# cardiac arrest tips and tricks you have learned along the way...?



## tazman7 (Jun 16, 2009)

Just wondering what some of your tips and tricks are that you have learned along the way to make codes run alot smoother.


Seems like the few that I have been on have turned out to be a cluster f*** by peoples carelessness. IE: Ripping ivs out...


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## tazman7 (Jun 16, 2009)

Also have a question on this code.

Got called for seizure, turned out to be code. When I went to intubate his jaw was clinched very very tight. I had to stick my fingers in his mouth and pry it apart. Guy had esophageal cancer with lots of scar tissue. Very difficult intubation for a newer medic. Iv was unobtainable at that time. Would it be ok to give versed via mad device to relax the pt jaw? It was like he was biting down.. I know he isnt breathing but with spraying it up the nose would it absorb through the mucosal membranes? Or give it im?


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## Melclin (Jun 16, 2009)

Don't cut through the defib cables with the trauma sheers. Lol. Didn't do it, but sure came close on my first arrest.

But seriously I'd be really interested in tips too. There must be heaps of stuff that's not in the textbook.


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## Outbac1 (Jun 16, 2009)

Take your time. The pt is not going anywhere in a hurry. Two min of cpr gives lots of time to set up the defib and start a basic airway, *IF* the person wanted resusatation.(One of the first questions I ask of bystanders). Get your scene organised. Extra people? Give them a job, move furniture, get stretcher, prepare to take over cpr etc. 

  I know several who have given versed to try to loosen a trismissed jaw, in seizure pts not arrests.  But it didn't work.  Drugs tend to need circulation to work and its a fact that dead people have poor circulation. 

 My 2 cents.


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## Epi-do (Jun 16, 2009)

Don't be afraid to call for orders to stop CPR if you are getting no response after a reasonable attempt.  There is nothing the hospital is going to do in this situation that we cannot do onscene.  The cardiac arrest patient isn't going to get any worse, and let's face it, they rarely get better.  We need to stop needlessly transporting corpses.  Think about it.  How many cardiac arrest patients have you taken into the ER that have been worked for more than just a few minutes before the doc calls them?  Chances are, very few.


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## el Murpharino (Jun 16, 2009)

Proper training alleviates some of the confusion involved with a code.  If everyone knows their position and their role in the care of the patient, it gets rid of that clusterf*ck feeling that seems to find its way into every code. Everyone wants to get their hands in the mix and make an impact on the call....but don't be afraid to tell people to get back...you don't need that many people on a code.


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## tazman7 (Jun 16, 2009)

el Murpharino said:


> Proper training alleviates some of the confusion involved with a code.  If everyone knows their position and their role in the care of the patient, it gets rid of that clusterf*ck feeling that seems to find its way into every code. Everyone wants to get their hands in the mix and make an impact on the call....but don't be afraid to tell people to get back...you don't need that many people on a code.



that was the entire problem with this code. to many people in the way. six guys in the back of the ambulance is to much.  3 people working 1 person writing I think would be perfect..maybe even 2:1


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## akflightmedic (Jun 16, 2009)

Here is something I always do even with field termination guidelines now.

If the call comes in as unconscious, not breathing, possible cardiac arrest or CPR in progress, I always bring in my long spine board as well.

If I decide to work the patient, me and my partner rapidly place him on the board before we start. This extra 5 seconds at the beginning enables the code to run much smoother for a couple reasons.

First, you do not have to worry about any wires, tubes, or IVs being ripped out or dislodged later on by moving the pt around because you have him on the board BEFORE these interventions are done.

(You still have to reassess these things and yes they can still come out, but the likelihood has been reduced)

Second, when other rescuers arrive, you can move the patient quicker and more efficiently because again you have the board in place. You do not have to wait for someone to bring it in, you do not have to wait to move it under him with special care to all the devices, it is already done.


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## Flight-LP (Jun 16, 2009)

tazman7 said:


> Also have a question on this code.
> 
> Got called for seizure, turned out to be code. When I went to intubate his jaw was clinched very very tight. I had to stick my fingers in his mouth and pry it apart. Guy had esophageal cancer with lots of scar tissue. Very difficult intubation for a newer medic. Iv was unobtainable at that time. Would it be ok to give versed via mad device to relax the pt jaw? It was like he was biting down.. I know he isnt breathing but with spraying it up the nose would it absorb through the mucosal membranes? Or give it im?



Why not IO him? Then your access problem is resolved..............

Why would you give him Versed out of curiosity? Why not nasally intubate him or if all else fails go with a failed airway device?


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## el Murpharino (Jun 17, 2009)

Flight-LP said:


> Why not IO him? Then your access problem is resolved..............
> 
> Why not nasally intubate him or if all else fails go with a failed airway device?



Or go with a King-LT, Combitube, LMA....or any other secondary airway device the agency/protocols allow.  

I only mention this because we can't nasally intubate in our region...


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## terrible one (Jun 17, 2009)

Flight-LP said:


> Why not IO him? Then your access problem is resolved..............
> 
> Why would you give him Versed out of curiosity? Why not nasally intubate him or if all else fails go with a failed airway device?



i thought a contraindiction to nasally intubating was an apenic pt? it was my understanding that they needed spontaneous respirations? or maybe thats just by county/st




el Murpharino said:


> Or go with a King-LT, Combitube, LMA....or any other secondary airway device the agency/protocols allow.
> 
> I only mention this because we can't nasally intubate in our region...




if you cant open the jaw how can you can you get an LMA/Combi in?
maybe i read something wrong from the OP


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## MSDeltaFlt (Jun 17, 2009)

tazman7 said:


> Also have a question on this code.
> 
> Got called for seizure, *turned out to be code*. When I went to intubate his *jaw was clinched* very very tight. I had to stick my fingers in his mouth and pry it apart. Guy had esophageal cancer with lots of scar tissue. Very difficult intubation for a newer medic. Iv was unobtainable at that time. Would it be ok to give versed via mad device to relax the pt jaw? It was like he was biting down.. *I know he isnt breathing but with spraying it up the nose would it absorb through the mucosal membranes? Or give it im*?


 
A dead person's jaw tends to be loose... at least until rigor mortis sets in. If they're apneic with clinched jaws, they're not dead yet.  Odds are they're still seizing and not breathing from continuous stimulation of the diaphragm. Nasally tube them. They might still be able to cough, thus facilitating ETI. Even if they're not, you can manipulate trachea externally to help here.

Also, a "code" generally means your pt has no pulse. One does not sedate the dead. Tends to be counter productive.



Flight-LP said:


> *Why not IO him*? Then your access problem is resolved..............
> 
> Why would you give him Versed out of curiosity? Why not nasally intubate him or if all else fails go with a failed airway device?


 
Some areas, and even services, don't have adult IO. Down here in BFE on the ground truck we don't.



el Murpharino said:


> Or go with a King-LT, Combitube, LMA....or any other secondary airway device the agency/protocols allow.
> 
> *I only mention this because we can't nasally intubate in our region*...


 
You're not allowed to nasally intubate?!? Wow.



terrible one said:


> *i thought a contraindiction to nasally intubating was an apenic pt*? it was my understanding that they needed spontaneous respirations? or maybe thats just by county/st
> 
> 
> 
> ...


 
It's not contraindicated. Unless, of course, your protocols say it is. It's just harder.


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## 46Young (Jun 17, 2009)

If you have capnography capabilities, attach the ETCO2 after you drop the tube, before you attach the BVM for tube confirmation. Along with all other confirmation techniques, good waveform can be the clincher for placement verification. A change in waveform or #'s should alert you to recheck the tube, suction, etc. Check tube placement each and every time the pt is moved. You don't want to have a dislodgement or Rt mainstem displacement for a prolonged time, or at all for that matter. After dropping a tube, placing a C-collar would be a good idea, to help minimize dislodgement potential. If you have a free moment during the arrest, preplan dose calcs for any weight based post arrest drips you may need to admin, if ROSC should occur.


