# NG Tubes and Airway Management



## 18G (Apr 12, 2011)

I am looking for research that has been done on the use and benefit of NG tubes in the pediatric population during positive pressure ventilation. I have searched online and have not been able to find a whole lot. 

I have been advocating NG tubes at my service for a few months and would like to have research to back up my claims that NG tubes are important adjuncts to airway management in both children and adults.

If anyone has any links or other resources on the issue I would appreciate it very much!


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## 8jimi8 (Apr 13, 2011)

The problem with OG and NG tubes is that even in the hospital, we are not allowed to use them without radiographic confirmation of correct placement.

You don't want to be suctioning out any lung lobes do ya?


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## usafmedic45 (Apr 13, 2011)

If you have a properly placed ETT, there's really no need in the emergent setting to spend time placing an ETT.  There is some evidence that it reduces the rate of pneumonia/pneumonitis associated with intubation/ventilation in ICU patients but the main reason.  The only conceivable reason for it in the field/ER with a ventilation patient where it really would be an adjunct would be to reduce gastric insufflation and honestly if you're going to spend the time placing the OG/NG tube (which is not that easy to do nor quick, not to mention that you can't ventilated the patient while doing so unless they are tubed) the better option is simply to take that time to place an ETT or an LMA.

Suffice to say, I see where you're coming from and applaud you for thinking proactively, but don't agree that we should be spending time dropping gastric tubes in the field when we have much more immediate fixes to the issues at hand and the technical issues inherent with your suggestion make it feasible in a minority of cases.


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## MrBrown (Apr 13, 2011)

For neonate resuscitation we place an LMA wherever possible (we have always generally done this but it is now stated firmly as preference rather than trying to intubate) and have the option of using a small, soft suction catheter to decompress the stomach if required.


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## Aidey (Apr 13, 2011)

usafmedic45 said:


> If you have a properly placed *ETT*, there's really no need in the emergent setting to spend time placing an* ETT*.



I think you need another cup of coffee 

I have only heard of a couple of places having pre-hospital NG tubes and all of them were either flight agencies or had long transports.


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## usafmedic45 (Apr 13, 2011)

*facepalm*  Actually I can blame it on a lack of caffeine.  I'm about 10 days "sober".   Thank you for catching that.


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## 18G (Apr 13, 2011)

*Here is my stance on NG tubes:*

I view them as a very valuable adjunct to airway management in both the adult and pediatric populations of patients... more so pediatrics and here is why. 

It's no secret that we don't get the intubation experience that we should with adults let alone children. And it has been showed that BVM ventilations in children during short transport times is as effective as ventilations with an ETT. So, if were going to be providing positive pressure ventilation with a BVM then why not help mitigate the negative effects with an NG tube? I understand your not gonna be able to ventilate the patient during insertion, but I feel confident in saying that an NG tube can be placed quicker and safer than multiple attempts at intubating and is a much lower acuity skill than intubation. 

I think we all agree that the pressures required for air to enter the stomach in an unconscious/arrested child are very low and further decrease the deeper the level of unconsciousness. Air takes the path of least resistance which is going to be right down into the stomach. 

Gastric insufflation is dangerous along two fronts:

Airway Compromise / Aspiration
Ineffective Ventilation / Decreased Tidal Volume

Problem #1
As air accumulates in the stomach, the diaphragm is compressed and the abd organs are pushed up into the thoracic cavity impeding lung expansion and delivery of an adequate tidal volume - there is a decreased lung compliance and overall difficulty with ventilation and oxygenation of the child.

Problem #2
Regurgitation and aspiration risk. It's inevitable that a child receiving BVM ventilations is going to vomit making airway management much more difficult and putting the child at great risk for aspiration. I think we all also agree on the great dangers of aspiration which result in severe infection which will compound the already present problem the patient is experiencing. 

To me these are priority issues that need to be addressed in the field and not overlooked. Almost every resource I have read advocates use of NG tubes so I am kinda surprised the posters so far haven't really been in favor of their use. And these resources ranged from those for EMS and In-hospital.

They are cheap, quick, and easy to insert. Carry a very low risk from insertion and yield great benefits. 

Why do providers not favor NG/OG tubes given the benefits of their use? Our goal is to maximize ventilation and oxygenation and protect the airway, right? Isn't that what an NG/OG tube helps us do?



> You don't want to be suctioning out any lung lobes do ya?


We intubate in the field which is later confirmed by x-ray so I'm not seeing the difference.


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## MrBrown (Apr 13, 2011)

Brown has not found gastric distention/aspiration a significant problem with manual ventilation.

Most patients who are being manually ventilated here either have LMA in place or have been intubated although LMA exceeds intubation by far and if working well, there is now a firm preference it not be changed over to an endotrachel tube in the field.


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## 18G (Apr 13, 2011)

We don't use LMA's and I am in favor of having NG tubes available for certain cases where intubation cannot be achieved.



> Brown has not found gastric distention/aspiration a significant problem with manual ventilation.



Really? None of your arrested or ventilated patients vomit? That's unique.

EDIT: Pennsylvania allows Paramedic's to use NG tubes its just my service does not currently carry them. NG tubes received specific mention in the revised resuscitation protocols that go into effect 7/11.


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## Veneficus (Apr 13, 2011)

8jimi8 said:


> The problem with OG and NG tubes is that even in the hospital, we are not allowed to use them without radiographic confirmation of correct placement.
> 
> You don't want to be suctioning out any lung lobes do ya?



No offense, that sounds like somebody's agenda to bill for radiology or make up for substandard employees using radiology more than an actual legitimate concern of the device.

I have placed easily a hundred of them, never once were they confirmed unless there was another reason for the CXR/AXR.


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## MrBrown (Apr 13, 2011)

18G said:


> Really? None of your arrested or ventilated patients vomit? That's unique.



Of course some patients vomit.  We may be upside down and use that funny stuff called adrenaline but physiology is the same ;P

Brown however does not consider it to be a significant problem to the point of where prophylactic gastric tube placement should be undertaken.

If it is that much of a problem - where is the real problem; with the patient or with the person who is ventilating them?


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## 18G (Apr 13, 2011)

MrBrown said:


> Brown however does not consider it to be a significant problem to the point of where prophylactic gastric tube placement should be undertaken.
> 
> If it is that much of a problem - where is the real problem; with the patient or with the person who is ventilating them?



I see your point and appreciate your feedback. I guess I am coming from the point of view that a gastric tube does aid in support of the airway and is beneficial to reduce the risk of vomiting and aspiration. Would we be using them in every case? No. But in the cases where we may not be able to secure an ETT than why not place an NG tube while "bagging" a infant or small child for 20mins or more? 

And I don't view a provider opting to use a BVM, OPA, and an NG tube as bad airway management. If I can achieve the same results doing the above then why attempt to intubate 2 or 3 times, cause bradycardia and possibly hypoxia?

And I don't view the use of an NG tube as being prophylactic. It is an active modality that maintains tidal volumes and lung compliance and prevents complications from vomiting. How is this not a good thing? That is what I am asking? What am I missing?


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## 8jimi8 (Apr 13, 2011)

Veneficus said:


> No offense, that sounds like somebody's agenda to bill for radiology or make up for substandard employees using radiology more than an actual legitimate concern of the device.
> 
> I have placed easily a hundred of them, never once were they confirmed unless there was another reason for the CXR/AXR.



With what we use these for I think a protocol for radiographic confirmation is a necessary evil.  I have seen many times... Ng and og tubes end up in the trachea.

18g,Have you seen how much people gag when you use these devices?


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## usafmedic45 (Apr 13, 2011)

> And it has been showed that BVM ventilations in children during short transport times is as effective as ventilations with an ETT.



It's been showed?  LOL  Sorry after my recent flub, I couldn't resist.  



> So, if were going to be providing positive pressure ventilation with a BVM then why not help mitigate the negative effects with an NG tube?



Why not resort to simply placing a non-visualized airway?  Are the medics' ego in your area too sensitive and too overwhelming of patient safety that we must have an all or nothing approach?

The main reason I would argue against placing an NG tube in a patient that is being bagged is that it significantly interferes with mask seal, carries a decent risk of inducing vomiting and it is seldom a quick procedure especially when talking about a decompensating patient who needs to be ventilated.  Also, most people's BVM technique makes your average paramedic's intubation skills look like those of an anesthesiologist.  It's the one airway skill that most EMS providers spend the least amount of time on and have the least amount of pride for. 



> We don't use LMA's and I am in favor of having NG tubes available for certain cases where intubation cannot be achieved.



Then what is your backup airway? So you have a failed airway and you're advocating not ventilating the patient for a minute or two while you place an NG tube?



> I feel confident in saying that an NG tube can be placed quicker and safer than multiple attempts at intubating and is a much lower acuity skill than intubation.



