# Scope of Practice(Combi Tubes)?



## Zalan (Oct 13, 2010)

My emt instructor recently got back from a EMS confrence in Texas. He said there were possable changes if Indiana, excepts the new National Scope of Practice. One being no longer being able to put in combi tubes, kings, or rush airways(sorry if I misspelled anything).

Just wondering how many States still allow Emt-B`s to insert these airways?


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## feldy (Oct 13, 2010)

louisiana still allows it.


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## 46Young (Oct 13, 2010)

Zalan said:


> My emt instructor recently got back from a EMS confrence in Texas. He said there were possable changes if Indiana, excepts the new National Scope of Practice. One being no longer being able to put in combi tubes, kings, or rush airways(sorry if I misspelled anything).
> 
> Just wondering how many States still allow Emt-B`s to insert these airways?



Virginia allows EMT-B's to drop the "tube of shame," commonly known as the King. We got rid of combitubes, since they showed no benefit for out of hospital discharge. Nasals have always been in the EMT-B's scope. Whether or not each state chooses to adopt the new National Scope of Practice depends on many things, such as supply of medics, or supply of EMS in general for rural areas, for example.


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## LucidResq (Oct 13, 2010)

Allowed in CO


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## CAO (Oct 13, 2010)

EMT-IV's in Tennessee are allowed to drop tubes.


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## Motojunkie (Oct 13, 2010)

B's are allowed to drop Kings at my company (so I would assume the rest of FL as well), but almost all the trucks are medic-basic so usually the medic does their thing.


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## TransportJockey (Oct 13, 2010)

NM and TX allow supraglottic airways for BLS providers


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## medicRob (Oct 13, 2010)

TN EMT-IV is allowed Combi, PTL, and King, again the EMT-IV being trained to i/85 and not just the b standard


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## Cohn (Oct 13, 2010)

Southern Arizona (SAEMS) is trying to bring back the Combitube for us (especially us very remote locations,) they alow EMT-Bs here for departments like mine to start IVs.


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## lampnyter (Oct 13, 2010)

I just finished my EMT course and i never even heard of a combitube or king. What are those?? (Im in CT)


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## Cohn (Oct 13, 2010)

lampnyter said:


> I just finished my EMT course and i never even heard of a combitube or king. What are those?? (Im in CT)



http://lmgtfy.com/?q=Combitube+and+King+Airway


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## lightsandsirens5 (Oct 13, 2010)

Basics in WA can use "multi-lumen, esophageal-tracheal intubation devices"

So yes. WA basics can use Combitubes. I believe paramedics are required to use them after one unsuccessful standard intubation attempt.


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## lampnyter (Oct 13, 2010)

Wow, EMT-I cant even intubate here.


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## fast65 (Oct 13, 2010)

EMT-B's here can use the Combitube, however the majority of agencies don't even carry them from my understanding...


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## mikie (Oct 13, 2010)

CombiTube dropped from MD protocols.

Contains latex.


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## EMS/LEO505 (Oct 13, 2010)

NM allows Combi, King and LMA for basics


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## CAO (Oct 13, 2010)

medicRob said:


> TN EMT-IV is allowed Combi, PTL, and King, again the EMT-IV being trained to i/85 and not just the b standard



I really should have been clearer in my post.  "Tubes" was just too open to interpretation.

Thanks for clarifying, Rob!


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## zmedic (Oct 13, 2010)

Thought the King was pulled from most places in the US because the FDA found that it wasn't approved for prehospital use.


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## socalmedic (Oct 13, 2010)

they did, the king LT was not however a King LTS-D apparently is approved. same tube but the LTS-D has a NG port and larger balloons.


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## JPINFV (Oct 13, 2010)

zmedic said:


> Thought the King was pulled from most places in the US because the FDA found that it wasn't approved for prehospital use.



The King wasn't approved for prehospital use, but the FDA doesn't regulate the practice of medicine in that fashion. It's just an example of off-label use.


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## usalsfyre (Oct 13, 2010)

Our basics can do Kings, and I regularly have them do it. They can drop a King while I'm doing an IO and first responders are doing high quality, uninterrupted chest compressions. It works well.


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## TransportJockey (Oct 14, 2010)

EMS/LEO505 said:


> NM allows Combi, King and LMA for basics



Last I checked (which has been a bit) the whole catagory of supraglottic airways is in there since I believe there is one volly service that still has a stock of EOAs


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## EMS/LEO505 (Oct 14, 2010)

Lol, idk....Mike is only teaching us those 3 haha ^_^


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## TransportJockey (Oct 14, 2010)

EMS/LEO505 said:


> Lol, idk....Mike is only teaching us those 3 haha ^_^



Really the ones you're most likely to come across in the field are the MLA and King. LMAs aren't carried too often in NM anymore on trucks, and the EOAs really really need to die already.


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## medicRob (Oct 14, 2010)

jtpaintball70 said:


> Really the ones you're most likely to come across in the field are the MLA and King. LMAs aren't carried too often in NM anymore on trucks, and the EOAs really really need to die already.



LMA stands for "Let me aspirate" as far as I'm concerned, just sayin..


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## MrBrown (Oct 14, 2010)

medicRob said:


> LMA stands for "Let me aspirate" as far as I'm concerned, just sayin..



I am kinda inclined to agree, however that said LMAs are working well within our system at all levels.  They are an easy skill to become proficent at especially for Technicians but there is still a little resistance at Intensive Care level.

From this year if an LMA is in place and working well we are actively discouraging the practice of changing it to an endotracheal tube however if the patient will not tolerate it snd is unable to maintain an airway we should be requesting an RSI trianed Intensive Care Paramedic or Doctor


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## usalsfyre (Oct 14, 2010)

*LMAs...*

LMAs are approved for short term airway control in an NPO patient. Anything else is an off-label use. That said, this is the exact same way a King airway is approved. The problem with LMAs (and most standard supraglotic airways) is they leave no way to evacuate the stomach and clear the upper airway of debris. Leaving the patient at risk for aspiration when those substances inevitablly make their way past the airway and get blown into the trachea. I am interested to see how the new LMAs with the NG tube port work. 

I will say I have seen far less problems regarding placement with the Kings than LMAs (fairly extensive experince with both, for EMS anyway), as LMAs are a little tricky to place. A key factor all around is making sure you adaquately suction prior to placement, and lubing ONLY where the manufacturer suggest. What we really need is an anesthetists to give us a real run down on which is better.

The intubating LMAs on the other hand, are pure, unadulturated awsomeness...


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## emtJR86 (Oct 15, 2010)

Michigan still allows it, and in 2013(i believe), we are dumping the NR, due to these very issues


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## usalsfyre (Oct 15, 2010)

emtJR86 said:


> Michigan still allows it, and in 2013(i believe), we are dumping the NR, due to these very issues



emtJR86, I recently came across an article about Michigan and NR, which basicly was focused around FDs whining that their inhouse medic programs would no longer be allowed to test NR due to accredidation issues. Meaning they would have to send their employees to an outside program. I'm betting this has FAR more to do with MI dumping NR than any easily corrected state vs national scope/educational issue.


