# Is an ET Tube Really ALS?



## MMiz (Jun 21, 2008)

A month or so ago I flew back home to get some pratical CEUs for my EMT-Basic renewal, and the instructor, like almost all EMT classes, finished hours early.  Because he couldn't let us out five hours early, he got out the intubation supplies and gave us a quick tutorial on intubating an adult.

I won't say that I was a pro by any means, as dropping a tube down Annie's throat isn't quite like the real world, but it got me thinking as to whether it should be incorporated into the BLS curriculum.  

So much of EMS, like many medical jobs, is about performing a skill.  EMT-Basics lack so muck of the knowledge, but I wonder if the benefits of adding ET inbutation outweigh the risks, time, and added money of training.

What do you think?


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## Chiron (Jun 21, 2008)

I think they are teaching ET placement to our Basics here in Ohio. I cant see why they wouldn't, no airway no Pt. just seems like common sense.


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## mikeylikesit (Jun 21, 2008)

i think that one must know proper anatomy and physiology before blindly placing tubes. there are many errors that can come from miss placement, knowing not only how and why but what to do if something is to go wrong is extremely important.


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## daedalus (Jun 21, 2008)

It is taught as an optional module, although its a terrible chapter in the Brady book.


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## Guardian (Jun 21, 2008)

No, I don't think it would be a good idea.  That’s based on personal experience and the majority of medical directors agree with me.  I think the reasons have been made clear.  

Speaking broadly, the old risk benefit analysis is always much more complicated than it first appears.  For example, if you do a risk benefit analysis and implement changes on the US Military using only military threat as your risk and cost reduction as your benefit, our military could easily be reduced to about 1/8 of the size it is today (No more super power threat from Communists).  Of course, common sense tells us we shouldn't do that for various other reasons.  My point being: always be cautious of deceptively simple risk benefit analysis.  In other words, sometimes you have to use common sense to see past the black and white and interpret the grey.


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## MMiz (Jun 21, 2008)

While it wouldn't make sense for me to have the skill, with ALS only a five minutes away (max), couldn't it be a useful skill in a rural setting?


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## Chiron (Jun 21, 2008)

With respect to others, I absolutely agree that proper training is required, but come on its not really that difficult of a skill to master. we all had to start somewhere, not a single one of us was born into emergency medicine knowing anything without first being trained.

If you look back into our own not to distant past this same topic was being hotly debated among the medical elite as to allowing Paramedics to intubate. It is a foundational skill and if a Basic can be trained to meet the standard then I say good on em'. If I were the one who was down and my only options were an ineffective BLS airway or allowing a Basic to tube me then I'd pick the Basic placing the tube.

Just my 2c. But then again who am I..... Just a street medic with 10yrs experience, a nobody you've never heard of me.


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## VentMedic (Jun 21, 2008)

Where would they get their live intubation skills training?  Hospitals are becoming more and more reluctant to allow Paramedics to perform the skill in their ORs and EDs.  

What type of patient?   Any patient that is not pulseless may need meds to facilitate intubation.  

What about competency and proficiency quality control?

How prepared will they be to alleviate the complications caused by direct trachea intubation or attempts?


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## MSDeltaFlt (Jun 21, 2008)

Chiron said:


> I think they are teaching ET placement to our Basics here in Ohio. I cant see why they wouldn't, *no airway no Pt.* just seems like common sense.



Define "airway".  By definition in my Taber's 17th edition medical dictionary, an "airway" is defined as a natural path from the air to your lungs.  That's it.  It doesn't say ETT, Combitube, it dosen't even say OPA.  A lot of people tend to forget that, I think.

Besides, if you go by the new AHA algorithm, intubation is a bit further down the line, and they don't want you to stop chest compressions.


http://www.acls.net/acls2005/vfpvt.htm


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## Ridryder911 (Jun 21, 2008)

Hmm.. let's look at it this way, Paramedics are sucking at intubation. Now would you consider a Basic without any real knowledge of anatomy and definitely no in-depth knowledge of airway control to perform this procedure?

Again, one should not base procedures on the "ease" of a skill, heck removing an appendix is a breeze.. but, would you want just anyone to do it?.. Knowledge of the indications, procedures attaining to why, the etiology of disease process of why your intubating, and well as being able to control or fix things if a mishap during the procedure if it should occur. 

R/r 911


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## JPINFV (Jun 21, 2008)

No... just. no. A 110 hour training course with an entire 2 hours of anatomy and physiology should not be enough to go around putting tubes into people's tracheas.


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## Jeremy89 (Jun 21, 2008)

I think if one has had proper anatomy classes (such as A&P for Nursing students like myself) then they should be allowed to do so.  I agree, the Brady book has a sucky chapter for ALS assist skills...


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## JPINFV (Jun 21, 2008)

Jeremy89 said:


> I think if one has had proper anatomy classes (such as A&P for Nursing students like myself) then they should be allowed to do so.  I agree, the Brady book has a sucky chapter for ALS assist skills...



Is "ALS assist skills" really that complicated? It shouldn't take longer than a few minutes to teach just about anyone how to prime IV tubing or place electrodes.


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## Guardian (Jun 21, 2008)

MMiz said:


> While it wouldn't make sense for me to have the skill, with ALS only a five minutes away (max), couldn't it be a useful skill in a rural setting?



I think there are always extreme situations that require unconventional courses of action.  So, maybe it could be done in some rare situations.  But in general, I think it’s a bad idea and moves the profession backwards.

I would suggest that anyone wanting to promote this as an emt-b skill, should get their paramedic cert.  Then, work as a paramedic for a while.  Then come on here and promote the idea of emts intubating.  I could almost guarantee you would have changed your mind by then.  On that note, any paramedics on here in favor of giving emts this skill?


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## daedalus (Jun 21, 2008)

I wouldn't be against it should the EMT curriculum be expanded. The only case I see permissible would be both pulse-less and apenic. But again only when the BLS level becomes more...educated and less arrogant.


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## DBieniek (Jun 21, 2008)

It is BLS in some states/per the national standards...

When I run on the squad in Ohio (as I frequently do), I can intubate using an ET tube as an EMT-basic.


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## ccfems540 (Jun 22, 2008)

I agree with Rid.  Ekg interpretation and defibriallation are also easy skills to acquire.  With a quick pharmacology and intubation class, which aren't that difficult, a basic could perform as a paramedic.  Sounds kind of silly doesn't it.  It is not just the skill, but all the background knowledge that is needed to make a procedure safe for one to perform.  I am not knocking basic EMT's, I was once one.  If you want to perform advanced procedures, you need to have a great understanding of anatomy and physiology as well as all the contraindications/complications and resolution of problems that may result from them.  This is just not taught in basic EMT school.


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## firemedic31075 (Jun 22, 2008)

> Hmm.. let's look at it this way, Paramedics are sucking at intubation. Now would you consider a Basic without any real knowledge of anatomy and definitely no in-depth knowledge of airway control to perform this procedure?
> 
> Again, one should not base procedures on the "ease" of a skill, heck removing an appendix is a breeze.. but, would you want just anyone to do it?.. Knowledge of the indications, procedures attaining to why, the etiology of disease process of why your intubating, and well as being able to control or fix things if a mishap during the procedure if it should occur.



I agree with you except for saying paramedics suck at intubating. Yes there are medics out there that truely do suck, but intubating in the field most of the time is difficult at best. In the back of a rescue car driving 50 mph down the road and hitting every bump possible or the 350 lb code or OD found in the bathroom naked and lodged between the toilet and the bath tub in a house with barely any light. Intubating in the the hospital is quite a different experience as you know. But seeing how medics have a tough time with intubation even with the schooling and understanding I would not want an EMT-B performing that skill with no real understanding of what their doing or consequences of, and no ability to fix certain complications of intubation...bradycardia, laryngospasm, ICP etc.


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## VentMedic (Jun 22, 2008)

firemedic31075 said:


> I agree with you except for saying paramedics suck at intubating. Yes there are medics out there that truely do suck, but intubating in the field most of the time is difficult at best. In the back of a rescue car driving 50 mph down the road and hitting every bump possible or the 350 lb code or OD found in the bathroom naked and lodged between the toilet and the bath tub in a house with barely any light. Intubating in the the hospital is quite a different experience as you know. But seeing how medics have a tough time with intubation even with the schooling and understanding I would not want an EMT-B performing that skill with no real understanding of what their doing or consequences of, and no ability to fix certain complications of intubation...bradycardia, laryngospasm, ICP etc.



