ET Intubation

hangit said:
i mentioned this thread to an older medic and had a couple questions on two things he talked about.

1. he said if you see fog on the inside of the tube- you're in.

2. he said if you try on first attempt and miss, leave the first tube in and insert a second and the second will automaticaly go into the trachea.

i'm sure these are probably not accepted practices, but was just wondering.
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Condensation (fogging) of the tube is a secondary indication of propper tube placement, not to be the ONLY method of confirmation, but can be documented in addition to bilateral Lung Sounds, absent gastric sounds, and positive Color Change capnography to make for a VERY good case for propper intubation.
 
hangit said:
i mentioned this thread to an older medic and had a couple questions on two things he talked about.

1. he said if you see fog on the inside of the tube- you're in.

2. he said if you try on first attempt and miss, leave the first tube in and insert a second and the second will automaticaly go into the trachea.

i'm sure these are probably not accepted practices, but was just wondering.
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1. Most likely you are in but you really need to check properly. Listen to epigastric and lungs sounds, and use capnography or other detection device.

2. Definitely a NO! The esophagus will stretch enough to allow more than one tube in it. It is easier to intubate the esophagus twice then the trachea. You can leave the first tube in, but it is anything but automatic on the second attempt. You still need to visualize the tube passing the cords and confirm placement.
 
Fogging the tube is an myth.. Yes, usually condensation will occur, when you are in the trachea... but, will also occur in the esophagus. Remember, condensation is only moisture and heat escaping the body..

If you miss, yes it is acceptable to leave the tube in and intubate around it... you only have one hole to hit now. As well you drop a gastric tube and evacuate or decompress the stomach (gastric distention) at the same time.

The only true legal approved verification methods are :
1) EtCo2 - better with capnography wave forms (for documentation)
2) Auscultation - Bi-lateral lung sounds, and absent epigastric sounds
3) CXR
Other notable ones are Bulb detector, whistle device (breathing patients)

R/r 911
 
I have yet to see anyone state the most obvious way to know that you are in and that is to WATCH THE TUBE PASS THRU THE CORDS.
 
jeepmedic said:
I have yet to see anyone state the most obvious way to know that you are in and that is to WATCH THE TUBE PASS THRU THE CORDS.
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Very true ! However, nearly all claim that statement..

R/r 911
 
Interesting topic. Luckily, I do not see our state going that direction. If anything we are becoming less restrictive, now adopting RSI programs (very restrictive to limited personell). Our state and local medical directors are very supportive. I don't know the ratio of misses, but I have yet to see a patient who has presented to our ED's with improperly placed tubes. Sometimes with no tube on a difficult airway. I do know that the state would come down hard on anyone who left an tube in the esophagus.

Personally, i think any attempt to take it out of protocol is BAD, BAD, BAD. Our patients deserve the standard of care.
 
The biggest problem lies in the masses paying the price for the few. In the EMS system I work in we have a lot of 1-2 year medics that are only using the private box as a stepping stone until they can obtain a fire job. The skill level is just not the same as a system that has retained it's medic's for 10-20 years. You have EMS crews bringing patients into ED's without tubes, without lines, etc. In my honest opinion a combi-tube or an LMA shouldn't be a backup for poor intubation skills.

My company is sending myself and another Medic to the SLAM conference in Texas in June. I'm very excited, as it looks like an excellent course. A few of our Medics went last year and it sounds like a blast.

Check it out: http://www.airwayeducation.com/knowledge_corner.asp

This is the kind of training that should be standardized across the country.
 
SLAM courses are awesome. I too hate to see potential fire monkeys going through clinicals because "that gives them points to get hired".. They never really truly have an interest in EMS only a side line or potential part time job.

That is why we have a general unwritten policy once we find out their intention they get "observation clinicals".. if they show an interest, I will teach, if they do not.. they get to sit and ride. I won't waste my time with them.

R/r 911
 
Ridryder911 said:
I too hate to see potential fire monkeys going through clinicals because "that gives them points to get hired".. They never really truly have an interest in EMS only a side line or potential part time job.

That is why we have a general unwritten policy once we find out their intention they get "observation clinicals".. if they show an interest, I will teach, if they do not.. they get to sit and ride. I won't waste my time with them.

