The case for prehospital ventilators

As a critical care paramedic, I use a transport ventilator frequently, almost exclusively on high-acuity interfacility transfers. My employer does, however, allow its critical care paramedics to use their specialized CCT medications and equipment on 911 calls if the situation calls for it. Having a broader medication formulary and a wider array of tools for patient care has been a useful capability at times.

On one such occasion, a young man took an exceedingly ill-conceived dare to lie down between the rails of the railroad tracks as a train was coming, allowing the train to pass over him as long as he lay perfectly flat.

Let’s just say that the young man didn’t lay as flat as he had hoped, or raised his head at an inopportune time, and found himself stuck under a miles-long train, half a mile from the nearest crossing, and suffering from a depressed skull fracture.

Enter the stalwart paramedic and his handy transport ventilator.

I’d like to tell you I brought my ventilator with me to the scene, but frankly since I half-expected a body recovery rather than a patient, and because my ambulance was on the wrong side of the tracks, I had to ferry equipment over the top of a stopped train and lug it by hand the half mile to the patient. I kept it light and left the ventilator in the rig.

Once I arrived at the scene, however, I realized the magnitude of the problem. Not only was my patient stuck under a crossmember of a well car (a sort of hollow frame that shipping containers nestle into for rail transport), he was trismic, with decorticate posturing, and the position he was in did not allow for effective ventilation with a BVM. Complicating matters was that the sides of well cars are much taller than they appear from the driver’s seat of your car at a railroad crossing. We’d have had to move the patient hand-over-hand, over a wall that was as high as our heads, on a spine board, to another crew waiting on the other side ... all while he was being ventilated via BVM.

Not an optimal solution.

I remember thinking then, “Man, it sure would be nice to have my ventilator right now. That would free up a set of hands, and we could likely move the kid with the vent strapped to the board between his knees.”

And then I did something better: I acted upon that wish. I sent a firefighter in a rescue truck to the crossing where my ambulance was parked to fetch my ventilator and circuit, and a cop in a patrol car to the other crossing where it was most feasible to break the train.

Long story short, we RSI-ed the kid, intubated him and put him on the vent, and slid him out on a spine board underneath the walls of the rail car. He cleared the space by maybe a couple of inches. By the time I climbed out of the well car, the firefighters had fetched my ambulance, and we transported him to a trauma center. He recovered.

Cognitive offloading

Along the way, I’ve found numerous other reasons to use my vent on 911 calls.

Like cardiopulmonary resuscitations.

Or respiratory distresses.

Or other head injuries where controlled ventilation is paramount.

Or really, any other situation that would allow me to do some cognitive offloading and focus my thought processes on assessment and problem-solving, rather than trying to deliver 500 mL of oxygen at 10-12 breaths per minute while maintaining an adequate mask seal and allowing adequate time for exhalation and avoiding barotrauma and making sure the patient had a PEEP adequate to maintain alveolar recruitment and retention ... see where I’m going with this?

The real value of tools and devices like automatic CPR devices or transport ventilators isn’t that they necessarily work better than a trained pair of hands, it’s that they allow us to be clinicians and critical thinkers, rather than being task-focused to the point that we lose sight of the bigger picture.