What do you think?

[Jeremy89]

While looking for local EMT Protocols online, I recently found the following:

R9-25-808. Protocol for an EMT-B to Perform Endotracheal Intubation

A. Endotracheal intubation performed by an EMT-B is an advanced procedure that requires medical direction.

B. An EMT-B is authorized to perform endotracheal intubation only after completing training that:

1. Meets all requirements established in the EMT-B Endotracheal Intubation Training Curriculum, dated January 1, 2004, incorporated by reference and on file with the Department, including no future editions or amendments; and available from the Department's Bureau of Emergency Medical Services; and

2. Is approved by the EMT-B's administrative medical director.

C. An EMT-B shall perform endotracheal intubation as:

1. Prescribed in the EMT-B Endotracheal Intubation Training Curriculum, and

2. Authorized by the EMT-B's administrative medical director.

D. The administrative medical director shall be responsible for quality assurance and skill maintenance, and shall record and maintain a record of the EMT-B's performance of endotracheal intubation.


Among the requirements of the training cirriculum are:

3. Attempted a minimum of 3 endotracheal intubations in the prehospital setting.

4. Performed a minimum of 1 successful endotracheal intubation in the prehospital setting.


Should an EMT be allowed to intubate if they have the proper training? Just curious to get everyone's opinion on this one...

 

[WuLabsWuTecH]

I am just a student, but my understanding is with the advanced airway curriculum in Ohio, Ohio EMT-B are not only allowed to intubate, they are expected to intubate as part of their duties.

Once again, correct me if I am wrong

info obtained here: http://www.grantlifelink.com/emseducation/emtbasic.htm
here: http://www.emt-national-training.com/ohio-emt.php
and here: http://ems.ohio.gov/ems.asp

 

[JPINFV]

Only 1 actual prehospital tube is required? So a basic batting 0.333 is considered experienced enough?

Any OR tubes required?

 

[el Murpharino]

NYS has a level for this...it's called EMT-Intermediate. It's different from the NREMT-Intermediate level in that NYS EMT-I's can do IV's and Intubate, without being able to push almost all the meds, with exception of Saline, D5W, and LR. When I took that class about...oh, 6 years ago, we spent the majority of the class on airway. The average EMT-B curriculum is about 120-150 hours. I just don't know if there is enough time in the EMT-B class to cover the finer points of intubation, acid-base balances, airway anatomy, etc. without missing some of the basic skills every EMT-B should be proficient at. But the NREMT feels this is a skill basics can perform...

 

[snaketooth10k]

Yes

In NJ, we aren't allowed to. However, I think we should be since it is included in our course book. It is also needed immediately in some situations; a patient could be dead by the time the medics show up. It also isn't a very complicated procedure, though the consequences can be quite the opposite.
I believe that Intubation should be allowed for EMT-B.

 

[Arkymedic]

While looking for local EMT Protocols online, I recently found the following:

R9-25-808. Protocol for an EMT-B to Perform Endotracheal Intubation

A. Endotracheal intubation performed by an EMT-B is an advanced procedure that requires medical direction.

B. An EMT-B is authorized to perform endotracheal intubation only after completing training that:

1. Meets all requirements established in the EMT-B Endotracheal Intubation Training Curriculum, dated January 1, 2004, incorporated by reference and on file with the Department, including no future editions or amendments; and available from the Department's Bureau of Emergency Medical Services; and

2. Is approved by the EMT-B's administrative medical director.

C. An EMT-B shall perform endotracheal intubation as:

1. Prescribed in the EMT-B Endotracheal Intubation Training Curriculum, and

2. Authorized by the EMT-B's administrative medical director.

D. The administrative medical director shall be responsible for quality assurance and skill maintenance, and shall record and maintain a record of the EMT-B's performance of endotracheal intubation.


Among the requirements of the training cirriculum are:

3. Attempted a minimum of 3 endotracheal intubations in the prehospital setting.

4. Performed a minimum of 1 successful endotracheal intubation in the prehospital setting.


Should an EMT be allowed to intubate if they have the proper training? Just curious to get everyone's opinion on this one...

I need to see the training syallabus before I make any comments or piss anyone off... My EMT-I partner can intubate here in OK. OK does not accept EMT-I for reciprocity without the I recipient being trained in advanced airway, and demonstrating such in OR, prehospital, and training.

