# How do you intubate someone?



## JJR512 (Jan 27, 2008)

I'm an EMT-B with a critical care transport service. My role is that of driver, and of assistant to the Paramedic and Nurse with whom I am on a call. Obviously, I will not be intubating anyone myself. However, because there are time when I will be working with only a Paramedic, I may need to be his/her "extra pair of hands" from time to time. I may need to be ready to hand him whatever he needs if he's got his hands busy with an intubation.

I know absolutely nothing about intubating. I am hoping someone can explain to me, in relatively simple terms, what is done. I'm looking for a chronological layout, with the equipment named, the drugs named, etc. I need to know the names of all the equipment that is or might be used, as well as the drugs, and anything else, so I'll know what I'm likely to need and what I might need. We have an "intubation kit" that theoretically has everything (equipment, drugs, etc.) that would be needed. I think I basically need to know what I'm likely to need to grab next.


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## Flight-LP (Jan 27, 2008)

Have you sat down with one of your Paramedic's or a Nurse to discuss this? Why not ask the people who you will be helping? They would be able to tell you exactly how they want it. As none of us are familiar with the specifics of your equipment, protocols, or unit set up, it is difficult to offer advice that would be beneficial. Part of being a collaborative team member, especially on a CCT team, is the ability to openly communicate directly with your co-workers. I'd start with them..................................


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## KEVD18 (Jan 27, 2008)

flight nailed it. ask one of your medics to teach you.


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## bstone (Jan 27, 2008)

This is one of the reasons why I am glad ETT was part of the Basic course in IL. Mannequin and all.


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## VentMedic (Jan 27, 2008)

double post


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## VentMedic (Jan 27, 2008)

I suggest you borrow a Paramedic text and start reading.  Most usually have a good outline as well as some basic anatomy. 

If you want to learn intubation, don't approach it as just another skill.  Unfortunately, it is taught with this mentality in many EMS programs.  Many people spend too much time memorizing a "list" and less on understanding each step. Know the A&P of the respiratory system thoroughly and the reasons for intubation.  That will also give you an idea as to why certain equipment works better for some intubators than others. For example, curved vs straight blade is sometimes a personal preference and sometimes each blade serves a pupose for anatomical reasons.   

An overview of the medications will also be in the paramedic text. However, for CCT each team may have meds in their protocols that are the discretion of their medical director.  Different meds may be used for different patients for different disease processes also.

Of course, every nurse, RRT or EMT-P will have their own preferences and the team members you work with most can assist you in getting familiar with the lay out of the intubation equipment.  The equipment should be stored in a logical order for easy access by all team members.  

Also, familiarize yourself with the alternate airways they carry.  This might be where you will actually be most helpful as adrenaline and a little panic kicks in for some intubators when they miss a tube.  This might just be bagging until they regain composure or readying another ETT or different airway.


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## Ridryder911 (Jan 27, 2008)

Not much to add from the other excellant ideas except to be sure the basics are covered such as having a working suction with Yankuer suction tip, BVM is attached to oxygen, tube holder, etc.. Little things like that sure helps. 

R/r 911


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## Anomalous (Jan 27, 2008)

Until the tube is secured, the most important thing for you...



don't knock it loose.


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## MSDeltaFlt (Jan 27, 2008)

Most critical care transport services; either ground or air, will more than likely have very explicit and detailed procedures for their intubation protocols.  The best, simplest, and probably most easily accessible resource I could offer you is to ask your partners, look through their protocols, and, if able, ask them to walk you through it on a mannequin.

Good luck.


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## VentMedic (Jan 27, 2008)

For this CCT sevice, how many intubations do the Paramedics and/or RNs get on the job per month or year?  

How many intubations are they required to have per month/quarter or year either on transport or in the hospital (OR, ED, ICU, Lab)? 

Does the CCT service also transport pediatrics?   If so, how do the team members maintain their pedi intubation competencies? 

One of the complaints Paramedics have working some CCT services is that they don't get to intubate as often as they did working EMS.   The RNs actually get more intubation opportunities if they are part of a hospital based service and work the ICUs.

Our Adult CCT RNs work for the hospital and ride with whatever ALS truck shows up for transport.  Occasionally an RRT will accompany if it is a difficult respiratory or unstable ICU patient.   The specialty teams (NICU & PICU) are a whole different set of team members and protocols.


