Is an ET Tube Really ALS?

[VentMedic]

eh wording was kind of off. Not saying there's no use for an ETT but they have a tendency to be overused. I've seen medics get on scene where a FR has already placed a combi that was working fine and the first thing they did was remove the combi to place an ETT. For us as long as we have some sort of airway that is facilitating the transport of O2 we will let it be until after we start a line, hook up the ECG, etc depending on the call. We do place ETT's but it's not a priority thing when we arrive on scene when other lifesaving interventions are indicated.

I don't know about overused especially if one has the ability to do ETI.

However, the debate of "to pull or not to pull" can be a thread to itself and frequently is on the flight forums.

In the hospital, we will definitely change the tube but I have left an alternative airway in place when doing scene response on a flight team if there was any doubt of quickly establishing another provided I had excellent ventilations and the airway was secure. LMAs are not that secure in moving vehicles.

 

[Zippo1969]

Wanna intubate? Go to Paramedic school. Otherwise use the (numerous) tools already out there, such as Kings, Combitubes, simple adjuncts with good BVM technique et al.

It's hard enough (and getting harder) to convince Anes. to let medics intubate with the stats we're seeing, let alone getting a basic into surgery to get tubes...but this has already been said.

Also, with new technology (capnography being the one off the top of my head) there is no excuse for a misplaced ETT. Zolls, LP12s, and other monitors have continuous logs to monitor whether there is proper gas exchange during transport.
MANY tubes get pulled transferring pt.s to ER beds...I wonder how many of these are counted against EMS and not overzelous ER staff, and are these capno. logs factored into the results of studies like Dr. Wangs'?

 

[Hal9000]

I'm sure I could do an ET tube and not hurt the patient.

After a lot of practice and schooling so that it means more than just shoving a tube in someone.

I'm a -B, and the combitube is fine. A good BVM also works well for me, and that's as far as I want to go with it.

A lot of -Bs forget that the simplest and least invasive way is the way to go. I know some -Bs that are good EMTs but would use a combitube over a standard oral airway, even if they both worked the same, because they have the cert.

I guess that I just don't feel the same way. I wouldn't want someone shoving a tube inside me if something else would work.

 

[VentMedic]

Unless the patient is very unconscious, an ETT is not always tolerated very well. If you intubate, the sedation after the procedure is as important as prior to intubation in most cases. If the patient wakes up after you have intubated with coughs and spasms, you will not be able to effectively ventilate even with the ETT. Oxgenation will also fall as a result.

 

[Medexpresso]

Pennsylvania is moving in the direction of getting rid of the ET tube all together. medical directors are pushing for the use of the Combitube and/or a King Airway, just slam it down and pick the lumen that ventilates and bam there you go. we also us an IO drill as opposed to manual IO... it seems as if the equipment is changing so much that EMT-Bs will most certainly be performing these skills in the near future

 

[EMT-P633]

it seems as if the equipment is changing so much that EMT-Bs will most certainly be performing these skills in the near future

I most certainly hope not, just like the ETT an IO is alot more then just shoving or drilling a hole in a bone.

Again as it has been said numerous times in this thread, If a B wants to be able to do more for the good of the patient then go to medic school. learn the anatomy and physiology of the body. KNOW why you are doing something and what to expect before it happens. Why would anyone allow a B to start an IO before they are even proficient in IV's?

I work in TN. and here we have a different set up then most of the country, we do not have basics. we have EMT-IV and medics. And here we at different services we discuss these same topics. and I usually point out the same points as in this thread. A basic just simply does not have the education needed to know how / why the body is acting or reacting the way it is. Yes they are fully capeable of performing the skill. BUT what about the what if's? What if they are using an IO on a ped patient and they hit the growth plate? Do they know that this child will most likely be deformed for the rest of thier life with a short leg? What if they are using a B.I.G. and do not have the proper alignment and shatter the bone? these are just a few examples.

One big change that has recently happened here in TN is that EMT-IV's have been authorized to aquire 12-leads and transmitt them to the recieving hosp. this is only done on units that are BLS. They are not taught to interpert the rythym, authorized to treat the rythym. What if they hook up the PT to the 12-lead. PT converts from sinus rythym to V-tach or V-fib. they recongize this rythym, attached the AED and defib the patient. Did they not just practice outside thier scope of practice?

