# Sorry If I Upset You



## CFRBryan347768 (Apr 1, 2008)

Any one off for posting here but i believe this is related to the Paramedics.
1. What is this, and why is it needed? 
2. Are Paramedics still allowed to do this(i heard at some point they were)
http://www.youtube.com/watch?v=MK1mqM1LHW4


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## JPINFV (Apr 1, 2008)

Kinda of, sorta.

That was a chest tube being put into a kid who had pus in his chest cavity due to infection. 

How you breath is your chest is pulled up and outward which puts a negative pressure on your lungs. Since your lungs are open to the outside via your bronchioles, trachea, and pharynx, this causes the air outside to move into your lungs to equalize pressure (note: Any movement of gas involves a pressure gradient). When you you get fluid, air, or pus inside of your chest cavity (hemothorax, pneumothorax, pyothorax respectively) the ability for your body to change the pressure inside of your chest cavity is decreased. The way you solve that is to remove what is inside the chest. Normally, your chest (plural cavity) has a pressure of -6mmHg.

You can see the effect of the pyothroax clearly in the first few moments of the video. If you notice, only the boy's right side is moving when he breaths. You can also see it in the x-ray because the left side (patient's left side... right side of the physical x-ray) is white while the right side is mostly black (patient's right.... left side of the physical x-ray).

Paramedics, for the most part (I believe some frontier and some aeromed services may be able to) can not insert a tube as shown. What they can do, though, is use a needle to achieve a similar result in patients who have air in their chest cavity.


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## CFRBryan347768 (Apr 1, 2008)

Thank you!!


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## rmellish (Apr 8, 2008)

I believe that chest tube placement is a skill  taught as part of the Critical Care Paramedic training. If so it then becomes an issue of whether your state recognizes CC/EMT-P *and* if your service has the protocol and the equipment.

Any CC/EMT-Ps out there, please correct me if I'm wrong.


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## firecoins (Apr 8, 2008)

I don't see this being a 911 skill at all.  Not in my area at least  It is possible that it could be on critical care transfers but I assume an MD/DO could do it before being transfered.


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## rmellish (Apr 8, 2008)

I agree with that. 
My understanding is that the CC/EMT-P cert is intended more for critical inter-facility or long distance transports. Not the conventional prehospital situations.


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## Ridryder911 (Apr 8, 2008)

Chest tubes *do have* there placement in emergency treatment and care of those with pneumo and hemopneumothorax. Such conditions are *life threatening* events. When they should be justified is dependent on whom, where and type of service provided. 

Chest decompression can be adequate sometimes, yet all dependent on the amount of pneumo the patient has as well time duration until a chest tube can be placed. Please remember, a chest tube is a definitive treatment and if one demonstrates the symptoms of a pneumo, chances are they need one and definitely will get one. I have performed chest decompressions using a 14g Jelco so much they looked like a porcupine. Remember, chest decompressions will occlude in a few minutes. Fortunately, the one we now use is slightly larger and has a silicone lining that prevents clotting and cannot be kinked as well. 

Should every Paramedic be able to perform or have the ability to? No, but again there are areas and situations that warrants the procedure. Again, pneumothorax should be considered a * life threatening event, it is a lower airway obstruction and if not treated aggressively and immediately that patient will die!*

I was taught to place chest tubes as a CCEMT/P and in my Flight Nurse Trauma Course, as well in ATLS, etc. I have performed ten or twelve chest tubes, and several chest decompression. I was taught on cadavers, pigs, cats, etc.. all monitored and instructed by surgeons, and closely critiqued. There are different ways and techniques that can be learned and used. Those that do perform such techniques in the field, I am assured are closely monitored. 

In regards to CCEMT/P it is an educational course above the normal Paramedic curriculum. Yes, its focus in specialty care transports but it is not the sole focus, it still involves the prehospital aspect as well. 

In regards to the video, it is not prehospital arena. It appears to be in remote setting such as in third world countries. The child appears to have a pleural effusion containing myo or pus and fluid. This can be caused by several conditions, and again although this develop over a period of time, it is still a life threatening condition. The child was anesthetized with Lidocaine or similar anesthetic before chest tube insertion, and probably attached to a closed suction drainage unit. I have assisted in such on medical missions, with children with multiple problems. The lung may reinflate over time and tube will removed (usually 24-48) dependent on the condition. 

R/r 911


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## LucidResq (Apr 8, 2008)

Does anyone know who usually inserts chest tubes in the ED? I know that nurses can, but is this usually done by the surgeon/physician?


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## rmellish (Apr 8, 2008)

Of the two I've witnessed, one was done by the ED doc, the other by a general surgeon. I remember the surgeon making the comment that, to him at least, "Its a very simple and straightforward process.....watch this."


