NG Tubes and Airway Management

[18G]

I am beginning to think that you've got your mind made up and are unwilling to critically assess your desire to add this skill.

Not at all.... but I am failing to see your position and the other minority opinions on the forum as absolute. I have yet to hear anything convincing to make me abandon my support of gastric tubes to improve ventilation and help protect against aspiration in certain patients.

I'm surely not going to disregard highly regarded texts, journals, my own knowledge, and other medical professionals all because of a few opinions. Don't get me wrong I do respect them and appreciate the input but there is no way four people on EMTlife.com override what is accepted by a majority in the medical community.

If anything, given the wide advocation and practice of NG tube use to improve ventilation and reduce aspiration risks in peds, the burden of proof falls in the minority.

Show me where NG tubes are harmful? Show me where they do not improve ventilation. Show me where they are not effective at relieving gastric distention.

This thread has been discussed to the max so I will bring it to a close with these last thoughts.

1) Healthy patients, especially kids, have great respiratory reserves and oxygen transport ability. The 30sec to a minute time in most cases its gonna take to do the insertion, is not gonna result in hypoxia. And only in a few cases does the insertion cause vomiting. But if it does cause vomiting, at least the providers are immediately available to react the very second it happens.

2) The argument is the NG tube "may" cause vomiting on insertion. What do you think is gonna happen on a larger scale and with greater force if you don't decompress!!! At least if you decompress you, 1) gain the chance of avoiding vomiting and aspiration, 2) prevent it from reoccurring if it does happen on insertion, and 3) you gain increased pulmonary compliance and improved ability to ventilate.

3) And again, I am not wanting gastric tubes to place in every single patient we BVM. They are to be used on a PRN basis when needed to decompress severe distention and improve ventilation when a kids diaphragm and organs are being squashed up into their chest. They are a valuable tool to assist in managing the airway and provide complete patient care which is what I strive for.

4) They are a cheap and easy to use device that serves an important purpose that needs to be available pre-hospital. I have been on many arrest where all interventions have been performed and were just doing the compressions and the ventilations the rest of the way to the hospital. So why not insert an NG tube to aid ventilation and protect against aspiration when we have plenty of time to do so?

If anyone has any literature for or against pre-hospital NG tube placement I would love to see it. Thanks!

 

[Veneficus]

No offense, but no one is going to argue they aren't good during surgery. It is pre-hospital that is the concern.

I am going to have to argue now.

There is no difference in medicine inside the hospital as outside.

If something works inside, then it works outside.

What the difference really is, is the practicality of using said intervention in terms of the level of care that is going to be provided later.

Now that we got that out of the way...

I can see both sides to this argument. Likewise, I'll bet you could find a physician to argue either way.

But I really don't think the issue described is really about NG tubes.

It has been argued here that there is a question of witholding ventilation in order to place the tube.

So What?

Those tubes can be placed both accurately and rapidly. It seems reasonable that not only would there be minimal interruption of ventilations, but that interruption might actually slow the rate to something reasonable in all the excitement.

There are still other methods that can be employed to reduce gastric distention and its sequele before the tube, as I mentioned above.

I still think these devices and interventions need to be looked at prior to worrying about an NG/OG tube. In both adults and infants.

The question I think that really needs to be answered is:

If you are using large volumes of air from a self inflating BVM, once you have distention, how do you keep the regurg from simply going around the tube?

Keep in mind this regurg could be subclinical, not making it as far as the mouth.

Even under constant suction, the diameter of the peds NG/OG is so small, you may not be able to suck air out faster than it is being put in. Then you are back to square 0.

If we are talking about the green topped peds NG tubes, they don't readily hook up to suction anyway. So you may need a provider to fool around with adapters and the like.

From the operational standpoint, a BVM/OPA instead of an ET tube with a NG/OG looks like desperation to me. If you are at that point, why not?

But why would anyone use that point as their endgame?