 

[KEVD18]

 

[TheMowingMonk]

what emts can do very greatly by state to state, county to county. Like in california, based on state law, EMT-B's cause do IV's, ET Tubes, blood glucose plus an extra handful for drugs. the thing with that though is each county can choose weather or not to let their emts use those skills. In my case with Santa Clara county, emts arent allowed to do any of those things. They wont even let us do pulse ox readings or take a temp which i think is rediculus. but thats what the county want, but the point is depending on where you are, your skills vary greatly.

 

[VentMedic]

Actually this is not totally like "beating a dead horse" since a few states are revising their statutes even as this post is being written.

The areas that I am familiar with the EMT-B intubating, per protocol the patient must be pulseless or in other words, dead. If BLS is all you have responding to a code situation, then chances of ROSC may be slim anyway. If the EMT-B can not establish an IV/IO or push meds, orally intubating someone with an ETT that isn't dead already would be risky and may lead to death. Of course, then once the patient is without pulse or dead, it would be okay.

 

[fma08]

i would think with the proper training and knowledge base about airway anatomy and the procedure then sure. But that 3 attempts in field, and 1 successful in OR requirement is bogus. In school we need at least 10 intubations and all of mine have been in the OR, not the field. I kinda wish it would have been more (just because i haven't had the chance to intubate since).

 

[BossyCow]

Washington State differs a bit. We have adjuncts to the EMT-B. You can be an EMT-B with an add-on for IV and Airway. You can maintain those two skills with a Basic Cert. However, there is also EMT - I which includes (I think, I Might be wrong) some pharmacology.

As I understand it, this will be changing in our state with the adoption of the new National Standards. The last meeting I was at wasn't real clear on how it would be altered, but said it would have to change somewhat. They sounded like they were leaning towards making the IV/Airway cert a strictly ILS skill, but nothing was final.

 

[triemal04]

Actually this is not totally like "beating a dead horse" since a few states are revising their statutes even as this post is being written.

The areas that I am familiar with the EMT-B intubating, per protocol the patient must be pulseless or in other words, dead. If BLS is all you have responding to a code situation, then chances of ROSC may be slim anyway. If the EMT-B can not establish an IV/IO or push meds, orally intubating someone with an ETT that isn't dead already would be risky and may lead to death. Of course, then once the patient is without pulse or dead, it would be okay.

Really funny when you consider that airway is getting to be less emphasized in a code and circulation is starting to take priority; or at least has become much more important than before. Add in that compression will be stopped for quite awhile while they're attempting the tube (I'll gaurentee this) and I'll go out on a limb and say that no code that get's tubed by a basic will be coming back.

Pointless to be doing this without the required knowledge of why it's being done, when to do it, when not to do it, how to really do it, complications that might come up, how to deal with those complications, what to do to stop doing it, and why you'd do that.

Just like everything else.

 

[BossyCow]

Really funny when you consider that airway is getting to be less emphasized in a code and circulation is starting to take priority; or at least has become much more important than before. Add in that compression will be stopped for quite awhile while they're attempting the tube (I'll gaurentee this) and I'll go out on a limb and say that no code that get's tubed by a basic will be coming back.

Pointless to be doing this without the required knowledge of why it's being done, when to do it, when not to do it, how to really do it, complications that might come up, how to deal with those complications, what to do to stop doing it, and why you'd do that.

Just like everything else.

Umm... I have two combi-tubes who survived and are alive today. One was a drug overdose and the other a drowning. I think their familiies would disagree with you. Now, the combi-tube was placed enroute to an ALS intercept, but the 10 minutes of O2 they received until ALS took over meant that ALS had a viable pt to work with instead of a self watering vegetable.

 

[triemal04]

Umm... I have two combi-tubes who survived and are alive today. One was a drug overdose and the other a drowning. I think their familiies would disagree with you. Now, the combi-tube was placed enroute to an ALS intercept, but the 10 minutes of O2 they received until ALS took over meant that ALS had a viable pt to work with instead of a self watering vegetable.

Both of those had a better chance of surviving that the average code anyway.

And if you can't see the difference in putting a combi-tube in someone and performing endotracheal intubation, it's just more reason that this skill should not be performed by lesser-trained individuals.

