Over the years of moving vented patients and watching new clinicians get their heads around the vented patient, I have come to observe the same mistakes/oversights with some frequency. With respect to DOPE and SCOPE for troubleshooting some of the alarms that may be encountered, I have a different acronym that I use as more of a pre-departure checklist. These are the things that the rookie is most likely to SKIP or miss early on, so this one is for the preceptors/FTOs.

SKiPS
SKiPS is more of a pre-departure checklist of things that need to be done no matter what, on each and every transport. Forgetting to suction can cause “stuff” to build up in the tube and give you bizzare feedback and alarms that can be solved simply by suctioning. Packaging a mess of tubes and lines underneath the life blanket will most assuredly become a problem when you can least afford it. Don’t be the person, like I was, that had IV lines tangled around IV lines tangled around the vent tubing.
Pain control and sedation are musts, especially in transport. With a monsoon of respect to the evidence that is out there on ICU delerium from long-term sedation, the transport environment is not the ICU. The level of care is the same, but the environment is a total assault on the patient. The sicker they are and need respiratory therapy, the more we need to remove them from the equation with a good pain control and sedation strategy. I do not advocate that the patient be taken down to a RASS of -5 everytime, but I do advocate for adequate pain control and sedation… if you have to tie their hands down for the transport, you probably could give them more pain control (first) and then some more sedation. Go up on the pressors if you have to.
Here is the pre-departure checklist:
Suction – suction the tube and the mouth before you depart.
Kinks – package the patient to avoid the vent tubing and feedback lines from getting stuck under a wheel or kinked during movement.
Pain Control – this is paramount. None of the vent feedback numbers you get matter if the patient is overbreathing or fighting the vent. Get their pain under control!
Sedation – sometimes it is necessary to supplement pain meds with some sedation. Remember, sedated in the hospital is not the same as sedated for flight/ground movement.
DEEP
When there are alarms, these are the things you monitor for and actively exclude them as problems when the alarms start going off and things do not look right:
Deep Tube / Deflated Cuff – both of these give you pressure alarms that if you miss them can have you chasing your tail.
Exhalation Problem – Do they have enough time to exhale? Often the rookie will make a rate adjustment and not ensure the I:E ratio allows for a full exhalation.
Empty O2 Tank – this one sneaks up on you in the elevator or during your walk across the parking lot. Stay ahead of it!
Pneumothorax / Pressure Limits – you have to look for and aggressively treat a pneumo in the vented patient. Along with that, you have to ensure that the pressure limits and alarms (especially with the T1) are set appropriately.
Close Out:
These are not evidence based medicine issues that I present here. They are experience based medicine lesson that I learned the hard way over the years either as the operator or by not paying attention to a new trainee as a preceptor. Some of these issues can be fatal if they are left unrecognized, and at the very least will leave you exasperated and exhausted from chasing your tail if you miss one.
Feel free to copy and share with your teams.
