# Combitube question



## TransportJockey (Dec 3, 2007)

Well, I did pass my skill test for combitube, but I was wondering how many other EMT-B's can use the skill? I know out instructor said we were one of the few states where they are allowed to.


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## Capt.Hook (Dec 3, 2007)

HI jt.  Don't know if this helps, but in WI, First Responders and Basics are allowed to use combitubes.  Our FR's just completed training and we put the skill into service, but soon we will change to the King LT.  Our MD has decided to slowly implement a change to a (assumably) better product with the LT.  Personally, I don't know much about it.  TRAINING!


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## TransportJockey (Dec 3, 2007)

Capt.Hook said:


> HI jt.  Don't know if this helps, but in WI, First Responders and Basics are allowed to use combitubes.  Our FR's just completed training and we put the skill into service, but soon we will change to the King LT.  Our MD has decided to slowly implement a change to a (assumably) better product with the LT.  Personally, I don't know much about it.  TRAINING!



FR's using the skill is news to me, but yea that helps. Thanks


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## katgrl2003 (Dec 3, 2007)

EMTs in Indiana are allowed to use them too.

-Kat


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## MRE (Dec 3, 2007)

No combitubes for Basics in MA.  I'm very surprised to hear that FR's can do them, here our FR's can't even do OPAs and NPAs.


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## Guardian (Dec 3, 2007)

jtpaintball70 said:


> Well, I did pass my skill test for combitube, but I was wondering how many other EMT-B's can use the skill? I know out instructor said we were one of the few states where they are allowed to.




And for good reason.  Oh me, I shouldn't have typed that because of the massive debate that will follow.  If you search this site though, you can read about that debate--it's pretty interesting.  My opinion, they should only be used as als backup when ET intubation isn't successful and basics shouldn't touch them.  If you read the debate, you'll understand my reasoning and maybe even agree.  And, welcome to the site.  To answer your question, where I live (on the northern east coast) basics are allowed to use the combitube.


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## TransportJockey (Dec 3, 2007)

Guardian said:


> And for good reason.  Oh me, I shouldn't have typed that because of the massive debate that will follow.  If you search this site though, you can read about that debate--it's pretty interesting.  My opinion, they should only be used as als backup when ET intubation isn't successful and basics shouldn't touch them.  If you read the debate, you'll understand my reasoning and maybe even agree.  And, welcome to the site.  To answer your question, where I live (on the northern east coast) basics are allowed to use the combitube.



We actually had a similar debate in class. Part of the new procedure for most of ABQ area is that the medics get 1 shot to intubate, if they fail, we go in with an MLA. Or if we're the only unit available and it needs to be done.

Thanks for the welcome  And I'll check out the details of the online debate


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## FFPARAMEDIC08 (Dec 3, 2007)

Our basics are allowed to use the Combitube by state law. As long as they know how to do it, I don't see too big of a problem with it. FR's can use OPAs and NPAs.


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## skyemt (Dec 3, 2007)

NY state


we basics can not use them...


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## Capt.Hook (Dec 3, 2007)

Just to add, FR's have used OPA & NPA here for as long as I know.  We are generally 20ish minutes away from ALS.  We utilize a strong FR squad that works very closely with the ALS provider.  I have only ever "installed" (sorry, carpenter's term) one in the last year of our new protocols.  That case happened to be that the ALS crew, upon arrival, chose to leave it in place and use it for transport.

Side note, not to hi-jack:  with our newer protocols, we are now assisting patients with epi-pens.  We also are allowed to package a patient in the KED prior to ALS arrival.


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## TransportJockey (Dec 3, 2007)

Capt.Hook said:


> Side note, not to hi-jack:  with our newer protocols, we are now assisting patients with epi-pens.  We also are allowed to package a patient in the KED prior to ALS arrival.



Thread-jacking is fine with me 

We are KED trained at Basic here, and we also carry Epi in the rigs.


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## BossyCow (Dec 3, 2007)

WA Basics with one year experience can use Combi-tubes.  Only used if ALS is not available in our district.  Not sure about other systems in the state.


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## Ridryder911 (Dec 3, 2007)

Wow! What a dangerous predicament! I am surprised that a medical director would ever sign off a "blind intubation" to a MFR. That is asking to be sued, and to be in litigation. I personally do not believe basics should even be able to perform this tasks. It is an advanced airway, with the potential (or goal) is to be able to intubate the trachea. 

Sorry, a first-aider should never be allowed to introduce anything or device into the trachea. There is too many complications and dangers involved. It would be much wiser to emphasize, stress, and mandate complete perfection of basic level devices.