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## emtJR86 (Oct 15, 2010)

usalsfyre said:


> emtJR86, I recently came across an article about Michigan and NR, which basicly was focused around FDs whining that their inhouse medic programs would no longer be allowed to test NR due to accredidation issues. Meaning they would have to send their employees to an outside program. I'm betting this has FAR more to do with MI dumping NR than any easily corrected state vs national scope/educational issue.



Not sure...we brought this up the other night in class...not really sure about the FD issue. I know that we have alot of very Rural areas that cannot afford Paramedics, therefore Michigan is looking to expand the Scope of Practice for EMT-I and EMT-B


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## mikie (Oct 15, 2010)

Would it even matter that pt. has an latex allergy?  Since they're probably coding any...  

or would this just exacerbate it?


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## himynameismj (Oct 15, 2010)

zmedic said:


> Thought the King was pulled from most places in the US because the FDA found that it wasn't approved for prehospital use.



This is the only secondary device my sponsor uses. I got to use it for the first time today. It is really an awesome piece of equipment. PTL on the other hand, blah.


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## BSI (Oct 20, 2010)

In Indiana we are still allowed to use any non-visualized airways (Combi-Tube, King, LMA, etc.).  I know the the commission is considering using the national standard for basics, however to the best of my knowledge it is just a consideration.  All of my services basic trucks carry them.  I also have an Illinois license, and they are not allowed in that state at all for basics.


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## medicRob (Oct 20, 2010)

usalsfyre said:


> LMAs are approved for short term airway control in an NPO patient. Anything else is an off-label use. That said, this is the exact same way a King airway is approved. The problem with LMAs (and most standard supraglotic airways) is they leave no way to evacuate the stomach and clear the upper airway of debris. Leaving the patient at risk for aspiration when those substances inevitablly make their way past the airway and get blown into the trachea. I am interested to see how the new LMAs with the NG tube port work.
> 
> I will say I have seen far less problems regarding placement with the Kings than LMAs (fairly extensive experince with both, for EMS anyway), as LMAs are a little tricky to place. A key factor all around is making sure you adaquately suction prior to placement, and lubing ONLY where the manufacturer suggest. What we really need is an anesthetists to give us a real run down on which is better.
> 
> The intubating LMAs on the other hand, are pure, unadulturated awsomeness...




Don't get me wrong, LMA's are great when you are in a nice, air conditioned, climate controlled, well-lighted surgical suite, but in the street they are $@!%. 

I am really liking the SALT airways.


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## reaper (Oct 20, 2010)

medicRob said:


> Don't get me wrong, LMA's are great when you are in a nice, air conditioned, climate controlled, well-lighted surgical suite, but in the street they are $@!%.
> 
> I am really liking the SALT airways.



We tried the SALT airways out about 3 months ago. After one month on the street and not a single use, that did not have problems, the rest were returned. We ended up with the King LT. I was happy for this. I have used the King LT for 5 years and have never seen one fail. The SALT is a great idea, that just was not designed correctly.


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## usalsfyre (Oct 20, 2010)

Never used the SALT, but a similar option does exist with the King LTS-D and the LMA, as long as you have a bougie available. Pass the bougie down the bore of the airway, it should emerge at the larynx. Pass the bougie as normal, remove the LMA/King and pass the tube. Confirm via standard methods, plus direct visualization if needed.


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## mikie (Oct 20, 2010)

BSI said:


> I also have an Illinois license, and they are not allowed in that state at all for basics.



I Worked in Peoria, IL...placed a few Combitubes in my day as a basic (07-09).  Recent change or something?


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## Lucy212 (Oct 21, 2010)

*I'm not sure...*



lampnyter said:


> I just finished my EMT course and i never even heard of a combitube or king. What are those?? (Im in CT)




Lampnyter,

I was wondering the same myself. We didn't speak of that in my EMT-B course either. I'm in New York City.

~ L


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## Icenine (Dec 19, 2010)

BSI said:


> In Indiana we are still allowed to use any non-visualized airways (Combi-Tube, King, LMA, etc.).  I know the the commission is considering using the national standard for basics, however to the best of my knowledge it is just a consideration.  All of my services basic trucks carry them.  I also have an Illinois license, and they are not allowed in that state at all for basics.



Not sure which system in IL, but my AOR (Mclean County) allows Combitube for B-P.  And ET Tubes for I-P.

I _think_ its a required secondary device for I's and suggested for P's for multiple attempts.


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## CodyHolt83 (Dec 20, 2010)

Allowed for use by EMT-B in Texas.  Pretty cool, I think.  Loved playing with them in school.  lol


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## jjesusfreak01 (Dec 20, 2010)

usalsfyre said:


> Never used the SALT, but a similar option does exist with the King LTS-D and the LMA, as long as you have a bougie available. Pass the bougie down the bore of the airway, it should emerge at the larynx. Pass the bougie as normal, remove the LMA/King and pass the tube. Confirm via standard methods, plus direct visualization if needed.



Don't get me wrong, its a cool concept, but that seems like a giant waste of time to me. If you think King isn't going to work well, intubate and save yourself the trouble of having to explain to your medical director why you needed to shove a tube down your patients mouth twice. We have Kings and ET tubes, and we try to avoid using either as much as possible. EMS based EMTs can place Kings in the field here.


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## firemed17 (Dec 20, 2010)

Here in Florida all we are allowed to use as Basics are: LMA's and Kingtube's.


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## whizkid1 (Dec 21, 2010)

Our service we do combi-tubes and now we are starting to use king airways.I am from Minnesota.


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## yotam (Dec 22, 2010)

*Here in the holy-land...*

(Yea, the real one) combi's aren't even heard of, and the only kings we have here are dead. Then again, we don't even get nasal airways:glare:


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## bigmoosewi (Dec 29, 2010)

Wisconsin still allows Combi-tube.  We actually just tested out on it about a month and a half ago for class.


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## 18G (Dec 29, 2010)

In PA EMT-B's are not allowed to use supraglottic airway devices. ALS services have the option of using the Combitube or King. My service uses the King.


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## EMTRyan232 (Dec 29, 2010)

In SC, the basics are allowed to drop a King, in my area they don't even carry the combi on the truck anymore. but once ALS gets on scene they are going to pull it and intubate anyway


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## jjesusfreak01 (Dec 29, 2010)

EMTRyan232 said:


> In SC, the basics are allowed to drop a King, in my area they don't even carry the combi on the truck anymore. but once ALS gets on scene they are going to pull it and intubate anyway



No reason to pull a perfectly good airway to put in a much more invasive one if the first one's doing a good job.


