# What do you think?



## Jeremy89 (May 21, 2008)

While looking for local EMT Protocols online, I recently found the following:
_
R9-25-808. Protocol for an EMT-B to Perform Endotracheal Intubation

A. Endotracheal intubation performed by an EMT-B is an advanced procedure that requires medical direction.

B. An EMT-B is authorized to perform endotracheal intubation only after completing training that:

1. Meets all requirements established in the EMT-B Endotracheal Intubation Training Curriculum, dated January 1, 2004, incorporated by reference and on file with the Department, including no future editions or amendments; and available from the Department's Bureau of Emergency Medical Services; and

2. Is approved by the EMT-B's administrative medical director.

C. An EMT-B shall perform endotracheal intubation as:

1. Prescribed in the EMT-B Endotracheal Intubation Training Curriculum, and

2. Authorized by the EMT-B's administrative medical director.

D. The administrative medical director shall be responsible for quality assurance and skill maintenance, and shall record and maintain a record of the EMT-B's performance of endotracheal intubation.


Among the requirements of the training cirriculum are:

3. Attempted a minimum of 3 endotracheal intubations in the prehospital setting.

4. Performed a minimum of 1 successful endotracheal intubation in the prehospital setting._


Should an EMT be allowed to intubate if they have the proper training?  Just curious to get everyone's opinion on this one...


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## WuLabsWuTecH (May 21, 2008)

I am just a student, but my understanding is with the advanced airway curriculum in Ohio, Ohio EMT-B are not only allowed to intubate, they are expected to intubate as part of their duties.

Once again, correct me if I am wrong

info obtained here: http://www.grantlifelink.com/emseducation/emtbasic.htm
here: http://www.emt-national-training.com/ohio-emt.php
and here: http://ems.ohio.gov/ems.asp


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## JPINFV (May 21, 2008)

Only 1 actual prehospital tube is required? So a basic batting 0.333 is considered experienced enough?

Any OR tubes required?


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## el Murpharino (May 21, 2008)

NYS has a level for this...it's called EMT-Intermediate.  It's different from the NREMT-Intermediate level in that NYS EMT-I's can do IV's and Intubate, without being able to push almost all the meds, with exception of Saline, D5W, and LR.  When I took that class about...oh, 6 years ago, we spent the majority of the class on airway.  The average EMT-B curriculum is about 120-150 hours.  I just don't know if there is enough time in the EMT-B class to cover the finer points of intubation, acid-base balances, airway anatomy, etc.  without missing some of the basic skills every EMT-B should be proficient at.  But the NREMT feels this is a skill basics can perform...


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## snaketooth10k (May 21, 2008)

*Yes*

In NJ, we aren't allowed to. However, I think we should be since it is included in our course book. It is also needed immediately in some situations; a patient could be dead by the time the medics show up. It also isn't a very complicated procedure, though the consequences can be quite the opposite.
I believe that Intubation should be allowed for EMT-B.


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## Arkymedic (May 21, 2008)

Jeremy89 said:


> While looking for local EMT Protocols online, I recently found the following:
> 
> _R9-25-808. Protocol for an EMT-B to Perform Endotracheal Intubation_
> 
> ...


 
I need to see the training syallabus before I make any comments or piss anyone off... My EMT-I partner can intubate here in OK. OK does not accept EMT-I for reciprocity without the I recipient being trained in advanced airway, and demonstrating such in OR, prehospital, and training.


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## KEVD18 (May 21, 2008)




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## TheMowingMonk (May 21, 2008)

what emts can do very greatly by state to state, county to county. Like in california, based on state law, EMT-B's cause do IV's, ET Tubes, blood glucose plus an extra handful for drugs. the thing with that though is each county can choose weather or not to let their emts use those skills. In my case with Santa Clara county, emts arent allowed to do any of those things. They wont even let us do pulse ox readings or take a temp which i think is rediculus. but thats what the county want, but the point is depending on where you are, your skills vary greatly.


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## VentMedic (May 21, 2008)

Actually this is not totally like "beating a dead horse" since a few states are revising their statutes even as this post is being written. 

