BLS Intubations

[Ray1129]

I have a question. It's probably something I'm going to have to look into here in Maryland, but do any of you have suggestions or ideas as to who I would talk to in reference to suggesting the idea of BLS providers using ET Tubes, or even Combi-tubes for that matter, and possibly being allowed to use/read/decipher EKG's?

I was thinking that maybe I should talk to my local medical director.....but is there someplace lower I would have to start with?

Ray

 

[rescuecpt]

I don't want to discourage you, but adding those two skills would add probably 50 hours to the EMT-B curriculum. And what good is it to know how to read an ECG if you can't do anything for it (no drugs)? At a basic level, it's either "SHOCK" or "NO SHOCK". I know that stinks, but that's what Intermediate, Critical, and Advanced courses are for.

Although, some municipalities are working LMA's or Combi-tubes into the Basic protocols. Start with your city or county medical director. They know what ideas are on the table, what the feasibility is, and when it'll happen.

It's great that you want to provide better patient care. You should consider an advanced course.

Good luck.

 

[Ray1129]

Well, it's not so much knowing how to read/decipher EKGs for treatment, but to help the ALS providers when the need-be. I can kinda-sorta read EKGs, which helps my paramedic when he/she's busy doing other things. It also comes in handy when you have a paramedic en route and you can tell them what kind of rhythm the patient is in before they even get there....

But I was more focused on the BLS Intubation, primarily with the Combi-tube. While the BLS provider is doing that, the first responder is doing chest compressions, the ALS provider can play ALS provider and push what needs to be pushed/play with the monitor.

Ray

 

[Margaritaville]

Ray,

I think I know what you are looking for and what you need. PM me and we will figure out a way to discuss this. I am also aware of the reasoning behind the EMT-B skills, but i won't go into that discussion here.

Take care -

Margaritaville

 

[SafetyPro2]

Check out my post entitled We Lost Advanced Airway for BLS further down in this forum. We used to have ET intubation as an optional skill for BLS, but the State/LA County yanked it earlier this month. We were the only BLS agency in the county doing it for the last couple years.

CombiTubes were supposed to be part of the new scope, but alas, that's not going to happen either.

Good luck.

 

[kyleybug]

I had training in both combi and PTL during my course as an EMT-IV it was also a station for NR. If you have NR certification then you are required to know the skill of both tubes. My state (TN) doesn't have a state test, they use the NR test and if you pass it then you get your license. I am not sure whom you would contact about it. I figure I will just go ahead and do the Medic course too and then I really get to play......RSI looks like a whole lot of fun to me

 

[Alpha752]

This reply will not help you at all, but I know in Ohio we, as Basics can Intubate and use CombiTubes. Perhaps you can find stats from states who let Basics do this for your argument.

Advanced Airway I think Basics can handle. EKG's are a whole nother kettle of fish. Thats starting to get into ACLS type stuff, and as a Basic, I dont think that is something we should have to deal with. I am a paramedic student and I know cardiology is going to be one of our hardest sections. In my opinion, EKG/Monitor is a bit much for basics, AEDs work well for our uses. Becides what good is it to identify the rythem if you cant treat it. Sure you can give the medic a heads up, but they have to assess for themselves anyway.

Russ

 

[ResTech]

But I was more focused on the BLS Intubation, primarily with the Combi-tube. While the BLS provider is doing that, the first responder is doing chest compressions, the ALS provider can play ALS provider and push what needs to be pushed/play with the monitor.

Ray1129,
I totally understand your intention's in wanting to provide a more advanced level of care to your patients and wanting to make the team approach to patient care more efficient between ALS & BLS. I am all for BLS providers having the authority to utilize the Combi-Tube and think all states should permit this skill. It is a very easy airway to use with minimal risk for improper use.

Although in the above scenerio that you mentioned, the Combi-Tube would definitely not be considered the airway of choice when an ALS provider is onscene. Endotracheal Intubation is the "gold standard" for airway control and using an airway device that offer's no additional clinical benefit and is deemed to be inferior to an ET tube would just not be providing good patient care. I do see your rationale though and understand how it would seem to free up the medic to initiate other treatment modalities but again, airway control is of vital importance as we all know and inserting a Combi-Tube when an ET tube is sitting right there beside the patient just is'nt prudent.

And also, you mentioned about while BLS is inserting the CT the medic can be pushing drugs and what not. Here's something to think about. After the patient is intubated by the paramedic, they're is now a direct pulmonary route for drug administration and certain medication's can be pushed down the tube. A very good way for a BLS provider to help the medic is to open the medications, assemble them, and be ready to hand the correct drug to the medic as soon as the ET tube is in. And in some states where EMT's can start IV's (MARYLAND), while the medic is intubating you as an EMT can get the line established and secured.

I just don't see where the CT would best serve the patient's interest in this scenerio. The main reason for me mentioning all this is so when you do approach administration about adding this treatment modality you will hopefully not use this scenerio as a foundation to base your recommendation on. I just don't think it would add any weight to your recommendation and could actually "backfire" by not showing a firm understanding of the treatment importance and sequence, and interface between ALS and BLS.

