# Advanced Airway: unconscious to conscious



## johnguillen68 (Apr 30, 2009)

Ok, if I'm transporting a pt that had to be intubated, but along the trip to the hospital the pt's conditions improves and becomes combative, pt appears to be breathing without assistance: what can I do?

1 -request a paramedic to give her a sedative drug
2 -contact medical control for instructions
3 -have suction ready and remove ET tube
4 -restrain pt and continue ventilations


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## VentMedic (Apr 30, 2009)

???????????????????

What level are you and are you by yourself and must call for an ALS intercept?

Is this a test question or from real experience?

I also thought they were doing away with ETTs in your area and going with just the suprglottic?


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## Sasha (Apr 30, 2009)

No one here is going to be able to take the NREMT for you, I suggest instead of asking all these questions you go back and reread your textbook.


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## johnguillen68 (Apr 30, 2009)

Sasha said:


> No one here is going to be able to take the NREMT for you, I suggest instead of asking all these questions you go back and reread your textbook.



its a question thats on a practice sheet. I don't have my EMT book to look at that advance airway chapter. I don't know why that question is even in this quiz. Its a scenario question.
Plus its a forum you're supposed to ask questions that you don't know and I don't know this one.


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## LAS46 (Apr 30, 2009)

johnguillen68 said:


> Ok, if I'm transporting a pt that had to be intubated, but along the trip to the hospital the pt's conditions improves and becomes combative, pt appears to be breathing without assistance: what can I do?
> 
> 1 -request a paramedic to give her a sedative drug
> 2 -contact medical control for instructions
> ...



First off... What level of EMS are you??

Are you in this question on a Iner Facility Transfer (IFT)? Who started the ET?

If it was like any other advanced airway (i.e. combi-tube, king tube, LMA) I would follow the same procedure for those, which is to remove them and have section ready. If you are on a IFT and you are a basic level I do not think you should be transporting someone with a ET in unless there is a EMT-I or P on board monitoring that PT while you are driving.

Hope you understand this.

:usa:


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## johnguillen68 (Apr 30, 2009)

LAS46 said:


> First off... What level of EMS are you??
> 
> Are you in this question on a Iner Facility Transfer (IFT)? Who started the ET?
> 
> ...



EMT-B and it was a scenario question that was on a quiz. I don't know why this question was brought into this quiz but I didn't know the answer so I brought to this site.
I'm not asking anybody to take the NREMT for me. I am practicing to retake the test and on one of the books I bought to practice had this question. I didn't know the answer to this question and was concern that it might pop up on my test. Thats all.


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## Sasha (Apr 30, 2009)

johnguillen68 said:


> its a question thats on a practice sheet. I don't have my EMT book to look at that advance airway chapter. I don't know why that question is even in this quiz. Its a scenario question.
> Plus its a forum you're supposed to ask questions that you don't know and I don't know this one.



You aren't supposed to use us to do your homework. if you have a question on a quiz who better to ask then the one who gave the quiz?


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## LAS46 (Apr 30, 2009)

Sasha said:


> You aren't supposed to use us to do your homework. if you have a question on a quiz who better to ask then the one who gave the quiz?




Sasha you are not understanding what he is saying... The question he has is from a book that he is using as a review, not from a test that he is doing.


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## VentMedic (Apr 30, 2009)

LAS46 said:


> If it was like any other advanced airway (i.e. combi-tube, king tube, LMA) I* would follow the same procedure for those, which is to remove them and have section ready.* If you are on a IFT and you are a basic level I do not think you should be transporting someone with a ET in unless there is a EMT-I or P on board monitoring that PT while you are driving.
> 
> Hope you understand this.


 
A supraglottic device is very different than an ETT (subglottic). Most patients can not tolerate a supraglottic device when awake and will need to have them removed. An ETT is considered a definitive airway and may be there for a very good reason. If you remove it, you may now have LOST the airway. This is also a good chance they will vomit compounding whatever airways issues were present. Then you might also have to worry about laryngeal edema or spasm. Then, if your Paramedic can not do RSI, the patient may die. 

