Intubation

[Juxel]

What if the patient is unable to be intubated?

As the next poster states, you shouldn't be performing RSI on a patient who hasn't been adequately assessed. Using techniques like MOANS (Difficult BMV), LEMON (Difficult Intubation), RODS (Difficult Extraglottic Device), and SHORT (Difficult Cricothryrotomy) should give you a very good idea of what to expect with the intubation.

 

[sir.shocksalot]

I think some medics are a little too gung-ho about intubating people. I couldn't see myself intubating a drunk person, if they were really not maintaining an airway whatsoever and vomiting to the point where they may aspirate I might consider nasally tubing them, but if they are just having some airway problems w/o a risk of aspiration shouldn't an NPA do the trick? BLS before ALS right?

 

[csykes]

No intubation!!! The patient is controlling their airway right now. NPA is great and NRB. Respirations at 14, not bad. Remember the average for a pt is 12-20, one that is doing nothing, lower. Capnography would be nice on this patient. RSI is totally out of the question, unless something really starts going south. As mentioned possible CVA, if this is the case and the pts sats and capnography become very abnormal, then intubation should be considered. RSI is a dangerous tool, especially here in a pt that is maintaining their airway. Also, a thorough assessment of the airway with LEMON and MOANS should have been done. It doesn't really present as a narc overdose, but hey, 2mg narcan will not hurt, especially if there is evidence she has taken more than prescribed. Assess all Hs, Ts. BSFS would be a high priority for me on this type of call, in addition to 12-lead.

 

[Ridryder911]

I'll ask this, what will you tell the Judge and Jury if the patient aspirates and dies? Yes, I was taught to secure an airway in an unresponsive patient but.... hey, he was drunk or O.D. Show me a medic that presumes that they know when a patient is going to vomit and I will show you puke on their uniform.

R/r 911

 

[VentMedic]

I'll ask this, what will you tell the Judge and Jury if the patient aspirates and dies? Yes, I was taught to secure an airway in an unresponsive patient but.... hey, he was drunk or O.D. Show me a medic that presumes that they know when a patient is going to vomit and I will show you puke on their uniform.

R/r 911

Rid,

I do respect your caution but right now I have 12 patients in our holding ward that fit your criteria for intubation. This is a slow night. Friday and Saturday were even more fun. We had 2 holding rooms full. A suction machine is close by for the pukers and there will be at least 1 or 2. But, that usually happens when they start to awaken. Patients will still puke with a tube and that cuff does little to prevent aspiration. The advantage of a tube is the vomit can be suctioned out a little easier. But, if a regular ETT is used, the vomit will continue to drip into the lungs from what is trapped between the cuff and the glottis.

If every patient matching this description arrived by ambulance intubated or got intubated immediately upon arrival to the ED, there would not be enough ICU beds anywhere in this country. I can run alot of ventilators in the ED but I would rather have the doctors do their magic and kick these patients out when the sun rises. Once the fluids start to do their job, we'll have other problems on our hands but that's another story. A tube buys a patient an ICU or at least a tele bed and an NPO menu even if we can extubate in the ED.

 

[csykes]

VentMedic, I agree 100%. People are trying to intubate way too many people by means of RSI. This highly risky skill should be used only when absolutely necessary, i.e. airway burns, chest circumferential burns, CHF when pt crashes and cpap is not helping, but most of all, HEAD TRAUMA (hemorraghing in the cranial vault from cva or mvc that is rendering pt unable to maintain airway) and herniating head injuries. Only the sickest of the sick, which turns out to be a small minority of the patients we actually pick up in the field.

 

[emtbill]

As the next poster states, you shouldn't be performing RSI on a patient who hasn't been adequately assessed. Using techniques like MOANS (Difficult BMV), LEMON (Difficult Intubation), RODS (Difficult Extraglottic Device), and SHORT (Difficult Cricothryrotomy) should give you a very good idea of what to expect with the intubation.

Any provider who has been taught to correctly RSI knows these mnemonics and should use them during the inspection and pre-oxygenation, but no assessment is perfect, and intubation can still fail. Now you've got a bigger problem on your hands after paralyzing a patient who frankly didn't need it in the first place. As most of the posters here have been saying, RSI should be used infrequently and with mandatory Q&A afterwards on only the most critical of patients. There are plenty of other ways to maintain a patient's airway. I don't know how EMT-B's get by...

