the 100% directionless thread

[PotatoMedic]

DA..DA..DA..double post

 

[STXmedic]

et intubation twice before moving on.


In the place I worked prior it was three attempts at getting an et prior to moving on.


Many use nasal as a first attempt ET. A lot use bougies as well.



Hospitals prefer an et as opposed to a supraglottic. But of course, you get what you get.

Yes, it's typically two attempts by one provider, a third by a second, then a backup airway. And yes, almost always a bougie. What I was confused about was you saying nasal intubation was your backup. That's an odd (and in my opinion, bad) choice.

Studies.

They are often overinflated and cause restricted perfusion.

Singular- A study. On pigs. That hasn't been repeated, especially on humans.

 

[ViolynEMT]

I just got a Galaxy S5 this morning. I've been wanting to switch from my iPhone 5 for a while. Only had it for a few hours, but I love it so far.

I have an S5. I absolutely love it.

 

[Ewok Jerky]

Thanks for the phone tips.

Just found out that we are getting another half a foot of snow on Tuesday when I need to drive 70 miles to take my board exam

 

[NomadicMedic]

I've decided it's way better to be working as a paramedic because I like to, rather than I HAVE to.

 

[COmedic17]

Yes, it's typically two attempts by one provider, a third by a second, then a backup airway. And yes, almost always a bougie. What I was confused about was you saying nasal intubation was your backup. That's an odd (and in my opinion, bad) choice.

Singular- A study. On pigs. That hasn't been repeated, especially on humans.

A third attempt by what other provider?
If your the only medic, that's it. Two attempts at ET ( oral, then nasal, or whatever ) then goes to supraglottic.

Perhaps you feel nasal is a poor choice because your not as comfortable with it. Here, they are just as common as oral ET intubation. There are even some statistics saying they have a higher success rate, but I think that can be debated on wether the medics are trained to use that method or not, and what kind of test group was used to determine those statistics.



But here's some studies on disadvantages of king tubes that are not based on pigs or other livestock, more based on tongue engorgement after extended king tube usage.

http://www.researchgate.net/publica...nged_use_of_the_King-LT_laryngeal_tube_device



And you are correct. The experiments were preformed on pigs. Much in the same way a lot of medication is first tried on animals prior to humans. Pigs were chosen for having a similar (notice I said similar, not identical) anatomy with the vascular system in the esophagus. And the results did show decreased perfusion.

Secondly, I'm not a medical director. I didn't chose Combi over king. I stated we used Combi, and the reason as to why it was chosen for us to use Combi over king. As I stated prior, there are disadvantages and advantages to every supraglottic Airway. People are naturally going to prefer the one they use the most and have the most experience with- or feel the most comfortable using.

An airway is an airway.

.......but at the end of the day the hospital is going to pull that sucker out and drop an ET regardless.

 

[9D4]

This guy took a walk today. 6 months before I can walk unassisted has turned into 6 weeks. Did a mile today before I called it quits. Don't even have a horrible limp. My 6:16 mile turned into about 20 minutes though
Im disappointed that the scaphoid fx is taking so damned long though. Still another 2 weeks before PT for that. Severely limited ROM still. Almost no ability to extend the wrist.
Good luck on the board @Ewok Jerky
Hopefully the drive isn't too bad.

 

[DesertMedic66]

A third attempt by what other provider?
If your the only medic, that's it. Two attempts at ET ( oral, then nasal, or whatever ) then goes to supraglottic.

Perhaps you feel nasal is a poor choice because your not as comfortable with it. Here, they are just as common as oral ET intubation. There are even some statistics saying they have a higher success rate, but I think that can be debated on wether the medics are trained to use that method or not, and what kind of test group was used to determine those statistics.



But here's some studies on disadvantages of king tubes that are not based on pigs or other livestock, more based on tongue engorgement after extended king tube usage.

http://www.researchgate.net/publica...nged_use_of_the_King-LT_laryngeal_tube_device



And you are correct. The experiments were preformed on pigs. Much in the same way a lot of medication is first tried on animals prior to humans. Pigs were chosen for having a similar (notice I said similar, not identical) anatomy with the vascular system in the esophagus. And the results did show decreased perfusion.

Secondly, I'm not a medical director. I didn't chose Combi over king. I stated we used Combi, and the reason as to why it was chosen for us to use Combi over king. As I stated prior, there are disadvantages and advantages to every supraglottic Airway. People are naturally going to prefer the one they use the most and have the most experience with- or feel the most comfortable using.

