Spock

Glad to see humor has not disappeared from the City. I did not intend to imply that c-collars would or should go away, only that they really do not restrict very much motion. Collars will always be used as long as lawyers chase ambulances. Spock

I certainly remember teaching and using the standing board take down but it is gone. The new Pennsylvania (July 2015) spine injury care protocol specifically states the standing take down should not be used. We also used to put the MAST trousers on every trauma patient although actually inflating them was rare. Finished my Doctor of Nursing Practice (DNP) degree from Carlow University in May 2016. It is my fifth college degree and I think I can safely say it will be my last. The negative outcomes from LSB use was a given based upon the literature. The question is: Will a change to spinal motion restriction cause injury by missing significant spinal injuries and causing more harm by movement? Morrissey et al. (2014) found only two missed spinal injuries after switching to SMR from using the board in a patient population of 5800 in a service area population of 1.5 million. Both of these "missed" spinal injuries were insignificant (spinal process fractures). My work looked at three services in suburban Pittsburgh and had no missed injuries in patient population of 543 and a service area population of 143,000. Since Eyre (2006) reported an estimated 13 million people seek care in emergency departments each year with an incidence of significant spinal injure of 0.3%, one would need a very large patient population in order to achieve power when looking for spinal injuries made worse by SMR. Getting follow up information from hospitals is very difficult as both the Morrissey and my study found. So the jury is still out on SMR and it is interesting that spinal immobilization was instituted by consensus and not evidence just as SMR is being instituted by consensus. Ten years from now we may look back and say how stupid we were to use SMR and cervical collars but only time will tell. Considering we used the LSB for almost 50 years before moving away from it, if we recognize problems with SMR in only ten years we have learned something. Don't get me started on the effectiveness of cervical collars. I bet ERDoc will agree with my next statement. Ask any ED physician about the worst spinal injury they ever saw and they will probably tell you the patient walked into the hospital under their own power and not on an ambulance stretcher. Bottom line is that changing to SMR from SI resulted in an initial decrease in the use of the LSB by about 60%, Unpublished data indicates use of the LSB has dropped almost 95% since changing protocols. Are there still times when a LSB should be used? Yes, but as I mentioned previously, it should be the exception and not the rule. Never say never! Spock

It just so happens my doctoral dissertation was on this exact subject. The literature since the early 1980s demonstrated that the LSB increases pain, causes respiratory compromise, leads to tissue breakdown, and is ineffective. Yet, the practice continued until 2013 when the NAEMSP released a position paper that called for the limited use of the LSB. ACEP followed in 2015. Using it as an extrication device is warranted and the services in my area have stopped using it except for the entrapped patient with multi system injuries (multiple fractures) but we have transport times to the trauma center of less than 10 minutes. My dissertation showed a 60% decrease in the use of the LSB in the first six months after implementing a spinal motion restriction protocol by the state. Additional service QA indicates the decrease continued the next year to the point use of the LSB is the exception and not the rule. If anybody wants a copy of my references, let me know and I would be happy to send them. They date to 1966. Spock

Sugamadex is not the answer to a failed intubation. While it will reverse neuromuscular blockade from a non-depolariizing agent such as rocuronium, it does not reverse the induction agents administered such as versed, fentanyl, etomidate, propofol, or any combination of those medications. I've used sugamadex several times when a surgical case ended much sooner than expected and it reverses the blockade in about 30 seconds. The best approach for prehospital RSI should include video laryngoscopy along with the usual induction agents including succinylcholine which is safe in the vast majority of patients. Solid QA medical oversight along with operating room time to maintain skills are also required for good RSI outcomes. As I cited before, versed alone as an induction agent for RSI is not supported in the literature and the drop in BP can be lethal. That does not negate the anecdotal experiences of many folks including myself, but it is not a good option. Spock

Good question and I think the value of the organs harvested would be minimal after prolonged cardiac arrest. Tissue would probably be viable but other than that, I doubt there is value. I took my organ donator tag from my drivers license a few years ago after getting summoned to the OR late at night for a donor harvest only to find the staff was doing CPR when they arrived in the OR. Organ donation is a very personal decision but that episode changed my mind. May the tube be with you. Spock