So I am of the mind that while it is not a bad idea, there are so many more better ideas to focus energy on first.

The greatest of which is the proper rate and volume of delivering ventilations by BVM.

an NG/OG after securing at ET tube? Certainly, by all means.

But here is another question:

If you are putting significant amounts of air into the stomach, how much volume is going into the lungs?

Because aside from the potential pneumo, if air keeps going in, but only minimally coming out, that is going to be a bigger issue than some vomit.

 

[18G]

Amazing that's how I feel when i'm reading your posts.

Really? I think my post are articulated very well and are well grounded and medically sound. Am I headstrong? Unfortunately I have to admit yes I am. But that's just who I am. I've never been one to play follow the leader. I am very humble and will gladly change my opinion if I am wrong. I just need to see something solid before that happens.

I just realized.... I have yet to see any thread where you make a reply that consists of something more than a one or two line comment of which is never medically driven.

What is your opinion on pre-hospital use of NG tubes to improve pulmonary compliance and mitigate aspiration risks?

I wondered if he migrated over from "the City" where the folks aren't as focused on education and more on maintaining the status quo and stroking each other's egos. He mentions other forums and that's the only one I know of that wouldn't treat him the way we have been. Well, that and the Firehouse one, but that's not even a medical forum. You mention anything about "evidence" and they think you're talking about arson investigation.

Actually I don't post on EMTcity. The only other forum I post on is JEMS Connect. And education is what drives me totally, so that's not a real accurate assessment.

 

[18G]

Vene.. I agree with you! can u believe that... haha. Good post.

 

[Veneficus]

Vene.. I agree with you! can u believe that... haha. Good post.

Generally, once people reach the hate phase, they start to see the light.

 

[usafmedic45]

but I am failing to see your position

So is the problem with your ability to actually read or the ability to comprehend what I'm writing? Is there an issue with your screen resolution? I can always use smaller words and a larger font if that would help.

the other minority opinions on the forum as absolute.

"Minority opinions" are no longer the minority when everyone except you is saying it.

And education is what drives me totally, so that's not a real accurate assessment.

Then why do you seem to have a hard time doing basic research, understanding what constitutes evidence, grasping that most medical "standards" are based largely on supposition and taking constructive criticism? None of those seem to be major parts of your interactions here and all of them are the hallmarks of someone with a vested and real interest in learning and applying evidence based practice that. Riddle me that one there Batman.

I think my post are articulated very well

....other than the various repeated spelling and grammatical errors.

are well grounded

Eh....

and medically sound

...in the same way that saying my fellow Jewish folks are common sights in the banking industry and then extrapolating from there that we all are responsible for the current economic situation. That's the problem with your posts is that you're taking a basically accepted matter and trying to stretch it to fit your current goal. Sorry if we don't share your enthusiasm.

What is your opinion on pre-hospital use of NG tubes to improve pulmonary compliance and mitigate aspiration risks?

If you would actually read what I've posted, I've already given that several times over. So much for "education is what drives me totally".

I've never been one to play follow the leader.

\

I would never have guessed. I suggest you read Darker Shades of Blue by Tony Kern. It might be insightful for you. Even though it is written about and for the aviation community, it has a lot of applicability to this discussion and especially folks of your mindset.

3) And again, I am not wanting gastric tubes to place in every single patient we BVM.

They are to be used on a PRN basis when needed to decompress severe distention and improve ventilation when a kids diaphragm and organs are being squashed up into their chest.

OK. The organs aren't actually "squashed up into their chests". That's a common mistake, but it's flat out wrong. It's the prevention of diaphragmatic excursion that causes the problem. There's no organ between stomach and diaphragm to be pushed upward. Actually as much as there is upward pressure on the diaphragm there is downward pressure pushing the intestines and other organs AWAY from the chest. It's gastric distention, not a diaphragmatic hernia.

They are a valuable tool to assist in managing the airway and provide complete patient care which is what I strive for.

