No RSI- Teeth clenched from Head Injury-WWYD

[NomadicMedic]

I'm curious as to where this system is... can you tell me the state?


Sent from my iPhone.

 

[EMS Patient Care Advocate]

Needle and durgical cric have been removed from NH EMS protocols completely. Its public knowledge, so yes I can tell you.

 

[NomadicMedic]

Yikes. Sounds like a scary place to work. I would be nervous, when doing my job, knowing that I was not allowed to use life saving skills that are considered a standard of care everywhere else.

Glad I'm not in NH.


Sent from my iPhone.

 

[EMS Patient Care Advocate]

Yikes. Sounds like a scary place to work. I would be nervous, when doing my job, knowing that I was not allowed to use life saving skills that are considered a standard of care everywhere else.

Glad I'm not in NH.


Sent from my iPhone.

The state NH also mandated ALL intubation be monitored by capnography- SMART. However they permitted lag time for services to make purchases-DOH. What I am getting at is there is a system I work both 911 and transfers. With no capnography for 911, that means no intubation. Summery - no cric, no needle airway, no intubation and one large size combi tube as the ONLY avail back-up. Anyone looking for a Medic? As a cherry on top I work as a paramedic on one of the ALS 911 trucks- AND WE DONT HAVE A 12 LEAD. Im so lost without it, im such a newbie who likes his toys I guess? When I asked what I should do I was offered the door :-(

 

[ah2388]

It sounds to me like you seeking new employment might be a good decision for you.

With all this being said, there are several things that concern me regarding some posts in this thread. If it is true that you are unable to perform surgical airways or RSI because of state regulations and the unwillingness of your service to provide proper equipment that is a standard of care for most systems, I'd definitely suggest finding a different service to work for. You are setting yourself up for failure by doing anything else.

Usaf is smart, and I would advise you to digest the posts made in this thread as nothing more than a learning opportunity. Getting defensive won't accomplish much. At the end of the day, it appears that your heart is in the right place, but the manner in which you approach conversations like these could use some work.

 

[EMS Patient Care Advocate]

It sounds to me like you seeking new employment might be a good decision for you.

With all this being said, there are several things that concern me regarding some posts in this thread. If it is true that you are unable to perform surgical airways or RSI because of state regulations and the unwillingness of your service to provide proper equipment that is a standard of care for most systems, I'd definitely suggest finding a different service to work for. You are setting yourself up for failure by doing anything else.

Usaf is smart, and I would advise you to digest the posts made in this thread as nothing more than a learning opportunity. Getting defensive won't accomplish much. At the end of the day, it appears that your heart is in the right place, but the manner in which you approach conversations like these could use some work.

I agree. BUT I cant afford to just walk tho, and I love my job-it just morally irks me.
I have a LOT to learn, about paramedicine, life, forums, blogging. My intentions are always good, I worry I do not express it correctly often. I will be careful to avoid being defensive in the future. Thank you for the advice and bearing with me through this learning experience.

 

[Wes]

Hearing crap about state mandates and protocols makes me exceptionally proud to be a paramedic in Texas. Thank goodness we are an almost completely delegated practice state where EMS providers' protocols are written by the agency's medical directors. Thank goodness again that I'm fortunate enough to have an outside career that allows me to be picky on the EMS systems I choose to be affiliated with.

By the way, IIRC, there have been exceptionally few basilar skull fractures aggravated by nasal intubation.

As I've heard more than once, "If your patient can't breathe, nothing else matters."

 

[EMS Patient Care Advocate]

Hearing crap about state mandates and protocols makes me exceptionally proud to be a paramedic in Texas. Thank goodness we are an almost completely delegated practice state where EMS providers' protocols are written by the agency's medical directors. Thank goodness again that I'm fortunate enough to have an outside career that allows me to be picky on the EMS systems I choose to be affiliated with.

By the way, IIRC, there have been exceptionally few basilar skull fractures aggravated by nasal intubation.

As I've heard more than once, "If your patient can't breathe, nothing else matters."

I considred it. However I feared causing nasal truama and causing blood in the last way I had to get air in. Id that a consideration do you think?

 

[Wes]

Respectfully, I'd suggest a bit of research. I would imagine that "nasotracheal intubation" and "basilar skull fracture" on a generic search engine like Google or a medical related site such as PubMed would provide more than enough answers.

It's great that you're a relatively new paramedic and posting lots of questions. It would be even greater if you developed a go-to list of medical books (Yes, the old fashioned sources of knowledge) and appropriate medical websites to aid you in your quest for knowledge. As I'm sure you are finding out, the world of medical knowledge, even in emergency medicine, extends way beyond a set of protocols and your paramedic textbook(s).

 

[EMS Patient Care Advocate]

Respectfully, I'd suggest a bit of research. I would imagine that "nasotracheal intubation" and "basilar skull fracture" on a generic search engine like Google or a medical related site such as PubMed would provide more than enough answers.