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## Shishkabob (Dec 29, 2010)

jjesusfreak01 said:


> Don't get me wrong, its a cool concept, but that seems like a giant waste of time to me. If you think King isn't going to work well, intubate and save yourself the trouble of having to explain to your medical director why you needed to shove a tube down your patients mouth twice.




Several reasons, actually:

First, the basics at our company can do Kings, so they may drop a King right off the bat for some reason.

Second, the King may be working at first but something can change to where we will need an ET tube.


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## 18G (Dec 29, 2010)

jjesusfreak01 said:


> No reason to pull a perfectly good airway to put in a much more invasive one if the first one's doing a good job.



That was my thought exactly... especially during an arrest. The mindset still exist that "we have to intubate". Airway management is just that... managing the airway with whatever technique achieves control and not necessarily inserting an ETT just because you can.


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## Flight-LP (Dec 29, 2010)

jjesusfreak01 said:


> No reason to pull a perfectly good airway to put in a much more invasive one if the first one's doing a good job.



Please define "doing a good job".

In an arrest, where there are obvious priorities that directly influence whether the patient will regain circulation and thus possibly improve neuro status, I could agree in some situations.

However, outside of that, if a patient lacks the ability to maintain the patency of their own airway, is not adequately ventilating to maintain appropriate perfusion, or their predicted clinical course includes potential long term airway management, then they need definitive airway management. Simplistic rescue devices and failed airway adjuncts do not meet definitive airway criteria. As such, I would intubate them and reserve the use of other devices only for the situation of a failed airway.

My personal belief is that this philosophy allows for the practice of quality medicine. Some agree, some don't. Fortunately, those involved in my collaborative practice of medicine (i.e. MD, QA and Clinical Department) agree with this philosophy and promotes it within our clinical practice.


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## Sassafras (Dec 29, 2010)

mikie said:


> CombiTube dropped from MD protocols.
> 
> Contains latex.



That would be why my hands started itching when we played with them in ALS assist class.  That would be bad...very very bad if they shoved that down my throat.


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## 18G (Dec 29, 2010)

On an arrest I would not hesitate to insert a King airway after a single failed attempt at intubation. As long as the airway device is providing good tidal volume and giving some protection from aspiration I feel confident that is an airway "doing a good job". And if BLS has one inserted prior to ALS with good ventilations going on, why mess with it? Insert an NG tube and I say you have pretty good airway control. Is intubating going to provide any better outcome than the King or Combi-Tube in an arrest? of course not. The AHA is even recommending going with a supra-glottic device during arrests. 

As for other clinical scenarios... obviously intubation needs to be attempted but don't prolong the decision to switch to a supra-glottic device. It doesn't mean your a crappy Medic because you "couldn't get the tube". Anyone who still thinks this needs re-educated. And I don't buy the standard "3 attempts" to intubate before switching to an alternative airway. Attempting to intubate up to three times in a head injured patient would be much worse then going with a supraglottic device after one ET attempt if you aren't feeling confident with being able to get the tube. The vagal response and risk of increasing ICP and inciting an episode of hypoxia in these patients is extremely detrimental. There is debate on the benefits of pre-hospital intubation of the head injured patient with much worse outcomes in several studies. So is intubation really the best medicine or is securing an airway as quickly as possible in adverse field conditions the best medicine? 

I don't worry about upholding philosophies... I only worry about my patient at that exact moment and doing what needs to be done.


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## Hellsbells (Dec 29, 2010)

46Young said:


> Virginia allows EMT-B's to drop the "tube of shame," commonly known as the King. We got rid of combitubes, since they showed no benefit for out of hospital discharge. Nasals have always been in the EMT-B's scope. Whether or not each state chooses to adopt the new National Scope of Practice depends on many things, such as supply of medics, or supply of EMS in general for rural areas, for example.



I hate this attitude that its shamful to miss an intubation. There is no reason not to go right to a superglottic airway after a failed intubation attempt. It is critical to avoid hypoxia while wasting time on multiple attempts while trying to fulfill some heroic mentality that good medics always get the tube. 

That said, I have my reservations about the combitube and LMA's. Combitubes are rather bulky and can cause significant trauma when used roughly. The problems with LMA's and aspiration have been detailed in this thread already. However, I think that the King tubes with the suction ports are a great primary device for basics and a good back up for paramedics.


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## usalsfyre (Dec 29, 2010)

Flight-LP said:


> Please define "doing a good job".
> 
> In an arrest, where there are obvious priorities that directly influence whether the patient will regain circulation and thus possibly improve neuro status, I could agree in some situations.
> 
> ...



I agree to a point. That said I've also shown up when a King has been placed as a rescue device in a failed airway and opted to leave it be. I might try the tube changer trick, but I'm somewhat disinclined to go digging around in what has already proved itself to be a difficult airway (granted it may be the skill of the laryngoscipist), not to mention deal with the trauma probably caused during multiple ETT attempts. A King with an NG in place actually works fairly well for delivering mechanical ventilation. The receiving facility will most likely have full time anesthesia, fiber optics, ect to help get a tube placed.   

That said if the King appears inadequate, we're going to pull it and place a better airway, even if that means a cric.


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## Bosco836 (Dec 29, 2010)

firemed17 said:


> Here in Florida all we are allowed to use as Basics are: LMA's and Kingtube's.



Does this mean no OPAs/NPAs in FL?


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## usafmedic45 (Dec 30, 2010)

> Virginia allows EMT-B's to drop the "tube of shame," commonly known as the King.



That's a really mature attitude.  The only airway one should be ashamed to admit to is the one you don't maintain because you let your ego get in the way of good patient care.



> We got rid of combitubes, since they showed no benefit for out of hospital discharge.



Last time I checked, neither did King Airway or ET tubes for that matter.


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## Phlipper (Dec 30, 2010)

We use Kings in NC and I dropped one during my first month.  Very easy, very effective (just didn't help in this case).  I may feel differently when I finish medic school and have more experience, but for now it seems so easy and quick that I'm not sure RSI/intubation should always be first line.  I don't quite grasp what ET does in most cases that can't be accomplished by a King.  I still have lots to learn, though, and may change my mind later.


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## usalsfyre (Dec 30, 2010)

Phlipper said:


> We use Kings in NC and I dropped one during my first month.  Very easy, very effective (just didn't help in this case).  I may feel differently when I finish medic school and have more experience, but for now it seems so easy and quick that I'm not sure RSI/intubation should always be first line.  I don't quite grasp what ET does in most cases that can't be accomplished by a King.  I still have lots to learn, though, and may change my mind later.



Isolation of the trachea, ability to perform procedures such as broncoscopy, route for suctioning, the ability to provide long term ventilatory support including multiple modes of ventilation and effective PEEP, ability to keep the patient conscious without stimulating the gag reflex and prevention of stasis injuries to the upper airway are just some I came up with off the top of my head, I'm sure usafmedic45, Journey and Flight-LP can provide more. ETT placement may not appear more advantageous, but if it can be done skillfully and without complication it is far superior in the overall continum of care.