R/r 911
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I never said that hate potential fire medics. They are an integral part of many EMS systems. I work in an area where all ALS is provided by private ambulance. Some of the fire departments have paramedics working for them, but they do not have ALS equipment. Fire is a wonderful resource to have at scene, and I am not one to complain when I get help from another agency. To call them "Fire Monkeys", and not afford them good clinical experience simply because they were smart enough to find a career that offers excellent wages, benefits , and retirement is a little petty.

I was just commenting on the fact that many of our medics only have a few years of experience. Who could blame them for the wages we get. If anything, I respect the ones who spend time in private EMS prior to moving on. Everyone of them that I have met have verbalized the desire to become a good Medic, so that later on, they would not just be a "fire monkey" as it was so elegantly put.

BTW, if my house ever catches fire, I hope those monkeys have wings, because I would want them out of their cages and to my house very quickly.;)

I am actually working towards a career in law enforcement. I would love to utilize my skills in a tactical environment. I suppose that would make me a "handcuff monkey"?:P
 
And let's not forget that a medical license does not make you foolproof either. My wife's mom was sent for emergency surgery following complications during a cath. Gross swelling of the thoracic cavity was attributed to a lacerated artery and treated with 4 units of packed cells, LR, etc. She died hours later with no significant or contributory pre-op problems at age 64. Surgical notes made during the thoracotomy to repair said vessels revealed a ruptured stomach, probably due to excessive inter-gastric pressure from an incorrectly placed ET tube that was inserted by the anesthesiologist in the OR. The small amount (<50ml) of blood discovered in the thoracic cavity was attributed to secondary loss from the ruptured stomach. Please hold all the recommendations about contacting 1-800-Lawyer; I bring up the point only to illustrate that those who make the rules that affect us are not always guilt-free themselves.
 
No one is fool proof, especially me, I admit I have made errors (hopefully learn off them & not repeat them). However many F.D. have prevented the growth of EMS, and there are very few that allow medics to be medics without dual roles. As well, very few actually are into the "medical part" rather it to be more part of the job (no more special than venting a roof).

I am quite aware of the responsibilities and duties of fire service, before a lashing occurs to me. In fact my first love was firefighting rescue and obtained a degree in Fire Service and Safety Engineering, and served as an line fire officer for ten years. In fact I am still in the IFSTA Rescue manual, and was one of the first Level II F/F to professional level. The problem most F.D. at that time did want to participate in EMS activities and continued to do so, until recently when there is grant money to obtained and to be able to keep FTO for justification.

There are some exceptional Fire Medics and Fire EMS out there, but the majority of the students we receive that are geared towards F.D have no desire to learn anything about EMS or patient care. It is a more a "chore" they have to do to be able to apply for F.D.

Personally, I feel it is a shame that F.D. would be considered to be a " step up" for any EMS member. EMS requires more educational level than those of majority of F.D. require, as well as response volumes are more than those of fire alarms. It is unfortunate that we in EMS do not provide the pay, benefits of those in the Fire Service. Again, the addage and importance of the need of education and promoting of our profession.

R/r 911
 
I'm not trying to lash out, I was merely clarifying that I did not hate to see up-and-coming fire medics.

Your first post inferred that "I also" feel that way. I just did not want my name associated w/ the fire monkey comment.

Ridryder911 said:
I too hate to see potential fire monkeys going through clinicals because "that gives them points to get hired"

R/r 911
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BTW, very impressive resume. You seem to have been around the block a few times. What is it that you do currently?
 
Currently in grad school for acute nurse practitioner. Been in EMS going on 30 years, at various levels from national and state development to air, ER Manager, Field Supervisor at various types of EMS services. Currently, I work as a Paramedic and in education division for a service, work at a ER as a ER nurse. It is much simpler to work only ten days a month that way.. lol.

I am involved in several state and national committees for education development and work adjunct for a collegiate Paramedic program.

R/r 911
 
And I thought I was spread thin:wacko:
 
I too hate to see potential fire monkeys going through clinicals because "that gives them points to get hired".. They never really truly have an interest in EMS only a side line or potential part time job.
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I was hired as part of a move to create a 4th shift for my Department (24/48-24/72). The last few years they have had a requirement in employment contract that ALL new hires must obtain and maintain their ALS certification to the level offered. What that means is when they say to go to "I" school, you report. And when you get sent to the "I" to "P" bridge, you go. Or now they are doing the EMT-B to Paramedic. Regardless, we either pass or we risk getting fired. Nobody that I know of off probation has been fired yet, and it is becoming an issue with the union and lawyers involved.