But, many of the schools that require only 700 hours of training or the career schools have limited intubation training facilities.  5 intubations in the OR does not constitute enough experience and the paramedic is set up to fail in the field.  Thus, probably by the standards of other professionals in the hospital who are called to do regular and difficult intubations, the paramedic, by far, lacks in the necessary skills and education for intubation from the very beginning.  Do you know how many intubations a CRNA or RRT must do before they are given their competency cert?  And that is for a relatively controlled environment.  A NICU RRT and/or RN may need 100 intubations to even be eligible for the transport team.  There's no margin of error or excuses for them when they are called to pick up a sick baby in need of an airway. 

How many Paramedics actually know they are going to have a difficult time or identify the problems prior to inserting the blade?

Now, the EMT-B will have even less of the few advantages of the paramedic.  I believe someone posted on another thread the requirements for the EMT-B intubation cert.  It read something like "3 attempts".


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## Jon (Jun 22, 2008)

So... those of you saying medics don't often make airway errors:

Have you read any of Dr. Wang's stuff? I don't really agree with all of what he says... but he's got some points. Here are a few articles found with Google:
http://content.healthaffairs.org/cgi/content/abstract/25/2/501
http://lib.bioinfo.pl/pmid:17597255


I think that BLS providers using the Combitube or the King LTD would be a good idea. LA County has had issues with their paramedics not getting enough tubes to be proficient... it would be worse if the EMT's were trying to get tubes too.


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## MedicineMan975 (Jun 23, 2008)

*Post du jour*

Talking as a newbie medic, I feel that the limited exposure to client's actually requiring advanced airway adjunct's plays a major part in the decreased proficiency. I mean come on, I know of times where there may be a total of 4-5 clients who require intubation in an entire month. That's for the service as a whole! I mean come on, repetition does a good provider make. And considering the fact that most calls are BLS at best, it's easy to see why missed placement's occur. Now, as for the whole letting EMT-Basics perform intubation, I'm going to have to say no for a couple of reasons:


By allowing Basics to perform advanced airway procedures, you would have to end up throwing the baby out with the bath water. What I mean to say is, if you're going to teach one advanced life support skill you would eventually have to teach them all. The possible complications associated with endotracheal intubation alone require additional pharmacological,  invasive and  advanced cardiac skills/knowledge to properly correct them. So in essence, you would require in depth knowledge of A&P, pathophysiology, pharmacology, cardiology, AND pulmonology just to perform a "simple" procedure. Yeah, it's "easy" to slip a tube. But what do you do when it hits the fan as a result? (Here's a link to a PDF on intubation and possible complications http://medind.nic.in/iad/t05/i4/iadt05i4p308.pdf)
Like my boy MSDletaFLT said, intubation is down the line in the AHA protocols. Compressions are king right now and all new research in indicate that in the absence of defibrillation, compressions save lives a darn sight quicker than an ETT will.


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## DBieniek (Jun 23, 2008)

I understand what you all are saying, and truth be told I don't disagree with you! 

Typically when someone needs intubated they are to the point where a lack of action would do more harm. If someone is pulseless/apneic then they are at a critical low point. If you are unable to establish an airway, they will remain at this critical low point. Attempting to intubate them isn't going to hurt them, but it may help them.


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## VentMedic (Jun 23, 2008)

DBieniek said:


> I understand what you all are saying, and truth be told I don't disagree with you!
> 
> Typically when someone needs intubated they are to the point where a lack of action would do more harm. If someone is pulseless/apneic then they are at a critical low point. If you are unable to establish an airway, they will remain at this critical low point. *Attempting to intubate them isn't going to hurt them*, but it may help them.



Say what?!

There are other devices such as the King that can be also be used that requires less skill maintenance.   Although, that is not to say one should not practice the technique with the King many times at many different times.    

With ETI, any damage you could do with just the blade insertion can blow your one and only shot at any airway including the BVM in the field by even the ALS team. 

Proficiency with the BVM is your best friend. Even in the hospital we may not dive into intubation for a code or any other situation until the right person and the right equipment are at hand for the job.  Outside of facial trauma, there have been very few patients that I have not been able to provide some ventilation/oxygenation to with a BVM over the past 30 years.


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## reaper (Jun 24, 2008)

When I came to SC I couldn't believe that they let B's intubate. I told them right away that it would not happen on a truck I was on. Well, what do you know, not 3 weeks later they put out a memo stating the state had revoked intubation for EMT-B's.

 Like was said before. Medics don't get enough intubations, to keep proficient. What makes anyone think that an EMT would?

 I understand the EMT's wanting to do everything they can to help a pt. If that is you, the best thing you can do to help a pt is go to medic school. This way you are learning everything you need to know, not just bits and pieces.


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## Epi-do (Jun 24, 2008)

Anyone can be taught to do a _skill_, but having the training to understand the _prodcedure_ is what differentiates ALS from BLS.  Can you teach an EMT-B to intubate?  Sure, but you could also teach a monkey how to go through the motions of the _skill_.  Understanding the _procedure_ of intubation comes with the increased education and knowledge. 

Before doing any invasive procedure, one should know the indications, contraindications, expected outcome, complications (and how to manage them), as well as anatomy & physiology pertaining to the issue at hand.  I am sorry, but the majority of EMT-B classes do not contain the information needed to safely and effectively perform any procedure.  Heck, I don't think my medic class has provided me with all the information I am going to need to be a good medic.  I do feel as if I have been given a good foundation to build from, but it is up to me to continue to learn.  That is part of what makes this such a dynamic profession.  So many things are constantly changing as new discoveries are being mad in medicine.  Every day studies show findings of things we are doing well, things we are doing not so well, and things that could potentially revolutionize how patients are treated.  Hence, the title practitioner - the more we learn, the more there is to practice, the more there is to learn.


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## Ridryder911 (Jun 24, 2008)

Epi-do said:


> Anyone can be taught to do a _skill_, but having the training to understand the _prodcedure_ is what differentiates ALS from BLS.  Can you teach an EMT-B to intubate?  Sure, but you could also teach a monkey how to go through the motions of the _skill_.  Understanding the _procedure_ of intubation comes with the increased education and knowledge.
> 
> Before doing any invasive procedure, one should know the indications, contraindications, expected outcome, complications (and how to manage them), as well as anatomy & physiology pertaining to the issue at hand.  I am sorry, but the majority of EMT-B classes do not contain the information needed to safely and effectively perform any procedure.  Heck, I don't think my medic class has provided me with all the information I am going to need to be a good medic.  I do feel as if I have been given a good foundation to build from, but it is up to me to continue to learn.  That is part of what makes this such a dynamic profession.  So many things are constantly changing as new discoveries are being mad in medicine.  Every day studies show findings of things we are doing well, things we are doing not so well, and things that could potentially revolutionize how patients are treated.  Hence, the title practitioner - the more we learn, the more there is to practice, the more there is to learn.



Wow! I think I have seen this somewhere before  .. Epi  over the past years, I have seen you mature more in thoughts and methodologies of true medicine... good going! 


R/r 911


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## Epi-do (Jun 24, 2008)

Gee, thanks Rid!


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## CFRBryan347768 (Jun 24, 2008)




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## Ops Paramedic (Jun 25, 2008)

Got here a bit late, and not a lot left to say, except for maybe enhancing the the point.

I can take a newspaper vendor off the side of the road and teach him how to intubate in not even 10 minutes.  Does this now allow him to do so in future??  The most difficuilt aspect of intubation is not placing the tube itself, but deciding when to do it.  At one of our country's largest training hospitals, it is often said that: "see one, do one, teach one", with regards to skills, such as placing chestdrains and urine catheters, but funny enough when it comes to intubating a patient, the skill is reserved soley for the dr...

Yes, there clear indications for intubations, but how many patients fit these criteria 100%.  Many times you will have to make an EDUCATED decision as to intubate or not, as it can be benefical or detremental at times.  Hence, as mention, you need indepth knowledge of A & P, pharmacology (and the licsense to use the medication), Diagnostic skills, having the ability to perform other procedures should you fail, increased exposure and experience of palcing tubes (supervised and unsupervised), etc.

I firmly believe that this an advanced skill/procedure in totality, and should remain as such.