Thank you for clarifying. It sure sounded like you were suggesting that the approach should be preventative in anyone you could not get a tube on. Examples:

So, if were going to be providing positive pressure ventilation with a BVM then why not help mitigate the negative effects with an NG tube?

This was especially alarming given your seeming lack of experience and familiarity with the procedure.....:

but I feel confident in saying that an NG tube can be placed quicker and safer

..lack of understanding of the mechanism for the problem in question....:

Air takes the path of least resistance which is going to be right down into the stomach.

(the rigid and continuously open trachea is the path of least resistance, whereas it takes excessive pressure or volume to get gas down the esophagus which is a "potential tube" at best)

THAT is what we had a problem with, not with the use of gastric tubes.

We've offered suggestions as to how to fix the problem and the problem of unprotected airways in neonates, infants and toddlers but you seem fixated upon the idea of shoving NG tubes into them. Why not work proactively to prevent the problem rather than working proactively to be able to retroactively fix the problem?

 

[18G]

"Minority opinions" are no longer the minority when everyone except you is saying it.

Who is everyone? You and three other people? I have had several people PM me and tell me that they support me and agree over several threads in the past.


Then why do you seem to have a hard time doing basic research, understanding what constitutes evidence, grasping that most medical "standards" are based largely on supposition and taking constructive criticism? None of those seem to be major parts of your interactions here and all of them are the hallmarks of someone with a vested and real interest in learning and applying evidence based practice that. Riddle me that one there Batman.

I did do the research and specified that.

....other than the various repeated spelling and grammatical errors.

Please accept my apologies for not being 100% correct when firing off my replies.

...in the same way that saying my fellow Jewish folks are common sights in the banking industry and then extrapolating from there that we all are responsible for the current economic situation. That's the problem with your posts is that you're taking a basically accepted matter and trying to stretch it to fit your current goal. Sorry if we don't share your enthusiasm.

My only goal is to have the freak'n things available on the units so if they are needed they are there. What are you even talking about?

If you would actually read what I've posted, I've already given that several times over. So much for "education is what drives me totally".

Your not the one and only ultimate source of information and say on the issue.

I would never have guessed. I suggest you read Darker Shades of Blue by Tony Kern. It might be insightful for you. Even though it is written about and for the aviation community, it has a lot of applicability to this discussion and especially folks of your mindset.

Perhaps I'll check that out


Thank you for clarifying. It sure sounded like you were suggesting that the approach should be preventative in anyone you could not get a tube on. Examples:

I know for a fact I specified my intent several times.


We've offered suggestions as to how to fix the problem and the problem of unprotected airways in neonates, infants and toddlers but you seem fixated upon the idea of shoving NG tubes into them. Why not work proactively to prevent the problem rather than working proactively to be able to retroactively fix the problem?

And what you don't understand is the rural area and all volunteer EMT system we have. There are only two Paramedic's on-duty in the County at any given time. The volunteer EMT's don't all have the best grasp on how to minimize gastric distention and there is nothing I can do about that. I am not in a position to teach them at the current moment in time and no one else is going to take it upon themselves to do it.

And no, I am not fixated on shoving NG tubes into kids. I just realize that they are sometimes needed and work well when indicated. It's not my fault if what I was initially asking for was taken a completely different way. All I wanted was some reference and research articles, not a whole multi-page debate.

I am trying to achieve what is best for the EMS system I am involved with. It's one thing to say forget about the NG tubes and teach people how to provide good BVM ventilations and a completely different thing when that is not currently possible. I can't snap my fingers and make that happen.

...

 

[Sasha]

I am often late to the party and don't care to parrot what other people have said, but look harder, you'll see posts where I give an opinion.

I don't have experience with NG tubes. I also don't often have to do airway management beyond suctioning. I am IFT. So I don't feel that I can make a well thought opinion about the particular subject at hand

 

[Aidey]

I am going to have to argue now.

There is no difference in medicine inside the hospital as outside.

If something works inside, then it works outside.