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## Guardian (Jun 17, 2009)

46Young said:


> If you have capnography capabilities, attach the ETCO2 after you drop the tube, before you attach the BVM for tube confirmation. Along with all other confirmation techniques, good waveform can be the clincher for placement verification. A change in waveform or #'s should alert you to recheck the tube, suction, etc. Check tube placement each and every time the pt is moved. You don't want to have a dislodgement or Rt mainstem displacement for a prolonged time, or at all for that matter. After dropping a tube, placing a C-collar would be a good idea, to help minimize dislodgement potential. If you have a free moment during the arrest, preplan dose calcs for any weight based post arrest drips you may need to admin, if ROSC should occur.



I think continuous capnography monitoring should become the gold standard.  My agency has been using it for years and haven't brought in a misplaced tube in a long time.


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## Guardian (Jun 17, 2009)

akflightmedic said:


> Here is something I always do even with field termination guidelines now.
> 
> If the call comes in as unconscious, not breathing, possible cardiac arrest or CPR in progress, I always bring in my long spine board as well.
> 
> ...



Or better yet, if you can, just throw them on the stretcher before you start.  This works especially well when treating patients in nursing homes or apartment buildings.  This also helps if you need to drop a tube.  If you can't see the cords, you can drag them back until their head in hanging off the stretcher, which hyper extends the neck.

A reeves also works well.


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## Guardian (Jun 17, 2009)

I'm big on utilizing all the responders on scene.  I usually have an emt partner and four firefighters/emts.  I make sure that everyone has a job and that I'm always thinking four steps ahead of everyone else.  This is easy to do if you have planned in advance.  This is important, not just to make the call go smoothly, but for successful outcomes and efficient care.  It also allows me to focus on the overall scene more and to make sure every one is doing their job properly.  For example, making sure the firefighter isn't bagging at 50 times a min on a closed airway.  

So I'll usually have my emt setting up IVs and other equipment.  I'll have one FF do bagging, one write down my important observations and medication admin times, the fire Capt. talking to the family and getting the pt's personal info, etc.

This stuff seems like common sense, but believe me, it will make all the difference in pt outcome.  Giving people specific jobs also creates a more relaxed atmosphere and prevents people from running around excited and ripping out IVs without getting anything done.  

You usually know you've done a good job when arrest calls start to get boring and you find yourself without anything to do while you're waiting for the meds to circulate.


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## tazman7 (Jun 17, 2009)

MSDeltaFlt said:


> A dead person's jaw tends to be loose... at least until rigor mortis sets in. If they're apneic with clinched jaws, they're not dead yet.  Odds are they're still seizing and not breathing from continuous stimulation of the diaphragm. Nasally tube them. They might still be able to cough, thus facilitating ETI. Even if they're not, you can manipulate trachea externally to help here.
> 
> Also, a "code" generally means your pt has no pulse. One does not sedate the dead. Tends to be counter productive.




Yeah thats what I always thought until this guy. 

Just a quick summary on the call.

Called for seizure, half way there were told by other first responders it was full code. UOA they were doing cpr to a witnessed arrest, had aed pads on, already shocked twice. tried twice on a king airway and they pulled it out. our Crew then switched to our pads, pt was in vfib- no pulse, agonal respirations, clinched jaw. shock advised, shock administered. i tried intubating, had to force pt jaw open, couldnt see vocal cords. was told pt had history of esophageal cancer, throat was full of scar tissue. couldnt intubate. so i dropped in a king airway and i had to go to the smallest size we had. got it in and it kept popping out, i literally had to keep my hand on it and hold it down his throat, that wasnt working so we put in an oral airway and bagged, partner got iv started pushed epi, she then tried intubating and couldnt even get his mouth to open. pt then went to asystole on way to ambulance, tried intubating again to no avail. iv got ripped out by fd on way to ambulance, another iv wasnt obtainable. tried 4 times.  enroute pt then went into vfib, shocked again, then pea, then vfib, then pea. arrived at hospital with pt in pea. they worked him for 30 minutes. pt was transferred to icu.


An IO was out of the question...our rigs dont have them which is very very dumb. hospital based company doesnt have the funds...


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## jedirye (Jun 17, 2009)

I come from a service where it's a medic and an EMT- that's it. This "pit crew" concept will be helpful for services that roll with fire departments and have several people on scene to assign jobs to beforehand, etc. 

Article located Here

Excerpt:
_
While the CIRC study is a trial, Hillsborough County Fire Rescue has already implemented another procedure.  With a nod to NASCAR, the Fire Rescue has started using the “pit crew” approach to emergencies.
As in a race pit crew, each person on a team is assigned specific duties to carry out. The three-person EMS crew follows a pre-defined, standardized process for assessing the scene and starting treatment.  Now, crews arrive on the scene and start providing manual or electronic chest compressions, as well as many of the other life saving measures in as little as 45 seconds, a process that previously could have taken a few minutes. This consistency extends to every Fire Rescue crew in the County, and has already improved results with just this new technique of managing the scene._


-rye


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## reaper (Jun 17, 2009)

Sounds like another great FL idea. Let's dumb it down some more!


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## el Murpharino (Jun 18, 2009)

terrible one said:


> if you cant open the jaw how can you can you get an LMA/Combi in?
> maybe i read something wrong from the OP



You're right...I was just talking in a general sense, not so much about this particular case.  My apologies...


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## mmorgan184 (Jun 18, 2009)

Epi-do said:


> Don't be afraid to call for orders to stop CPR if you are getting no response after a reasonable attempt.  There is nothing the hospital is going to do in this situation that we cannot do onscene.  The cardiac arrest patient isn't going to get any worse, and let's face it, they rarely get better.  We need to stop needlessly transporting corpses.  Think about it.  How many cardiac arrest patients have you taken into the ER that have been worked for more than just a few minutes before the doc calls them?  Chances are, very few.



I know it is protocol in my area to contact Med Control after 20 minutes to cease resuscitation efforts.


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## djmedic913 (Jun 18, 2009)

Remember Dead is the most stable patient you have. Our job on a code is to try and make them unstable again. Always remember BLS before ALS. Blood goes round and round with CPR and aire goes in and out with a BVM and OPA. ET tubes, IV's, IO's are helpful, but even a Basic can work a code.

1 tip I can add about starting an IV that they did not teach me in class, I learned on my 1st code...Don't be surprised if you don't get a good flash...remember not enuff pressure. Anyway I was an Intermediate running my 1st code alone and my mind was racing...Everything went well except for the IV coz I got a bad flash so I thought it was blown, but after removing the angio and looking for another vein the 1st spot kept bleeding with CPR...doh...anyway, that was my tip I learned...



terrible one said:


> i thought a contraindiction to nasally intubating was an apenic pt? it was my understanding that they needed spontaneous respirations? or maybe thats just by county/st


Apnea is a contraindication to nasal intubation. You need the patient to take a breath to pass the tube. when the pt inhales you advance the tube. You keep doing this until the tube is in place. 



terrible one said:


> if you cant open the jaw how can you can you get an LMA/Combi in?
> maybe i read something wrong from the OP



Good question 



Guardian said:


> I think continuous capnography monitoring should become the gold standard.



It is heading that way..we are gearing up to start using it...



mmorgan184 said:


> I know it is protocol in my area to contact Med Control after 20 minutes to cease resuscitation efforts.



Our most recent protocol roll out, states we can work the code for 15 mins in the house and call it. No med control required. I don't want to call a code in the house if I started working him..obvious death equals no working, I will call those at the scene. But I don't the responsibility of having to inform a family that there is nothing else we can do. The way I look at it from a families perspective, we did not do all we could because we never transport the pt to a doc. Sometimes the mere perception of doing all we can, is what makes the family feel better.