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## firecoins (Jan 28, 2008)

google intubation.  There are google videos of surgical teams intubating patients but use equipment EMS would never use.


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## MedicPrincess (Jan 28, 2008)

Anomalous said:


> Until the tube is secured, the most important thing for you...
> 
> 
> 
> don't knock it loose.


 

Even after its been secured....don't pull on it...push it in...mess with it.

I am surprised one of the Medics in the service you work for hasn't set you down and said "this is your part" during intubation.  

Get with your training person/dept.  Ask them to let you look/feel/play with the airway supplies, that way you can get an idea without having to open your supplies on the truck.

And do what all these other members here have said....they are pretty smart, with excellent ideas.


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## Markhk (Jan 28, 2008)

If you used the "Orange Book" during EMT training (Emergency Care and Transportation of the Sick and Injured), instructions on intubation is like one of the last chapters as an additional module. Probably would help in understanding what the paramedic needs to do.


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## MasterIntubator (Jan 28, 2008)

Your crew is your best bet for training, as they will all have their own little preferences.  For instance, my crew knows exactly what set up I prefer, which handle, which blade and how to set up the tubes/holders/magills/fiber-optics/etc.

That way, while I am intubating, and I see the cords, all I have to do is hold my hand up without even looking away from the cords, and that tube will place itself in my hand the correct way, with syringe attached.

From the time we grab the tube roll, from set up to finished intubating the average pt, about 30-40 seconds. ( laryngoscopy to passing the tube is about 10 seconds of that ).

We used to drill regularly for meconium aspiration prevention.  Your partner needs to be quick, accurate, and have a line of extra tubes waiting while you, as the intubator, never look away from the air hole. 

Good luck with your learning, train with your crew, learn from others and expand your knowledge.  Be open to all ideas, and pick the best one that suits you.


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## JJR512 (Jan 29, 2008)

Thanks for the replies so far.

One of the problems I am having at work is that I have a lot less experience (either with a 911 service, or working with an ALS partner at a commercial ambulance company) than they are used to hiring. They've hired me, as a relatively inexperienced EMT-B driver, because they need more Emergency Vehicle Operators but are finding it increasingly difficult to find the kind of people they want. So, they are using me as a guinea pig, to see if they can hire people with less experience, and train them up to their standards.

Because of that, they are proceeding at an achingly slow pace (in my opinion). They are showing me one thing at a time, and waiting until I demonstrate a pretty good understanding of that one thing until they move on to the next. For example, I have recently been taught the basics of how to set up their transport ventilator (LTV-1000) (turn it on, set up the tubing, program the numbers supplied to me by the nurse). Until I do this several times on live patients and they feel confident I know what I'm doing, they will not go over anything else with me.

The problem that I have with this approach to my training is that although I am inexperienced, I am not stupid. I believe I can start to learn something else, or review something else, without the vent knowledge falling out of my head just because I haven't practiced it on live patients yet.

So, yes, I agree that I should be going over my service's intubation procedures with my service's paramedics. But this will not happen until they decide "I'm ready". But I believe I am ready for some of this information now. Thus I am going behind their backs.

I would at least like to learn the names of the different tools and equipment used, the purpose of each piece, the names of the commonly used drugs and what they do, etc.



VentMedic said:


> For this CCT sevice, how many intubations do the Paramedics and/or RNs get on the job per month or year?
> 
> How many intubations are they required to have per month/quarter or year either on transport or in the hospital (OR, ED, ICU, Lab)?
> 
> ...


I don't know the answers to most of these questions off the top of my head. Most of our paramedics also work (or volunteer) with county 911 services as well, so they're still getting their field experience that way. Yes, we transport pediatrics; they make up a fairly sizable percent of our transports. Our nurses are specialized into adult-only and peds-only. It is my understanding that with our adult patients, the paramedic is far more likely to do the actual intubation, whereas with the peds patients, it's the nurse who is far more likely.

