# Intubation



## MinnesotaMedicStudent (Jan 14, 2009)

I'm going to probably sound like an idiot, but please don't be too hard on me.  It's my first time posting and I'm a relatively new medic student.  

We have not covered intubation yet and I have some questions.  I was doing some of my BLS rides (riding on an ALS rig but only being able to do interview, vitals and such) and my preceptor confused me.  The call was for an overdose.  

We get on scene to find an 84 year old woman unresponsive on the floor.  She is breathing (R-14, SPO2- 95% on RA), has a GCS of 5 (E-1, V-2, M-2), and has bounding distal pulses (BP 112/64, P 60 regular).   There are about 12 empty pill containers in the bathroom, husband states she takes her pills and goes to bed before him, he last saw her about 1.5 hours ago.

One of the bottles was for percocet, husband states he thinks that was already empty.  Pupils dilated (equal at 4mm, reactive, round).  Pt does not appear to have vomited, is not diaphoretic (warm to touch, skin appears normal), and has good cap refill.  

She has snoring respirations that are easily corrected with a simple head-tilt.  Here's where my question comes in.  My preceptor was the attending and he elected to place a nasal pharyngeal airway and provide oxygen via mask.  His partner appeared to think the lady should be intubated and after some not-so-subtle hints at such the preceptor attempted to place an oral airway and then said "not going to happen, she has a gag-reflex".

Should she have been intubated?  I've read that a gag-reflex doesn't mean the patient is protecting her airway.  If your service, like this one, doesn't have RSI, can you intubate a patient with a gag reflex?  When you intubate someone who is breathing adequately, how do you bag them?  Try to do it when they are inhaling but still only 8-10 times a minute, even if they are breathing faster (in this instance 14)?  Do you try to sedate them with the drugs you have?

This service carries versed and morphine for controlled substances.  No etomidate, vec, succ, or anythings like that.  

Thanks for your help.  Also, if you have any links to reading material that may help me it would be much appreciated.  I apologize if I sound like an idiot.


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## Sasha (Jan 14, 2009)

She was breathing fine on her own, so it seems. No need to intubate. If it's not broken, don't fix it!


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## Epi-do (Jan 14, 2009)

First of all, you don't sound like an idiot.  You are a student, therefore, you are building the foundation all other learning will build off of.  I have only been a medic for a couple months and am still learning so much.  It's almost like I am still in school because I have moved from a controlled environment to one that I have to control.

Based on the information you presented, I would not have intubated the patient.  At the time, she was breathing adequately on her own.  I agree with the NPA, and I would have continued to monitor her airway.  

We do not have RSI, so I can't really comment on that.  As far as intubating a patient with a gag reflex, I have only seen it done once.  It was for an asthmatic that was teetering on respiratory arrest and was in the middle of respiratory failure.  They had been tubed in the past and were begging us to do it again.  The medic I was working with at the time did a blind nasal intubation on them.

Any sort of sedation of the patient you had would depend upon local protocol, but I would be hesitant to put any more drugs onboard if you are treating an overdose of multiple substances.  At the very least, I would contact medical control before doing anything along those lines.



> When you intubate someone who is breathing adequately, how do you bag them?


If someone is breathing adequately, I am not sure why you would intubate them, or bag them.  Maybe one of the more seasoned medics can address this one better for you.

As for bagging a patient with inadequate respirations, if they are alert, I try to bag with their respiratory effort as long as it is within a "normal" range.  Sometimes, they just aren't able to get the tidal volume on their own for whatever reason.  You will also find that an alert patient may fight you when you try to bag them.  Sometimes you can talk them through it, and they will relax enough to accept it.  Othertimes, you just do the best you can.

For an unresponsive patient, I bag them at an appropriate rate.  If they are breathing too slowly, I still try to bag when they are inspiring, but will put extra breaths in there as well.  If they are breathing too quickly, I only bag them at around 10 breaths/minute to try and slow them down.

I personally don't have any links readily available for you, but if you do a search on the net I am sure you can find info.  Good luck in school, and keep asking good questions of those around you.


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## tydek07 (Jan 14, 2009)

Hi,
 It does not sound like this pt needed to be intubated. From what you have told us, I would not have intubeted this person... But remember, I was not there and do not know what all was going on. 

Can you intubate someone with a gag reflex without RSI? Very rare that it would need to be done...

How do you bag them if they are breathing on their own? Lets say a person is breathing 6/min. and you are assisting them with ventilations. It helps that you find a rythym so when they take a breath, you are also giving them a breath... just find the rythym. 

I used a resp. rate of 6/min. as if a person were "breathing adequately" (as you put it) there is no reason to assist ventilation, little own intubate the person.

Take Care,


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## MSDeltaFlt (Jan 14, 2009)

MinnesotaMedicStudent said:


> I'm going to probably sound like an idiot, but please don't be too hard on me.  It's my first time posting and I'm a relatively new medic student.
> 
> We have not covered intubation yet and I have some questions.  I was doing some of my BLS rides (riding on an ALS rig but only being able to do interview, vitals and such) and my preceptor confused me.  The call was for an overdose.
> 
> ...



Hope this helps.


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## tydek07 (Jan 14, 2009)

Oh, I forgot:

_I'm going to probably sound like an idiot, but please don't be too hard on me. It's my first time posting and I'm a relatively new medic student. _

Your not an idiot, you are a student  Students are suppose to ask questions and learn... 

There two types of students: 1) Students that ask question after question after question. 2) Students that do not ask questions and think they know it, or will learn it on there own.

Do you think students 1 or students 2 become better medics?

Take Care,


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## MinnesotaMedicStudent (Jan 14, 2009)

Thanks for the replies.  So for everyone who said she doesn't need to be intubated because I said she was "breathing adequately":  What would you do if she was breathing at, say 4 per minute and SPO2 is 60 but still has a gag reflex.  Would/do you nasally intubate?  Do you keep the NPA in place and just bag her?

Thanks again all!

Also a few replies to questions/comments:


> A medic student and doing BLS rides?!? I'm confused. If you're a medic student and not allowed to do medic stuff, why are you doing any rides at all?



The rides are the very beginning of our internship.  We do 40 hours of "BLS" rides to get familiar with the service, get to know the preceptor so they can get comfortable allowing you to do things, and such.



> Doesn't sound like an overdose per se. At least not of narcotic origin. Narcs suppress. She'd more than likely be breathing slow and shallow; not 14/min with a RA SpO2 of 95%. Even though BP's not high, I'd be thinking CVA with BP normalizing. Semmantics, I know. But I digress.


Yes, you are right that it wasn't narcotic.  Of the 12 bottles, her husband thought all had pills EXCEPT the percocet.  The rest were a combination of anxiety, depression, sleep, hypertension, and metformin.  He was sure that those had pills, most of them had been filled in the last week.


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## MinnesotaMedicStudent (Jan 14, 2009)

Oh, one other thing I forgot that added to my question was that the first thing they did on our arrival to the ER was intubate this patient, with RSI.  I know we aren't the ED, but it just made the question stand out that much more.


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## marineman (Jan 14, 2009)

I know MSDeltaFlt will probably have a bit of science to his answer but at my service we would probably ask med control but technically per protocol we are supposed to intubate anyone with a GCS of 8 or less. I know that's really an arbitrary number and two patients at 8 could be completely different than each other but that's what the guy with the license says to do that's what we do. 

