Study on Survival vs Intubation during IHCR

[Tigger]

Dat gold standard amigo. In all seriousness, I like that is expected we just go straight to an igel. Cardiac arrest is one of those cases I don't really see a need to intubate for a couple reasons. Just pull that big ******* out and it'll do its job perfectly fine.

And if you discover that the patient must be intubated at a later point, you can still do that.

For a while we were doing passive oxygenation on cardiac arrests of non-respiratory etiology. If we got pulses back, then they got intubated. Arrests were way easier that way. Realistically it takes two people to intubate someone undergoing compressions. That's two less people to monitor the code...

 

[mttbdtd]

I agree that this debate will never be over. I think some of the things I said were taken the wrong way and I'm not going to write out more clarification. I think it's a skill that's needed. I agree there are some out there that are not behaving as clinicians and are also terrible at the skill of intubation. Both of which are detrimental. More training at the foundational levels of paramedicine is necessary for more than just intubation.

 

[VentMonkey]

My issue isn't with the skill itself. In and of itself it's just that, a skill. How rudimentary did or does the procedure seem when you learned on "Fred the Head"?

Maybe read what others have said. It's only a fraction of airway management. If you're a fairly new paramedic, it would be hoove you to realize sooner rather than later you're best bet would be to re-educate yourself on the "Alphas and Omegas" of airway management; NOT intubation, airway management.

Saying it's "just needed" does nothing for you, me, or any other paramedic as clinicians plain and simple. If you felt that firmly about your position with adequate reasoning to support such you would have no hesitation writing out what or why it is you think what you do. Again, this is all in the sake of dialogue; hardly an argument, how else can we (all of us) learn from one another?

Also, you're hardly the only paramedic who feels this way, but at least you had the stones to post your opinion, so kudos for that.

 

[mttbdtd]

Bustin my balls here vent. The skill in itself is no more difficult than any others we perform. My medic instructor apparently used to bring in his grade school daughter and show that she could intubate. He hounded us on WHEN to intubate not how to.
Speaking on certain situations and barring unforeseen complications. First, CPR in progress. Walk in, patients dead. Everything handled appropriately. You intubate. You now have a definitive airway. No need to change if rosc, or things like gastric distention come to get you. At least in my experience as soon as I walk in with rosc RT and the doc "is that an ET or a king?". I'm not comparing paramedic to doctors but in this situation doctors are intubating for the same reasons we are and are apparently making the same mistakes. By chance I run an assload of codes and I intubate every one of them when I get a chance. It's not intubation itself it is the "wake effects" of a medic intubating. As long as it's in my scope and I can mitigate those effects then I will intubate.

Phone dying more coming in a bit

 

[mttbdtd]

The second is your alive but dying patient. Pill overdoses with unresponsive patients you've got a good chance of vomiting. It's not easy to manage a large patient in the back of an ambulance that is vomiting all over, aspirating and compounding their already significant problems. It is easy to manage a properly timed and performed ETT. Not in the sense that you've nothing left to do but in the interest of the patient there are times where taking absolute control of that patients airway is very nessasary. I do not work in a system that allows RSI and I have only once come across a patient that had me wishing I could. He was immediately RSId in the ER. And again no, just because a doc will do it anyways is not the reasoning.
I'm not of the crowd that is saying I want to intubate more people!!!
If I contnue to come across as a [unneeded expletives] new paramedic swingin my [unneeded reference to anatomy] around that is not me. I am new to this game but I'm not running in to calls laryngoscope in hand like [unneeded expletive] yes my patient is dying. I posted before regarding narcan use routinely. I'm not for a big blanket, black and white practice but medicine. I don't have study's I can pull out of my *** at the moment I can only speak from my limited experience. And as I said before all of us could benefit from more foundational knowledge and experience.

EDIT for language.

 

[VFlutter]

The second is your alive but dying patient. Pill overdoses with unresponsive patients you've got a good chance of vomiting. It's not easy to manage a large patient in the back of an ambulance that is vomiting all over, aspirating and compounding their already significant problems. It is easy to manage a properly timed and performed ETT. Not in the sense that you've nothing left to do but in the interest of the patient there are times where taking absolute control of that patients airway is very nessasary. I do not work in a system that allows RSI and I have only once come across a patient that had me wishing I could. He was immediately RSId in the ER. .

Wait, so you are using risk of vomiting as justification for intubation yet you do not have the ability to RSI? Something seems a little off with that rationale. If you have only seen one patient in your career that would benefit from RSI over sedative only intubation then that is another discussion in and of itself.

 

[mttbdtd]

Not so much that I've only seen one patient that would benefit. I can think of one particular case that sticks out in my mind in which a patient was on the verge of being unresponsive but never quite there and I knew I would not be able to go any farther without RSI. He needed it right at that second.
No, it's not solely vomiting. Your patient starts semi responsive most likely with a gag reflex and then becomes suddenly unresponsive despite your interventions. Patient is not dead, not in a ventricular rhythm, secure that airway.

 

[mttbdtd]

Let's make this about nitpicking me. Not the issue at hand. I have a particular stance, presented it and you would rather hit my lack of experience and obviously less education in EMS. Calling me young and dumb is not a discussion.

