Intubation in Flight

[SeeNoMore]

What is your current thinking (personal or program wide) on intubation in flight?

I have been discussing this issue with my regular partners. While we have no program wide policy - it is common to avoid intubation in flight if possible. This seems reasonable for many interfacility transfers - but I question whether truly acute trauma patients should stay in the back of an ambulance for RSI to be completed. I have seen studies which show that high performance programs can achieve high rates of success in flight.

Personally , all of my intubations in the helicopter have been for pts who have deteriorated en route (seizures, declining mental status etc) and find that it is more of a question of organization then anything else. I have opted to use a video device in these cases to mitigate issues with positioning. Some of us now regularly drill this practicing taking out and placing equipment w/ the airway head on the stretcher.

 

[VentMonkey]

What is your current thinking (personal or program wide) on intubation in flight?

I have been discussing this issue with my regular partners. While we have no program wide policy - it is common to avoid intubation in flight if possible. This seems reasonable for many interfacility transfers - but I question whether truly acute trauma patients should stay in the back of an ambulance for RSI to be completed. I have seen studies which show that high performance programs can achieve high rates of success in flight.

Personally , all of my intubations in the helicopter have been for pts who have deteriorated en route (seizures, declining mental status etc) and find that it is more of a question of organization then anything else. I have opted to use a video device in these cases to mitigate issues with positioning. Some of us now regularly drill this practicing taking out and placing equipment w/ the airway head on the stretcher.

I'm in line with you on this, SeeNoMore. When landing at a scene, briefly assess said patient, is there an immediate need to control said patients airway? No? Have my RN set the sled up, and ask they remove the VL from the airway bag should the need arise en route to take over or contril their airway.

Our program tries to stick by the "10 minutes skids down to skids up rule", but I think that there is always a time, place, and patient who's airway may need immediate control, and it is sometimes best not to rush these things even if it means taking longer than the 10 minute mark (we all know of the awesome studies regarding the "golden rule/ 10 minutes" in trauma patients...oh, wait?..).

Again, our particular helicopter is quite crammed though not impossible, I am all for making things easier on the patient, and myself.

To answer your original question though, my thinking is it's all circumstantial, but if I could help it, it will be performed somewhere with more maneuverability and the like than an aircraft.

 

[Carlos Danger]

I spent a little over 10 years in HEMS and only intubated during flight a few times. These were long transports where the patient's condition unexpectedly deteriorated.

Of course it depends on different factors, but I always felt that the best practice was to do it before you lifted. On the other hand, I know that approach is used to justify an overly aggressive posture towards airway management, intubating lots of patients who wouldn't otherwise need it and exposing them to unnecessary risk. It certainly did at my program, anyway.

The presence of VL would probably have made me more comfortable of the idea of intubating in flight more routinely.

 

[CANMAN]

I spent a little over 10 years in HEMS and only intubated during flight a few times. These were long transports where the patient's condition unexpectedly deteriorated.

Of course it depends on different factors, but I always felt that the best practice was to do it before you lifted. On the other hand, I know that approach is used to justify an overly aggressive posture towards airway management, intubating lots of patients who wouldn't otherwise need it and exposing them to unnecessary risk. It certainly did at my program, anyway.

The presence of VL would probably have made me more comfortable of the idea of intubating in flight more routinely.

This... We have VL accessible for every intubation. That being said we will normally take the airway at the scene, or in the hospital. If the patient is buying plastic in the aircraft it's because of an un-expected deterioration. While I don't always agree with the whole "the hospital is a higher level of care then a transport vehicle" I do believe it's always safer to perform an RSI in the facility vs. in the aircraft based on availability of lights, room, equipment, etc. Just my opinion though.

 

[VentMonkey]

Does/ did anyone's local ALS ground service ever have their airway equipment already set up and ready to go when you are/ were requested to their scene?

Ours does in the event it is presumed that the patient will need to be induced (e.g.,TBI, impending respiratory failure). This helps tremendously with both time, and efficiency, IMO.

 

[EpiEMS]

What is your current thinking (personal or program wide) on intubation in flight?

Given the difficulties of operating in a small space, do folks often elect to drop a non-visualized airway?

 

[VentMonkey]

Given the difficulties of operating in a small space, do folks often elect to drop a non-visualized airway?

By "non-visualized", I take you're referring to an SGA?

Our program is pretty standard. 3 attempts at DL, one of which will be VL, until we move on to an SGA.

 

[EpiEMS]

By "non-visualized", I take you're referring to an SGA?

Our program is pretty standard. 3 attempts at DL, one of which will be VL, until we move on to an SGA.

Sorry - yes, I was referring to an SGA. VL makes sense, I just haven't seen it used in very small spaces.

(Then again, many of the clinicians I know couldn't themselves fit in small spaces...)