We usually clarify with online med direction before doing it in a borderline situation like that and in that case would probably depend on which MD is on duty that day.


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## remote_medic (Jan 14, 2009)

I'm going to echo what others have said. Did this patient need to be intubated...yes. Did it need to be done prehospital by a service that does not do RSI (as evidenced by your lack of paralytics)...NO!!!

Attempting to intube a patient with a gag reflex should not be done with some exceptions (airway burns and asthmatics come to mind). If they hadn't vomitted before they most certainly will once you try intubating. The last thing this patient needed is an aspiration pneumonia on top of the polypharmacy overdose.

As for your questions, they are not dumb. They are very valid and I would encourage you to ask more as things come up. I'm pretty new around here myself but have learned a lot by reading what other experienced EMTs/medics/nurses/RRTs/Med students/etc have to offer. Some will be a bit more harsh then others but we should all have the same goal of bettering ourselves and our field.


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## Epi-do (Jan 14, 2009)

MSDeltaFlt said:
			
		

> A medic student and doing BLS rides?!? I'm confused. If you're a medic student and not allowed to do medic stuff, why are you doing any rides at all?



I don't think this is all that uncommon.  (At least it isn't around here.)  I know in my medic program we were required to have a certain number of BLS contacts.  Similar to what MnMedicStudent said, it gave us a chance to get to know the preceptors and also gave them a chance to see how well we could evaluate a patient and make sure we had good BLS skills to build off of.  Likewise, we did no ALS skills until second semester.


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## el Murpharino (Jan 14, 2009)

Also you mentioned about a gag reflex not being an indication that your patient can maintain their airway.  The ability to swallow is a better indication that your patient will be able to maintain their airway (don't take this as gospel, as it hasn't been adequately studied).  Also, if you're testing the gag reflex to determine airway patency, you run the risk of aspiration (aspiration of gastric contents carries a 90%+ mortality rate).  Nasal intubation is always a choice in breathing patients - if your area allows it.    

A couple of other factors to think about:  Transport time, anticipated clinical course of your patient, available help...and that's not even considering your patient.  Are they going to be an easy tube, are there reversible conditions?  Now granted this isn't as applicable for this patient as much as future ones, but there is a multitude of factors to consider before intubating a patient.


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## Juxel (Jan 14, 2009)

This can be a complex case and many different sides can be argued.  Does your patient need an airway?  Yes.  Does he or she need immediate field intubation (even with RSI)?  Probably not.  Transport time, the judgement of how difficult of an intubation the patient will be and many other factors will play a role in the decision.  My service allows RSI but we are a dual-state service and if you are on one side of the river the law dictates that both medics or RN/medic must be at the patient's side for RSI.  That also plays a factor in the decision.

In the described situation, if the service you are with does not have RSI and does not allow nasal intubation, or nasal intubation is unsuccessful, I would place the patient in the recovery position (with the O2 via mask and NPA) and have suction ready in the event she vomits.  

A gag reflex _does not_ indicate the airway is being protected.  See:

Moulton C, Pennycook A, Makower A. Relation between the Glasgow Coma Scale and the gag reflex. BMJ 1991;303:1240–1241.
Bleach N. The gag reflex and aspiration: a retrospective analysis of 120 patients assessed by videofluoroscopy. Clin Otolaryngol 1993;18:303–307.
Davies AE, Kidd D, Stone SP, et al. Pharyngeal sensation and gag reflex in healthy subjects. Lancet 1995;345:487–488.
Chan B, Gaudry P, Grattan-Smith TE, et al. The use of Glasgow Coma Score in poisoning. J Emerg Med 1993;11:579–582.


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## Flight-LP (Jan 15, 2009)

Lets look at the variable we know..........

12 empty pill bottles.

A strong historian (the husband).

A severly altered patient with relatively normal hemodynamics.

Way to many questions and not enough information immediately available to put 1+1 together. 

In other words, she just bought herself an endotracheal tube. RSI would be ideal and would minimize potential risks associated with an intact gag, however if not available, there is this beautiful skill that many are afraid to do and many aren't even taught any more; that being nasotracheal intubation. The reality to this is that any competent physician will intubate this person upon arrival at the ER until he/she can get some answers. Having someone in that room constantly manually monitoring an airway is not practical, nor efficient; intubation and vent placement takes care of that problem for the short term. 

Distance to ER is irrelevant. If something needs to be done, then do it. The 'pawning it off on the ER 'cause I don't feel comfortable with doing it' attitude and belief that diesel medicine is still appropriate is one major downfall of progressive EMS. This skill is well within a Paramedic's scope of practice, not doing it when needed is just negligent, sorry.


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## Juxel (Jan 15, 2009)

Flight-LP said:


> Distance to ER is irrelevant. If something needs to be done, then do it...not doing it when needed is just negligent, sorry.



I disagree with this as a blanket statement.  For example, let's say you are 3 minutes from definitive care, as can be very frequent in a large urban setting.  Realistically, it's going to take you about 7-8 minutes to RSI someone when you combine starting the IV, monitor, preparing intubation equipment, drawing up meds, giving meds, tubing, verifying, and then moving from back of rig to front to transport.

If you call the hospital and say "I've got a 100kg male who is going to need to be RSI'ed as soon as we arrive" they can have all the equipment ready, the meds drawn up, and with the line you started during the 3 minute transport the patient can be intubated in a more controlled setting in the same amount of time it would have taken you to do it AND the patient is now at a definitive care site.


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## triemal04 (Jan 15, 2009)

Juxel said:


> I disagree with this as a blanket statement.  For example, let's say you are 3 minutes from definitive care, as can be very frequent in a large urban setting.  Realistically, it's going to take you about 7-8 minutes to RSI someone when you combine starting the IV, monitor, preparing intubation equipment, drawing up meds, giving meds, tubing, verifying, and then moving from back of rig to front to transport.
> 
> If you call the hospital and say "I've got a 100kg male who is going to need to be RSI'ed as soon as we arrive" they can have all the equipment ready, the meds drawn up, and with the line you started during the 3 minute transport the patient can be intubated in a more controlled setting in the same amount of time it would have taken you to do it AND the patient is now at a definitive care site.


Or you walk in and are met with a nurse who says "so what where you blabbering about on the radio?" and then proceeds to assess the pt, call the doctor who assess's the pt, calls for meds to be drawn up and respiratory to be called, sets up his equipment, waits for the meds to be drawn up, pushes them, and then intubates the pt.  So at this point how long has the pt been waiting to be RSI'd from the time you did your initial assessment?

Point being that you might, might be able to get away with that sometimes but in all reality many times an ER will not be able to immedietly perform the procedure that you could have done when you walk in.  It may work out sometimes, but others you will be left holding the bag.  And hopefully will have to answer for your actions (pawning off the pt on someone else instead of treating them)  Blanket statements like YOUR'S are not a good way to go.

Just bringing someone into the ER does not mean that they will magically be treated at the snap of your fingers; there will still be a time lag before anything happens.  How much depends on where you are and what is wrong, but delaying your treatement because you are close is almost always a bad idea.