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## TransportJockey (Dec 30, 2010)

The only one of those that you mentioned that is not quite right is suctioning. The newer King's have a suction port on them. Might not be able to do it as well as with ETT, but you can at least do it.


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## usalsfyre (Dec 30, 2010)

jtpaintball70 said:


> The only one of those that you mentioned that is not quite right is suctioning. The newer King's have a suction port on them. Might not be able to do it as well as with ETT, but you can at least do it.



It's a gastric suction port. I suppose you could try to jam a French cath through the hole used for a tube changer, but it would have to be a small fr and you'd have to hope it stayed on course to go in to the trachea.

Another one I just thought of is decrease in airway resistance.  I can't imagine trying to suck air through a King would go well...


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## usalsfyre (Dec 30, 2010)

So on further research, I was wrong and you were right. The port your refering to IS considered a suction port. However, I still can't see how this would facilitate deep suctioning very well.


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## 18G (Dec 30, 2010)

hmmm... I was under the impression that the port on the side of the King was for an NG tube which obviously goes into the stomach. How are you going to perform deep suctioning of the trachea with an airway placed in the esophagus?


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## jjesusfreak01 (Dec 30, 2010)

t





18G said:


> hmmm... I was under the impression that the port on the side of the King was for an NG tube which obviously goes into the stomach. How are you going to perform deep suctioning of the trachea with an airway placed in the esophagus?



You are correct. I don't believe there is any safe way to do deep suctioning through a King airway. It is possible to run a small catheter through the main tube (the ventilating tube, not the NG canal), I believe, but you would have no control over the catheter and no way to verify it was going where you wanted.


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## usalsfyre (Dec 30, 2010)

18G said:


> hmmm... I was under the impression that the port on the side of the King was for an NG tube which obviously goes into the stomach. How are you going to perform deep suctioning of the trachea with an airway placed in the esophagus?



The LTS-D at least has a port that exits at the distal end of the main lumen of the airway (where the 15mm adapter is).  I guess the idea is you would slip a small suction catheter through that. In practice I'm not sure it would make it into the trachea, go deep enough, or have a large enough diameter to acomplish much.


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## Phlipper (Dec 31, 2010)

usalsfyre said:


> Isolation of the trachea, ability to perform procedures such as broncoscopy, route for suctioning, the ability to provide long term ventilatory support including multiple modes of ventilation and effective PEEP, ability to keep the patient conscious without stimulating the gag reflex and prevention of stasis injuries to the upper airway are just some I came up with off the top of my head, I'm sure usafmedic45, Journey and Flight-LP can provide more. ETT placement may not appear more advantageous, but if it can be done skillfully and without complication it is far superior in the overall continum of care.



I'm not talking about long-term, where ETT certainly makes sense.  I'm talking purely field use when you need an airway asap and have a whole lot of other things going on.  

If even a newbie like me can drop a king, inflate it, check compliance, and tape it off and be bagging without interrupting CPR that quickly I see it as a very very good tool.  The King appears - based on everything I've ever read, including the recent Wake Co studies - to work very, very well for what it was designed to do.  And in many cases, I just don't see a reason to automatically grab the tube kit automatically.  Ask me again in a year when I finished medic class.


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## usalsfyre (Dec 31, 2010)

Phlipper said:


> I'm not talking about long-term, where ETT certainly makes sense.  I'm talking purely field use when you need an airway asap and have a whole lot of other things going on.  And suctioning thru the King tube does work.  I've seen it done, but have not done it.



Outside of cardiac arrest (where airway period is pretty dubious), you should have time to place an airway. If you don't (a true can't intubate/can't ventilate scenario), you should probably be considering a cric anyway.


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## Phlipper (Dec 31, 2010)

I've seen a clip on suctioning with the King and it appears to work ok for fluids.  In the real world who knows?  Maybe I'll get to find out in the next year or so, though, since I seem to be a black cloud.  h34r:


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## Phlipper (Dec 31, 2010)

Something else to consider, in my service we usually only have one medic on scene.  And if we're on an arrest or shooting or whatever and the medic is drilling shin bones who's gonna tube the pt?  I is.  And I cain't do ET per NC guidelines.  Heah come da King.


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## TransportJockey (Dec 31, 2010)

Tubing should be done pretty much last during a code. Its not exactly a high priority. 





Phlipper said:


> Something else to consider, in my service we usually only have one medic on scene.  And if we're on an arrest or shooting or whatever and the medic is drilling shin bones who's gonna tube the pt?  I is.  And I cain't do ET per NC guidelines.  Heah come da King.


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## Phlipper (Dec 31, 2010)

jtpaintball70 said:


> Tubing should be done pretty much last during a code. Its not exactly a high priority.



Really?  I've always read/been taught A-B-C.  Seems like an airway is pretty high up on the ladder.  Even though C is usually prioritized for arrest, trauma, GSWs, etc.  We'll have to agree to disagree on that one.  My Medical Director will also disagree with you, and he makes the rules I play under.


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## TransportJockey (Dec 31, 2010)

Phlipper said:


> Really?  I've always read/been taught A-B-C.  Seems like an airway is pretty high up on the ladder.  Even though C is usually prioritized for arrest, trauma, GSWs, etc.



For a code compressions take priority over everything.


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## usalsfyre (Dec 31, 2010)

Phlipper said:


> Really?  I've always read/been taught A-B-C.  Seems like an airway is pretty high up on the ladder.  Even though C is usually prioritized for arrest, trauma, GSWs, etc.  We'll have to agree to disagree on that one.  My Medical Director will also disagree with you, and he makes the rules I play under.




The AHA is going to disagree with you on this one too. In cardiac arrest good quality compressions and defib take precedence over anything else. The new CPR accronym is "CAB".

Serious trauma, including GSW should be treated the same way with regard to exangunating hemmorhage.


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## Phlipper (Dec 31, 2010)

usalsfyre said:


> The AHA is going to disagree with you on this one too. In cardiac arrest good quality compressions and defib take precedence over anything else. The new CPR accronym is "CAB".
> 
> Serious trauma, including GSW should be treated the same way with regard to exangunating hemmorhage.



Since you didn't read the whole post here ... "Even though C is usually prioritized for arrest".

And CAB still puts A and B right up there in the top three.  If A and B are that unimportant, why are you guys trying to justify RSI/ET above all else?  Why not just wait till you get to the ER and let the docs do it?  You're contradicting yourselves.

I know you like playing with your toys.  But perhaps you should consider the possibility that Kings are becoming more and more accepted as a first line adjunct.  If I understood correctly, already in Wake Co only the APPs are RSI'ing now.  Since their review of data suggested King is the way to go more often than not, I'm betting more agencies are looking at it as well, if they haven't been already.


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## reaper (Dec 31, 2010)

There is times when a secure airway is a must. An arrest is not one. You can push it down the line. A and B can be done with OPA and BVM.