Again, CT are great for BLS and good luck in your endeavor to get this skill added.

 

[MMiz]

Some great points were made here, let's see if I can add something.

I absolutley believe EMT-Basics should be trained in the use of the CombiTube, and it should be available as a piece of equipment.

I don't see CombiTubes being used a lot in the field, and I've never heard of an EMT-Basic inserting one. I have heard Paramedics talk about using them when it's difficult to secure an airway, and seen one used in this situation. Combitubes also have a place in rural EMS, allowing EMT-Basics to secure an airway when ALS is not immediately available.

Where I work, we EMT-Basics are permitted to insert Combitubes. This isn't a reality in my mostly suburban county though, as ALS must be available for all respiratory calls. An ALS intercept is also only minutes away, and hospitals would rather us bag w/ oral airways than intubate. I'd get a weird look if my BLS unit arrived at a hospital with a patient intubated.

Most importantly though, there is no reason why you shouldn't push to get the combitube available as a tool on your unit. It's just another option available when one is having difficultly securing an airway.

Combitube training is part of the National Registry, and part of the national registry curriculum. I believe either Ohio or Indiana also allow their EMT-Basics to insert ET tubes, and the training is only an additonal 10 hours. I can tell you that learning to insert a combitube can be done in a matter of hours, and after enough repetition on the practical stations, it becomes second nature.

I hope that helps a bit.

 

[ddman466]

hee in ky. emt b can use a combitube. right now it is a testing phase and my squad is doing it as a pilot prog. i see nothing wrong with bls using combitubes.it will provide a almost positive airway, and yes you can push drugs thru it. one of the issues when looked at was the paramedics said yu cant push drugs and if it were in place it would have to be removed when als got there. with a et tube if you cant see the cords, your not supposed to use it. a combitube dont require oyu to be able to see the cords. if a comb goes in to the stomach and you dont hear lung sounds to varify you blow up the other bulb and there you are, an established airway. that is my thought on it, but im only a first responder of 6 years. i have been to many emtb trainings, and no i dont think im in any way as good as an emt. but im just as important. dont mean to offend anyone here with this post, that is just my opinion.

 

[rescuecpt]

Originally posted by ddman466@Nov 29 2004, 02:49 PM
hee in ky. emt b can use a combitube. right now it is a testing phase and my squad is doing it as a pilot prog. i see nothing wrong with bls using combitubes.it will provide a almost positive airway, and yes you can push drugs thru it. one of the issues when looked at was the paramedics said yu cant push drugs and if it were in place it would have to be removed when als got there. with a et tube if you cant see the cords, your not supposed to use it. a combitube dont require oyu to be able to see the cords. if a comb goes in to the stomach and you dont hear lung sounds to varify you blow up the other bulb and there you are, an established airway. that is my thought on it, but im only a first responder of 6 years. i have been to many emtb trainings, and no i dont think im in any way as good as an emt. but im just as important. dont mean to offend anyone here with this post, that is just my opinion.

The problem with drug administration through the Combi tube is that the majority of the time, the tube ends up in the esophagus. Air is forced into the trachea through the holes in the side of the tube. The cuffs above and below these holes force the air down the trachea. If you were to push drugs (liquid) this way, they will pool at the end of the tube, which is blocked distal to the air holes. Gravity and the force with which the drugs are pushed will win the fight and not spread the drugs through the holes. The small amount that does make it through will not make it deep into the lungs, where circulation occurs (which is already less effective than intravenous, hence the reason we give twice as much down the tube).

If it were me, and I couldn't get an IV line to push drugs through, I would remove the Combi tube and attempt to intubate so that I would have a patent route for drug administration. Worse comes to worse I dont get the tube - I put the Combi tube back in and pray that the patient makes it to the hospital.

Our protocols are 2 attempts on intubation, then the Combi tube as the last resort. This is before you ever start an IV (because B comes before C in ABC's)... and if you get the tube, you win a double prize - you secure the airway and a drug route at the same time. So it is more important (in my State's theory) to intubate than to start an IV (obviously we're talking about unconscious patients who are not breathing.)

Check this out for a diagram - Figure 4 shows you how the tube works when it's in the esophagus.
http://www.medradio.org/combitube/
Click on "Description & Direction" on the left side menu.

 

[ks_medic]

As far as being allowed to read ECG no one can really stop you from learning how. you can take a ecg class or read books and self teach your self. i know a lot of emt-b's that
can read ecg strips they just cant treat them.

as far as ET tubes go, theres a lot of liabitlity in it. its cosidered a highly advanced skill.
nurses and some dr. cant intubate. I wouldn't mined an emt-b intubating but if it went to court they could say they don't have the qualification for it. you spend a lot of time in
paramedic school refining your intubation skills. you learn to intubate in just about
every position posable from standing to laying flat. you also learn RSI and other difficult intubations. I had to spend almost 3 weeks in a OR clinical to get the 20
intubations required by my school. plus not too mention all the lab time and state boards.

as for the combi-tube i prefer the EOA. and emt-b'a can use them.