 

[JPINFV]

what emts can do very greatly by state to state, county to county. Like in california, based on state law, EMT-B's cause do IV's, ET Tubes, blood glucose plus an extra handful for drugs. the thing with that though is each county can choose weather or not to let their emts use those skills. In my case with Santa Clara county, emts arent allowed to do any of those things. They wont even let us do pulse ox readings or take a temp which i think is rediculus. but thats what the county want, but the point is depending on where you are, your skills vary greatly.

Yea, but it would be interesting to see how many areas actually use the extra modules (my personal favorite is the one that allows EMT-Bs to manually defibrillate if directly supervised by a paramedic). Similarly, California still has an EMT-Intermediate (EMT-II [two]) level, but it's only used in a handful of counties use it, and the last report I've been able to find about it listed the total number of EMT-II providers in the state at less than 200.

As far as pulse ox's, why is it ridiculous? Respiratory and cardiac physiology is simply not covered in depth enough to even begin to understand the number, or what conditions will either cause a false high or low or make the number useless (example of the distinction. SpO2 reading is 'valid' (valid in the sense of "correct," not valid in the sense of "useful") in patients with cyanide poisoning since cyanide disrupts the electron transport chain. Carbon monoxide, on the other hand, screws with oxygen binding, thus giving a false high reading).

As a semi-aside, since it seems you're making the "it's so easy" argument, why not let basics push drugs? After all, we've all got opposable thumbs and that's all it takes to push a syringe. It's the same argument that getting a SpO2 is as simple as putting a clip on someone's finger. It'd be like me claiming I'm an ALS provider because I know how to do EEGs.

 

[BossyCow]

Both of those had a better chance of surviving that the average code anyway.

And if you can't see the difference in putting a combi-tube in someone and performing endotracheal intubation, it's just more reason that this skill should not be performed by lesser-trained individuals.

Where in my post did I say that I did not understand the difference between an ET tube and a combi-tube? The original post referred to both ET and Combi-tube (which is not universally accepted as a BLS skill). While I agree that both my saves were not your typical code, both of them would most likely have died if they had to wait the full ten minutes for ALS without BLS intervention.

 

[triemal04]

Where in my post did I say that I did not understand the difference between an ET tube and a combi-tube? The original post referred to both ET and Combi-tube (which is not universally accepted as a BLS skill). While I agree that both my saves were not your typical code, both of them would most likely have died if they had to wait the full ten minutes for ALS without BLS intervention.

Actually, the original post just referenced ET tubes. Which is what I referenced in my first post. As well, the time it takes to place a combitube is extremely short when compared to an ET tube, and it can be accomplished without interrupting compressions, something that is EXTREMELY important. Add in that it is much harder to screw up a combitube (though not impossible; I have seen it done) and you'll see why I posted what I did.

And both those pt's would not have neccasarily died; like I said, they aren't your standard code, and a crew who knew what they were doing and were able to provide good compressions and good ventilations/suction using a BVM and OPA (good meaning they didn't squeeze the bag hard as they could and inflate the belly) would have helped a lot. Also, do you really think that just placing the combitube made all the difference? If so, please elaborate.

 

[WuLabsWuTecH]

Really funny when you consider that airway is getting to be less emphasized in a code and circulation is starting to take priority; or at least has become much more important than before. Add in that compression will be stopped for quite awhile while they're attempting the tube (I'll gaurentee this) and I'll go out on a limb and say that no code that get's tubed by a basic will be coming back.

Pointless to be doing this without the required knowledge of why it's being done, when to do it, when not to do it, how to really do it, complications that might come up, how to deal with those complications, what to do to stop doing it, and why you'd do that.

Just like everything else.

I'm gonna disagree with you here. One of my Instructors intubated 4 times as a basic and got 3 of them back...

 

[Ridryder911]

I'm gonna disagree with you here. One of my Instructors intubated 4 times as a basic and got 3 of them back...

I say B.S. ! Prove it.. he/she better write a journal article. In adults respiratory arrests alone does usually lead into cardiac arrest until severe hypoxia has began. After an cardiac arrest occurs the likelihood of even with pharmacological agents is <6%.

R/r 911

 

[Hastings]

Just no. Basics have the tools to keep a patient alive long enough for ALS to arrive and intubate. The risk just far outweigh the benefit. Especially when the risks include death, and the paramedics are, in most cases, a mere call away.