Airway and breathing emergencies
Facilitator: Grace + Becca
Medics: Charis + Greg
Patients: Choking pt, Stacy
Time: 25 mins; 1005-1030
Actual time:
Learning Objectives:
Materials: Epi-pen, Readers.
Introducing the Airway
Facilitator says
We breathe through a tube that runs from the nostrils and lips to the air sacs deep in the lungs. The whole length of the tube must be open and undamaged.
If the airway narrows enough to cause respiratory distress -- laborious inhalation or exhalation -- it is an emergency. Stop and fix and call 911. Restricted airway can be as frightening for you as for the patient.
If air cannot get in or out, it is an emergency. Stop and fix and call 911 -- tell the dispatcher your patient has an obstructed airway. Expect fear, altered mental status, and fast ambulance response time.
About 5 minutes after airway obstruction the heart stops beating. During the next 5 minutes cellular damage in the brain starts and about 5 minutes later (approximately 10 minutes after the heart stops beating) enough brain damage has occurred that death probably can't be reversed.
Facilitator asks
What might endanger an alert person's airway (What might cause respiratory distress or obstructed airway)? Good answers:
Anaphylaxis / allergic shock.
Choking / foreign body in airway.
Injury to airway.
Asthma / COPD (chronic obstructive pulmonary disease) / bronchitis.
Facilitator says
Respiratory distress is the result of a partially restricted airway. An airway can be restricted by swelling, muscle spasm, or a foreign body.
A partially restricted airway can become completely obstructed by swollen anatomy or by a foreign body. Once the airway is completely obstructed the patient can't make any sounds, has a sense of impending doom, can't breathe and will soon lose consciousness.
Anaphylaxis
Facilitator says
Anaphylaxis is a severe allergic reaction, usually to drugs such as penicillin, foods such as nuts and shellfish, or stinging insects such as bees. Most people with severe allergies have been to the hospital because of them before and carry a self-injectable medication called an Epi-pen.
Imagine that when you looked, listened, and felt for Lisa's breathing, there was none. You told your buddy, who told the 911 dispatcher that she was unresponsive with an obstructed airway. You search her for medic alert bracelets or an Epi-pen. Your buddy finds out from a friend that Lisa is severely allergic to nuts, that she threw up before she passed out, and that she was not hit on the head today. You find her Epi-pen. Your buddy finds out that Food Not Bombs put peanut butter in the cookies they were serving at the protest. The ambulance arrives, and you tell the EMTs about Lisa's allergy, the cookies, and that there was no MOI for head injury. The EMTs administer Epi on the ambulance, and Lisa is breathing and talking before she arrives at the hospital.
At the hospital, she tells her intake nurse that after she ate the cookies, her scalp and tongue started itching, then it got harder and harder to breathe because of swelling of her airway. Before she became unresponsive, her skin flushed over her whole body, her blood pressure abruptly dropped (she had to sit down suddenly because she was light-headed), and she got severe abdominal cramps and threw up. The last time Lisa ate peanut butter all that happened was that she got hives over her whole body and a headache so bad she went to the hospital. Even though she was carrying her Epi-pen she had forgotten about it, because her allergies had never been so severe.
Anaphylaxis is usually worse each time a person is exposed to the allergen. It is absolutely terrifying to not be able to breathe.
Facilitator says
Anaphylaxis is an emergency because swelling constricts the airway. If you suspect anaphylaxis and the person is alert:
Ask "Are you having an allergic reaction?"
Ask "Do you have an Epi-pen?" Help the person find it and self-administer it.1
Call 911.
Calm, comfort, reassure, and help the person sit or lay in position of comfort.
Warning: Epi wears off within 15 minutes and anaphylaxis returns. The Epi-pen only buys time. Always call 911.
Choking on foreign body
Facilitator asks
Who has seen someone choke on something so badly that the person couldn't breathe and had to go to the emergency room?