Prove it.  Even if you can prove that even the dumbest person on your squad (because one should write protocols for the guy with the worst skills, not the best) can do what you're saying, it still is not the most practical option for the failed airway because it still leaves the patient prone to complications associated with NG placement (including vomiting) and without any airway protection whatsoever.  



> It's inevitable that a child receiving BVM ventilations is going to vomit making airway management much more difficult and putting the child at great risk for aspiration.



And the surest way to make a patient with gastric insufflation vomit is to shove something through the cardiac sphincter.  It's also not "inevitable" if you actually practice giving ventilations, are careful, cautious and are not simply using the risk of aspiration to justify adding another skill to your bag of tricks.



> They are cheap, quick, and easy to insert. Carry a very low risk from insertion and yield great benefits.



How many have you placed?


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## 18G (Apr 13, 2011)

usafmedic45 said:


> It's been showed?  LOL  Sorry after my recent flub, I couldn't resist.
> 
> *I know it should have been spelled "shown" *
> 
> ...





> 18g,Have you seen how much people gag when you use these devices?



The patient's we would be inserting an NG tube in wouldn't even know it was being inserted. There would be no gag reflex. 


Again, I appreciate the feedback guys but want to stress the use would be for arrest or unconscious patients only.


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## usafmedic45 (Apr 13, 2011)

> The only supraglotic device we have is a King Airway which isn't going to work in an infant or small child.



Then instead of trying to get your medical director to let you drop NG tubes on difficult airways, how about working to get him and the state to give you more options to actually handle the problem?  Pointing out the field day a good malpractice attorney and an expert witness (such as myself) would have with this scenario should help out.



> I hear what your saying and my rebuttal to you is, why does virtually every text from PALS, PEPP, Paramedic text, Physician authored articles, and other clinical resources, specifically state to utilize NG tubes for reasons I already stated? And not to mention my States EMS protocols which are highly based on best practices as demonstrated through research now includes mention of NG tubes. How do you explain the differences in your opinion compared to other authoritative sources?



Two things: 
1.  Show me actual research specifically on NG tubes in this setting.  These "authoritative sources" are basically making an educated best guess.  
2.  All those sources are talking about as an adjunct to another airway device, not as a replacement for it.  There's little to no evidence that what you're suggesting when used outside of the presence of either an ETT or a non-visualized airway is a good idea.



> Define failed?



As in the common paramedic definition of it:  "I couldn't secure an airway on that guy.  The tube just wouldn't go in so I had to bag him".



> s the ability to assess an airway and decide to BVM versus take 5 attempts at intubating really a failure or a success as long as ventilation and oxygenation is sufficient?



No, and I'm glad you see that.  However, I would argue that wasting time dropping an NG as a matter of course is a pretty questionable action given the attendant risks of hypoxia and vomiting.  



> Airway management is not intubation.



Isn't that what I just said?  Remember, you're talking to a guy who specializes in the cardiopulmonary systems,  who gets paid a couple hundred dollars an hour on weekends to speak at conferences on difficult airway management and also acts as an expert witness for malpractice attorneys (normally, malpractice defense) when RTs and EMS personnel manage to screw up this sort of thing bad enough to wind up in court over it.



> And in an unconscious / arrest patient, the gag reflex and stimulation of vomiting is gonna be pretty much non-existent in most cases.



But in a hyper-inflated and partially food laden stomach, if you shove an NG into it you're going to often explosively decompress it.  It's not a gag reflex issue, it's a "path of least resistance being something other than that skinny little tube you put down there" issue.  



> Even with intubation, an NG tube is standard care.



Yes, after the airway is secured.  You don't endanger the patient simply to drop an NG.  Secure the airway first and then worry about the long term risk of aspiration pneumonitis.



> Yeah, its great I got the tube but now sucks that lung compliance is so poor from the poor child's diaphragm being compressed and abd organs being pushed up into the chest rendering ventilation extremely difficult and in efficient. Because of poor lung compliance we would have to use greater pressure which is gonna just add to the problem to gastric distention, agreed?



Agreed.  That's when you drop the NG but that's not the scenario you were suggesting in your initial posts.


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## mikie (Apr 13, 2011)

*3rd Reason?*



18G said:


> Gastric insufflation is dangerous along two fronts:
> 
> Airway Compromise / Aspiration
> Ineffective Ventilation / Decreased Tidal Volume



How about from vagal stimulation from the gastric distention, especially in the (younger) pedi patients?


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## 8jimi8 (Apr 13, 2011)

Not to mention the difficulty of maintaining stomach decompression /s automated mechanical suction.


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## 18G (Apr 13, 2011)

> Two things:
> 1. Show me actual research specifically on NG tubes in this setting. These "authoritative sources" are basically making an educated best guess.



To build on that... as an expert witness aren't you just making a "best guess" as well if there really isn't any evidence out there to support your position? I know there is evidence that shows benefits of gastric tube placement in kids in cardiac arrest with BVM and ETT ventilation because I have found it but don't have access to the sites to access the full-articles on the research. 



> But in a hyper-inflated and partially food laden stomach, if you shove an NG into it you're going to often explosively decompress it. It's not a gag reflex issue, it's a "path of least resistance being something other than that skinny little tube you put down there" issue.



You make a really great point. My take on that is this though.... if you address the issue of distention late in the patients care your more than likely going to have a worse problem then if you avoid the "explosive" forces and decompress early when the distention and decreasing lung compliance is first noticed. Granted, by the time we get to the pt. the FD / BLS crew may already have lots of air in the stomach and we need to consider that but what do you do about the problem? Not address it? Continue with difficult ventilation when u have a tool to fix it?  



> You don't endanger the patient simply to drop an NG. Secure the airway first and then worry about the long term risk of aspiration pneumonitis.



Expand on this. I'm not seeing how you can outright say that inserting an NG tube to relieve gastric distention which has been proven to substantially increase the effectiveness of ventilation and helps protect against aspiration is dangerous.

What I see as dangerous is an ever increasing size of the stomach that goes unaddressed and results in vomitus occulding the airway and impeding good ventilation. To me that is more dangerous. 

At least with an NG tube you MAY encounter vomitng as a result of its insertion, but at least it's more than likely a one time deal and you can be immediately prepared for it and expect it and aggressively suction and roll the patient.

The alternative is to not insert the gastric tube, not have any idea when the patient is gonna erupt all over the place, not be as quick on the suction and log roll, and then what? Start bagging again only to have a repeat of what just happened?

The NG tube can prevent the reoccurrence.

Like I said, it's a Paramedic skill here in PA and the Medical Director has no objections with it. In fact I talked to the CRNP who advises and handles most of the ALS stuff with my service and he agree that we should be carrying them as well. I just have been having a problem getting my department to actually spend the money and order em which after a meeting last night sounds like they have ordered em already.

I don't want to sound all wrong... no they are not a miracle tool and certainly are not to be used in every pt who is being ventilated. But if its clear distention is taking place and compliance is worsening than we need to have the tool on the ALS units to be able to handle the issue and provide more complete care.


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## 18G (Apr 13, 2011)

8jimi8 said:


> Not to mention the difficulty of maintaining stomach decompression /s automated mechanical suction.



As an RN your totally against these little tubes aren't ya? 

Im just curious, if your in the field and have say a 1y/o who is in arrest, being ventilated with an OPA and BVM, and has noted gastric distention and it's hard to ventilate, and you have an NG tube on your unit, your not gonna use it?

Your gonna keep exerting higher ventilatory pressures to bag this poor child causing their problem to worsen? Your going to actually contribute to your patient puking and getting pneumonia and having an even harder time at recovery if your lucky enough to achieve ROSC?

I don't understand.


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## Veneficus (Apr 14, 2011)

8jimi8 said:


> With what we use these for I think a protocol for radiographic confirmation is a necessary evil.  I have seen many times... Ng and og tubes end up in the trachea.



I don't think you are using these for anything anyone else isn't. If the tube is winding up in the trachea, it is time the providers paid more attention to what they are doing. 

The only reasons that I can think of to use xray for these is to adequetely withdraw the tube if it winds up in the duodenum or if there is perforation/herniation of the abdominal lumen.

Are the people placing these tubes auscultating that the tube is in place or are they just cramming it down somebody and waiting for the xray?


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## Veneficus (Apr 14, 2011)

*For the OP*

I am not taking sides in the for or against an NG/OG, but if gastric inflation is your concern, could I suggest something less invasive in the interest of patient care?

Get a flow inflating bag. The esophagus requires pressure to unseal it from its natural position. 

The self inflating bag maybe providing too much pressure and volume, especially when the people using it are excited and over bagging and squeezing the bag not just to chest rise, but with all the force they can muster.

If you are going to try and institute an NG/OG protocol, you might have some difficulty for a couple of reasons.

As was pointed out, this is an adjunct to intubation, not a replacement, which basically means you are asking for more with the argument that you may not be successful at the first step.

You will have to train and maintain proficency at this skill. Wouldn't that time be better spent on practicing peds intubation if it is going to be attempted?