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## rmellish (Jun 18, 2009)

djmedic913 said:


> Our most recent protocol roll out, states we can work the code for 15 mins in the house and call it. No med control required. I don't want to call a code in the house if I started working him..obvious death equals no working, I will call those at the scene. But I don't the responsibility of having to inform a family that there is nothing else we can do. The way I look at it from a families perspective, we did not do all we could because we never transport the pt to a doc.* Sometimes the mere perception of doing all we can, is what makes the family feel better.*



Life's rough. I'd much rather work for a few rounds in the living room than bouncing down the highway, or some backa** country roads l/s just so the doc in the ER can can call the patient within five minutes of rolling through the door. 

No, if I'm on a medic unit, I'd much rather work on scene and call on scene. No sense risking my life for one that's probably over before we even get there.


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## Epi-do (Jun 18, 2009)

djmedic913 said:


> But I don't the responsibility of having to inform a family that there is nothing else we can do.



So, what about the little old lady that keeps telling you to help her husband despite the obvious signs of death because she is in denial?  Like it or not, telling family that a loved one is deceased is part of our job.  In all honesty, most of them do already know when they call us, they just don't know what else to do.  Been there, done that - even on patients that we have started to work but did not respond to our efforts and have remained in asystole.



djmedic913 said:


> The way I look at it from a families perspective, we did not do all we could because we never transport the pt to a doc. Sometimes the mere perception of doing all we can, is what makes the family feel better.



We are going to have to agree to disagree on this one.  Transporting a corpse "to make the family feel better" does more harm than good in my opinion.  But I digress to the multiple other times we have discussed this in other threads.  No reason to beat a dead horse.


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## reaper (Jun 18, 2009)

djmedic913 said:


> Remember Dead is the most stable patient you have. Our job on a code is to try and make them unstable again. Always remember BLS before ALS. Blood goes round and round with CPR and aire goes in and out with a BVM and OPA. ET tubes, IV's, IO's are helpful, but even a Basic can work a code.
> 
> *Can we stop dumbing down medicine?*
> Apnea is a contraindication to nasal intubation. You need the patient to take a breath to pass the tube. when the pt inhales you advance the tube. You keep doing this until the tube is in place.
> ...



So we want to work in the medical field, but not have the responsibility of it?


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## Flight-LP (Jun 18, 2009)

djmedic913 said:


> Apnea is a contraindication to nasal intubation. You need the patient to take a breath to pass the tube. when the pt inhales you advance the tube. You keep doing this until the tube is in place.



Can someone please provide factual documentation stating this (other than a physicians opinion, i.e. a protocol).

I would really like to know how securing an ETT via direct tracheal intubation can be contraindicated in a pt. who will tolerate better than most without need for paralysis or sedation. You do NOT need the pts. breath to advance the tube. Yes it can be a little more complex, but ETCO2 will confirm proper placement. What options do you have if you can't RSI them and cannot ventilate them via BVM. ANSWER: Only one option and that involves slicing their neck open.

If I was subjected to the inadequent environment of this scenerio, I'll nasal them, thank you...............................


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## djmedic913 (Jun 18, 2009)

rmellish said:


> Life's rough. I'd much rather work for a few rounds in the living room than bouncing down the highway, or some backa** country roads l/s just so the doc in the ER can can call the patient within five minutes of rolling through the door.
> 
> No, if I'm on a medic unit, I'd much rather work on scene and call on scene. No sense risking my life for one that's probably over before we even get there.







Epi-do said:


> So, what about the little old lady that keeps telling you to help her husband despite the obvious signs of death because she is in denial?


As I said previosly...


djmedic913 said:


> obvious death equals no working, I will call those at the scene.





Epi-do said:


> We are going to have to agree to disagree on this one.  Transporting a corpse "to make the family feel better" does more harm than good in my opinion.  But I digress to the multiple other times we have discussed this in other threads.  No reason to beat a dead horse.



Customer service = perception...end of story...As I said before, you can screw up in front of the family but if you have good customer service they will not lodge a complaint...you can be the best medic in the world, if if you have crappy customer service, complaints WILL be filed.

In a cardiac arrest you have more then 1 pt. there is the obvious dead pt, but you also have the distraught family. I would rather the distraught family be in the hospital waiting room or family when they receive the news where counselors are present. 

I have started codes on scene and I never thought anything would come from..dead, still dead, remaining dead. but since I transported so my time with Pt is now 20-30 mins by the time I arrive at the hospital with spontaneous pulses back. Many have died the next day but again the family has bought another 24 hrs to say goodbye...[I know taking up an ICU bed for nothing...wasting money...etc] but last time I checked Emergency Medical SERVICE and customer SERVICE has nothing to do with money...


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## djmedic913 (Jun 18, 2009)

Flight-LP said:


> Can someone please provide factual documentation stating this (other than a physicians opinion, i.e. a protocol).
> 
> I would really like to know how securing an ETT via direct tracheal intubation can be contraindicated in a pt. who will tolerate better than most without need for paralysis or sedation. You do NOT need the pts. breath to advance the tube. Yes it can be a little more complex, but ETCO2 will confirm proper placement. What options do you have if you can't RSI them and cannot ventilate them via BVM. ANSWER: Only one option and that involves slicing their neck open.
> 
> If I was subjected to the inadequent environment of this scenerio, I'll nasal them, thank you...............................



I believe you read it wrong...apnea is contraindicated in NASAL intubation...
apnea and Endotracheal intubation go hand in hand... 

below is what I originally stated:


djmedic913 said:


> Apnea is a contraindication to *nasal intubation*. You need the patient to take a breath to pass the tube. when the pt inhales you advance the tube. You keep doing this until the tube is in place.


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## Flight-LP (Jun 18, 2009)

I did not read it wrong, nor did you supply any supporting evidence to the contrary.

Your response makes no sense. "Apnea and Endotracheal intubation go hand in hand". O.k. i'll give you the semantics to that one, but how are you going to drop that tube if the pt. is clenched????????

Go back and read it again. While your at it, bring the proof of contraindication............


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## reaper (Jun 18, 2009)

Sure it does. When you transport a show code you are handing a grieving family a huge EMS and ED bill, that they do not need.

Same way as you don't fly someone, unless they need it. I know medics that will fly a pt just so they do not have to transport. They do not care about the 5k flight bill that pt will get stuck with. 

So yes, money is a factor in your customer service side.

BTW- I will take doing what is right and getting a complaint filed. Rather then playing hero, so I do not receive one!


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## Flight-LP (Jun 18, 2009)

djmedic913 said:


> I believe you read it wrong...apnea is contraindicated in NASAL intubation...
> apnea and Endotracheal intubation go hand in hand...
> 
> below is what I originally stated:



 And yes, BTW I am baiting you as you bring a strong teaching point to this thread........

I'll explain later and this is actually a subject that I will be starting a thread about soon.


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## djmedic913 (Jun 18, 2009)

Flight-LP said:


> And yes, BTW I am baiting you as you bring a strong teaching point to this thread........
> 
> I'll explain later *or PM with the explanation* and this is actually a subject that I will be starting a thread about soon.



OK, now I am confused. I am bringing a strong teaching point to this thread? I am lost...I must have made a wrong turn at Albuquerque. 

The information I have, which was I was taught in medic school and yes my current protocols as well, is that nasal intubation requires the breath to in essence help 'suck' in the NT tube since it is  a blind insertion device...

Yes a clenched jaw is a reason to try to nasally intubate but with no breath, it becomes near impossible to get that tube in the trachea

This is what I was taught in medic school...

What flight medics can do over and above a regular medic, I do not know...I don't have that extra training....yet...someday perhaps..


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## Flight-LP (Jun 18, 2009)

Man, you almost had it, you were putting up a really good fight until the end. 