Facilitator says
Imagine how frightening it is to have a foreign body obstructing your airway. You are unable to explain your problem, can't ask for help, can't breathe, are about to die, and are alert enough to know it. Now imagine how comforting it is when someone -- anyone -- walks up to you, looks in your eyes -- which are just alive with fear -- and assures you that she understands the problem and can help.
Facilitator asks
Choking is a true emergency. What do you do for all true emergencies? Answer: call 911. Even if the object comes out before the ambulance arrives, damage to the airway from the object will probably cause swelling to the airway similar to anaphylaxis.
Facilitator asks
How do you know a person is choking? Encourage discussion -- there are many good answers. Keep these two points clear: if the person can speak or cough, choking is respiratory distress; if the person is silent, it is obstructed airway.
Facilitator encourages students to stand up
and come in close to see.
Trainer slowly demonstrates current Red Cross choking protocol 2
(on a volunteer or another trainer).
Just do it: When someone is choking, speed is essential. This is the rare occasion where you do intros after touching somebody. If the person shrugs you off, that's refusal.
Ask "Are you choking?" If the person person can speak or cough, encourage coughing but do not interfere. Tell bystander/buddy: "She's choking! call 911!"
If breathing stops
Give 5 back blows between the person's shoulder blades with the heel of your hand. Each blow is a separate attempt to dislodge the object.
Give 5 abdominal thrusts (also known as the Heimlich maneuver). Each thrust is a separate attempt to dislodge the object.
Alternate between 5 blows and 5 thrusts until the blockage is dislodged.
Trainer slowly demonstrates
proper abdominal thrusts.
Stand behind the person. Wrap your arms around his waist. Put one foot between his feet. Tip him forward slightly.
Make a fist with one hand and position it -- thumb-in -- one fist's width above the person's navel.
Grab the fist with your other hand. Press hard into the abdomen with a quick, upward thrust -- as if trying to lift the person up.
Facilitator says
Abdominal thrusts often cause injury even when applied correctly. This is one of the only interventions we encourage you to use that is not do no harm.
Facilitator says
Choking might happen when you are alone with a choking person. When not with your buddy and there are no bystanders, perform back blows and abdominal thrusts before calling 911.
Trainer slowly demonstrates standing take-down
for when the person develops lowered LOR and can no longer stand.
Assume andominal thrust position (Standing behind the person, arms around his waist, one foot between his feet; he is tipped forward slightly).
Lunge backwards, allowing the person's weight to rest on your front knee until he is sitting. Slide your arms under his armpits.
Kneel and gently lower his back to the ground.
Roll him into Recovery Position.
"Does anyone know CPR?" I do. "Okay, I need your help now."
Students gently practice
choking first aid (encourage choking, activate EMS, back blows, abdominal thrusts, standing take-down) in groups of 3.
Facilitator quickly debriefs students.
Call students into a circle. Ask students if they have any questions or had problems with the skills. Trainers can briefly give feedback in circle.
Trainer demonstrates clearing airway of pregnant person
or someone you cannot get your arms around.
Encourage coughing.
Tell bystander/buddy: "She's choking! call 911!"
If airway is obstructed (no sound)
Help person get her back against a wall.
Position hands higher than abdominal thrusts, at base of breastbone just above joining of lowest ribs.
Proceed as with abdominal thrusts, pressing hard into chest with quick thrusts.
Repeat until food or other blockage is dislodged or person can no longer stand.
Be aware of where the foreign body will go when it comes out. You don't want it on your face.
Trainer demonstrates abdominal thrusts to self
If you are alone and choking, you can't do back blows, but you can call 911 and do abdominal thrusts.
Call 911 immediately even though you cannot speak. Leave phone off hook.
Make a fist with one hand and position it -- thumb-in -- one fist's width above your navel.
Grab the fist with your other hand and bend over a countertop or other hard surface.
Let your body's own weight shove your fist inward and upward until the object is dislodged.