The areas that I am familiar with the EMT-B intubating, per protocol the patient must be pulseless or in other words, dead.   If BLS is all you have responding to a code situation, then chances of ROSC may be slim anyway.    If the EMT-B can not establish an IV/IO or push meds, orally intubating someone with an ETT that isn't dead already would be risky and may lead to death.   Of course, then once the patient is without pulse or dead, it would be okay.


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## fma08 (May 23, 2008)

i would think with the proper training and knowledge base about airway anatomy and the procedure then sure. But that 3 attempts in field, and 1 successful in OR requirement is bogus. In school we need at least 10 intubations and all of mine have been in the OR, not the field. I kinda wish it would have been more (just because i haven't had the chance to intubate since).


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## BossyCow (May 23, 2008)

Washington State differs a bit. We have adjuncts to the EMT-B. You can be an EMT-B with an add-on for IV and Airway. You can maintain those two skills with a Basic Cert. However, there is also EMT - I which includes (I think, I Might be wrong) some pharmacology. 

As I understand it, this will be changing in our state with the adoption of the new National Standards. The last meeting I was at wasn't real clear on how it would be altered, but said it would have to change somewhat. They sounded like they were leaning towards making the IV/Airway cert a strictly ILS skill, but nothing was final.


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## triemal04 (May 23, 2008)

VentMedic said:


> Actually this is not totally like "beating a dead horse" since a few states are revising their statutes even as this post is being written.
> 
> The areas that I am familiar with the EMT-B intubating, per protocol the patient must be pulseless or in other words, dead.   If BLS is all you have responding to a code situation, then chances of ROSC may be slim anyway.    If the EMT-B can not establish an IV/IO or push meds, orally intubating someone with an ETT that isn't dead already would be risky and may lead to death.   Of course, then once the patient is without pulse or dead, it would be okay.


Really funny when you consider that airway is getting to be less emphasized in a code and circulation is starting to take priority; or at least has become much more important than before.  Add in that compression will be stopped for quite awhile while they're attempting the tube (I'll gaurentee this) and I'll go out on a limb and say that no code that get's tubed by a basic will be coming back.  

Pointless to be doing this without the required knowledge of why it's being done, when to do it, when not to do it, how to really do it, complications that might come up, how to deal with those complications, what to do to stop doing it, and why you'd do that.

Just like everything else.


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## BossyCow (May 23, 2008)

triemal04 said:


> Really funny when you consider that airway is getting to be less emphasized in a code and circulation is starting to take priority; or at least has become much more important than before.  Add in that compression will be stopped for quite awhile while they're attempting the tube (I'll gaurentee this) and I'll go out on a limb and say that no code that get's tubed by a basic will be coming back.
> 
> Pointless to be doing this without the required knowledge of why it's being done, when to do it, when not to do it, how to really do it, complications that might come up, how to deal with those complications, what to do to stop doing it, and why you'd do that.
> 
> Just like everything else.



Umm... I have two combi-tubes who survived and are alive today. One was a drug overdose and the other a drowning. I think their familiies would disagree with you. Now, the combi-tube was placed enroute to an ALS intercept, but the 10 minutes of O2 they received until ALS took over meant that ALS had a viable pt to work with instead of a self watering vegetable.


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## triemal04 (May 23, 2008)

BossyCow said:


> Umm... I have two combi-tubes who survived and are alive today. One was a drug overdose and the other a drowning. I think their familiies would disagree with you. Now, the combi-tube was placed enroute to an ALS intercept, but the 10 minutes of O2 they received until ALS took over meant that ALS had a viable pt to work with instead of a self watering vegetable.


Both of those had a better chance of surviving that the average code anyway.

And if you can't see the difference in putting a combi-tube in someone and performing endotracheal intubation, it's just more reason that this skill should not be performed by lesser-trained individuals.