Along the same lines, if the act of ventilating is being done with poor technique/results, wouldn't it be better to practice that?

How often are you running into this problem that it is a concern enough to spend the money and time on NG/OG?


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## systemet (Apr 14, 2011)

I'm having trouble understanding the reasoning here.  

-  Is it being suggested that in a patient undergoing BVM ventilation, that we should abandon ventilation for however long it takes to insert an OG / NG tube to decompress the stomach?

- Has consideration been given to how having an NG / OG tube sticking out is going to interfere with BVM mask seal?

- Is there a problem I'm unaware of with either (i) pushing a few cc's of air down the NG while listening over the epigastrum or (ii) aspirating stomach contents through the NG, to confirm placement?  Is this insensitive or nonspecific for correct placement?  Is this no longer current practice?

I used to throw in an NG when I had an intubated patient with a long transport time, and there was nothing more pressing that needed taking care of.  It didn't rate very high in my priority list in an adult.  I can see how it could be a critical intervention in a neonate or young ped.


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## usafmedic45 (Apr 14, 2011)

> know there is evidence that shows benefits of gastric tube placement in kids in cardiac arrest with BVM and ETT ventilation because I have found it but don't have access to the sites to access the full-articles on the research.



Then give me the citations and I'll get the articles.



> As an RN your totally against these little tubes aren't ya?



Wow.....can we say "bias"?



> Im just curious, if your in the field and have say a 1y/o who is in arrest, being ventilated with an OPA and BVM, and has noted gastric distention and it's hard to ventilate, and you have an NG tube on your unit, your not gonna use it?



In that setting, yes, but then again, I'm also going to be working towards getting us better options so we minimize our chances of winding up in that situation.  It's not going to be "I have an unintubated pediatric respiratory failure patient, let me stop bagging him for a couple of minutes while I drop this NG tube".  If there is a direct and overt indication for it- which there is not in most cases- then, yes, do the procedure but making it standard practice in cases where you cannot secure the airway definitively is asking for trouble both clinically, professional and- most likely- in the civil legal sense.



> if you address the issue of distention late in the patients care your more than likely going to have a worse problem then if you avoid the "explosive" forces and decompress early when the distention and decreasing lung compliance is first noticed.



But if you take time inserting the NG tube- which requires forgoing the need to ventilate for anywhere from 30 seconds to two minutes (much like an intubation attempt)- to prevent a problem that might not happen at all if you're being careful otherwise, then you are probably going to significantly worsen the chances of the patient having a good outcome.

If you're going to argue for a new skill, argue for one that fixes the primary problem, not just something else you can do to the patient.



> Granted, by the time we get to the pt. the FD / BLS crew may already have lots of air in the stomach and we need to consider that but what do you do about the problem? Not address it? Continue with difficult ventilation when u have a tool to fix it?



Like I said before, not the scenario you originally posed when you started this thread.  The more proactive approach would be to get the BLS crew to have an airway adjunct so they can have a protected airway just like most of us have for adults.  Work to get LMAs into your protocols both BLS and ALS.  That's something I'll support.  This idea that taking time to drop an NG on every patient is not something I can because you're afraid of gastric distention.  You can have better options, work to get permission to use them.  Using an NG tube in an unprotected airway in an unconscious (or especially a semi-conscious) and unstable patient is asking for trouble, especially when it is used for no immediate and pertinent indication (i.e. the patient isn't distended).  



> The alternative is to not insert the gastric tube, not have any idea when the patient is gonna erupt all over the place, not be as quick on the suction and log roll, and then what? Start bagging again only to have a repeat of what just happened?



How about learning to bag in a way that doesn't cause gastric distention?



> But if its clear distention is taking place and compliance is worsening than we need to have the tool on the ALS units to be able to handle the issue and provide more complete care.



I agree with you there, but what I don't agree with (and judging by Veneficus' post, I'm not the only one picking up on this) is that you somehow have come to see dropping an NG tube as a magic bullet in fixing what ails the unprotected pediatric airway.  It's not.  It's not a replacement for intubation and without means for continuous or mechanically controlled intermittent suction, you're simply doing four things:
1.  Increasing the chance of vomiting
2.  Making it more difficult to get a good mask seal
3.  Increasing the chance of a vagal reaction in a non-arrested patient (minor risk comparatively)
4.  Delaying timely access to more appropriate care 

If there's an indication, go for it, but don't paint it like this is something that should be done on every patient getting ventilated.  



> Your gonna keep exerting higher ventilatory pressures to bag this poor child causing their problem to worsen? Your going to actually contribute to your patient puking and getting pneumonia and having an even harder time at recovery if your lucky enough to achieve ROSC?
> 
> I don't understand.



No, you've got this idea that you're correct, can't seem to locate the evidence you claim backs up your stance but yet get defensive and resort to attacks on other career fields (nursing) when we point out better options and the limitations of your idea.  It seems to be you who doesn't understand the bigger implications here.  You're thinking proactively, which I have to laud you for but your approach is kind of like bailing water out of one side of a canoe as water continues to pour in through the gaping hole in the other.


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## 8jimi8 (Apr 14, 2011)

Veneficus said:


> I don't think you are using these for anything anyone else isn't. If the tube is winding up in the trachea, it is time the providers paid more attention to what they are doing.
> 
> The only reasons that I can think of to use xray for these is to adequetely withdraw the tube if it winds up in the duodenum or if there is perforation/herniation of the abdominal lumen.  just wait, you will encounter one of these patients who has a 60cc h2o bolus plus some meds in their lungs one day.
> 
> Are the people placing these tubes auscultating that the tube is in place or are they just cramming it down somebody and waiting for the xray?




We use them for gastric decompression/ intermittent suctioning and enteral feeds/ meds.  


All OG/NG/ND/NJ tubes are to be inserted using the 2 step method.  

1.  An order is obtained and the tube is inserted using the standard of care. then a CXR is obtained.  If the CXR shows that the tube is not in the lungs, proceed to step 2.

2.  Advance the tube [For DHT obtain a KUB.] the tube is ok to use (but must have a doctors order).


Repeated failed insertions will result in placement under fluoroscopy.



It is no longer accepted hospital protocol to use auscultation or pH measurement as methods for verification of correct tube placement.

Acceptable verification of correct placement is (per hospital policy)

1. Radiographic confirmation
2. measurement of external tube
(no longer acceptable are auscultation or pH measurement of aspirate.)


My opinion on enteral tubes?  I don't care if the patient has them or not.
Do I auscultate for placement, yes, every time.  Do i just shove a tube in someone and walk away...

Vene, I realize that you are on fire to improve healthcare, is there any medical profession that does not need improvement?  


My opinion on these monologues of pediatric cardiac arrests... 

 "The incidence of pediatric OHCA was 8.04 per 100 000 person-years (72.71 in infants, 3.73 in children, and 6.37 in adolescents) versus 126.52 per 100 000 person-years for adults." http://circ.ahajournals.org/cgi/content/short/119/11/1484 
Pediatric Cardiology

Epidemiology and Outcomes From Out-of-Hospital Cardiac Arrest in Children

The Resuscitation Outcomes Consortium Epistry–Cardiac Arrest  Dianne L. Atkins, MD; Siobhan Everson-Stewart, MS; Gena K. Sears, BSN; Mohamud Daya, MD, MS; Martin H. Osmond, MD, CM, FRCPC; Craig R. Warden, MD, MPH; Robert A. Berg, MD; the Resuscitation Outcomes Consortium Investigators


I feel like your heart is in the right place 18G.  But first of all, please don't just make up arguments, ascribe them to me, and then proceed...


Here's the scenario, infant cardiac arrest. (because the stats up there says roughly 70% of POHCA)

Failed ETT.  (Do the new AHA HCPCPR guidelines state that the ped algorithm starts with Circulation, also?)

next intervention, OG/NG tube... NOT

REALISTIC next intervention:  LMA  - (or other approved rescue airway device).  [hmm do they make infant LMAs /c NG/OG tube ports??]

How are you going to get the NG/OG tube down the esophagus when there is an LMA "occluding" the lumen?



OK.  Now we can move to your box on the algorithm.

INFANT OOH CARDIAC ARREST

FAILED ETT
NO APPROVED RESCUE AIRWAY
NGTUBE INSERTION (DURING CPR -- yea right.)
BVM and NPA, OPA

(what provider is double fisted bagging an infant, or an adult sized ped for that matter?)


Sorry Bro,  just doesn't sound realistic to me.  

But oh yah, for the record, i don't care one way or the other about enteral tubes.  gottem or don't.  You are the only one who stated i had an opinion on that matter.


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## usafmedic45 (Apr 14, 2011)

> How are you going to get the NG/OG tube down the esophagus when there is an LMA "occluding" the lumen?



You throw a bougie or tube exchanger down the lumen of the LMA, pull the LMA, introduce an ETT and then go from there if you really have a need to decompress the stomach.


