Spock

Thanks for the information everybody. I also use 7.5 for women and 8.0 for men. We do not trach our burn patients because the trach is a very good source of infection and these patients are behind the eight ball already. An emergency cric is a different matter. Succinylcholine is safe during the first 24 hours and I use it in the trauma bay in all patients unless they are hyperthermic. Suxs is a triggering agent for malignant hyperthermia so using it on a patient already hyperthermic is risky. It looks like we have a local problem with the tube size so I plan on discussing it with our prehospital coordinators. Again, thanks for the input. Live long and prosper. Spock

etfink--Go to www.aana.com which is the American Assoc. of Nurse anesthetists for more information. That would be a better resource than me telling you what I do. I will say that I love my job and am quite happy I pursued this career. Rid--I often tell people I pass gas for a living. I also used to tell people that my father sold drugs (he was a pharmacist.) Dust--I drive the Mercedes and my wife drives the BMW. Currently looking for a used Porsche for a new toy. Live long and prosper. Spock

We have two hospitals with burn units in Pittsburgh and I work at the only one that is also a Level 1 trauma center. Just the other day we received a patient that had been trapped in an apartment fire. He had burns to his face, chest, back, and left arm for about a 50% BSA burn mostly second degree. The medics did a good job with early airway control by getting him intubated in the field. The pt arrived with an SBP of 135 and pulse rate of around 100 and was still breathing. The problem was the medics intubated him with a 6.0 tube that had a pretty good air leak even though the cuff was inflated to the maximum. I had to change the tube and although the procedure went well it was not fun. The pt was at least six foot and weighed 230 and I intubated him with an 8.0 tube. Total time from fire to my intubation was about an hour and the airway was full of soot. My question is: What are your guidlelines/protocols for intubation of the burn patient? Do people routinely place small tubes because that is what you were taught? This was not an isolated instance as I have had to do this several times on patients that have arrived by ground and air and transferred from community hospitals. I'm just curious as to what everyone has been taught across the country. The crew left before I could talk to them. Live long and prosper. Spock

Look elsewhere on this forum because we covered this topic in some detail. Good luck. Live long and prosper. Spock

Nuclear engineer to EMS? Boy, you don't see that every day! Rid offers some excellent advice. I have had several careers including Certified Athletic Trainer and college instructor in sports medicine before getting EMT and paramedic certifications. I left athletic training and went to a second degree nursing program where I earned a BSN in 16 months. After working in the ER and ICU for a year I went into anesthesia and earned an MS in nursing anesthesia. It helps to talk to a bunch of people to learn their educational experiences before making your own decisions. Being a nuclear engineer means you are educated and intelligent so I suspect you might find EMS boring and not very stimulating intellectually. That doesn't mean EMS folks are dumb just that you think on a different level. Good luck. Live long and prosper. Spock

The combitube and LMA should only be used by ALS providers and I'm still not convinced that the LMA is appropriate for prehospital use. I would like to see all providers master BVM with OP airway ventilations first because I routinely see paramedic students come to the OR for intubations and they can't mask the patient. We don't let them intubate if they can't mask ventilate. I might be able to make a case for the King LT-D for use by BLS providers but I'm thinking we need more experience with it. That's probably a change from what I've said previously. Live long and prosper. Spock

OK, I have some experience with AICD's. We put in several every week and have to sedate the patient for the testing. Every patient I have ever talked to say it feels like a horse kicking them in the chest when it goes off. People that say it is only uncomfortable are tough hombres. Dispatch for an AICD firing should always be ALS. There are two reasons for it to fire: arrhythmia or malfunction with malfunctions rare. Put the patient on the EKG and see if it shocks sinus rhythm. If it does then the thing is malfunctioning. Treat with oxygen, IV access, versed and fentanyl for comfort. Transport immediately. Be prepared for an R on T and V-fib. If BLS can get to the hospital before ALS gets on scene then by all means go but remember that ALS should have been dispatched from the outset. If the pt is having arrhythmia's then treat with amiodarone and sedation if necessary. We use a donut shaped magnet to disable the AICD in an emergency. Otherwise we have staff from the EP lab come down and interrogate the device. That is the wand chbare was talking about. They can determine the type of device and even battery life. They disarm the defib capability while leaving the pacer function operational. We then put the defib pads on and have the pt connected to a Zoll defib until whatever surgery they are having is complete and the pt is in the PACU. A bovie used to cauterize bleeding during surgery will set off the AICD unless it is turned off. All of the new AICD's for about the past five years (maybe longer) are defib and pacer combined. Put the magnet on the device and the defib is off and pacer function is operational (usually VVI). Remove the magnet and the AICD is operational. Some devices will give off an audible sound when the magnet is placed on it. Also remember most units have bipolar leads so the pacer spikes are very small. I don't think a paramedic should use a magnet in the ambulance unless he had orders to do so and also had the appropriate magnet. In any event, the device should only be shut off if malfunction is documented. I don't know of any reason why the device should shut off for 10 minutes and then be operational again. Battery life is indeed 5-10 years depending on how many times it has to shock and pace. I've seen patients who have come in for battery changes after many years and they say it has never gone off. Live long and prosper. Spock