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## Juxel (Jan 15, 2009)

triemal04 said:


> Or you walk in and are met with a nurse who says "so what where you blabbering about on the radio?" and then proceeds to assess the pt, call the doctor who assess's the pt.



You guys must operate much differently than we do.  We can call on the radio, "3 minutes out with a critical patient, need a doctor at *Insert hospital*"  We'll have a doctor within seconds.  The doctors are great and trust our field judgement. If you tell them someone needs something, it is ready when you get there.

I'm not saying you should "pawn" off care because you are lazy or not comfortable doing your job.  However, I do believe there are times when a patient shouldn't be RSI'ed in the field, my above example being one of them, especially if you judge the patient to be a difficult intubation.


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## MSDeltaFlt (Jan 15, 2009)

Juxel said:


> I disagree with this as a blanket statement.  For example, let's say you are 3 minutes from definitive care, as can be very frequent in a large urban setting.  Realistically, it's going to take you about 7-8 minutes to RSI someone when you combine starting the IV, monitor, preparing intubation equipment, drawing up meds, giving meds, tubing, verifying, and then moving from back of rig to front to transport.
> 
> If you call the hospital and say "I've got a 100kg male who is going to need to be RSI'ed as soon as we arrive" they can have all the equipment ready, the meds drawn up, and with the line you started during the 3 minute transport the patient can be intubated in a more controlled setting in the same amount of time it would have taken you to do it AND the patient is now at a definitive care site.



True.  However, even with your knowledge, training, and experience, you know that a lot can happen in 3 minutes.  Not just with hypoxia, but also with the increased ICP's associated with hypercapnia AND the cerebral ischemia associated with hypocapnia.


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## VentMedic (Jan 15, 2009)

Juxel said:


> You guys must operate much differently than we do. We can call on the radio, "3 minutes out with a critical patient, need a doctor at *Insert hospital*" We'll have a doctor within seconds. The doctors are great and trust our field judgement. If you tell them someone needs something, it is ready when you get there.


 
That is the way many EDs and EMS teams work together. 

However, there are those that prefer to sit in the hospital parking lot for 15 minutes while the ED staff is waiting and wondering if the truck broke down. We've even sent one of our LEOs (stationed in the ED) to check on them only to find the Paramedics were trying for the 5th time to get a tube because of someone's ego not letting them come into the ED without one. 

If you can not maintain an airway on a patient that still has spontaneous respirations for 3 minutes as you pull into the ED you probably shouldn't be messing with RSI either.


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## triemal04 (Jan 15, 2009)

Juxel said:


> You guys must operate much differently than we do.  We can call on the radio, "3 minutes out with a critical patient, need a doctor at *Insert hospital*"  We'll have a doctor within seconds.  The doctors are great and trust our field judgement. If you tell them someone needs something, it is ready when you get there.
> 
> I'm not saying you should "pawn" off care because you are lazy or not comfortable doing your job.  However, I do believe there are times when a patient shouldn't be RSI'ed in the field, my above example being one of them, especially if you judge the patient to be a difficult intubation.


Sure, I can agree with that.  And I love taking pt's to hospitals like the one you mention.  Unfortunately I also take pt's to ones that are the exact opposite.  This is where knowing your system and really thinking about what needs to happen and how long it'll actually take to happen if you don't do it comes into play.  Even if you are right across the street, there are times when it'll still be better for you to do something versues transporting and waiting.  And times when it won't.

And yeah, in the given situation, if the pt was say, 300+ pounds and 5'4", and the hospital was 3 minutes away (and the time away should always be measured from where you find the pt, not just drive time) then electing to not RSI, and give enough info to the ER before getting there to ensure that they were ready...good choice.  But if the pt was normal sized...still have to go with RSI in the field.  

Out of curiousity, what if this pt had vomitted, or been vomitting?  Would you still transport without RSI, or perform it right then?


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## Ridryder911 (Jan 15, 2009)

Sasha said:


> She was breathing fine on her own, so it seems. No need to intubate. If it's not broken, don't fix it!



It is broken. Unresponsiveness = inability to control airway = high percentage of aspiration, hypoxia, anoxia, death. 



Juxel said:


> This can be a complex case and many different sides can be argued.  Does your patient need an airway?  Yes.  Does he or she need immediate field intubation (even with RSI)?  Probably not.  Transport time, the judgement of how difficult of an intubation the patient will be and many other factors will play a role in the decision.  My service allows RSI but we are a dual-state service and if you are on one side of the river the law dictates that both medics or RN/medic must be at the patients side for RSI.  That also plays a factor in the decision.



Just how long does it take for someone to blow chow and then aspirate? Transport time should never take precedence over ensuring a safe and effective airway. Again, just how long does it take to perform RSI? Remember, even in the ED setting it still will be another additional 3-5 minutes to have RSI performed in the best of the systems. So now, we are now looking at 10 minutes longer, when RSI should be accomplished in usually < than 3 minutes? 

Use common sense. Judge wisely based upon multiple reasons. 

Remember this thought, if you think of the possibility of intubation is needed, it was. 

R/r 911


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## VentMedic (Jan 15, 2009)

Ridryder911 said:


> Just how long does it take for someone to blow chow and then aspirate? Transport time should never take precedence over ensuring a safe and effective airway. Again, just how long does it take to perform RSI? Remember, even in the ED setting it still will be another additional 3-5 minutes to have RSI performed in the best of the systems. So now, we are now looking at 10 minutes longer, when RSI should be accomplished in usually < than 3 minutes?


 
From the original post:



MinnesotaMedicStudent said:


> If your service, like this one, *doesn't have RSI*, can you intubate a patient with a gag reflex? When you intubate someone who is breathing adequately, how do you bag them? Try to do it when they are inhaling but still only 8-10 times a minute, even if they are breathing faster (in this instance 14)? Do you try to sedate them with the drugs you have?


 
Jumping to RSI is the easy solution.  Of course every service has RSI ability. 

If you are 3 minutes from the hospital, have a breathing patient that can be assisted and no RSI, how long do you want to stay on scene while attempting to intubate with the risk of aspiration? 

In the ED, we can get an NG tube within the first minute and to suction if necessary while the airway is being maintained. 

RSI can be done in 3 minutes by a very experienced Paramedic under ideal situations. Some Paramedics don't get enough intubations each month or in a year to get that efficient with or without RSI. You are also assuming every patient will react the same with the RSI recipe. Not all patients go down easy even with a drug OD on board.


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## Ridryder911 (Jan 16, 2009)

I understand and respect your opinion Vent, but here is my opinion. If you are unable to intubate a few times a year, privileges should be considered yet then again.... I know the majority of physicians never intubate that often and yet they are still able to. 

In my opinion I have found intubating a patient is just as easier as placing a NG tube in and in some cases I have actually seen gastric tubes actually cause vomiting and aspiration, hence why many recommend securing the airway especially in drug induced and those that might have potential vomiting. I agree both should be used, dependent upon the case which I would perform first. 

Point being, use common sense and the situation should be based upon each individual case. Some I might elect to intubate and some I may not; hence why I am a practitioner. The patient is breathing and you are comfortable assisting with and monitoring airway; so be it. Just remember the BVM does increase the risks of gastric distention and vomiting.  

Again, alike any other scenario and situation(s) there maybe and usually are many approaches that could be considered right or wrong. 

