Advanced Airway: unconscious to conscious

[Mountain Res-Q]

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.

 

[johnguillen68]

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.

 

[VentMedic]

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.

 

[VentMedic]

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.

 

[JPINFV]

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.

 

[CAOX3]

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.

 

[BrianJ]

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

Good luck with your studying.

 

[Mountain Res-Q]

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.

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.

 

[GeekMedic]

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

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

 

[Ensihoitaja]

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

 

[VentMedic]

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?

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.

 

[johnguillen68]

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.

 

[Mountain Res-Q]

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!)

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.

 

[VentMedic]

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.

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.

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:

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.

 

[Sasha]

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.

 

[JPINFV]

^
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.

 

[lightsandsirens5]

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.

 

[Mountain Res-Q]

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).

 

[marineman]

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.

 

[VentMedic]

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.