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## wolfwyndd (Jun 25, 2008)

MMiz said:


> A month or so ago I flew back home to get some pratical CEUs for my EMT-Basic renewal, and the instructor, like almost all EMT classes, finished hours early.  Because he couldn't let us out five hours early, he got out the intubation supplies and gave us a quick tutorial on intubating an adult.
> 
> I won't say that I was a pro by any means, as dropping a tube down Annie's throat isn't quite like the real world, but it got me thinking as to whether it should be incorporated into the BLS curriculum.
> 
> ...


I think this thread goes right up there with the 'lights and siren on POV = whacker' thread.

Intubation is a NREMT-B skill.  Personally, despite all the arguments against,  I see now reason why a basic shouldn't be allowed to intubate a pt. as long as their local protocol allows it.


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## tazman7 (Jun 25, 2008)

If emt's want to learn how to do als procedures then they can spend the time going to medic school instead of going to a bs one semester basic class.  Just like others have said, you need to learn the anatomy part before you attempt to shove a laryngoscope in someones mouth.

Thats what the combitube and king airways are for...

As long as you are getting good chest rise with a bvm the only benefit to having an et tube in, is what? To only use 1 hand instead of 2 and to secure the airway from aspiration


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## wolfie23b (Jun 25, 2008)

*Combi ok in Ok*

Here in Oklahoma I think they just released protocols for Basics to drop Combi tubes, an ET is considered invasive and for some reason the combitube isn't.


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## wolfie23b (Jun 25, 2008)

I am a paramedic student and to be honest if a basic is competent enough then why not let them drop an ET.  Its really not that big a deal and paramedics who forget that the basic and medic are a team and the medic cannot do his/her job without a competent basic needs to retrained and remember that its BLS b4 ALS.


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## mikeylikesit (Jun 25, 2008)

wolfie23b said:


> I am a paramedic student and to be honest if a basic is competent enough then why not let them drop an ET. Its really not that big a deal and paramedics who forget that the basic and medic are a team and the medic cannot do his/her job without a competent basic needs to retrained and remember that its BLS b4 ALS.


skill competency is one thing but actually knowing where the tube is and where it is going is another. If all intubation's were easy then...yes why not. but in prehospital especially hospital settings this is in fact a rarity. say i am taking care of a patient and them EMT stimulates or create a sudden airway problem...now i have to not only deal with what i was doing but also what i have to fix on their behalf.


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## triemal04 (Jun 25, 2008)

wolfie23b said:


> I am a paramedic student and to be honest if a basic is competent enough then why not let them drop an ET.  Its really not that big a deal and paramedics who forget that the basic and medic are a team and the medic cannot do his/her job without a competent basic needs to retrained and remember that its BLS b4 ALS.


Have you performed any intubations on live people yet?
Have you performed any intubations on live people in the field yet?
Have you been fully educated on when to intubate, why to intubate, this risks associated with it, the complications that may arise, how to fix the complications, how to avoid them, when not to intubate, how to judge the difficulty of an intubation before attempting it, and what you will do if intubation is impossible yet?
When you are able to answer yes to all those questions I'll be curious to hear if your answer changes. 

And I actually function just fine without a basic, competant or otherwise.


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## VentMedic (Jun 25, 2008)

wolfie23b said:


> I am a paramedic student and to be honest if a basic is competent enough then why not *let them drop an ET*.



How many intubations and on who or what will you need to maintain that competency?   

http://www.jems.com/news_and_articles/columns/Rodenberg/How_Much_Training_Is_Enough.html

Are you talking about EMT-Bs intubating only the pulseless "dead" patients as a few states do or are you wanting to intubate everybody?




wolfie23b said:


> Its really *not that big a deal* and paramedics who forget that the basic and medic are a team and the medic cannot do his/her job without a competent basic needs to retrained and remember that its *BLS b4 ALS*.



Not that big of a deal?  It is considered a big deal every time someone gets intubated in the field because that is a very serious situation.  Even for those that get intubated for minor procedures in the hospital under controlled settings are fully informed of all the things that can happen with intubation.

Can you start an IV started?
Can you give any type of sedation?
Can you give cardiac meds to fix any arrhythmias you cause?
Can you do a cric?  

Have you ever talked to a patient that has had an awake intubation?  They will tell you that is one of the most uncomfortably painful and suffocating experiences of their life.   To put a patient through that needlessly because you are not trained, educated or certifed to do anything to prevent that much physical and emotional trauma on a patient in addition to whatever else is going on medically is just inhuman.


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## JPINFV (Jun 25, 2008)

wolfie23b said:


> I am a paramedic student and to be honest if a basic is competent enough then why not let them drop an ET.  Its really not that big a deal and paramedics who forget that the basic and medic are a team and the medic cannot do his/her job without a competent basic needs to retrained and remember that its BLS b4 ALS.



"BLS before ALS" is just about as self serving cliche as any cliche is. What exactly does an basic bring to the table that a paramedic doesn't? Besides that, who gets to decide which basics are smart enough to start placing ET tubes? A 110 hour course is not going to make anyone competent to start placing ET tubes.


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## MSDeltaFlt (Jun 25, 2008)

JPINFV said:


> "BLS before ALS" is just about as self serving cliche as any cliche is. What exactly does an basic bring to the table that a paramedic doesn't? Besides that, who gets to decide which basics are smart enough to start placing ET tubes? A 110 hour course is not going to make anyone competent to start placing ET tubes.



It takes 2 minds to do one task or one skill.  Your partner, at whatever level, needs to have common sense.  That being said, medics are the lowest level of provider that should be able to intubate.


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## VentMedic (Jun 25, 2008)

There are also the questions that will arise from a failed intubation, a poor outcome or the damage that is done during intubation.

Our ED (teaching hospital) is fortunate to have RRTs in the ED who have fairly immediate access to a video-bronchoscopy cart if a particularly bad intubation attempt arrives.  We literally have dozens of videos of every imaginable complication.   After the Paramedics present their information, the physicians (ED and another specialist) will review the information and videotape.   Many times it will be agreed that everything within the scope of the Paramedic was done correctly and the doctors will stick by that if a lawsuit occurs.   There have been a few botched intubations where that may not always be the case.  

What defense can the doctors present on the EMT-B's behalf?  
Did they have enough proven competencies and live intubations prior to the intubation in question?
Did they assess a difficulty score prior to intubation and adjust accordingly?
Did they adequately sedate?
Was RSI available to them? 
Did they perform preventive measures for aspiration?
Did they do corrective measures after the failed intubation?
Did they utilize capnography?

The above is not even scratching the surface of questions one will encounter in a room of attorneys.


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## DBieniek (Jun 26, 2008)

Okay, and that's perfectly fine. I respect your opinion as a paramedic. However, I follow the protocols set by my squad medical director who just so happens to be an MD that doesn't have any issues with it.^_^


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## VentMedic (Jun 26, 2008)

DBieniek said:


> Okay, and that's perfectly fine. I respect your opinion as a paramedic. However, I follow the protocols set by my squad medical director who just so happens to be an MD that doesn't have any issues with it.^_^



One more time...

By your protocols, are you intubating *only* the pulseless patient that is a "code"?   Or, a patient that could also tolerate a King or Combitube in respect to absent gag?


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## mikeylikesit (Jun 26, 2008)

VentMedic said:


> One more time...
> 
> By your protocols, are you intubating *only* the pulseless patient that is a "code"? Or, a patient that could also tolerate a King or Combitube in respect to absent gag?


And Vent's opinion is more than just from a paramedic...RRT Registered Respiratory Therapist.


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## Ridryder911 (Jun 26, 2008)

wolfie23b said:


> I am a paramedic student and to be honest if a basic is competent enough then why not let them drop an ET.  Its really not that big a deal and paramedics who forget that the basic and medic are a team and the medic cannot do his/her job without a competent basic needs to retrained and remember that its BLS b4 ALS.



Spoken just a like an individual that does not understand medicine. Show me a Paramedic that forgets the so called "basics" and I will show you ten Basics that can't find their way home.. C'mon, do you really, really think anyone would forget anything so simple as the basics... duh! That is why they are called such!.... Do you forget the "basics", why would a Paramedic forget because they have learned more? So this means when a Basic forgets the basic, they do nothing?

Besides there is *NO SUCH THING AS BASIC or ADVANCED!!* Rather there is full care or inadequate care.!


R/r 911


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## VentMedic (Jun 26, 2008)

Yeah, and I also work for a couple of medical directors who also have MD behind their name.  They prefer the people they are overseeing have the best possible education, training, access/experience to alternative equipment and abilities to keep them (the providers AND the MDs) from answering the questions from my previous post in front of administrators and attorneys.