R/r 911


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## ki4mus (Dec 3, 2007)

VA

EMT-B can use them, not sure about FR


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## FFMedic1911 (Dec 3, 2007)

Here in Kentucky basics and medic can use the combitube.I think it is a wonderful device.Sure it isn't as nice as an Et tube but it has it place.The first thing beat into are head as a FR,basic,or medic is airway,airway,airway.Maybe the ones that don't think it is right for a basic to use it have had bad results from first responding units that have used them.Have I seen them used wrong, yes and that was by a doctor.Long story short medic had an airway with it doc pulled it out because that wasn't a secured airway.End result pt ended up with a surgical cric.Of coarse that may be a little out of the realm we are discussing.But the point being no matter how many degrees you have you must use common sense and know how to use the tools laid in front of you.


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## Ridryder911 (Dec 3, 2007)

I read where WI has 2 levels of First Responders. Basic and Advanced (combitube and Epi) Wow! Geez let's add some more levels ... might as well  just train them to do surgery... 

Why is it states attempt to allow anyone to perform anything they choose without research and scientific studies first? 

How well do we do they know that they can perform those skills, as well as maintaining performance levels? Is there such a shortage of EMS personal in WI, that we need anyone that attends a few hours of class to able to perform these procedures? Is it really in the best interest of the patient, or would having qualified personal be the best case? Or is this a good way to justify "the same care, only cheaper and easier" method? 

R/r 911


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## FFMedic1911 (Dec 3, 2007)

Rid I also see your side of the coin too.Yes I agree we have to many different levels of providers,and depending on where you are at determines what each one of those levels can provide.As a fire based paramedic I fined it silly that when I am here at work there is somethings I can't do that when I am home working for a private I can.


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## Capt.Hook (Dec 3, 2007)

Simple answer to the OP's simple question.  RR, why does everything always turn into an argument why no one is nearly as good as you?  
I don't care why the medical direction allows me to use these skills.  I care that they are there for me to use.  You have an issue about how and why we do things here, become a doctor and take it up with my medical director.


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## Ridryder911 (Dec 4, 2007)

Capt.Hook said:


> Simple answer to the OP's simple question.  RR, why does everything always turn into an argument why no one is nearly as good as you?
> I don't care why the medical direction allows me to use these skills.  I care that they are there for me to use.  You have an issue about how and why we do things here, become a doctor and take it up with my medical director.



Simple EMS is part of medicine. I know and realize many EMT's do not understand that. Medicine is science and requires research. As in the past, we jump into something not knowing why and if what we are doing is really in the best interest of the patient. 

You are right, I don't take things at face value. I am an educated  professional, and as such I realize that I should question and be able to validate any and all of my treatment. If your medical director asked or wrote protocols for enema, would you not question it? 

If EMS and those that want to be treated as a professional, then we need to become one. We need to question and be sure what we do is the best for patient care. MFR may be great, or maybe not.. but, we should at least attempt to validate it with research prior to ever implementing it. Our history of errors such as PASG, CISD is a good example of that. 

I am still searching for lit review and studies on MFR using such devices. 

R/r 911


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## FFPARAMEDIC08 (Dec 4, 2007)

> I don't care why the medical direction allows me to use these skills.



Hook, that is a rather ignorant approach to _emergency medicine_. That's right, as rr put it, we are employed in the medical field as healthcare providers and need to act accordingly.

It's your JOB as a professional healthcare provider to be a _patient advocate_. Which, in this case, is knowing whether or not allowing you to use a combitube to intubate the patient is really in that patient's best interest.

I see two issues with your personal attack on rr:

1) I have seen no instances where he claims to be the top authority on emergency medical treatment.

2) He DOES hold a very high level certification. When you get the same certification as him, then maybe you'll be able to see his side of the argument. 

I honestly don't see why you take his opinion so personally, yet you expect him and everyone else to "become a doctor and take it up with your medical director" when they disagree with your opinion.


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## reaper (Dec 4, 2007)

Capt.Hook said:


> Simple answer to the OP's simple question.  RR, why does everything always turn into an argument why no one is nearly as good as you?
> I don't care why the medical direction allows me to use these skills.  I care that they are there for me to use.  You have an issue about how and why we do things here, become a doctor and take it up with my medical director.



You have made Rid's whole point in that one statement. That is exactly why people that think like that, should not be doing any kind of invasive procedures!!:unsure:

When you gain the medical knowledge, you may understand the whole issue!