Google "contraindications to Nasal Intubation" and there it is; in many printed formats that apnea IS considered a contraindication to nasaling a patient. Backing up your statements with evidentiary documentation is part of proficient critical thinking. If you know you are right, then stick to your guns. It will make you a stronger and more respected medic.

Alas, falling back on the "I was taught this way" and "its in my protocols" is the very premise restricting us from being able to advance our career. We must know the why's!

Please do not take this as a personal attack, I just find it very frustrating when medics make a solid statement, but fail to produce the proof of why. Consider this part of a life long advancement of education.......................

I stand behind my opinion, before I tell you why, lets look at what the professionals say. In the United states, there is a professional opinion that is not only accepted by medical professionals, but also those within the legal system. That would be the professional views from Dr. Ron Walls. In his book, "Manual of Emergency Airway Management", he clearly outlines various algorhithms that truly define airway management. It is on the foundation of this accepted manual and beliefs that I base my view.

So lets look at this scenerio..................

Clenched patient, apnic (o.k. I know that this is a highly unusual circumstance having these two together, but I digress as it can potentially happen), no RSI available. So in essence, you have a "can't intubate" situation. Hopefully, you can still oxygenate with patent nasal passages. If so, then simply assist ventilations with a BVM and get them to more definitive care. If not, as in the assumed scenerio, you now have a "can't intubate, can't oxygenate" (CICO) situation. There is generally only one solution; immediate tube cricothyrotomy. There is only one possible exception to the "CICO = immediate cric" rule; the ability to rapidly place an extraglottic airway device simultaneously with the preparation of the cric (Walls - Manual of Emergency Airway Management, Ch.2-19). In other words, if you can pass a device and successfully turn a CICO into a simply "can't intubate, but CAN ventilate" situation, then you may forego the cric.

Now lets take it a step even further and actually truly secure the airway while simultaneously setting up for the cric. How is it possible, dropping an ET tube on an apnic patient will take longer and is significantly more difficult?!?!?!?!? Or is it?????

In today's age of EMS, we have all sorts of new toys that help with intubation. One of those is the GUM elastic bougie................See where I am going with this??????

How do we perform intubation on grade III or IV airways? We use the bougie to blindly guide us. This is the same concept. Insert the ETT into the nasal passage and hold in the posterior nasopharynx. Slide the bougie through and aim anteriorly, wait for the "clicking" feeling when the bougie slides against the tracheal rings and the advance the tube. It really is that simple and can be done in a matter of seconds. Try it sometime...........

Now of course, RSI would be the ideal remedy as also viewed by Dr. Walls. Also, again the likelihood of having an apnic and clenched pt. is unlikely. But, more people are likely to have bougies than RSI it seems as many medical directors are still shying away from it. Thats a separate argument all in itself!

Hope this was somewhat insightful. Maybe I'll start doing some more scenerios like I used to do a while back. Ever since getting back to the US, I have been re-introduced to the failed education shortcomings of many in EMS. Since we are all here as one happy dysfunctional family, why not have an educational experience when we read throught these threads. Unless we want to continue the current trends of bashing and pointless discussions on TV show similarities and differences. Besides, it will help keep me out of trouble (well, maybe not!).

Stay safe everyone!


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## djmedic913 (Jun 18, 2009)

Flight-LP said:


> Man, you almost had it, you were putting up a really good fight until the end.
> 
> Google "contraindications to Nasal Intubation" and there it is; in many printed formats that apnea IS considered a contraindication to nasaling a patient. Backing up your statements with evidentiary documentation is part of proficient critical thinking. If you know you are right, then stick to your guns. It will make you a stronger and more respected medic.
> 
> ...



Yeah I wavered at the end...I had figured I missed something...I even double checked my protocols...lol...but at least in the end I actually had a clue...lol

But I like the bougie stick idea...that is a great idea...I actually plan on bringing that idea to my education department... I know 1 of our ed coordinators will love this idea...

And thank you...not for the attack...lol...but for the education about bougie idea with nasal intubation...I hope I will never need it but I can tell ya, I will never forget the idea...


----------



## hrmeeks (Jun 18, 2009)

Fat bald kid in the back slowy raises his hand and asks

with your difficult intubations why cant you attempt the 1st time and leave it place then reattempt with the same size or ( and in this case with the heavy scar tissue )smaller tube?

serious question


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## Flight-LP (Jun 18, 2009)

Because you can put multiple tubes into the esophagus and look kinda foolish........


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## terrible one (Jun 18, 2009)

so now im curious, as i was also told by protocols and in school you cant nasally intubate an apenic pt. but why? 
and also what is a "bougie stick"? maybe its called something different in CA, would you mind describing it?


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## Ridryder911 (Jun 18, 2009)

terrible one said:


> so now im curious, as i was also told by protocols and in school you cant nasally intubate an apenic pt. but why?
> and also what is a "bougie stick"? maybe its called something different in CA, would you mind describing it?



I have nasally intubated breathing/non-breathing patients. Yes, more challenging but can be done. As one usally gains clinical experience, you can "feel" the tube go past the epiglottis and pass into and through the cords. Not always sucessful but I attempt before cutting. 

Another name for the Bougie for prehospital is the _Flex Guide_. Their much smaller than the traditional elastic gum bougie or swizzel stick that is used in the hospital setting. Yes excellent tool and nominal costs to use. I have seen services that uses them increase intubations rate to >98% even on difficult airways. Hence reduction of false or failed intubation rates, and the need for less agressive airway procedures. 

Another trick I have used is pulling the "bell" off a cheap stethoscope and placing the tube into the ETT itself while performing a breathing patient when attempting to nasally intubate. True, many may whince because of the lack of it not being sterile ... so be it. Especially in conditions where ambient noise such as extrication and sirens makes it difficult to hear.

R/r 911


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## jedirye (Jun 18, 2009)

hrmeeks said:


> Fat bald kid in the back slowy raises his hand and asks
> 
> with your difficult intubations why cant you attempt the 1st time and leave it place then reattempt with the same size or ( and in this case with the heavy scar tissue )smaller tube?
> 
> serious question




Typically when you have a failed intubation and realize this, you need to still oxygenate your pt via BVM. It would be difficult to create a mask seal with a tube sticking out of their nose or mouth still.


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## djmedic913 (Jun 18, 2009)

hrmeeks said:


> Fat bald kid in the back slowy raises his hand and asks
> 
> with your difficult intubations why cant you attempt the 1st time and leave it place then reattempt with the same size or ( and in this case with the heavy scar tissue )smaller tube?
> 
> serious question



the text book answer is: in between attempts you are supposed to ventilate your pt. it is impossible to properly vent your pt with an ET tube hanging out. so you are supposed to remove the missed intubation that ended up in the esophagus.


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## NESDMEDIC (Jun 19, 2009)

Had a patient a couple day's ago with HX of alcholism and esophogial varices. Predicted difficult intubation. esophogial varices is a contraindiction for a combitube for my back up plan for establishing an airway. Airway was a grade 3 to 4 , used the bougie was able to get the tube first try, bougie's are inexpensive and can definataly aid you in a difficult situation. For nasal intubations I also use the ET tubes that have the ring with a cord attached to the distal end that allows you to move the distal end anteriorally when you pull the ring these also help when nasally intubating.


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## remote_medic (Jun 19, 2009)

If I can add a comment here...this is the most civil and intelligent thread I've read on here in a long time. No name calling, no education bashing...just good ole fashion discussion and experience sharing.

Lets see more topics like this please!!!

Chris


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## tazman7 (Jun 19, 2009)

so back to  the question on my pt being clinched.

Now we know that you can attempt nasal intubation. But what would cause the pt to still be clinched down after being pulseless, with agaonal breaths and in vfib?  

pt entire body was limp except his jaw.