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## Veneficus (Apr 14, 2011)

8jimi8 said:


> Vene, I realize that you are on fire to improve healthcare, is there any medical profession that does not need improvement?


 
I don't see this as improvement, I see it as a US hospital basically trying to use technololgy to make up for a relatiely uncommon adverse event. (at least uncommon if providers aren't botching it up.) 

What's next at your hospital? Radiology confirmation of peripheral IV placement because there are extravasiations?

This seems to me like nothing more than waste and abuse, are they billing for this too?


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## 8jimi8 (Apr 14, 2011)

Veneficus said:


> I don't see this as improvement, improvement is not the original statement that I typed here. At first, I said something defensive, then I realized that you weren't really directing the statements personally at me.I see it as a US hospital basically trying to use technololgy to make up for a relatiely uncommon adverse event. (at least uncommon if providers aren't botching it up.)
> 
> What's next at your hospital? Radiology confirmation of peripheral IV placement because there are extravasiations?
> 
> This seems to me like nothing more than waste and abuse, are they billing for this too?




Perhaps you didn't realize american healthcare is still a captitalist mechanism?

Sorry Vene, you are not going to find an argument with me about the price or who is charged what.  I know that i strive to live up to the virtue of stewardship for my patients every day, by canceling extraneous costs, e.g. charting something as a 29 minute bolus ($200) versus an IVPB ($500).  I honestly can proudly say that I NEVER look into the financial status (funded/unfunded) of my patients.  The only time that I will ask a patient about anything regarding a financial situation is when I am forced to ask if the patient is worried about incurring hospital costs, during my admission history (it is a MUST FILL response in the computer form).

I bet they charge for it.  Will you?

Of course I can be quoted as saying... "when the sh*t hits the fan, i'll be the guy trading cardioversion for chickens... that's why I wanna be a paramedic..."

Is this still on topic?


----------



## 8jimi8 (Apr 14, 2011)

usafmedic45 said:


> You throw a bougie or tube exchanger down the lumen of the LMA, pull the LMA, introduce an ETT and then go from there if you really have a need to decompress the stomach.




So in the END... you wind up INTUBATING THE PATIENT.


THEN 


MAYBE AN NG/OG...



USAF...  Do they make infant size ILMAs?  Or are you talking about blindy enchanging /c a bougie?   Does a bougie fit in an infant trachea?!!  diameter of a standard bougie is 1cm... right?

At the cctmc we intubated ferrets...(which was supposed to simulate neonatal airway)  i don't think you could get a bougie in a ferret /s massive trauma.


----------



## Veneficus (Apr 14, 2011)

8jimi8 said:


> Perhaps you didn't realize american healthcare is still a captitalist mechanism?
> 
> Sorry Vene, you are not going to find an argument with me about the price or who is charged what.  I know that i strive to live up to the virtue of stewardship for my patients every day, by canceling extraneous costs, e.g. charting something as a 29 minute bolus ($200) versus an IVPB ($500).  I honestly can proudly say that I NEVER look into the financial status (funded/unfunded) of my patients.  The only time that I will ask a patient about anything regarding a financial situation is when I am forced to ask if the patient is worried about incurring hospital costs, during my admission history (it is a MUST FILL response in the computer form).
> 
> ...



Jimi, 

My comments are not directed at you personally.

The probelm is not whether capitalism is right or wrong, it is about gouging who is paying regardless of medical need. (which in turn drives up everyone's costs.)

I have no doubt that patients are not told that most of the civilized world doesn't xray these tubes routinely. Which means the patient is getting an uneeded screening test.

That may be beyond your job description, but it doesn't make me less angry hearing it and I am really not trying to start an argument with you. More like just venting my frustration.

Especially since I am willing to bet money that the hospital doesn't really do it for the patient, they do it for the hospital. No different than performing a test for a lawyer. Which I know is often needed but I still don't like it.


----------



## 8jimi8 (Apr 14, 2011)

Veneficus said:


> Jimi,
> 
> My comments are not directed at you personally.
> 
> ...




We are on the same page my friend.


----------



## 18G (Apr 14, 2011)

British Journal of Anaesthesia (1999)
Pediatric Trauma
E.H. Dykes

Dept of Pediatric Surgery, University Hospital Lewisham, London.

"... gastric distention also increases the likelihood of vomiting and aspiration, a major concern for those responsible for airway management. For these reasons, the presence of even minimal adbominal distention, respiratory compromise or diminished consciousness is an indication for the passage of an oro- or nasogastric tube. Although this intervention may be potentially distressing for a conscious child, the consequences of untreated gastric distention may be fatal".


----------



## Aidey (Apr 14, 2011)

18G said:


> British Journal of Anaesthesia (1999)
> Pediatric Trauma
> E.H. Dykes
> 
> ...



No offense, but no one is going to argue they aren't good during surgery. It is pre-hospital that is the concern.


----------



## 18G (Apr 14, 2011)

The context of the article has nothing to do with surgical care specifically. The article deals with all phases of pediatric trauma from initial assessment, resuscitation, etc. 

*The quoted section I provided is from the article heading "Initial Resuscitation and Primary Survey".*


----------



## 18G (Apr 14, 2011)

I'm tempted to start a discussion on bleeding and direct pressure and see how many people are oppositional and see if we get 7 pages of replies on how direct pressure is a waste, all bleeding stops on its own, it's really only useful in certain cases, show me the research that it works so well, etc, etc, etc. 

Why do I always feel the need to don a helmet and beat my head off the wall continuously when I post on here????? 

This is the only forum where people speak of the complete opposite of what is standard and accepted every where else. I could read in 31 different texts and medical journals that something works and is indicated, but then state it here and be informed that the 31 texts and journals authored and reviewed by physicians are all wrong.


----------



## usafmedic45 (Apr 14, 2011)

> So in the END... you wind up INTUBATING THE PATIENT.



Right.  It's just a different way of achieving the same end.



> THEN
> 
> 
> MAYBE AN NG/OG...



If specially clinically indicated, yes.  Otherwise, leave it for the hospital.



> USAF... Do they make infant size ILMAs? Or are you talking about blindy enchanging /c a bougie? Does a bougie fit in an infant trachea?!! diameter of a standard bougie is 1cm... right?



No, a bougie is not 1 cm.  It's the same diameter as an ETT stylet. The ones we use are about 3mm if that (and outside of premies, there's no good reason to be using a 2.0 or 2.5 ETT because it's so small you can't pass a suction catheter through it).  The widest one I've seen is only about 4-5mm.  A vascular guidewire could also be used if you were really concerned about the width of the bougie.  

I don't know if they make infant ILMAs but you don't need an ILMA to intubate someone in the manner I described.  A normal LMA works just fine.



> British Journal of Anaesthesia (1999)
> Pediatric Trauma
> E.H. Dykes
> 
> ...



OK.  Where does that say you should interrupt ventilations to do so?  That's not really good evidence.  It's like you typed in "pediatric, gastric distention, airway" into Pubmed and grabbed the first article you found.  I am beginning to think that you've got your mind made up and are unwilling to critically assess your desire to add this skill.


----------



## 8jimi8 (Apr 14, 2011)

Glad you clarified.  Not sure where I got 1cm from b/c obviously I remembered it incorrectly.


----------



## usafmedic45 (Apr 14, 2011)

> I'm tempted to start a discussion on bleeding and direct pressure and see how many people are oppositional and see if we get 7 pages of replies on how direct pressure is a waste, all bleeding stops on its own, it's really only useful in certain cases, show me the research that it works so well, etc, etc, etc.



It's not the tool that is the problem in this case, it is how you're trying to apply it.



> Why do I always feel the need to don a helmet and beat my head off the wall continuously when I post on here?????



I think it has something to do with the attitude (at least the perceived attitude most of us take away) from your posts that you have it all figured out, that you're right and any attempt to question you, suggest alternatives or to inquire further are met with resistance and hostility.  Even as the reigning forum ***hole, I'm more amenable to change and being questioned than you seem to be.



> This is the only forum where people speak of the complete opposite of what is standard and accepted every where else.



You're taking a standard and leaving out a couple of vital elements and then trying to hide because a particular indication when we call you on the discrepancy.  It's like saying that you believe we should change the oil in the ambulance but not bother to put the new oil filter in after removing the old one. 



> could read in 31 different texts and medical journals that something works and is indicated,



Probably, but you'll notice that none of them say to interrupt ventilation or airway management efforts to pass an NG tube.



> but then state it here and be informed that the 31 texts and journals authored and reviewed by physicians are all wrong.



Three things:
1. Physicians are fallible.  All of us are.
2. Just because something is in writing does not make it correct.  Examples include such wildly different tomes as _Mein Kampf _and the medical "standards", many of which are not based on any scientific evidence.
3. I didn't say they were wrong, I said they were making educated best guesses.  (the last clause of point #2).