R/r 911


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## VentMedic (Jan 16, 2009)

Ridryder911 said:


> The patient is breathing and you are comfortable assisting with and monitoring airway; so be it. Just remember the BVM does increase the risks of gastric distention and vomiting.


 
And intubating without RSI may also increase the risks of intubation greatly. Correct BVM may have less risk. I emphasize correct BVM because without some comfort in that skill, again referencing to the initial post, you should NOT be doing RSI.

You must also work within what your system has to offer. If your system doesn't do RSI, you can talk about all the benefits of it you want but that ain't gonna help you out for that moment in time.

Placing an NG tube also takes experience and that is why those that do them the most do them the best.


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## VentMedic (Jan 16, 2009)

Abstract from Prehospital Emergency Care. 

Abstracts for the 2009 NAEMSP Scientific Assembly 

www.naemsp.org

Link to Publications

* Paramedic Endotracheal Intubation Experience Improves Patient Survival*

 Henry E. Wang, Goundappa K. Balasubramani, Judith R. Lave, Donald M. Yealy, Lawrence J. Cook, University of Pittsburgh

Introduction. The effect of paramedic endotracheal intubation (ETI) experience on patient outcomes is unknown. We evaluated the association between paramedic ETI experience and patient survival. Methods. Using 2000-2005 Pennsylvania statewide emergency medical services (EMS) data, we calculated total clinical ETI experience for each individual paramedic during 2000-2005, categorizing total (6-year) ETI experience as low (1-10 ETIs), medium (11-25 ETIs), high (26-50 ETIs), and very high (> 50 ETIs). Using multiple imputation triple-match algorithms, we probabilistically linked 2003-2005 (3 years) EMS ETI records to statewide death and hospital admission data, identifying the primary outcome survival on hospital discharge. We determined the association between patient survival and paramedic total ETI experience, adjusting for paramedic total clinical experience; patient age, Glasgow Coma Scale score (GCS), heart rate, systolic blood pressure, and major trauma; and EMS population setting. We separately evaluated cardiac arrest ETI and nonarrest ETI. We analyzed the data using multivariate random-effects regression, clustering by individual paramedic and combining imputed results using Rubin's method. Results. Across the imputed sets, we linked 25,718 (77.7% linkage rate) ETIs performed by 5,433 paramedics to patient outcomes. There were 4,835 (18.8%) by low-, 9,850 (38.3%) by medium-, 8,513 (33.1%) by high-, and 2,289 (8.9%) by very-high-ETI-experience paramedics. Survival was 17.4% (3,204/18,414) for cardiac arrest ETI and 68.2% (4,981/7,304) for nonarrest ETI. Adjusted survival was higher for cardiac arrest patients intubated by high-and very-high-ETI-experience paramedics; combined odds ratio (OR) (95% confidence interval [CI]) vs. low ETI experience: medium 1.04 (0.91-1.18), high 1.18 (1.01-1.38), and very high 1.29 (1.04-1.61). Adjusted survival was higher for nonarrest patients intubated by high-and very-high-ETI-experience paramedics; combined OR (95% CI) vs. low ETI experience: medium 1.05 (0.8-1.25), high 1.31 (1.07-1.60), and very high 1.59 (1.21-2.10). Conclusion. Increasing paramedic clinical ETI experience is associated with improved ETI patient survival.


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## Flight-LP (Jan 16, 2009)

Sorry, but it takes less than 2 minutes to prep and slide an ET tube through someone's nasopharynx. The problem lies in (as usual) education and retention of practical knowledge due to disuse. I see medics that are petrified by the notion of performing a blind intubation. Yet they have no problem with their pt. getting aspiration pneumonia because the hospital "is so close". Too much can happen in an instant, much less several minutes. It would be nice to have the NBC "ER" version of care where the doc's meet you at the back door, but here in the world we call reality, that isn't the case. Even if they were ready and rearin' to go, what happens when the MI pt. they just brought back from triage decides to code 1 minute before your arrival??????

There will always be exceptions to the rules, but not providing a definitive airway based solely on the lack of RSI is absurd. Nasopharyngeal intubation, LMA, Combi-tube, and King LT, are all acceptable methods. But just bagging an altered pt is asking for trouble.

Treat your patients as you have been educated to do. Relying on others to provide accetable treatments that are available to Paramedics is negligent. Agree or disagree, thats my belief and I am sure the belief of many other professionals.


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## VentMedic (Jan 16, 2009)

Flight-LP said:


> Sorry, but it takes less than 2 minutes to prep and slide an ET tube through someone's nasopharynx. The problem lies in (as usual) education and retention of practical knowledge due to disuse. I see medics that are petrified by the notion of performing a blind intubation.


 
Yes, nasointubation is an alternative and in 3 minutes at the hospital that tube will quickly be removed and O-ETI will be done. 

I am not oposed to NTI in the field but it is not my top choice either especially if I am 3 minutes to the hospital. Blood aspiration and vomit run neck to neck for PNA.

Maybe you just want to stick a face mask over the end of that tube also instead of using the Bag-Valve.

Taken an ACLS class lately?


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## Flight-LP (Jan 16, 2009)

I guess its a local thing for you, because I have rarely encountered an occurance where a patent ET tube has been replaced regardless of its entry point. Maybe instead of complicating a situation by removing the tube and replacing (risking the pts. condition even further), perhaps your physicians could verify placement, maybe confirm with radiography? That's what most physicians I worked with for nearly 2 decades have done. But if there is a trust issue with your local medics or just the need for a self servent feeling of superiority, maybe then your medics should not perform any invasive procedure. Then your physicians can do it all by themselves. Maybe diesel medicine is appropriate for your facility to ensure that no adverse issues ever occur and the allmighty ER staff can save the world. 

I've had ER's kill more pts. than I could ever attempt to. While I value your opinions and highly respect your experience and knowledge, lately there seems to be a trend of "Vent and her facility right, everyone else wrong". Maybe its me, maybe I'm overtired, but it really gets exhausting after a while......................

I'm done with it, people can pick through the info posted and decipher how they wish. I'm through with hitting my head on a brick wall...................

p.s. I taught an ACLS class last week for any relevance that it may remotely have on this topic. Of course the day I rely on the AHA to provide me religious guidance on how to practice medicine is the day I retire~


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## Juxel (Jan 16, 2009)

triemal04 said:


> Out of curiousity, what if this pt had vomitted, or been vomitting?  Would you still transport without RSI, or perform it right then?


That changes it.  If they have vomited or are actively vomiting with an altered LOC, they will get a tube even if we are one block from the hospital.


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## VentMedic (Jan 16, 2009)

Flight-LP said:


> I've had ER's kill more pts. than I could ever attempt to.


 
 How you alerted the Police for an investigation?  Can you prove it? Or is this just because you as a TV quarterback could do it so much better?   That is a serious accusation to make unless you have what it takes to follow through with your comments and file a formal complaint.  

I rarely post here anymore because of the bashing.  Some don't want to hear another way to do things or just think anything a hospital does is wrong because only those in EMS know how it really is mentality.   Your way may not always be the most correct way either.    

Haste also makes waste.  Trying to do something too quickly because you are just 3 minutes from the hospital can also lead to poor preparation and a paralyzed but poorly sedated and poorly oxygenated patient getting tubed also.