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## JPINFV (May 23, 2008)

TheMowingMonk said:


> what emts can do very greatly by state to state, county to county. Like in california, based on state law, EMT-B's cause do IV's, ET Tubes, blood glucose plus an extra handful for drugs. the thing with that though is each county can choose weather or not to let their emts use those skills. In my case with Santa Clara county, emts arent allowed to do any of those things. They wont even let us do pulse ox readings or take a temp which i think is rediculus. but thats what the county want, but the point is depending on where you are, your skills vary greatly.



Yea, but it would be interesting to see how many areas actually use the extra modules (my personal favorite is the one that allows EMT-Bs to manually defibrillate if directly supervised by a paramedic). Similarly, California still has an EMT-Intermediate (EMT-II [two]) level, but it's only used in a handful of counties use it, and the last report I've been able to find about it listed the total number of EMT-II providers in the state at less than 200. 

As far as pulse ox's, why is it ridiculous? Respiratory and cardiac physiology is simply not covered in depth enough to even begin to understand the number, or what conditions will either cause a false high or low or make the number useless (example of the distinction. SpO2 reading is 'valid' (valid in the sense of "correct," not valid in the sense of "useful") in patients with cyanide poisoning since cyanide disrupts the electron transport chain. Carbon monoxide, on the other hand, screws with oxygen binding, thus giving a false high reading). 

As a semi-aside, since it seems you're making the "it's so easy" argument, why not let basics push drugs? After all, we've all got opposable thumbs and that's all it takes to push a syringe. It's the same argument that getting a SpO2 is as simple as putting a clip on someone's finger. It'd be like me claiming I'm an ALS provider because I know how to do EEGs.


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## BossyCow (May 23, 2008)

triemal04 said:


> Both of those had a better chance of surviving that the average code anyway.
> 
> And if you can't see the difference in putting a combi-tube in someone and performing endotracheal intubation, it's just more reason that this skill should not be performed by lesser-trained individuals.




Where in my post did I say that I did not understand the difference between an ET tube and a combi-tube? The original post referred to both ET and Combi-tube (which is not universally accepted as a BLS skill). While I agree that both my saves were not your typical code, both of them would most likely have died if they had to wait the full ten minutes for ALS without BLS intervention.


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## triemal04 (May 23, 2008)

BossyCow said:


> Where in my post did I say that I did not understand the difference between an ET tube and a combi-tube? The original post referred to both ET and Combi-tube (which is not universally accepted as a BLS skill). While I agree that both my saves were not your typical code, both of them would most likely have died if they had to wait the full ten minutes for ALS without BLS intervention.


Actually, the original post just referenced ET tubes.  Which is what I referenced in my first post.  As well, the time it takes to place a combitube is extremely short when compared to an ET tube, and it can be accomplished without interrupting compressions, something that is EXTREMELY important.  Add in that it is much harder to screw up a combitube (though not impossible; I have seen it done) and you'll see why I posted what I did.

And both those pt's would not have neccasarily died; like I said, they aren't your standard code, and a crew who knew what they were doing and were able to provide good compressions and good ventilations/suction using a BVM and OPA (good meaning they didn't squeeze the bag hard as they could and inflate the belly) would have helped a lot.  Also, do you really think that just placing the combitube made all the difference?  If so, please elaborate.


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## WuLabsWuTecH (Jun 12, 2008)

triemal04 said:


> Really funny when you consider that airway is getting to be less emphasized in a code and circulation is starting to take priority; or at least has become much more important than before.  Add in that compression will be stopped for quite awhile while they're attempting the tube (I'll gaurentee this) and I'll go out on a limb and say that no code that get's tubed by a basic will be coming back.
> 
> Pointless to be doing this without the required knowledge of why it's being done, when to do it, when not to do it, how to really do it, complications that might come up, how to deal with those complications, what to do to stop doing it, and why you'd do that.
> 
> Just like everything else.


I'm gonna disagree with you here.  One of my Instructors intubated 4 times as a basic and got 3 of them back...


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## Ridryder911 (Jun 12, 2008)

WuLabsWuTecH said:


> I'm gonna disagree with you here.  One of my Instructors intubated 4 times as a basic and got 3 of them back...




