Airway - Trauma Scenario

[Carlos Danger]

What's harder to do, ET intubation or properly using a BVM?
Considering how ****ty nearly all medics are at using a BVM, I'd say BVM use is at least as hard as intubation.
Sometimes paramedics brag about their intubation skills. Ever hear anyone brag about how great their are at using a BVM? Usually the task of BVM ventilations isn't done by the medic anyway. It's passed on to a single firefighter or EMT.
Consider how much damage you can do to a head-injured patient by improperly bagging him--even if it's only for a few minutes before you get to "definitive care."

Just because some paramedics brag about being good at intubating doesn't mean they really are good at it.

You can easily cause more damage with a botched RSI attempt than with less-invasive airway maneuvers, not to mention spending a lot more time on scene. Even with first-pass success, you can cause hypotension, a huge spike in ICP, and/or hypoxemia. This is probably the hardest type of patient to intubate without making them worse. Which is exactly why the literature does not support prehospital intubation in these patients.

With such a short transport time, a SGA is really the way to go here.

 

[VentMonkey]

On topic with @Remi's above post, at the conclusion of the advanced airway lecture I was reviewing this morning, the conclusion of the instructors lecture was basically:

"The whole purpose of airway management isn't to successfully intubate, it's to properly oxygenate and ventilate."

I don't know if, or when as a whole paramedics will accept this cold, hard fact as I am sure there are plenty out there still of the "it's the gold standard" train of thought who still lack the support in patient outcomes to back their train of thought.

I would love to be a fly on the wall in a room with two veteran paramedics who have been around long enough to have been trained this way; one with this backwards and outdated thought process, and the other the progressive and most likely more proficient of the two.

 

[Carlos Danger]

On topic with @Remi's above post, at the conclusion of the advanced airway lecture I was reviewing this morning, the conclusion of the instructors lecture was basically:

"The whole purpose of airway management isn't to successfully intubate, it's to properly oxygenate and ventilate."

I don't know if, or when as a whole paramedics will accept this cold, hard fact as I am sure there are plenty out there still of the "it's the gold standard" train of thought who still lack the support in patient outcomes to back their train of thought.

I would love to be a fly on the wall in a room with two veteran paramedics who have been around long enough to have been trained this way; one with this backwards and outdated thought process, and the other the progressive and most likely more proficient of the two.

Medicine on the whole is pretty bad about sacred cows and doing things just because it's how you were trained, or just because it seems to make sense. And EMS is far worse than the rest of medicine in this regard. And anything to do with airway management is even worse because for some reason, there's this irrational, almost emotional attachment to intubation.

In EMS we are quick to embrace the evidence when it supports something we want to do anyway, but we simply ignore the evidence when it tells us that something we really like doing might not be the best thing for our patients.

 

[VentMonkey]

Medicine on the whole is pretty bad about sacred cows and doing things just because it's how you were trained, or just because it seems to make sense. And EMS is far worse than the rest of medicine in this regard. And anything to do with airway management is even worse because for some reason, there's this irrational, almost emotional attachment to intubation.

In EMS we are quick to embrace the evidence when it supports something we want to do anyway, but we simply ignore the evidence when it tells us that something we really like doing might not be the best thing for our patients.

 

[EpiEMS]

Medicine on the whole is pretty bad about sacred cows and doing things just because it's how you were trained, or just because it seems to make sense. And EMS is far worse than the rest of medicine in this regard. And anything to do with airway management is even worse because for some reason, there's this irrational, almost emotional attachment to intubation.

In EMS we are quick to embrace the evidence when it supports something we want to do anyway, but we simply ignore the evidence when it tells us that something we really like doing might not be the best thing for our patients.

All, if you're looking for a new forum signature, this is it. Remi, well summarized, my good sir!

 

[Akulahawk]

With such a short transport time, a SGA is really the way to go here.

Considering that the patient is in trismus, it might not be easy to place a SGA without having to resort to RSI or DSI...

 

[Carlos Danger]

Considering that the patient is in trismus, it might not be easy to place a SGA without having to resort to RSI or DSI...

I was thinking in more general terms than the specific scenario that Robb posted.

There will always be occasions where an airway can not be managed without NMB, which is why I'm not completely opposed to prehospital RSI.

But whether everyone can do RSI or only a small % of medics, it should only be done when there is a reasonable expectation that it will make things better for the patient.

 

[StCEMT]

I don't have RSI in my protocols, only the critical care medics do. So answering in the context of what I actually have available, a cric would be my only choice if I wanted/needed something more definitive than a BVM.

 

[Akulahawk]

There will always be occasions where an airway can not be managed without NMB, which is why I'm not completely opposed to prehospital RSI.

But whether everyone can do RSI or only a small % of medics, it should only be done when there is a reasonable expectation that it will make things better for the patient.

I'm not opposed to prehospital RSI either. You and I are very much on the same page in that it should only be done when there's a reasonable expectation that it will make things better for the patient. In that vein, so to speak, if a given crew is authorized to do RSI, they should be provided with a few options for accomplishing the task, not just one single tool (med or recipe).