PA is in the process of writing statewide ALS protocols. I just saw the first draft of the airway protocol and it includes the combitube and the King LT as approved backup devices. The drug assisted intubation protocol will include etomidate but it has not been finished as of yet. I'm supposed to get a copy of the first draft for review. I agree with you Medic 26 that the King would be great for a study for use by BLS providers because I feel it is so simple to use that anybody allowed to insert an OP airway could also place a King. First things first though, we have to get it approved for ALS. Regarding capnography: there is strong sentiment in the medical advisory committee for the state EMS office to require capnography for all ALS units. Cost is a factor but they may give highest priority for the EMS grant program to services purchasing capnography. We are moving forward. Oh, before somebody suggests otherwise, I have no financial interest in the King LT or it's parent company. Live long and prosper. Spock

I respond to calls from home while off duty all the time. I call in with my portable and tell dispatch I'm enroute which covers me for insurance plus my bunker gear and first in bag is in my trunk. I only respond to calls that are priority one and are closer to my home than the station. I mostly drive at space normal speed and obey all traffic laws although there was the one time I followed a state trooper on the interstate at 100+ to a very bad MVC. He was pretty pissed when we pulled up on scene but he laughed when he saw me and I said "Couldn't you go any faster?" It helps to be the only medic in area driving a Mercedes especially since most of the local cops know my car as well. All of that said, the bottom line is: 1. Give a good windshield report. 2. POV's on scene should be the exception and not the rule. 3. When responding from home whatever you do don't get on scene first! Live long and prosper. Spock

I'll double check on our price for the King LT-D. Perhaps the price you saw was for the reusable King LT? Even at $67 that is much cheaper than the reusable LMA. Live long and prosper. Spock

WOW! Tough subject with no right or wrong answer. Personal responsibility is important and perhaps lacking here but a little bit of compassion would be in order. I used to be very critical of smokers until I saw the reimbursement for a thoracotomy for lung CA. Changed my tune pretty quick not to mention how fun and challenging are these cases. It's called job security so smoke 'em if you got 'em! Live long and prosper. Spock

I agree with ERDoc in that you must read and analyze the entire research article before coming to a conclusion. Newspapers have to condense things for the space available so what you read is somebody's interpretation of facts. I would like to point out one possible reason for higher save rates with fewer paramedics if that is indeed the case. Perhaps you get better BLS (CPR) when the first responders know the medics are more than a few minutes out and they have to treat the patient until the medics arrive. Remember the emphasis the AHA has placed on compressions in the new guidelines and you may see some logic here. Live long and prosper. Spock

The website I was thinking of is www.kingsystems.com One thing I left out is the cost of a combitube which I believe is around $70. When I mentioned capnography I was thinking specifically of the wave form capnography we have with our Lifepack 12. The easy cap colorimetric CO2 detector has severe limitations which many providers do not recognize. I go ballistic when I roll into a hospital with an intubated patient and show the physician the ETCO2 wave form on my monitor and they then insist on using an easy cap to "confirm" my tube placement. It is another example of prehospital technology outpacing inhospital technology. PA is working on a final draft for state wide ALS protocols. There was talk of requiring wave form capnography but I don't know if it made into the protocols. Many services would have to spend some money so it may never happen. Live long and prosper. Spock