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## Flight-LP (Jun 19, 2009)

Multiple neurological conditions, such as peripheral neuropathy for example, can cause nerve impulse transmission delays or alterations. These can potentially cause an increased calcium influx into the cell due to inappropriate signals from the CNS and cause hyper-excitibility of skeletal muscles, thus causing rigidity. Think of it as a V-fib of the skeletal muscles in a way. It can also occur due to certain auto-immune issues. It can actually be common during the initial stages of an arrest as the brain is still being oxygenated by the body's reserve (3-4ish minutes).

Trismus itself can be caused by a multitude of issues. More commonly is a trigeminal nerve (CN V) deficiency. Also a common cause is excessive ecstacy use. Others include peritonsillar abscess and TMJ.

Keep something in mind though, we are no longer intubating first thing in a code. Wait a few minutes and use good ventilation with a BVM and OPA / NPA's. Give it a few minutes, if you are still working them, then drop the tube, they should be relaxed by then.


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## tazman7 (Jun 19, 2009)

Flight-LP said:


> Keep something in mind though, we are no longer intubating first thing in a code. Wait a few minutes and use good ventilation with a BVM and OPA / NPA's. Give it a few minutes, if you are still working them, then drop the tube, they should be relaxed by then.



Wow thanks,

yeah thats what we did I tried intubating right when I got there because  the fd was doing cpr and bagging for approx 3-4 minutes before we arrived.


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## Guardian (Jun 19, 2009)

Flight-LP said:


> Man, you almost had it, you were putting up a really good fight until the end.
> 
> Google "contraindications to Nasal Intubation" and there it is; in many printed formats that apnea IS considered a contraindication to nasaling a patient. Backing up your statements with evidentiary documentation is part of proficient critical thinking. If you know you are right, then stick to your guns. It will make you a stronger and more respected medic.
> 
> ...



Or we could just cut this one in a million son of a gun and go on with life.  That’s what my gut is telling me at least.  I think it would depend a lot on the provider and we have a long way to go to reach the kind of proficiency you’re advocating here.  Anyway, I know this was as much theoretical as anything else, so good point.


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## djmedic913 (Jun 20, 2009)

Flight-LP said:


> Man, you almost had it, you were putting up a really good fight until the end.
> 
> Google "contraindications to Nasal Intubation" and there it is; in many printed formats that apnea IS considered a contraindication to nasaling a patient. Backing up your statements with evidentiary documentation is part of proficient critical thinking. If you know you are right, then stick to your guns. It will make you a stronger and more respected medic.
> 
> ...



I have brought this idea to my education department and there was a discussion over it. They seemed intrigued. They are quite interested in the idea.

Have you ever done this technique? I have never nasally intubated anyone..never had a need, so not opportunities for me to nasally intubate ever presented itself.


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## Flight-LP (Jun 21, 2009)

I have, twice.

Once on a cadaver during a skills lab.

Once for a pt. with trismus, apnic thanks to an overzealous anesthesiologist.

As Guardian said, this is one of those "one-in-a-million" presentations, but still one that is feasible.


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## tazman7 (Jun 22, 2009)

Flight-LP said:


> As Guardian said, this is one of those "one-in-a-million" presentations, but still one that is feasible.



Yeah and it had to happen to me as a new medic. This was my first code since getting my medic license...learn stuff everyday.


Just read the paper, guy ended up passing away 3 days later in the icu. :unsure:


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## SurgeWSE (Jun 23, 2009)

Flight-LP said:


> As Guardian said, this is one of those "one-in-a-million" presentations, but still one that is feasible.



The premise also extends into other, more common scenarios (i.e. COPDer in extremis, MDMA OD, APE advanced to resp. failure, apneic status seizure, metabolic coma, etc.), so it is something worth exploring further.  I would imagine that the reason most protocols contraindicate NTI in apneic patients is that the writers assume that the procedure will be done in a specific fashion.  Ideally, we'd be using a soft, trigger tube (Endotrol, et al.) with a BAAM whistle and be operating in a calm, quiet environment (hah!).  The primary reason for advancing the tube during inhalation it to prevent damage to the vocal chords and to prevent any associated subglotic hematoma or stenosis, but let's face it, NTI is a messy process and if you're performing it, is likely a critical intervention.  Obviously, a BAAM whistle is going to be useless if the person is apneic, but we've done NTI with a standard tube and no BAAM for years using only cric. pressure and silent prayers, so it is quite possible.  

On a personal note, I hate using Versed to alleviate clenching.  Anecdotally, it has failed for me more times than it has worked.  In a situation where we are simply attempting to sedate someone to facilitate ETI, it's fine, but if a clenched jaw is the problem it's just not the right tool for the job.  Until RSI is more mainstream, NTI will remain a necessary skill.  With the addition of CPAP, I've seen my personal number of NTIs drop significantly (haven't nasally intubated a CHFer in the 6 months since we got CPAP).  While that's certainly a good thing, it means that our proficiency as a group with nasal tubes is going to suffer.  Like with other skills, it becomes easier and less intimidating with practice (things like properly positioning the tube once it's in the nasopharynx, applying the correct amount of cric. pressure, and knowing sensation of a tube passing through the crycoid membrane beneath your fingers, etc.), so manikin and cadaver training is a must.

It's interesting to hear about using a Bougi and the stethoscope trick.  One of my complaints about the BAAM is that I have used it twice during extrications and couldn't hear a thing, so next time that scenario comes up I'll have to flip a coin and decide which alternative to try.


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## ResTech (Jun 23, 2009)

Since this has turned into a great airway discussion during arrests.... I was wondering if anyone runs at a service that uses the Glidescope and has any good patient uses to share? We were taught how to use the Glidescope in class and got to practice with it which seemed to be a very nice tool. 

At the service I do my field clinicals, the EMS supervisor units each have a Glidescope... too expensive to equip 6 or 7 Paramedic ambulances.


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## quewiwi (May 18, 2011)

Wow. Just joined the forum today and i have already learned a ton from this one thread, thank-you!

Now, my comments, lol!

I too was taught that apnea was a contraindication to NTI and our current protocol also states this. I greatly appreciate all the insight and info regarding alternate techniques. We will never have capnography or CPAP where I work so this has been helpful.

Also, as far as the discussion regarding continuing care and transporting the continually unresponsive code pt. vs. calling on scene; I also feel that as emergency medical professionals we have a responsibility to the public to act respectful and compassionate. Remember that the pt may be just another code to us but they are likely the world to the person standing by and watching you work them. We see death and hold it in our hands everyday, the average person never sees it, except on t.v.. Whatever you think that person standing by is already thinking about or already knows that the pt. is dead is irrelevant. They are watching everything and will process it all later. I feel it is our obligation to give them peace of mind that every possible thing was done to try and revive their loved one so that they may begin the grieving process fully and move on with their life. 

I'll shut up now


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## reaper (May 18, 2011)

If pt is viable! If they are dead, they are dead.


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## usalsfyre (May 18, 2011)

quewiwi said:


> We will never have capnography or CPAP where I work so this has been helpful.


I'm going to try to be as civil as possible, but...

If you are placing endotracheal tubes without continuous waveform capnography your service's practice is negligent. In this day in age with easily available, relatively inexpensive and reliable ETCO2 and/or extraglotic airways there's no reason to keep placing tubes without waveform capnography or eliminate them all together. 

I understand we didn't use to have waveform capnography and we placed tubes. Cars also didn't have seatbelts at one point, does that mean we shouldn't utilize them? (and yes I put these on par with one another). I also understand the technology may fail. However, that should fall under the "extraordinary occurrence" category.



quewiwi said:


> I feel it is our obligation to give them peace of mind that every possible thing was done to try and revive their loved one so that they may begin the grieving process fully and move on with their life.


Transporting can interfere with the grieving process by giving false hope. Our FIRST responsibility to render the best care possible to the patient, which can't be done for a cardiac arrest in the back of a moving ambulance. I've been terminating resuscitations in the field for several years. I've never had anyone imply "everything wasn't done". I've usually seen this excuse used by medics who are uncomfortable with the notion of making death determinations and notifying the family of the patient's death.