You had better have your Paramedic sedate this patient to keep that airway. This is also a serious hit on the Paramedic for not monitoring the patient's vital signs and sedation level. Even an EMT-I should not be monitoring an intubated patient that may require enough sedation to maintain an airway for adequate ventilation and oxygenation.

If for some reason beyond belief that it is only you as an EMT-B with this patient, you would have to restrain and maintain control of the airway. However, your ability to ventilate and oxygenate this patient may be very poor even with the tube in place.


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## LAS46 (Apr 30, 2009)

VentMedic said:


> A supraglottic device is very different than an ETT (subglottic). Most patients can not tolerate a supraglottic device when awake and will need to have them removed. An ETT is considered a definitive airway and may be there for a very good reason. If you remove it, you may now have LOST the airway. This is also a good chance they will vomit compounding whatever airways issues were present. Then you might also have to worry about laryngeal edema or spasm. Then, if your Paramedic can not do RSI, the patient may die.
> 
> You had better have your Paramedic sedate this patient to keep that airway. This is also a serious hit on the Paramedic for not monitoring the patient's vital signs and sedation level. Even an EMT-I should not be monitoring an intubated patient that may require enough sedation to maintain an airway for adequate ventilation and oxygenation.
> 
> If for some reason beyond belief that it is only you as an EMT-B with this patient, you would have to restrain and maintain control of the airway. However, your ability to ventilate and oxygenate this patient may be very poor even with the tube in place.



Now that you have put it that way I can understand that. But like I said, If you are only a BLS unit you should not be transporting this patient. If it was me doing a IFT with this type of PT I would have to refuse the transport because that PT needs a ALS unit or a Chopper ride to the other facility.


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## Mountain Res-Q (Apr 30, 2009)

All the options given suck:

1 -request a paramedic to give her a sedative drug
    Who he hell am I as an EMT to tell the medic what to do.  Shouldn't he know?

2 -contact medical control for instructions
    When given an answer that you can't answer, this is usually what the test wants you to say.

3 -have suction ready and remove ET tube
    Where in the EMT cirriculum does it teach EMT's how to extubate?  Beyond the medical contriindications for an EMT doing so, this is just STUPID!

4 -restrain pt and continue ventilations
    Can we say assault?  Not to mention, why the hell you wou ventalate a patient that is already moving air adequately?'

The real answer:  Don't be the primary care provider at the EMT level on a transport of a patient with an advanced airway, which is usually an indication of an injury/illness for which you can provide limit care a the BLS level.


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## Shishkabob (Apr 30, 2009)

What is a BLS unit doing transporting an intubated pt?


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## Sasha (Apr 30, 2009)

Linuss said:


> What is a BLS unit doing transporting an intubated pt?



Maybe they're EMT+'s


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## rmellish (Apr 30, 2009)

Linuss said:


> What is a BLS unit doing transporting an intubated pt?



Not under my protocols. For good reason too....


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## LAS46 (Apr 30, 2009)

Linuss said:


> What is a BLS unit doing transporting an intubated pt?



In Colorado, NO EMT-B or I can transport a intubated PT. I still would recommend a PT who needs a IFT to another hospital should be flown due to the shortage of units available in my area.

Just my opinion.


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## rmellish (Apr 30, 2009)

LAS46 said:


> In Colorado, I still would recommend a PT who needs a IFT to another hospital should be flown due to the shortage of units available in my area.
> 
> Just my opinion.



Guess I don't really know your area, but that seems a bit excessive. Intubated patients can go by ground...


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## LAS46 (Apr 30, 2009)

Yes they can go by ground but I perfer to send them by air.


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## Shishkabob (Apr 30, 2009)

Why?  Just because they have a tube down their throat?


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## Sasha (Apr 30, 2009)

LAS46 said:


> In Colorado, NO EMT-B or I can transport a intubated PT. I still would recommend a PT who needs a IFT to another hospital should be flown due to the shortage of units available in my area.
> 
> Just my opinion.



So, you want to put the entire flight crew at risk (You've heard all those stories about them crashing!) for something that could've gone by ground?