I stayed out of this topic for a few days in order to give other folks an opportunity. I have experience with all of the devices mentioned so I'll offer some thoughts in no particular order. Endotracheal intubation is still the gold standard although there has been research done that is sharply critical of paramedic intubating skills. If you are not aware of this literature you should educate yourself because there are some physicians who would like to see intubation removed from the paramedic's arsenal.. Also, I feel that if you do not have wave form capnography available in your truck you should not be intubating anyone. One thing 4-5,000 intubations has taught me is that not everybody can be intubated and one or two backup devices are necessary. We use the LMA in the operating room. If we anticipate a difficult intubation we either use an intubating LMA or do an awake fiberoptic intubation. The ILMA is much easier and less time consuming but does take a certain amount of practice to maintain proficiency and it is not always successful. If I've gone a few weeks without using an ILMA I will use one electively in order to maintain my skill. Awake FOI requires even more skill and practice and is actually becoming a lost art since the advent of the ILMA. I don't necessarily agree that the LMA is easy to place. I felt the learning curve was about 25 because that was how many it took before I was comfortable. Perhaps I'm a slow learner! Also, just like ETI, there are some patients that can't be ventilated with an LMA. We use the regular LMA for simple cases where a general anesthetic is required and it works well. As people have mentioned, losing the seal with an LMA is easy and I feel this along with its inability to prevent gastric aspiration are the biggest drawbacks to prehospital use. The LMA is available in disposable and reusable models. Sizes range from pediatric #1 up to #6 (giant size). Sizes are based on weight. I guess I've put in 8-900 LMA's. My experience with the combitube is limited to intubating around it in the ER. The combitube is the only backup device approved in PA and we have seen it several times in the ER. I had to do an in service for my anesthesia department on how to change a combitube after the first time one came through the doors because nobody had ever seen one although we all had heard of them. The ER calls anesthesia when they get word a combitubed patient is on the way because they figure it is a difficult intubation and they punt it to us. The most important part is to decompress the stomach with the suction catheter provided in the kit before removing the combitube. The manufacturer has a recommended procedure for removing the combitube. Now to my favorite backup the King LT-D. the King came to the USA from Germany in 2005. We added it to our department a few months ago and I've used it 12 times so far. I've used it for cases where I would normally have used an LMA. I feel the learning curve is zero. The first person to use one in our department was a first year SRNA. She had no problem with it. It maintains a good seal when moving the patient. The sales rep put one into a mannequin head and was able to pick the head off the table by the holding the King which was not secured with tape. It provides a small amount of protection against gastric aspiration and you can ventilate with a higher amount of positive pressure than an LMA (30 cm H2O vs 20 with the LMA). I feel it is so easy to use that if an EMT can place an OP airway he/she can place a King LT-D. You can pass a bougie through a King, remove the King, and then pass an endotube over the bougie into the trachea. We have not done that in our department as of yet but we did run a fiberoptic scope down a King and found the vocal cords directly in line with the opening of the King. If you go to the King website you can view a video of the procedure. I'm at work and don't have the exact website but will post it when I get home tomorrow. The King comes in three sizes: #3, #4, & #5. No pediatric sizes right now. Sizes are based on height. Now for cost. My hospital pays $1.10 for an endo tube, $8 for a disposable LMA, $14 for a King LT-D (the D is for disposable), about $200 for a reusable LMA, and about $600 for an intubating LMA. We are pushing the King because we want to go to an all disposable system and frankly the disposable LMA's are harder to place than the reusable LMA's. Sorry to be so long but I hope that helps. I'm interested in your experiences with back up airway devices in the field especially anyone using an LMA routinely. Am I correct about easily losing the seal when moving the patient? Also, I'm working on getting the King approved for use in PA so if your state has approved use of the King please let me know here. Live long and prosper. Spock