I say B.S. ! Prove it.. he/she better write a journal article. In adults respiratory arrests alone does usually lead into cardiac arrest until severe hypoxia has began. After an cardiac arrest occurs the likelihood of even with pharmacological agents is <6%. 

R/r 911


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## Hastings (Jun 13, 2008)

Just no. Basics have the tools to keep a patient alive long enough for ALS to arrive and intubate. The risk just far outweigh the benefit. Especially when the risks include death, and the paramedics are, in most cases, a mere call away.


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## snaketooth10k (Jun 13, 2008)

Hastings said:


> Just no. Basics have the tools to keep a patient alive long enough for ALS to arrive and intubate. The risk just far outweigh the benefit. Especially when the risks include death, and the paramedics are, in most cases, a mere call away.



Maybe where you live, but our squad has seen medic delays of over 30 minutes while carrying critical patients. I just read a long instructional article on use of the combitube, and it seems like a viable option if using a standard ET tube is too risky for a B. The LMA also seems like a good tool for basics. I do think that the patients must be in cardiac and respiratory arrest as well as unresponsive though.


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## Hastings (Jun 13, 2008)

snaketooth10k said:


> Maybe where you live, but our squad has seen medic delays of over 30 minutes while carrying critical patients. I just read a long instructional article on use of the combitube, and it seems like a viable option if using a standard ET tube is too risky for a B. The LMA also seems like a good tool for basics. I do think that the patients must be in cardiac and respiratory arrest as well as unresponsive though.



Yes. The combitube is a great alternative for a basic. It's easy to put in, it secures the airway, and even medics resort to it if they can't get an ET.


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## triemal04 (Jun 13, 2008)

WuLabsWuTecH said:


> I'm gonna disagree with you here.  One of my Instructors intubated 4 times as a basic and got 3 of them back...


So your instructor tubed 4 people who were pulseless and apneic, then performed BLS care only, and got a heartbeat back on 3 of them?  Hmmm....


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## Hastings (Jun 13, 2008)

triemal04 said:


> So your instructor tubed 4 people who were pulseless and apneic, then performed BLS care only, and got a heartbeat back on 3 of them?  Hmmm....



Earth-shattering CPR and a Magic AED.


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## Jon (Jun 13, 2008)

Hastings said:


> Yes. The combitube is a great alternative for a basic. It's easy to put in, it secures the airway, and even medics resort to it if they can't get an ET.


Combitube... that's so 2 years ago.

King LTD all the way!


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## So. IL Medic (Jun 14, 2008)

Vent, a question. A Basic asked me this and I didn't have a good answer other than an ET tube is a more definative airway.

We had a code, an obese pt with a very anterior trach. I couldn't get the tube on the first pass. Didn't try for a second, instead grabbed a King and inserted it while he was doing compressions. Good lung sounds bilat. Off we went. On arrival at the ER, the doc pulled the King. Tried four times to get the tube unsuccessfully. The question my partner asked was why remove a good, workable airway in the middle of a code? I've seen it happen a few times too.


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## Hastings (Jun 14, 2008)

Jon said:


> Combitube... that's so 2 years ago.
> 
> King LTD all the way!



Actually, heard our service recently switched to those due to the price of the Combitube, but I haven't been trained on it yet since medics do tend to rely on the ET instead. I should get on that.


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## el Murpharino (Jun 14, 2008)

Hastings said:


> Actually, heard our service recently switched to those due to the price of the Combitube, but I haven't been trained on it yet since medics do tend to rely on the ET instead. I should get on that.



I'm pretty sure you can be trained on the King in about....oh...10 minutes.  That may even be stretching it.


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## Ridryder911 (Jun 14, 2008)

So. IL Medic said:


> Vent, a question. A Basic asked me this and I didn't have a good answer other than an ET tube is a more definative airway.
> 
> We had a code, an obese pt with a very anterior trach. I couldn't get the tube on the first pass. Didn't try for a second, instead grabbed a King and inserted it while he was doing compressions. Good lung sounds bilat. Off we went. On arrival at the ER, the doc pulled the King. Tried four times to get the tube unsuccessfully. The question my partner asked was why remove a good, workable airway in the middle of a code? I've seen it happen a few times too.



