Please take myself or my family to the academic center bypassing any community center along the way unless there is failure to get an airway.
This has been repeated a lot in our station lately. Meeting with the Medical Director this weekend for all of the crewmembers, and I think it has to to with addressing this issue.
I don't really like the "it doesn't matter if we miss the airway because they are dead" argument. My issue is that if you esophageally intubate and you get ROSC, those pulses aren't going to last very long. Most EMTs don't have the sort of tools that medics carry to confirm tube placement like wave form capnography.
It's also much harder to intubate than you think. I was trained as an EMT to intubate, had probably intubated the airway head 60 times. And I felt "I could do this if my protocols let me, no problem." Now as a resident I intubate all the time and I realize how little I knew. It took at least 15 real tubes before I felt somewhat competent. So I don't agree with letting EMTs do it if they haven't had OR time. And the data isn't holding up intubation as "this is so important we need to get it out in the boonies even if it means EMTs are doing it." Bag them, or throw in a Combi tube.
We do have capnography on board on our monitors. We have to confirm with 2 methods before using it though, so ascultation and the changing color thingy. Though because you've introduced some CO2 into the stomach from bagging and/or the environment, the color change thingy may not always be accurate. Even on a waveform capenography you may get a few breaths with CO2 registering before it stops registering due to the fact that you can introduce CO2 into the stomach.
I'm never going to intubate at the level of a resident until I am a resident, but I feel that it's not a tool we should have taken away. The Scope in Ohio is written as a maximum, so unlike Texas, our medical director is limited by law to the scope. If intubation is something that a MD feels his crew is not ready to do, then don't let them do it. Simple as that, but to not let those of use who have a use for it and whose medical director feels can do it satisfactorily, is taking a tool out of our arsenal. In our general protocols, we do not have RSI for medics, and most basics cannot give drugs off the truck. But for certain people, the MD has approved the RSI protocol and allowed people like me to give drugs off of the truck because he knows that we know what we are doing, and in my case he knows I have the indications and contraindications memorized for each one of the drugs I'm allowed to give.
Like I said, Ohio is stuffed full of EMS leaders who think the ability to intubate is the one true faith of EMS. Especially Southern Ohio. The fact it may be on the ropes and going down now is a huge step in realing in the many good hearted but "amateur" vol. departments that have way too much power in state EMS.
I have also seen some recent stuff that the SGAs are doing harm in survivors as well.
Despite the huge marketing of device manufacturers, maybe we need to accept both "less is more" and skilled providers over a device to make up for inability?
Radical idea, I know.
I agree, but unless you find funding for those skilled providers, this is all we've got. I'm on an ALS department, but that means one paramedic. The rest of us are basics, and if he's already tied up, why can't we, as trained providers use those skills? I agree, there are way to many volunteer departments (some that we run mutual aid or ALS with) that are too cavalier, but we can't keep writing the laws to suit the dumbest person!
My department has 3 med students, 2 pre-meds, and an ER intern on it not to mention numerous other very intelligent people. Why not lest us use our knowledge and skills? We are all very aware of the fact that a well trained monkey can probably perform the skills of a paramedic and treat a patient, but it requires an intelligent person to recognize when to not use those skills to treat a patient.
I've always had an impression that SGAs are not as good a ET tubes, but other than securing it, I can't really enumerate the other reasons as to why right now. I think you're right though in that there is a perception of using technology and equipment to make up for the shortcomings of personnel.
zmedic, ROSC usually doesn't last that long anyway. Like that laptop that stops working, you shake it and it works again even though you didn't do anything tangible to address the root problem.
No, but you can patch it up to keep it running long enough to take it to someone who can fix the root of the problem!