 

[MSDeltaFlt]

Vent and Rid,

I honestly believe the two of you are looking at the opposite ends of the same d*mn coin. Yes, there are drunks that have no business being intubated. Wake them up and send their *sses home. However, for those moronic Darwin Award nominees who have consumed enough ETOH that their GCS's have dropped to... oh, I don't know... somewhere in the neighborhood of 5 or 6 - maybe even lower, they should probably be sucking plastic.

I don't know. That's just my call.

 

[VentMedic]

Vent and Rid,

I honestly believe the two of you are looking at the opposite ends of the same d*mn coin. Yes, there are drunks that have no business being intubated. Wake them up and send their *sses home. However, for those moronic Darwin Award nominees who have consumed enough ETOH that their GCS's have dropped to... oh, I don't know... somewhere in the neighborhood of 5 or 6 - maybe even lower, they should probably be sucking plastic.

I don't know. That's just my call.

But look at the number of patients that are taken care of everyday that have impaired or no gag from CVAs, TBIs and SCIs as well as weak to almost nonexistent coughs. Many have no way of communicating either. If they aren't vent dependent they MIGHT have a cuffless trach but most will not have even that. Even if they are vent dependent they might have a cuffless trach. Yes, these patients will vomit from time to time. Somehow these patients survive, even at home, by their caregivers learning a few basic airway principles such as head of bed elevated, rolling if necessary and suctioning (orally and NT).

Many EMT(P)s are not proficient in the use of any type of suction or don't even carry the proper equipment to perform the procedure. If they do, they may not have looked at it for 4 years or more.

Honestly, how many have NT suctioned a patient within the last year? I don't mean just sticking a tonsil tip down their throat or put the tip to the nose. How extensive was it even covered in EMT(P) class?

I do know this since I see examples of this in two different states on two different coasts. Trying to get just a trach patient from point A to point B can be a big hassle if you mention the patient might need to be suctioning. Someone has to run out to the truck and see if the suction is working. What usually happens is an RN or RRT has to tag along with their own equipment "just in case" that dreaded suction stuff is required.

The use of a BVM on a patient for extended periods of time is not something that some are not experienced in either. No, we do not intubate someone we are doing a conscious sedation on that went a little deeper than expected. We just bag them through the procedure. If they puke we place an NG or just suction.

To perform advanced airway procedures one has to be comfortable and confident in ALL aspects of airway care and not just the cool stuff like RSI.

For flight, yes, it is better to secure as airway while on the ground...just in case.

Disclaimer (before anyone gets ruffled): Skills and the education to go with them will vary from city to city in this country.

 

[triemal04]

Disclaimer (before anyone gets ruffled): Skills and the education to go with them will vary from city to city in this country.

Ok, you work in Florida and California...2 states that have multiple problems with their EMS system, both the educational structure and overall system.

 

[reaper]

Ok, you work in Florida and California...2 states that have multiple problems with their EMS system, both the educational structure and overall system.

I won't speak for California, but Florida EMS as a whole state system, is far ahead of the times compared to most states. Yes, they need to shut down the mills, but their college courses are top notch. Not to many states stand behind EMS and support it the way FL does. I wish more states would take that active of a role in it.

 

[VentMedic]

I won't speak for California, but Florida EMS as a whole state system, is far ahead of the times compared to most states. Yes, they need to shut down the mills, but their college courses are top notch. Not to many states stand behind EMS and support it the way FL does. I wish more states would take that active of a role in it.

Florida does provide ALS for 911 to all areas of the state. Some EMS systems in Florida are state of the art and was probably one of the first states in the country to do 12-leads and even did the field trials for thrombolytics over 20 years ago.

However, it was thought a little of a good thing could be improved by having a whole lot of it. Thus, medic mills on every corner and every FF is to be a Paramedic.

California and Florida are two very large and diverse states, each with differing styles for their state EMS structure.

 

[Sasha]

Thus, medic mills on every corner and every FF is to be a Paramedic.

Not to hijack the thread more than it already has been, but isn't Florida moving to 100% degree program medics in the near, next ten year, future? I've heard that from a couple of people but have yet to find an article that supports it.

 

[VentMedic]

Not to hijack the thread more than it already has been, but isn't Florida moving to 100% degree program medics in the near, next ten year, future? I've heard that from a couple of people but have yet to find an article that supports it.

At one time a degree was offered in almost 100% of the schools, along with the certificates, in Florida since they were college based.