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## Ridryder911 (Jan 16, 2009)

I am curious why anyone in EMS would have a displaced tube anymore. EtCo2 monitoring with waveform can verify as well as good assessment. Not having an ETT in the proper place is inexcusable and assuming that another airway is comparable is foolish and not true. Again, just because there is those that perform poor techniques is not a reason not to endorsethe most effective proper treatment, rather emphasis should be placed upon the problem... lack of and poor quality control of the performance of the personnel. 

We have to be careful comparing EMS systems. For example in my area, the metro EMS has a >99% intubation rates all with confirmation upon arrival to ED. The reason is simple, evaluation of ETI was getting <95% and re-education with introduction of devices such as flex-guide and confirmation using EtCO2 immediately changed the outcomes. 

Instead of making sacrifices to the patient care, we should focus upon the problem and source of the problem... poor or lack of education. 

Should we abolish other care because certain areas of the country EMS perform poor skills or techniques? If there were EMS that administred NTG wrong, should other EMS stop administering it? The med is still needed, it still works yet should our treatment change because of ill prepared and monitored personell? 

I realize Vent is frustrated with EMS programs. From reading posts from the nation I can understand why and as well upset too. Yet, we need to remember not all is created equal (thank goodness) and the majority of Paramedics can intubate effectively and there are thousands that perform RSI and even intubation more effective and faster than physicians in a ED. Again, it is how well one want to be proficient and knowledgeable in their profession. 

R/r 911


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## tydek07 (Jan 16, 2009)

Oh my, this thread is getting to be a fighting ground 

Everyone is going to have their own opinion(s) on how to handle situations like this. One medic will say intubate, the other will say don't intubate. It also depends on the area that the person is working. We do not do RSI and we are close the ER's (prob. max of 15 minutes in most cases)... Some of mentioned that you could nasointubate this pt if you do not have RSI, yes that is an option... but then again, it depends on the medic and what he opts to do.

Pretty much everything done in the field, can be handled more then one way...

Take Care,


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## VentMedic (Jan 16, 2009)

Ridryder911 said:


> I am curious why anyone in EMS would have a displaced tube anymore. EtCo2 monitoring with waveform can verify as well as good assessment.


 
What percentage of services have ETCO2? I would be happy if all could do a 12-lead but some still can not. I would be even more delighted if some of those doing 12-leads were not relying on machine interpretations. 

I still live in one state that has over 50% of its Paramedics programs being unaccredited medic mills feeding the FDs. 

I visit another state frequently that is still stuck in 1984 for advancements and that is the one where 12-lead EKGs are "science fiction" stuff. 

People do need to know their options for any given circumstance and know that if they can not get a tube, they don't have to stay and play on scene just so they can save face at the ED. There is nothing worst than having a patient with multiple attempts at an IV or ETI arrive with vomit rolling out. The vomit is actually easier to deal with than the butchered cords and throat. 

If one believes their patient can make it 3 minutes to the ED, they shouldn't be criticized for exercising their clinical judgement and comfort level to maintain an airway. Choosing not to intubate should also not be considered the sign of a poor Paramedic if you scored the patient as having the potential for problems. It is when an argument is presented as my way only and bashing those who dare to question you. I will try to provide my view without the use of slander and profanity to get a point across. I enjoy a good debate but not when it turns to personal attacks, personal bashing or bashing facilities and other professionals. However, this is a forum about EMS and those in EMS should be aware of the problems so hopefully the next generation can fix what we haven't over the last 40+ years.


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## Juxel (Jan 16, 2009)

Our service has great ETI success rates and we have not had an unrecognized esophageal intubation in over a decade (not that it should have ever happened).  We have a strict policy on continuous ETCO2 monitoring and every chart with an invasive airway (King, Combitube, or Endotracheal tube) is automatically audited for compliance in documentation.  

We just had re-education on both skills and documentation because people were writing a blanket statement like "monitored ETCO2 and had good waveform throughout patient contact".  We are required to document the numerical reading every 5 minutes and to document verification of lung sounds and waveform anytime the patient is moved.

Two employees were recently fired (after the educational sessions) for failure to properly document despite the fact that their tube placements were verified by chest x-ray upon arrival to ED.


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## Ridryder911 (Jan 16, 2009)

VentMedic said:


> What percentage of services have ETCO2? I would be happy if all could do a 12-lead but some still can not. I would be even more delighted if some of those doing 12-leads were not relying on machine interpretations.



Again, we are discussing poor education. I am surprised how antiquated Florida must be in some areas. Even here is the boondocks all will have either colormetric and anyone that has a LP12 has switched to EtCo2 monitoring for assessment and documentation. Anyone here using the idiot box for interpretation would be laughed or riduculed into disgrace. 

Alike what I said, one should not base treatment upon the adequacy or inadequacy of the system or lack of but on what is proper for the patient. 

Let's not throw out the baby with the bathwater,  instead of making excuses of not properly treating let us fix the problem.

R/r 911


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## daedalus (Jan 16, 2009)

I find myself lucky to have CPAP, 12 lead, ETCO2, etc. I however do not have RSI (Medics have been known to rapidly push versed...). In the OP's situation, the patient requires ETI, there is no doubt in my mind. The patient also could have been managed effectively with a NPA and mask ventilation with a BVM until arrival at the ER, but I believe one should make an attempt at least to secure the gold standard in airway maintenance before transporting with a substandard method. While it may not be negligent it is certainly close.

Mommy and Daddy fighting again? It is okay, because they still love you children.


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## emtjack02 (Jan 16, 2009)

Just playing devils advocate so don't shoot.  Personally I think that NTI would have been a good alternative but... NTI takes more skill and practice to do (so i've read, never had the chance) and if the medics are not well versed in intubating someone with a gag they, IMHO, should not be practicing on this pt.


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## emtjack02 (Jan 16, 2009)

I was also wondering what the standard def of definitive airway is...


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## emtbill (Jan 17, 2009)

Juxel said:


> That changes it.  If they have vomited or are actively vomiting with an altered LOC, they will get a tube even if we are one block from the hospital.



I'm not trying to bash you, but that criteria would be having a lot of my patients getting intubated when they don't need it. Are you going to RSI every drunk patient you get because they have an altered LOC and are vomiting from the EtOH? I can't imagine preforming RSI on a patient who is simply drunk...it has too many potential complications in this scenario. Since this hypothetical patient clearly has food in his stomach evident form his active vomiting, as soon as you push a paralytic he looses all airway protection. Although sellick's manoeuvre should prevent aspiration during laryngoscopy the chance of vomiting has increased significantly now that the patient is paralyzed. What if the patient is unable to be intubated? Sure vomiting threatens the patient's airway, but is it enough of a threat to preform a procedure that has inherent risks in itself? It's a judgment call you have to make yourself, but in my opinion it's not worth it. Would you be negligent for not preforming RSI on this patient? Probably not. Would you be negligent for bringing a paralyzed patient into the ER without an airway who has aspirated because you couldn't get him intubated? Absolutely. I have been doing EMS for going on three years now, and in my service that runs about 4,000 calls a year and I would have preformed RSI on two patients.