Not to mention tack on the helicopter bill which I imagine is significantly more than an ambulance bill to their final total.

And I think there are fewer helicopters then there are ALS ground units.


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## Shishkabob (Apr 30, 2009)

Along with tying over an air ambulance, and screwing over air traffic control.


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## Mountain Res-Q (Apr 30, 2009)

LAS46, A Paramedic can intubate the patient, so why can't they monitor an intubated patient for a ground ambulance transfer.  I ran CCT (Critical Care Transfers) for a short while.  We had one MICN and two EMTs on the rig and we transferred more than our far share of intubated and ventalator patients (sometimes hours).  Locally, the ambulance uses a MICP and an EMT to do the same, and if they need help on the transfer, they grab an MICN from the hospital.  An intubated patient should not be transfered by a BLS crew, but why do they need an airship, except in very rare cases?  At the MFR level you may prefer an airship, but that dosen't make it the best course of action.  now if you are talking about a 911 call with an intubated patient:  The call to fly them should be based not on them being intubated, but on why they are intubated.


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## johnguillen68 (Apr 30, 2009)

Sasha said:


> You aren't supposed to use us to do your homework. if you have a question on a quiz who better to ask then the one who gave the quiz?



holy moly, I know that but I thought I share this tough question because as a EMT-B we won't do that transport. But out of those choices given I didn't know what would be the answer. I know in the ER where I work we keep them under but in the field I don't know.
It seems like a tough one because I'm getting lots of responses. It looks like according to State or County protocols.

I'm not using this site for homework. I'm using this for simply knowledge, information, and getting to know people in the EMS field.


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## VentMedic (Apr 30, 2009)

Mountain Res-Q said:


> LAS46, A Paramedic can intubate the patient, so why can't they monitor an intubated patient for a ground ambulance transfer. I ran CCT (Critical Care Transfers) for a short while. We had one MICN and two EMTs on the rig and we transferred more than our far share of intubated and ventalator patients (sometimes hours). Locally, the ambulance uses a MICP and an EMT to do the same, and if they need help on the transfer, they grab an MICN from the hospital. An intubated patient should not be transfered by a BLS crew, but why do they need an airship, except in very rare cases? At the MFR level you may prefer an airship, but that dosen't make it the best course of action. now if you are talking about a 911 call with an intubated patient: The call to fly them should be based not on them being intubated, but on why they are intubated.


 
Are you in California? MICP? The scope for a Paramedic is very, very limited, thus you have MICNs. One good MICN is better than two very limited Paramedics which is why two EMT-Bs are used (hoping the MICN is good) and no Paramedic. 

An intubated patient on an IFT needs a little more than "monitoring". Paramedics in CA can not give or maintain a paralytic. 

If the patient requires more sedation or advanced intervention than what a ground EMS crew can do, a helicopter is sometimes dispatched. This is also the case in Florida since that is where I did many years on the helicopter responding often to some places just because the ALS in the area was too limited for most drips or didn't have ventilator knowledge or equipment to most do ICU/ED patients. Bagging a critical care patient for any length of time other than for moving from one bed to another is NOT is good time.


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## VentMedic (Apr 30, 2009)

Mountain Res-Q said:


> 4 -restrain pt and continue ventilations
> Can we say assault? Not to mention, why the hell you wou ventalate a patient that is already moving air adequately?'


 
By our policy, all newly intubated patients in the ED, IFT and ICUs are *required* to have restraints. If the patient pulls the tube on your watch, you will have to answer. If the patient suffers serious consequences from pulling the tube, you may take the charge for the sentinel event which can be reported to your licensing board (RRTs & RNs).   

Pts that have been intubated or trached for awhile can be unrestrained unless there are procedures being done, various medications and AMS. Then, a restraint order will be placed. 

BTW, in the response to extubating, you do not pull out what you can not put back in.


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## JPINFV (Apr 30, 2009)

VentMedic said:


> By our policy, all newly intubated patients in the ED, IFT and ICUs are *required* to have restraints. If the patient pulls the tube on your watch, you will have to answer. If the patient suffers serious consequences from pulling the tube, you may take the charge for the sentinel event which can be reported to your licensing board (RRTs & RNs).