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## Ridryder911 (Apr 8, 2008)

LucidResq said:


> Does anyone know who usually inserts chest tubes in the ED? I know that nurses can, but is this usually done by the surgeon/physician?




Emergency nurses do NOT usually place them. It is considered a surgical procedure and not a nursing procedure. The ED Doc usually places them, some places allows NP/P.A.'s to perform this and some do not. 

Dependent on the case the ED Doc will turn over the case to the surgeon. 

R/r 911


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## LucidResq (Apr 8, 2008)

Ridryder911 said:


> Emergency nurses do NOT usually place them. It is considered a surgical procedure and not a nursing procedure. The ED Doc usually places them, some places allows NP/P.A.'s to perform this and some do not.
> 
> Dependent on the case the ED Doc will turn over the case to the surgeon.
> 
> R/r 911



Some flight nurses can though, right?


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## Jeremy89 (Apr 8, 2008)

LucidResq said:


> Does anyone know who usually inserts chest tubes in the ED? I know that nurses can, but is this usually done by the surgeon/physician?



On the code I had the doctor did, but not after trying an OPA (Dunno why he wanted to try that first when he coulda intubated....he was the new guy), and yes, Lucid, most flight nurses can as well...


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## Ridryder911 (Apr 8, 2008)

Actually, there are very *few* services that can insert chest tubes. As well, many flight nurses and medics are NOT always taught this procedure, even if they have, does not mean they can perform it. I could in some states, while in other states, I was strictly prohibited. It all depends on the Nursing Scope of Practice within that state. I can assure as well, I have never seen a ER Nurse insert one. 

I can assure you as well, that is a rare occurrence that flight teams to insert one, as most will attempt chest decompression first. This is a heated debate among SCT and Flight Teams if it is a procedure that should be performed by non physician and potentially dangerous procedure. 

It does come with severe dangers. It is *NOT* a simple procedure as mentioned. One of punctures the lung, and with this lacerates vessels. Along when placing the tube can lacerate major vessels such as the subclavian, puncture the pericardium or even damage the heart itself, along with possible performing nerve damage on the intercostal region of the chest wall. So NO it is not just a simplistic procedure.. again, why most flight teams DO NOT perform such. It has a lot of hype, similar to what central lines did until EZ I/O drill came along and now central lines is almost a thing of the past per flight or ground crews. 

R/r 911


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## VentMedic (Apr 8, 2008)

Agree with Rid. 

Although, Rid and I both probably learned chest tube insertion (along with intra cardiac epi injections) in Paramedic school back in the 1970s,  a little device came along called the McSwain Dart  that made life easier.  There was also that thing we did with the finger of the glove and needle...and some spit....

Chest tube insertion is not a "skill" that can be performed often enough to adequately maintain proficiency even by those working in hospital based flight programs.  Even though we see several a week, there is more risk and can be time consuming to get the tube positioned correctly to drain.  Infection is a big risk also. 

That being said, some Neonatal transport RNs and RRTs do insert chest tubes.  But, these professionals are very well trained by their medical directors and have many years of experience.  It there are not enough babies to work with they may be forced to use bunny rabbits to maintain their skills.


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## tydek07 (Apr 8, 2008)

This is not a skill that is taught to most paramedics. I think some Critical Care Medics may get the training, and maybe some flight medics. I know that flight nurses are able to put one in, in a lot of areas. 

This is really considered a surgical procedure, so its not done my many people in the EMS setting.


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## Jeremy89 (Apr 8, 2008)

I know here in AZ it is part of the scope of practice for our fire medics.  I have a friend that works at a hospital and he says Mesa FD always brings the pt in and says "we _thought about_ intubating but.....(some excuse)"

J


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## tydek07 (Apr 8, 2008)

We were talking about chest tubes, and who can place those.

Every medic should be able to intubate.


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## Ridryder911 (Apr 8, 2008)

Jeremy89 said:


> I know here in AZ it is part of the scope of practice for our fire medics.  I have a friend that works at a hospital and he says Mesa FD always brings the pt in and says "we _thought about_ intubating but.....(some excuse)"
> 
> J



I assume you mean intubation right? Chest tubes is not routinely taught in the Paramedic curriculum. 

R/r 911


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## Jeremy89 (Apr 8, 2008)

tydek07 said:


> We were talking about chest tubes, and who can place those.
> 
> Every medic should be able to intubate.



I second that, but then again, I'm just a 'basic' that knows nothing


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## tydek07 (Apr 8, 2008)

Jeremy,
  You just must must of read it wrong..... it happens. Chest Tubes and Intubation's are totally different.

Not very many medics can put Chest Tubes in, so you must have been talking about AZ FF being able to intubate.

But hey, at least your not afraid to post what you think. 

Take Care,


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## Jeremy89 (Apr 8, 2008)

tydek07 said:


> Jeremy,
> You just must must of read it wrong..... it happens. Chest Tubes and Intubation's are totally different.
> 
> Not very many medics can put Chest Tubes in, so you must have been talking about AZ FF being able to intubate.
> ...