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## Capt.Hook (Dec 4, 2007)

Yes, I may have somewhat jumped to a presumptuous (sp) conclusion.  I understand your points towards my statements.  The comments posted are very good points.  Makes me want to understand more about seemingly simple items like the combitube.  It's definately a skill most FR or basics may never use, yet when that time is upon, are expect to perform flawlessly.
I give mucho credit to anyone with even parts of an alphabet behind their name.  That said, it should be given in return.  I take offense to RR statements, not personnally, but (semi) professionally.  In rural areas like mine and many other places, we volunteer to offer the MOST care that we can as quickly as we can.  I take it for granted that when my MD gives me a skill that they say will help people, and they train me to use these skills, that I should be able to perform them to the best of my ability. 
With that, I do now realize there is more to what is considered an invasive procedure like combitube.  Tell me about the King LT.  wait, I'll start another thread tonight.   
I do, in fact, care why we do our skills.  I am a student of the game as much as the next person. 
I always enjoy these threads, however, it gets very tiring when a question is asked then gets turned into a basic bashing.  I volunteer.  Maybe that's many people's "out" to not knowing all the in's and out's. I know for a fact of the importance of a FR system in my area.  I will defend that to the end.  I wish all FR and Basics could automatically become some form of ALS and we wouldn't need to wait for transport.  The training isn't there.  I have a paramedic trained woman on my squad.  I (as a basic, even a FR) don't even trust her with some of the simplest FR skills.  What to do?  Well, for starters we need to trust our MD to point us the way to being the best we can with the few skills we use.
Again, I appreciate the professionalism around here.  Thanks for insights.

Aryn


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## Ridryder911 (Dec 4, 2007)

There are multiple problems. One we allow someone to take a few week course prompting them that they actually know something about medicine. Sorry, this would be in comparison of someone taking a week-end course on changing beds, learning vital signs, and then calling themselves a nurse. 

Again, it is NOT EMT bashing, rather recognizing the place and role for MFR and Basic level. Does your MFR understand esophageal perforation, or those with possible esophageal varices or even if successful tracheal intubation risks, and the common risks associated with each? 

Please, please don't give me the old adage pity..."_"We are rural"_...sympathy card. I have worked in rural areas the majority of my career. Just because one is rural does NOT mean they have to deliver substandard care, nor does it mean they should have any excuses or allowance given to the them either. In fact, since the likelihood and percentage of them being able to perform any procedure is lower, should indicate and mandate that they should have more in-depth training and then be monitored closely for skill deterioration. It should not matter the location on quality of delivery of care. Again, I have been a manager of ER's, EMS and provided in very rural remote areas. It does not take in account or matter per medical standards, or in court where one is delivering that care.... there are standards for a reason. 

Sorry, if your not "into" knowing the in's and out, then you have *NO* business touching or treating anyone. Even at MFR level they are a representative of medicine, if one don't want to participate correctly then get out! Yes, someone else will take your place that will. As well, if you have a trouble with your Paramedic then document it and present it to your medical director. Maybe, you don't trust your Paramedic as a basic because  you do fully understand the treatment, or maybe she does not trust you? Yes, I agree there are crappy Paramedics...one of my most pit peeves next to basics that think they know all about medicine. 

My whole point was to emphasize instead of adding another level, and then  introducing tools that could endanger patients, maybe the medical direction should be sure that the MFR can perform their current level flawlessly. How well, can that MFR perform BVM without gastric distention, how well do they perform suctioning and prevent aspiration? How often is your MFR or even you as a basic are tested and the patient care is actually reviewed and monitored? 

Even AHA and other medical organizations, have indicated advance airway techniques should only be taught and used by those proficient in that area. There are too many risks that could happen.

Many medial directors have well intentions and objectives, however'; just because they are an M.D. does not mean they understand EMS or EMT training. There are many that are even medical directors that have not a clue what it is like in EMS. If your medical director is active and participates, then you are lucky and are in the minority. 

Short cuts in medicine always lead into long term problems. Apparently we never learn.  

R/r 911


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## skyemt (Dec 4, 2007)

CaptHook,

wow! playing the rural card AND the volly card!

well, i as well am a Volly EMT-B in a rural area...

i run at least 200 calls per year, and the more experience i get, the more i realize that certain skills, such as combitube should NOT exist at the basic level...

i'm sure you are aware that many basic's do not keep their knowledge and skills up to par, and frankly, it scares me that they would be able to introduce a device into a pt's trachea...

now before anyone jumps on me, i would like to use these devices... but i feel that i should be certified at a higher level to do so... and i will use them, why i am better educated and trained.

just because you "can" do something does not make it "wise" to do so...

I have been down the defensive "basic" bashing thing before...

if you have to sit down and really be honest with yourself, as i did, you know in your heart of hearts that the very qualified paramedics out here are right a majority of the time. Basic's will never win any arguments about level of pt care... it is low. that is why it is called Basic.

if you feel strongly about patient care, and doing more skills, just become certified at a higher level.


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## ffemt8978 (Dec 4, 2007)

I'm glad to see that everyone is getting this thread back on track so it doesn't have to be closed.

Just a friendly reminder to all that everyone needs to play nice in the sandbox.


