Intubations dissapearing?

[karaya]

Where would we be without items that required tubes? RSI? Drug administration via the tube? Not going to happen IMO.

Now that the preferred alternate to drug administration lacking an IV in cardiac arrest patients is intraosseous infusion; the argument of the ET tube as a drug delivery method appears to be waning.

 

[MSDeltaFlt]

So what is the BIGGEST concern at hand with ETI in the prehospital setting?

Is it that paramedics don't have a high enough success rate?
Is it that paramedics don't know when and when not to ETI?
Is it that the same job can be done just as effective as with other airway adjuncts?
Is it that Paramedics are just flat out not doing ETI correctly?
Is it all of these? or is it something else entirely different from these??

Sorry for the dalay, MCGLYNN. This has been one hell of a month at work. But to answer your questions. I believe it's going to more along the lines of your last question...kind of.

What I mean is that the biggest problem with ETI in the prehospital setting is a lack of situational awareness and experience when it comes to prehospital ETI. ETI is like any skill. It's easy to learn, but hard to master. And skills are like muscles. If you don't use them, you lose them.

What does that mean? It means you can't teach experience. Getting proficient is one thing. Maintaining proficiency is all together different. That, my friend, is where the problem(s) arise(s).

There are many medics who get pretty good at ETI in the controlled setting of the OR during paramedic school under the guidance of the Certified Registered Nurse Anesthetist or the Anesthesiologist. The only thing is it may be 6 months to a year after they've passed NREMT before they get their first tube during a code at a nursing home, and even longer, a year or more, before they're faced with a bad trauma pt needing a definitive airway.

And people wonder why some medics miss their tubes. It ain't rocket science. I know a helicopter mechanic who used to build missiles for Lockhead-Martin. Them's rockets. He knows what rocket science is, and he can tell you this ain't it.

As said earlier. You can't teach experience. Skills are like muscles. You don't use them, you lose them. Period.

 

[resq330]

I just wanted to throw this out there...our squad has recently been introduced to and trained to use the King Airway, all the way down to the EMT-B level. We now carry them on our trucks. This is taking the place of the CombiTube and rumor has it could possibly take the place of ETT. Just sayin....

 

[MCGLYNN_EMTP]

We need to learn when to tube and when not to tube....I worked a call with another paramedic the other night and we had an overdose patient....he decided to intubate the patient...he couldnt get the tube no to mention while he was fighting to get the tube in..i happened to look at the monitor and he dropped that guy from ST at 140 to SB at 35..amazing.....so he put in a combi tube....then for some unknown reason gave 2mg of narcan...well you can immagine what happened from there..needless to say when he dropped his patient off at the hospital...the patient had a combi tube in his hand and not in his esophagus.

that patient should have never been tube..and shoud nver have been given the whole 2mg of narcan either... 0.5mg would have been enough to bring his resp. up enough to hold for his own.

We (no pointing fingers) but as a whole really need to watch who we intubate and why we are doing it...is there another way to fix respirations?

I do believe that ETI will remain on the truck but I dont think it should be useed nearly as often as it is.

 

[Jeremy89]

We need to learn when to tube and when not to tube....I worked a call with another paramedic the other night and we had an overdose patient....he decided to intubate the patient...he couldnt get the tube no to mention while he was fighting to get the tube in..i happened to look at the monitor and he dropped that guy from ST at 140 to SB at 35..amazing.....so he put in a combi tube....then for some unknown reason gave 2mg of narcan...well you can immagine what happened from there..needless to say when he dropped his patient off at the hospital...the patient had a combi tube in his hand and not in his esophagus.

that patient should have never been tube..and shoud nver have been given the whole 2mg of narcan either... 0.5mg would have been enough to bring his resp. up enough to hold for his own.

We (no pointing fingers) but as a whole really need to watch who we intubate and why we are doing it...is there another way to fix respirations?

