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CFRBryan347768

CFRBryan347768

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Any one off for posting here but i believe this is related to the Paramedics.
1. What is this, and why is it needed?
2. Are Paramedics still allowed to do this(i heard at some point they were)
http://www.youtube.com/watch?v=MK1mqM1LHW4
 
Kinda of, sorta.

That was a chest tube being put into a kid who had pus in his chest cavity due to infection.

How you breath is your chest is pulled up and outward which puts a negative pressure on your lungs. Since your lungs are open to the outside via your bronchioles, trachea, and pharynx, this causes the air outside to move into your lungs to equalize pressure (note: Any movement of gas involves a pressure gradient). When you you get fluid, air, or pus inside of your chest cavity (hemothorax, pneumothorax, pyothorax respectively) the ability for your body to change the pressure inside of your chest cavity is decreased. The way you solve that is to remove what is inside the chest. Normally, your chest (plural cavity) has a pressure of -6mmHg.

You can see the effect of the pyothroax clearly in the first few moments of the video. If you notice, only the boy's right side is moving when he breaths. You can also see it in the x-ray because the left side (patient's left side... right side of the physical x-ray) is white while the right side is mostly black (patient's right.... left side of the physical x-ray).

Paramedics, for the most part (I believe some frontier and some aeromed services may be able to) can not insert a tube as shown. What they can do, though, is use a needle to achieve a similar result in patients who have air in their chest cavity.
 
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Thank you!!
 
I believe that chest tube placement is a skill taught as part of the Critical Care Paramedic training. If so it then becomes an issue of whether your state recognizes CC/EMT-P and if your service has the protocol and the equipment.

Any CC/EMT-Ps out there, please correct me if I'm wrong.
 
I don't see this being a 911 skill at all. Not in my area at least It is possible that it could be on critical care transfers but I assume an MD/DO could do it before being transfered.
 
I agree with that.
My understanding is that the CC/EMT-P cert is intended more for critical inter-facility or long distance transports. Not the conventional prehospital situations.
 
Chest tubes do have there placement in emergency treatment and care of those with pneumo and hemopneumothorax. Such conditions are life threatening events. When they should be justified is dependent on whom, where and type of service provided.

Chest decompression can be adequate sometimes, yet all dependent on the amount of pneumo the patient has as well time duration until a chest tube can be placed. Please remember, a chest tube is a definitive treatment and if one demonstrates the symptoms of a pneumo, chances are they need one and definitely will get one. I have performed chest decompressions using a 14g Jelco so much they looked like a porcupine. Remember, chest decompressions will occlude in a few minutes. Fortunately, the one we now use is slightly larger and has a silicone lining that prevents clotting and cannot be kinked as well.

Should every Paramedic be able to perform or have the ability to? No, but again there are areas and situations that warrants the procedure. Again, pneumothorax should be considered a life threatening event, it is a lower airway obstruction and if not treated aggressively and immediately that patient will die!

I was taught to place chest tubes as a CCEMT/P and in my Flight Nurse Trauma Course, as well in ATLS, etc. I have performed ten or twelve chest tubes, and several chest decompression. I was taught on cadavers, pigs, cats, etc.. all monitored and instructed by surgeons, and closely critiqued. There are different ways and techniques that can be learned and used. Those that do perform such techniques in the field, I am assured are closely monitored.

In regards to CCEMT/P it is an educational course above the normal Paramedic curriculum. Yes, its focus in specialty care transports but it is not the sole focus, it still involves the prehospital aspect as well.

In regards to the video, it is not prehospital arena. It appears to be in remote setting such as in third world countries. The child appears to have a pleural effusion containing myo or pus and fluid. This can be caused by several conditions, and again although this develop over a period of time, it is still a life threatening condition. The child was anesthetized with Lidocaine or similar anesthetic before chest tube insertion, and probably attached to a closed suction drainage unit. I have assisted in such on medical missions, with children with multiple problems. The lung may reinflate over time and tube will removed (usually 24-48) dependent on the condition.

R/r 911
 
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Does anyone know who usually inserts chest tubes in the ED? I know that nurses can, but is this usually done by the surgeon/physician?
 
Of the two I've witnessed, one was done by the ED doc, the other by a general surgeon. I remember the surgeon making the comment that, to him at least, "Its a very simple and straightforward process.....watch this."
 
