Advanced Airways for Basics

My EMT class is using Brady's 10 Edition and one of the last chapters goes over combitubes. From what I can tell, EMT-Basics are allowed to use combitubes in Illinois but most agencies do not let them.
 
I also forgot to mention that in Ohio EMT-B's are allowed to intubate
 
BossyCow said:
We're improving the pt's chances of being viable when we rendezvous with ALS. We reduce the incidence of gastric inflation and improve the delivery of O2. Without the combi-tube we have an airway adjunct but no real airway either. While there may be better options, of the options available to us, Combi-tube is the best.
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This sounds like nothing but excuses to me, and I'm tired of them. Why aren't you a paramedic? I'm sorry, but if you're truly smart enough to use a combitube, then there is no reason why you shouldn't be striving for the gold standard of care. The esophagus is a smooth elastic muscle and gastric contents and air pressure can easily overcome the combitube and because of that big cuff in the middle, you might be pumping crap down someone’s airway and not even know it. This is just my opinion, don't take offense, take it for what it's worth. Your "best" might be good enough for you, but it's not good enough for me.
 
Guardian,
You have no sense of humor! Lighten up!

I don't like the Combitube either especially if used by a Paramedic who should have access to other devices if he/she can't intubate for whatever reason.

If this is what the EMT-B has and they have a lengthy transport, so be it. I survived and so did some of my patients with the EOA on BLS and backup on ALS trucks in my early years.

The guy is probably an Intern (1st year medical resident) learning his ABCs.
 
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VentMedic said:
Guardian,
You have no sense of humor! Lighten up!

I don't like the Combitube either especially if used by a Paramedic who should have access to other devices if he/she can't intubate for whatever reason.

If this is what the EMT-B has and they have a lengthy transport, so be it. I survived and so did some of my patients with the EOA on BLS and backup on ALS trucks in my early years.

The guy is probably an Intern (1 year medical resident) learning his ABCs.
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well, it's all fun and games until he gags and vomits. Since the esophagus stretches, the vomit will pass right into the lower airway and promptly be aspirated. He would then panic and probably rip out the ETC without deflating the cuffs. And that's when I would probably hit the floor from laughing so hard. Yes, i do have a sense of humor.
 
Hopefully all of those things are covered in training very thoroughly.

My last court depo a couple years ago was on a patient brought into the ED by paramedics with the largynx relocated and fractured. It was a very young patient who the paramedics didn't think "needed an ETT". "The patient was only drunk". Go figure. Costly binge for the college kid.

But, there are horror stories about all medical devices even with the most highly of skilled people using them.

Good education and advancing education is still key at any level. There is no reason an EMT-B can't continue learning even if they don't advance their certifications. Yes, I agree being a Paramedic would be helpful in many situations. But, if you're working in a BLS system, it's BLS. I wish this country would be able to advance services everywhere in every area of healthcare. It ain't going to happen anytime soon.

You've made some good points GUARDIAN. Hopefully you're half my age and will be able to make changes in the System for the future.
 
About 2 years ago I was at a BLS ConEd run by a nurse for Chicago North EMS. Dozens of BLS firefighters and EMT-Bs from the city were there.

The nurse asked, "How many of you have used CombiTubes?" There were maybe 200 EMTs in the room.

Not a single hand went up. All of the ambulances have them. We carry them on my private service's BLS ambulances. I have only ever used them on mannequins.
 
drg said:
My EMT class is using Brady's 10 Edition and one of the last chapters goes over combitubes. From what I can tell, EMT-Basics are allowed to use combitubes in Illinois but most agencies do not let them.
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Basics in IL are trained to use endotrachael intubation. Most PMDs don't let us and instead give us CombiTubes.
 
Guardian said:
This sounds like nothing but excuses to me, and I'm tired of them. Why aren't you a paramedic? I'm sorry, but if you're truly smart enough to use a combitube, then there is no reason why you shouldn't be striving for the gold standard of care.
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I'm 'smart enough' to be a paramedic and I'm not making excuses. I am a volunteer with a small rural agency. I personally cannot afford to pay the tuitiion and give up a year of my life to attend paramedic school so that I can volunteer that skill for free.