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## Shishkabob (May 18, 2011)

quewiwi said:


> I feel it is our obligation to give them peace of mind that every possible thing was done to try and revive their loved one so that they may begin the grieving process fully and move on with their life.



Don't know about your service, but I can do every single thing out in the field that a hospital can in a medical cardiac arrest.  


I make sure that when I go talk to the family about calling it, I let them know that fact.


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## Sasha (May 18, 2011)

Always ask for a DNR


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## quewiwi (May 18, 2011)

>sigh<

I am not here to argue.

I am expressing my gratitude to the participants of this thread (up to this point) for providing so much information on these topics.

I work for a private ambulance company so you can preach to them about how inexpensive capnography is and make the case as to why they should invest in equipping our units. They are not very receptive to new ideas there, let alone any that would cost them money. I will, however, be bringin it up to them anyway.

As for declaring death in the field, I am not going to waste my time arguing the moot details of certain scenarios where it is and isn't appropriate, just expressing my opinion on the topic as a whole and one of the many considerations.

And Sasha, yes, thank-you, I always do. 

...


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## usalsfyre (May 18, 2011)

quewiwi said:


> I work for a private ambulance company so you can preach to them about how inexpensive capnography is and make the case as to why they should invest in equipping our units. They are not very receptive to new ideas there, let alone any that would cost them money. I will, however, be bringin it up to them anyway.


A word of advice for this argument. One of the few true areas of legal liability for EMS is misplaced endotracheal tubes. See if you can find out how much equipping your services fleet with waveform capnography would cost. It shouldn't be too hard to find examples of judgements against services for misplaced ETTs. This kinda makes your argument for you.



quewiwi said:


> As for declaring death in the field, I am not going to waste my time arguing the moot details of certain scenarios where it is and isn't appropriate, just expressing my opinion on the topic as a whole and one of the many considerations.


The AHA has some pretty good literature on this, although I don't have it handy. Basically they have the same recommendations as what I stated above. There's more situations where it's appropriate than not. I have found many medics (myself included) are very uncomfortable with family notification initially, however it gets easier with experience.


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## medicstudent101 (May 18, 2011)

usalsfyre said:


> A word of advice for this argument. One of the few true areas of legal liability for EMS is misplaced endotracheal tubes. See if you can find out how much equipping your services fleet with waveform capnography would cost. It shouldn't be too hard to find examples of judgements against services for misplaced ETTs. This kinda makes your argument for you.
> 
> 
> The AHA has some pretty good literature on this, although I don't have it handy. Basically they have the same recommendations as what I stated above. There's more situations where it's appropriate than not. I have found many medics (myself included) are very uncomfortable with family notification initially, however it gets easier with experience.



Standard of Care.


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## JPINFV (May 18, 2011)

medicstudent101 said:


> Standard of Care.



Standard of care? Standard of care?!? This! Is! EMS!

ARRRRRRRRRRRHHHHHHHH


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## usalsfyre (May 18, 2011)

JPINFV said:


> Standard of care? Standard of care?!? This! Is! EMS!
> 
> ARRRRRRRRRRRHHHHHHHH



When did Gary Ludwig grow a beard?!? 

h34r:


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## Melclin (May 18, 2011)

JPINFV said:


> Standard of care? Standard of care?!? This! Is! EMS!
> 
> ARRRRRRRRRRRHHHHHHHH



HAHAHAHA. Launch the ROFLcopters.


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## Sasha (May 18, 2011)

JPINFV said:


> Standard of care? Standard of care?!? This! Is! EMS!
> 
> ARRRRRRRRRRRHHHHHHHH



Damn I thought it was Sparta.


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## BandageBrigade (May 19, 2011)

You can equip several supervisors vehicles with glidescopes (est at 10,000 each) but cannot get waveform cap or even cpap? Somethings not adding up. IMO glidescopes have no place prehospital. There are much cheaper more portable options that require no setup time.


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## Too Old To Work (May 19, 2011)

usalsfyre said:


> When did Gary Ludwig grow a beard?!?
> 
> h34r:



I don't care who you are, that's funny right there!


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## Too Old To Work (May 19, 2011)

medicstudent101 said:


> Standard of Care.



Out of curiosity, do you know who sets standard of care and how it is set?

As to waveform capnography, it's a great tool. We use it for every intubation, but we use it a lot more for conscious patients. It's very useful for monitoring sedated patients, such as those to whom we give Versed or Ativan. That includes seizure patients, agitated patients, people we are going to cardiovert, and well anyone that we sedate. We also use it for all respiratory distress patients. I haven't done it, but someone I know uses it for SVT patients to see if they are hypoperfusing. His theory being that once the ETCO2 falls below 37 or so, the patient is probably not perfusing well enough to ventilate at the cellular level. Sounds good in theory, but I haven't seen any science to back that up. 

What's interesting is that only one of the hospitals I transport to has wavform capnography in the ED. I find that incomprehensible. They do have colometric devices, but they can only use them for ETT placement confirmation. 

Of course it's been well known for over 15 years that quantitative capnography is a good predictor of ROSC. I seem to remember Roger White MD, from the Mayo Clinic talking about this at EMS Today in 1995 or '96. It only took EMS about 10 years to catch up on that.


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## usalsfyre (May 19, 2011)

BandageBrigade said:


> You can equip several supervisors vehicles with glidescopes (est at 10,000 each) but cannot get waveform cap or even cpap? Somethings not adding up.


I agree with this, but...



BandageBrigade said:


> IMO glidescopes have no place prehospital. There are much cheaper more portable options that require no setup time.


What setup are you talking about, and how often do you not have a few minutes prior to an intubation? Not to mention what "cheaper and more portable" options are out there that provide the same view, ease and comfort of use? Not the Airtraq and certainly not that stupid blade with what looked like a telescope in it.


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## jwk (May 19, 2011)

BandageBrigade said:


> You can equip several supervisors vehicles with glidescopes (est at 10,000 each) but cannot get waveform cap or even cpap? Somethings not adding up. IMO glidescopes have no place prehospital. There are much cheaper more portable options that require no setup time.



What setup time?  More time than hooking a laryngoscope blade on a handle?  

I'm not sure how portable you want, but our battery-powered ones are pretty small and light.  

I haven't found anything cheaper that I like better than a GlideScope - not even close.


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## BandageBrigade (May 19, 2011)

Setup - it has quite awhile since I have used a glidescope, but the service I was on that had it kept it in this big bulky pelican case(first mistake) with all its supplies. If I remember correctly, there was a blade cover to take off, and a write to screw on/connect, as well as waiting for the screen to load. I can concede that in reality its probably not much longer than a setup for regular intubation takes.  
Airtrach (traq? Cant remember how it was spelled). Did not like those at all. Cheap however.
Do you remember what the 'telescope' ones were called? We had a demo for them but did not even bother with a trial use.  We have been trialing the mcgrath system; so far everyone seems impressed with the results. We will see how much cheaper than the glidescope it is. It may just be a personal preference, but I like that the screen is attached, with no seperate screen to have to mount somewhere, or find a convenient place to set with a good view while intubating. It being smaller and all one piece is what makes it more 'portable'


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## quewiwi (May 19, 2011)

BandageBrigade said:


> You can equip several supervisors vehicles with glidescopes (est at 10,000 each) but cannot get waveform cap or even cpap? Somethings not adding up. IMO glidescopes have no place prehospital. There are much cheaper more portable options that require no setup time.



I think you got mine and RESTECH's comments mixed up. We don't carry glidescopes on our units...or cpap or capnography.

And thanks for the tips Usalsfyre!

...

...


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## BandageBrigade (May 19, 2011)

You are correct! My mistake.


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## usafmedic45 (May 20, 2011)

> Apnea is a contraindication to nasal intubation. You need the patient to take a breath to pass the tube. when the pt inhales you advance the tube. You keep doing this until the tube is in place.