 

[VentMonkey]

Sorry - yes, I was referring to an SGA. VL makes sense, I just haven't seen it used in very small spaces.

(Then again, many of the clinicians I know couldn't themselves fit in small spaces...)

One of our flight paramedics is well over 6' tall, and our helicopter is pretty tight inside, that being said, if/ when airway management is needed in flight, we follow our regular sequence.

I'm almost certain it's safe to say that this is expected in just about every flight program. We're held to a higher standard, and expected to be able to perform in confined spaces as if it wasn't an issue. It's part of the reason (IMO) we're expected to have the experience we are coming into the job.

Again, if three attempts doesn't yield an ETI, then an SGA will suffice.

 

[EpiEMS]

I'm almost certain it's safe to say that this is expected in just about every flight program. We're held to a higher standard, and expected to be able to perform in confined spaces as if it wasn't an issue..

Makes sense to me!

 

[TransportJockey]

When i flew we tried to tube on the ground first. But we were in an AC poorly set up for eti at my ft gig, and marginally better at my hybrid gig. Did one tube in the middle of a four hour flight, and it was a pain since our KA200 had dual sleds and the head of the first sled was almost at the partition.

Sent from my SM-N920P using Tapatalk

 

[VentMonkey]

Did one tube in the middle of a four hour flight, and it was a pain since our KA200 had dual sleds and the head of the first sled was almost at the partition.

Sent from my SM-N920P using Tapatalk

This^^^. Again, while ideally doing it somewhere with adequate space and lighting is best, sometimes adapting and overcoming are all but required.

 

[DesertMedic66]

Does/ did anyone's local ALS ground service ever have their airway equipment already set up and ready to go when you are/ were requested to their scene?

Ours does in the event it is presumed that the patient will need to be induced (e.g.,TBI, impending respiratory failure). This helps tremendously with both time, and efficiency, IMO.

Our HEMS services will use their own equipment

 

[VentMonkey]

Our HEMS services will use their own equipment

Mercy Air, and/ or REACH I'm sure do, since we are often being requested by our parents company's paramedics on the ground it's nice to have some ground paramedics who are at times ahead of the curve.

I simply wondered if any other flight services allow for this to happen, and/ or experience it, and if so what their take and experiences with it in regards to efficiency and time savings were.

 

[NomadicMedic]

Totally a different thing in DE, or at least in Sussex. The ground medics would perform the RSI and (usually) fly with the patient to Christiana. (The level I)
Really, the only time the county ground medic didn't fly with the DSP trooper medic was if the patient was relativly stable and they were making a quick hop to one of the local hospitals. Any unstable patient would get a county ground medic to manage the patient and the trooper medic as a second set of hands.

 

[VentMonkey]

Totally a different thing in DE, or at least in Sussex. The ground medics would perform the RSI and (usually) fly with the patient to Christiana. (The level I)
Really, the only time the county ground medic didn't fly with the DSP trooper medic was if the patient was relativly stable and they were making a quick hop to one of the local hospitals. Any unstable patient would get a county ground medic to manage the patient and the trooper medic as a second set of hands.

Do/ did DSP paramedics RSI?

 

[NomadicMedic]

They were RSI (or DFI, as it's known in DE) trained, but I don't believe they had much opportunity to practice. They were handy for an extra 10mg of Versed when you needed it though.

DE statewide protocol says two ALS providers need to be present, with at least one a Delaware DFI certified medic.

If you're curious, the DE protocols are here: http://www.dhss.delaware.gov/dph/ems/files/paramedicstandingorders2014.pdf

 

[VentMonkey]

They were RSI (or DFI, as it's known in DE) trained, but I don't believe they had much opportunity to practice. They were handy for an extra 10mg of Versed when you needed it though.

DE statewide protocol says two ALS providers need to be present, with at least one a Delaware DFI certified medic.

If you're curious, the DE protocols are here: http://www.dhss.delaware.gov/dph/ems/files/paramedicstandingorders2014.pdf

Just curious, without side tracking from this thread too much. Do all 3 county ALS providers do DFI in Delaware?

 

[NomadicMedic]

Just curious, without side tracking from this thread too much. Do all 3 county ALS providers do DFI in Delaware?

When I left a couple of years ago, New Castle wasn't performing any. Kent had only done a handful and Sussex had the majority of DFIs. Makes sense, due to the location.

 

[SeeNoMore]

So an associated question - does your program make full use of methods to minimize on scene time for RSI? I have made use of Sydney HEMS material to try and advocate formal checklists , drilling where to place equipment, bougie every time (unless VL is used) etc. On a team by team basis some of us do this but it is not technically program wide. My whole reason for starting the thread was that I feel that some patients do in fact benefit from a rapid flight to a Trauma center, and we may be doing them a disservice by extending on scene times. Obviously this is not every patient flown from a scene, as we all know well.