How do you intubate someone?

JJR512

JJR512

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I'm an EMT-B with a critical care transport service. My role is that of driver, and of assistant to the Paramedic and Nurse with whom I am on a call. Obviously, I will not be intubating anyone myself. However, because there are time when I will be working with only a Paramedic, I may need to be his/her "extra pair of hands" from time to time. I may need to be ready to hand him whatever he needs if he's got his hands busy with an intubation.

I know absolutely nothing about intubating. I am hoping someone can explain to me, in relatively simple terms, what is done. I'm looking for a chronological layout, with the equipment named, the drugs named, etc. I need to know the names of all the equipment that is or might be used, as well as the drugs, and anything else, so I'll know what I'm likely to need and what I might need. We have an "intubation kit" that theoretically has everything (equipment, drugs, etc.) that would be needed. I think I basically need to know what I'm likely to need to grab next.
 
Have you sat down with one of your Paramedic's or a Nurse to discuss this? Why not ask the people who you will be helping? They would be able to tell you exactly how they want it. As none of us are familiar with the specifics of your equipment, protocols, or unit set up, it is difficult to offer advice that would be beneficial. Part of being a collaborative team member, especially on a CCT team, is the ability to openly communicate directly with your co-workers. I'd start with them..................................
 
flight nailed it. ask one of your medics to teach you.
 
This is one of the reasons why I am glad ETT was part of the Basic course in IL. Mannequin and all.
 
I suggest you borrow a Paramedic text and start reading. Most usually have a good outline as well as some basic anatomy.

If you want to learn intubation, don't approach it as just another skill. Unfortunately, it is taught with this mentality in many EMS programs. Many people spend too much time memorizing a "list" and less on understanding each step. Know the A&P of the respiratory system thoroughly and the reasons for intubation. That will also give you an idea as to why certain equipment works better for some intubators than others. For example, curved vs straight blade is sometimes a personal preference and sometimes each blade serves a pupose for anatomical reasons.

An overview of the medications will also be in the paramedic text. However, for CCT each team may have meds in their protocols that are the discretion of their medical director. Different meds may be used for different patients for different disease processes also.

Of course, every nurse, RRT or EMT-P will have their own preferences and the team members you work with most can assist you in getting familiar with the lay out of the intubation equipment. The equipment should be stored in a logical order for easy access by all team members.

Also, familiarize yourself with the alternate airways they carry. This might be where you will actually be most helpful as adrenaline and a little panic kicks in for some intubators when they miss a tube. This might just be bagging until they regain composure or readying another ETT or different airway.
 
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Not much to add from the other excellant ideas except to be sure the basics are covered such as having a working suction with Yankuer suction tip, BVM is attached to oxygen, tube holder, etc.. Little things like that sure helps.

R/r 911
 
Until the tube is secured, the most important thing for you...



don't knock it loose.
 
Most critical care transport services; either ground or air, will more than likely have very explicit and detailed procedures for their intubation protocols. The best, simplest, and probably most easily accessible resource I could offer you is to ask your partners, look through their protocols, and, if able, ask them to walk you through it on a mannequin.

Good luck.
 
For this CCT sevice, how many intubations do the Paramedics and/or RNs get on the job per month or year?

How many intubations are they required to have per month/quarter or year either on transport or in the hospital (OR, ED, ICU, Lab)?

Does the CCT service also transport pediatrics? If so, how do the team members maintain their pedi intubation competencies?

One of the complaints Paramedics have working some CCT services is that they don't get to intubate as often as they did working EMS. The RNs actually get more intubation opportunities if they are part of a hospital based service and work the ICUs.

Our Adult CCT RNs work for the hospital and ride with whatever ALS truck shows up for transport. Occasionally an RRT will accompany if it is a difficult respiratory or unstable ICU patient. The specialty teams (NICU & PICU) are a whole different set of team members and protocols.
 
google intubation. There are google videos of surgical teams intubating patients but use equipment EMS would never use.
 
Anomalous said:
Until the tube is secured, the most important thing for you...



don't knock it loose.
Click to expand...


Even after its been secured....don't pull on it...push it in...mess with it.

I am surprised one of the Medics in the service you work for hasn't set you down and said "this is your part" during intubation.

Get with your training person/dept. Ask them to let you look/feel/play with the airway supplies, that way you can get an idea without having to open your supplies on the truck.

And do what all these other members here have said....they are pretty smart, with excellent ideas.
 
If you used the "Orange Book" during EMT training (Emergency Care and Transportation of the Sick and Injured), instructions on intubation is like one of the last chapters as an additional module. Probably would help in understanding what the paramedic needs to do.
 