My service (Maryland ExpressCare) is based at a hospital (University of Maryland Medical Center, the teaching hospital of the UofMD School of Medicine, home of the world-renowned pioneering Shock Trauma Center). ExpressCare is not actually its own company; it's a service operated by UMMC, and we exist to bring other hospitals' problems to UMMC to be solved there. Our paramedics and EVOs are employees of a separate commercial ambulance company (TransCare) who are basically rented by UMMC to staff ExpressCare. Our nurses and communications center staff are employees of UMMC. We all wear the same uniform and, despite having different employers, collectively we operate as a team. Being based at a hospital, our nurses, who are also UMMC nurses, get plenty of opportunity to go into the ICUs and other areas. We get a lot of opportunities that other commercial ambulance companies do not, such as being able to stay a bit longer with many of the patients to see what the unit teams start to do, to help out the unit teams, to talk to the doctors and nurses and ask them questions and try to learn from them. That's one of the big reasons I wanted to work at ExpressCare, actually.


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## KEVD18 (Jan 29, 2008)

heres the issue as is see it: your wanting to get ahead of the curve, which i think is great. always wanting more education is never a bad thing. but your service had developed a training program for new employees that they feel is appropriate. staying with the class so to speak will keep you in line with what the company wants you to know. it will also keep your attitude in check. i dont know you personally but i have had quite a bit of experience with new emts. a little bit of knowledge is a very dangerous thing.

picture this: we, the collective group of emtlife members, explain in detail the process by which a pt is intubated. the equipment, anatomy, pharmacology. the whole nine. you'll remember(i cant remember tha actual stats so i'll guess) say 10% of that just from having it explained to you in words and maybe a few pics. now fast forward to when your service says its time to go over it. the medic(who for the purposes of this discussion just came off a 24 at another service, has a head cold and is fighting with the wife about whos turn it was to take out the trash) start with the very basics, because he know as you have proclaimed "I have a lot less experience (either with a 911 service, or working with an ALS partner at a commercial ambulance company) than they are used to hiring". so he begins with "this is an endotracheal tube". and you respond with "yeah i know. its a 7.5mm cuffed ETT with a stylet". 

some people might relish this. geart, i dont have to teach this kid everything about everything. others might think that your trying to be a smartass.

my reccomendation, stick to what they give you. they are prepared to show you everything you'll ever need to know. let them. it will make you a better emt.

JMHO


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## Ridryder911 (Jan 29, 2008)

Although, it may appear that they are teaching you slow, be glad they are making sure that you have "mastered" each step. I do doubt that think you are stupid or slow, it is that in comparison of education and expectations they want you to perform the tasks flawlessly. 

Since you are one of the first, expect a little more time and tried attempts. It is appear they are attempting to do something new, and actually you may make or break the deal. Again, nothing personal but you ask about intubation and the steps, yet complain about being slow about teaching on assisting. Remember, in most of the general medical care, one is taught how to assist far before allowing to actually perform the procedure. You can't have your cake and eat it too. 

I would be *very cautious* about going behind their backs and learning anything. There is a reason they are doing what they are doing, unfortunately you do not have the education level to quite understand that yet. Remember, that the majority of the care they will provide is very little skill and mostly will be based upon medical knowledge. They appear to prefer that you are taught within the scope that they want you to perform at, not what you assume you should do or know. If not careful, you may exceed or over-step your job description or what they want in a person at this time, they are in control and supersede you, they know and realize what they need, not vice versa. As the old saying when in Rome... or you can be replaced by someone that will meet that need. Not to be condescending but in reality your main job is to be an EVO and secondary job is to be a go-for. 

If they want you to assist or know the meds, they will tell you and teach you. Personally, I would not want my EVO or basic to know much about the med.'s they have no business even handling paralytics, etc, if I have another medial person, sorry that is just medicine. 

Study on your own to be proficient and master what they want, they will allow you to increase with time and demonstration. 

R/r 911


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## JJR512 (Jan 29, 2008)

KEVD18 said:


> heres the issue as is see it: your wanting to get ahead of the curve, which i think is great. always wanting more education is never a bad thing. but your service had developed a training program for new employees that they feel is appropriate.


I just want to point out that they have not developed a training program for me. They are developing it as they put me through it. I am the guinea pig, the lab rat. They do not know if it is appropriate; they want to see how it succeeds or fails with me, and make appropriate adjustments as needed. (This is partly my own fault: I have retail/restaurant management and training experience, and one of my selling points was that I could help them develop their new training program for under-experienced EMT-Bs.)