An airway is an airway.

.......but at the end of the day the hospital is going to pull that sucker out and drop an ET regardless.

In a lot of systems across the US (maybe not yours) there is more than one medic on scene. We can have up to 6 medics all on scene of a general 911 call. It all depends on staffing of the ambulance (we have some dual Medoc units) and the fire department (fire go on all medical aids here. Can have no medics or can have 4 medics).

 

[MonkeyArrow]

Anyone else disappointed by the SNL 40 special? Im liking the NBA all-star game better...

 

[COmedic17]

In a lot of systems across the US (maybe not yours) there is more than one medic on scene. We can have up to 6 medics all on scene of a general 911 call. It all depends on staffing of the ambulance (we have some dual Medoc units) and the fire department (fire go on all medical aids here. Can have no medics or can have 4 medics).

More then one medic would be nice. EMTs here have IV certs which helps.

 

[Carlos Danger]

But here's some studies on disadvantages of king tubes that are not based on pigs or other livestock, more based on tongue engorgement after extended king tube usage.

http://www.researchgate.net/publica...nged_use_of_the_King-LT_laryngeal_tube_device



And you are correct. The experiments were preformed on pigs. Much in the same way a lot of medication is first tried on animals prior to humans. Pigs were chosen for having a similar (notice I said similar, not identical) anatomy with the vascular system in the esophagus. And the results did show decreased perfusion.

Secondly, I'm not a medical director. I didn't chose Combi over king. I stated we used Combi, and the reason as to why it was chosen for us to use Combi over king. As I stated prior, there are disadvantages and advantages to every supraglottic Airway. People are naturally going to prefer the one they use the most and have the most experience with- or feel the most comfortable using.

An airway is an airway.

.......but at the end of the day the hospital is going to pull that sucker out and drop an ET regardless.

When I asked where the belief that overinflation causes issues comes from, it was a sincere question.....I wasn't being a smartass. I try to stay up on the airway literature and have never heard of any studies showing that overinflation of SGA's causes problems in the emergency setting, as you stated. Of course there will be isolated cases here and there, such as the one you posted above, but I've never seen anything that establishes a problem with the basic design or proper use of any of these devices.

The swine study is interesting and academically important, but really offers no cause for concern at all as far as using these devices in humans. It was very small study to begin with - just nine animals - and it is important to note that these pigs were both well anesthetized and in cardiac arrest. In other words, an extremely low-flow state to begin with. So if this study were transferrable to humans, it would only apply to those in cardiac arrest, not to someone with a blood pressure. There have been several studies looking at outcomes of SGA vs. ETT in human cardiac arrest; none that I'm aware of show any clinically important advantage to either over the other.

 

[Chewy20]

Everyone on the road took their stupid pill this morning. Every call multiple different times people lose their brain when they see an ambulance coming their way. They should add lights and sirens behind people in driving tests to get their license.

 

[COmedic17]

When I asked where the belief that overinflation causes issues comes from, it was a sincere question.....I wasn't being a smartass. I try to stay up on the airway literature and have never heard of any studies showing that overinflation of SGA's causes problems in the emergency setting, as you stated. Of course there will be isolated cases here and there, such as the one you posted above, but I've never seen anything that establishes a problem with the basic design or proper use of any of these devices.

The swine study is interesting and academically important, but really offers no cause for concern at all as far as using these devices in humans. It was very small study to begin with - just nine animals - and it is important to note that these pigs were both well anesthetized and in cardiac arrest. In other words, an extremely low-flow state to begin with. So if this study were transferrable to humans, it would only apply to those in cardiac arrest, not to someone with a blood pressure. There have been several studies looking at outcomes of SGA vs. ETT in human cardiac arrest; none that I'm aware of show any clinically important advantage to either over the other.

I didn't think you were being a smartness, sorry if that's how I came across.

But Like I said, all airways have disadvantages. LMAs supposedly cause decreased perfusion as well. Combi tubes are proven to take longer to place (by just seconds, but more time none the less). I think it's really a game of "pick your poison". But the decreased perfusion theory is why kings aren't used here. Many places use kings because they are faster to place. But at the end, any airway is better then no airway. i like LMAs. No idea why I like them. I think it's because they look like comfy little throat pillows *shrugs*.

 

[Tigger]

I didn't think you were being a smartness, sorry if that's how I came across.