----------



## Sasha (Apr 14, 2011)

> Why do I always feel the need to don a helmet and beat my head off the wall continuously when I post on here?????



Amazing that's how I feel when i'm reading your posts.


----------



## usafmedic45 (Apr 14, 2011)

Sasha said:


> Amazing that's how I feel when i'm reading your posts.


I wondered if he migrated over from "the City" where the folks aren't as focused on education and more on maintaining the status quo and stroking each other's egos.  He mentions other forums and that's the only one I know of that wouldn't treat him the way we have been.  Well, that and the Firehouse one, but that's not even a medical forum.  You mention anything about "evidence" and they think you're talking about arson investigation.


----------



## 18G (Apr 14, 2011)

usafmedic45 said:


> I am beginning to think that you've got your mind made up and are unwilling to critically assess your desire to add this skill.



Not at all.... but I am failing to see your position and the other minority opinions on the forum as absolute. I have yet to hear anything convincing to make me abandon my support of gastric tubes to improve ventilation and help protect against aspiration in certain patients.

I'm surely not going to disregard highly regarded texts, journals, my own knowledge, and other medical professionals all because of a few opinions. Don't get me wrong I do respect them and appreciate the input but there is no way four people on EMTlife.com override what is accepted by a majority in the medical community.

If anything, given the wide advocation and practice of NG tube use to improve ventilation and reduce aspiration risks in peds, the burden of proof falls in the minority. 

Show me where NG tubes are harmful? Show me where they do not improve ventilation. Show me where they are not effective at relieving gastric distention. 

This thread has been discussed to the max so I will bring it to a close with these last thoughts. 

1) Healthy patients, especially kids, have great respiratory reserves and oxygen transport ability. The 30sec to a minute time in most cases its gonna take to do the insertion, is not gonna result in hypoxia. And only in a few cases does the insertion cause vomiting. But if it does cause vomiting, at least the providers are immediately available to react the very second it happens.

2) The argument is the NG tube "may" cause vomiting on insertion. What do you think is gonna happen on a larger scale and with greater force if you don't decompress!!! At least if you decompress you, 1) gain the chance of avoiding vomiting and aspiration, 2) prevent it from reoccurring if it does happen on insertion, and 3) you gain increased pulmonary compliance and improved ability to ventilate. 

*3) And again, I am not wanting gastric tubes to place in every single patient we BVM. They are to be used on a PRN basis when needed to decompress severe distention and improve ventilation when a kids diaphragm and organs are being squashed up into their chest. They are a valuable tool to assist in managing the airway and provide complete patient care which is what I strive for.*

4) They are a cheap and easy to use device that serves an important purpose that needs to be available pre-hospital. I have been on many arrest where all interventions have been performed and were just doing the compressions and the ventilations the rest of the way to the hospital. So why not insert an NG tube to aid ventilation and protect against aspiration when we have plenty of time to do so? 

If anyone has any literature for or against pre-hospital NG tube placement I would love to see it. Thanks!


----------



## Veneficus (Apr 14, 2011)

Aidey said:


> No offense, but no one is going to argue they aren't good during surgery. It is pre-hospital that is the concern.



I am going to have to argue now.

There is no difference in medicine inside the hospital as outside. 

If something works inside, then it works outside. 

What the difference really is, is the practicality of using said intervention in terms of the level of care that is going to be provided later.

Now that we got that out of the way...

I can see both sides to this argument. Likewise, I'll bet you could find a physician to argue either way.

But I really don't think the issue described is really about NG tubes. 

It has been argued here that there is a question of witholding ventilation in order to place the tube. 

So What? 

Those tubes can be placed both accurately and rapidly. It seems reasonable that not only would there be minimal interruption of ventilations, but that interruption might actually slow the rate to something reasonable in all the excitement.

There are still other methods that can be employed to reduce gastric distention and its sequele before the tube, as I mentioned above. 

I still think these devices and interventions need to be looked at prior to worrying about an NG/OG tube. In both adults and infants.

The question I think that really needs to be answered is:

If you are using large volumes of air from a self inflating BVM, once you have distention, how do you keep the regurg from simply going around the tube? 

Keep in mind this regurg could be subclinical, not making it as far as the mouth.  

Even under constant suction, the diameter of the peds NG/OG is so small, you may not be able to suck air out faster than it is being put in. Then you are back to square 0. 

If we are talking about the green topped peds NG tubes, they don't readily hook up to suction anyway. So you may need a provider to fool around with adapters and the like. 

From the operational standpoint, a BVM/OPA instead of an ET tube with a NG/OG looks like desperation to me. If you are at that point, why not? 

But why would anyone use that point as their endgame?

So I am of the mind that while it is not a bad idea, there are so many more better ideas to focus energy on first. 

The greatest of which is the proper rate and volume of delivering ventilations by BVM.

an NG/OG after securing at ET tube? Certainly, by all means.

But here is another question:

If you are putting significant amounts of air into the stomach, how much volume is going into the lungs? 

Because aside from the potential pneumo, if air keeps going in, but only minimally coming out, that is going to be a bigger issue than some vomit.


----------



## 18G (Apr 14, 2011)

Sasha said:


> Amazing that's how I feel when i'm reading your posts.



Really? I think my post are articulated very well and are well grounded and medically sound. Am I headstrong? Unfortunately I have to admit yes I am. But that's just who I am. I've never been one to play follow the leader. I am very humble and will gladly change my opinion if I am wrong. I just need to see something solid before that happens. 

I just realized.... I have yet to see any thread where you make a reply that consists of something more than a one or two line comment of which is never medically driven.

What is your opinion on pre-hospital use of NG tubes to improve pulmonary compliance and mitigate aspiration risks?



> I wondered if he migrated over from "the City" where the folks aren't as focused on education and more on maintaining the status quo and stroking each other's egos. He mentions other forums and that's the only one I know of that wouldn't treat him the way we have been. Well, that and the Firehouse one, but that's not even a medical forum. You mention anything about "evidence" and they think you're talking about arson investigation.



Actually I don't post on EMTcity. The only other forum I post on is JEMS Connect. And education is what drives me totally, so that's not a real accurate assessment.


----------



## 18G (Apr 14, 2011)

Vene.. I agree with you! can u believe that... haha. Good post.


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## Veneficus (Apr 14, 2011)

18G said:


> Vene.. I agree with you! can u believe that... haha. Good post.



Generally, once people reach the hate phase, they start to see the light.


----------



## usafmedic45 (Apr 14, 2011)

> but I am failing to see your position



So is the problem with your ability to actually read or the ability to comprehend what I'm writing?  Is there an issue with your screen resolution?  I can always use smaller words and a larger font if that would help.  



> the other minority opinions on the forum as absolute.



"Minority opinions" are no longer the minority when everyone except you is saying it.  



> And education is what drives me totally, so that's not a real accurate assessment.



Then why do you seem to have a hard time doing basic research, understanding what constitutes evidence, grasping that most medical "standards" are based largely on supposition and taking constructive criticism?  None of those seem to be major parts of your interactions here and all of them are the hallmarks of someone with a vested and real interest in learning and applying evidence based practice that.  Riddle me that one there Batman.



> I think my post are articulated very well



....other than the various repeated spelling and grammatical errors.



> are well grounded



Eh....



> and medically sound



...in the same way that saying my fellow Jewish folks are common sights in the banking industry and then extrapolating from there that we all are responsible for the current economic situation.  That's the problem with your posts is that you're taking a basically accepted matter and trying to stretch it to fit your current goal.  Sorry if we don't share your enthusiasm. 



> What is your opinion on pre-hospital use of NG tubes to improve pulmonary compliance and mitigate aspiration risks?



If you would actually read what I've posted, I've already given that several times over.  So much for "education is what drives me totally".



> I've never been one to play follow the leader.


\

I would never have guessed.  I suggest you read Darker Shades of Blue by Tony Kern.  It might be insightful for you.  Even though it is written about and for the aviation community, it has a lot of applicability to this discussion and especially folks of your mindset.  



> 3) And again, I am not wanting gastric tubes to place in every single patient we BVM.







> They are to be used on a PRN basis when needed to decompress severe distention and improve ventilation when a kids diaphragm and organs are being squashed up into their chest.



OK.  The organs aren't actually "squashed up into their chests".  That's a common mistake, but it's flat out wrong.  It's the prevention of diaphragmatic excursion that causes the problem.  There's no organ between stomach and diaphragm to be pushed upward.  Actually as much as there is upward pressure on the diaphragm there is downward pressure pushing the intestines and other organs AWAY from the chest.  It's gastric distention, not a diaphragmatic hernia. 



> They are a valuable tool to assist in managing the airway and provide complete patient care which is what I strive for.



Thank you for clarifying.  It sure sounded like you were suggesting that the approach should be preventative in anyone you could not get a tube on.  Examples:


> So, if were going to be providing positive pressure ventilation with a BVM then why not help mitigate the negative effects with an NG tube?