We use the terms interchangeably here, well, at least no one corrected me in 8 weeks of school....  so what is the difference?


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## tydek07 (Apr 8, 2008)

I wonder if your thinking of something else?

Intubation and Chest Tube are not the same at all.

Lets see here if I can post some pictures... I have never tried this, so will see what happens.

Ok, so here is an Intubation:







And here is a Chest Tube:






Images are from google.com, I take no credit for them.

Anyway, if you want to read about them, just google them.


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## Jeremy89 (Apr 8, 2008)

Well first, those are HUGE pictures.

So back to the original question...I've only seen a chest tube done during my ER clinicals so I don't see any need for one to be done in the field...

So our medics are not trained for chest tubes here...

Wow thats embarrassing...


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## firecoins (Apr 8, 2008)

single post


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## LucidResq (Apr 8, 2008)

Wow about that chest tube picture... they really snake it up that far into the pleural space? I've never seen it done.


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## firecoins (Apr 8, 2008)

*teaching video of chest tube procedure*

Check this out:
http://video.google.com/videoplay?d...=17&start=0&num=10&so=0&type=search&plindex=1

Is this an accurate video Rid?


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## Ridryder911 (Apr 9, 2008)

Jeremy89 said:


> Well first, those are HUGE pictures.
> 
> So back to the original question...I've only seen a chest tube done during my ER clinicals *so I don't see any need for one to be done in the field*...
> 
> ...




Okay, sorry for the rant and please do not consider as an attack but her we go again! Really, you don't see any need for it. Thank you so much. Wow! One that did not even know the difference between an intubation and chest tube, or in other words similar to the old saying not knowing your head from your. ***. An 8 week course, allowed you to make the determination to know what is needed in the field right? 

Sorry, it is not just you alone, rather any of the lower ranking or less trained individuals actually think they have the knowledge to judge or question what is acceptable or not. Similar to me telling a surgeon what procedures would be acceptable or not. Both would be considered ludicrous. 

Back to the chest tube. My summary of performing the procedure of the chest tube is to make an opening large enough for the diameter of the tube. Usually one either can use a stylet (looks like a large knitting needle) or curved Kelly clamp the chest wall is incised with a scalpel then the tube is introduced. A finger is inserted to feel the lining of the lung, (making sure you are in the right place) then the tube is introduced cephalic or up towards the head. There are markers on the tube to give location and amount is in the chest wall. There are formulas on  how much should be introduced. Technically, a x-ray should be performed immediately after the insertion to verify placement. 

Again, this is a surgical procedure performed daily in hospitals. Very few air services perform it. As Vent and I described there are conditions that need it, hopefully as we become more educated this procedure will added more. I doubt I will see this in the next ten years. 


R/r 911


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## Ridryder911 (Apr 9, 2008)

firecoins said:


> Check this out:
> http://video.google.com/videoplay?d...=17&start=0&num=10&so=0&type=search&plindex=1
> 
> Is this an accurate video Rid?



Yep, did not see your post until I posted my previous one. Good video, especially in a nice clinical setting. Alike other medical procedures, the field method is modified somewhat...

R/r 911


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## Jeremy89 (Apr 9, 2008)

Ridryder911 said:


> Okay, sorry for the rant and please do not consider as an attack.....not knowing your head from your. ***. An 8 week course, allowed you to make the determination to know what is needed in the field right?...
> R/r 911



So saying I don't know my head from my *** isn't considered an attack??  Not sure who taught you manners.

So basically if I understand you correctly, I'm another dumb EMT because I don't know the difference between a surgical procedure and an ALS skill??  I know what I need to treat a patient with BLS skills.  My 8 week course obviously worked just fine if I'm a licensed EMT, now didn't it??...

I asked a simple question and instead of explaining it in a simple manner like Tydek did, you have to go on this rant about how stupid EMT's are and all that :censored::censored::censored::censored:.  Lemme ask you, do you even remember what it was like to be an EMT?  What was your first call like?  I'm sure your preceptor didn't say "no dumbass, that's not what we use ____ for".  No, I bet if you asked a question or made a mistake o if you are even capable of such) your preceptor kindly explained what was going on.

I consider myself a medical professional and will not to tolerate this on a public forum for the EMS community.  I'll be honest- I don't care how many posts or how much experience you have.  We are all medical professionals and should be treated as such.  End of story.


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## rmellish (Apr 9, 2008)

Jeremy89 said:


> So basically if I understand you correctly, I'm another dumb EMT because I don't know the difference between a surgical procedure and an ALS skill??



I think Rid was commenting on the fact that it looks rather unprofessional when you confuse two somewhat common procedures for patients. One of the best ways to earn the respect of other health care *professionals* is to be able to speak intelligently about the tools of the field. 