In all honesty I feel that allowing basics and intermediates to do advanced skills. or moving skills down the ladder is only going to open up too many "can -o- worms". It will end up biting someone in their forth point of contact before it is over.

As for the aurgument of teach them the why's along with the how's, of these advanced skills. then once again as said too many times already in this thread. why not just bite the bullet and go to medic school?

 

[mbcwgrl]

EMTs can (somnetimes) use combi tubes and such... As an EMT you should learn the basics first, then move on. In my state we dont usually recognize EMT-I but it would be good to take the class for those that are interested in a little bit more medicine but not quite ready for the responsibility.

 

[VentMedic]

In my state we dont usually recognize EMT-I but it would be good to take the class for those that are interested in a little bit more medicine but not quite ready for the responsibility.

Unfortunately that pretty much sums up EMS education and all of its little "certs".

 

[Melbourne MICA]

Lets just pop in an ET tube.

Our intubation guideline goes for 11 pages. It contains 13 discrete sections each with multiple sub sections. It has about 10 drugs involved in one part of the process or another, a dozen other bits of equipment go along with it, a dozen or more separate skills, there are anywhere from two to four people involved in setting up, there are about a dozen or so situations where ETT is indicated, another dozen or so contraindications somewhere in the process, 1/2 dozen required methods to confirm placement, a whole section just on capnography, airway patho knowledge,drug patho knowledge, chest patho, brain patho, spinal patho........................................................

And thats just to get the ball rolling.

I've done literally hundreds of them; dead, alive, with drugs without drugs, on a floor, in a car, in the street, in the rain, blinded by the sun, as job number one at 0700, as job number 15 at 0630.

I look at all that stuff up there and it still sends shivers down my spine.

It should do the same to you.

There's no such thing as just "popping a tube in".

MM

 

[el Murpharino]

How true, Melbourne. I never truly appreciated how intricate intubation was until I went through paramedic class, and more recently a SLAM class. Just a small part of the problem lies in fast-tracking many people through the training for intubation. Alot of providers don't even know how to properly assess their patient and anticipate a difficult airway, a difficult patient to bag, etc. And they wonder why there is such a push here to take intubation away from medics...

 

[Melbourne MICA]

How true, Melbourne. I never truly appreciated how intricate intubation was until I went through paramedic class, and more recently a SLAM class. Just a small part of the problem lies in fast-tracking many people through the training for intubation. A Lot of providers don't even know how to properly assess their patient and anticipate a difficult airway, a difficult patient to bag, etc. And they wonder why there is such a push here to take intubation away from medics...

Quick anecdote. I had a 40 something pt who collapsed GCS 3 with no Hx etc.
Seemed to me and my partner like a neuro bleed. The pt had no airway reflexes so at risk - ETT. My partner did a beautiful job on ET insertion, took less a than a minute from setup to securing. A piece of plastic down a hole.

Not.

No sooner had the tube tickled the cords than the HR went south -130/min to 30 a min in front of our eyes. BP went with it of course. Not good for a neuro bleed.

But we had atropine and EPI already drawn. 60secs late back to normal.

Point is of course all our training had prepared us for the multitude of things that can happen - like a big vagal kick. Then there's understanding the side effects of atropine, secondary hypoxic brain injury, how you are going to ventilate the neuro bleed pt, Mx the BP, using paralytic drug issues, interpreting the capno and so and so on.

And all for this one pt and her specific medical circumstances on the day. On to the next pt who will be completely different again but who also might need an ETT.

Our Medicos were considering giving our BLS guys ETT - they looked at the training, experience, prac skills, revision, further education issues etc - they use BVM and LMA NP OP etc already. Not a good idea was their view.

So you can use a combitube, LMA, KingAirway whatever. Now you can stick an ETT down a manikins plastic throat during "training".

Not.

It doesn't count as far as I'm concerned and be ready for the "awakening" for those who do.

MM

 

[tydek07]

I think it should stay as an ALS skill. You need to know a lot of why's and how's before you can just go out and do a skill. It would be way to costly to put into the EMT-B course. You would need to learn more anatomy, as well as .... wow... too much to type....nope, just will not work haha