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"Running" a Cardiac Arrest isn't an easy feat and is dramatically harder if your the only Paramedic (advanced skills provider) in a room filled with basic providers. My partner and I (both paramedics) can typically run a code with the assistance of 3 EMT-B's pretty routly but take one of us out of the mix and its twice the trouble. On the topic of intubation alone there is alot that goes into a sucessful intubation and if your still in training you don't know the stress of being the only Paramedic in the room yet. Obviously the important points of: -patient posistion, airway assessment -suction, preoxy, equip prep -the actual attempt -secure/etc02 Can take alot away from running the rest of the code... Patient posistion can be easily overlooked if you don't know how much it helps! My partner and I always bring and have the port. suction set up prior to the blade ever going into the patient's mouth. In the last 10 intubations I think all have required minimal to heavy suction use. There is nothing worse then getting into the airway and then realizing you need something you don't have and you just wasted an attempt. Bagging the patient and setting up the equipment along with an assessment of the airway can give you 30-60 seconds to take a deep breath, relax and prepare for the intubation. When you finally make your attempt have someone set aside as your "assistant" who can hand you equipment, move the patient, apply cric pressure, tell you to stop, etc. As your in the airway a few seconds to get the lay of the land is ok if you ask me. You may have to suction, readjust, and see your landmarks clear before you actually insert the tube. I even take a second with the tube as I pass it to make sure its going through and to try and not "burry" the tube in the patient. How long does that acutally take? I don't know but the point is make everything possible in your favor before making your attempt. And now a story... I recently had a trauma code which at the surface appeared like a car accident. But after removing the patient we discovered a gun and turned into a gsw to the head. So what factors do we have that make this intubation difficult? Blood in the airway that will require alot of suction, c-collar, drama of the moment, oh yea and the patient was a police officer (off duty/but in uniform.) To make the story short the intubation was sucessful but some won't so learn from each.

It's not acceptable at all, and a major reason the survival rate for sudden cardiac arrest is so dismal in the United States and across the World. We know that continuous chest compressions are an important part of saving more people, so anything that interrupts chest compressions is bad, including tracheal intubation. Why not intubate without interrupting chest compressions or use a King LT-D to accomplish the same thing? It's working great in Wake County, NC where the survival rate for people observed to collapse from cardiac arrest with an initial rhythm of VF/VT approaches 50% in the City of Raleigh. They start compressions immediately, drop a King LT-D (with a ResQPOD and waveform capnography), defibrillate after 2 minutes, start a couple of IOs, and induce hypothermia for patients with ROSC and persistent unconsciousness. It's a simple and repeatable formula that is not so dependent on the experience level of the paramedics. But by God, we don't care how many people die in EMS! Just don't take away our authority to intubate! Tom

Interesting question. I know that when I read the NREMT test questions, I often wonder if they were written by someone who speaks English.

LTC facilities are definitely a challenge, I can safely say, as I'm sitting here on graveyard shift at an assisted living. There are many that provide good care, if not excellent care... I would second what Dave said, though, as far as staffing inadequacies and weird mixes of levels. Now that I work in this setting, I totally see where some of the LTC stuff comes from as far as why we didn't call sooner, what we didn't do, etc. The honest to God truth is that LTC facilities attempt to care for problems until it becomes WAY out of their capacity (which is part of what they're supposed to do), OR, problems just honestly get missed/overlooked. It's not intentional neglect, as far as I can tell- it's mainly that the nursing staff is overworked and simply doesn't remember everything reported to them by the care providers/CNA's over the course of a shift. I had to report someone's SOB with exertion and increasing pedal edema about 5 times over the course of 1.5 weeks before he finally went to the doctor. Surprise- nurses got fired in between his doctor visit and results being faxed back, and it took another week before folks realized that he had been diagnosed with CHF. The BIGGEST challenge to providing good care is consistent communication. Where EMS only has to get the basic history info and acute history and treat the patient for ~ 1hr at most, LTC facilities provide care for weeks, months, or even years. Try getting every nuance observed over your shift communicated to the next shift, and have them communicate that in turn to the shift after that... it's like a giant game of "Telephone" and so you have to be vigilant in your documentation and reporting to make sure important stuff doesn't fall through the cracks. Then there's the issue of how good your nursing staff is... we had a few LPN-FAIL! types and now we mostly have very good LPNs with a few pool nurses to help fill out the schedule. I totally get why it's frustrating from both sides and why LTC facilities and EMS don't always play well together- they're coming from different worlds, and sometimes EMS sucks and sometimes the LTC facility sucks. Throw some egos and misunderstanding of what the medical purpose of your given role is in there, and you've got a grade A cluster! Just my rambling... Wendy CO EMT-B

Posting from work so I must be brief. More info on request. To what extent do you feel that taking a little over a minute to intubate a cardiac arrest pt (refractory VF scenario), whilst compressions have been ceased, is acceptable/unacceptable. This example is from a job I went to recently where the attending medic instructed me to cease compressions for probably around 40 seconds, failed, I did perhaps another 15-20 compressions, while he prepared again. When I ceased, it took another 30-40 seconds to get the tube. I didn't feel this was acceptable, but given my inexperience, I was wondering what you all thought about the matter. I believe I've heard of some of you yanks tubing with compressions in progress. Did I misunderstand? Whats the go with this issue?

Honestly, are people even trying anymore? What was your first call? I am wondering, what was your first call? This doesn't include ride-alongs. Seriously people, at least try...I am not grammatically correct all the time. At least I try and CAPITALIZE things or form some type of understandable sentence structure. My first call? Honestly I don't recall.