I'm out.

 

[VFlutter]

Let's make this about nitpicking me. Not the issue at hand. I have a particular stance, presented it and you would rather hit my lack of experience and obviously less education in EMS. Calling me young and dumb is not a discussion.

I'm out.

I never questioned your experience or your education, and I never called you young and dumb. But if you feel so strongly about your position then you should be able to defend it, this is meant to be a discussion. I am guessing this is the first time people have challenged your practice, don't get defensive. I am playing the devils advocate a little. I won't harp on the RSI vs drug assisted intubation too much but I think you have a much harder time justifying taking someone's airway when you lack the proper tools. My last comment wasnt meant as a jab at your experience but rather that having not used RSI you may not be familiar with it's advantages, the evidence behind it, the effects on outcomes, etc.

 

[VentMonkey]

The second is your alive but dying patient. Pill overdoses with unresponsive patients you've got a good chance of vomiting. It's not easy to manage a large patient in the back of an ambulance that is vomiting all over, aspirating and compounding their already significant problems. It is easy to manage a properly timed and performed ETT. Not in the sense that you've nothing left to do but in the interest of the patient there are times where taking absolute control of that patients airway is very nessasary. I do not work in a system that allows RSI and I have only once come across a patient that had me wishing I could. He was immediately RSId in the ER. And again no, just because a doc will do it anyways is not the reasoning.
I'm not of the crowd that is saying I want to intubate more people!!!
If I contnue to come across as a badass motherfuckin new paramedic swingin my **** around that is not me. I am new to this game but I'm not running in to calls laryngoscope in hand like **** yes my patient is dying. I posted before regarding narcan use routinely. I'm not for a big blanket, black and white practice but medicine. I don't have study's I can pull out of my *** at the moment I can only speak from my limited experience. And as I said before all of us could benefit from more foundational knowledge and experience.

Yeah, I have to agree with Chase, no one called you young, or dumb; inexperienced, perhaps? But it seems like you've taken it the wrong way. If anything, maybe you should be flattered the guy is trying to enlighten you. He's a well educated, and experienced nurse with significant ICU time.

Something also worth mentioning is that this thread was created and shown to question the importance of early in-hospital intubation. If it's postulating it's ineffectiveness in early in-hospital arrests in a much more controlled, and presumably sterile environment with a vast array of experienced airway experts why should we be allowed the same privileges without any profound documentation, EBM, literature, etc. other than it being the "gold standard"?

Again, I can respect your opinion, and know I too was once there, but I chose to take it upon myself to become better acquainted with airway management, not just the intubation; I seem to be echoing this a lot. I had a instructor who was adamant about gastric tubes being placed, and that an ET tube without one is just about useless, where does this fit into your aspiration patient? If you intubate said patient should you be placing them on the ventilator immediately even with very basic settings, and parameters? Is hand-bagging with a BVM the same as the ventilator, why or why not? If you arrive to find fire or whoever has placed a SGA that is showing adequate oxygenation, and ventilation why do WE need to pull it? What about the morbidly obese patient with a grade 4 mallampati? How would you protect their airway? are we going to need to change our choice of airway devices from the start, is a SGA sufficient in this case? What about DL vs. VL, where do they fit into one's plans for first time success? That is the goal, and not because any of us should be ego-driven, but because the patient doesn't deserve anything less. What techniques can you use to improve their likelihood of not desaturating? When you first walk in and find a patient that needs to be intubated should you have a back up airway in mind already, and if so, what would it be, and can it provide adequate oxygenation, and ventilation in the face of the unforeseen failed intubation?

I'm not asking you to answer any of these questions, nor do I care how much experience you do, or don't have. This is merely the "tip of the iceberg" that should be going through a prudent airway clinicians mind pre-intubation, at least in my opinion; they go through my mind.

 

[StCEMT]

And if you discover that the patient must be intubated at a later point, you can still do that.

For a while we were doing passive oxygenation on cardiac arrests of non-respiratory etiology. If we got pulses back, then they got intubated. Arrests were way easier that way. Realistically it takes two people to intubate someone undergoing compressions. That's two less people to monitor the code...

Do you have (or have plans?) VL for intubating? I would probably feel better about intubating an arrest after oxygenating them for a bit if I had that. Then again, I don't know that I would actually stray away from an igel in this case even if it was available.

 

[Tigger]

Do you have (or have plans?) VL for intubating? I would probably feel better about intubating an arrest after oxygenating them for a bit if I had that. Then again, I don't know that I would actually stray away from an igel in this case even if it was available.

We will have McGraths on the truck soon. I plan to use it for every tube, especially since that particularly device can be used as a regular DL handle/blade as well.

 

[StCEMT]

We will have McGraths on the truck soon. I plan to use it for every tube, especially since that particularly device can be used as a regular DL handle/blade as well.

I never got to try one on a messy airway, but I am a fan of them. They are comfortable and in my limited experience, work well. Should be a good addition for you.

 

[mttbdtd]

Sorry guys. This is typically why I don't participate in online forums. I get misconstrued or someone misconstrues me. Then someone gets butt hurt and this time it was me.