This was especially alarming given your seeming lack of experience and familiarity with the procedure.....:  


> but I feel confident in saying that an NG tube can be placed quicker and safer



..lack of understanding of the mechanism for the problem in question....:


> Air takes the path of least resistance which is going to be right down into the stomach.


  (the rigid and continuously open trachea is the path of least resistance, whereas it takes excessive pressure or volume to get gas down the esophagus which is a "potential tube" at best)

THAT is what we had a problem with, not with the use of gastric tubes.

We've offered suggestions as to how to fix the problem and the problem of unprotected airways in neonates, infants and toddlers but you seem fixated upon the idea of shoving NG tubes into them.  Why not work proactively to prevent the problem rather than working proactively to be able to retroactively fix the problem?


----------



## 18G (Apr 14, 2011)

usafmedic45 said:


> "Minority opinions" are no longer the minority when everyone except you is saying it.
> 
> *Who is everyone? You and three other people? I have had several people PM me and tell me that they support me and agree over several threads in the past.*
> 
> ...



...


----------



## Sasha (Apr 14, 2011)

I am often late to the party and don't care to parrot what other people have said, but look harder, you'll see posts where I give an opinion.

I don't have experience with NG tubes. I also don't often have to do airway management beyond suctioning. I am IFT. So I don't feel that I can make a well thought opinion about the particular subject at hand


----------



## Aidey (Apr 14, 2011)

Veneficus said:


> I am going to have to argue now.
> 
> There is no difference in medicine inside the hospital as outside.
> 
> ...



Oh, don't get me wrong. I wasn't saying that there is a difference between how well something works in hospital vs. out of hospital. My point was that something deemed practical, necessary and a priority during surgery may not be practical, a priority or strictly necessary out of the hospital.


----------



## 18G (Apr 14, 2011)

Sasha said:


> I am often late to the party and don't care to parrot what other people have said, but look harder, you'll see posts where I give an opinion.
> 
> I don't have experience with NG tubes. I also don't often have to do airway management beyond suctioning. I am IFT. So I don't feel that I can make a well thought opinion about the particular subject at hand



Honest you are. I can respect that  If all goes as planned I will be doing IFT full-time as well. I'm pretty much just waiting on my certification to be processed in the State I will be working.


----------



## Sasha (Apr 14, 2011)

I think you'll enjoy IFT. I love it, it's a great opprotunity to learn.


----------



## usafmedic45 (Apr 14, 2011)

> Who is everyone? You and three other people? I have had several people PM me and tell me that they support me and agree over several threads in the past.


Isn't that convenient, your supporters won't do it publicly.  



> Your not the one and only ultimate source of information and say on the issue



I never said that I was.  I simply suggested that based on what you were originally saying that you seemed to be trying to apply research to a personal theory where it had questionable applicability.  Calling your idea into question and asking you to defend it with something more than "I believe", "I think", "I've been told" or "I've read somewhere" isn't painting oneself as a sole expert.  It's called the standard practice of an academic.  May G-d have mercy upon your soul if you ever find yourself in a truly important debate (one where your reputation or career are on the line) and get approached by someone well versed in how researchers and other academics (such as physicians) are taught to approach situations like this.



> And what you don't understand is the rural area and all volunteer EMT system we have.



If you want to talk about small town EMS, you need to remember, I've probably gotten you beat in that regard.  I was the EMS officer for a volunteer fire department serving a town of 175 and a township with maybe 2,000 total.  It's not a "You're a big city EMT-I, you don't know how we work or what we have to deal with in the country". 



> The volunteer EMT's don't all have the best grasp on how to minimize gastric distention and there is nothing I can do about that. I am not in a position to teach them at the current moment in time and no one else is going to take it upon themselves to do it.



Don't take this the wrong way, but that sounds a lot like a cop-out.  



> I am trying to achieve what is best for the EMS system I am involved with. It's one thing to say forget about the NG tubes and teach people how to provide good BVM ventilations and a completely different thing when that is not currently possible. I can't snap my fingers and make that happen.



Perhaps you should look at getting the BLS crews a non-invasive adjunct so they aren't bagging unprotected?  That way you're not simply trying to fix a complication but minimizing that issue.  Always look for a solution that is best for the patient, even if it's not the most expedient or seemingly practical.


----------



## 18G (Apr 14, 2011)

Sasha...
I totally agree with ya. I currently work for a FD in a rural area that has a small hospital so we get called a lot to transfer the critical and higher acuity patients to larger hospitals. It's a nice mix of 911 and IFT.

I have come to appreciate the IFT part of EMS and find it more engaging sometimes then 911. Having the chance to talk one on one with the transferring physician and the patients RN, correlating the lab results with the diagnosis, actually seeing the diagnosis first hand, getting exposed to drip meds we don't use real often in 911, etc make it a really cool experience.

I agree with ya on the learning a lot part. Most providers shun IFT since its not lights and siren, all glorious stuff. But I really enjoy it. 

One IFT patient I had the other night I was working was a child with appendicitis. She needed surgery and needed transported to a facility that could do it. She was stable and slept most of the way but I found it engaging on several fronts. 

She was having N&V and pain so she was treated in the ED with morphine which caused a localized reaction at the IV site and running up her arm. She was given 12.5 of benedryl which cleared it up and knocked her out.... but it was nice to see first hand what works in that case. So knowing the MS caused an issue I discussed giving Fentanyl for pain which was a nice discussion.

Enroute patient does pretty good until she wakes up vomiting and says, "mommy it really hurts" (mom was with us). So I called Medical Command and got orders for Fentanyl q20mins PRN and Zofran q30mins PRN. The Zofran did a great job as did the dose of Fentanyl. Even though something simple and calm it was nice to be able to really take care of this pedi patient and make her comfortable during the 1.5hr transport.

Even though it wasn't a 911 arrest, OD, or the like it was a learning experience.


----------



## ffemt8978 (Apr 14, 2011)

Okay, fair warning, this thread has now attracted my attention.


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## 18G (Apr 14, 2011)

usafmedic45 said:


> Perhaps you should look at getting the BLS crews a non-invasive adjunct so they aren't bagging unprotected?  That way you're not simply trying to fix a complication but minimizing that issue.  Always look for a solution that is best for the patient, even if it's not the most expedient or seemingly practical.



Actually, PA approved the AEMT level which is currently being developed and supposed to be rolled out 2/2012. I have no clue how its going to be implemented but from the wording in the EMS Act the new skills are obtainable through con-ed for current EMT's. To me this is scary. I was hoping it would be an entire program and conducted much like a Paramedic program but doesnt sound like it. But who knows. 

Our EMT's are allowed to carry Epi auto-injectors and if you mention sympathomimetic, sympathetic nervous system, or catecholamine you just get a bunch of blank stares. 

But I do agree if the EMT's are taught good ventilation technique consisting of minimal tidal volumes, being conscious of ventilatory pressure, maintaining good mask seal, placing an oral adjunct, and using constant cricoid pressure if personnel are available, they can give good ventilation and minimize gastric distention very much so.


----------



## 18G (Apr 14, 2011)

Look... now we have the sheriff involved...lol.


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## Veneficus (Apr 15, 2011)

You mentioned that the problem is with poorly skilled and if like most EMS providers, terrified of peds. 

Do you think under those circumstances that the providers would be skilled and in the mental state in order to place an NG tube proficently?

Would that not just be adding another procedure to the mix that could complicate things?

Honestly, if your people cannot be proficent at bagging a ped, how are they going to maintain proficency at putting another tube in one?

Generally the accepted norm for unskilled providers is to give them less to do damage with, not more. 

I see the goal you are trying to accomplish, but in this case, I don't think that invasive technology is going to be the solution. 

The only 2 ways I have found to be comfortable with various patients is foremost to see them regularly, second to that to be educated on them. Unfortunately rural EMS does not lend itself to vast quantity of experience. To my knowledge only the Aussies have tried to address that. Not sure how it turned out though.


----------



## systemet (Apr 15, 2011)

This isn't directed in anyone at particular, but I'm a little disappointed to see a good and valuable discussion into the utility of OG / NG tubes deteriorate into a bunch of bickering and ad hominem attacks.


----------



## MrBrown (Apr 15, 2011)

Veneficus said:


> The only 2 ways I have found to be comfortable with various patients is foremost to see them regularly, second to that to be educated on them.



Precisely why we do not have an Intensive Care Paramedic on every corner, fire truck and ambulance.  They are reserved for sick people in order to see a sufficient quantity of them to maintain knowledge and skill rather than rust out taking Nana to the doctor.

Brown is also terrified of paediatric patients.


----------



## 18G (Apr 15, 2011)

Veneficus said:


> You mentioned that the problem is with poorly skilled and if like most EMS providers, terrified of peds.
> 
> Do you think under those circumstances that the providers would be skilled and in the mental state in order to place an NG tube proficently?



