Intubation WITH gag reflex

IrightI said:
Sounds like my regular pts :rofl: You say what now...and I say Cric. There is always a way, and just for kicks il have bicarb on standby.

The last thing you want is to paralyze someone, and have to bag them through the ER doors without having a tube. We make sure that never happens with our service. :cool:
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You are most assuredly a paramedic student judging from this statement.

If you can bag a patient effectively and still cut their throat you'd be decredentialed so fast your head would spin here. That's a gross misunderstanding of airway management. The "gold standard" is not a tube. The gold standard is the chest going up and down in an effective manner.
 
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usalsfyre said:
You are most assuredly a paramedic student judging from this statement.

If you can bag a patient effectively and still cut their throat you'd be decredentialed so fast your head would spin here. That's a gross misunderstanding of airway management. The "gold standard" is not a tube. The gold standard is the chest going up and down in an effective manner.
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Maybe its just our progressive protocols that allow us to "cut their throats" if there is no other option. BLS before ALS, you should know this. And im glad that you understand that the chest going up and down and blood going round and round is the gold standard.

Dont fear the Cric.
 
IrightI said:
Maybe its just our progressive protocols that allow us to "cut their throats" if there is no other option.
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I've worked under one or two sets of progressive protocols as well...

IrightI said:
BLS before ALS, you should know this. And im glad that you understand that the chest going up and down and blood going round and round is the gold standard.
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And yet, earlier you stated you'd still cric even if a BVM was working? Which is it?

Not to mention those "progressive protocols" I've worked under (so progressive they read more like "general suggestions" in many cases) allowed me to bypass basic measures and jump straight to the scalpel in an appropriate situation. You didn't give an appropriate situation. What you described was knackering an airway because you used NMBAs when you shouldn't have and doing a cric to bail yourself out.

IrightI said:
Dont fear the Cric.
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If can't intubate/can't ventilate doesn't scare the ever-loving micturation out of you than I feel sorry for your patients. Hopefully you learn to temper your "aggressiveness" before you get in a bad situation.
 
While we dont carry any drugs for RSI, we usually have a resident riding along in the sprint who does carry them.
 
usalsfyre said:
I've worked under one or two sets of progressive protocols as well...


And yet, earlier you stated you'd still cric even if a BVM was working? Which is it?

Not to mention those "progressive protocols" I've worked under (so progressive they read more like "general suggestions" in many cases) allowed me to bypass basic measures and jump straight to the scalpel in an appropriate situation. You didn't give an appropriate situation. What you described was knackering an airway because you used NMBAs when you shouldn't have and doing a cric to bail yourself out.


If can't intubate/can't ventilate doesn't scare the ever-loving micturation out of you than I feel sorry for your patients. Hopefully you learn to temper your "aggressiveness" before you get in a bad situation.
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You take things said on a forum wayyy to seriously and relate it to what would be done in the rig. That is your first short coming. Your second is assuming that I would jump to such measures when I am in a "bad situation" based off of a comment that I posted. Chill out dude. We both have that P-number and we both know the basis and understanding, or shall I say "Standard of Care" to appropiate airway management, this is rudimentary to us.

There is no CANT in the back of MY rig...EVERYTHING gets done for the benefit of my patient. So dont tell me to "temper my aggressiveness". Its that AGGRESSIVENESS that hasnt put me in a bad situation. Sorry you are in a "mommy may I" system.

Chill out and take forum chit-chat with a grain of salt. Who knows, you might be a needing a cric if you keep getting yourself all hot and bothered over these forums. Lets hope its not me who goes enroute to that call, I wouldnt want to get aggressive with you now. :rofl:
 
IrightI said:
You take things said on a forum wayyy to seriously and relate it to what would be done in the rig. That is your first short coming. Your second is assuming that I would jump to such measures when I am in a "bad situation" based off of a comment that I posted. Chill out dude. We both have that P-number and we both know the basis and understanding, or shall I say "Standard of Care" to appropiate airway management, this is rudimentary to us.
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If I hadn't seen a fair number of airway disasters caused by the displayed attitude I wouldn't be so quick to judge.

IrightI said:
There is no CANT in the back of MY rig...EVERYTHING gets done for the benefit of my patient.
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Even hospitals are willing to defer procedures that they don't have the volume to pull off. Instead, you've got the attitude of "supermedic". This can and will bite you in the butt. It's entirely appropriate to look at an airway and go "not today, they can stick it out". Preferred? No. Ego lacerating? Sure. But you don't end up with a patient you've killed.

IrightI said:
So dont tell me to "temper my aggressiveness". Its that AGGRESSIVENESS that hasnt put me in a bad situation.
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Thinking with your balls will put your patient in a bad place. Anyone who thinks otherwise hasn't been doing this long enough to be there or is too dumb to realize they painted themselves in that corner. There's times its appropriate to be aggressive and other times that benign neglect is a GREAT policy.

