OK, Now What?

      Last month in BTB, we looked at the skill of assisting ventilations and some of the challenges associated with this infrequently used intervention. This month, I'd like to share one of the most valuable training techniques I've ever come across that will improve both your BVM technique and your understanding of what this intervention really means.

   Well over 10 years ago, I was teaching at the Oklahoma EMT Association conference and the topic of assisting ventilations came up, generating quite a dialogue after the talk. At some point in the conversation, an EMS instructor said to me, "Things would improve if you would teach Bag-a-Buddy." I'm certain the look on my face betrayed the fact that I had no clue whatsoever as to what this lady was talking about. Thank goodness, she took time to explain it. As a result of what she taught me, every paramedic class I've taught since that point has included at least three or four skills labs where Bag-a-Buddy was practiced and polished. Why? Read on as we look at this incredible training technique.

What is Bag-a-Buddy?

   Here's the basic plan for Bag-a-Buddy training. The equipment list is short: a new disposable mask for every trainee; lots of O₂; O₂ connector tubing; disposable or reusable BVMs. The methodology is equally simple. One person lies on the floor or blanket (depending on the floor status), legs uncrossed, hands at his sides. A towel or pad placed under the occiput will usually put them at or closer to neutral position. The person acting in the provider role positions himself in the position he would normally assume to ventilate a patient. The patient needs to focus on "relaxing" and letting the other person breathe "for him." A key to this is to actually try NOT to actively take a breath when the person tries to ventilate you. If you take a breath in sync with the ventilation, it makes the breath go in far faster than normal. It also distorts the ventilator's ability to ascertain lung compliance, i.e., the ease or difficulty with which a breath goes in. Also, relax when the provider positions your head/neck/airway. Don't make him fight to keep you properly positioned. Lastly, make certain that at least 10 LPM of oxygen is flowing through those bags. First-timers routinely breathe far too slow, and that extra oxygen is a blessing to the patient who is getting hypoventilated.

   When you practice Bag-a-Buddy, there are multiple benefits to be gained, depending on which role you are in at the time.

   You as Provider: In this role, your actual ventilation skills are the main beneficiaries of this training. Even the best high-cost patient simulators are a far cry from working with a real human being. Neck pliability, mechanical function of the mouth and jaw, and skin likeness/ability to get a seal are much different on people vs. manikins. Much, much different.

   Properly positioning your fingers in the oft called "c-clamp" position takes lots of practice to get it right the first time, every time. Finding the right jaw structure so that you can lock in a finger to help maintain both mask position and seal is truly a finesse technique. Positioning the head/neck in extension is relatively easy. Keeping it there, breath after breath, takes focus, because with each breath, the tendency is for the chin to drop and the head/neck to move closer to neutral position. Without an OPA in place, this anatomical problem is much more pronounced. Bag-a-Buddy requires that you be continuously attentive to the position of the head/neck, since you don't have a mechanical device to assist you. Lastly, if you are using a decent quality BVM, AND the patient doesn't work to actively inhale, you can develop a much better feel for lung compliance.

   You as the Patient: In this role, there are far different lessons to be learned, but they are every bit as important as those learned in the provider role. Clearly, the most important lessons on this side of the equation are empathy and understanding. The first time somebody clamps their fingers onto your jaw and slaps that plastic mask on your face, while at the same time sliding your head back as they pull your neck into an extended position, is an unnerving experience to say the least. The squeezing thighs around your head aren't that pleasant either. Those first few breaths can be quite a unique experience as well.

   As the provider starts to breathe for you, if he is talking to you and getting you in sync with his squeeze, being ventilated is a relatively relaxing experience. I've had many students say they've actually dozed off during a 4- or 5-minute practice session.

   When I teach this technique, I start with having students ventilate two of their comrades for two minutes each. That may not sound like much, but believe me, four minutes of breathing for somebody else is. Eventually, I have them do four people for five minutes each. It's helpful to work with these time frames. For EMT-Bs working in ALS systems that do rapid sequence inductions, with longer-acting paralytics, if the patient cannot be intubated and has to be manually ventilated until the paralytic wears off, 15 to 20 minutes is a pretty common time frame. It is often said, "The way you practice is the way you will perform." If you are only good for 5 minutes of quality ventilations and your patient needs 20 minutes, it's the patient who will come up short in that equation every time.

   Until next month…

   Mike Smith, BS, MICP, is program chair for the Emergency Medical Services program at Tacoma Community College in Tacoma, WA, and a member of EMS Magazine's editorial advisory board.