I know little about those web based nursing programs but I was always under the impression that you had to get your own clinical experience. That would be a very large drawback in my mind. You need solid classroom education and good clinical experiences to succeed as a nurse. One option you may have fire 911 medic is the second degree program since you already have an undergraduate degree. In these programs you earn a BSN in a short time (12 to 16 months). You do not have to take anything but the nursing classwork and clinicals are 4-5 days per week. It is full time. There are usually quite a few prerequisites that are completed prior to entry such as nutrition, A&P, microbiology, etc. I was a paramedic and had a BA and MEd when I entered the second degree program at Duquesne University in 1992. It was a good program and I felt I was well prepared to function as an RN upon graduation. I was hired directly into an ICU as a GN which was unusual at that time. My background as a medic helped. One word of caution is that some nursing instructors don't like medics and will give you a hard time. I also agree with Ridryder that nursing is different than EMS so do some investigating before making a commitment. If you choose nursing be prepared to do many things you'd rather not during your education and do it with a smile. Somebody mentioned nursing and the military. I was always under the impression that you needed a BSN to serve as an officer in the military. It wasn't always that way because my mother was a Navy nurse in World War II and she was a hospital trained RN. She was discharged as a Lieutenant JG. Good luck. Live long and prosper. Spock

Good luck and be careful Dust. Also, thank you. May the Force be with you. Live long and prosper. Spock

Good point Race. The kidneys can take a hit even with one short episode of hypotension. If the brain and the beans are perfused everything else will take care of itself. Live long and prosper. Spock

Hey Sarge--don't make the same mistake twice regarding not talking about a bad call. Always talk about things that bother you otherwise it will eat you alive and you will never survive in medicine. To many people let it get to them and they go home and drink or kick the dog or worse. You did your best and that is what's important. Some day you will have a save and that will make it all worth while. Live long and prosper. Spock

Ativan is the drug of choice for seizures if available otherwise valium. The half life of versed is to short for use in seizures. If by premedication you mean preparing a breathing patient for intubation then I would say versed is the drug of choice. I give 100mg of lidocaine, 4mg versed, and 100mcg of fentanyl when I need to put a patient down for intubation in the prehospital arena. This has worked well for me and although I would prefer other drugs these are the only ones available in my system. I do adjust the dosages based on size and age. We don't carry ativan but will probably add it to our drug boxes in the near future. I'm under the impression that refrigeration is no longer a concern with ativan. Live long and prosper. Spock

I like your differentiation between protocols and guidelines because it makes a great deal of sense. Unfortunately, we have protocols in my area because we also have far to many "cookbook" medics. The medical directors don't trust many medics to treat patients properly. We only give D50 if the BGM is <80. Thiamine is not provided in our drug boxes. Giving D50 to an unconscious patient having a stroke is harmful unless hypoglycemia is documented. As far as narcan I have never been impressed that pinpoint pupils absolutely and positively means opioid overdose. Bystander information and evidence found at the scene is very important. When in doubt, assess your patient. That is an alien thought for the cookbook medic. Live long and prosper. Spock

I thought the retrograde intubation concept had disappeared. Rid-what kind of patients were retrograde intubations necessary? With 8-9 you are the expert here. Live long and prosper. Spock

QED Live long and prosper. Spock

There is no doubt our hospital policy is anecdotal but it is the policy. Like I mentioned, we have no control or input over local EMS which is very fragmented and ranges from excellent to very bad. The good get lumped in with the bad. Live long and prosper. Spock

At PSU they get experience and education while earning money. Many have gone on to become paramedics and EMS managers, nurses, and a few are physicians. One alumnus is a well known EMS attorney. They provide a valuable service to a campus of over 60,000 people. Universities have their own police departments so why not EMS? PSU EMS responds to mutual aid calls throughout the county and is the first due EMS agency for the county airport because they are the closest. Do these EMT's get the same "real world experience" found in the big city? No. They do provide a valuable service that would be a drain on the local EMS community. It is not their fault they are BLS. The county medical director wants all ALS to be under his control so a paramedic response unit provides ALS. This makes for better EMT's because they have to treat the patient for 15 to 20 minutes before they meet up with a medic. They load and go for just about everything and meet the medic enroute. Dust--your well recognized bias (hatred) towards EMT's is tiresome. Perhaps you need to move on. Live long and prosper. Spock

I am currently a co-editor of a textbook and wrote the chapter on assessment and vital signs. I included pulse rate, respiratory rate, BP, SPO2, temperature, and pain scale rating. I chose these because limited technology is required and the text is for entry level professionals. For advanced professionals with the necessary technology I would add ETCO2. Frankly, if you are advanced level and able to intubate you should have and use waveform capnography. No ETCO2 means no intubation. Live long and prosper. Spock