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## jjesusfreak01 (Dec 31, 2010)

Phlipper said:


> Really?  I've always read/been taught A-B-C.  Seems like an airway is pretty high up on the ladder.  Even though C is usually prioritized for arrest, trauma, GSWs, etc.  We'll have to agree to disagree on that one.  My Medical Director will also disagree with you, and he makes the rules I play under.



ABCs are somewhat relative (ok, maybe completely relative). On anything other than a trauma or cardiac arrest, airway always comes first. If you come upon an arrest scene and the patient has not been getting compressions, thats obviously a top priority, as many body tissues use little oxygen when a patient is fully arrested, but if the blood isn't moving, they are getting no oxygen. If bystanders are doing compressions and you have a second person on your crew, one can secure the airway while the other sets up for electrical therapy. 

Likewise, on a trauma scene, massive hemorrhage has to be treated first, since inadequate blood volume impedes your ability to restore adequate perfusion regardless of whether you can ventilate the patient or even get their heart restarted. Its a simple, "what is going to kill my patient first?" question. Well, actually, its even simpler than that. Hypoperfusion (shock) is probably what's going to kill a critical patient in the end, 90% of the time. All you have to do is determine the causes that currently (or will lead to) inadequate perfusion, and treat them.


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## Phlipper (Dec 31, 2010)

If I can get done with the database I'm supposed to be working on (while I sit here playing on the web  ) I'll see if I can re-find the info I dug up last month when we were discussing this at work (EMS work ... I still do both).  Bottom line, there are states/counties/ERs looking into King Airways as first line for arrest and other kinds of events.  NC and Vermont are two that I remember specifically, and there were two ERs who dropped Kings or Combis in the trauma rooms, also, rather than ETI.  

There is _something _to it, whether we like it or not.  And if, as some at my service and at my school have predicted, ETI is taken away from us in the field, just remember: it's the patient who should come first.  Our egos and our toys are secondary, and justifying it ten ways to Sunday isn't going to change the trend if it is found to be valid wrt pt outcomes.  Just like increased education requirements and national licensing, lots of changes are on the horizon for us that we may, or may not agree with.  Keep an open mind and a stiff upper lip.


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## usalsfyre (Dec 31, 2010)

Phlipper said:


> If I can get done with the database I'm supposed to be working on (while I sit here playing on the web  ) I'll see if I can re-find the info I dug up last month when we were discussing this at work (EMS work ... I still do both).  Bottom line, there are states/counties/ERs looking into King Airways as first line for arrest and other kinds of events.  NC and Vermont are two that I remember specifically, and there were two ERs who dropped Kings or Combis in the trauma rooms, also, rather than ETI.
> 
> There is _something _to it, whether we like it or not.  And if, as some at my service and at my school have predicted, ETI is taken away from us in the field, just remember: it's the patient who should come first.  Our egos and our toys are secondary, and justifying it ten ways to Sunday isn't going to change the trend if it is found to be valid wrt pt outcomes.  Just like increased education requirements and national licensing, lots of changes are on the horizon for us that we may, or may not agree with.  Keep an open mind and a stiff upper lip.



Your trying to equate airway control in cardiac arrest (which is pretty effing pointless in most cases anyway) with other situations in which you might place an advanced airway. They're MASSIVELY different, as such your argument is incredibely flawed. 

Your lack of knowledge of RSI is hugely apparent. If I'm using drugs to facilitate intubation, then a King was not an option at the outset. Otherwise I wouldn't need sedation and paralysis to stick a Miller blade down thier gob. If I'm going to that level of trouble then why am I not trying to place a more protective airway with better long-term options? Unless you can find me an intensivist who says a King is acceptable for ICU care (hint, you won't).

The reason RSI and ETI is going away is that medics are showing to be hugely inadaquate at performing it without complication. Which thanks to strong QA, oversight and education has not been a problem at my agency.


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## Flight-LP (Dec 31, 2010)

Phlipper said:


> I'm not talking about long-term, where ETT certainly makes sense.  I'm talking purely field use when you need an airway asap and have a whole lot of other things going on.
> 
> If even a newbie like me can drop a king, inflate it, check compliance, and tape it off and be bagging without interrupting CPR that quickly I see it as a very very good tool.  The King appears - based on everything I've ever read, including the recent Wake Co studies - to work very, very well for what it was designed to do.  And in many cases, I just don't see a reason to automatically grab the tube kit automatically.  Ask me again in a year when I finished medic class.



That statement is contradictory. How many folks out there who need an immediate airway in the field are going to be short term ventilatory patients? The answer is very few, with the majority of them being non-surviving arrest patients. Even if an adjunct is placed, is it not going to be replaced upon arrival to the ER? If you have the capabilities and the resources to provide definitive care, why wouldn't you knowing it is beneficial to the patient and possibly detrimental to their outcome?

In a code, the airway is still first. But intubation is no longer a huge priority PROVIDING you are adequately ventilating your patient through an alternative method. If I deem a code viable and choose to work them, then I will still intubate them as I know it will provide a more definitively secured airway, even if I am the only ALS provider on scene. That's just me, individual mileage will vary. You have 3-5 minutes between medications, that is more than plenty of time to perform the laryngoscopy. In addition, it is a reasonable expectation to accomplish the laryngoscopy without interrupting CPR.

Does the King have a place in EMS? Yes, absolutely, however it was designed and received FDA approval as an oropharyngeal adjunct for a controlled ventilated patient. In an arrest with non-compliant ventilation, or placement by a BLS provider for airway management versus none at all, it could work well. However, I am hearing other ALS providers make statements that they would use it as a frontline airway in the patients that clearly need endotracheal intubation (outside of an arrest). Folks, this is not a substitute for maintaining proficiency in one of the few skills that can actually sustain a life and provide a positive outcome. 

I also don't buy the "whole lot of other things going on". This is so simple, the airway is first, period. The rest will wait. Didn't every single provider in this forum learn that at one point or another? 

Sorry, but I see this trend of moving to airway adjuncts and completely half-a$$ed and a dilution of the medicine that we clearly can provide. If they need intubating, then put an endotracheal tube where it belongs.   

As always, just my humble opinion. Take it as you will..........................................


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## Flight-LP (Dec 31, 2010)

usalsfyre said:


> The reason RSI and ETI is going away is that medics are showing to be hugely inadaquate at performing it without complication. Which thanks to strong QA, oversight and education has not been a problem at my agency.



DING*DING*DING

We have a winner.

This says it all! The prime reason some peanut counting researchers make the blanket "Paramedics can't intubate" statement is because they evaluate substandard EMS systems with limited QA and questionable educational oversight. Wong's study and the San Diego study are both prime examples. Both provide on paper some statistical facts, there is no doubt, but what neither study addresses is the underlying deficiencies of the agency as a whole in their lacking oversight and education.