C'mon, Rid's not giving you crap about not knowing that, for example, Augmentin is an antibiotic consisting of amoxicillin and clavulanic acid which acts as a suicide inhibitor for Beta-lactamases, no, he's commenting that not all EMTs know their way around common procedures for ER patients. Wait, kinda like the same ER patients that EMTs bring in, and sometimes even transport to other facilities. You want be treated as a professional, sound like one.




Jeremy89 said:


> I know what I need to treat a patient with BLS skills.  My 8 week course obviously worked just fine if I'm a licensed EMT, now didn't it??...



Certified as an EMT does not mean that you are a good EMT. One would hope the two go together, but hey, I suppose that now you're done with your 8-week course you can just stop learning and save the world all by yourself. 

No good health care *professional* ever stops learning. The EMT-B curriculum is the bare minimum knowledge. I would hope that a *professional* would attempt to expand on such.




Jeremy89 said:


> I asked a simple question and instead of explaining it in a simple manner like Tydek did, you have to go on this rant about how stupid EMT's are and all that :censored::censored::censored::censored:.  Lemme ask you, do you even remember what it was like to be an EMT?  What was your first call like?  I'm sure your preceptor didn't say "no dumbass, that's not what we use ____ for".  No, I bet if you asked a question or made a mistake o if you are even capable of such) your preceptor kindly explained what was going on.



You know, you're taking what I read as a general commentary on the lack of medical literacy among EMTs very personally. And I'm pretty sure Rid is an EMT, and might know a thing or two about a job he's been doing for awhile. Don't hold me to that though, maybe he just puts CC/*EMT*-P in his signature for fun.



Jeremy89 said:


> I consider myself a medical professional and will not to tolerate this on a public forum for the EMS community.  I'll be honest- I don't care how many posts or how much experience you have.  We are all medical professionals and should be treated as such.  End of story.



Here we go with the medical professional bit....once again, part of being a true medical *professional* is sounding the part.


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## Ridryder911 (Apr 9, 2008)

Sorry, noobie maybe I was a little rough on you. I apologize but still believe that you need to learn that some real life in the profession. As well, NO I never was a Basic EMT, I went straight through my Paramedic and have always worked as one for over 31 years. Yes, I do remember what is was like, the reason I stated what I did. 

My point was to try to inform you of a some professional tact. One should learn that you should not try give an opinion of a procedure if it should or not should be done by an individual, especially when it was obvious you knew nothing about it. By giving a poor statement would be considered just as unprofessional, don't believe me say to an experience Paramedic and see what happens.  

As well, completing a EMT/B does not impress any healthcare professional. Seriously, it has a >80% pass rate the first time and really it is just barely a starting point. So don't expect to get much credit. I am quite aware of the EMT Curriculum. 

I suggest if this simple post offended you, you might want to learn to roll with the flow.  Much better me than a surgeon, or better yet your field preceptor. It is not a kumba-ya out there. You were the one that suggested your opinon that the procedure was not needed or necessary, after seeing a one time procedure, and just completing a very elementary fundamental course. That is not bad, just what it is. Just be sure, to be aware when other professionals hear statements like what you had made maybe very offensive and don't be surprised to be chastized even more.  

This why forums like this help others. It deals with real life and real people who work in the field, trauma center, O.R. etc. It is not a classroom, where the field is sometime viewed through rose colored glasses. I guess we are both alike, I am not trying to impress anyone. You described you are a nursing student, I as well as those that have been through such will forewarn you they are much more critical on statements. Again, sorry if I offended you.

P.S. I work in the field as a Critcal Care Paramedic (field) full time, and RN part time. 
Good luck, 

R/r 911


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## Jeremy89 (Apr 9, 2008)

rmellish said:


> Certified as an EMT does not mean that you are a good EMT. One would hope the two go together, but hey, I suppose that now you're done with your 8-week course you can just stop learning and save the world all by yourself.
> 
> No good health care *professional* ever stops learning. The EMT-B curriculum is the bare minimum knowledge. I would hope that a *professional* would attempt to expand on such....
> 
> ...



I understand there are good and bad EMT's; there are also good and bad doctors, but you know what they call the doctor that graduates first in his class and the last in his class??  Doctor.  This quote was from my EMT instructor who has been a medic for years, as well as an RN/BSN.  He's one of the best instructors around and has a completely different perspective than Rid seems to...
I understand learning is an ongoing process, however, how can one learn if they can't get simple questions answered in a polite manner?  I also understand the field can be stressful and is not always the best place to ask questions but again, I do what I need to in order to be the best EMT I can be.

Not quite sure what you meant by my lack of sounding 'professional'... I simply replied to a thread in defense of myself...


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## ffemt8978 (Apr 9, 2008)

That's enough...


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