These comments are great and prove that the folks that post on the City are really smart. Off label may not realize the difference in the types of capnography and may not have the advantage of the sophisticated technology available today. If I do a sedation case in the operating room, I have the patient on oxygen via a simple face mask and attach my ETCO2 tubing to the mask. This gives me an indication of the patients respiratory pattern but the number is always low and has no real value other than tell me a quick glance that the patient is breathing. You may ask why I don't just look at the patient and that is a good question. I am frequently distracted by other things in the OR (the surgeon wants the table moved or some other BS) or the lights have been dimmed because of the procedure and I can't see the patient. The capnography we use in our ambulances around here use micro stream technology and the quantitative values given have true meaning. Capnography is one more tool in your tool box and is just as important as your BP cuff, pulse oximeter and EKG monitor. Tube or not, ETCO2 is important for every patient with respiratory compromise. May the tube be with you. Spock

I think the key to this question is good emergency planning. These ambulatory surgery centers (ASC) are required to have a plan for unexpected hospital admissions and this plan includes the receiving hospital and the local EMS agency. I agree with ERDoc that not all are true emergencies and are often related to an unexpected result or complication that may not be life threatening but do require hospital admission for further evaluation and treatment. I have worked in the ASC setting and never had to transfer a patient but that is only because of dumb luck. If I would have had to transfer a patient, I probably would have gone in the ambulance but since most of the crews in this area know me, it would not have been an issue. Working together is paramount for good patient care and the treating physicians should provide solid information on the events that caused emergent transfer to a higher level of care. When in doubt or faced with a conflict, consult medical command and let the doctors figure it out. May the tube be with you. Spock

These are nice comments, all based upon clinical experience which should never be minimized. That said, if you look at the literature, versed as a sole induction agent is not supported and has been associated with increased mortality and morbidity. There is no substitute for true RSI (induction agent and paralytic) when faced with an emergent airway crisis. I have used versed and fentanyl for intubation in the ambulance and etomidate or propofol alone in the hospital with good success but that is only because I have around 10,000 intubations under my belt. Give me enough time to anesthetize an airway, I can intubate an awake patient. Prehospital staff are being dealt a raw deal when it comes to intubating a patient not in cardiac arrest but you must remember that if you have poor first pass intubation success rates, RSI is not the answer. May the tube be with you. Spock

Thank you for the interesting comments. I have to agree with most everything posted which makes this a dull topic. My EMS service uses the King Vision and after a rough start, our first pass intubation success rate has improved by about 30%. I've used just about all of the VL's and really like the second generation McGrath. I do a lot of thoracic and esophageal cases in the OR and since I classify all of these patients as a difficult airway and high risk for aspiration, the VL seems the way to go. Those that argue VL will dilute DL skills are correct. I struggle with new nurse anesthesia students on using VL at all since I can't help them if I can't see what they are seeing. If I have a student that has had trouble with DL, I will use the McGrath in order to identify problems with their technique and remediate them. We then go back to DL but sometimes I really wonder where we are going. I would predict that in ten years, DL will be a lost art. This week in the OR was amusing. Our chief of thoracic surgery was on vacation so I wound up doing regular surgical cases and I got out my miller 3 for each intubation. The OR staff all laughed and asked if I remembered how to use a miller. There are pros and cons to advanced technology but I have to come down on using technology as much as possible even though I am an old fart and came into the computer age kicking and screaming and dragging my feet. I was surprised that nobody mentioned the cost of the VL devices. May the tube be with you. Spock

The micro stream technology used with some monitors gives a remarkably accurate reading with the nasal cap ETCO2 plus it can also provide an indication of perfusion status. Capnography has been demonstrated to be a more reliable and quicker monitor to detect hypoventilation than a pulse oximeter. Case study: A 13 year old boy is injured in a zip line accident sustaining a significant blow to the occipital region of his head. He is unconscious and bleeding profusely. The crew arrives on scene, controls the bleeding, and immobilizes him on a spine board with a collar. Yes, this was two years ago when we still did such things routinely. They called for a helicopter and transported to the LZ. I met the crew at the LZ and did a quick assessment. The boy was still unconscious, skin pink, BP normal, saturation 100% on room air, and breathing about 20 times per minute but shallow. I applied the nasal capnography and the first number was 60. I didn't look to see if it went higher because I was grabbing the BVM. The kid looked fine but the capnography proved otherwise. I bagged him until the helicopter arrived and we RSI'd him. Capnography is not necessary for every patient you see, but it is an essential vital sign in the critically ill or injured. I just don't buy the argument that "we don't use it because it is to expensive". May the tube be with you. Spock