It's great that you're a relatively new paramedic and posting lots of questions. It would be even greater if you developed a go-to list of medical books (Yes, the old fashioned sources of knowledge) and appropriate medical websites to aid you in your quest for knowledge. As I'm sure you are finding out, the world of medical knowledge, even in emergency medicine, extends way beyond a set of protocols and your paramedic textbook(s).

and research I shall. Thank you. So you promote nasal intubation in this scenario?
Why are you confident we are dealing with a basilar skull fracture?

 

[Wes]

It's something I'd consider in this situation. I wasn't there, so it's hard for me to say. To me, the medical term consider means that you use your clinical judgment to make the best possible decision for your patient, factoring in all considerations such as your skill level, available resources, and time to definitive care.

I too have had some crap-burger trauma calls where airway became an issue. And I too have had arguments with others about the best way to manage the airway. I'll probably continue to have such experiences.

I tend to favor Kelly Grayson's "Airway Continuum" approach of doing only so much as is necessary to maintain the airway. (BTW, I've massively oversimplified his approach.)

I suppose that, in summation, I can't disagree with the approach you took to this patient, especially considering the limitations presented to you. As a paramedic, attorney, and EMS educator, part of my mission is to present options.

 

[usafmedic45]

So you promote nasal intubation in this scenario?

Not in the slightest.

Why are you confident we are dealing with a basilar skull fracture?

Because a direct blow to the anterior aspect of the mandible will transmit the force straight to the base of the skull through the temporomandibular joints. It's the standard mechanism for what is known as a 'hinge fracture'. In the case of facial trauma severe enough to cause airway issues, especially with an altered mental status, one should pretty much operate from the standpoint that they are dealing with a basilar skull fracture until proven otherwise by CT or autopsy.

 

[Wes]

I am most likely mistaken, probably even flat-out wrong, but isn't there some study that indicated that the risk from nasal intubation (or inserting a NPA) in a patient with a basilar skull fracture is actually fairly minimal?

And if nasal intubation is contraindicated, I seem to remember that a NPA is also contraindicated in these patients.

Again, I'm probably wrong, so please correct me.

 

[usafmedic45]

I am most likely mistaken, probably even flat-out wrong, but isn't there some study that indicated that the risk from nasal intubation (or inserting a NPA) in a patient with a basilar skull fracture is actually fairly minimal?

I recall the same study and it makes sense from a biomechanics standpoint, however I would not want to rely on it in court when there are better options for that particular setting.

 

[Wes]

I don't disagree there. I just like to throw options out there. I think the "devil's advocate" role came with the JD.... <_<

 

[mikie]

could be wrong as usual

Not that I'm advocating nasal intubation here, but I think the original fears stemmed from the NG tube and kind of trickled down to every other nasally inserved device (NTI, NPA, etc)

 

[usafmedic45]

I don't disagree there. I just like to throw options out there. I think the "devil's advocate" role came with the JD....

Mine's just because I'm difficult. Oh, and I'm an admitted expert witness for EMS, respiratory therapy and aviation safety. Suffice to say, I get paid to be that particular blend of "difficult".

 

[Smash]

Dammit, no-one pays me for my court appearances. "Expert witness" is the same as "defendant" right?

Anyway, avoiding nasal intubation in the head injured patient is not merely matter of avoiding plunging a piece of plastic through the cribriform plate into the the thinking jelly. We owe it to these patients to do all we can to avoid secondary brain injury and increased ICP or decreased CBF. That means not fossicking around in the snout with plastic, which one has to imagine is pretty unpleasant and would certainly give rise to more ICP unhappiness. The OP identified this, which is great, and I wholeheartedly agree with him not poking a tube up the snout.

Therefore we carefully provide analgesia, sedation and elimination of reflexes with paralytics whilst intubating, and ensure that we continue to do so once the tube is passed.

If your service does not allow road-based RSI (and that is fine by me, unless everyone is willing and able to step up and do it properly) then you have to make do with what you have. If this means making a hole in the patient's throat, so be it.

Someone smarter than me like USAF or someone has probably already mentioned it, but one of the biggest failings with surgical airways is not identifying the need and performing it. We are all a bit scared of cutting (and fair enough too) but if it needs to be done we need to HTFU and do it.

If none of this makes sense, or is completely out of context, I apologize. I'm currently tweaking on coffee, cold and flu tablets and no sleep, so my grip on reality is a touch tenuous at the moment.

 

[EMS Patient Care Advocate]

it was my understanding risk of putting a NPA was more than minimal and worth the gain as far as risking it going into the brain-i thought in this situation. I felt nasal intubation would have been too much. I think there is more science supporting its safety than the possibility of entering into the brain. I agree, you all have me thinking I should have done the cut. I will remember this the next time, so it is a leraning experience. A lot of good conversation has come out of this im glad I brought it out.

 

[usafmedic45]

If none of this makes sense, or is completely out of context, I apologize. I'm currently tweaking on coffee, cold and flu tablets and no sleep, so my grip on reality is a touch tenuous at the moment.

Only the part about me being smarter than you. Give yourself credit where it is due.