I do believe that ETI will remain on the truck but I dont think it should be useed nearly as often as it is.

Perfect example, Mcglynn. Speaking from a hospital standpoint, I find medics are hesitant to intubate if they need to paralyze and sedate (I'm sure the documentation for that is horrendous).

The one pre-hospital tube I saw was very poorly done (It was a trauma code- I bet an MD couldn't do any better). The airway was barely in place- I held as RT bagged.

Once you decide to drop that tube, you're cutting all communication off with that pt- so you better be damned sure you have all the hx, meds, etc.

We had a pt that PHX fire brought in once- asthma exacerbation. She was literally begging for the tube. And our MD listened...
Come to find out she was admitted to the ICU on a vent and was extubated 3 hours later. The medics made the right call by holding back the tube.

Just my 2 cents

 

[VentMedic]

We had a pt that PHX fire brought in once- asthma exacerbation. She was literally begging for the tube. And our MD listened...
Come to find out she was admitted to the ICU on a vent and was extubated 3 hours later. The medics made the right call by holding back the tube.

Just my 2 cents

Are you saying the doctor was wrong for intubating? Why?

What were her numbers on the ventilator at intubation as far as compliance, resistance, PIP and Pplat? What alternative methods of ventilation did the ED have? Heliox?

We do have a few short term intubations and if a patient has been intubated before to where he/she knows the procedure we may listen rather than wait for total failure. Few patients beg for the tube if they have had it before unless they feel they really need it. We may also need to mechanically ventilate the patient for a few hours with heliox until the effects of the steroids kick in.

Each situation is considered individually and on one's ability to maintain their airway on heliox and/or other alternatives. If no alternative gases such as heliox are available in that ED, I would definitely not criticize the doctor for intubation. Establishing an airway on a crash and burn asthmatic is never good. Putting the tube in the throat is the easy part but once the airways have tightened up, no about of paralytics, sedation, bronchodilators and heliox may be effective. Again, good assessment skills and knowledge are needed to avoid that situation as well as the necessary devices and meds/gases.

 

[Jeremy89]

Are you saying the doctor was wrong for intubating? Why?

What were her numbers on the ventilator at intubation as far as compliance, resistance, PIP and Pplat? What alternative methods of ventilation did the ED have? Heliox?

We do have a few short term intubations and if a patient has been intubated before to where he/she knows the procedure we may listen rather than wait for total failure. Few patients beg for the tube if they have had it before unless they feel they really need it. We may also need to mechanically ventilate the patient for a few hours with heliox until the effects of the steroids kick in.

Each situation is considered individually and on one's ability to maintain their airway on heliox and/or other alternatives. If no alternative gases such as heliox are available in that ED, I would definitely not criticize the doctor for intubation. Establishing an airway on a crash and burn asthmatic is never good. Putting the tube in the throat is the easy part but once the airways have tightened up, no about of paralytics, sedation, bronchodilators and heliox may be effective. Again, good assessment skills and knowledge are needed to avoid that situation as well as the necessary devices and meds/gases.

Usually its something we can control using various Neb's, steroids and even bipap. The MD didn't try anything- just went straight for RSI because thats what the pt wanted.

 

[VentMedic]

Usually its something we can control using various Neb's, steroids and even bipap. The MD didn't try anything- just went straight for RSI because thats what the pt wanted.

Usually but not always...

Do you happen to remember the initial numbers?

 

[Jeremy89]

I was working triage that day so all I saw was EMS go by saying "She's ready for the tube", then heard "Dr Murphey to 15 stat" as one of the techs cracked the code/ intubation cart. Later I saw her on a vent...

 

[Tal]

I keep reading articles on intubations in the field and how studies are really leaning towards simply using sup. O2 and BVM verses actually intubation the patient. What do you guys think about this???

I just had my ACLS-AHA course, they said that intubation should come after eprox. 600 compressions, or after ROSC.
I think its nice and all in class but in the field BVM sometimes, even for a good paramedic, is not that easy.