LucidResq said:
Does anyone know who usually inserts chest tubes in the ED? I know that nurses can, but is this usually done by the surgeon/physician?
Click to expand...


Emergency nurses do NOT usually place them. It is considered a surgical procedure and not a nursing procedure. The ED Doc usually places them, some places allows NP/P.A.'s to perform this and some do not.

Dependent on the case the ED Doc will turn over the case to the surgeon.

R/r 911
 
Ridryder911 said:
Emergency nurses do NOT usually place them. It is considered a surgical procedure and not a nursing procedure. The ED Doc usually places them, some places allows NP/P.A.'s to perform this and some do not.

Dependent on the case the ED Doc will turn over the case to the surgeon.

R/r 911
Click to expand...

Some flight nurses can though, right?
 
LucidResq said:
Does anyone know who usually inserts chest tubes in the ED? I know that nurses can, but is this usually done by the surgeon/physician?
Click to expand...

On the code I had the doctor did, but not after trying an OPA (Dunno why he wanted to try that first when he coulda intubated....he was the new guy), and yes, Lucid, most flight nurses can as well...
 
Actually, there are very few services that can insert chest tubes. As well, many flight nurses and medics are NOT always taught this procedure, even if they have, does not mean they can perform it. I could in some states, while in other states, I was strictly prohibited. It all depends on the Nursing Scope of Practice within that state. I can assure as well, I have never seen a ER Nurse insert one.

I can assure you as well, that is a rare occurrence that flight teams to insert one, as most will attempt chest decompression first. This is a heated debate among SCT and Flight Teams if it is a procedure that should be performed by non physician and potentially dangerous procedure.

It does come with severe dangers. It is NOT a simple procedure as mentioned. One of punctures the lung, and with this lacerates vessels. Along when placing the tube can lacerate major vessels such as the subclavian, puncture the pericardium or even damage the heart itself, along with possible performing nerve damage on the intercostal region of the chest wall. So NO it is not just a simplistic procedure.. again, why most flight teams DO NOT perform such. It has a lot of hype, similar to what central lines did until EZ I/O drill came along and now central lines is almost a thing of the past per flight or ground crews.

R/r 911
 
Agree with Rid.

Although, Rid and I both probably learned chest tube insertion (along with intra cardiac epi injections) in Paramedic school back in the 1970s, a little device came along called the McSwain Dart that made life easier. There was also that thing we did with the finger of the glove and needle...and some spit....

Chest tube insertion is not a "skill" that can be performed often enough to adequately maintain proficiency even by those working in hospital based flight programs. Even though we see several a week, there is more risk and can be time consuming to get the tube positioned correctly to drain. Infection is a big risk also.

That being said, some Neonatal transport RNs and RRTs do insert chest tubes. But, these professionals are very well trained by their medical directors and have many years of experience. It there are not enough babies to work with they may be forced to use bunny rabbits to maintain their skills.
 
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This is not a skill that is taught to most paramedics. I think some Critical Care Medics may get the training, and maybe some flight medics. I know that flight nurses are able to put one in, in a lot of areas.

This is really considered a surgical procedure, so its not done my many people in the EMS setting.
 
I know here in AZ it is part of the scope of practice for our fire medics. I have a friend that works at a hospital and he says Mesa FD always brings the pt in and says "we thought about intubating but.....(some excuse)"

J
 
We were talking about chest tubes, and who can place those.

Every medic should be able to intubate.

:)
 
Jeremy89 said:
I know here in AZ it is part of the scope of practice for our fire medics. I have a friend that works at a hospital and he says Mesa FD always brings the pt in and says "we thought about intubating but.....(some excuse)"

J
Click to expand...

I assume you mean intubation right? Chest tubes is not routinely taught in the Paramedic curriculum.

R/r 911
 
tydek07 said:
We were talking about chest tubes, and who can place those.

Every medic should be able to intubate.

:)
Click to expand...

I second that, but then again, I'm just a 'basic' that knows nothing ;)
 
Jeremy,
You just must must of read it wrong..... it happens. Chest Tubes and Intubation's are totally different.

Not very many medics can put Chest Tubes in, so you must have been talking about AZ FF being able to intubate.

But hey, at least your not afraid to post what you think.

Take Care,
 
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