I bet you also believe you have to have a laryngoscope to place an ETT orally as well.  



> the text book answer is: in between attempts you are supposed to ventilate your pt. it is impossible to properly vent your pt with an ET tube hanging out. so you are supposed to remove the missed intubation that ended up in the esophagus.



No offense, but do you actually run this crap through your head first before letting it out or is more of an unconscious stream of drivel you have no control over?  Yeah, you can ventilate with the tube "hanging out". You push it over to the corner of the mouth the same way you would do if the person had an NG tube in before they coded.



> It would be difficult to create a mask seal with a tube sticking out of their nose or mouth still.



Point taken, but there is a difference between 'difficult' and 'impossible'.  The more practical reasons for removing the ETT from the first attempt is to have it available for use and to also not clutter up the oropharynx should you decide to try laryngoscopy again.



> True, many may whince because of the lack of it not being sterile ... so be it. Especially in conditions where ambient noise such as extrication and sirens makes it difficult to hear.



I always like to point out that the lungs aren't anymore sterile than the inside of one's rectum.


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## systemet (May 20, 2011)

usafmedic45 said:


> I always like to point out that the lungs aren't anymore sterile than the inside of one's rectum.



I think you misspoke here.  The pharyx is part of the GI tract, and full of bacteria, not least of all because of the amount of sugar we consume.

But the lower airways are virtually sterile in the healthy individual.  I'm sure you're aware of this.


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## usafmedic45 (May 20, 2011)

> But the lower airways are virtually sterile in the healthy individual. I'm sure you're aware of this.



No orifice (read as "cavity with communication to the outside" before someone tries to point out the knee joint space) is even virtually sterile.  Don't confuse "absence of clinically significant levels of pathogenic organisms" with "sterile".  Remember that most chronic bronchitis is simply an opportunistic infection of normally present flora going after tissues whose defenses have been lessened by whatever issue is at hand (smoking being the obvious and most common one). 

The fact that we aren't putting something into the lower airways (at least intentionally...some have differing opinions of 'upper' vs 'lower' airways; I use the carina as the dividing line for the sake of a ready reference point) and have to go through the frighteningly polluted cesspool that is the average human mouth, notwithstanding of course.


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## JPINFV (May 20, 2011)

I see your clarification and raise you the bladder and ureters...

I'd also raise you the peritoneal cavity in females.


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## usafmedic45 (May 20, 2011)

> I see your clarification and raise you the bladder and ureters...



*facepalm* I figured one of the med students would find an actual exception to my statement.


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## JPINFV (May 20, 2011)

usafmedic45 said:


> *facepalm* I figured one of the med students would find an actual exception to my statement.



I'm more proud of thinking of the peritoneal cavity in females... Fallopian tube openings and all that jazz...


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## legion1202 (May 20, 2011)

I don't have any real tips yet since i`m still a medic student. But as a emt i`ve been on a few codes. I`ve learned fast that organization is key to prevent that cluster F***. Also someone needs to have command. The last code I was on had 5 medics telling everyone what to do and as the only EMT I didn't know who to listen too.

The best code I was on was with BSO fire rescue as a emt student at st 37. It was 2 medics and my self as a emt student with no back up.. It wasnt a save but we did everything we needed to do imo with just 3 guys. My buddy and his partner had there stuff together that day..


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## johnrsemt (May 20, 2011)

I totally agree with the not transporting corpses:  I like the area's that won't do it, UNLESS it is an infant.   What makes an infant arrest different?  Most of them are SIDS and have been dead longer than most adult arrests.

  I won't transport dead people from here because we have a 45 min transport time from gate, and up to 2-3 hours to the gate.  And no helicopter service will transport an arrest unless they have ROSC and has a pulse when they land.


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## johnrsemt (May 20, 2011)

But I do have coworkers here that think I am a bad medic because I don't want to transport dead people.  Good thing the ones that think that are Basics; and I don't have to listen to them.


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## vamike (May 30, 2011)

Where Im at CPR doesnt end until we get to the ER and turn the patient over.


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## usalsfyre (May 30, 2011)

vamike said:


> Where Im at CPR doesnt end until we get to the ER and turn the patient over.



Poor practice as defined by no lesser an authority than the AHA.


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## Shishkabob (May 30, 2011)

vamike said:


> Where Im at CPR doesnt end until we get to the ER and turn the patient over.



Utterly retarded as in general a Paramedic can do everything a doctor can in a medical cardiac arrest, up to and including calling it in the field and ceasing resuscitation.



Either your medical control sucks, your agency sucks, your medics suck, or a combination of the 3.


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## 8jimi8 (May 30, 2011)

Linuss said:


> Utterly retarded as in general a Paramedic can do everything a doctor can in a medical cardiac arrest, up to and including calling it in the field and ceasing resuscitation.
> 
> 
> 
> Either your medical control sucks, your agency sucks, your medics suck, or a combination of the 3.




cmon man. Don't rip their medics because policy is weaksauce.  You know damn well that you cannot change your medical control's mind without a critical mass.


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## Shishkabob (May 30, 2011)

Well.. if the med control doesn't trust the medic, than there's 2 problems:  Crappy medics, and a crappy agency that hires crappy medics.  


Or crappy medics, and a crappy med control that doesn't try to educate them to be better.


Or a crappy agency that hired a crappy med control who is stuck in the old days of "Drive them here real fast"


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## usalsfyre (May 30, 2011)

I've seen this attitude supported by volunteer agencies (which VA has a crapload of) more staunchly than paid agencies. I think it has to do with the fact that your serving your friends and neighbors, and therefore much more likely to know (and have a relationship afterward) the individuals and family involved. 

Most volunteer providers I've run into really don't want to be "the guy" when it comes to things like death notifications, it's much easier to pass it off on the facelessness of "the ER" and "the doctor". Who can blame them? Do you want to make the decision to stop coding your highschool girlfriend's mom? Especially if your not receiving finacial compensation? Now throw in the fact that a person's reasons for volunteering may, or may not be the most altruistic in the world...

All of the above are my perception made on anecdotal observations. They are solely my opinion and may not represent reality. No volunteers were harmed in the making of this post, it is known to the State if California usalsfyre's post cause cancer, ect, ect, ect...


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## vamike (May 30, 2011)

My statement that CPR  doesnt end until the ER is policy, not my desire to prove anything or show off.


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## vamike (May 30, 2011)

And yes we are a rural paid/volly squad, mostly volly.  Everyone in this county is either kin or neighbors.


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## usalsfyre (May 30, 2011)

vamike said:


> My statement that CPR  doesnt end until the ER is policy, not my desire to prove anything or show off.



Yeah, but are the powers that be(or for that matter the providers) interested in changing what's outdated to follow best practice?


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## usalsfyre (May 30, 2011)

vamike said:


> And yes we are a rural paid/volly squad, mostly volly.  Everyone in this county is either kin or neighbors.



I got my start as a volly in the Lower Valley as an EMT. Looking back I see that a lot of things were motivated by what was good for the agency and provider, not always the public.


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## vamike (May 30, 2011)

Im a Noob and glad to know that when the Medic says it's over, that there really is nothing else they can do at the ER.  No need to kill yourself with useless CPR right?  My first code the family followed directly behind the rig to ER.  They watched us the whole way.  Medic said we had to make a show even though there was no chance of patient recovery. Forgive my stupidity and ignorance people. Im here to learn is all.  (Im oozing humility.)


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## usalsfyre (May 30, 2011)

"Making a show of it" is the part that bothers me and others. It doesn't help the patient, gives the family false hope and generally the only advantage is allowing the medics to pass blame (in their own and the public's mind) on to the ED. 

There's a lot of smart people here who represent agencies who follow best practices all over the country. Learn from them, and never stop fighting to have your agency follow best practice.