Facilitator says
Always go to the hospital after a choking emergency. The airway may swell due to damage caused by the object, and abdominal thrusts may cause injury. Just because the object is out does not mean the emergency is over.
To be more prepared for choking emergency, or to practice responding to choking in infants and children, take a CPR course with the American Heart Association, the American Red Cross, or the National Safety Council.
Return to Stacy: Moderate asthma attack
Facilitator says
Asthma is similar to anaphylaxis, but involves swelling or spasm deeper in the airway. Remember Stacy from last night?
He got to Denver a week and a half ago with a sketchy past, and has been staying at the 24-hour foreclosure resistance vigil in an elderly lady's front yard. He has medication-dependent diabetes, gets bad asthma attacks when he is upset, and really hates cops. Jail is a very bad place for him.
Colorado Foreclosure Resistance Coalition set up a food table this morning, and the Denver Police arrived in full force. 100 cops in all-black riot gear blocked the street, with big cans of pepperspray strapped to the fronts of their uniforms and big sticks in their gloves. Stacy got worked up and was screaming at a shotgun-holding cop. A police lieutenant pointed at Stacy and said, "He's first." Stacy started wheezing so bad he couldn't yell anymore and bracing his hands on his knees, but stood his ground and flipped off the lieutenant.
Facilitator asks students
to respond with a preparedness line-up: "I know what I would do in this situation."
Forum theater: Stacy's asthma attack
One trainer gets ready to play Stacy (struggling to breathe, tripoding, struggling to cough, gesturing, getting increasingly scared and self-protective). Another gets ready to play his friends (want to be helpful, but kind of ignorant and scared).
Facilitator says:
Everybody who knew what you would do in this situation is going to get a chance to do it. This is called Forum Theater. The first buddy pair should start with "Stop 1, 2, 3, 4, 5" from the Rosehip Triangle, but if they forget something, you can stop them. When you see an opportunity, shout "FREEZE!" Everybody freezes and you can tag out one of the buddies and take her place. Watch!
Trainers model
Trainer A and student approach Stacy, trainer says "Hey what's up?"
Trainer B: "FREEZE!" tags out Trainer A, backs up with buddy, goes through 1 (safe), 2 (asthma), 3 (gloves), 4 (probably not), reminds self of 5 (decides trainer A will do pt care and student will watch scene), then walks up behind Stacy.
Trainer A: "FREEZE!" tags out Trainer B, comes around in front of Stacy at eye level.
Facilitator says
Who's going to be brave, take it from the top, and help out Stacy? He's dyin' out here.
Students practice
responding to Stacy's asthma attack with Forum Theater.
Give it a few minutes to see how the exercise works. Try to get creative ideas out into the ring.
If anybody gets stranded out there too long, a trainer should yell "FREEZE!" and ask the group what the medics should do next. "Okay, who's gonna tag somebody out and try that, then?"
We want to see medics matching energy, asking if he has his inhaler, "Breathe with me" stuff, getting him to consensually step away from the action (maybe off the grass) and maybe sit down, considering EMS.
Facilitator leads debrief
Was Stacy alert? Yes. Was he oriented? Probably; kind of.
How was consent negotiated?
Was the airway open? Yep, as long as he was still making noise, breathing, coughing. How do you know?
Was he experiencing a breathing emergency (was his life in immediate danger)? Maybe -- depends on how bad Stacy played it up, whether he pretended he had an inhaler or not, and what happened after he used it. Activating EMS is never a bad idea.
What did the medics do for his breathing?
Asthma lecture
Facilitator briefly lectures
on anything that wasn't covered in forum theater and debrief. If they hit all these points, facilitator can summarize and move along to teaching acupressure for asthma.
Suspect asthma attack if:
Person: "I'm having an asthma attack."
Friend: "He's having an asthma attack."
Coughing, wheezing, short of breath, and/or chest tightness.
Call 911 if moderate/severe asthma attack, pt does not have medicine, or condition does not improve -- this is an airway emergency. Pt can always refuse care when ambulance arrives.