I may not have been real clear when I was talking about poor BVM skills. I was talking about the volunteer EMT's. The EMT's are not allowed to use NG tubes so they would not be getting the added skill. 

Paramedic's have been allowed to use NG/OG tubes in PA for a very long time. It's just that they are not a "required" piece of equipment that every ALS service must have and I was wanting my company to acquire them so we had them if needed. 



> The only 2 ways I have found to be comfortable with various patients is foremost to see them regularly, second to that to be educated on them. Unfortunately rural EMS does not lend itself to vast quantity of experience. To my knowledge only the Aussies have tried to address that. Not sure how it turned out though.



There is current discussion with the Hospital to get us into the ED and possibly intubate in the same-day surgery unit as well to address low call volume and maintain skill proficiency.


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## Shishkabob (Apr 15, 2011)

I did an NG tube on an intubated/RSI'd patient yesterday.

HAHAHAHAHA.


----------



## MrBrown (Apr 15, 2011)

18G said:


> I may not have been real clear when I was talking about poor BVM skills. I was talking about the volunteer EMT's.



In 2008 we introduced a new qualification for our volunteer Ambulance Officers which takes about a year to complete from start to finish.  The practice level is now called "Emergency Medical Technician".

Some people moaned it was too long and hard, the reply was very simple; turn in your boots and good luck, it is the expected standard and we will not compromise because you are not willing to complete it.

This is the same as the "take away intubation from paramedics" argument, it would simply fix a symptom of a problem and not address the problem itself.

Manual ventilation is a tricky skill to develop and maintain Brown agrees, however is there no structured clinical education program or Clinical Support capacity within the Ambulance Service for people to maintain clinical competency and address clinical concerns?

Brown thinks perhaps there is a spare airway manakin lurking somewhere on station ... hmm wonder what postage on that would be


----------



## Veneficus (Apr 15, 2011)

MrBrown said:


> Brown thinks perhaps there is a spare airway manakin lurking somewhere on station ... hmm wonder what postage on that would be



Nobody talks about brave men and their proud simulators.

The trouble with all these high tech baby dolls is they are always the same, and anyone can properly ventilate in a classroom or in the station.

It is when the patient is real, the adrenaline running high, eyes on you, and the whole team that depends on your ability to focus and properly perform your part that seperates the men from the boys so to speak.

IN some of the rural hospitals I have seen, even the physicians start to see skills degredation. The monotony also seems to dull the wit as much as the skills.

Nothing against the providers, but it is the nature of the beast. Somebody has to staff those hospitals.


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## Smash (Apr 15, 2011)

Veneficus said:


> Nobody talks about brave men and their proud simulators.
> 
> The trouble with all these high tech baby dolls is they are always the same, and anyone can properly ventilate in a classroom or in the station.
> 
> ...



That's why I love heroin overdoses. (On road that is)  I get everyone (myself included) to have a go at ventilating the patient, which lets the newer people get some real life hands on experience in managing airways and using a BVM in a less pressing situation.  As long as ventilation is occuring there is no problem.  After we all have had a go, and the patient is nice and well oxygenated and had all that CO2 washed out, they can have some naloxone and be on their merry way.  Everyone wins!


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## usafmedic45 (Apr 15, 2011)

> I was talking about the volunteer EMT's.



I like how you feel the need to point out that they are volunteer EMTs when you mention them as though that is the explanation for the lackluster skills.  LOL


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## 18G (Apr 15, 2011)

usafmedic45 said:


> I like how you feel the need to point out that they are volunteer EMTs when you mention them as though that is the explanation for the lackluster skills.  LOL



And I like how you take my statements out of context and apply your own meaning. 

They are volunteer EMT's. They are not paid. And yes, a distinguishment between paid and volly is sometimes necessary. Our system is very rural which doesnt present many opportunities for calls to begin with let alone with they have to work a full-time job doing something other than EMS.


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## ffemt8978 (Apr 15, 2011)

DO NOT turn this into another paid vs volly debate.


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## jwk (Apr 17, 2011)

NG tubes are not necessary in ALS.  If you think you NEED one because of abdominal distention, then you need to be working on your basic airway management skills (BVM) and learn how to avoid it in the first place.  Violating that cardiac sphinter is a BIG DEAL in an unprotected airway.


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## 18G (Apr 17, 2011)

I couldn't agree more on good BLS skills to prevent it. HOWEVER, even with the best BLS airway skills there is no guarantee that gastric distention will not be an issue from time to time in certain patients. 

It's just nice to have the tools necessary to address patient issues as they arise. 

And everyone keeps saying that the NG tube may cause vomiting, or will "violate the cardic sphincter", etc. So what is the alternative? Keep exerting increased ventilatory pressures to compound the problem? Tolerate decreased tidal volume delivery?

When u have a patient who has gastric distention and has poor pulmonary compliance what do you suggest to correct this problem? Great BLS airway management wasn't enough to prevent the distention so now what?

To me its either tolerate the poor compliance and difficult ventilation which predisposes the patient to increased airway pressure and additional distention and increased risk of aspiration, or place the NG tube to improve compliance, tidal volume delivery, and reduce aspiration risks. 

If there is a better idea to deal with this problem I'm totally open to hear it.


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## usafmedic45 (Apr 17, 2011)

> And everyone keeps saying that the NG tube may cause vomiting, or will "violate the cardic sphincter", etc. So what is the alternative? Keep exerting increased ventilatory pressures to compound the problem? Tolerate decreased tidal volume delivery?



The answer is to either train the folks to avoid it or give them an engineering fix to prevent it.  Basically, the best option is prevention.  

Honestly, once you get to the point of having gastric distention, you're in a very tough situation due to the very high risk of aspiration associated with relieving it.


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## Veneficus (Apr 17, 2011)

18G said:


> I couldn't agree more on good BLS skills to prevent it. HOWEVER, even with the best BLS airway skills there is no guarantee that gastric distention will not be an issue from time to time in certain patients.
> 
> It's just nice to have the tools necessary to address patient issues as they arise.
> 
> ...



Just to clarify please...

Are you suggesting that more forceful ventilation is a solution to pulmonary pathology?

I want to make sure I understand you properly before I comment.


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## usafmedic45 (Apr 17, 2011)

He's stating that if you can't decompress the stomach that they only option you have to is ventilate against more resistance.


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## 18G (Apr 17, 2011)

What ^^^^^ said....


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## 8jimi8 (Apr 17, 2011)

18G said:


> What ^^^^^ said....



18G.  What you are failing to see is that everyone agrees that an NGT can be used to decompress the stomach.

You are out on the very tip of a long thin branch.  What all of the argument was about is that you seemed to want to overuse the skill by applying it to too many situations.  That is the way I was reading it anyway.


Now you've changed your story midthread and it seems that you are trying to say that all you were asking is for the devices to be available on your unit, just in case.


I think we all agree, yes, you should be able to have an NGT to drop on your patient, should an event arise that predicates the use of that device.

Yes you should be able to have it and use it.

No it should not be used on every patient

And it will never take priority over other airway interventions.


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## jwk (Apr 17, 2011)

usafmedic45 said:


> The answer is to either *train the folks to avoid it *or give them an engineering fix to prevent it.  Basically, *the best option is prevention*.
> 
> Honestly, once you get to the point of having gastric distention, you're in a very tough situation due to the very high risk of aspiration associated with relieving it.



Key point for the entire thread.


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## 18G (Apr 17, 2011)

8jimi8 said:


> Now you've changed your story midthread and it seems that you are trying to say that all you were asking is for the devices to be available on your unit, just in case.
> 
> 
> I think we all agree, yes, you should be able to have an NGT to drop on your patient, should an event arise that predicates the use of that device.
> ...



I feel like I have been repeating myself the entire thread. I thought I was clear in the intent and haven't changed my story.


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## BandageBrigade (Apr 18, 2011)

Not to change the topic, but 18G I suggest that you and your service do some research on the different styles and sizes of King tubes available. 
     I have never felt the need to drop an NG emergently in the field, but I have put them in before leaving the hospital on transfers.


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## usafmedic45 (Apr 18, 2011)

> Not to change the topic, but 18G I suggest that you and your service do some research on the different styles and sizes of King tubes available.



...or go with what hospital use in kids they can't intubate: the LMA.  I've never understood the argument for having a more or less prehospital specific device.  The King Airway seems to fit that description.  I've seen plenty of Combitubes in hospitals but not Kings.


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## BandageBrigade (Apr 18, 2011)

There is a local hospital here, a small one. They stock Kings in the ER amd LMAs in the OR. Ive never understood it. I was just making the point that there are multiple sizes available, including child. Not promoting any one item.


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## mikie (Apr 18, 2011)

BandageBrigade said:


> There is a local hospital here, a small one. They stock Kings in the ER amd LMAs in the OR. Ive never understood it. I was just making the point that there are multiple sizes available, including child. Not promoting any one item.