Having personal experience with this, I'd much rather face false imprisonment or assault charges  than deal with the mess of having a patient pull an ETT or trach.


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## CAOX3 (Apr 30, 2009)

johnguillen68 said:


> I'm not using this site for homework. I'm using this for simply knowledge, information, and getting to know people in the EMS field.



Kudos, 

Nice to meet ya.


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## BrianJ (Apr 30, 2009)

To answer the OP question: The answer for the quiz's purpose is contact medical control.

Good luck with your studying.


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## Mountain Res-Q (Apr 30, 2009)

VentMedic said:


> Are you in California? MICP? The scope for a Paramedic is very, very limited, thus you have MICNs. One good MICN is better than two very limited Paramedics which is why two EMT-Bs are used (hoping the MICN is good) and no Paramedic.
> 
> An intubated patient on an IFT needs a little more than "monitoring". Paramedics in CA can not give or maintain a paralytic.
> 
> If the patient requires more sedation or advanced intervention than what a ground EMS crew can do, a helicopter is sometimes dispatched. This is also the case in Florida since that is where I did many years on the helicopter responding often to some places just because the ALS in the area was too limited for most drips or didn't have ventilator knowledge or equipment to most do ICU/ED patients. Bagging a critical care patient for any length of time other than for moving from one bed to another is NOT is good time.



All justified California EMS aside, you said it yourself, "a helicopter is _sometimes_ dispatched".  The earlier comment was a blacketed response from a MFR:  "Patient is intubated I want a helicopter."  My point (one that I believe you would agree with) was that not every intubated patient needs a helo; MICP: Sure, MICN: Maybe, EMTs only: No Way.  That is why I mentioned the CCT system that I am familiar with (1 MICN and 2 EMTs).  The MICP / EMT method may not be the way to go all the time (as is the case in CA - in your opinion), which is why I mentioned the occasional need to throw a Hospital MICN on the rig in my counties EMS system.  On top of that, I am told our counties Paramidic guidlines are among the most liberal in CA; so I am told by the Medics I know (and highly respect) that they often run CCT-tpye calls without an MICN, which are hard to come by in my neck of the woods.



VentMedic said:


> By our policy, *all newly intubated *patients in the ED, IFT and ICUs are *required* to have restraints. If the patient pulls the tube on your watch, you will have to answer. If the patient suffers serious consequences from pulling the tube, you may take the charge for the sentinel event which can be reported to your licensing board (RRTs & RNs).
> 
> Pts that have been intubated or trached for awhile can be unrestrained unless there are procedures being done, various medications and AMS. Then, a restraint order will be placed.
> 
> BTW, in the response to extubating, you do not pull out what you can not put back in.



The option given was to restrain and continue to ventilate and patient that was adequately moving air.  I am by no means advocating the removal of the ETT, but to actively restrain a patient from interferring with a treatment that they no longer want and apparently don't need (the ventilation, not ETT) at the BLS level in liberal CA, soooooo boarders on assault!  Not saying I wouldn't prevent the patient from doing so if I had a newly intubated patient on a ALS 911 call that tried to pull the tube after coming to, but we are still talking BLS transfer.  Which is why my arguement stands:  A the EMT level, you shouldn't be the primary care provider on an intubated transfer patient... call ALS or CCT (or whatever passes for that in your area) or (if the cirrcumstances call for it) a Helo.  But to call a helo as a matter of course is irresposible and may not be justified.


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## GeekMedic (Apr 30, 2009)

johnguillen68 said:


> Ok, if I'm transporting a pt that had to be intubated, but along the trip to the hospital the pt's conditions improves and becomes combative, pt appears to be breathing without assistance: what can I do?
> 
> 1 -request a paramedic to give her a sedative drug
> 2 -contact medical control for instructions
> ...



is that the only context the question gives you or is there more to the scenario?