We don't take intubation lightly.  One should  respect it as a lifesaving skill but also know it can cause death and disability.   It should not be viewed with the attitude of "just another skill because I can".

How many times has your Medical Director personally seen you intubate a live patient?  Or personally checked any of your competencies?

Regardless of one's title, be it RRT, MD, DO, NP, PA or RN, they do not get intubation privileges easily at our hospitals.  The same for Flight and CCT.   They must repeated show their knowledge and skills.


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## wolfie23b (Jun 26, 2008)

I have done plenty of Intubations, "What happens in the back of a rig, stays in the back of the rig."  You may operate just fine w/o a basic emt in YOUR rig but a paramedic that forgets the value of a competent basic is a paramedic that is gonna get someone hurt.  The Basic is what rminds the Paragod that IT ALL STARTS WITH BLS.  And too many paramedics, or shall I say "Paragods" seem to jump straight to their cool machines and drugs b4 they do the simple tasks.  Treat the Pt not the monitor.


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## wolfie23b (Jun 26, 2008)

your posts have always gotten me up in arms because its RN's like you that think they no everything there is to know.  There are plenty of PARAGODS out there and they don't belong on MY rig.


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## VentMedic (Jun 26, 2008)

wolfie23b said:


> your posts have always gotten me up in arms because its RN's like you that think they no everything there is to know.  There are plenty of PARAGODS out there and they don't belong on MY rig.



*First*
I am not an RN.
That was even spelled out in a previous post by mikeylikesit.

*Second * 

What's with the attitude about Paragods and no EMT or EMT-Ps in the back of the truck?  This thread  is about competency for intubation. 

*Third* 


> "What happens in the back of a rig, stays in the back of the rig."



That comment has no business being in your vocabulary.  For one it will give anyone, layperson or other HCWs, the WRONG impression about your competency and will start to question your   charting.  Your partner may not be as willing to lie for you as you think especially if it also jeopardizes their license.

It is very easy to do a direct visualization to determine how much damage is done by intubation.  Of course, when the patient is extubated and has no vocal cord function, that also is a good indicator that things may not have gone smoothly. 

*Fourth*


> *drugs b4 they do the simple tasks*.



This statement definitely indicates that you have little understanding about intubation.


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## wolfie23b (Jun 26, 2008)

i won't dignify with a response, I know my skills and  know that I for one can do the skill at hand.  I also know that a combi tube can do just as much damage and basics in my state are getting the ok to do those so what is reall the difference.  I do not beleive that any part of my comment was out of line or that it can be mis construde about my skills.  I graduate Paramedic scool in a couple of weeks and I am a very competent medic.  I have been a basic since 1992 and Loved every bit of it, and still learn something new everyday.


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## VentMedic (Jun 26, 2008)

wolfie23b said:


> i  I graduate Paramedic scool in a couple of weeks and I am a very competent medic.



None of your remarks so far have indicated any advanced training or education.   You will continue to use the skills you practiced as an EMT but you will also have to assess and treat at a higher level as a Paramedic.  

Are the Paramedics in your area not allowed to premedicate with anything prior to intubation, or after, if the patient is even somewhat awake?   Was this not covered at all in Paramedic school?   

For clarification, I am not talking about RSI.

I see nothing wrong or "Paragod" about being concerned for patient safety and ensuring the best possible care has been provided.


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## JPINFV (Jun 26, 2008)

wolfie23b said:


> I have done plenty of Intubations, "What happens in the back of a rig, stays in the back of the rig."  You may operate just fine w/o a basic emt in YOUR rig but a paramedic that forgets the value of a competent basic is a paramedic that is gonna get someone hurt.  The Basic is what rminds the Paragod that IT ALL STARTS WITH BLS.  And too many paramedics, or shall I say "Paragods" seem to jump straight to their cool machines and drugs b4 they do the simple tasks.  Treat the Pt not the monitor.



Holy cliche Batman!

1. Your patient does not stay in the back of your ambulance. That patient represents your care and the quality of that work. Therefore, your performance most definitely does not stay in your unit. 

2. It all starts with patient care. An EMT-Paramedic who fails at delivering the basics of patient care will fail regardless of who else is in the back of the unit. It does not matter who is or isn't in the back of the unit and has absolutely nothing to do with EMT-Basics. A provider's education should be what's reminding them of basic care.

3. Who reminds a physician to provide basic patient care? As an alternative, are you just insinuating that all paramedics are idiots? 

4. Sorry, but not all patients follow a continuum that goes from basic procedures to advanced procedures. Some patients need advanced procedures immediately.


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## Ridryder911 (Jun 26, 2008)

wolfie23b said:


> i won't dignify with a response, I know my skills and  know that I for one can do the skill at hand.  I also know that a combi tube can do just as much damage and basics in my state are getting the ok to do those so what is *reall* the difference.  I do not* beleive* that any part of my comment was out of line or that it can be *mis construde* about my skills.  I graduate Paramedic *scool* in a couple of weeks and I am a very competent medic.  I have been a basic since 1992 and Loved every bit of it, and still learn something new everyday.


 
Are you really sure about what you say? Do I see you at the EMSAC, ORSAC and State EMS Advisory Meetings or are you just the typical EMT that shows up for work and do whatever is allowed at the time? As well are you sure about comments you made the combitube, or are you just pulling this and other stuff from your arse? Please back it up with citations and references of medical literature, otherwise it's just ignorant rambling.  

You might be graduating from Paramedic *school* in a couple of weeks ( I would like to know from where?) but you still can't even spell it ? C'mon!  



R/r 911


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## Ridryder911 (Jun 26, 2008)

wolfie23b said:


> your posts have always gotten me up in arms because its RN's like you that think they no everything there is to know.  There are plenty of PARAGODS out there and they don't belong on MY rig.



Just remember, it is Paragods and RN's like me that wrote your legislation for a license to work, as well a Paragod & RN that wrote the trauma diversion to allow patient to be taken the *most appropriate* facility instead of the nearest which cost needless deaths, as well as developing the regulations and establishing Trauma Centers in OK. 

As well it is the RN & Paragods that continue to fight for you to have death & injury benefits in your state and funding for your EMS to function..to be able to be in that so called "rig"..... 

It as well those you would love to be able to work with on a helicopter or in that " rig " with... and will either hire you or not....

So from one of those, your welcomed. 

R/r 911


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## BEorP (Jun 26, 2008)

I can't even believe this thread... I may save the link for anyone who asks why American EMS will never reach the level of professionalism that is generally seen in Ontario.


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## mikeylikesit (Jun 26, 2008)

BEorP said:


> I can't even believe this thread... I may save the link for anyone who asks why American EMS will never reach the level of professionalism that is generally seen in Ontario.


LOL, oh no just see the EMT education and Do we need EMT posts.


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## Ridryder911 (Jun 26, 2008)

BEorP said:


> I can't even believe this thread... I may save the link for anyone who asks why American EMS will never reach the level of professionalism that is generally seen in Ontario.



I do wished we required the same entry and educational requirements. If we did we would not have a Paramedic course taught at a trade school, and most would be able to understand general medicine as well have a literacy rate level above the elementary level. 

As well, I assume that most of your fellow Countrymen understands the local and regional laws and regulations. I have seen and discussed the difference with many from Canada and do wish we could implement similar requirements and standards.

R/r 911


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## Ridryder911 (Jun 26, 2008)

I want to apologize for my blasting on my previous posts. Not excusable but I have just spent most of the day fighting for raises for EMS personnel. I have been describing how we are educated and it is only justifiable to have professionals to be paid as such.. 

It is hard to make a point to only to be proved wrong.. 

R/r 911


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## reaper (Jun 26, 2008)

wolfie23b said:


> I have done plenty of Intubations, "What happens in the back of a rig, stays in the back of the rig."  You may operate just fine w/o a basic emt in YOUR rig but a paramedic that forgets the value of a competent basic is a paramedic that is gonna get someone hurt.  The Basic is what rminds the Paragod that IT ALL STARTS WITH BLS.  And too many paramedics, or shall I say "Paragods" seem to jump straight to their cool machines and drugs b4 they do the simple tasks.  Treat the Pt not the monitor.



You have not even started working as a medic and you have this attitude already? You have not even come close to doing ENOUGH intubations, to understand what most are talking about. You need to step back and keep learning from those that have the experience. Once you think you are good enough, it will all go down hill from there!!