Your crew is your best bet for training, as they will all have their own little preferences. For instance, my crew knows exactly what set up I prefer, which handle, which blade and how to set up the tubes/holders/magills/fiber-optics/etc.

That way, while I am intubating, and I see the cords, all I have to do is hold my hand up without even looking away from the cords, and that tube will place itself in my hand the correct way, with syringe attached.

From the time we grab the tube roll, from set up to finished intubating the average pt, about 30-40 seconds. ( laryngoscopy to passing the tube is about 10 seconds of that ).

We used to drill regularly for meconium aspiration prevention. Your partner needs to be quick, accurate, and have a line of extra tubes waiting while you, as the intubator, never look away from the air hole.

Good luck with your learning, train with your crew, learn from others and expand your knowledge. Be open to all ideas, and pick the best one that suits you.
 
Thanks for the replies so far.

One of the problems I am having at work is that I have a lot less experience (either with a 911 service, or working with an ALS partner at a commercial ambulance company) than they are used to hiring. They've hired me, as a relatively inexperienced EMT-B driver, because they need more Emergency Vehicle Operators but are finding it increasingly difficult to find the kind of people they want. So, they are using me as a guinea pig, to see if they can hire people with less experience, and train them up to their standards.

Because of that, they are proceeding at an achingly slow pace (in my opinion). They are showing me one thing at a time, and waiting until I demonstrate a pretty good understanding of that one thing until they move on to the next. For example, I have recently been taught the basics of how to set up their transport ventilator (LTV-1000) (turn it on, set up the tubing, program the numbers supplied to me by the nurse). Until I do this several times on live patients and they feel confident I know what I'm doing, they will not go over anything else with me.

The problem that I have with this approach to my training is that although I am inexperienced, I am not stupid. I believe I can start to learn something else, or review something else, without the vent knowledge falling out of my head just because I haven't practiced it on live patients yet.

So, yes, I agree that I should be going over my service's intubation procedures with my service's paramedics. But this will not happen until they decide "I'm ready". But I believe I am ready for some of this information now. Thus I am going behind their backs.

I would at least like to learn the names of the different tools and equipment used, the purpose of each piece, the names of the commonly used drugs and what they do, etc.

VentMedic said:
For this CCT sevice, how many intubations do the Paramedics and/or RNs get on the job per month or year?

How many intubations are they required to have per month/quarter or year either on transport or in the hospital (OR, ED, ICU, Lab)?

Does the CCT service also transport pediatrics? If so, how do the team members maintain their pedi intubation competencies?

One of the complaints Paramedics have working some CCT services is that they don't get to intubate as often as they did working EMS. The RNs actually get more intubation opportunities if they are part of a hospital based service and work the ICUs.

Our Adult CCT RNs work for the hospital and ride with whatever ALS truck shows up for transport. Occasionally an RRT will accompany if it is a difficult respiratory or unstable ICU patient. The specialty teams (NICU & PICU) are a whole different set of team members and protocols.
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I don't know the answers to most of these questions off the top of my head. Most of our paramedics also work (or volunteer) with county 911 services as well, so they're still getting their field experience that way. Yes, we transport pediatrics; they make up a fairly sizable percent of our transports. Our nurses are specialized into adult-only and peds-only. It is my understanding that with our adult patients, the paramedic is far more likely to do the actual intubation, whereas with the peds patients, it's the nurse who is far more likely.

My service (Maryland ExpressCare) is based at a hospital (University of Maryland Medical Center, the teaching hospital of the UofMD School of Medicine, home of the world-renowned pioneering Shock Trauma Center). ExpressCare is not actually its own company; it's a service operated by UMMC, and we exist to bring other hospitals' problems to UMMC to be solved there. Our paramedics and EVOs are employees of a separate commercial ambulance company (TransCare) who are basically rented by UMMC to staff ExpressCare. Our nurses and communications center staff are employees of UMMC. We all wear the same uniform and, despite having different employers, collectively we operate as a team. Being based at a hospital, our nurses, who are also UMMC nurses, get plenty of opportunity to go into the ICUs and other areas. We get a lot of opportunities that other commercial ambulance companies do not, such as being able to stay a bit longer with many of the patients to see what the unit teams start to do, to help out the unit teams, to talk to the doctors and nurses and ask them questions and try to learn from them. That's one of the big reasons I wanted to work at ExpressCare, actually.
 