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## Ensihoitaja (Apr 30, 2009)

LAS46 said:


> In Colorado, NO EMT-B or I can transport a intubated PT. I still would recommend a PT who needs a IFT to another hospital should be flown due to the shortage of units available in my area.
> 
> Just my opinion.



That's not strictly true. Colorado EMT-Is are capable of intubating patients. They would, however, need a waiver to use a transport ventilator, while that's allowed for paramedics.

Rule 500


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## VentMedic (Apr 30, 2009)

Mountain Res-Q said:


> All justified California EMS aside, you said it yourself, "a helicopter is _sometimes_ dispatched". The earlier comment was a blacketed response from a MFR: "Patient is intubated I want a helicopter." My point (one that I believe you would agree with) was that not every intubated patient needs a helo; MICP: Sure, MICN: Maybe, EMTs only: No Way. That is why I mentioned the CCT system that I am familiar with (1 MICN and 2 EMTs). The MICP / EMT method may not be the way to go all the time (as is the case in CA - in your opinion), which is why I mentioned the occasional need to throw a Hospital MICN on the rig in my counties EMS system. On top of that, I* am told our counties Paramidic guidlines are among the most liberal in CA; so I am told by the Medics I know (and highly respect) that they often run CCT-tpye calls* without an MICN, which are hard to come by in my neck of the woods.


 
CCT type calls? That could mean just a cardiac monitor since even a room air trach gets an MICN in many parts of California. Read the state scope of practice for the Paramedic at a CCT level. Do you know why almost every flight program in Califorrnia has at least one if not two RNs? 




Mountain Res-Q said:


> *The option given was to restrain and continue to ventilate and patient that was adequately moving air.* I am by no means advocating the removal of the ETT, *but to actively restrain a patient from interferring with a treatment that they no longer want and apparently don't need (*the ventilation, not ETT) at the BLS level in liberal CA, soooooo boarders on assault! Not saying I wouldn't prevent the patient from doing so if I had a newly intubated patient on a ALS 911 call that tried to pull the tube after coming to, but we are still talking BLS transfer. Which is why my arguement stands: A the EMT level, you shouldn't be the primary care provider on an intubated transfer patient... call ALS or CCT (or whatever passes for that in your area) or (if the cirrcumstances call for it) a Helo. But to call a helo as a matter of course is irresposible and may not be justified.


 
You know the patient no longer needs this how? Could the EMT-B out of sync with the patient? Could the patient actually need more support than what is being provided? Could the patient be fighting for his life because of crappy bagging or worsening respiratory condition?

The patient was combative in the OP. What meds were given for the intubation? AMS before the intubation? AMS from the meds given prior to transport? Once tubed, that tube stays in. It is up to the care giver to see the patient does not do harm to themselves. If the patient has a death wish, let the hospital and their ethics committee sort out the end of life and don't take it upon yourself to allow this during transport.


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## johnguillen68 (Apr 30, 2009)

BrianJ said:


> To answer the OP question: The answer for the quiz's purpose is contact medical control.
> 
> Good luck with your studying.



thank you. I didn't know this question would bring up 4 pages of information. It shows how great you all are to respond. That shows character and it tells me how much you care. thanks.


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## Mountain Res-Q (Apr 30, 2009)

VentMedic said:


> CCT type calls? That could mean just a cardiac monitor since even a room air trach gets an MICN in many parts of California. Read the state scope of practice for the Paramedic at a CCT level. Do you know why almost every flight program in Califorrnia has at least one if not two RNs?


 
As I said, MICNs are not easy to come by in the sticks, which is beyond the point of what I was originally saying.  The point was that just because a patient is intubated does not automaticly make it a helo transfer.  Whether or not you believe that it should doesn't matter, it is how it is until we do away with ground ambulance and everyone gets a helo... or site to site transport (beam me up, Venty!)