As far as the OP's original question goes regarding intubating a patient with a gag reflex: I wouldn't have tried it. In this given scenario the pt was ventilating adequately, and her airway was managed with BLS techniques. There was no indication for intubation to assist her ventilations, and if laryngoscopy was preformed in an effort  to protect against _possible_ vomiting, she very may well vomit from the laryngoscopy itself, and now you have a bigger problem on your hands. The patient would be better served by trying to identify the etiology of her altered LOC after her airway was managed with an NPA. If you can fix that, she can manage her airway on her own. If you have a patient with a gag reflex and who clearly needs intubation the next best thing to RSI would be nasal intubation.


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## triemal04 (Jan 17, 2009)

emtbill- small difference between someone who is drunk and vommiting and someone who's OD'd on meds, has a GCS of 5 and is vommiting (although there are people who get themselves drunk enough to buy a tube unfortunately).  Save for a narcotic OD, you really aren't going to reverse anything in the field.  What you need to do is treat your pt, which in this case would mean protecting the airway against further aspiration risks.  

As far as not being ABLE to intubate...this is where properly assessing your pt prior to trying is important.  What are the odds you will be successful?  Good?  Bad?  Is this predicted to be an easy airway or is this the airway from hell where more than likely you will have to use a backup airway that will still not protect the trachea as well as an ET tube and potentially you will have to use a BVM to ventilate the pt which will also be very difficult?  As said before, there may be times when it will be more appropriate to not attempt intubation, but there will also be many times when it is appropriate to tube someone in this situation, with or without vommiting.  As with all medicine, you should have a good, appropriate and justifiable reason for doing, or not doing something.

Juxel-  figured.  Just had to be sure.  B)


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## Juxel (Jan 25, 2009)

emtbill said:


> What if the patient is unable to be intubated?



As the next poster states, you shouldn't be performing RSI on a patient who hasn't been adequately assessed.  Using techniques like MOANS (Difficult BMV), LEMON (Difficult Intubation), RODS (Difficult Extraglottic Device), and SHORT (Difficult Cricothryrotomy) should give you a very good idea of what to expect with the intubation.


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## sir.shocksalot (Jan 25, 2009)

I think some medics are a little too gung-ho about intubating people. I couldn't see myself intubating a drunk person, if they were really not maintaining an airway whatsoever and vomiting to the point where they may aspirate I might consider nasally tubing them, but if they are just having some airway problems w/o a risk of aspiration shouldn't an NPA do the trick? BLS before ALS right?


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## csykes (Jan 26, 2009)

No intubation!!!  The patient is controlling their airway right now.  NPA is great and NRB.  Respirations at 14, not bad.  Remember the average for a pt is 12-20, one that is doing nothing, lower.  Capnography would be nice on this patient.  RSI is totally out of the question, unless something really starts going south.  As mentioned possible CVA, if this is the case and the pts sats and capnography become very abnormal, then intubation should be considered.  RSI is a dangerous tool, especially here in a pt that is maintaining their airway.  Also, a thorough assessment of the airway with LEMON and MOANS should have been done.  It doesn't really present as a narc overdose, but hey, 2mg narcan will not hurt, especially if there is evidence she has taken more than prescribed.  Assess all Hs, Ts.  BSFS would be a high priority for me on this type of call, in addition to 12-lead.


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## Ridryder911 (Jan 26, 2009)

I'll ask this, what will you tell the Judge and Jury if the patient aspirates and dies? Yes, I was taught to secure an airway in an unresponsive patient but.... hey, he was drunk or O.D. Show me a medic that presumes that they know when a patient is going to vomit and I will show you puke on their uniform. 

R/r 911


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## VentMedic (Jan 26, 2009)

Ridryder911 said:


> I'll ask this, what will you tell the Judge and Jury if the patient aspirates and dies? Yes, I was taught to secure an airway in an unresponsive patient but.... hey, he was drunk or O.D. Show me a medic that presumes that they know when a patient is going to vomit and I will show you puke on their uniform.
> 
> R/r 911


 

Rid,

I do respect your caution but right now I have 12 patients in our holding ward that fit your criteria for intubation. This is a slow night. Friday and Saturday were even more fun. We had 2 holding rooms full. A suction machine is close by for the pukers and there will be at least 1 or 2. But, that usually happens when they start to awaken. Patients will still puke with a tube and that cuff does little to prevent aspiration. The advantage of a tube is the vomit can be suctioned out a little easier. But, if a regular ETT is used, the vomit will continue to drip into the lungs from what is trapped between the cuff and the glottis. 

If every patient matching this description arrived by ambulance intubated or got intubated immediately upon arrival to the ED, there would not be enough ICU beds anywhere in this country. I can run alot of ventilators in the ED but I would rather have the doctors do their magic and kick these patients out when the sun rises. Once the fluids start to do their job, we'll have other problems on our hands but that's another story. A tube buys a patient an ICU or at least a tele bed and an NPO menu even if we can extubate in the ED.


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## csykes (Jan 26, 2009)

VentMedic, I agree 100%.  People are trying to intubate way too many people by means of RSI.  This highly risky skill should be used only when absolutely necessary, i.e. airway burns, chest circumferential burns, CHF when pt crashes and cpap is not helping, but most of all, HEAD TRAUMA (hemorraghing in the cranial vault from cva or mvc that is rendering pt unable to maintain airway) and herniating head injuries.  Only the sickest of the sick, which turns out to be a small minority of the patients we actually pick up in the field.


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## emtbill (Jan 26, 2009)

Juxel said:


> As the next poster states, you shouldn't be performing RSI on a patient who hasn't been adequately assessed.  Using techniques like MOANS (Difficult BMV), LEMON (Difficult Intubation), RODS (Difficult Extraglottic Device), and SHORT (Difficult Cricothryrotomy) should give you a very good idea of what to expect with the intubation.



Any provider who has been taught to correctly RSI knows these mnemonics and should use them during the inspection and pre-oxygenation, but no assessment is perfect, and intubation can still fail. Now you've got a bigger problem on your hands after paralyzing a patient who frankly didn't need it in the first place. As most of the posters here have been saying, RSI should be used infrequently and with mandatory Q&A afterwards on only the most critical of patients. There are plenty of other ways to maintain a patient's airway. I don't know how EMT-B's get by...


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## MSDeltaFlt (Jan 26, 2009)

Vent and Rid,

I honestly believe the two of you are looking at the opposite ends of the same d*mn coin.  Yes, there are drunks that have no business being intubated.  Wake them up and send their *sses home.  *However*, for those moronic Darwin Award nominees who have consumed enough ETOH that their GCS's have dropped to... oh, I don't know... somewhere in the neighborhood of 5 or 6 - maybe even lower, they should probably be sucking plastic.

I don't know.  That's just my call.


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## VentMedic (Jan 26, 2009)

MSDeltaFlt said:


> Vent and Rid,
> 
> I honestly believe the two of you are looking at the opposite ends of the same d*mn coin. Yes, there are drunks that have no business being intubated. Wake them up and send their *sses home. *However*, for those moronic Darwin Award nominees who have consumed enough ETOH that their GCS's have dropped to... oh, I don't know... somewhere in the neighborhood of 5 or 6 - maybe even lower, they should probably be sucking plastic.
> 
> I don't know. That's just my call.