heres the issue as is see it: your wanting to get ahead of the curve, which i think is great. always wanting more education is never a bad thing. but your service had developed a training program for new employees that they feel is appropriate. staying with the class so to speak will keep you in line with what the company wants you to know. it will also keep your attitude in check. i dont know you personally but i have had quite a bit of experience with new emts. a little bit of knowledge is a very dangerous thing.

picture this: we, the collective group of emtlife members, explain in detail the process by which a pt is intubated. the equipment, anatomy, pharmacology. the whole nine. you'll remember(i cant remember tha actual stats so i'll guess) say 10% of that just from having it explained to you in words and maybe a few pics. now fast forward to when your service says its time to go over it. the medic(who for the purposes of this discussion just came off a 24 at another service, has a head cold and is fighting with the wife about whos turn it was to take out the trash) start with the very basics, because he know as you have proclaimed "I have a lot less experience (either with a 911 service, or working with an ALS partner at a commercial ambulance company) than they are used to hiring". so he begins with "this is an endotracheal tube". and you respond with "yeah i know. its a 7.5mm cuffed ETT with a stylet".

some people might relish this. geart, i dont have to teach this kid everything about everything. others might think that your trying to be a smartass.

my reccomendation, stick to what they give you. they are prepared to show you everything you'll ever need to know. let them. it will make you a better emt.

JMHO
 
Although, it may appear that they are teaching you slow, be glad they are making sure that you have "mastered" each step. I do doubt that think you are stupid or slow, it is that in comparison of education and expectations they want you to perform the tasks flawlessly.

Since you are one of the first, expect a little more time and tried attempts. It is appear they are attempting to do something new, and actually you may make or break the deal. Again, nothing personal but you ask about intubation and the steps, yet complain about being slow about teaching on assisting. Remember, in most of the general medical care, one is taught how to assist far before allowing to actually perform the procedure. You can't have your cake and eat it too.

I would be very cautious about going behind their backs and learning anything. There is a reason they are doing what they are doing, unfortunately you do not have the education level to quite understand that yet. Remember, that the majority of the care they will provide is very little skill and mostly will be based upon medical knowledge. They appear to prefer that you are taught within the scope that they want you to perform at, not what you assume you should do or know. If not careful, you may exceed or over-step your job description or what they want in a person at this time, they are in control and supersede you, they know and realize what they need, not vice versa. As the old saying when in Rome... or you can be replaced by someone that will meet that need. Not to be condescending but in reality your main job is to be an EVO and secondary job is to be a go-for.

If they want you to assist or know the meds, they will tell you and teach you. Personally, I would not want my EVO or basic to know much about the med.'s they have no business even handling paralytics, etc, if I have another medial person, sorry that is just medicine.

Study on your own to be proficient and master what they want, they will allow you to increase with time and demonstration.

R/r 911
 
KEVD18 said:
heres the issue as is see it: your wanting to get ahead of the curve, which i think is great. always wanting more education is never a bad thing. but your service had developed a training program for new employees that they feel is appropriate.
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I just want to point out that they have not developed a training program for me. They are developing it as they put me through it. I am the guinea pig, the lab rat. They do not know if it is appropriate; they want to see how it succeeds or fails with me, and make appropriate adjustments as needed. (This is partly my own fault: I have retail/restaurant management and training experience, and one of my selling points was that I could help them develop their new training program for under-experienced EMT-Bs.)

staying with the class so to speak will keep you in line with what the company wants you to know. it will also keep your attitude in check. i dont know you personally but i have had quite a bit of experience with new emts. a little bit of knowledge is a very dangerous thing.
Click to expand...
It's now what they want me to know; it's when they want me to know it that's the problem. I am endeavoring to express my concerns to management; this is, after all, what they want to learn from me. However, I do agree with you about the dangers of a little bit of knowledge.
 
well fair enough. so they are testing out a new field precepting system out on you. in that case, you have to expect things to be a little disorganized.
 
Airway management should be a book, in itself. The first chapter beginning with an overview of the importance of airway management followed by the history of airway management(what worked, what did not). The next chapter should be on Anatomy of the Airway followed by a chapter of respiratory physiology then one on anatomical variations, once they have covered these topics--The techniques , their theory, and application should be explained and detailed.

If you are looking to learn how to assist, one person before recommended Emergency Care and Transport of the Sick and Injured(This is the book our EMT-IV's use here). It is approved by the AAOS and can be found at emszone.com

I think they did a good job when writing this book, however please note that the anatomy/physiology is nowhere near the level you would need to begin actual intubations; however--technique is described in the last few chapters:

ALS Techniques

Advanced Airway Management
Assisting in Cardiac Monitoring
Assisting in IV Therapy
 
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