VentMedic said:


> You know the patient no longer needs this how? Could the EMT-B out of sync with the patient? Could the patient actually need more support than what is being provided? Could the patient be fighting for his life because of crappy bagging or worsening respiratory condition?
> 
> The patient was combative in the OP. What meds were given for the intubation? AMS before the intubation? AMS from the meds given prior to transport? Once tubed, that tube stays in. It is up to the care giver to see the patient does not do harm to themselves. If the patient has a death wish, let the hospital and their ethics committee sort out the end of life and don't take it upon yourself to allow this during transport.



You are throwing out to many extenuating circumstances that are not described in the OP's post.  The question is a simple BLS EMT question (not ALS/CCT/MICN/MICP), don't try to put an ALS spin on an BLS textbook question.  The choices are stupid.  Which one would you choose from the available answers if you were teaching an EMT class?  Just give a simple A, B, C, D answer.  Becasue in the end the question should be moot, because no EMT should be the primary care provider for any intubated patient, which is illistrated by the question "You know the patient no longer needs this how?"  I don't, neither does the OP, or anyone else BLS answering the question (which was who it dirrected to).  Once again, I agree that removing the tube is the stupidest option given.  Asking the Medic to sedate the patient is just as stupid for an EMT (why are we telling teh Medic what to do on an ALS call).  The option for restraining the patient:  Well if it was protocol for all intubate patients to be restrained on transfer, then why is restraining them now an option?  The answer they want is to contact medical control, the old standby answer when it is very clear that the EMT don't know jack and shouldn't have been transfering this patient in the first place.  CCT (either MICP or MICN - don't really care what everyone believes is the best as long as the patinet is given the best care *available*) is your best bet, but if no other option exists than ALS Paramedic Rig may have to do (not everyone has the _"advantage"_ of living in Urbania 90210), but to use Helo as your first option if a safer and more readily option exists is OVERKILL.  Treatment and transport needs to be determined on a case by case bases, not given a blanketed "cookbook" response.


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## VentMedic (Apr 30, 2009)

This whole thread just provides arguments that show how ridiculous it is for an EMT-B to even be able to do ETI if they can do nothing to maintain an airway. I am referring to the handful of states that do allow this. 

Now back to the this particular topic.



Mountain Res-Q said:


> As I said, MICNs are not easy to come by in the sticks, which is beyond the point of what I was originally saying. *The point was that just because a patient is intubated does not automaticly make it a helo transfer.* Whether or not you believe that it should doesn't matter, it is how it is until we do away with ground ambulance and everyone gets a helo... or site to site transport (beam me up, Venty!)


 
Never said intubation alone gets a helicopter ride. 

That being said, There are several very rural services that do rely on helicopters to get their intubated patients to a hospital. 




Mountain Res-Q said:


> *You are throwing out to many extenuating circumstances that are not described in the OP's post.* The question is a simple BLS EMT question (not ALS/CCT/MICN/MICP), don't try to put an ALS spin on an BLS textbook question. The choices are stupid. Which one would you choose from the available answers if you were teaching an EMT class? Just give a simple A, B, C, D answer. Becasue in the end the question should be moot, because no EMT should be the primary care provider for any intubated patient, which is illistrated by the question "You know the patient no longer needs this how?" I don't, neither does the OP, or anyone else BLS answering the question (which was who it dirrected to). Once again, I agree that removing the tube is the stupidest option given. Asking the Medic to sedate the patient is just as stupid for an EMT (why are we telling teh Medic what to do on an ALS call). The option for restraining the patient: Well if it was protocol for all intubate patients to be restrained on transfer, then why is restraining them now an option? The answer they want is to contact medical control, *the old standby answer when it is very clear that the EMT don't know jack and shouldn't have been transfering this patient in the first place.* CCT (either MICP or MICN - don't really care what everyone believes is the best as long as the patinet is given the best care *available*) is your best bet, but if no other option exists than ALS Paramedic Rig may have to do (not everyone has the _"advantage"_ of living in Urbania 90210), but to use Helo as your first option if a safer and more readily option exists is OVERKILL. Treatment and transport needs to be determined on a case by case bases, not given a blanketed "cookbook" response.


 
This is the original post:



> Ok, if I'm transporting a pt that had to be intubated, but along the trip to the hospital the pt's conditions improves and becomes combative, pt appears to be breathing without assistance: what can I do?