 
But look at the number of patients that are taken care of everyday that have impaired or no gag from CVAs, TBIs and SCIs as well as weak to almost nonexistent coughs. Many have no way of communicating either. If they aren't vent dependent they MIGHT have a *cuffless* trach but most will not have even that. Even if they are vent dependent they might have a cuffless trach. Yes, these patients will vomit from time to time. Somehow these patients survive, even at home, by their caregivers learning a few basic airway principles such as head of bed elevated, rolling if necessary and suctioning (orally and NT). 

Many EMT(P)s are not proficient in the use of any type of suction or don't even carry the proper equipment to perform the procedure. If they do, they may not have looked at it for 4 years or more. 

Honestly, how many have NT suctioned a patient within the last year? I don't mean just sticking a tonsil tip down their throat or put the tip to the nose. How extensive was it even covered in EMT(P) class?

I do know this since I see examples of this in two different states on two different coasts. Trying to get just a trach patient from point A to point B can be a big hassle if you mention the patient might need to be suctioning. Someone has to run out to the truck and see if the suction is working. What usually happens is an RN or RRT has to tag along with their own equipment "just in case" that dreaded suction stuff is required.

The use of a BVM on a patient for extended periods of time is not something that some are not experienced in either. No, we do not intubate someone we are doing a conscious sedation on that went a little deeper than expected. We just bag them through the procedure. If they puke we place an NG or just suction. 

To perform advanced airway procedures one has to be comfortable and confident in *ALL *aspects of airway care and not just the cool stuff like RSI.

For flight, yes, it is better to secure as airway while on the ground...just in case.

*Disclaimer (before anyone gets ruffled): Skills and the education to go with them will vary from city to city in this country.*


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## triemal04 (Jan 26, 2009)

VentMedic said:


> *Disclaimer (before anyone gets ruffled): Skills and the education to go with them will vary from city to city in this country.*


Ok, you work in Florida and California...2 states that have multiple problems with their EMS system, both the educational structure and overall system.


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## reaper (Jan 26, 2009)

triemal04 said:


> Ok, you work in Florida and California...2 states that have multiple problems with their EMS system, both the educational structure and overall system.



I won't speak for California, but Florida EMS as a whole state system, is far ahead of the times compared to most states. Yes, they need to shut down the mills, but their college courses are top notch. Not to many states stand behind EMS and support it the way FL does. I wish more states would take that active of a role in it.


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## VentMedic (Jan 26, 2009)

reaper said:


> I won't speak for California, but Florida EMS as a whole state system, is far ahead of the times compared to most states. Yes, they need to shut down the mills, but their college courses are top notch. Not to many states stand behind EMS and support it the way FL does. I wish more states would take that active of a role in it.


 
Florida does provide ALS for 911 to all areas of the state. Some EMS systems in Florida are state of the art and was probably one of the first states in the country to do 12-leads and even did the field trials for thrombolytics over 20 years ago. 

However, it was thought a little of a good thing could be improved by having a whole lot of it. Thus, medic mills on every corner and every FF is to be a Paramedic. 

California and Florida are two very large and diverse states, each with differing styles for their state EMS structure.


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## Sasha (Jan 26, 2009)

> Thus, medic mills on every corner and every FF is to be a Paramedic.



Not to hijack the thread more than it already has been, but isn't Florida moving to 100% degree program medics in the near, next ten year, future? I've heard that from a couple of people but have yet to find an article that supports it.


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## VentMedic (Jan 27, 2009)

Sasha said:


> Not to hijack the thread more than it already has been, but isn't Florida moving to 100% degree program medics in the near, next ten year, future? I've heard that from a couple of people but have yet to find an article that supports it.


 
At one time a degree was offered in almost 100% of the schools, along with the certificates, in Florida since they were college based. 

What you just stated is also a sales pitch by one of my "favorite" medic mills that now offers and "Associates" degree. However, the words: may or might transfer" to other colleges are also used in the contract. Since their school is relying on the accreditation of a private technical school system, their instructors do not meet all to same requirements for teaching as do those accredited in the state system.

I seriously doubt if all or even half of the private programs will be CoAEMSP/CAAHEP accredited in 10 years since Florida uses its own state exam for the Paramedic. These schools make up 50% of the programs that teach the Paramedic program. The other 50% are the community colleges which have their accreditations. However, these community colleges are offering a certificate which has changed greatly over the past 30 years and now resembles a medic mill type training to stay competitive. Not many students are completing the degree programs and there has been  talk about closing some of degree offerings due to budget constraints. At this time I do not believe the state of Florida has made any statement. If they do, the FFs' union will oppose it since it will cramp their requirement of being a certified Paramedic within one year of hire.


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## Sasha (Jan 27, 2009)

That would explain why I couldn't find anything online about it :]! 

Thanks!


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## MSDeltaFlt (Jan 28, 2009)

VentMedic said:


> But look at the number of patients that are taken care of everyday that have impaired or no gag from CVAs, TBIs and SCIs as well as weak to almost nonexistent coughs. Many have no way of communicating either. If they aren't vent dependent they MIGHT have a *cuffless* trach but most will not have even that. Even if they are vent dependent they might have a cuffless trach. Yes, these patients will vomit from time to time. Somehow these patients survive, even at home, by their caregivers learning a few basic airway principles such as head of bed elevated, rolling if necessary and suctioning (orally and NT).
> 
> Many EMT(P)s are not proficient in the use of any type of suction or don't even carry the proper equipment to perform the procedure. If they do, they may not have looked at it for 4 years or more.
> 
> ...



How acute of a change in status of the CVA's, TBI's, and SCI's are you referring, Vent?  Are meaning Acute, Subacute, or Chronic? Because I'm talking about the dipsticks who are getting ''crunk'' one moment, and the next moment their sh*t's f*cked up as stated earlier.

With respect.


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## VentMedic (Jan 28, 2009)

MSDeltaFlt said:


> How acute of a change in status of the CVA's, TBI's, and SCI's are you referring, Vent? Are meaning Acute, Subacute, or Chronic?


 
Of all phases. Not every CVA get intubated. Not all TBIs or SCIs get intubated. We have a lot of patients in various vegetative states that don't get an artificial airway. If they are not pharmacologically sedated and paralyzed on a machine, doctors can also assess the injury better and provide a different and maybe more progressive therapy. 




> Because I'm talking about the dipsticks who are getting ''crunk'' one moment, and the next moment their sh*t's f*cked up as stated earlier.


 
Are you referring to patients? 

Not all intoxicated or drugged patients get intubated either especially if you have to stop at the driveway and do you intubation attempts in the ED doorway. 

Putting a CHF or COPD patient on CPAP can be extremely risky also. That definitely can cause a patinet to vomit if they had recently eaten or feel nausous from a hypoxic or cardiac event. The continuous flow with pressure will not give anyone much of a chance to get that mask off before the vomit will be pushed very deep into their lungs quickly. Hospitals have very strict P&Ps about who gets CPAP/BiPAP(trade name), when and where. However, to prevent these patients from being intubated, we still take may that chance.  

While there are some patients that will definitely need a tube, many don't and shouldn't. If a patient doesn't have to be attached to a ventilator as a "feel good" measure for someone else, it can speed the patient's progress through the system. Those with drugs and alcohol problems can go to the appropriate facility faster.

Sometimes clinical judgement has to be used instead of following a recipe or doing something just because you now have RSI and can.


