VL exclusively

[DrParasite]

If it's on every set of ALS gear, why do paramedics are your agency not like using it?

 

[FiremanMike]

Just like ultrasound for line and nerve block placements took a while but is now unquestionably considered the standard of care, I'm pretty confident there will be a time not too long from now when VL is considered the standard of care.

There's quite a bit of research on VL vs. DL in the ED setting, with all of the studies showing anywhere from no advantage to a significant advantage (and most showing at least some advantage) with VL, and none that I know of that show VL as inferior to DL. The advantages of using VL will increase as the devices become better and more affordable, which is already happening compared to the first generations of them.

The biggest issue I see with VL in the ED is that they generally go with the glide scope and I swear it seems like they just toss those things at residents and say "use this, you'll figure it out". Glide-scopes work well if you know the technique, but they work terribly if you don't, and it's usually pretty obvious whether or not the person you're watching has been appropriately trained on the technique or not.

My exposure to this only ever comes in the ED, I'm sure you've seen this behavior throughout the hospital.

I have to wonder if these scenarios aren't skewing the data.

 

[NomadicMedic]

If it's on every set of ALS gear, why do paramedics are your agency not like using it?

Not sure. I think part of it is “Paramedics intubate with a real laryngoscope” bravado.

Some of the guys have poor technique and that lead to “it must be this #%^ video POS”

 

[VentMonkey]

Not sure. I think part of it is “Paramedics intubate with a real laryngoscope” bravado.

Some of the guys have poor technique and that lead to “it must be this #%^ video POS”

Going out on a limb here and gonna say this is yet another s/s of paragoditis. I’m also willing to bet that this is hardly an isolated regional mindset.

If we have paramedics who still chastise Bougies and see them as a crutch, I can’t imagine how “weak” they feel having to learn VL.

All in all, we don’t deserve a lot of the skills we’re afforded, at least not until the national model is restructured.

 

[StCEMT]

All in all, we don’t deserve a lot of the skills we’re afforded, at least not until the national model is restructured.

Unfortunately I think the only way anything will change any time soon is individual initiative within departments to implement their own changes.

 

[NPO]

Does your service mandate video laryngoscopy? If so, how did you make the change? What drove the change? How did the medics react? Did your first pass success rate improve? What VL are you using?

Can you tell I want to know everything?

I'm in Southwest Missouri where everything varies by agency as there is little state oversight.

At my agency we have KingVisions on every truck and are required by policy to attempt VL prior to manual laragoscopy. That policy is loose however, for example KingVision doesn't have pediatric sizes, in cases of FBAO, etc...

 

[DrParasite]

Not sure. I think part of it is “Paramedics intubate with a real laryngoscope” bravado.

Some of the guys have poor technique and that lead to “it must be this #%^ video POS”

That's kind of where I was getting at.... Have you, ummm, asked them? You are now a white shirt, what's stopping you from pulling someone into your office and saying "you missed the tube on the first attempt, why did you not use the VL, which is exactly what policy requires that you do?" They might say something else like "the VL picture sucks, I can't see as clearly, the batteries are always dead, the thing is too heavy, etc." I don't know, but instead of guessing, does it hurt to ask everyone one on one, especially after a failed airway attempt?

I mean, if they can tube without the VL, than you can trust them to use their judgement, however if they are failing (for whatever reason, poor technique, not using the VL, not using the bougie, etc), than corrective action should be taken.

If we have paramedics who still chastise Bougies and see them as a crutch, I can’t imagine how “weak” they feel having to learn VL.

I've heard of this.... my former medical director also told every one he didn't care if they used a bougie every time, whatever tools that he approved you need to do the job, use them!!!

I had a paramedic FTO who refused to touch a SGA on a cardiac arrest.... if he needed an airway, he was using an ETT. a SGA was only in case he was able to use the ETT after multiple attempts.

 

[Bullets]

We are rolling out Airtraqs to all ALS units May 1. We will see how it goes.

 

[NomadicMedic]

We are rolling out Airtraqs to all ALS units May 1. We will see how it goes.

I like the new airtraq. It’s pretty nice.

 

[E tank]

Going out on a limb here and gonna say this is yet another s/s of paragoditis. I’m also willing to bet that this is hardly an isolated regional mindset.

If we have paramedics who still chastise Bougies and see them as a crutch, I can’t imagine how “weak” they feel having to learn VL.

Those medics would be laughed out of every anesthesia lounge in the country.

 

[TXmed]

Those medics would be laughed out of every anesthesia lounge in the country.

Because of bougie use or VL use?