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## Shishkabob (May 30, 2011)

I'm not risking my life, or the publics, running lights and sirens to the hospital for a cadaver... let alone allowing the family to follow us when runnings L&S.  




If I see a car following us through red lights, I shut down the run.


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## the_negro_puppy (May 30, 2011)

We generally dont transport codes unless they arrest enroute and we are not far away. Having the family follow is bad all around. Theres no use is giving false hope to the family. The best thing you can do is let them know what is going on: "Your husbands heart has stopped, and we are doing our best to resuscitate him. We are doing everything the hospital would do, however you need to prepare yourself for the worst".


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## AnthonyTheEmt (Jun 1, 2011)

Flight-LP said:


> Why not IO him? Then your access problem is resolved..............
> 
> Why would you give him Versed out of curiosity? Why not nasally intubate him or if all else fails go with a failed airway device?



You cant nasally intubate a cardiac arrest patient because the patient has to be breathing to be nasally intubated


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## TransportJockey (Jun 1, 2011)

Breathing helps,  but is not mandatory. Especially with an endotrol where you can somewhat adjust the angle of the tube.


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## Shishkabob (Jun 1, 2011)

AnthonyTheEmt said:


> You cant nasally intubate a cardiac arrest patient because the patient has to be breathing to be nasally intubated



It's not really mandatory that they be breathing:  You're still sticking a tube in from the upper airway to the trachea.  The reason why you usually see that it's "mandatory" is because of the BAAM... helps you verify when you're in the trachea much more easily.



Not really too much different than doing a blind intubation on a Mallampati 4... friggin giant tongues.  Hate them.


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## Crunch (Jun 3, 2011)

Linuss said:


> I'm not risking my life, or the publics, running lights and sirens to the hospital for a cadaver... let alone allowing the family to follow us when runnings L&S.
> 
> 
> 
> ...



This is my biggest pet peeve. I normally try and avoid the situation all together by instructing the family to leave the hospital a few minutes before we do. 

I'll have my partner pull the ambulance over if the families following us emergency (thinking that its okay because there 4 way flashers are equivalent to our lights and sirens) regardless of the patient condition. I'm not willing to put the general driving public at risk.

I've stopped before when the families were following too closely or recklessly even on non-emergent transports.

Safe driving is one of the biggest responsibilities in EMS


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## MasterIntubator (Jun 5, 2011)

Lots of good tips here.  Biggest thing I can offer is... keep calm and relaxed.  Those providers that end up yelling, rushing, getting flustered and such... kinda gets infectious and it all goes nuts.  Get your best Bob Ross voice going and run yourself a good efficient code.

If you happen to be someone on the sideline watching waiting for something to do... spot a family member and go to them, explain to them calmly what is going on, give them the confidence that folks with some of the best training in the world are doing their best ( and hopefully they are showing proficiency to help back your statement up ) and offer them time for questions.  Get history, etc as well if no one else is.  
That is a task not always done, and always appreciated and most of time beneficial for info.


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## G00CH 53 (Jun 19, 2011)

If they're in the bathroom.....get them out! You'd be surprised at how many people forget this little fact and try to do everything in the darn bathroom! Make your job a little easier and get them into either A) an open room where you can start working or B) have someone bring in the backboard or Reeves then get them in the bus.


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## usalsfyre (Jun 19, 2011)

G00CH 53 said:


> If they're in the bathroom.....get them out! You'd be surprised at how many people forget this little fact and try to do everything in the darn bathroom! Make your job a little easier and get them into either A) an open room where you can start working or B) have someone bring in the backboard or Reeves then get them in the bus.



Good advice...until you find your 120 kg patient in the garden tub :blink:...


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## G00CH 53 (Jun 19, 2011)

Stack some extra white sheets on your cot...roll and slide under the Pt. Then drag them out.


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## usalsfyre (Jun 19, 2011)

G00CH 53 said:


> Stack some extra white sheets on your cot...roll and slide under the Pt. Then drag them out.



We actually worked it in place, there was enough room to place a chest compressor beside the patient in the tub sorta comfortably, the airway was managed with a King and access acheived via EZIO. Removing the patient from the tub and carrying them through two doors and around the corner(tub was in the back of bathroom, through door was toilet and vanity, next door went into hallway leading to den) would have lead to an unacceptably long off the chest time.


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## G00CH 53 (Jun 19, 2011)

usalsfyre said:


> We actually worked it in place, there was enough room to place a chest compressor beside the patient in the tub sorta comfortably, the airway was managed with a King and access acheived via EZIO. Removing the patient from the tub and carrying them through two doors and around the corner(tub was in the back of bathroom, through door was toilet and vanity, next door went into hallway leading to den) would have lead to an unacceptably long off the chest time.



When's it's just you and your partner waiting for the next E.Co it's a little complicated. However, the biggest problem we run into is "off chest" time. We don't carry our "rib breaker" anymore.


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## usalsfyre (Jun 19, 2011)

G00CH 53 said:


> When's it's just you and your partner waiting for the next E.Co it's a little complicated. However, the biggest problem we run into is "off chest" time. We don't carry our "rib breaker" anymore.



We only run two to a unit and in the county often don't have extra hands. Swap every two minutes, ACLS gets done when it gets done. Don't screw around with ETTs and IVs when an IO and BIAD will do (if your practice guideline support this of course).


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## Melclin (Jun 20, 2011)

usalsfyre said:


> Swap every two minutes, ACLS gets done when it gets done. Don't screw around with ETTs and IVs when an IO and BIAD will do (if your practice guideline support this of course).



+1.

We are specifically instructed to focus on compressions and ventilations as first crew on scene. The second crew or MICA will do the fancy useless s**t later ;-)


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## b2dragun (Jul 12, 2011)

If the pt codes on the upper deck of a double decker bus use a sheet to get the pt out...not a backboard.  The backboard is too long to get down the stairs, this guy was pretty much hanging straight upside down...almost took his head off.  Needless to say that was a cluster.

I agree with the don't feel bad about asking for orders to call it, on the same note remember to check for obvious signs...dead is dead.

Always assume any call at a nursing home is going to be a code, no matter what it comes in as.  It is just easier to bring extra equipment out then have to go running.

My last piece of advice comes from my last "code."  Always remember to check a pulse before working a code, don't assume the person doing CPR actually did that.  The other week I ran a code and when I walked in I stopped the facility CPR, as I go to check for a pulse the pt looks up at me and says "Hey"...they were just enjoying their Soma's a little too much.  We all had a pretty good laugh.  The pain did say her chest was a little sore. LOL

I worked 9 codes in 3 weeks, they are all just a blur now.  The bus one wasn't one of them.


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## MediMike (Jul 12, 2011)

MasterIntubator said:


> Lots of good tips here.  Biggest thing I can offer is... keep calm and relaxed.  Those providers that end up yelling, rushing, getting flustered and such... kinda gets infectious and it all goes nuts.  Get your best Bob Ross voice going and run yourself a good efficient code.
> 
> If you happen to be someone on the sideline watching waiting for something to do... spot a family member and go to them, explain to them calmly what is going on, give them the confidence that folks with some of the best training in the world are doing their best ( and hopefully they are showing proficiency to help back your statement up ) and offer them time for questions.  Get history, etc as well if no one else is.
> That is a task not always done, and always appreciated and most of time beneficial for info.



+1

I'm originally from the south, been living up in the PNW for years now, somehow developed a Minnesota accent while working codes. 

"Okey dokey guys...why 'bout ya go ahead 'n start pumpin' away..."

Keeping calm is the absolute best tip I can think of.  Not my problem, chances are if you're dead you ate a few too many cheeseburgers in your life, weren't wearing your seatbelt (not that we work those anyways), or made some pretty poor decisions.  Having that dedicated time keeper/recorder is a lifesaver (hah) as well.


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## CalMedic (Jul 19, 2011)

Some good stuff.


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