> staying with the class so to speak will keep you in line with what the company wants you to know. it will also keep your attitude in check. i dont know you personally but i have had quite a bit of experience with new emts. a little bit of knowledge is a very dangerous thing.


It's now what they want me to know; it's when they want me to know it that's the problem. I am endeavoring to express my concerns to management; this is, after all, what _they_ want to learn from _me_. However, I do agree with you about the dangers of a little bit of knowledge.


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## KEVD18 (Jan 29, 2008)

well fair enough. so they are testing out a new field precepting system out on you. in that case, you have to expect things to be a little disorganized.


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## disassociative (Jan 29, 2008)

Airway management should be a book, in itself. The first chapter beginning with an overview of the importance of airway management followed by the history of airway management(what worked, what did not). The next chapter should be on Anatomy of the Airway followed by a chapter of respiratory physiology then one on anatomical variations, once they have covered these topics--The techniques , their theory, and application should be explained and detailed. 

If you are looking to learn how to assist, one person before recommended Emergency Care and Transport of the Sick and Injured(This is the book our EMT-IV's use here). It is approved by the AAOS and can be found at emszone.com

I think they did a good job when writing this book, however please note that the anatomy/physiology is nowhere near the level you would need to begin actual intubations; however--technique is described in the last few chapters:

ALS Techniques

Advanced Airway Management
Assisting in Cardiac Monitoring
Assisting in IV Therapy


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## JJR512 (Jan 29, 2008)

Is this book (Emergency Care and Transport of the Sick and Injured) an alternative or competitor to the Emergency Care by Limmer, O'Keefe, et. al, published by Brady Books/Prentice Hall, or is this book a step past that book--higher-level/more in-depth than Emergency Care?

I ask because I was going to buy a new copy of Emergency Care because my original was lost, and I want it (now more than ever) to refer to when I realize I don't know something as well as I should. But if this other book, Emergency Care of the Sick and Injured, is an alternative to it, then I'll just get that instead, and get basically another take on the same thing. But if it's a higher level book, then I still may need to buy both.


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## disassociative (Jan 29, 2008)

This book is by Jones and Bartlett, and I personally think it is more thorough than Brady. However, others might differ in opinion. 

In TN, as I have said before--we do not have EMT-B. We have EMT-IV; our providers can do more techniques including initiating IV therapy and using certain meds and fluids. The typical EMT-IV class here in TN uses:

Emergency Care & Transport of the Sick and Injured
(http://emszone.com/catalog/0763744050/)

Companion Site: http://emtb.com
------------------------------------------------------------
IV Therapy for the Prehospital Provider
(http://www.jbpub.com/catalog/0763715794/)

Companion Site: http://ivprehospital.com
------------------------------------------------------------
Also, for the EMT-B looking to learn more about assisting in ACLS and other
ALS level interventions:

ACLS for EMT-BASICS
(http://www.jbpub.com/catalog/9780763743956/)

Companion Site: http://acls.emszone.com/

 Note: I have not reviewed this book


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## VentMedic (Jan 30, 2008)

I think you will really enjoy this job. It would be nice if they provided a job outline with a detailed checkoff sheet.  Our drivers for the NICU/PICU specialty teams know exactly from a written job description and a detailed list of expected responsibilities what they can do.  The list and job description are made carefully within the quidelines of the state scope of practice for the EMT-B.  There are some things that are allowed to be expanded and some things that they must be careful not to cross the line of what only certain licensed persons can do.  Our specialty teams must keep accurate records of training/competencies on each team member in accordance to their job description for the various inspections hospitals based teams must endure.  The same goes for the CCT RNs in the adult world. 

It doesn't really matter for us how much experience the EMT-B has because a NICU/PICU specialty team operates with a very different set of protocols and with very specialized equipment.  Safe transport is key and they rarely if ever run L/S.  We do want them to meet the minimum safe driving requirements to satisfy the insurance company. The interview will give us a clue if you are motivated to learn the other responsibilities.  The specialty teams don't have paramedics and if they are hired as a driver, they function with the same job description as the EMT-B/EVO. 