Mild: some chest tightness, no difficulty speaking, no difficulty breathing.
Moderate: difficulty breathing (hissing, wheezing, coughing, short of breath, etc.), difficulty speaking due to shortness of breath (must take a breath between words).
Severe: extreme difficulty breathing or unable to breathe; unable to speak due to airway constriction; may have lowered LOR.
Facilitator asks:
How bad was Stacy?
Facilitator says
For asthma attack, always do initial assessment, then:
Ask if he has a fast-acting inhaler. Encourage him to use it. You may help him find it. He must use only his inhaler; dosages and medicines vary.
Speak calmly. Encourage him to match your breathing patterns (calm him while slowing his breathing rate). Direct eye contact can help facilitate this.
Get to safe scene; encourage sitting tripod position.
In mild/moderate attacks (can speak, no lowered LOR), encourage drinking several cups of room-temp water consecutively. This is a surprisingly effective antispasmodic/anti-inflammatory.
Acupressure for asthma attack practice
Facilitator says
It is common for protesters to forget their inhalers.
During asthma attack or coughing fit, large muscle groups in the upper back spasm, which makes breathing more difficult. Pressing specific acupressure points on the chest, throat, neck, and upper back benefits the respiratory system, relaxes spasm, and relieves asthma and cough.
Ding Chuan (Extra Point 17) is the acupressure region most often used by street medics, because it is easy to locate, easy to apply lots of pressure, and does not feel invasive to most people. Ding Chuan is located to each side and a little above the C-7 (7th cervical) vertebra that protrudes at the top of the spine when the head is hung downward.
Vital Diaphragm (B 38) is another acupressure point that is useful for relieving breathing problems. It is located on the back between the shoulder blade and the spine at the level of the heart.
Students practice
Cup your right hand over your right shoulder, so that your pinky finger follows the curve of your neck and your ring finger nests between C-7 and C-6. Your middle finger is over the right Ding Chuan point in a slight depression between two muscle groups.
Facilitator says
This helps you locate the point on yourself -- but it is very difficult for to apply sufficient pressure to Ding Chuan to interrupt your own asthma attack.
After you have asked Stacy if he has his inhaler (he doesn't), breathed with him, gotten to a safe scene, called 911, and given him some water to drink, explain Ding Chuan acupressure therapy to him and get his informed consent.
Trainer demonstrates stimulating Ding Chuan on "Stacy."
"Stacy" is sitting in a chair in tripod position. Invite students to come close to see.
Locate the point on right side with your middle finger. "I will be applying a lot of pressure to this point with my elbow. I want you to tell me when your breathing starts to improve. Okay?"
Stacy nods his head.
"If your breathing does not improve, I will move my elbow. When I have located the correct point, you will be able to breathe better on the right side. I will hold pressure for a while, then start to work on the left side. I need you to tell me when I have located the correct point."
Stacy nods his head.
"May I support your torso with my other hand just under your collarbone?" Reach left hand around and nest thumb and forefinger in the depressions under collarbone on each side of sternum at Elegant Mansion (K 27).
Stacy nods his head.
"I am going to apply pressure to your upper back now." Stimulate the right Ding Chuan point with strong pressure which may be painful (with your thumbs, knuckles, or elbow). Hold until respiratory distress abates. Continue supporting Stacy with thumb and forefinger on K 27. below his collarbone.
"I want you to breathe with me." After a few breath cycles, "Do you notice any change?"
Stacy: "Not really."
Move elbow a half-inch away in any direction (stay above the heart, below the neck, and between the shoulderblade and the spine) and keep checking in and breathing with him until he says, "There." Then hold, and breathe together until he wants you to switch to the other side.
When breathing has improved, offer to Stacy that you can teach his buddies to stimulate the Ding Chuan points. You may even mark the points on his back with a Sharpie marker.