What the difference really is, is the practicality of using said intervention in terms of the level of care that is going to be provided later.

Now that we got that out of the way...

Oh, don't get me wrong. I wasn't saying that there is a difference between how well something works in hospital vs. out of hospital. My point was that something deemed practical, necessary and a priority during surgery may not be practical, a priority or strictly necessary out of the hospital.

 

[18G]

I am often late to the party and don't care to parrot what other people have said, but look harder, you'll see posts where I give an opinion.

I don't have experience with NG tubes. I also don't often have to do airway management beyond suctioning. I am IFT. So I don't feel that I can make a well thought opinion about the particular subject at hand

Honest you are. I can respect that If all goes as planned I will be doing IFT full-time as well. I'm pretty much just waiting on my certification to be processed in the State I will be working.

 

[Sasha]

I think you'll enjoy IFT. I love it, it's a great opprotunity to learn.

 

[usafmedic45]

Who is everyone? You and three other people? I have had several people PM me and tell me that they support me and agree over several threads in the past.

Isn't that convenient, your supporters won't do it publicly.

Your not the one and only ultimate source of information and say on the issue

I never said that I was. I simply suggested that based on what you were originally saying that you seemed to be trying to apply research to a personal theory where it had questionable applicability. Calling your idea into question and asking you to defend it with something more than "I believe", "I think", "I've been told" or "I've read somewhere" isn't painting oneself as a sole expert. It's called the standard practice of an academic. May G-d have mercy upon your soul if you ever find yourself in a truly important debate (one where your reputation or career are on the line) and get approached by someone well versed in how researchers and other academics (such as physicians) are taught to approach situations like this.

And what you don't understand is the rural area and all volunteer EMT system we have.

If you want to talk about small town EMS, you need to remember, I've probably gotten you beat in that regard. I was the EMS officer for a volunteer fire department serving a town of 175 and a township with maybe 2,000 total. It's not a "You're a big city EMT-I, you don't know how we work or what we have to deal with in the country".

The volunteer EMT's don't all have the best grasp on how to minimize gastric distention and there is nothing I can do about that. I am not in a position to teach them at the current moment in time and no one else is going to take it upon themselves to do it.

Don't take this the wrong way, but that sounds a lot like a cop-out.

I am trying to achieve what is best for the EMS system I am involved with. It's one thing to say forget about the NG tubes and teach people how to provide good BVM ventilations and a completely different thing when that is not currently possible. I can't snap my fingers and make that happen.

Perhaps you should look at getting the BLS crews a non-invasive adjunct so they aren't bagging unprotected? That way you're not simply trying to fix a complication but minimizing that issue. Always look for a solution that is best for the patient, even if it's not the most expedient or seemingly practical.

 

[18G]

Sasha...
I totally agree with ya. I currently work for a FD in a rural area that has a small hospital so we get called a lot to transfer the critical and higher acuity patients to larger hospitals. It's a nice mix of 911 and IFT.

I have come to appreciate the IFT part of EMS and find it more engaging sometimes then 911. Having the chance to talk one on one with the transferring physician and the patients RN, correlating the lab results with the diagnosis, actually seeing the diagnosis first hand, getting exposed to drip meds we don't use real often in 911, etc make it a really cool experience.

I agree with ya on the learning a lot part. Most providers shun IFT since its not lights and siren, all glorious stuff. But I really enjoy it.

One IFT patient I had the other night I was working was a child with appendicitis. She needed surgery and needed transported to a facility that could do it. She was stable and slept most of the way but I found it engaging on several fronts.

She was having N&V and pain so she was treated in the ED with morphine which caused a localized reaction at the IV site and running up her arm. She was given 12.5 of benedryl which cleared it up and knocked her out.... but it was nice to see first hand what works in that case. So knowing the MS caused an issue I discussed giving Fentanyl for pain which was a nice discussion.