I am in the process of getting my EMT-I which will allow me to intubate. The problem with that is there is no local access to EMT-I OTEPS which will allow me to maintain my training and skills. This means I will have to challenge the test every 3 years and the local MPD is balking at allowing me to get a skill that I may not be able to maintain.

I understand the 'Gold Standard' but where I live, it's not a reasonable expectation under the current system of health care. We are a tiny rural logging community. We often are not able to get airlift due to the geography, our ALS support is spotty and 20 minutes away. There have been major calls where it's been one EMT-B and a couple of kid firefighters handling a trauma code.

It's nice for those in more urban environments to toss 'Shoulds' at the rest of the world. But we are not all operating under the same conditions or resources. Some of us are doing what we can and what we can afford, to improve things as much as we can. Nice to hear that this is considered not quite good enough!
 
No matter what I write, I’m sure you could come up with more excuses. I’m sure you have an endless supply of them. The thing is, I don’t care. The fact remains the ETC by itself is not good enough, in any setting, under any set of circumstances (maybe not combat but that’s another discussion). The fact your system has some problems doesn’t suddenly make the ETC an effective airway. We are talking about two different things. I’m talking about ems airway devices and you’re talking about geography, financial problems, compromising, etc. etc. etc. I don’t care about any of that. Those are your problems and it’s your responsibility to work them out. Judging by your previous posts on this thread, what worries me is that you seem to think the ETC is good enough given your circumstances. I don’t think so. If you lived in a small village in the himalayan mountains, I’d feel the same way. In fact, it’s even more important to have a proper airway in your setting! All of those problems you mentioned can be solved and have been solved before. The problem with the ETC cannot be solved. So scrap that damn thing and find a way to implement ETTs. If you think it would help, I’d be glad to post 20 or so, truly rural ems agency websites from around the country that have found a way to implement ETTs. If that’s not enough, I can show you where medical officers (paramedics) are using ETTs in some of the most remote places in Africa.
 
Here in NC the EMT-B class covers advanced airway, which includes combitube and ET tube. and in class we learned and practiced these skills. However i havent heard of a service in NC whos protocol allows basics to use advanced airway.
 
Guardian said:
The fact remains the ETC by itself is not good enough, in any setting, under any set of circumstances (maybe not combat but that’s another discussion). Judging by your previous posts on this thread, what worries me is that you seem to think the ETC is good enough given your circumstances. I don’t think so. If you lived in a small village in the himalayan mountains, I’d feel the same way. In fact, it’s even more important to have a proper airway in your setting! All of those problems you mentioned can be solved and have been solved before. The problem with the ETC cannot be solved. So scrap that damn thing and find a way to implement ETTs. If you think it would help, I’d be glad to post 20 or so, truly rural ems agency websites from around the country that have found a way to implement ETTs. If that’s not enough, I can show you where medical officers (paramedics) are using ETTs in some of the most remote places in Africa.
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I can't get permission to use an ETT in my system. The best tool I am allowed to use is a combi-tube. It's not a matter of Combi-tube being better than an ETT... it's a matter of Combi-tube or nothing. These are my options. In that case, Combi-tube is better than the alternative.

African Paramedics are going to be allowed to practice paramedicine. I am a member of a BLS agency. There is no ALS here. ETT is an ALS skill and is practiced by ALS providers.

I think what you are saying is that we should all be ALS. That is a Should and when you rule the world, you can make that your first act of office. In the meantime, I will continue to try to convince my agency to allow me to have the ETT. Until I am granted that right, I will continue to use my combi-tube, whether you approve or not.
 
Guardian said:
The fact remains the ETC by itself is not good enough, in any setting, under any set of circumstances (maybe not combat but that’s another discussion). The fact your system has some problems doesn’t suddenly make the ETC an effective airway.

The problem with the ETC cannot be solved. So scrap that damn thing and find a way to implement ETTs.