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## Ridryder911 (Jun 26, 2008)

wolfwyndd said:


> Intubation is a NREMT-B skill.



Just a clarification.. Intubation is NOT a NREMT-B skill nor an NREMT-I (89) skill. Some states do add intubation to their respective certifications or license levels, however; this is NOT an NREMT guideline. 

R/r 911


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## Jon (Jun 26, 2008)

Ridryder911 said:


> Just a clarification.. Intubation is NOT a NREMT-B skill nor an NREMT-I (89) skill. Some states do add intubation to their respective certifications or license levels, however; this is NOT an NREMT guideline.
> 
> R/r 911


Time out - so why was it in the back of my EMT-B text as an "optional module"... I thought that was what the national standard had it as.


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## traumateam1 (Jun 26, 2008)

To answer the question, yes I think that an ET Tube, or intubation is ALS.


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## mikeylikesit (Jun 26, 2008)

Jon said:


> Time out - so why was it in the back of my EMT-B text as an "optional module"... I thought that was what the national standard had it as.


It shouls have only included the combitubbe in the Brady books that i assume your talking about.


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## Ridryder911 (Jun 26, 2008)

Jon said:


> Time out - so why was it in the back of my EMT-B text as an "optional module"... I thought that was what the national standard had it as.



Optional module is the key.. meaning not in the standard curriculum. NREMT has never endorsed EMT Basics to intubate nor even the standard Intermediate level. Their experts agree as well, it is a skill far more advanced that is in the curriculum. ETI is only endorsed by the NREMT level as EMT/I -99 and EMT/Paramedic level. The States may supersede and test while performing the NREMT examination, and be testing for their own state level requirement. Alike mine does.. Intermediate can intubate here, so one tests while getting evaluated for the NREMT. 

There are so many myths about what is in NREMT and the curriculum. Again, I suggest that anyone that has problems sleeping read a few pages of the curriculum outline and NREMT by-laws and educational standards for testing. It will make a good sleep enhancer.. 

R/r 911


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## wolfie23b (Jun 26, 2008)

Ridryder911,
I apologize for the fact that I shot in here talking about the "Paragods", it is only that I am educated, and a competent basic, and pride myself in my quality of work that my Paramedic partner enjoys, why, because I can either interpret her every move or I already have what she needs ready for her.  I worked a shift the other day without my normal partner and he treated me like I was "Just a Basic" and that I wouldn't know an ET tube from a OPA.  He literally told me that because he is the Paramedic that I am below him and don't belong in the back of an ambulance.  I am a 68 Whiskey in the Oklahoma Army National Guard, ad recieved a Combat Medic Badge for actions that saved 3 of my comrades lives in Baghdad.  I think I deserve a little more respect then that.


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## Ridryder911 (Jun 26, 2008)

wolfie23b said:


> Ridryder911,
> I apologize for the fact that I shot in here talking about the "Paragods", it is only that I am educated, and a competent basic, and pride myself in my quality of work that my Paramedic partner enjoys, why, because I can either interpret her every move or I already what she needs ready for her.  I worked a shift the other day without my normal partner and he treated me like I was "Just a Basic" and that I wouldn't know an ET tube from a OPA.  He literally told me that because he is the Paramedic that I am below him and don't belong in the back of an ambulance.  I am a 68 Whiskey in the Oklahoma Army National Guard, ad recieved a Combat Medic Badge for actions that saved 3 of my comrades lives in Baghdad.  I think I deserve a little more respect then that.




I honor your position, but that does not gather automatic respect in the medical profession. I have worked along and seen many combat medics.. some are the most outstanding heroic and best medics I have ever seen, some I wonder how they ever 
stayed alive, even more so to keep somebody else alive.. some of those even being awarded heroic citations. 

Again, I honor you as a citizen for what you did over there, but in civilian terms military/combat medicine is a specialty medicine. The same as gerontology, pediatrics, etc.. You maybe great at implosion injuries, and be able to crich a 25 year old under fire, but that does not help granny with an inferior wall AMI. Again, that is not intended to be disrespectful. Just the truth. The reason I do not believe in "blanket cert" for military that many are trying to legislate. 

Maybe your partner was not being diplomatic or even being an arse.. (yes, there are plenty out there on all levels, who knows?} Do I agree that an EMT should not be in the back... yes if it is a true medical emergency patient. One does not hand off from a RN to nurse aide..the same should be said about Paramedic to EMT..  

I believe or hope you will see a much difference after you start practicing as a Paramedic. When it is * your * license on what happens. It will be *you* that will get sued and loose *your* license when that other person intubated and broke the teeth & did not have a license to do so.. One starts having a much different idea and feeling.. Believe it or not, my attitude was a lot different several years ago.. then I started becoming more familiar and educated more in depth of EMS and more in emergency medicine.. not just EMT. Again, not that they do not have a place or should be disrespected..rather that their roles and education do not meet the expectations of today's requirements of emergency care. 

Again, welcome home.. and thanks.. 

p.s. I have a fellow Paramedic that had been instructing some of your division ?, I believe at Camp Gruber...

R/r 911


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## mikeylikesit (Jun 26, 2008)

wolfie23b said:


> Ridryder911,
> I apologize for the fact that I shot in here talking about the "Paragods", it is only that I am educated, and a competent basic, and pride myself in my quality of work that my Paramedic partner enjoys, why, because I can either interpret her every move or I already have what she needs ready for her. I worked a shift the other day without my normal partner and he treated me like I was "Just a Basic" and that I wouldn't know an ET tube from a OPA. He literally told me that because he is the Paramedic that I am below him and don't belong in the back of an ambulance. I am a 68 Whiskey in the Oklahoma Army National Guard, ad recieved a Combat Medic Badge for actions that saved 3 of my comrades lives in Baghdad. I think I deserve a little more respect then that.


Well as a Whiskey you once were a Paragod yourself. the difference is that in the Military you wouldn't ever catch one of your fellow colleague talking down to you...if they did your unit would have something to say about it.


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## wolfie23b (Jun 26, 2008)

ridryder,  When was your paramedic friend there.  I wasn't pre-mobilized in Gruber but I know some that were.


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## mycrofft (Jun 27, 2008)

*This discussion shows a weakness in EMS at all levels:*

Itching to be able to do one more trick, technic, thingee.
On one hand, you can always bring up a limitless array of "what-if's" to try to support getting another thingee.

On the other hand, considering frequency of need, time to next higher level of care, how it will interfere with that next level, and time element of pt need, how much stuff do we hanker to do because it makes us feel better?

Try this measure : since you MUST know intubating (or other procedures/thingees) with real people is almost always much harder than the dummies, what can you bring to the table if your thingee goes to sh#t on you? Will you even recognize it? Some experienced para's will do better than third year medical students with no experience, and some para's, due to "target fixation", will fail to spot a botched attempt a bystander would see.

Know what your role in the big scheme is, and if you want to play with the neat thingees, get yourself to class and get some experience too, but do not cite class hours as certainty of proficiency. Be nice, we're all brethern and sisteren... .


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## mycrofft (Jun 27, 2008)

*PS Wolfie: Hooah!*

Mycrofft, former USAF 57150, 90270, then O-4 Nurse.


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## wolfie23b (Jun 27, 2008)

I am going to Paramedic SCHOOL at Oklahoma State.  I will have a Assoc. of Applied Science.  NOT A " Trade School".  Happy?


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## Ridryder911 (Jun 27, 2008)

wolfie23b said:


> I am going to Paramedic SCHOOL at Oklahoma State.  I will have a Assoc. of Applied Science.  NOT A " Trade School".  Happy?



So you will be graduating this fall or had graduated this spring? .. Since they usually do not have summer end sessions. Russ & Mike are personal friends of mine. In fact, statements of increasing the need of professional standards and education was heavily discussed by the three of us at the last State EMS Educators meeting held at the OSU/Safety Campus. 

Although, I cannot speak for them, I do believe I know the instructors well enough to say that would had never taught or endorse anyone to perform procedures before getting a license to do so. As well, I am glad you are correcting your postings per spelling and some grammar. Would you not agree, it kinda defeats the purpose of describing that one is educated if the posts are filled with misspelled words and very poor grammar? Again, just one representation of a way to demonstrate being educated, the other is to recognize your current limitations. 