I asked simple questions about the mentation of a patient which an EMT-B should have a little understanding of.

Now for the answers to the questions:



			
				johnguillen68 
1 -request a paramedic to give her a sedative drug
2 -contact medical control for instructions
3 -have suction ready and remove ET tube
4 -restrain pt and continue ventilations[/quote said:
			
		

> If you are transporting an intubated patient you better have suction available regardless. You will also have to restrain the patient because if you are in California the Paramedic will have to call their Medical Control to give something out of their very short list of sedatives.  That could take a while and the sedation probably won't be adequate.


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## Sasha (May 1, 2009)

> *This whole thread just provides arguments that show how ridiculous it is for an EMT-B to even be able to do ETI if they can do nothing to maintain an airway. I am referring to the handful of states that do allow this. *



I don't think EMTs are able to intubate, I was under the impression this referred to an IFT transport or something, in which place they should have never accepted the patient. Don't take a patient with something you can't maintain and monitor. That goes for tubes, IV drips, all those lovely things.


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## JPINFV (May 1, 2009)

^
Reminds me of an ICU to Sub acute discharge. Vent dependent patient and the discharge coordinator accidently scheduled it as a RT CCT. Needless to say, my tongue in cheek recommendation that we could always bag the patient through the 5-10 minute transport went over like a lead balloon.


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## lightsandsirens5 (May 1, 2009)

So Vent, assuming that you are on a BLS rig, (Although why would a tubed pt be on a basic truck? Can't see that happening aroung here at least.) Answer 3 would be right, right? 1,2, and 4 would not work. (again, on a basic truck) Now if it was on an ALS truck, the basic would not even be making this call. (I think:wacko The whole thing is just kinda confusing.


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## Mountain Res-Q (May 1, 2009)

lightsandsirens5 said:


> So Vent, assuming that you are on a BLS rig, (Although why would a tubed pt be on a basic truck? Can't see that happening aroung here at least.) Answer 3 would be right, right? 1,2, and 4 would not work. (again, on a basic truck) Now if it was on an ALS truck, the basic would not even be making this call. (I think:wacko *The whole thing is just kinda confusing*.



My point.  Why are we transfering a tubed patient at the BLS level.

And, Vent, I never said that you said that all intubated patients get a helo.  That was a comment made by someone else, to which I disagreed, to which you disagreed (or were just argueing... I'm not sure).


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## marineman (May 1, 2009)

lightsandsirens5 said:


> So Vent, assuming that you are on a BLS rig, (Although why would a tubed pt be on a basic truck? Can't see that happening aroung here at least.) Answer 3 would be right, right? 1,2, and 4 would not work. (again, on a basic truck) Now if it was on an ALS truck, the basic would not even be making this call. (I think:wacko The whole thing is just kinda confusing.



option 3 is the only one that is 100% incorrect. 

the way I'm reading option one is call for a medic intercept and have a medic give a paralytic, not that a medic is already on board and ask them to give it. That could be correct depending on the situation.

Calling medical control is always the correct answer if it's an option on the basic level test.

restraining the patient is a good choice as well depending on local restraint protocols. 


To the OP a few tricks on the NR test. If BSI/ scene safety is an option, that's the correct answer. If ensure ABC's are in tact is an option that is the correct answer. If contact med direction for orders is an option that is the correct answer. If any combination of those exist, choose all of the above.


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## VentMedic (May 1, 2009)

Mountain Res-Q said:


> And, Vent, I never said that you said that all intubated patients get a helo. That was a comment made by someone else, to which I disagreed, to which you disagreed (or were just argueing... I'm not sure).


 
I gave you examples of where a helicopter is needed and you seemed to think that meant for everyone. 




> the way I'm reading option one is call for a medic intercept and have a medic give a paralytic, not that a medic is already on board and ask them to give it. That could be correct depending on the situation.


 
You give sedation before a paralytic. In California, paralytics are not within the scope of practice for a Paramedic. In the rare situations in a couple of counties, a paralytic was allowed for RSI and we saw how that turned out. 