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## Ridryder911 (Jan 28, 2009)

VentMedic said:


> Sometimes clinical judgement has to be used instead of following a recipe or doing something just because you now have RSI and can.



This is the point I believe is missing in many of the newer produced medics. Unfortunately so many educators and instructors have lost the intent of educating of critical thinking skills. I believe it started at the first level. Just read the posts from Basic Level EMT's that want to argue upon subjects as "protocols say" and or have limited to no knowledge level in that specific area but still want to refer to a step by step or lump care as "always". 

If one has to perform more than a few ETT suctions a year to remember aseptic and sterile techniques, then they should not be providing care. If these so called providers are inept or stupid to remember such basic skills as suctioning, I now see the problems of why intubation is such a difficult procedure. When realistically, there is far more difficult procedures performed daily by other health care providers. Not to be sarcastic and demean the importance of a thorough education in intubation but realistically, there are only two holes to be able to place a tube in and they cannot perform this too? This does raise the question of wondering the competence in other areas. 

I have to admit my States EMS education and training program has a lot to be desired. There is still a lot of work to meet the minimal areas, but now after reading posts from other so called renown areas, I realize we are not as bad in comparison. 

It rather upsets me that professional EMS educators are still allowing such training to occur. Not proposing legislative changes is as much condoning it as teaching it. I do ask what if the State EMS Division doing? Are they purposefully blind by outside influences or have reached the point of bureaucracy they have ignored the problems? 

Instead of discarding of what or how one performs, focus upon the problem and how to fix those problems should be addressed. 

R/r 911


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## MSDeltaFlt (Jan 28, 2009)

VentMedic said:


> Of all phases. Not every CVA get intubated. Not all TBIs or SCIs get intubated. We have a lot of patients in various vegetative states that don't get an artificial airway. If they are not pharmacologically sedated and paralyzed on a machine, doctors can also assess the injury better and provide a different and maybe more progressive therapy.
> 
> 
> 
> ...



Yes, I am referring to pts.  And you are right.  It does take clinical judgement and common sense in stead of following a recipe.  I've always said, the trick to this job is not knowing what to do and being able to do it.  That's easy.  Any moron and be taught that.  The trick to this job is being able to do something, and knowing when and when *not* to do it.

That being said, I can learn a lot from you because you are a little more judiciously aggressive than I.  You have a few more toys at your disposal and that's how you help me stay current.


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## VentMedic (Jan 28, 2009)

Ridryder911 said:


> Instead of discarding of what or how one performs, focus upon the problem and how to fix those problems should be addressed.
> 
> R/r 911


 
Rid,

We offer extra training and have almost 100 subacute and another 200 SNF patients as a living laboratory where some can come in for a little refresher or education/training about the new technology, stabilization devices for SCIs, trachs and suction methods that can be used on different patients including children. Most of what we have to show can be found in LTC facilities and in homes. 

Few Paramedics get the chance to NT sx a patient in their clinicals but yet that is what many nursing home patients need before anything else.

The problem is getting EMT(P)s to come into these classes that have the stigma of being "BLS" or chronic care issues and not EMERGENCY stuff. 

The same comments can be applied to various vascular access devices. There are numerous discussions on the EMS forums where some are trying to speculate or "guess" what they can and can not do with these devices. It wouldn't take much to attend a CE class at a hospital or community college to learn more even if it isn't mandatory or your chief isn't forcing you to do it. Of course, the fact that it might be under the "nursing" section can scare off some. 

There is a world of information and education out there and sometimes if one's own program was not that great, one still has opportunities to make the most of their own career destiny by seeking out whatever they can. Of course, one must also realize that their EMT(P) program didn't give them all the knowledge needed to be successful in this profession.


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## redcrossemt (Jan 28, 2009)

VentMedic said:


> Few Paramedics get the chance to NT sx a patient in their clinicals but yet that is what many nursing home patients need before anything else.
> 
> The problem is getting EMT(P)s to come into these classes that have the stigma of being "BLS" or chronic care issues and not EMERGENCY stuff.



Well said. 

At the last EMS Expo I attended, I remember going to see a lecture and hands-on practical station on critical interventions for the chronic care patient, and another on interventions for the chronic care child. 

There were about 12 of us in those classes. At the same time, there were 100's of other providers attending lectures about intubation, cardiac arrest, and all sorts of other flashy things (I bet their Powerpoints even had siren noises).


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## nova5267 (Feb 6, 2009)

I would have to disagree with most.  No offense here just my outlook on it!
She is an elderly overdose patient, so you have to look at the possible complications.
While she is unresposive yet still breathing adequately, it is on the safe side to go ahead and intibate  before the patient needs it because if you wait for the last minute if she DOES need it, then it may be too late and you could loose her!  Your preceptor was following the CYA guideline, COVER YOUR @$$! lol He did the safe thing there is nothing wrong with thinking on the safe side of the near future!  Just like when you start an IV on a patient who does not need one yet but may in the near future so you already have it when you need it!  Make sense?


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## TransportJockey (Feb 6, 2009)

SOunds like a good candidate for a nasal tube. But if what hte preceptor did worked, I can't fault it too much... but I'm just another student too...


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## redcrossemt (Feb 7, 2009)

nova5267 said:


> I would have to disagree with most.  No offense here just my outlook on it!
> She is an elderly overdose patient, so you have to look at the possible complications.
> While she is unresposive yet still breathing adequately, it is on the safe side to go ahead and intibate  before the patient needs it because if you wait for the last minute if she DOES need it, then it may be too late and you could loose her!  Your preceptor was following the CYA guideline, COVER YOUR @$$! lol He did the safe thing there is nothing wrong with thinking on the safe side of the near future!  Just like when you start an IV on a patient who does not need one yet but may in the near future so you already have it when you need it!  Make sense?



The OP's preceptor did NOT intubate. Instead, he did a head-tilt chin-lift, placed a simple NPA, and administered oxygen with a NRB. BLS skills woot! 

Nova, are you advocating for oral intubation on this patient?

I highly disagree with intubation just to be "on the safe side" and prepare for when you need it. The patient is breathing adequately for the time being. As said here by many posters, if you feel comfortable with nasal intubation (you should), or have RSI, those are okay choices. Oral intubation of this patient, just because, is a bad decision, IMO.


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## nova5267 (Feb 8, 2009)

redcrossemt said:


> The OP's preceptor did NOT intubate. Instead, he did a head-tilt chin-lift, placed a simple NPA, and administered oxygen with a NRB. BLS skills woot!
> 
> Nova, are you advocating for oral intubation on this patient?
> 
> I highly disagree with intubation just to be "on the safe side" and prepare for when you need it. The patient is breathing adequately for the time being. As said here by many posters, if you feel comfortable with nasal intubation (you should), or have RSI, those are okay choices. Oral intubation of this patient, just because, is a bad decision, IMO.



I know he did NOT intubate, i was simply stating that if he had, it wouldnt have been a stupid call, pointless maybe, but definitely not risky. Sorry i guess i didnt fully explain in the first place!


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## VentMedic (Feb 8, 2009)

nova5267 said:


> I know he did NOT intubate, i was simply stating that if he had, it wouldnt have been a stupid call, pointless maybe, *but definitely not risky*. Sorry i guess i didnt fully explain in the first place!


 
Any intubation presents with risks.


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