By doing so, this is NOT being derogatory. Even though you have been in EMS for a while, you have just now reached a new level. So in reality, it is like starting over. Yes, you have some road experience, but no you do not have the Paramedic experience. Again, totally two different things. Something most lower levels do not and cannot understand. Many Paramedics realize this in the later part of their first year of being a Paramedic. After you and only you were responsible for that patient with conscious V-tach, or that difficult intubation and realizing others assisted and helped you; but it was you that was solely responsible for the procedures, the outcome and treatment of the patient. That anything good or screwed up was going to be solely on *your* shoulders. It is a humbling feeling, something that can only be recognized after being there. 

After you have been a Paramedic on a truly critical patient without any other ALS support members, I would then like to see your opinions to see if it remains the same. If you work at EMSA, you will probably never get to experience it to the full degree but will understand the jest of it. 

I wish you luck, and success in your career...

R/r 911


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## MasterIntubator (Jun 30, 2008)

http://www.emtlife.com/showthread.php?p=64545#post64545

I believe it should be an ALS skill by an experienced provider.  BLS should be hand selected based on experience and need to be personally trained by the OMD and known on a first name bases with the OMD if chosen to intubate.


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## alex71 (Jul 15, 2008)

i have signed up for a class in a few months titled defibrillation/combi tube , which would allow me to analyze rhythems and intubate, the class is 14 hours , and the only way they will allow you to practice your skills is if you are on an ALS rig for the county anyways, so i dont see it being any major problem since you have a trained and experienced medic literally 3 ft away shoul anything go wrong


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## Jeremy89 (Jul 15, 2008)

alex71 said:


> i have signed up for a class in a few months titled defibrillation/combi tube , which would allow me to analyze rhythems and intubate, the class is 14 hours , and the only way they will allow you to practice your skills is if you are on an ALS rig for the county anyways, so i dont see it being any major problem since you have a trained and experienced medic literally 3 ft away shoul anything go wrong



Slow down there Alex...  As far as I knew (and I did a lot of research, as I was once considering moving to California) the defib/combitube only touches on the AED, and obviously combitube.  You're right in saying you'll be able to intubate, but it will only be with a combitube and not an ET tube.  That takes much more education and skills than are provided in the defib/combitube class.

Maybe you're talking about a more advanced class, but this is just what I heard...

I just didn't want you to get excited over a fairly simple class 

Jeremy


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## alex71 (Jul 15, 2008)

im pretty sure you right haha, for some reason i thought this thread was about both . either way im still excited ill be able to provide more care than a opa or npa . my major concern is always not being able to provide some life saving intervention because i dont know how, so education is always number one on my list and always the most exciting and rewarding for me


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## WuLabsWuTecH (Jul 16, 2008)

It was mentioned that OTT isn't a NR standard, but out of curiosity, why were we (in Ohio) tested on NREMT Practical sheets for our intubation checkoff?

Also it was mentioned vocal cord paralaysis is a possibilitity, we learned that its more important to get a patent airway thna worry about vocal cords, if pt is not breathing and you can't get chest rise with BVM, you have to try intubation.  Also, if pt is choking with full blockage, you might be able to shove the obstruction into the right mainstem and at least get the left lung some air.  Worse case scenario, i know, but better than the alternative.


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## firecoins (Jul 16, 2008)

alex71 said:


> i have signed up for a class in a few months titled defibrillation/combi tube , which would allow me to analyze rhythems and intubate, the class is 14 hours , and the only way they will allow you to practice your skills is if you are on an ALS rig for the county anyways, so i dont see it being any major problem since you have a trained and experienced medic literally 3 ft away shoul anything go wrong



combitube in not intubation.


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## Sapphyre (Jul 16, 2008)

I dunno, Wu, but we didn't "sign off" ETT, or Combi at all.  We got to "play" with them, after a lecture and demonstration, for familiarization only.


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## WuLabsWuTecH (Jul 16, 2008)

Yeah, we had a signoff for combitube and another one for ETT.  That one was especially memorable since the there were so many points to get and the hwole sheet was filled with lines of points and critical criteria.

We had familiarization with LMA but no signoff.

Also with the other ALS skills like CPAP and 12 Lead EKG we didn't have NEMT sign offs but we had one for ETT for some reason.


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## VentMedic (Jul 16, 2008)

WuLabsWuTecH said:


> Also it was mentioned vocal cord paralaysis is a possibilitity, we learned that its more important to get a patent airway thna worry about vocal cords, if pt is not breathing and you can't get chest rise with BVM, you have to try intubation.  Also, if pt is choking with full blockage, you might be able to shove the obstruction into the right mainstem and at least get the left lung some air.  Worse case scenario, i know, but better than the alternative.



I hope this is not a justification for the minimal hours of training.  The indication in OH's protocols for EMT-Bs intubating is pulseless and apneic.    Not worrying about what damage is done is never accepted in other professions regardless of the situation.  You are trained and educated to the best of your ability to minimize any further complications that may also distract from the situation at hand and eventually decrease any chances of survival for the patient.  The excuse "it's an emergency" should not mean you perform sub par.  You do not skimp on your technique or skill and do things haphazardly.  Of course, this comes easier with adequate training and experience.   Accountability and monitoring quality of care is something EMS still has to accept within the profession as a whole. 

As far as the choking scenario, if the blockage is above the cords, I would hope a "skilled" provider has the good sense and training to  make a good attempt to remove it.   If the blockage is already past the cords and lodged in the trachea, then yes, pushing it through may be the only option besides a cric in the field.   

*My next question would be, are these EMT-Bs that intubate also trained to remove obstructions with the laryngoscope and Magill forceps?  * 

I know that is covered in at least one EMT Enhanced program but not covered in another because the intubation by laryngoscope is very specific in the protocols and forceps are not carried.  And then, you have it in the protocols for one service but not another for that same state.


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## mikeylikesit (Jul 16, 2008)

VentMedic said:


> *My next question would be, are these EMT-Bs that intubate also trained to remove obstructions with the laryngoscope and Magill forceps? *


 i have seen it in the ER since a Tech who was a Basic had the equipment and supervision to do so. My huge question was "why didn't the supervisor do it himself?" no no, not like it was an emergency.


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## Ridryder911 (Jul 16, 2008)

WuLabsWuTecH said:


> It was mentioned that OTT isn't a NR standard, but out of curiosity, why were we (in Ohio) tested on NREMT Practical sheets for our intubation checkoff?
> 
> Also it was mentioned vocal cord paralaysis is a possibilitity, we learned that its more important to get a patent airway thna worry about vocal cords, if pt is not breathing and you can't get chest rise with BVM, you have to try intubation.  Also, if pt is choking with full blockage, you might be able to shove the obstruction into the right mainstem and at least get the left lung some air.  Worse case scenario, i know, but better than the alternative.



Sorry, WuLabsWuTecH not to just to be singling you out but there is * SO MUCH WRONG* with statements and ideologies as such. This is becoming a dangerous approach on teaching and learn in airway techniques. As well, why *intubation soon maybe a thing of the past for prehospital providers.* 

There is *far* more to be taught and learned in than in a simplistic manner. Not worrying about damaging vocal cords? .. See ya' in court buddy! Yes, I will testify against any EMT or Paramedic that describes such! 

We have to get a handle on this! Whom and what is able to provide medical care, especially advanced airway area. Folks, we are talking about potentially n-e-v-e-r ever talking again, and possibly walking around with a stoma for the rest of their lives, *all* because someone was not taught or learned properly!..  YES it is that serious!

If you do not know the importance and the dangers *as well* as having the education and knowledge to treat if there is a mishap.. One should NOT be doing the procedure!

R/r 911


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## WuLabsWuTecH (Jul 17, 2008)

VentMedic said:


> I hope this is not a justification for the minimal hours of training.  The indication in OH's protocols for EMT-Bs intubating is pulseless and apneic.    Not worrying about what damage is done is never accepted in other professions regardless of the situation.  You are trained and educated to the best of your ability to minimize any further complications that may also distract from the situation at hand and eventually decrease any chances of survival for the patient.  The excuse "it's an emergency" should not mean you perform sub par.  You do not skimp on your technique or skill and do things haphazardly.  Of course, this comes easier with adequate training and experience.   Accountability and monitoring quality of care is something EMS still has to accept within the profession as a whole.
> 
> As far as the choking scenario, if the blockage is above the cords, I would hope a "skilled" provider has the good sense and training to  make a good attempt to remove it.   If the blockage is already past the cords and lodged in the trachea, then yes, pushing it through may be the only option besides a cric in the field.
> 
> ...



We are trained in how to remove obstructions, be we are taught if we can't get it, then the next option is to push it down.