What you just stated is also a sales pitch by one of my "favorite" medic mills that now offers and "Associates" degree. However, the words: may or might transfer" to other colleges are also used in the contract. Since their school is relying on the accreditation of a private technical school system, their instructors do not meet all to same requirements for teaching as do those accredited in the state system.

I seriously doubt if all or even half of the private programs will be CoAEMSP/CAAHEP accredited in 10 years since Florida uses its own state exam for the Paramedic. These schools make up 50% of the programs that teach the Paramedic program. The other 50% are the community colleges which have their accreditations. However, these community colleges are offering a certificate which has changed greatly over the past 30 years and now resembles a medic mill type training to stay competitive. Not many students are completing the degree programs and there has been talk about closing some of degree offerings due to budget constraints. At this time I do not believe the state of Florida has made any statement. If they do, the FFs' union will oppose it since it will cramp their requirement of being a certified Paramedic within one year of hire.

 

[Sasha]

That would explain why I couldn't find anything online about it :]!

Thanks!

 

[MSDeltaFlt]

But look at the number of patients that are taken care of everyday that have impaired or no gag from CVAs, TBIs and SCIs as well as weak to almost nonexistent coughs. Many have no way of communicating either. If they aren't vent dependent they MIGHT have a cuffless trach but most will not have even that. Even if they are vent dependent they might have a cuffless trach. Yes, these patients will vomit from time to time. Somehow these patients survive, even at home, by their caregivers learning a few basic airway principles such as head of bed elevated, rolling if necessary and suctioning (orally and NT).

Many EMT(P)s are not proficient in the use of any type of suction or don't even carry the proper equipment to perform the procedure. If they do, they may not have looked at it for 4 years or more.

Honestly, how many have NT suctioned a patient within the last year? I don't mean just sticking a tonsil tip down their throat or put the tip to the nose. How extensive was it even covered in EMT(P) class?

I do know this since I see examples of this in two different states on two different coasts. Trying to get just a trach patient from point A to point B can be a big hassle if you mention the patient might need to be suctioning. Someone has to run out to the truck and see if the suction is working. What usually happens is an RN or RRT has to tag along with their own equipment "just in case" that dreaded suction stuff is required.

The use of a BVM on a patient for extended periods of time is not something that some are not experienced in either. No, we do not intubate someone we are doing a conscious sedation on that went a little deeper than expected. We just bag them through the procedure. If they puke we place an NG or just suction.

To perform advanced airway procedures one has to be comfortable and confident in ALL aspects of airway care and not just the cool stuff like RSI.

For flight, yes, it is better to secure as airway while on the ground...just in case.

Disclaimer (before anyone gets ruffled): Skills and the education to go with them will vary from city to city in this country.

How acute of a change in status of the CVA's, TBI's, and SCI's are you referring, Vent? Are meaning Acute, Subacute, or Chronic? Because I'm talking about the dipsticks who are getting ''crunk'' one moment, and the next moment their sh*t's f*cked up as stated earlier.

With respect.

 

[VentMedic]

How acute of a change in status of the CVA's, TBI's, and SCI's are you referring, Vent? Are meaning Acute, Subacute, or Chronic?

Of all phases. Not every CVA get intubated. Not all TBIs or SCIs get intubated. We have a lot of patients in various vegetative states that don't get an artificial airway. If they are not pharmacologically sedated and paralyzed on a machine, doctors can also assess the injury better and provide a different and maybe more progressive therapy.

Because I'm talking about the dipsticks who are getting ''crunk'' one moment, and the next moment their sh*t's f*cked up as stated earlier.

Are you referring to patients?

Not all intoxicated or drugged patients get intubated either especially if you have to stop at the driveway and do you intubation attempts in the ED doorway.

Putting a CHF or COPD patient on CPAP can be extremely risky also. That definitely can cause a patinet to vomit if they had recently eaten or feel nausous from a hypoxic or cardiac event. The continuous flow with pressure will not give anyone much of a chance to get that mask off before the vomit will be pushed very deep into their lungs quickly. Hospitals have very strict P&Ps about who gets CPAP/BiPAP(trade name), when and where. However, to prevent these patients from being intubated, we still take may that chance.

While there are some patients that will definitely need a tube, many don't and shouldn't. If a patient doesn't have to be attached to a ventilator as a "feel good" measure for someone else, it can speed the patient's progress through the system. Those with drugs and alcohol problems can go to the appropriate facility faster.

Sometimes clinical judgement has to be used instead of following a recipe or doing something just because you now have RSI and can.