Also, I dont think intubation ig going to dissapear cause you will allways have the 4:00 am CHF old lady with the 260 sys.B)

 

[Pyromedic]

We had a conversation in class about this today. They are thinking of getting rid of intubating just because the many fail attempts and pt. injuries thanks to Medic pride. Now I heard this might be happening in florida, I'm not sure about the rest of the us. :/

 

[MCGLYNN_EMTP]

I had a talk with some other medics while making crew change today... One of them was telling me how there are 2 states that allow EMT-Basics to do ETI! We kind of discussed everything that this post has discussed and one of the medics said that before they pull ETI from paramedics nationally they will have to pull ETI from those states that they allow basics to do ETI.....see how that effects the stats of ETI then determine from there what needs to be done.

In the end, I dont think this will be leaving our scope of practice any time soon. Some people just really need to be intubated and there's just no way around it.

 

[Dwindlin]

I had a talk with some other medics while making crew change today... One of them was telling me how there are 2 states that allow EMT-Basics to do ETI! We kind of discussed everything that this post has discussed and one of the medics said that before they pull ETI from paramedics nationally they will have to pull ETI from those states that they allow basics to do ETI.....see how that effects the stats of ETI then determine from there what needs to be done.

In the end, I dont think this will be leaving our scope of practice any time soon. Some people just really need to be intubated and there's just no way around it.

Ohio is one, however its only in a cardiac arrest situation.

 

[MCGLYNN_EMTP]

I don't see anything wrong with the actual skill of intubation being performed by a basic...especially when its in a defined situation..(cardiac arrest) something you can't mistake..(unless you're a nursing home nurse)...but The main thing with intubations is I think we are doing it too often...more than we should be doing it. We should focus more on learning when to tube and when not to tube rather than how to do the skill.

 

[Tal]

. We should focus more on learning when to tube and when not to tube rather than how to do the skill.

spoken like a real genius!
any monkey with two hands could do ETI, the knowledge is when!

 

[Melclin]

I'll probably post about this and a few other things a bit later on in a new thread, but I thought I'd mention it here.

I've just got back from the conference I spoke about earlier where, amongst other things, Stephen Bernard presented his findings.

The study is not quite as perfect as I keep hearing from people but its still good. There is a clear reduction in mortality for the RSI group, but a worrying trend of cardiac arrest also. A couple of outcome measures were suggested during question time that seem quite obvious but that were never considered at the time, which is unfortunate (such as whether or not there was an equal number of cardiac arrests when the non-RSI arm was later RSI'd in the ED).

A/Prof Mark Fitzgerald pointed out that they often RSI haemodynamically unstable pts in the trauma centre without sedation (suxamethonium only) because it was safer. It seems possible that the mandatory pre sux sedation with midazolam and fentanyl could be responsible for the few cardiac arrests.

In any case it was clear that it was leading to better outcomes measured at 6 months. Apparently there is also a cost benefit analysis kicking around (it was very expensive to train, equip and oversee the process) that apparently was very positive, and the whole concept seemed to be very well received by the intensivists and EM physicians in attendance.

I asked Stephen later, if he felt the considerable education gap between Australian and US paramedics had anything to do with the difference in results between our study and some of yours. He felt that the more important factor was the continuing education components. I'll expand more on what he said in a new thread a bit later.

 

[guardian528]

I keep reading articles on intubations in the field and how studies are really leaning towards simply using sup. O2 and BVM verses actually intubation the patient. What do you guys think about this???

intubations are alive and well here, but the king tube is making itself more known. the standard for our company is that you go to the king tube after 2 failed attempts at intubating, or you can go directly to the king tube if you can tell it would be an extremely difficult/time consuming intubation.

however, i think ventura county has lost their's completely to the king tube for a 1 year trial or something like that.... pardon me if someone has already posted that, i didn't actually read these 10 pages