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## usalsfyre (Dec 31, 2010)

Flight-LP said:


> Sorry, but I see this trend of moving to airway adjuncts and completely half-a$$ed and a dilution of the medicine that we clearly can provide. If they need intubating, then put an endotracheal tube where it belongs.
> 
> As always, just my humble opinion. Take it as you will..........................................



I agree with this statement, but the half-@ssedry and dilution of medicine started long ago, and is only now starting to come full circle.


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## Flight-LP (Dec 31, 2010)

jjesusfreak01 said:


> Likewise, on a trauma scene, massive hemorrhage has to be treated first, since inadequate blood volume impedes your ability to restore adequate perfusion regardless of whether you can ventilate the patient or even get their heart restarted. Its a simple, "what is going to kill my patient first?" question. Well, actually, its even simpler than that. Hypoperfusion (shock) is probably what's going to kill a critical patient in the end, 90% of the time. All you have to do is determine the causes that currently (or will lead to) inadequate perfusion, and treat them.



And the majority of these cited cases are not going to be treated or controlled in the field anyways. Thats where the surgeon comes into play.........................

And if you assertation of treating hemorrhage first holds water, please tell us why not one State in the US nor National Registry evaluates a candidates' patient assessment in that manner?

I understand where you are coming from and that is where some multi-taking and delegation comes into play, but you still need to have a systematic approach to ensure consistency.


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## Bubz628 (Dec 31, 2010)

I've heard that Louisiana does allow EMT-B's to drop a Combitube, but the local protocol for the EMS company that I'm about to start working for doesn't allow it. Just for that company...


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## willings (Jan 1, 2011)

I'm an EMT-B from MO and we use Kings at my hospital based EMS service. Actually dropped one a couple months ago after a failed ETT attempt. Very useful and effective when you need them.


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## zmedic (Jan 1, 2011)

Flight-LP; said:
			
		

> This says it all! The prime reason some peanut counting researchers make the blanket "Paramedics can't intubate" statement is because they evaluate substandard EMS systems with limited QA and questionable educational oversight. Wong's study and the San Diego study are both prime examples. Both provide on paper some statistical facts, there is no doubt, but what neither study addresses is the underlying deficiencies of the agency as a whole in their lacking oversight and education.



The counter argument is that if I'm setting national policy, I don't care about what the best of the best are capable. I want to know if given the standard paramedic course, how well the average paramedic can intubate. So you look at average departments. I think with research the temptation is whenever a study comes out that people don't like the implications they say "well, they're not us, we're much better, that doesn't apply." 

Do I think that a department where medics are getting 40+ tubes a year, have continuous CO2 monitoring, get to go to the OR ever 3 months to get additional tubes, and have good QA can intubate? Sure. But those aren't the guys I worry about. It's the medics who get 4 or 5 tubes a year. And if this is a skill that the average medic can't do well then nobody should be doing it. Or set up an additional certification to be able to intubate that involves additional training and a certain number of tubes per year to maintain.


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## Flight-LP (Jan 1, 2011)

zmedic said:


> The counter argument is that if I'm setting national policy, I don't care about what the best of the best are capable. I want to know if given the standard paramedic course, how well the average paramedic can intubate. So you look at average departments. I think with research the temptation is whenever a study comes out that people don't like the implications they say "well, they're not us, we're much better, that doesn't apply."
> 
> Do I think that a department where medics are getting 40+ tubes a year, have continuous CO2 monitoring, get to go to the OR ever 3 months to get additional tubes, and have good QA can intubate? Sure. But those aren't the guys I worry about. It's the medics who get 4 or 5 tubes a year. And if this is a skill that the average medic can't do well then nobody should be doing it. Or set up an additional certification to be able to intubate that involves additional training and a certain number of tubes per year to maintain.



My argument to you then is that perhaps we should forcus on doing it right instead of just giving up and scraping it altogether. I hate to break it to you, intubation will not in my lifetime depart EMS as a whole. Fortunately, I enjoy being licensed in several states that allow individual Medical Directors determine the scope of practice, rather than have some political State power determine what is best for my clientele. As such, Texas for example, does not put a whole lot of stock into the proposed minimalistic scope of practice.

Instead, why not provide educational, hands on repetitive activites that allow the low volume clinicians get some exposure to maintain proficiency? The lack of exposure to intubation is a FAILURE on the part of the clinician and their agency. Both have a responsibility to maintain proficiency in an applicable skill set. In addition, both need to provide a non-punitive improvement process to ensure continuous advancement of their proficiency. It shouldn't be viewed as "the best of the best", it should be the bar!

We have got to stop resisting needed change. You either need to be a proficient medic and ensure you have the needed tools to produce a consistent level of quality medicine or you need to find another career. Not a personal attack on anyone as I believe most here agree, just something for some to chew on.


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## Shishkabob (Jan 1, 2011)

Put a medic in the OR with an anestheologist and compare the rates to eachother, or put the anestheologist out in the field and compare the rates with eachother.  Otherwise it is EXACTLY apples and oranges.  

Until all variables are the same except for medic vs doctor, the studies will be pretty darn close to worthless.


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## usalsfyre (Jan 1, 2011)

zmedic said:


> The counter argument is that if I'm setting national policy, I don't care about what the best of the best are capable. I want to know if given the standard paramedic course, how well the average paramedic can intubate. So you look at average departments. I think with research the temptation is whenever a study comes out that people don't like the implications they say "well, they're not us, we're much better, that doesn't apply."
> 
> Do I think that a department where medics are getting 40+ tubes a year, have continuous CO2 monitoring, get to go to the OR ever 3 months to get additional tubes, and have good QA can intubate? Sure. But those aren't the guys I worry about. It's the medics who get 4 or 5 tubes a year. And if this is a skill that the average medic can't do well then nobody should be doing it. Or set up an additional certification to be able to intubate that involves additional training and a certain number of tubes per year to maintain.



I don't think it takes 40+ tubes a year. There's a crapload of ED docs in rural settings who don't see close to 40 a year, yet you don't see a drive to remove intubation from them. Instead of lowering the level of care, how about we raise the level of the "average" paramedic. 

However, the states should step in and set up minimum requirements for QA, education and equipment to be able to intubate, since the services and medical directors can't seem to police themselves. Do it right, or give it up.


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## usalsfyre (Jan 1, 2011)

Linuss said:


> Put a medic in the OR with an anestheologist and compare the rates to eachother, or put the anestheologist out in the field and compare the rates with eachother.  Otherwise it is EXACTLY apples and oranges.
> 
> Until all variables are the same except for medic vs doctor, the studies will be pretty darn close to worthless.



The anestheologist will win every time, in every setting. Nothing a paramedic does will match three years of residency training.


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## Shishkabob (Jan 1, 2011)

usalsfyre said:


> The anestheologist will win every time, in every setting. Nothing a paramedic does will match three years of residency training.





True, and agreed, but one of the main things critics of ems field intubation is how "low" the rates of medics are compared to anesthelogist. Not a fair or logical conclusion.

