Is this normal? - ET Tubing

usalsfyre said:
Further, dropping. King or LMA is not equivilant to placing an ET tube under direct larengoscopy. The fact that paramedic programs and medical directors are saying they're the same, and then letting folks go out and place ET tubes when they may have not have done DL in months or years scares the crap out of me.
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Glad I'm not the only one.

Veneficus said:
Even for medical students, it seems in the US they are permitted to do less and less every year. If nobody is going to let somebody with at least 2 years of graduate medical education touch a patient, who is going to let a paramedic student?
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I saw the same attitude with IVs. To get my EMT-IV license, I needed to get 5 IVs, 3 I think with fluid administration. A lot of the places I went to on clinical rotations hardly wanted me to touch a patient, let alone perform an invasive procedure. I was struggling towards the end just to get those 5.
 
Shoot, I did every IV on every patient that came in to my clinical locations, even if it was a crashing kid.


Now... number of tubes I got? We won't go there.
 
Thanks everyone. And we do practice in the dark, a car, etc ....

Also, we do 24 hours in an OR for the purpose of airways.
 
usalsfyre said:
I'm all about the most approprite airway, from simple stimulation up to and including surgical cric. But....

CPAP is not an airway intervention. In fact, if the pt is not fully in control of their airway it's totally inappropriye and dang near negilgent to place a sealed mask over the patients airway. An incredibly useful adjunct to oxygenation and vetilation, absoloutely. Staves off a large number of intubations, sure. An airway control device, not by a long shot.

Further, dropping. King or LMA is not equivilant to placing an ET tube under direct larengoscopy. The fact that paramedic programs and medical directors are saying they're the same, and then letting folks go out and place ET tubes when they may have not have done DL in months or years scares the crap out of me.
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They aren't saying they are the same, they are saying they want people to use their heads and use the most appropriate. If CPAP will work, don't RSI the patient to get the tube. If the pt has a malampati of 4, and you've looked and can't see crap, don't try ETI 5 times, use a King.
 
Aidey, I applaud your medical direction for pushing this line of thinking. Airway SHOULD be a continuum, and not every patient will get an ET tube in the field. The one flaw in the approach your talking about is that the number of ETIs needed to maintain proficency does not decline because of CPAP and Kings. If anything you need to be more proficent, as your patients will be sicker when they need an ET due to CPAP. So reducing ETIs in favor of Kings and especially CPAP (really, it's sealing a mask, I could teach my three year old the skills behind it) is cheating your providers and patients.

My $0.50 worth for systems is either keep your folks up to speed on ETI, or get rid of it.
 
I know, that is the downside of the whole situation. The problem is that right now there are not enough intubations happening so that every medic and medic student can meet their total number needed. We are allowed a certain number on a mannequin, but the demand is still higher than the number of tubes available. I think they hope that by pushing the idea of the most appropriate intervention rather than the most advanced they hope to reduce the competition existing in the current system. When you are dealing with some 250 or so paramedics reducing the number of tubes required on a real human by 2 a year can made a difference hopefully without compromising quality.

I think that simply requiring that capnography be used on every intubated patient would be a big step in the right direction. And I mean required. You have one free pass, and after that if you don't use it, you don't get to intubate.
 
usalsfyre said:
My $0.50 worth for systems is either keep your folks up to speed on ETI, or get rid of it.
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I wish more people would think like this.
 
Aidey, I agree on waveform capnography. Any service that intubated and doesn't have it is negligent. Anyone who has it and won't use it on intubated patients needs to be whipped with a capnograph line until they have a change of heart.

I don't know how your system is set up, but the question that comes to mind is do all of your medics need to be able to intubate? Or would it be better to have the majority of them utilizing blind airways with a select few able to do ETI? This would ensure a higher level of oversight, and much more hands on time with a laryengoscope for the people who can intubate?
 
lol, I like how you think...I just threatened to whip someone with a NRB the other day :P


Realistically no, not all of the medics need to be able to intubate. However, no one will EVER be able to convince any agency to give it up or self limit. If my agency or medical director even suggested it, I know exactly what would happen. It would hit the media as either we aren't providing the same care as the FD, or that we are trying to limit the care the FD can provide.

The only way I could see it happening is if the medical directors collectively tell all the agencies "this is how it is going to be, suck it up and deal with it". I think the only way they would do that is either as a result of a lawsuit or because intubation success rates suck.

The other problem is that our state requires a certain number of intubations in order to recert, so that would have to be changed if they wanted to limit who can and can't intubate.

Now that all of the local ALS agencies have capnography the MDs are really starting to push it, and push the ERs into using it too, even if the RT isn't there. I think that it will take some time, but hopefully there eventually will be a mandatory use policy in place. It also wouldn't surprise me to see more lawsuits against agencies who don't have it, since it is becoming the standard of care. If we want to keep ETI as a pre-hospital skill capnography needs to be universal.

I have a personal policy that if I intubate someone they will be put on capnography. Period. I will use an OPA and BVM until it is available. In a perfect world it will be used on all intubated patients in my presence, whether I tube them or not. That policy actually recently saved my butt in a big way, so it won't be changing any time soon.
 
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My program was lucky to be able to do rotations in the OR. We had to do 16hrs which isn't much at all but you were almost guaranteed to get at least two intubations on real patients. And the ED physicians were cool about letting the Paramedic students intubate.

During our airway class we had an "airway rodeo"... this was where the instructors set the mannekin's up in atypical situations and we had to intubate them... some where upside down, in complete darkness, in a car pressed against the steering wheel, etc. It was a good experience and added some perspective of what real-world field intubations would be like.

To the OP.... its true that sometimes you only succeed after you fail. Even though you missed the tube you still got a first hand look at the airway anatomy, gained perspective of the airway, and experienced the motion of the procedure. As long as you can reflect on all of that its not really a failure when it happens during your clinicals. I admit its blows your confidence to pieces but its your time to learn.

As a student I had a patient in the ED that needed intubated and the doc allowed me an attempt... so here I am nervous, with a room full of staff people looking on, and I miss it... but looking back I can now see the esophagus that I intubated... it looked nothing like the trachea now that I am a little more versed with the airway structures. What I learned from that failure was how distinctly different the trachea and esophagus look and what it means when some people say "that patient was really anterior". This patient was and the doc even said so after the fact. With some cricoid pressure it would have brought the cords into view... lesson learned.

It will come... don't let it get you down.
 
Thanks 18G... it is coming to me. I was more frustrated with an exam score I got last week! Good grades take more than just smarts, you have to study!! Which, is what I need to get back to right now.
 
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