Your Controversial EMS-Related Opinion

MackTheKnife

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And yet little in the way of research supports this.
Please elucidate. Not sure which way you research comment goes.
 

Tigger

Dodges Pucks
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Please elucidate. Not sure which way you research comment goes.
Nearly every (I’d say all but don’t know this to be fact) piece of research regarding video scope and bougie use shows vast improvement over a stylette and DL, with the improvements even more well seen with the “occasional intubators” like EMS and many EDs.
 

MackTheKnife

BSN, RN-BC, EMT-P, TCRN, CEN
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Nearly every (I’d say all but don’t know this to be fact) piece of research regarding video scope and bougie use shows vast improvement over a stylette and DL, with the improvements even more well seen with the “occasional intubators” like EMS and many EDs.
Ok, understand now. My comment was from an experiential point of view. Again, from the same perspective, I watch doctors in the ED struggle to intubate with video and bougie and they call an anesthesiologist who directly intubates with a Mac or Miller and a stylet.
 

DrParasite

The fire extinguisher is not just for show
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Most emergency medicine providers of any level have zero business comparing their skill set with anesthesia.
Is that a fair comparison? Anesthesia intubates 3 people a shift, while many EM providers might intubate 3 times a month. so when it comes to airways, anesthesia is the expert, because they do it so frequently

but EM does a lot more stuff in a shift than simply airway management; in fact, if you drop an anesthesiologist in an ER, how do you think they will function, compared to an EM provider?

 

Summit

Critical Crazy
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, if you drop an anesthesiologist in an ER, how do you think they will function, compared to an EM provider?
Extremely ****ing well in terms of airway management. What else was the point of this line of discussion?
 

Tigger

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Is that a fair comparison? Anesthesia intubates 3 people a shift, while many EM providers might intubate 3 times a month. so when it comes to airways, anesthesia is the expert, because they do it so frequently

but EM does a lot more stuff in a shift than simply airway management; in fact, if you drop an anesthesiologist in an ER, how do you think they will function, compared to an EM provider?

Yea, it’s different. That’s the point. There isn’t a viable comparison, so don’t make one.
 

DrParasite

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Extremely ****ing well in terms of airway management. What else was the point of this line of discussion?
last I checked, EM did a lot more than just airway management... how do you think they will compare to the other 99 things the EM does during a 12 hour shift? or did you miss that point that was clearly made?
 

Summit

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last I checked, EM did a lot more than just airway management... how do you think they will compare to the other 99 things the EM does during a 12 hour shift? or did you miss that point that was clearly made?
Nah, I se a non-sequitur.

The question was whether success rates for techniques used by high frequency intubators like Anesthesia are relevant to low frequency intubators who probably shouldn't be reliant on the same techniques. Whether a high frequency intubator is good at doing non-airway things is not relevant to the original point.
 

Tigger

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Well I (and everyone else) thought it was pretty clear that we were talking about airway management skill sets; would you like a sign also labeling the sky as blue?
 

silver

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last I checked, EM did a lot more than just airway management... how do you think they will compare to the other 99 things the EM does during a 12 hour shift? or did you miss that point that was clearly made?
Although airway management comes up with most patients, you realize that anesthesiologists/CRNAs do 99 other things during a day too?
 

Carlos Danger

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Nearly every (I’d say all but don’t know this to be fact) piece of research regarding video scope and bougie use shows vast improvement over a stylette and DL, with the improvements even more well seen with the “occasional intubators” like EMS and many EDs.
You are correct, and this has been true for years. Not every airway requires a VL but the problem is, it is impossible to know which one will until you've already pushed the NMB, at which point it is (not infrequently, in the case of an emergent tube) almost too late unless you have really strong airway skills. So if you don't have really strong airway skills to begin with (I don't think ANY OF US have airway skills as strong as we like to think), it's important to give yourself every advantage possible. The research reflects this consistently.
Is that a fair comparison? Anesthesia intubates 3 people a shift, while many EM providers might intubate 3 times a month. so when it comes to airways, anesthesia is the expert, because they do it so frequently
I think the fact that it isn't a fair comparison is the whole point. The rules are different for someone who does a thing an average of several times a day vs. someone who only does that thing several times a month or even several times a week. There are a few things that I do sometimes that I'm pretty good at but am not nearly as good at as someone who does them much more frequently. We shouldn't hold ourselves to the same standard in that case.
 