Field intubations hardly compare to a nice, well lit, well controlled OR.   Not an excuse for undiagnosed esophageal intubations, but a miss or two in the field is hardly something to always freak about.


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## usalsfyre (Jan 1, 2011)

Linuss said:


> but a miss or two in the field is hardly something to always freak about.



Agree completely, as long as hypoxia isn't encountered.


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## zmedic (Jan 1, 2011)

usalsfyre; said:
			
		

> Agree completely, as long as hypoxia isn't encountered.



That's the issue. It's not misses in terms of not getting a tube, it's the rate of unrecognized esophageal intubations. Those are totally unacceptable, especially in this day and age of continuous CO2. And there are plenty of places that have way too many of those unrecognized misplaced tubes.  

I'm not sure how I feel about "education" to make up for lack of real tubes. I've intubated airway heads probably about 100-200 times, and it doesn't really compare to how the real tissues react. I'm not sure I'd feel comfortable saying "well, you've only done 1 real intubation this year, but you've done the airway head 20 so you are good to go." I think you need to get those medics with low volume into the hospital and have them do OR intubations. 

The other factor is we need less medics out there. If you have 5 FF/Medics on a fire truck well, they are each only getting 1/5 of the trucks tubes. Less medics= more tubes per medic. 

It wouldn't surprise me if ET intubation went away prehospitally in the next 20 years, and was just King/Combi for arrests. Because if you don't have RSI, and intubation isn't being prioritized in cardiac arrest when are you going to be intubating?


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## Icenine (Jan 3, 2011)

usalsfyre said:


> Never used the SALT, but a similar option does exist with the King LTS-D and the LMA, as long as you have a bougie available. Pass the bougie down the bore of the airway, it should emerge at the larynx. Pass the bougie as normal, remove the LMA/King and pass the tube. Confirm via standard methods, plus direct visualization if needed.



Like this?  

http://www.youtube.com/watch?v=LcgaQPfoYRs&feature=related


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## usafmedic45 (Jan 3, 2011)

> I don't think it takes 40+ tubes a year. There's a crapload of ED docs in rural settings who don't see close to 40 a year, yet you don't see a drive to remove intubation from them. Instead of lowering the level of care, how about we raise the level of the "average" paramedic.



Agreed with the idea of improving the quality of paramedics but that requires a massive amount of effort and it's easier to simply go for a simple engineering fix rather than (or at least while) working your way through the massive political, economic and social battles with those interested in maintaining the status quo.

I disagree with the analogy of rural ER docs.  The main difference between them and a paramedic in a low volume service is that while the paramedic has no backup, the doc often has two or three other people in the ER with him who can intubate (RTs and the paramedics who came in with the patient in many cases) and when all else fails they resort to the two best fallback options in an airway: non-visualized airways and a surgical airway.  The other major difference between most ER docs and most paramedics in this regards is that most ER docs don't think their penis shrinks when they have to resort to a non-visualized option.  



> The anestheologist will win every time, in every setting. Nothing a paramedic does will match three years of residency training.



Three years of training doesn't mean crap if they aren't doing a lot of intubations.  I know several anesthesiologists who intubate less frequently than I do because of the use of LMAs.  What about the ones who do chronic pain management?  You still think those docs is going to be better?  Recent experience has been shown to be a deciding factor among docs, paramedics, RTs, etc when it comes to most technical skills.  



> miss or two in the field is hardly something to always freak about.



The only airway issue to be ashamed of is the one where your ego or insecurity get in the way of doing what the patient needs done.  

Here are the rules of airway management I teach in the difficult airway courses I provide for both EMS and in-hospital professionals:
#1:  Oxygenation and ventilation are the goal, not intubation 
#2:	Your ego: check it at the door
#3:  Call for help; in fact, call for more help than you think you will need
#4:  If it is stupid and it works, it isn’t stupid
#5:  Newer is not always better
#6:   Plan ahead (avoid the “coffin corner”)
#7:  Hold your own breath
#8:  If it’s not working, let someone else try or try something else
#9:  When in doubt, skip to the end of the protocol (surgical airway)
    Corrolary:  “The hardest part of doing a cricothyrotomy is picking up the knife.” – Peter Rosen, MD
#10:  If they are still breathing and you are not sure you can take over, don’t stop them from doing so



> I've intubated airway heads probably about 100-200 times, and it doesn't really compare to how the real tissues react.



Talk to a local veterinarian and ask if they mind if you come practice on dogs or cats.  Cats are the best way to learn pediatric intubations short of actually tubing kids.


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## usalsfyre (Jan 3, 2011)

zmedic said:


> That's the issue. It's not misses in terms of not getting a tube, it's the rate of unrecognized esophageal intubations. Those are totally unacceptable, especially in this day and age of continuous CO2. And there are plenty of places that have way too many of those unrecognized misplaced tubes.



Absoloutely, do it right or don't bother doing it. 



zmedic said:


> I'm not sure how I feel about "education" to make up for lack of real tubes. I've intubated airway heads probably about 100-200 times, and it doesn't really compare to how the real tissues react. I'm not sure I'd feel comfortable saying "well, you've only done 1 real intubation this year, but you've done the airway head 20 so you are good to go." I think you need to get those medics with low volume into the hospital and have them do OR intubations.



Ideally, yes, however with the growing list of JACHO/TJC "never events" (anybody else find this as ludicrous as I do?) I see opportunities to learn airway management in the OR being reduced. 

Maybe I'm alone in this, but I don't feel like the psychomotor part of DL is all that difficult to learn and master to an acceptable level. the shortcoming I see in most paramedics is not the inability to actually perform the required manipulations, it's a complete misunderstanding of the anatomic landmarks they're looking for/at. 



zmedic said:


> The other factor is we need less medics out there. If you have 5 FF/Medics on a fire truck well, they are each only getting 1/5 of the trucks tubes. Less medics= more tubes per medic.



Maybe the systems that insist on this need to get rid of ET intubation and leave it to those of us who take it seriously. 



zmedic said:


> It wouldn't surprise me if ET intubation went away prehospitally in the next 20 years, and was just King/Combi for arrests. Because if you don't have RSI, and intubation isn't being prioritized in cardiac arrest when are you going to be intubating?



Unfortunately I agree. Look at what Australia and New Zeland have done with prehospital RSI and it's clear it CAN improve outcomes. Unfortunately most US EMS systems refuse to put the engineering and quality control measures in place to ensure this.


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## usalsfyre (Jan 3, 2011)

usafmedic45 said:


> Agreed with the idea of improving the quality of paramedics but that requires a massive amount of effort and it's easier to simply go for a simple engineering fix rather than (or at least while) working your way through the massive political, economic and social battles with those interested in maintaining the status quo.