ET Tubes are not the only airway devices Hospitals have & use...


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## usalsfyre (Apr 18, 2011)

usafmedic45 said:


> I've seen plenty of Combitubes in hospitals but not Kings.



They're getting more common in airway carts. The problem with Combitubes is the tracheal tears.....


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## 18G (Apr 18, 2011)

I thought most were going with the King mainly because it was latex free whereas the Combitube is not and it is slightly easier to insert and train on.


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## BandageBrigade (Apr 18, 2011)

mikie said:


> ET Tubes are not the only airway devices Hospitals have & use...



I never started they were. I was just starting that it was odd that the OR only uses LMAs as a backup while The ER only uses Kings. In the age of cost cutting you would think they would just use one or the other. Im sure each director just has his/her opinion on which is better.


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## jwk (Apr 18, 2011)

BandageBrigade said:


> I never started they were. I was just starting that it was odd that the OR only uses LMAs as a backup while The ER only uses Kings. In the age of cost cutting you would think they would just use one or the other. Im sure each director just has his/her opinion on which is better.



LMA's are a primary device in the OR (not just as a backup) and it is commonly used in cases that don't require endotracheal intubation.  The King airway is primarily a rescue airway when endotracheal intubation isn't possible, and has found little use in anesthesia and the OR.  You will however find them on difficult airway carts in a lot of OR's and ER's to have on hand just in case.  We've never had to use them.


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## 18G (Apr 21, 2011)

What type of NG tube are most using prehospital? The salem sump or single lumen levin type tubes?

I have seen the salem sump tubes used the most in and out of the hospital. So just curious.


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## 8jimi8 (Apr 21, 2011)

18G said:


> What type of NG tube are most using prehospital? The salem sump or single lumen levin type tubes?
> 
> I have seen the salem sump tubes used the most in and out of the hospital. So just curious.



What I've seen prehospital is a Salem sump.  In the hospital it is either Salem sump,OG, or a do dobhoff  ng/nd/nj


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## ShotMedic (May 8, 2011)

18 Gauge I agree with you for the placement of NG/OG tubes in the Pre-Hospital setting if theres enough time to do so. I work in the Rural San Diego County Area with most of our first responders BLS. With our ALS ETAs from 5-25mins to the scene I know how BLS CPR can cause major Gastric Distention and adversely effect the ventilation of the Patient as well as the Effectiveness of the Chest Compressions. Our normal transport times to the closiest hospital is 15 mins to 1hr If the helicopters arent available. We utilize the dual lumem levin, I havent had any trouble inserting it in the Intubated Patient. the King Airways have a Port that a 18gauge or smaller NG tube will slide down on certain model. I have yet to use that on scene but I hear it works well. I will Admitt I have not Had time to place the NG/OG tubes in every Patient due to many reasons but having the tool available never hurts.


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## jwk (May 9, 2011)

ShotMedic said:


> 18 Gauge I agree with you for the placement of NG/OG tubes in the Pre-Hospital setting if theres enough time to do so. I work in the Rural San Diego County Area with most of our first responders BLS. With our ALS ETAs from 5-25mins to the scene I know how BLS CPR can cause major Gastric Distention and adversely effect the ventilation of the Patient as well as the Effectiveness of the Chest Compressions. Our normal transport times to the closiest hospital is 15 mins to 1hr If the helicopters arent available. We utilize the dual lumem levin, I havent had any trouble inserting it in the Intubated Patient. the King Airways have a Port that a 18gauge or smaller NG tube will slide down on certain model. I have yet to use that on scene but I hear it works well. I will Admitt I have not Had time to place the NG/OG tubes in every Patient due to many reasons but having the tool available never hurts.



I assume you mean 18F, not 18ga.


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## ShotMedic (May 9, 2011)

hhaha yeah thanks for the catch


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## Ridryder911 (May 9, 2011)

8jimi8 said:


> With what we use these for I think a protocol for radiographic confirmation is a necessary evil.  I have seen many times... Ng and og tubes end up in the trachea.
> 
> 18g,Have you seen how much people gag when you use these devices?



What x-ray for an NG tube?..OMG I have never ever seen such! Somebody screwed up big time somewhere or the radiologist needs some extra cruise trips!  I can't imagine the cost for such a simple procedure! Listen auscultate and verify.. sorry, even with low suction.. either you have gastric contents or not... 

NG tubes are placed daily, thousands of times without any extra verification in NH, home health for tube feeding, pre-hospital environment. 

To the post, NG or OG to decompress the stomach to prevent pressure which causes vagal stimulation and on ped's is essential to perform and prevent! 

I rarely see OR's use ETI anymore in the surgical arena, YES they use LMA type devices called fastrach I have a video of them utilizing and intubating through it.. It is easier, less traumatic on the patient and less complicated for short procedures... 

http://www.youtube.com/user/Ridryder#p/a/u/0/HXjPdNSL96c

R/r 911


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## jwk (May 9, 2011)

Ridryder911 said:


> I rarely see OR's use ETI anymore in the surgical arena, YES they use LMA type devices called fastrach I have a video of them utilizing and intubating through it.. It is easier, less traumatic on the patient and less complicated for short procedures...



I use ETT's every day in the OR.  We also use LMA's, but the LMA FastTrack is more of a rescue device that's not intended for routine use.  It is a far more expensive device than the disposable LMA's we use daily.


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## usafmedic45 (May 13, 2011)

> They're getting more common in airway carts. The problem with Combitubes is the tracheal tears.....


'

You mean esophageal tears.  That's a problem with any object blindly and forcefully rammed down the throat of another.  And, yes, I do mean any. 



> LMA's are a primary device in the OR (not just as a backup) and it is commonly used in cases that don't require endotracheal intubation.



Actually, they are used in cases that require ETI or rather a protected airway.  It's just they use them instead of intubating.  You actually have to be more out of it to have an LMA placed than to have an ETT passed.


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## jwk (May 13, 2011)

usafmedic45 said:


> Actually, they are used in cases that require ETI or rather a protected airway.  It's just they use them instead of intubating.  You actually have to be more out of it to have an LMA placed than to have an ETT passed.



Those statements are incorrect.  There are specific indications and reasons why we use one or the other.  If a case "requires" an ETT, then that patient will get an ETT.  Many anesthetists are getting fairly cavalier about the use of LMA's in cases that really ought to have an ETT.  I've never been sorry about placing an ETT, but there have certainly been times I didn't when I wish I had.

"More out of it"?  Hmmmm, by what measure?  LMA's are far less stimulating than laryngoscopy, and are easily placed a few seconds after induction, unlike ETT's where we wait for the muscle relaxants to kick in.  LMA's are routinely placed before giving narcotics - not so with ETT's where virtually every patient will get narcotics during induction to blunt the sympathetic response to laryngoscopy.


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## usafmedic45 (May 13, 2011)

> Those statements are incorrect....where we wait for the muscle relaxants to kick in.



Define "we".  What's your role in all of this?



> LMA's are far less stimulating than laryngoscopy, and are easily placed a few seconds after induction,



You can place an ETT in a conscious patient with local anesthesia or even in a fully conscious patient sans any anesthesia if you go via the nasal route.  Unless your patient is Jenna Jamison, you're going to have to have them completely obtunded if you want to use an LMA.

All of the anesthesiologists I know- and I talk to a lot of them since I speak about difficult airway management and keep in touch with folks to stay up to date- freely admit they use the LMA over the ETT in most cases not to avoid any clinical aspects of standard intubation, but rather because it's quicker and there's somewhat less liability involved (no risk of breaking someone's teeth which is a large source of risk for anesthesiologists traditionally).


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## jwk (May 14, 2011)

usafmedic45 said:


> Define "we".  What's your role in all of this?
> 
> 
> 
> ...



I'm chief anesthetist for one of the largest anesthesia groups in the country, have been in practice more than 30 years, and am in the OR daily.  While in college many years ago, I worked for both rural and urban EMS to pay my way through school, back in the days when IC injections and lots of bicarb were still in vogue and there was no such thing as ACLS.  I'm still a clinical instructor in anesthesia and taught airway management and ACLS to paramedic students for years.


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## 18G (May 14, 2011)

Ridryder911 said:


> To the post, NG or OG to decompress the stomach to prevent pressure which causes vagal stimulation and on ped's is essential to perform and prevent!
> R/r 911



Thank you.


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## usafmedic45 (May 14, 2011)

jwk said:


> I'm chief anesthetist for one of the largest anesthesia groups in the country, have been in practice more than 30 years, and am in the OR daily.  While in college many years ago, I worked for both rural and urban EMS to pay my way through school, back in the days when IC injections and lots of bicarb were still in vogue and there was no such thing as ACLS.  I'm still a clinical instructor in anesthesia and taught airway management and ACLS to paramedic students for years.


Really now...that's very interesting.....


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