My point being, don't blame those that don't want to become ALS providers but are made to do so. Yes they knew what they signed up for, but still a tough pill for them. And many of them are jumping ship as soon as the local big city calls, but even there they require it now.

I personally had no desire to become a Paramedic. But, as I was sent through "I", and then the bridge to Paramedic, I found a few things out. 1. I liked it, 2. I was pretty good at it for a newbie. Now I work in dual roles, assigned to a firefighter position, but detailed mainly to ALS spots due to shortage of providers. The one good that i see in requiring all new hires to become ALS is that when we get enough, our new medic engine program may allow a rotation so those of us who want suppression time can get both.
 
firemedic1563 said:
I was hired as part of a move to create a 4th shift for my Department (24/48-24/72). The last few years they have had a requirement in employment contract that ALL new hires must obtain and maintain their ALS certification to the level offered. What that means is when they say to go to "I" school, you report. And when you get sent to the "I" to "P" bridge, you go. Or now they are doing the EMT-B to Paramedic. Regardless, we either pass or we risk getting fired. Nobody that I know of off probation has been fired yet, and it is becoming an issue with the union and lawyers involved.

My point being, don't blame those that don't want to become ALS providers but are made to do so. Yes they knew what they signed up for, but still a tough pill for them. And many of them are jumping ship as soon as the local big city calls, but even there they require it now.

I personally had no desire to become a Paramedic. But, as I was sent through "I", and then the bridge to Paramedic, I found a few things out. 1. I liked it, 2. I was pretty good at it for a newbie. Now I work in dual roles, assigned to a firefighter position, but detailed mainly to ALS spots due to shortage of providers. The one good that i see in requiring all new hires to become ALS is that when we get enough, our new medic engine program may allow a rotation so those of us who want suppression time can get both.
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I appreciate your candor and honesty. This is one of the problems I see with Fire Service being responsible for delivery of EMS. As well, many problems have been identified with multiple or "too many ALS" providers and not having those being proficient in skills.

Many years ago Dallas "drafted" Paramedics requiring every so number to become one, like it or not. This caused many complications and increased number of litigation's. The reason is simple, those that do not want to perform a job, usually does not excel and perform as those that do. The same would be true for those that were required to perform fire suppression and wished not to. I would hate to rely upon an individual that hated going through an academy, that hated and did not ever want to learn fire suppression or rescue.

By far it is not that I think all fire medics are bad or provide poor care.. by far, I know of very outstanding medics that are in fire service. But mandating personnel to attend courses that are customized is not good as well.

Hopefully, EMS will mature and develop upon its own. It is difficult enough to perform fire suppression and fire tactics without a being an expert and performing multiple jobs.

R/r 911
 
You raise valid points, and I agree with most of your points. Problem is this is a VERY complicated issue. And what works in one area will not work elsewhere. You have issues like politics, union involvement, call volume, infrastructure, etc.

I can't speak for other areas, as I am not well versed on them. I do know while our system has some serious flaws, mainly in the training area where they condense the training, leaving even the best intentioned students ill prepared and forced to rely on protocol for subjects they don't fully understand, it works for us. Mainly it provides rapid ALS care to every patient in need. We have all but phased out BLS units, and most BLS calls are handled by Paramedics.

The biggest problem with change, is that it leaves even more discontent. We have many medics who have spent 20 years on a medic unit, but would have loved to be on an engine. Now we are transitioning to a system that is slowly working toward a rotation, hopefully allowing those that do not wish to be in suppression not to. But we have hired over 200 employees for this. If they came out and said we all had to go into an EMS only role, a large number would quit.

I think the larger issue that breeds the problem of forcing people into EMS is the shortage of ALS providers. We need roughly 350 ALS providers to staff our units. With the mid level pay scale, it is hard to attract people. So they decide to "trap" people into doing EMS. The alternative is hiring the 5 or so they can get for every 50 person academy. And with the rate of retirements that is not an option. Like I said, complicated issue.
 
This is the medic of medic's wife. My wife pulled me to this board and I have to say, it is interesting conversation. I have heard the trends of removing intubation from a medics list of abilities but that has mostly been from the pediatric age group. Recently I attended a PALS instructor update. What do you know, advanced airway management has been removed from the standard curriculum.

I feel the problem lies on several fronts. First, our schools are rushing students to quickly. They need more airway training in the clinical arena. They learn the steps and are great with manikins, however, when you place them in a situation in which they are managing more than plastic, remembering those steps are much more difficult. With so many pediatric hospitals being built there is no reason medic students should not be allowed access to those clinical sites.