The EMT-B can assemble all equipment such as the isolette, intubation equipment, ventilator and arrange the IV pumps.  But, they can not touch any meds or do the actual settings on the ventilator or IVs pumps.  They are trained on how the pumps and ventilator function for cleaning. They also can run through the tightness check sequence on the ventilator as part of their job description requires when it is not on a patient.   They are then trained to anticipate every move the team makes.  Since these teams are very experienced and have been established for well over 3 decades, they will train their EMT-B driver to the responsibilities of the check off sheet in a few days of orientation both inhouse and with another driver.

As for you, JJR512, learning more about different processes, procedures and whatever else, that is excellent as long as it doesn't interfere with the flow of the team work or you try to change their ways.   You will find from observing and learning from each team member that they all may have been taught something slightly different in the way to do things especially if the paramedics are working in a 911 service also.  You may notice the biggest difference between the Paramedics and RNs in the infection control practices since the RNs are hospital trained.   Those issues have been stressed to us in our specialty team training since the beginning of time and have been revamped to a new level again in recent times.  

One of the reasons the EVO position is so appealing to some EMTs is the hospital will work with their scheduling for college classes.  We don't expect our drivers to make it a career of just driving for us and prefer those who have some motivation for education to continue on to some other position within the hospital.  You have the opportunity to be exposed to many occupations and not just nursing or paramedic which seems to be tunnel visioned as the "next" career move for the EMT-B.  Many of our "drivers" have gone on to be RNs, RRTs, PAs, Surgical Assistants, HBO technicians, MBAs or CPAs in the offices, and MDs.  

Check the bulletin boards at the teaching hospital and slide into any lecture that catches your eye. Even if you don't understand all of it, it will give you an opportunity to see have much there is to the world of medicine and the people involved. That is truly the greatest advantage of working for a large teaching facility.  I'm sure they also have an excellent medical library on the campus.  Usually the computers in the teaching hospitals are linked to the library.  I considered our medical library my temple during college and went there to worship the knowledge frequently.   I now utilize its resources by the internet but still feel more inspired when I am actually in the library building.


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## eggshen (Feb 6, 2008)

Check out S.L.A.M Street Level Airway Management. Not as cheesy as it sounds, an entire book (and course) dedicated to airway management.

Egg


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## Keith (Feb 16, 2008)

Im only paramedic student, so please don't take my words to close to heart. I would say based on my expierience, talk to a medic your close to, or friends with. Your gonna get the best instruction from someone you have already connected to on a personal level. Just keep you mind open and always be willing to learn, thats the way I always am, and so far its worked to my advantage.

...and by the way, props on working the CCT truck, I always thought that was a pretty damn cool gig, good lookin out.


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## Ops Paramedic (Mar 2, 2008)

*How do you intubate someone*

Are your EMT-B protocols along the same lines as our BAA's (Basic Amulance Attendants)protocols?? If so, then, our BAAs, are not allowed to intubate patients for various reasons.  Although, as per your post, it is extrmely helpfull to have a pair of well trained hands around during intubation and thereafter.

With intubation comes a whole lot more then just pasing a plastic tube between the vocal cords.  These include troubleshooting (DOPES), alternatve airway procedures should you fail when you have already commited and pharmacology amongst others.Remeber, anyone can be touhgt how to intubate, as it is a pshyco-motor skill, but not everyone knows when to intubate...


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## fma08 (Mar 13, 2008)

lots of great advice, the most i've learned about airway believe it or not has come from CRNA's, not class, but as being the "extra set of hands" talk with the medic, have him take you through your intubation/airway kit, if you do RSI or PAI chances are he/she'll have to draw up the meds necessary, but still doesn't hurt to ask them about it. kinda the big thing is to see how they like to do it, cuz the one big thing i've learned so far through school is everyone has their own way of doing things, so talk to them about it.


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## emtwacker710 (Mar 28, 2008)

Ridryder911 said:


> Not much to add from the other excellant ideas except to be sure the basics are covered such as having a working suction with Yankuer suction tip, BVM is attached to oxygen, tube holder, etc.. Little things like that sure helps.
> 
> R/r 911



I agree completely, also like everyone else said, sit down with the medic(s) you ride with all the time and ask them what their procedure is and remember it.


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