Dead horses, dead horses :glare:



usafmedic45 said:


> I disagree with the analogy of rural ER docs.  The main difference between them and a paramedic in a low volume service is that while the paramedic has no backup, the doc often has two or three other people in the ER with him who can intubate (RTs and the paramedics who came in with the patient in many cases)



Depends, RTs at the local doc in the box are not credentialed in that facility to provide airway management and if I touched a laryngoscope in there they'd likely try to pull my card at the state level due to politics. 



usafmedic45 said:


> and when all else fails they resort to the two best fallback options in an airway: non-visualized airways and a surgical airway.  The other major difference between most ER docs and most paramedics in this regards is that most ER docs don't think their penis shrinks when they have to resort to a non-visualized option.



Paramedics thinking ET intubation is related to penis size? Say it isn't so....



usafmedic45 said:


> Three years of training doesn't mean crap if they aren't doing a lot of intubations.  I know several anesthesiologists who intubate less frequently than I do because of the use of LMAs.  What about the ones who do chronic pain management?  You still think those docs is going to be better?  Recent experience has been shown to be a deciding factor among docs, paramedics, RTs, etc when it comes to most technical skills.



See above, I would still take a residency trained anesthesia doc over a six month fire medic even if the fire medics doing 50 tubes a year and the docs been doing pain management.   



usafmedic45 said:


> The only airway issue to be ashamed of is the one where your ego or insecurity get in the way of doing what the patient needs done.
> 
> Here are the rules of airway management I teach in the difficult airway courses I provide for both EMS and in-hospital professionals:
> #1:  Oxygenation and ventilation are the goal, not intubation
> ...



The only one I sort disagree with is #7, I've seen lots of missed tubes by people getting in a hurry and am a fan of using physiologic signs for termination of attempts .

I'm gonna steal this if you don't mind. Great way to distill airway mangement down for interns and students. 




usafmedic45 said:


> Talk to a local veterinarian and ask if they mind if you come practice on dogs or cats.  Cats are the best way to learn pediatric intubations short of actually tubing kids.



Never thought of that, although I have heard of PALS classes using ferrets.


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## usafmedic45 (Jan 3, 2011)

> The only one I sort disagree with is #7, I've seen lots of missed tubes by people getting in a hurry and am a fan of using physiologic signs for termination of attempts .



It's a good way to judge when you're taking too long to tube.  It's actually a much better option than waiting for the patient to desaturate to abort the attempt.  Also, in a large chunk of the population, controlling your breathing actually is a fairly good to calm down and focus.  

If you're in such a panic or in such bad shape that you have to "rush" while holding your breath, you probably should find other work (in the former) or be checked out by a doc (in the latter).



> I'm gonna steal this if you don't mind. Great way to distill airway mangement down for interns and students.



If you want me to come do the full presentation, let me know.  I don't mind you using the rules I outlined, so long as I am given credit for it.  Just call them "Steve's Rules" or something. LOL


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## usafmedic45 (Jan 3, 2011)

> Depends, RTs at the local doc in the box are not credentialed in that facility to provide airway management and if I touched a laryngoscope in there they'd likely try to pull my card at the state level due to politics.



Wow....every hospital I have worked at from a 25-bed critical access hospital to a 900-bed trauma center has let the RTs intubate.   Those are some screwed up politics right there.


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## lr2148 (Jan 3, 2011)

Ignore Post


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## lr2148 (Jan 3, 2011)

In Wisconsin(well, some parts), First Responders can drop a King or Combi!!!!


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## usafmedic45 (Jan 3, 2011)

lr2148 said:


> In Wisconsin(well, some parts), First Responders can drop a King or Combi!!!!


.....and why is that any reason to get excited?  My five year old could drop a Combitube.  She already knows how to operate an AED.   Hell, give me a weekend and I'm pretty sure I could get her to the point of being able to pass the EMT exam.


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## Phlipper (Jan 6, 2011)

usafmedic45 said:


> .....and why is that any reason to get excited?  My five year old could drop a Combitube.  She already knows how to operate an AED.   Hell, give me a weekend and I'm pretty sure I could get her to the point of being able to pass the EMT exam.



Wow, you're really wound tight aren't you?  Are you like this all the time or just recently?  Have you considered it might be time to find a new career?  Or at the very least, maybe a vacation or a meditation retreat?  It's obvious you're carrying around a lot of resentment and anger over something work/career related.  Seriously, is there someone you could talk to?   In your present state I wouldn't want you around patients in the service I work for, and neither would our director.  Please talk to someone.


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## Ridryder911 (Jan 6, 2011)

Okay, I guess an old timer will chime in... Intubation should not be removed from the curriculum. It is the _ Gold Standard _ and our patients should expect only the best... but be performed by the best. Unfortunately, we (EMS) have failed horribly! Alike ACLS education... uh... training... uh... demonstration...resuscitation componets have been so watered down, one should only expect poor outcome(s) and poor skill demonstration. 

Amazing, we still want to avoid the "source" of the problems, instead we want to substitute and "avoid" the real problems of why we have a decrease in success. When I was taught intubation over 30+ years ago, we were taught the same airway techniques at a physician level... (you’re performing a physician level skill, you need physician level understanding of the procedure).. We were assigned to "Code Teams" and were not allowed to intubate for the first 15 minutes, carefully monitored by the anesthesiologist/physician. We had to demonstrate that we could control the airway successfully by basic techniques of positioning, basic airway adjuncts, suctioning without any side effects such as gastric distention.. etc. Why? One should master the basics before proceeding to advanced procedures. 

We were taught not all patients need to be intubated, when deciding to intubate there is more to it than ... "dropping a tube"... A thorough but quick assessment of potential problems such as Mallampati scoring, hypomental distance.. (etc) so it was not a "Surprise" when you received an airway from Hates. The provider with a very good knowledge and skills of basic airway management could provide airway management no matter what! 

Yes, King and all other supplemental airway adjuncts (substitutes) are a good back up and should never be considered as the gold standard for those that will need a long term secured airway. 

This is where will we see a change and unfortunately, most of those in EMS (especially students and even instructors) fail to recognize cardiac arrest (cardiac origin) patients primary etiology and successful outcome criteria is not the lack of airway or even ventilation. Something of mind changes from decades of previous thinking. 

What I do foresee is intubation to be totally removed from the procedure of resuscitation of a cardiac arrest (cardiac etiology) and supraglottic airways (King/Combi etc) to be used due to the ease and truthfully the results will not change the outcomes. I do look for those patients that have a ROSC to be intubated for long term treatment (post resuscitation, hypothermia protocols, etc)... In other words, save aggressive treatment for those that demonstrate a potential of having a + outcome. 

Placing simplistic airways such as King and so forth is not a highly advanced skill. Anyone with more than two digits (fingers) can do such. A monkey could perform the procedure. Unfortunately, we have "pushed" placing these in lieu of truly teaching EMS students on primary airway control with the ability to master these techniques and then to use devices as an adjunct. Again, we _rush and push _ through essential education and we have seen the results, poor outcomes. 

R/r 911


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