 

[E tank]

Because of bougie use or VL use?

No, sorry for being so unclear...for disparaging the use of those things.

 

[VentMonkey]

Those medics would be laughed out of every anesthesia lounge in the country.

No, sorry for being so unclear...for disparaging the use of those things.

Sadly, our profession seems to work in opposition of this mindset, hence my remark:

All in all, we don’t deserve a lot of the skills we’re afforded, at least not until the national model is restructured.

Nothing like being the outlier, eh?...

 

[E tank]

Sadly, our profession seems to work in opposition of this mindset, hence my remark:

Nothing like being the outlier, eh?...

Well, don't be too hard on yourself. A lot of that mindset comes from immaturity and inexperience, not from a lack of merit on the part of some folks where those skills are seen as necessary for a given region.

The fact is that there just won't be the opportunity to become a true expert at things like DL/intubation even in most metro areas. Intubating 3 times a month is just enough to reinforce bad habits, not get better. This has nothing to do with merit on the part of the medics. Pure numbers, that's all.

 

[MSDeltaFlt]

I am an old school respiratory therapist and an old school paramedic. And I'm all for technology. Technology is great and getting better. But if and when technology fails (and it does and will), there is no school like the old school. But with old school technique is everything. Which, in my honest opinion, tends to be lost on more medics than they might be willing to admit.

My current service doesn't stress technique. My last air service I was with stressed technique... a lot. My air service before that one? Not as much.

Just my humble $0.02.

 

[E tank]

I am an old school respiratory therapist and an old school paramedic. And I'm all for technology. Technology is great and getting better. But if and when technology fails (and it does and will), there is no school like the old school. But with old school technique is everything. Which, in my honest opinion, tends to be lost on more medics than they might be willing to admit.

"Old school" was once cutting edge technology. And people got F'd up. Until "new school" came along. Pulse ox, ETCO2, heck, Miller blades. Ever even seen a Wis-Hipple blade? Google it and just imagine intubating a huge necked, short jawed, small mouthed dude with garbage in his airway. You're right about technique tho, Bro. But killing a lion with a rifle is way better than doing the same thing with a rock.

 

[MSDeltaFlt]

"Old school" was once cutting edge technology. And people got F'd up. Until "new school" came along. Pulse ox, ETCO2, heck, Miller blades. Ever even seen a Wis-Hipple blade? Google it and just imagine intubating a huge necked, short jawed, small mouthed dude with garbage in his airway. You're right about technique tho, Bro. But killing a lion with a rifle is way better than doing the same thing with a rock.

"Those who cannot remember the past are condemned to repeat it." - George Santayana (1863-1952), Reason in Common Sense, The Life of Reason, Vol.1

This can easily be applied to EMS. Specifically regarding one's training. BLS before ALS. My grandmamma used to always tell me, "Remember who are and where you come from". Wise woman. I use that a lot and it hasn't failed me yet. I highly doubt that it ever will.

Remember your training. Remember your technique. Don't be the one who forgets what they were before they were trained and began performing like they did before they were trained as I am referencing the above quote.

I think I mentioned something in my previous post I believe it was sentence number 2 that I am all for technology. These new toys are great and cool. And significantly increase first time pass rates. But technology fails. Everything that has been made has broken. EVERYTHING.

So when will your new fangled whatchamacallit break on you? When your patient can least afford it to break. Technology fails. Technique won't. Use technology. I know I will. But when it fails do your patient a huge favor and make d@mn sure your technique doesn't.

 

[VentMonkey]

I hope and pray for the day that RSA is the standard. Given the new “technology” of LMA’s, and other EGD’s/ SGA’s it makes total and complete sense that it should go this way.

Also, I fail to see the relevance in your point. Batteries fail with DL laryngoscopes as well.

Again, wouldn’t patients in the prehospital setting be better served with less bravado, and more simplistically-driven quality care? Or are we truly that lost in our own egos? I know what my personal opinions and answers are, what say you all?

 

[MSDeltaFlt]

Wow. So many appear to be very eager to forego the history of technique of airway management. Well, good luck with that. Just be sure and remember one thing. You're to raise your right hand, not your left, when you swear of affirm that the testimony will give with be the truth, the whole truth, and nothing but the truth so help you God.

 

[StCEMT]

Where do you see anyone advocating throwing technique aside? Did you miss the part where a few of us mentioned the importance of preparation and positioning? Or watch the video of the method Nomad is interested? Doctor Jarvis goes over technique in detail. So I don't see where you think anyone is saying to throw technique in any sense aside....