Ridryder911 said:


> Sorry, WuLabsWuTecH not to just to be singling you out but there is * SO MUCH WRONG* with statements and ideologies as such. This is becoming a dangerous approach on teaching and learn in airway techniques. As well, why *intubation soon maybe a thing of the past for prehospital providers.*
> 
> There is *far* more to be taught and learned in than in a simplistic manner. Not worrying about damaging vocal cords? .. See ya' in court buddy! Yes, I will testify against any EMT or Paramedic that describes such!
> 
> ...



What I'm saying is not that I won't take every precaution to prevent this, but that the risk of this happening is something that we have to accept in that situation.  When I say worry, i don't mean disregard, and I apologize if it came out that way, but that I won't lose sleep over taking that risk.


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## shannon williams (Jul 28, 2008)

Are you allowed any other airway techniques?  Like the Combi-Tube?  Our EMT-Bs are allowed to do that.


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## mikeylikesit (Jul 29, 2008)

shannon williams said:


> Are you allowed any other airway techniques? Like the Combi-Tube? Our EMT-Bs are allowed to do that.


 Most places allow an EMT acces to the King and Combi airways but rarely ever teach teh skills in class.


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## Jon (Jul 29, 2008)

mikeylikesit said:


> Most places allow an EMT acces to the King and Combi airways but rarely ever teach teh skills in class.


Most?

Some do. Some don't.

All the states in my area DON'T have advanced airways for BLS providers... NJ, PA, DE.


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## mikie (Jul 29, 2008)

mikeylikesit said:


> Most places allow an EMT acces to the King and Combi airways but rarely ever teach teh skills in class.



We were taught the BASICS on the CombiTube and the EOA.  We were expected to know how to use it for the NR practical test (random selection) and that's about it!  And from what it seems, they are becoming more plebeian amongst the basic curriculum.  I don't know about "most places" but surely are becoming popular.


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## piranah (Jul 29, 2008)

I am a medic STUDENT and I say basics should not intubate...so many things ca n go wrong that a basic does not have the skills or the knowledge to deal with...such as laryngospasm,ICP,anxiety(due to no premed for intubating because basics can't give the sedation meds), or how bout identifying certain situations not to intubate,how bout perforation.......let's say a pt has copd and you intubate...good luck weaning them off of it...if you can't control an airway as a basic you Do NOT deserve to be in that truck or touching any pt .....,sorry for any mispelled words I'm on an iPhone


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## Granola EMT (Jul 30, 2008)

It is definitely great for Basics to have the "know how" to assist ALS providers, but I'll leave the should they/should they nots alone...
There are other means of airway control, and I almost always use an OPA, even before an ETT. I would consider it an ALS skill though, but I have been taught BLS before ALS, so that's just me...


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## Ridryder911 (Jul 30, 2008)

Granola EMT;88720 but I have been taught BLS before ALS said:
			
		

> How about just medicine?.. seriously, can we ever remove such stigma that we in EMS only have?...


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## emtc9019 (Jul 30, 2008)

*ett ? als*

i have been a emt for 14 years the last 6 as a als provider i got my ett certifaction 1 year after i got my basic licence and i used it quite a bit as is helped the als provider to be doing his als tx. i guess it depends on how agresseve you ems system is, i am from rhode island


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## Nickjm908 (Sep 4, 2008)

*Yes I'm with ya on that one.*

Yeah during my basic class and refresher we've had time to practice Combi-tubes and ET tubes and i'll agree with you that tubing lil annie isnt too hard but i'm a firm believer that combi-tubes should be avail. to basics at least... can hardly go wrong. and it will def. save lives!


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## JPINFV (Sep 4, 2008)

emtc9019 said:


> i have been a emt for 14 years the last 6 as a als provider i got my ett certifaction 1 year after i got my basic licence and i used it quite a bit as is helped the als provider to be doing his als tx. i guess it depends on how agresseve you ems system is, i am from rhode island



Can someone translate this into English because I'm having a hard time telling if he's the paramedic provider or an EMT-B?


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## VentMedic (Sep 4, 2008)

He might be one of them EMT-Cs from Rhode Island.  Or, an EMT-B with an intubation "cert". 

Quote from RI's web:



> EMT-Cardiac ("EMT-C"): All EMT-B skills plus: IV therapy, adult and pediatric oral intubation, cardiac monitoring and interpretation, defibrillation, transcutaenous pacing, administration of IV medications, and modern concepts of trauma care.
> 
> *The EMT-C is a certification between the EMT-I and EMT-P, allowing the use of more cardiac drugs than the EMT-I, but fewer than the EMT-P. *


 
You can now refer to my recent post on the EMT-I thread.


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## marineman (Sep 5, 2008)

I don't know if it was mentioned yet but I don't think anyone should be doing ett's unless you carry and are allowed to push meds. If you don't get it right the first time and cause a laryngeal spasm you're kind of up a creek without a paddle. 

I see talk about basics and combitubes which I already thought was a NR skill but definitely all basics should be carrying combi's. Our FR/EMR's are carry combitubes.

And lastly I guess I don't understand the big deal about advanced airways. Yes you can technically put meds through an ett but studies are showing that they don't really work as well as we hoped. Our policy is use the most basic airway that you can get adequate ventilations. The biggest benefit I see is the advanced airways do fairly decent job of preventing aspiration.


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## KEVD18 (Sep 5, 2008)

every time this topic comes back to the top, i die a little inside.....


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## reaper (Sep 5, 2008)

marineman said:


> And lastly I guess I don't understand the big deal about advanced airways. Yes you can technically put meds through an ett but studies are showing that they don't really work as well as we hoped. Our policy is use the most basic airway that you can get adequate ventilations. The biggest benefit I see is the advanced airways do fairly decent job of preventing aspiration.




 Uhhhhh!!:unsure:


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## snaketooth10k (Sep 5, 2008)

Nickjm908 said:


> Yeah during my basic class and refresher we've had time to practice Combi-tubes and ET tubes and i'll agree with you that tubing lil annie isnt too hard but i'm a firm believer that combi-tubes should be avail. to basics at least... can hardly go wrong. and it will def. save lives!



WHAT?! 

hardly go wrong? I think what you say is based on ignorance. You can DEFINITELY mess up with a combi-tube. Most basics that I've met cannot discern between their own breath sounds and their patient's in the back of a bouncing rig.A Combi-Tube uses two lumens because it has a possibility of tracheal intubation. According to http://www.ispub.com/ostia/index.php?xmlFilePath=journals/ijeicm/vol5n2/combi.xml, the likelihood of esophageal intubation is "up to 98%". But what if you manage to do a blind ET?  If you seat the device improperly you could kill a patient. My friend with ALS has told me that he would take an ET tube over a Combi-Tube any day, and I believe him.


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## basicemtccm26 (Sep 19, 2008)

I agree with Reaper. I also work in Upstate SC, and yes the EMT_B training is miniscule at best. I think that it should be that advanced emts should be allowed to insert a ET tube and Basics only LMA's Or Combitubes. The only thing to that is you have basics that think they are Critical Care Paramedics and will buck the system as much as they can. We were their at one time or another (basic level EMT) but the more experience the better, so in conclusion please only let NREMT-P do a ETT placement, the numbers state the facts


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## emt_angel25 (Sep 19, 2008)

there are different means of obtaining an airway as a Basic EMT. i think teaching basics intubation is just crazy. i have no desire to learn how to intubate my pts as an EMT its a personal thing but i wouldnt want to do it. where i come from the EMT program is one semester long and that is NOT enough time to teach such a skill to  students.


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## marineman (Sep 19, 2008)

reaper said:


> Uhhhhh!!:unsure:



eh wording was kind of off. Not saying there's no use for an ETT but they have a tendency to be overused. I've seen medics get on scene where a FR has already placed a combi that was working fine and the first thing they did was remove the combi to place an ETT. For us as long as we have some sort of airway that is facilitating the transport of O2 we will let it be until after we start a line, hook up the ECG, etc depending on the call. We do place ETT's but it's not a priority thing when we arrive on scene when other lifesaving interventions are indicated.


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## VentMedic (Sep 19, 2008)

marineman said:


> eh wording was kind of off. Not saying there's no use for an ETT but they have a tendency to be overused. I've seen medics get on scene where a FR has already placed a combi that was working fine and the first thing they did was remove the combi to place an ETT. For us as long as we have some sort of airway that is facilitating the transport of O2 we will let it be until after we start a line, hook up the ECG, etc depending on the call. We do place ETT's but it's not a priority thing when we arrive on scene when other lifesaving interventions are indicated.