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## wolfwyndd (Dec 4, 2007)

jtpaintball70 said:


> Well, I did pass my skill test for combitube, but I was wondering how many other EMT-B's can use the skill? I know out instructor said we were one of the few states where they are allowed to.


Our dayton, OH area local protocol has allowed EMT-B's in this area to use a combitube for  . . . . . at least three years.  Not sure exactly when it was first allowed, but I know when first got my B three years ago I had no idea what a combitube was.  I had to have my training office teach me how to use one.


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## BossyCow (Dec 4, 2007)

I am allowed to use combi-tube.  I have actually used it several times.  We are required to train on it at least quarterly and only after a full year of working as an EMT-B.  

While I understand that there are complications that can result from any invasive procedure, the big complication of not having that tool at my disposal is death.  

I have seen increased perfussion result from the use of a combi-tube.  Resulting in a pt. arriving at the hospital in better condition than they would have without it.  (without it again being... dead).  Do they all survive?  No... many of them do die anyway, but my understanding of the basic level of EMS is we are supposed to do what we can to give each pt. we see a higher chance of survival than they would have had without our interventions.  

Since our protocols state that combi-tube is only to be used when the pt. is unconscious and not breathing, what would you have us do instead?  OPA? NPA? Do nothing?  

Understand with an average of 20 minutes in transport time, and ALS only available sometimes, when you weigh risk vs gain in this instance, the probability of complications from the combi-tube in my opinion do not out weigh the probable gain resulting from increased perfussion.


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## Capt.Hook (Dec 4, 2007)

Ok, I can understand now where many comments were coming from.  Never in any way was I trying to play the "volly and rural card".  Fact of life is such that there just isn't enough qualified EMS pros.  The para on our squad is a mute issue.  She sucks.  I feel she was pushed through the system.  

As for basic bashing.  Well, poor word choice.  I hope later to do a thread regarding "non-ALS care" and how we can be the best possible.  Covered here many times? fine.  Not for me.  I will appreciate any input from any source.  

I, personally, never meant to be an issue in the OP's thread.  I feel I merely stated what "is allowed" here in WI.  I feel the thread turned when posters took the secondary care route.  I get defensive when the best we have just isn't good enough.

I have thought about this all day.  It's nice to have things like this to consume my thoughts while I work on setting trusses in a mild snowstorm.  RR and others comments were well warranted.  

Bossy actually stated for me how my earlier posts should have read.  Thanks!

I appreciate this forum and look forward to many more threads.


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## Ridryder911 (Dec 4, 2007)

I understand your predicament Capt Hook, we all are under medical control in some form or another. The emphasis I want all levels to understand is not to take anything at face value. It is okay to question on what we do is really the best? Have there been enough scientific studies and proof on what we are doing is really the best for the patient. 

Unfortunately we in EMS assume on what we do must be in the best behalf of the patient or we would not do it right? ... I wished. Look at CISD, Trendelenburg, trauma care, cardiac arrest even CPR that have been performed wrong for years. Actually, very little what we do has ever been proven scientifically to be in the best interest of the patient. 

It is our profession and what we do is how we treat our patient. Let us be mindful that we have to proactive and be a patient advocate. 

Emergency medicine is an ever changing and revolving process. We can only provide better care by beter research and improvements of our care. 

R/r 911


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## disassociative (Dec 4, 2007)

Here in TN; our EMT-IV's(NREMT-B with extra training) can use Combitubes, PTL, and your standard NPA,OPA; ET Intubation is being considered; but I dont want to even get into that debate(as I am sure most of you dont, lol.)


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## Medic8388 (Dec 14, 2007)

I did my EMT-B training in Florida and we were trained to use the CombiTube.  I moved to Ga 3 days after finishing my course and as an EMT-B I was not allowed to use the device in Ga.  EMT-I's in Ga are allowed to use the combitube.  I love the combitube.  Its fast and easy and I can quickly move onto other things.  Also since in ga an EMT cannot use the EZ-IO I can allow an EMT partner to manage the airway while I get the IO access (if needed).  I really dont see any problem with basics using the combitube as long as they're trained and keep up with the skill (like they should be doing anyway).


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## skyemt (Dec 14, 2007)

basically, these threads all follow a familiar pattern...

emt'bs want to do as much as they can, so they can feel like more than an emt-b...
paramedics want them to do as little as possible, because they are afraid they will feel like more than an emt-b...

my question is, when ALS is not available, which can happen in many parts of the country, the risk of a poor pt outcome rises...

there must be interventions that paramedics feel emt-b's should perform because the poor pt outcome hangs in the balance...

in other words, the risk of the emt'b intervention is outweighed by the risk of a poor pt outcome, and the intervention becomes worthwhile...

to paramedics: which emt-b med or intervention do you feel meets the above, and which do you feel should not be done under any circumstances, no matter pt condition?


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