 

[Ray1129]

As far as being allowed to read ECG no one can really stop you from learning how. you can take a ecg class or read books and self teach your self. i know a lot of emt-b's that
can read ecg strips they just cant treat them.

Yes, that is a very good point. I should probably do that. But what I meant is an optional class for BLS providers just to help those along that can't teach themselves, or want additional help. Not anything mandatory.

Though, I'm still all over having Combi-tubes be an BLS skill. It would be nice for the Medic to get on scene and have an airway and a rapid acces to push drugs already established or even to have the BLS provider establish the airway while the Medic gets prepared. Though I'm going to have to look into what rescuecpt said:

The problem with drug administration through the Combi tube is that the majority of the time, the tube ends up in the esophagus. Air is forced into the trachea through the holes in the side of the tube. The cuffs above and below these holes force the air down the trachea. If you were to push drugs (liquid) this way, they will pool at the end of the tube, which is blocked distal to the air holes. Gravity and the force with which the drugs are pushed will win the fight and not spread the drugs through the holes. The small amount that does make it through will not make it deep into the lungs, where circulation occurs (which is already less effective than intravenous, hence the reason we give twice as much down the tube).

...I really appreciate everyones input!

-Ray

 

[rescuecpt]

As an ALS provider, there are only 3 people on my ambulance who I let tell me what the rhythm is:

1. A county designated field physician.
2. Another ALS provider (known to me)
3. ME.

Ultimately, the pt is my responsibility. If someone tells me what the rhythm is, I treat that, and it's wrong, that's my card you hear being torn up, and my *** being hauled off to jail.

 

[Jon]

Originally posted by rescuecpt@Dec 22 2004, 12:48 PM
As an ALS provider, there are only 3 people on my ambulance who I let tell me what the rhythm is:

1. A county designated field physician.
2. Another ALS provider (known to me)
3. ME.

Ultimately, the pt is my responsibility. If someone tells me what the rhythm is, I treat that, and it's wrong, that's my card you hear being torn up, and my *** being hauled off to jail.

Amen. But unless the other paramedic is my partner of 2+ years, I STILL would take another look.

But from an EMT prespective, most medics appreaciated it when I pointed out the FLB's or something else that seemed not right. Luckly I've usually worked with the same 2 squads, and know most of the guys and gals on a first name basis, and they are usually more than willing to help push me along towards that little -P after my name I hope to get one of these days.


Oh, and really quickly:

This is good:



ooooo/\ooooooooooooooo/\ooooooooooooooo/\ooooooooooooooo/\
/--,oo /o \oooo _____/--,o/oo\ooo______/--,oo/oo\ooo_____/--,oo/oo\oo_______
ooo\/ooo \oo /ooooooo\/ooo \oo /ooooooooo\/oooo\oo/ooooooo\/ooo\oo/
oooooooo\/ooooooooooooooo\/oooooooooooooooo\/ooooooooooooo\/

This is bad:

__________________________________________________________________



Beyond that, call a medic.




Jon

 

[coloradoemt]

My volunteer service carries some waivers that let us do certain things just to help out "soon to follow" ALS. Combi tubes are being looked at right now. Among a few other things if we have called for ALS we have the ok to hook up a moniter so when they do arrive they can just push print and start working their magic!! B)

 

[Ray1129]

Originally posted by rescuecpt@Dec 22 2004, 12:48 PM
As an ALS provider, there are only 3 people on my ambulance who I let tell me what the rhythm is:

1. A county designated field physician.
2. Another ALS provider (known to me)
3. ME.

Ultimately, the pt is my responsibility. If someone tells me what the rhythm is, I treat that, and it's wrong, that's my card you hear being torn up, and my *** being hauled off to jail.

I wouldn't expect you to treat something without you double checking it yourself.

What I meant is that I can give the paramedic a heads up, while they are still en route, as to what they have.... it was just a thought, anyway.

 

[PArescueEMT]

Even though I am (currently) an EMT, There are some medix that I know that I won't let touch my Pt.

Eika is one... did I just say that out loud :wub:

 

[rescuecpt]

Originally posted by PArescueEMT@Jan 17 2005, 11:03 PM
Even though I am (currently) an EMT, There are some medix that I know that I won't let touch my Pt.

Eika is one... did I just say that out loud :wub:

Well I wouldn't want to touch your Pt. anyway you dirty dirty boy! h34r:

 

[PArescueEMT]

Originally posted by rescuecpt+Jan 18 2005, 11:29 AM--></div><table border='0' align='center' width='95%' cellpadding='3' cellspacing='1'><tr><td>QUOTE (rescuecpt @ Jan 18 2005, 11:29 AM)</td></tr><tr><td id='QUOTE'> <!--QuoteBegin-PArescueEMT@Jan 17 2005, 11:03 PM
Even though I am (currently) an EMT, There are some medix that I know that I won't let touch my Pt.

Eika is one... did I just say that out loud :wub:

Well I wouldn't want to touch your Pt. anyway you dirty dirty boy! h34r: [/b][/quote]
I love you too.