminds me of my paramedic instructor. Of course, the latter’s screams were a little different: “Bleeding control! CPR! Rescue breathing! These skills save lives!”