Next, look at our own services, How many services have detailed protocols which address airway assessments, difficult airways, failed airways. What about QA programs, how many require at least 5 documentable confirmation techniques before a tube is considered confirmed? Medical directors should re-evaluate their roles. Instead of banning a valuable skill, why not participate in frequent paramedic refreshers and training.

These are just some ideas. As far as the physician intubation skills, they face the same problems as ourselves. I have seen too many physician missed airways. I have also secured the airway for some of those same physicians. Lets face it, we all face the same problems. Airway management is a valuable skill for all age populations. We are being forced to abandon some of the key principals that was drilled into our growing paramedical minds. Granted, not everyone is an expert airway clinician but we must help others that are lacking in the skill. Education and controlled experience for the uncontrolled situation is the answer, not a ban.



Remember, it is OK to miss an airway, however, failing to recognize a missed airway is not.
 
I totally agree with you. EMS is on a slippery slope of going downward, we have allowed excuses to replace the truth. We much rather place a band aid on an arterial bleed and then replace it with another instead of truly to stop and fix the problem.

The problem now is we are being examined for being incompetent. Although, many do not read it as such, but that is what is being said in diplomatic terms. Whenever studies point out that procedures should be removed and be replaced with "lesser difficult" airways and it would be better for the patient not to do anything, thenwe have a problem.

It is a shame those in the power to be in EMS are "pushing" training in lieu of formal education and continue to see that it the system is on a downward spiral. Allowing those with less education, credentials & certifications to perform advanced skills only increases problems. Even with a formal education a continuous monitoring of skills and performance has to be established as well as a program to correct eneffectiveness.

Programs forcing or requiring ones to be perform tasks they were never asked to do will only increase our poor track record. Studies have revealed it is much better to have a quick and good BLS response, followed by competent ALS than have multiple ALS providers. Communities should have ALS, but not all responders should have to be rated at such. It would be more adventitious to have fewer ALS providers that are competent and have the initial rescuers to provide competent BLS, than having poor ALS providers.

We should be at looking providing "quality versus quantity"....

R/r 911
 
The paramedics themselves need to become proactive. In one large metropolitain area, a couple of well liked Emergency physicians saw the need for more intubation training/skills. They offered the same course on two different days to give more shifts an opportunity. They borrowed the very expensive intubation manikins from the med school and arranged for a cadaver lab. They kept the cost very reasonable (the physicians were picking up most of the tab) and offered CEUs. There were at least easily 400 - 500 paramedics in the area. 25 total registered for the classes. I attended it and thought it was better than anything offered in many years in that area to the paramedics.

During one mandated refresher class (40 Paramedics-active on City or county rescue), I asked how many intubations each performed during the past 2 years. A couple had 10, majority had 6 or less and about 5 medics had 0. There was not time allowed in the refresher to cover intubation as it should be. I suggested they take part in one of the local Medical University's intubation ... labs. Everybody said they didn't have time for more "CEU" stuff. 24 hours were too much already. The City/County should offer it to them but none of them had even asked their agencies about it. They said it would "sound like they needed training". Most big agencies are oblivious to any extra training needs until it is brought to their attention by the paramedics themselves. If nobody speaks, then they assume all is well. After talking with other instructors, the responses have been the same. Even when our college offered to make the arrangements for them...very few expressed a desire to go for more training. This is just like when a couple of ERs offered paramedics the chance to start IVs to keep their skills...another lacking area for some. No paramedic took them up on the offer. Most said something about being used as cheap slave labor... In 4 hours they could have done easily 5 - 10 IVs and shown competency.

Can't help those who don't want to be helped. Even when there are alternatives to keeping their skills updated and they don't go for it. Even more unfortunate, there were probably those in that group that might actually want the additional training but felt they must go along with their louder peers.

As I have said in previous posts, over the past 30 years, paramedics in the U.S. have not increased their education minimums. All the other professions have passed them up at the national level. In the hospital setting, skill level/proficiencies are closely monitored by inhouse and outside agencies. Until the entry level eduacation levels are increased and there is some national unity with standards among paramedics, the 1970s will remain. Actually, I think I did more in the 70s as a paramedic - just didn't have a lot of fancy gadgets to do my assessments. The fancy gadgets shouldn't take the place of good assessment and intubation skills.
 
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