I am not Vent, but I will give you my opinion. As a Paramedic you should had recognize that all other airways are alternative airway. Only the ETT is a definitive airway. As well, I am sure he might not have known what the "king" airway was. I do not criticize for pulling the airway, but if he did not re-insert then there is a problem. 

Remember as well, the alternative airways are only temporary too. 

I ask if anyone is using the flexguide or bougie elastic guide? I now use it for anterior intubations, and have not had a problem. One of larger metro services has been using them for about fiver years now & their success went from 92% to 98% rate (>40 intubations per week). They are cheap, easy to use and disposable. 

R/r 911


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## Flight-LP (Jun 14, 2008)

We've used them for a couple of years now, great adjunct to assist with intubation.


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## el Murpharino (Jun 14, 2008)

The bougie is a great tool to assist with tough intubations; we've been using them for a year or two now.  I was introduced to them when I took a difficult airway management course.


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## VentMedic (Jun 14, 2008)

Ridryder911 said:


> I am not Vent, but I will give you my opinion. As a Paramedic you should had recognize that all other airways are alternative airway. Only the ETT is a definitive airway. As well, I am sure he might not have known what the "king" airway was. I do not criticize for pulling the airway, but if he did not re-insert then there is a problem.
> 
> Remember as well, the alternative airways are only temporary too.
> 
> ...



Inside the hospital, codes are critiqued heavily.  Airway will be the first thing to be scrutinized and what steps were taken to secure a definitive airway.   If the pt had ROSC, only an Endotracheal Tube is approved to be on a ventilator.  A hospital should have a difficult airway cart and some highly trained medical professionals capable of getting a definitive airway.   If not, another alternative airway could have been reinserted until the equipment and personnel arrived if the BVM was ineffective.  

Agree, the bougie is an excellent device.  

I have gotten a lot of intubation opportunities in the ED because of Combitubes and some ALS crews who don't bother keeping their intubation skills adequate or just lazy.  Changing out the Combitube is not my favorite thing to do because there is always the chance for esophageal or larynx/trachea damage that will later result in a legal process if there are complications that must be dealt with.  There will also be the lengthy medical recovery from those complications along with whatever caused them to be intubated that may be challenging for the patient if they live and the medical staff.  

We also change out some field ETTs that are not the appropriate size, are dirty (not just blood and vomit) or there is a possibility the patient will have several vent days.  We have tubes designed to decrease the risk of ventilator associated PNA.


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## Jon (Jun 14, 2008)

Vent - What's your take on King LTD vs. Combitube?


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## VentMedic (Jun 15, 2008)

Jon said:


> Vent - What's your take on King LTD vs. Combitube?



In all honesty, I have not put either of these tubes in a patient during an emergency. I have only removed them to intubate with an ETT.   I have practiced using them on manikins and cadavers.  The King seems to be easier.  The Combitube is large and can damage the cords if it does pass through them blindly. Of course, if the patient is coding, the concern for damaging the cords may not be a thought.  It may, however, present problems when a definitive airway is attempted and/or if the patient survives.  That problem I have encountered when changing tubes. 
I do like that you can suction the stomach easier with the Combitube.   

If I didn't have my other devices to facilitate intubation, I would probably go with the King.   It reminds me of the old EOA, which all the BLS trucks in my area used to carry in the 70s and 80s, only better.


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## PNWMedic (Jun 15, 2008)

Well I think that might be reserved for remote EMTs (EMT's responding to a call where it may take a while to arrive at definitive care). In my Wilderness EMT course we were trained in ET Tube Intubation, although I have never used it. So i'm not sure, could be a cert on top of the regular EMT-B?


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## So. IL Medic (Jun 17, 2008)

Thank you, Vent. I had not been thinking along the lines of post-resuscitation, instead focused on the immediate working the code. My thoughts are an airway with good ventilations is better than attempting the definitive airway during the code. Could the ETT wait until resuscitation is determined or would that be a negative in the code critique?


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