If that’s not enough, I can show you where medical officers (paramedics) are using ETTs in some of the most remote places in Africa.
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Whoa Guardian,
As much as I don't personally care for the Combitube, some big corperate types have put up some serious money for research and some big name docs and hospitals have endorsed it. There have been a serious amount of literature written on the Combitube. Just recently have I seen more about the complications. However, the marketing machine for this device is big. ETI is now controversial even for the paramedics in some areas. Some areas have eliminated ETI for pediatrics by paramedics. I now find it ironic that some services/states are endorsing EMT-Bs to do ETI. But that is for another day.

You or I as paramedics could not practice our ALS skills on a BLS unit. Period. You work within the scope of that agency and under the P&P of their Medical director. But, I suppose you carry your own scope and ETTs also.

EMT-Bs have the literature to back up their use of Combitubes.

Now, according to the literature, even more paramedics are using the Combitube as a first line instead of ETI. Can you tell me why? They have the training for ETI. Have they lost they confidence or ability to intubate? Lazy? That too can be discussed on another thread and time.

http://search.medscape.com/all-search?queryText=combitube

Negativity and unfounded criticism against someone because of the system their area uses is just poor professionalism and manners.

I can not find fault with a region that utilizes the resources they have available and if it is the Combitube, then it's the Combitube. I would rather have an EMT-B that is proficient with what they have than an EMT-P who is a perfect world idealist. I hope you never have to work under a disaster situtation like a hurricane or earthquake. Your resources will be limited and you may have to use what you got. Are you going to spend more time complaining or just get the job done?

If you do become ruler of the world:
Stop the war, fix the deficit, improve spending on education and healthcare. After that, solve world hunger and AIDS. I'll get a couple people together to take care of global warming.
 
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I agree to a point Vent, but as an experienced and educated medic, you have seen the multiple excuses in EMS.

Do you promote complaisance in your own profession in R.T. You would not promote having technicians in lieu of therapist, as well as of providing antiquated care and use of inferior equipment, such as MA1 vents, etc.

The reasons many medics are no longer have adequate ETI skill is being studied and some results are from poor education to begin with as well as no quality control to maintain skill adequacy. Some have even suggested because of laziness and the ease of placing more simplistic devices such as Combitube in. Personally, I do not think of them as an advanced airway, since majority of the time it only occludes the esophagus, not much better than a BVM or EOA.

Again, you are quite aware of the promotion of any device. You and I have both seen multiple promotions and even changes in patient care from this carelessness. (i.e. Bretylium, EOA, McSwain Dart's, MAST) Unfortunately, EMS is gullible and will purchase and promote anything that might appear to increase care. Intentions are admirable, but sometimes that is not always the best. This is where my personal problems lie. Misleading or leading that these devices are comparable to ETI, when even ECC and AHA describes that risks of aspiration can still occur, thus the whole purpose of the device.

I believe to many EMS communities much rather seek easy alternatives than to do the right way the first time. Yes, I agree there maybe remote areas that will never be able to provide the "gold standard; yet even that needs to be explored. Remote areas in Australia, Africa, Canada appear to address some of those problems, something again that should be addressed instead of immediately taking the being satisfied with taking the easy route.

We in EMS are way too eager to accept anything we can get. We need to evaluate why and what can be done to provide the best traditional method before seeking alternative routes.

R/r 911
 
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Ridryder911 said:
Do you promote complaisance in your own profession in R.T. You would not promote having technicians in lieu of therapist, as well as of providing antiquated care and use of inferior equipment, such as MA1 vents, etc.

Again, you are quite aware of the promotion of any device. You and I have both seen multiple promotions and even changes in patient care from this carelessness. (i.e. Bretylium, EOA, McSwain Dart's, MAST) Unfortunately, EMS is gullible and will purchase and promote anything that might appear to increase care.

R/r 911
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I agree whole heartedly about education. As long as someone wants to improve their knowledge and skills. However, one must also have a place to utilize the skills. Use it or lose it. One can not run around intubating if it is not in their protocols on a BLS truck.