Enroute patient does pretty good until she wakes up vomiting and says, "mommy it really hurts" (mom was with us). So I called Medical Command and got orders for Fentanyl q20mins PRN and Zofran q30mins PRN. The Zofran did a great job as did the dose of Fentanyl. Even though something simple and calm it was nice to be able to really take care of this pedi patient and make her comfortable during the 1.5hr transport.

Even though it wasn't a 911 arrest, OD, or the like it was a learning experience.

 

[ffemt8978]

Okay, fair warning, this thread has now attracted my attention.

 

[18G]

Perhaps you should look at getting the BLS crews a non-invasive adjunct so they aren't bagging unprotected? That way you're not simply trying to fix a complication but minimizing that issue. Always look for a solution that is best for the patient, even if it's not the most expedient or seemingly practical.

Actually, PA approved the AEMT level which is currently being developed and supposed to be rolled out 2/2012. I have no clue how its going to be implemented but from the wording in the EMS Act the new skills are obtainable through con-ed for current EMT's. To me this is scary. I was hoping it would be an entire program and conducted much like a Paramedic program but doesnt sound like it. But who knows.

Our EMT's are allowed to carry Epi auto-injectors and if you mention sympathomimetic, sympathetic nervous system, or catecholamine you just get a bunch of blank stares.

But I do agree if the EMT's are taught good ventilation technique consisting of minimal tidal volumes, being conscious of ventilatory pressure, maintaining good mask seal, placing an oral adjunct, and using constant cricoid pressure if personnel are available, they can give good ventilation and minimize gastric distention very much so.

 

[18G]

Look... now we have the sheriff involved...lol.

 

[Veneficus]

You mentioned that the problem is with poorly skilled and if like most EMS providers, terrified of peds.

Do you think under those circumstances that the providers would be skilled and in the mental state in order to place an NG tube proficently?

Would that not just be adding another procedure to the mix that could complicate things?

Honestly, if your people cannot be proficent at bagging a ped, how are they going to maintain proficency at putting another tube in one?

Generally the accepted norm for unskilled providers is to give them less to do damage with, not more.

I see the goal you are trying to accomplish, but in this case, I don't think that invasive technology is going to be the solution.

The only 2 ways I have found to be comfortable with various patients is foremost to see them regularly, second to that to be educated on them. Unfortunately rural EMS does not lend itself to vast quantity of experience. To my knowledge only the Aussies have tried to address that. Not sure how it turned out though.

 

[systemet]

This isn't directed in anyone at particular, but I'm a little disappointed to see a good and valuable discussion into the utility of OG / NG tubes deteriorate into a bunch of bickering and ad hominem attacks.

 

[MrBrown]

The only 2 ways I have found to be comfortable with various patients is foremost to see them regularly, second to that to be educated on them.

Precisely why we do not have an Intensive Care Paramedic on every corner, fire truck and ambulance. They are reserved for sick people in order to see a sufficient quantity of them to maintain knowledge and skill rather than rust out taking Nana to the doctor.

Brown is also terrified of paediatric patients.

 

[18G]

You mentioned that the problem is with poorly skilled and if like most EMS providers, terrified of peds.

Do you think under those circumstances that the providers would be skilled and in the mental state in order to place an NG tube proficently?

I may not have been real clear when I was talking about poor BVM skills. I was talking about the volunteer EMT's. The EMT's are not allowed to use NG tubes so they would not be getting the added skill.

Paramedic's have been allowed to use NG/OG tubes in PA for a very long time. It's just that they are not a "required" piece of equipment that every ALS service must have and I was wanting my company to acquire them so we had them if needed.

The only 2 ways I have found to be comfortable with various patients is foremost to see them regularly, second to that to be educated on them. Unfortunately rural EMS does not lend itself to vast quantity of experience. To my knowledge only the Aussies have tried to address that. Not sure how it turned out though.

There is current discussion with the Hospital to get us into the ED and possibly intubate in the same-day surgery unit as well to address low call volume and maintain skill proficiency.