 
I don't know about overused especially if one has the ability to do ETI.

However, the debate of "to pull or not to pull" can be a thread to itself and frequently is on the flight forums.  

In the hospital, we will definitely change the tube but I have left an alternative airway in place when doing scene response  on a flight team if there was any doubt of quickly establishing another provided I had excellent ventilations and the airway was secure. LMAs are not that secure in moving vehicles.


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## Zippo1969 (Oct 13, 2008)

Wanna intubate? Go to Paramedic school.  Otherwise use the (numerous) tools already out there, such as Kings, Combitubes, simple adjuncts with good BVM technique et al.

It's hard enough (and getting harder) to convince Anes. to let medics intubate with the stats we're seeing, let alone getting a basic into surgery to get tubes...but this has already been said.  

Also, with new technology (capnography being the one off the top of my head) there is no excuse for a misplaced ETT.  Zolls, LP12s, and other monitors have continuous logs to monitor whether there is proper gas exchange during transport.  
MANY tubes get pulled transferring pt.s to ER beds...I wonder how many of these are counted against EMS and not overzelous ER staff, and are these capno. logs factored into the results of studies like Dr. Wangs'?


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## Hal9000 (Oct 13, 2008)

I'm sure I could do an ET tube and not hurt the patient.

After a lot of practice and schooling so that it means more than just shoving a tube in someone.

I'm a -B, and the combitube is fine.  A good BVM also works well for me, and that's as far as I want to go with it.  

A lot of -Bs forget that the simplest and least invasive way is the way to go.  I know some -Bs that are good EMTs but would use a combitube over a standard oral airway, even if they both worked the same, because they have the cert.

I guess that I just don't feel the same way. I wouldn't want someone shoving a tube inside me if something else would work.


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## VentMedic (Oct 13, 2008)

Unless the patient is very unconscious, an ETT is not always tolerated very well. If you intubate, the sedation after the procedure is as important as prior to intubation in most cases. If the patient wakes up after you have intubated with coughs and spasms, you will not be able to effectively ventilate even with the ETT. Oxgenation will also fall as a result.


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## Medexpresso (Oct 13, 2008)

Pennsylvania is moving in the direction of getting rid of the ET tube all together. medical directors are pushing for the use of the Combitube and/or a King Airway, just slam it down and pick the lumen that ventilates and bam there you go. we also us an IO drill as opposed to manual IO... it seems as if the equipment is changing so much that EMT-Bs will most certainly be performing these skills in the near future


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## EMT-P633 (Oct 15, 2008)

Medexpresso said:


> it seems as if the equipment is changing so much that EMT-Bs will most certainly be performing these skills in the near future



I most certainly hope not, just like the ETT an IO is alot more then just shoving or drilling a hole in a bone. 

Again as it has been said numerous times in this thread, If a B wants to be able to do more for the good of the patient then go to medic school. learn the anatomy and physiology of the body. *KNOW* why you are doing something and what to expect before it happens. Why would anyone allow a B to start an IO before they are even proficient in IV's?  

I work in TN. and here we have a different set up then most of the country, we do not have basics. we have EMT-IV and medics.  And here we at different services we discuss these same topics. and I usually point out the same points as in this thread.  A basic just simply does not have the education needed to know how / why the body is acting or reacting the way it is.  Yes they are fully capeable of performing the skill. *BUT* what about the what if's?  What if they are using an IO on a ped patient and they hit the growth plate?  Do they know that this child will most likely be deformed for the rest of thier life with a short leg?  What if they are using a B.I.G. and do not have the proper alignment and shatter the bone?  these are just a few examples.

One big change that has recently happened here in TN is that EMT-IV's have been authorized to aquire 12-leads and transmitt them to the recieving hosp. this is only done on units that are BLS.  They are not taught to interpert the rythym, authorized to treat the rythym.  What if they hook up the PT to the 12-lead. PT converts from sinus rythym to V-tach or V-fib.  they recongize this rythym, attached the AED and defib the patient.  Did they not just practice outside thier scope of practice?  

In all honesty I feel that allowing basics and intermediates to do advanced skills. or moving skills down the ladder is only going to open up too many "can -o- worms".  It will end up biting someone in their forth point of contact before it is over.  

As for the aurgument of teach them the why's along with the how's, of these advanced skills. then once again as said too many times already in this thread. why not just bite the bullet and go to medic school?


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## mbcwgrl (Oct 16, 2008)

EMTs can (somnetimes) use combi tubes and such... As an EMT you should learn the basics first, then move on. In my state we dont usually recognize EMT-I but it would be good to take the class for those that are interested in a little bit more medicine but not quite ready for the responsibility.


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## VentMedic (Oct 16, 2008)

mbcwgrl said:


> In my state we dont usually recognize EMT-I but it would be good to take the class for those that are interested in *a little bit more medicine but not quite ready for the responsibility*.


 
Unfortunately that pretty much sums up EMS education and all of its little "certs".


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## Melbourne MICA (Oct 17, 2008)

*Lets just pop in an ET tube.*

Our intubation guideline goes for 11 pages. It contains 13 discrete sections each with multiple sub sections. It has about 10 drugs involved in one part of the process or another, a dozen other bits of equipment go along with it, a dozen or more separate skills, there are anywhere from two to four people involved in setting up, there are about a dozen or so situations where ETT is indicated, another dozen or so contraindications somewhere in the process, 1/2 dozen required methods to confirm placement, a whole section just on capnography, airway patho knowledge,drug patho knowledge, chest patho, brain patho, spinal patho........................................................

And thats just to get the ball rolling.

I've done literally hundreds of them; dead, alive, with drugs without drugs, on a floor, in a car, in the street, in the rain, blinded by the sun, as job number one at 0700, as job number 15 at 0630.

I look at all that stuff up there and it still sends shivers down my spine.

It should do the same to you.

There's no such thing as just "popping a tube in".

MM


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## el Murpharino (Oct 18, 2008)

How true, Melbourne.  I never truly appreciated how intricate intubation was until I went through paramedic class, and more recently a SLAM class.  Just a small part of the problem lies in fast-tracking many people through the training for intubation.  Alot of providers don't even know how to properly assess their patient and anticipate a difficult airway, a difficult patient to bag, etc.  And they wonder why there is such a push here to take intubation away from medics...


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## Melbourne MICA (Oct 18, 2008)

el Murpharino said:


> How true, Melbourne.  I never truly appreciated how intricate intubation was until I went through paramedic class, and more recently a SLAM class.  Just a small part of the problem lies in fast-tracking many people through the training for intubation.  A Lot of providers don't even know how to properly assess their patient and anticipate a difficult airway, a difficult patient to bag, etc.  And they wonder why there is such a push here to take intubation away from medics...




Quick anecdote. I had a 40 something pt who collapsed GCS 3 with no Hx etc.
Seemed to me and my partner like a neuro bleed. The pt had no airway reflexes so at risk - ETT. My partner did a beautiful job on ET insertion, took less a than a minute from setup to securing.  A piece of plastic down a hole.

Not. 

No sooner had the tube tickled the cords than the HR went south -130/min to 30 a min in front of our eyes. BP went with it of course. Not good for a neuro bleed.

But we had atropine and EPI already drawn. 60secs late back to normal.

Point is of course all our training had prepared us for the multitude of things that can happen - like a big vagal kick. Then there's understanding the side effects of atropine, secondary hypoxic brain injury, how you are going to ventilate the neuro bleed pt, Mx the BP, using paralytic drug issues, interpreting the capno and so and so on.

And all for this *one* pt and her specific medical circumstances on the day. On to the next pt who will be completely different again but who also might need an ETT.

Our Medicos were considering giving our BLS guys ETT - they looked at the training, experience, prac skills, revision, further education issues etc - they use BVM and LMA NP OP etc already. Not a good idea was their view.

So you can use a combitube, LMA, KingAirway whatever. Now you can stick an ETT down a manikins plastic throat during "training". 

Not. 

It doesn't count as far as I'm concerned and be ready for the "awakening" for those who do.

MM


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## tydek07 (Oct 27, 2008)

I think it should stay as an ALS skill. You need to know a lot of why's and how's before you can just go out and do a skill. It would be way to costly to put into the EMT-B course. You would need to learn more anatomy, as well as .... wow...  too much to type....nope, just will not work haha


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