As far as RT, we no longer have "technicians" (except those grandfathered for now). The A.S. is now standard entry for testing, B.S. preferred for employment in many areas. The title is Therapist. We gave people 5 years to get upgraded. The end of 2007 will determine the weakest links. The herd has spoken.

And yes, when I was a traveler, I found hospitals that still utilized some of the "oldies but goodies". Not all hospital systems are created equal either. I have used therapies 15 years out of date in places thought to be progressive like parts of California and other states.

I won't even bother commenting on California's individual county EMS certification system. That I find more difficult to tolerate than BLS systems in many areas of the country which still provide a vital service.

Guess what I preferred during Hurricane Andrew - MA1 and BEAR 1 and 3. Less electronics for the electrical flucts on generator power. Even put a few on the old MARKs. We still keep them in the warehouse for the next storm. I still admire the McSwain Dart. Yeah there's better stuff than all of these things I've mentioned, but sometimes you gotta use it.

I guess you've seen my posts in other places on CPAP. This is the latest "gadget" that EMS companies are getting suckered into buying some CR** and not CPAP. Demand Valves are another high ticket item that should only be in the hands of experienced providers. I loved my Elder Valve in 1979 as a new medic and used it for almost everybody. Then I got educated...:rolleyes:

A limited education about the way things work or the body functions can lead to some very bad purchases.

ETI in itself is a leader in aspiration just by the nature of doing it. People also think that the cuff below the cords prevents aspiration...NOT. The cords will still allow stomach material unless very chunky to pass. That's why tubes in some hospitals now have subglottic suction ports. These are too expensive for paramedic units at this time. However, ETI is a secured airway and forced ventilation will not be going to the stomach.

I wish everything was equal. I wish the Freedom House Ambulance service had its accepted place in EMS history. I wish Nancy Caroline M.D. would have been more recognized for her work both in and out of EMS. I wish our educational system had more money. I wish every county in this country had a trauma system. Every hospital should be like Jackson Memorial's Ryder Trauma Center or UCLA. There should be a brilliant paramedic like Guardian on every EMS truck. I wish everybody got the respect they deserve.

And as educators, we've allowed minimally educated people to continue teaching minimally educated.

Life and healthcare is just too full of inequalities. If all was equal, we probably would have nothing to post.
 
Here in Louisiana, Basics are allowed to use the CombiTube as well. Just thought I'd throw my 2 cents in. :)
 
Guardian said:
Your "best" might be good enough for you, but it's not good enough for me.
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When your best is all the patient has at that time thats is what the patient should get. When i started this discussion i was interested whether or not agencies are allowing EMT - BASIC were being allowed to use the combi tube. I think i speak for all of the Basics out there when i say that we know that ET intubation is the best airway for the patient. We know this and it does not have to be made anymore crystal clear then it already is. But my point is that our scope of practice is limited to for most of us a OPA and for a few the Combi Tube. I know its not as good as ETT, but its the best we can offer the patient. When that patient is in the back of my bus im going to give him the best care i know how to. Once ALS or some one with better training then i have i will gladly step aside and turn my patient care over to them. But until then i dont see anything wrong with attempting to "secure" { i know its not actually securing the airway so im using the term loosely} to the best of our abilities.
:excl: Guardian please don't take this as a direct attack its just my feelings on it.
 
BossyCow said:
I think what you are saying is that we should all be ALS. That is a Should and when you rule the world, you can make that your first act of office. In the meantime, I will continue to try to convince my agency to allow me to have the ETT.
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I don't think we should all be als providers, but I do think we should strive to offer als to everyone, no matter how rural, poor, rich, urban, etc. In your previous posts, you came across as a naively proud emt who was satisfied with the level of care provided in your system. In this one, it appears that you are not satisfied and you're at least trying to convince someone to provide better care. That's all I ask. I understand logic and I know there is no such thing as perfection. But I do know that people who strive for perfection usually get much closer to it than people who make excuses or generally don't care. So good for you and keep up the good work.
 
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