Facilitator says
If you can't find the exact points, try a firm but gentle massage of the upper back, in the triangle between the shoulder blades to where the neck meets the skull while you wait for the ambulance. Think of a parent comforting a crying child by rubbing his back. It is the intent that matters almost as much as the points.
We can practice this during the break or lunch if you want. For now, just find Ding Chuan and Kidney 27 on yourself.
Students practice
finding Ding Chuan again, and finding K 27.
Ding Chuan (EX 17): Cup your right hand over your right shoulder, so that your pinky finger follows the curve of your neck and your ring finger nests between C-7 and C-6. Your middle finger is over the right Ding Chuan point in a slight depression between two muscle groups.
Elegant Mansion (K 27): Place your fingertips below your collarbone. Rub with firm pressure, feeling for an indentation and soreness. When you get the point, you will feel a connection with your throat or chest, especially when you deepen your breath.
Asthma aftercare
Facilitator says
If he does not go to the hospital:
Encourage him to go home or to a safe place with fresh air.
He should rest for a day and drink lots of room-temperature water.
When he leaves your care, he should remain in a "buddy system" while he goes home or to a safe place to rest, in case his condition gets worse.
Respirarory distress review
Facilitator asks
Let's review. How can we tell a person has respiratory distress? Good answers:
Unresponsive or with altered mental status.
Choking, gasping, gurgling, can't talk or only talks in a few breaths at a time.
Shortness of breath -- "can't catch breath."
Combative or with other personality changes; terrified.
Using extra muscles to breathe.
Noisy breathing.
Fast or slow respirations.
Tripod position.
Color changes: turning ashy, pale, or blue (on skin or inside lip; eyelid).
Breathing
Facilitator says:
Breathing is a coordinated action of muscles to move air deep into the lungs where oxygen is traded for carbon dioxide. The airway can be open all the way down to the air sacs in the lungs and the person can still have difficulty breathing, ineffective breathing, or no breathing. Some causes:
Chest trauma: broken rib, punctured lung.
Poisoning: inhaled (carbon monoxide, gasoline), swallowed (sleeping pills), injected (heroin).
Medical: stroke, congestive heart failure/pulmonary edema.
Traumatic brain injury.
Facilitator says:
Always call 911 for airway or breathing emergencies.
If the person is alert, take a history by asking questions to discover the cause of breathing distress. This will be very useful information to pass on if the person's level of responsiveness (LOR) declines before the ambulance arrives, or before you arrive at an emergency department. We will practice taking a history after lunch.
You can help a person get into a position that makes breathing easier. Most breathing support positions -- whether sitting or standing -- involve leaning forward with the back straight and the knees spread apart. A person who is lying down may breathe better if propped up at a 45 degree angle with the back straight, the knees spread, and some pillows to wrap their arms around.
If a person is unresponsive and in respiratory failure, you can help in some cases with techniques learned in a CPR class. We don't teach CPR here; we teach you to flag down a bystander who knows it, so you don't get pinned down. The American Heart Association, the American Red Cross, and the National Safety Council all offer great CPR classes in Chicago: take one and get your card.
The American Red Cross offers a training on administering emergency oxygen until further help can arrive. This is outside street medic scope of practice in a protest, but is a great skill to have for community workers who visit elderly people in their homes.
Check out the Chicago Recovery Alliance website (anypositivechange.org). They have a really good training video for preventing overdose death, and can hook you up with a
The Harm Reduction Action Center is an incredible Denver based-resource for overdose prevention. 733 Santa Fe Drive, Denver (303) 572-7800. They can now legally prescribe narcan to many third party individuals, as well as active IVDUs. Narcan reverses overdose of heroin, vicodin, percocet, oxycontin, methadone or other opiates for an hour. If you know anyone who gets high on these drugs or uses them for pain control, it's not a bad idea to be prepared. Also check out the online training video on overdose response at anypositivechange.org.
Facilitator says
Basically, keep learning. This training is just a beginning.