EMT Held Against His Will in Maine

[NomadicMedic]

That's my point. They are sedated and paralyzed and because you can't get the tube you have very few options in terms of airway management.

Well, that's not really the case. How about an LMA, combitube or King. Pick an SGA that your medical director likes and go to it quickly when you cant get the tube. OPA/NPA and a BVM or that much feared and much maligned Surgical airway.

There are always options, unless you're in a true CICV scenario.

We typically use Versed to sedate our bath salt ingesters. We rarely field RSI them, but they almost always end up buying a tube in the ED.

 

[EMT B]

If there is a more bls way to manage the airway like a king or a combitube then why not use that instead of jumping right to the big guns. If the ED is gonna do it, let the ED do it in a more stable environment with someone who does it more often like a CRNA.

Even better, if the old method of restraints and bls works, why not just use that? Your trying to fix something that isn't broken by taking away the respiratory drive of a patient that can breathe fine on their own.

 

[CFal]

I spent the summer living and working almost 3 hours north of Bangor

 

[EMT B]

im sorry :lol:

 

[Tigger]

If there is a more bls way to manage the airway like a king or a combitube then why not use that instead of jumping right to the big guns. If the ED is gonna do it, let the ED do it in a more stable environment with someone who does it more often like a CRNA.

Even better, if the old method of restraints and bls works, why not just use that? Your trying to fix something that isn't broken by taking away the respiratory drive of a patient that can breathe fine on their own.

Did you read the part about the ED physician stating that he was pretty much going to immediately RSI these patients? It has nothing to with respiratory drive, it has to do with the total management of the patient, which in this case the physician believes is best done with the patient RSIed. You can't BLS they're airway since they don't actually have any respiratory compromise. The issue has nothing to do with airway but everything to do with an extremely combative patient.

Also RSI is not the "big guns." It's a procedure that has indications and can certainly be done appropriately by paramedics given proper system design.

 

[EMT B]

I did read that. Then like i said let the ED Physician or the CRNA do the RSI in the hospital. If your worried that the patient is going to become combative and cause harm to you, soft restraints and a versed/benadryl combo will certainly make them sleepy without having to take away the patients respiratory drive.

I also certainly agree that it has its indications, but I feel as though there are medics out there that will RSI any difficulty breathing patient to "protect their airway" just so they can play with their flashy cool toy. My opinion is that it should not be used unless the patient is going to loose their airway and respiratory drive anyway.

 

[Aprz]

If there is a more bls way to manage the airway like a king or a combitube then why not use that ... let the ED do it in a more stable environment with someone who does it more often ....

Even better, if the old method of restraints and bls works, why not just use that? Your trying to fix something that isn't broken....

You've been listening to wanna be progressive paramedics who talk about all the bleeding edge stuff in paramedicine, or you are making the same mistake as them.

BLS before ALS is a lie.

Intubation has recently been discouraged because interrupted chest compressions during cardiac arrest, just poor chest compressions in general, poor ventilation (rapid large breaths causing hyperoxyemia, mild arterioconstriction, but hypotension from increased intrathoracic pressure), and failure to recognize a failed airway.

Intubation still has it's place. I believe it really is the gold standard for airway management because it prevents aspiration. As long as you focus on good quality chest compressions without interruption (including for intubation attempts), that attempts aren't prolonged or tried more than three times, that you change how you are doing it if you failed the previous try, and to recognize a difficult airway where it may not be worthwhile to attempt intubation. Under those conditions, I think intubation is good to do still.

** I'd type more, but my brother is nagging me for lunch. I'll comment more later maybe.

 

[NomadicMedic]

I did read that. Then like i said let the ED Physician or the CRNA do the RSI in the hospital. If your worried that the patient is going to become combative and cause harm to you, soft restraints and a versed/benadryl combo will certainly make them sleepy without having to take away the patients respiratory drive.

I also certainly agree that it has its indications, but I feel as though there are medics out there that will RSI any difficulty breathing patient to "protect their airway" just so they can play with their flashy cool toy. My opinion is that it should not be used unless the patient is going to loose their airway and respiratory drive anyway.