This could be a real senario from a state that allows EMT to intubate such as Ohio.  Since the OP is from Florida, they do sometimes have a EMTs on ALS trucks.  

And, the word Paramedic was used in the question. It is not clear whether it is an EMT working for a Paramedic truck which would also be a good arguement for Paramedic/Paramedic trucks and keep the EMT-Bs on just a transfer truck for patients with no accessories like tubes or lines. 

Yes, sometimes to must phyically remove a patient's hand from their IV line or ETT to protect the patient from further harm. You do not have time to call med control to ask if you can remove the patient's hand. 

After reading the responses here I will definitely be more careful allowing an EMT-B around an ETT. I am known for getting them somewhat involved in Specialty transports and assisting with bagging an intubated patient in the ED while I set up a ventilator. If it seems some can not show good judgement to not allow a patient to pull an ETT out that I just put in, they do not need to be anywhere near that tube.


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## lightsandsirens5 (May 1, 2009)

marineman said:


> option 3 is the only one that is 100% incorrect.
> 
> the way I'm reading option one is call for a medic intercept and have a medic give a paralytic, not that a medic is already on board and ask them to give it. That could be correct depending on the situation.
> 
> ...




Well ok, that make sense. I guess I assumed that the pt was gagging. I see that the OP dosen't say that though, so............


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## Sasha (May 1, 2009)

lightsandsirens5 said:


> Well ok, that make sense. I guess I assumed that the pt was gagging. I see that the OP dosen't say that though, so............



Let them gag. We do not extubate, that's the hospital's job 

Of course, there's always option 5, knock them back out with an O2 cylinder.


Sarcasm, by the way.


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## marineman (May 1, 2009)

Administer 200cc of clipboard, doesn't leave as big of a mark as an O2 tank


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## daedalus (May 1, 2009)

Sasha said:


> So, you want to put the entire flight crew at risk (You've heard all those stories about them crashing!) for something that could've gone by ground?
> 
> Not to mention tack on the helicopter bill which I imagine is significantly more than an ambulance bill to their final total.
> 
> And I think there are fewer helicopters then there are ALS ground units.



Why the :censored::censored::censored::censored: would this guy want to fly a tubed patient? I transport them every shift on my CCT! Talk about waste and risk>>benefit!


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## piranah (May 1, 2009)

I can intubate as a basic in the field in cardiac arrest situations...I've successfully intubated 10 pts.(in hospital during medic clinical)...if i had a pt awake enroute i would calmly explain to them what happened,and advise them not to pull the tube.....I ALSO  would be calling for ALS intercept due to the fact im not working a BLS code.and by the way.....if you remove that tube incorrectly....you better deflate that cuff,listen for air passing if you don't....your F'd....when you remove it and suction and you hear upper resp stridor hang on to your socks and re-intubate because you'll be F'd ..(with a little jingle) ** put em' in a little box, cover em' over with dirt and rocks**..


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## MSDeltaFlt (May 2, 2009)

daedalus said:


> Why the :censored::censored::censored::censored: would this guy want to fly a tubed patient? I transport them every shift on my CCT! Talk about waste and risk>>benefit!


 
The reason is *why* the pt was tubed in the first place. Also, there are areas that do not have CCT's. They either have ALS 911 units or HEMS.

Responding from someone else's post earlier, just because a pt can extubate themselves does not mean they are ready to be extubated. There are those pts, Vent and I have seen them for years, that can extubate themselves and still need to stay on the vent. For example, TBI's, CVA's, or any other pt with a significant ALOC. Sometimes all they have is a momentary burst of energy to pull the tube. *That's about it *(said like Austin Powers in "The Spy who Shagged Me").

Which is why you need personnel (not just one person) with equipment and meds and protocols to safely transport these pts. Also bare in mind that there is a growing trend to keep from having to *paralyze* as many of these pts as possible. That requires a very judicious amount of sedation, very fine tuned tweaking of the specialized vents and settings, and very, very close monitoring as well as the knowledge, and training, and experience that comes with them all.


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