 

[Ridryder911]

Sometimes clinical judgement has to be used instead of following a recipe or doing something just because you now have RSI and can.

This is the point I believe is missing in many of the newer produced medics. Unfortunately so many educators and instructors have lost the intent of educating of critical thinking skills. I believe it started at the first level. Just read the posts from Basic Level EMT's that want to argue upon subjects as "protocols say" and or have limited to no knowledge level in that specific area but still want to refer to a step by step or lump care as "always".

If one has to perform more than a few ETT suctions a year to remember aseptic and sterile techniques, then they should not be providing care. If these so called providers are inept or stupid to remember such basic skills as suctioning, I now see the problems of why intubation is such a difficult procedure. When realistically, there is far more difficult procedures performed daily by other health care providers. Not to be sarcastic and demean the importance of a thorough education in intubation but realistically, there are only two holes to be able to place a tube in and they cannot perform this too? This does raise the question of wondering the competence in other areas.

I have to admit my States EMS education and training program has a lot to be desired. There is still a lot of work to meet the minimal areas, but now after reading posts from other so called renown areas, I realize we are not as bad in comparison.

It rather upsets me that professional EMS educators are still allowing such training to occur. Not proposing legislative changes is as much condoning it as teaching it. I do ask what if the State EMS Division doing? Are they purposefully blind by outside influences or have reached the point of bureaucracy they have ignored the problems?

Instead of discarding of what or how one performs, focus upon the problem and how to fix those problems should be addressed.

R/r 911

 

[MSDeltaFlt]

Of all phases. Not every CVA get intubated. Not all TBIs or SCIs get intubated. We have a lot of patients in various vegetative states that don't get an artificial airway. If they are not pharmacologically sedated and paralyzed on a machine, doctors can also assess the injury better and provide a different and maybe more progressive therapy.




Are you referring to patients?

Not all intoxicated or drugged patients get intubated either especially if you have to stop at the driveway and do you intubation attempts in the ED doorway.

Putting a CHF or COPD patient on CPAP can be extremely risky also. That definitely can cause a patinet to vomit if they had recently eaten or feel nausous from a hypoxic or cardiac event. The continuous flow with pressure will not give anyone much of a chance to get that mask off before the vomit will be pushed very deep into their lungs quickly. Hospitals have very strict P&Ps about who gets CPAP/BiPAP(trade name), when and where. However, to prevent these patients from being intubated, we still take may that chance.

While there are some patients that will definitely need a tube, many don't and shouldn't. If a patient doesn't have to be attached to a ventilator as a "feel good" measure for someone else, it can speed the patient's progress through the system. Those with drugs and alcohol problems can go to the appropriate facility faster.

Sometimes clinical judgement has to be used instead of following a recipe or doing something just because you now have RSI and can.

Yes, I am referring to pts. And you are right. It does take clinical judgement and common sense in stead of following a recipe. I've always said, the trick to this job is not knowing what to do and being able to do it. That's easy. Any moron and be taught that. The trick to this job is being able to do something, and knowing when and when not to do it.

That being said, I can learn a lot from you because you are a little more judiciously aggressive than I. You have a few more toys at your disposal and that's how you help me stay current.

 

[VentMedic]

Instead of discarding of what or how one performs, focus upon the problem and how to fix those problems should be addressed.

R/r 911

Rid,

We offer extra training and have almost 100 subacute and another 200 SNF patients as a living laboratory where some can come in for a little refresher or education/training about the new technology, stabilization devices for SCIs, trachs and suction methods that can be used on different patients including children. Most of what we have to show can be found in LTC facilities and in homes.

Few Paramedics get the chance to NT sx a patient in their clinicals but yet that is what many nursing home patients need before anything else.

The problem is getting EMT(P)s to come into these classes that have the stigma of being "BLS" or chronic care issues and not EMERGENCY stuff.

The same comments can be applied to various vascular access devices. There are numerous discussions on the EMS forums where some are trying to speculate or "guess" what they can and can not do with these devices. It wouldn't take much to attend a CE class at a hospital or community college to learn more even if it isn't mandatory or your chief isn't forcing you to do it. Of course, the fact that it might be under the "nursing" section can scare off some.

There is a world of information and education out there and sometimes if one's own program was not that great, one still has opportunities to make the most of their own career destiny by seeking out whatever they can. Of course, one must also realize that their EMT(P) program didn't give them all the knowledge needed to be successful in this profession.