But Like I said, all airways have disadvantages. LMAs supposedly cause decreased perfusion as well. Combi tubes are proven to take longer to place (by just seconds, but more time none the less). I think it's really a game of "pick your poison". But the decreased perfusion theory is why kings aren't used here. Many places use kings because they are faster to place. But at the end, any airway is better then no airway. i like LMAs. No idea why I like them. I think it's because they look like comfy little throat pillows *shrugs*.

We are dumping our Combi-Tubes for Kings as the Kings apparently are less likely to cause airway trauma. Kings are also easier to insert, though I don't think that's a great line of thinking.

Also has NTI a backup airway? If they aren't breathing isn't that kind of a rule out for one? It's an option here but most of those patients just get RSIed.

 

[Tigger]

It snowed here today finally. We went on a minor TA in a canyon and then had a tour bus get stuck across both lanes behind us and a four vehicle wreck involving a plow in front of us so we spent close to three hours just hanging out in the snow. Hooray?

 

[COmedic17]

We are dumping our Combi-Tubes for Kings as the Kings apparently are less likely to cause airway trauma. Kings are also easier to insert, though I don't think that's a great line of thinking.

Also has NTI a backup airway? If they aren't breathing isn't that kind of a rule out for one? It's an option here but most of those patients just get RSIed.

We don't have paralytics. It's first line for intubation when you don't have oral access (trismus,etc). It can also be done in people with intact gag reflexes. It can be done in patients with a CHF exacterbation while sitting, since they won't tolerate laying flat. obviously contraindicated in facial trauma (same contraindications as an NPA). They do need to have spontaneous respirations to nasally intubate. So its not used in codes. But in codes oral intubation usually works fine ( no gag reflex, etc). If not, supraglottic. But in living people, nasal typically works fine if you had a failed oral intubation attempt. If that makes sense.

 

[Ewok Jerky]

Im disappointed that the scaphoid fx is taking so damned long though. Still another 2 weeks before PT for that. Severely limited ROM still. Almost no ability to extend the wrist.
Good luck on the board @Ewok Jerky
Hopefully the drive isn't too bad.

Go easy on that wrist, the rate of non union for scaphoid fractures is pretty high, depending on the location of the fracture as much as 50%. And the treatment is more surgery.

 

[9D4]

Go easy on that wrist, the rate of non union for scaphoid fractures is pretty high, depending on the location of the fracture as much as 50%. And the treatment is more surgery.

See? It'd be nice if I was told this by my surgeon. He hasn't even seen me again since my surgery. Every time I go in, he has his MA ask the questions, relay it to him, then has the MA tell me. One occasion I had a PA, who could at least tell me most of the stuff.
All they told me to do was minimal weight bearing, try to do full ROM in the fingers and minimal movement of wrist when out of the brace. I've been limiting it as much as possible, but every morning I get up and stretch and that's always when I realize ha.
I'm trying to find all the info I can. Originally I was told surgery, soft brace for two weeks and Id be fine. Never was informed of any high chance of reoperation or anything. So I'm kinda finding out myself as I go along.

 

[Ewok Jerky]

Did they fix the scaphoid Fx or cast it?

Depending on where the fracture line is it its hard to say what the risk is. Distal fxs have a better blood supply than waist and proximal fxs and thus heal quicker. Definitely keep those fingers moving, but I would not lift anything heavier than a toothbrush with that hand. Maybe a few weeks out (your probly almost 6 weeks now?) I would start moving the wrist but no lifting until OKed by ortho or PT. Scaphoid fxs can bite you in the bite 5 years down the road with avascular necrosis (AVN), scaphoid nonunion advanced collapse (SNAC wrist), and arthritis. As long as you are being followed I am sure they would catch it if it wasn't healing, its the bozos that fall off the radar that come back in 5 years and wonder why their wrist doesn't work anymore.

AAOS
http://orthoinfo.aaos.org/topic.cfm?topic=A00012

Orthobullets
http://www.orthobullets.com/hand/6034/scaphoid-fracture
http://www.orthobullets.com/hand/12119/snac-scaphoid-nonunion-advanced-collapse

Wheeless
http://www.wheelessonline.com/ortho/scaphoid_scaphoid_fracture
http://www.wheelessonline.com/ortho/scaphoid_nonunion

 

[PotatoMedic]

All I can think of is that bones "poem" someone posted earlier.