StCEMT

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All for bougie and VL, y'all know the McGrath X3 and a bougie is my **** even if it kinda goes against the grain a bit for common VL set up advice.

Now I've absolutely successfully taken a bougie and Mac 3 for a DL on a person who checked 4/6 HEAVEN criteria boxes and all in all it wasn't too hard. I'd absolutely have preferred my McGrath though.
 

Aprz

Non flying critical care flight attendant
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All for bougie and VL, y'all know the McGrath X3 and a bougie is my **** even if it kinda goes against the grain a bit for common VL set up advice.

Now I've absolutely successfully taken a bougie and Mac 3 for a DL on a person who checked 4/6 HEAVEN criteria boxes and all in all it wasn't too hard. I'd absolutely have preferred my McGrath though.
I know of guidelines that don't just see HEAVEN as difficult airways, but makes recommendations based on them. DL for hypoxia, small patients (one of the extreme of sizes), vomiting, and exsanguination. They recommend VL for large patients (the other extreme of size), anatomical abnormalities, and neck mobility.
 

StCEMT

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I know of guidelines that don't just see HEAVEN as difficult airways, but makes recommendations based on them. DL for hypoxia, small patients (one of the extreme of sizes), vomiting, and exsanguination. They recommend VL for large patients (the other extreme of size), anatomical abnormalities, and neck mobility.
I mean I feel like that is how it should be. Gotta rehearse your solution, not just identifying the problem.
 

Aprz

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I mean I feel like that is how it should be. Gotta rehearse your solution, not just identifying the problem.
On the ambulance, I used to do that. I would go DL for fluids in airway or any potential for glare outside. All other patients got VL. So I liked that I did kinda like a mini HEAVEN before I went air.
 

EpiEMS

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DrParasite

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This study really is challenging my priors. I have to do a deep dive. There are multiple limitations but I hadn’t ever really considered the possibility that more than 3-4 providers would really make a difference, particularly in the era of the Lucas.

1) not all of us have a lucas device on every ambulance in our system
2) "The presence of seven or more prehospital providers on-scene was associated with significantly greater adjusted odds of survival to hospital discharge after OHCA compared to fewer on-scene providers." this must include people who are there purely for muscle/compressions. it's not saying you need 7 paramedics on scenes. 3-4 FFs on an engine, 1 ALS ambulance with an EMT & Paramedic, second ALS ambulance with EMT & Paramedic (or two units, one EMT/EMT & 1 Medic/Medic), maybe a supervisor to talk to the family, and you have more than enough people. 3) the city I live in sends 1 fire units to every cardiac arrest, and if it's a workable arrest, a second fire unit is sent (usually engine and ladder if in the the same house, or second due engine). Apparently using fire crews is cheaper than buying lucas devices for every ambulance, especially since we rarely transport with CPR in progress, and there are few studies that have shown that a lucas device is clinically better than manual compressions (outside of vendor sponsored ones).
 

EpiEMS

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1) not all of us have a lucas device on every ambulance in our system
2) "The presence of seven or more prehospital providers on-scene was associated with significantly greater adjusted odds of survival to hospital discharge after OHCA compared to fewer on-scene providers." this must include people who are there purely for muscle/compressions. it's not saying you need 7 paramedics on scenes. 3-4 FFs on an engine, 1 ALS ambulance with an EMT & Paramedic, second ALS ambulance with EMT & Paramedic (or two units, one EMT/EMT & 1 Medic/Medic), maybe a supervisor to talk to the family, and you have more than enough people. 3) the city I live in sends 1 fire units to every cardiac arrest, and if it's a workable arrest, a second fire unit is sent (usually engine and ladder if in the the same house, or second due engine). Apparently using fire crews is cheaper than buying lucas devices for every ambulance, especially since we rarely transport with CPR in progress, and there are few studies that have shown that a lucas device is clinically better than manual compressions (outside of vendor sponsored ones).

Agreed on your first point, I would argue it should be standard of care from a provider safety POV. Lucas has been shown to be non-inferior to hands on chest - so I’d argue it is more efficient, but reasonable people can disagree.

I think you’re probably right - no way are you getting 7 medics (except in California), nor would you need them. The optimal mix is going to vary widely by response time, I think.
 
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