IrightI said:
Sorry you are in a "mommy may I" system.
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I think you would likely be stunned at the standing order set I have. I haven't called for an order in 4+ years now.

IrightI said:
Chill out and take forum chit-chat with a grain of salt.
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If I didn't think you were being serious I wouldn't have jumped your @ss. I see about one guy a week in the QA office with an attitude like yours.

IrightI said:
Who knows, you might be a needing a cric if you keep getting yourself all hot and bothered over these forums. Lets hope its not me who goes enroute to that call, I wouldnt want to get aggressive with you now. :rofl:
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:rolleyes: Good luck is all I'm gonna say.

Quick question, without Googling, can you tell me how lemon relates to airway management?
 
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The knowledge and professionalism displayed in this thread is awe-inspiring.
 
IrightI said:
Lets start with 2 in a shift. One fly-out and one ground pounded to a level 1.
And that was on a slow day. Would my weekly total suit you more?.
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If you've done more than 2 in any given month (hell... Should be months) outside of the OR, either you're lying or you are clearly RSIing the wrong people.

When I did a somewhat busy rural system with usalsfyre, with an hour transport, I did 2 in 5 months.

In a VERY busy, VERY progressive system now, there's only 2-5 a month, in the WHOLE system.
 
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Linuss said:
In a VERY busy, VERY progressive system now, there's only 2-5 a month, in the WHOLE system.
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Now, now... I work in a somewhat busy, VERY progressive service and we did 29 RSIs in Q3 of 2011. So, not everyone is in the same boat you are.

Do we aggressively manage airways; some say yes... but not ONE of our RSIs was deemed inappropriate by our Medical Directors. (And we have a ridiculously in-depth QI system.)

However, I still believe the attitude displayed by IrightI is dangerously cavalier when it comes to airway management, and rather rude to the rest of the forum members.
 
Obviously these numbers are going to depend on the size of the service and the call volume as well. If you have 4 trucks doing 7500 calls, you're going to do a smaller number of RSIs in a given unit of time than 30 trucks doing 100,000 calls.

Surgical airways should be a very rare event, even for a large system (e.g. population served > 1 million for the sake of having a definition). There are situations where they are going to be an airway of first choice, and there are going to be situations where a failed RSI is going to require them. But there's no reason to cric someone if you're getting decent oxygenation and ventilation with basic maneuvers.
 
To RSI weekly, one would have to be in a very low medic concentration system to achieve those numbers. Not many exist in the US and I would be curious as to which this person is from. My guess... he's works for the one that exists only inside his head.
 
medicsb said:
To RSI weekly, one would have to be in a very low medic concentration system to achieve those numbers. Not many exist in the US and I would be curious as to which this person is from. My guess... he's works for the one that exists only inside his head.
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^this!
 
Too many RSI's and too many crics = really crappy airway management skills. IrightI needs to spend some quality time in an OR with an experienced anesthetist and actually learn how to manage an airway. Being proud of how many RSI's and crics you've done is really idiotic because in my expert opinion (I can claim that because my profession represents THE experts in airway management), it clearly indicates he doesn't know what he's doing. Or maybe it's the classic "you don't know what you don't know". Cowboys like him don't last very long in any profession.

I try not to stick my nose into these types of "mine is bigger than yours" discussions, because I've been out of EMS for many years (with the exception of teaching airway management in the OR to a variety of different healthcare students and professionals) and I'm not always up on the latest EMS standards and techniques. But airway management IS my thing - you're either dangerously cocky or trolling - I'm not quite sure which yet.
 
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And that's enough of this one.
 
Thread now reopened after I had to clean it up. If I have to do it again, somebody is getting a forum vacation.
 
I’m glad this thread is reopened, because it brings to light some interesting discussion points about the polarizing topic of RSI.

I feel there is no such thing as “too many RSIs”. If a patient presents with the need (or anticipated need) to have their airway managed, RSI performed by a trained professional is the best and safest option . I would much rather have a patient sedated, paralyzed and intubated in the back of a well-lit ambulance before climbing into a cramped State Police Bell 407. Safer for the patient and reduces my possibility having to perform a difficult intubation.

Now, having said that, I believe sending Paramedics out into the wild, direct form medic school, with no training other than, ‘This is Sux, push it after the Versed” is dangerous and irresponsible. I am lucky that I work in a system that has extensive training in RSI, quarterly OR time scheduled for the medics that are not getting field tubes and an exhaustive QI process that involves an entire separate packet of paperwork for every intubation, RSI or not, that is reviewed by a peer, the shift FTO, the education coordinator and the medical director. Every tube.

So, to those who are performing RSI, let's talk about it...

  • How is your department educating medics for RSI?
  • What’s the QI process like?
  • How often are you getting to the OR?
  • How many field tubes are you actively passing each year?
  • What is your criteria to determine RSI candidates and then what special protocols do you have to assue success?
 
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