I think you're misunderstanding what RSI is for. Responsible paramedics RSI their patients BEFORE they're behind the 8 ball on airway management. I've never considered RSI a "flashy new toy" and I think you'll find most medics who've been trained and vetted by medical directors to perform RSI take the decision to perform the procedure seriously.

As I mentioned, we usually simply sedate our Bath Salts/excited delirium patients, but I wouldn't hesitate to RSI one of these patients if I felt that I may encounter airway management issues during my contact.

You should know that "BLS measures" like an LMA or King work only on deeply unresponsive patients or dead people. If you've got a patient fighting you, he's got a gag and last time I looked that was a contraindications to an SGA.

And as a point of note, paramedics in my system perform far more RSI and airway management procedures than the ED docs.

 

[Brandon O]

And as a point of note, paramedics in my system perform far more RSI and airway management procedures than the ED docs.

Why do you think that is?

 

[EMT B]

I think you're misunderstanding what RSI is for. Responsible paramedics RSI their patients BEFORE they're behind the 8 ball on airway management.

Yes, RSI is to prevent getting behind on your airway management. But what is the real benefit to RSIing the bath salts patient that has been managed by more basic methods before?

Maybe I should just give up, as it appears I am missing something..

 

[chaz90]

Yes, RSI is to prevent getting behind on your airway management. But what is the real benefit to RSIing the bath salts patient that has been managed by more basic methods before?

Maybe I should just give up, as it appears I am missing something..

It's not an airway issue. It's management of the patient overall. If the patient is in such a great danger of hurting themselves or others and can't be safely restrained by other means, RSI allows complete control. Not all bath salts patients will need it, but it's something to keep in mind.

 

[NomadicMedic]

Why do you think that is?

Because we fly the majority of head trauma patients and intubate most of them. Because we are a small system that sees a fair number of sick and critically injured patients that require emergent airway management and we are proactive in managing the airways of patients that may become unstable during a long transport. The same as any other service that practices true RSI and doesn't just half *** it by trying to tube somebody with versed and brutane.

Also, many of the ED docs simply don't intubate enough patents to stay competent, by their own admission.

Trust me, an "unnecessary RSI" would be immediately flagged in QI.

 

[Brandon O]

Makes sense to me.

 

[NomadicMedic]

Maybe I should just give up, as it appears I am missing something..

Probably a good choice.

 

[Carlos Danger]

You've been listening to wanna be progressive paramedics who talk about all the bleeding edge stuff in paramedicine, or you are making the same mistake as them.

BLS before ALS is a lie.

Intubation has recently been discouraged because interrupted chest compressions during cardiac arrest, just poor chest compressions in general, poor ventilation (rapid large breaths causing hyperoxyemia, mild arterioconstriction, but hypotension from increased intrathoracic pressure), and failure to recognize a failed airway.

Intubation still has it's place. I believe it really is the gold standard for airway management because it prevents aspiration. As long as you focus on good quality chest compressions without interruption (including for intubation attempts), that attempts aren't prolonged or tried more than three times, that you change how you are doing it if you failed the previous try, and to recognize a difficult airway where it may not be worthwhile to attempt intubation. Under those conditions, I think intubation is good to do still.

** I'd type more, but my brother is nagging me for lunch. I'll comment more later maybe.

I strongly disagree that "BLS before ALS is a lie", or that advocates of BLS management are "wannabe progressive paramedics". That doesn't even make sense. Many times I've seen paramedics make serious mistakes that could have been avoided or saved by reverting to good BLS management. 90% of airway problems alone could be avoided if paramedics simply had stronger BLS airway skills.

Prehospital intubation has been increasingly questioned because it often leads to adverse outcomes. Even in systems that have good success rates, it is often impossible to demonstrate that it improves outcomes.

It has actually never been proven that ETI is "the gold standard" in prehospital airway management, and frankly I think the "ETI prevents aspiration" thing is waaaay overblown. I would be willing to bet that prehospital ETI has caused more harm than it has saved by preventing aspiration.

I think it still has its place, but only in select systems. IMO most prehospital advanced airway management should be SGA only.

Maybe I should just give up, as it appears I am missing something..

I don't think you are missing anything; in fact I think your point of view is quite valid. It is just more conservative than many want to hear.