Thanks for the input everybody. I think I'll see if we get a few more before I weigh in with my thoughts. I really wanted to get some idea of how wide spread these devices are in ground EMS because I suspect they have become standard equipment on HEMS. May the tube be with you. Spock

OK, I've been away for a long time but I'M BACK! I searched the site for this topic and not finding it, I thought I'd start it. If the topic is some place that I didn't see, tell me to shut up and we'll move on because I'm an old guy and technology is not my strong suit. How may services are using video laryngoscopes and what kind are you using? I've used the glidescope, C-MAC, King Vision, and McGrath and have very specific thoughts about each. There are others on the market and I wanted to know what people are using. Certainly cost is a factor but what does everybody think? I'll share my thoughts after reading some opinions. May the tube be with you. Spock

The bougie certainly has its place in your airway management tool box along with as many other tools has you can muster. Just yesterday, I had to use a bougie to place a tube even though I was using a McGrath video laryngoscope for a patient with a know difficult airway. You have to improvise, adapt, and over come. May the tube be with you. Spock

Obtaining vital signs is a basic function of every patient interaction. Any patient complaining of respiratory difficulty that requires the administration of oxygen should have ETCO2 measured. Cost is not a factor: You buy tires and put fuel in the truck so why don't you have the basic patient care modalities? My service has had ETCO2 since 2000 and I have rewritten the SOG's for its use four times. This is a no-brainer. Let the tube be with you. Spock

Well I certainly do recognize a few names and hope some remember me because it has been a very long time. When Dust Devil passed away the magic went out of the City and I moved on to other things. I'll make an effort to return as much as possible in a few months because I'll be finished with my Doctor of Nursing Practice degree. I hope to learn from the new folks as well as perhaps being able to impart some knowledge based upon experience if possible. May the tube be with you. Spock

I'm nor going to pass judgement on the medic's decision but we've had this happen in our area far to many times. Many medical directors have implemented protocols that require medical command consult before calling for HEMS. We had one medic who responded to a call for a patient with a nose bleed, she decided the pt had an abdominal aneurysm and she called for a bird. Pt was transported to a trauma center by HEMS and was later discharged with a diagnosis of epistaxis. Insurance companies need to take a role in this by refusing to pay and sending the bill to the ambulance service. It would make people think twice. In my 24 years of experience as a medic, I've only flown two people but we have short ground transport times to a trauma center.

Will has interesting information that may be useful in the future but cost will always come into play and I agree that vec is more reliable than roc but both take a long time to wear off which makes them suboptimal for RSI. Nothing is cheaper than Suxs (pennies versus dollars) but if it had to go through FDA trials now it would never pass. I do remember rapacuronium and there were a lot of deaths before it was pulled. Bottom line is any non-depolarizing neuromuscular blocking agent is a bad choice for RSi. The side effect profile of suxs is large but the profile doesn't apply to most prehospital situations. Crush injuries or ESRD (high K levels) may be the only ones I can think of just off the top of my head.

We used to carry 50% nitrous on the trucks but the maintenance and possibility of abuse got to be to much so we took it off. That was about the same time we added fentanyl to our drug boxes so the nitrous seemed to be extraneous. I pretty much stopped using nitrous in the operating room 5-6 years ago as did most of the people in my department. The downside (nausea and vomiting) seemed to outweigh the benefit. Nitrous does have a place in some systems but not in ours.

The only paralytic worse than vecuronium as an initial paralytic might be pancuronium but it would be close. Large doses of rocuronium (>1mg/kg) will come close to suxs for achieving intubating conditions but close only counts in horse shoes, hand grenades, and atom bombs. Push enough suxs (>2mg/kg) and you'll have intubating conditions in about 20 seconds. Always remember to administer an induction agent (etomidate or propofol are best) before the paralytic but in dire circumstances requiring RSI, I'd say push the induction agent with the suxs. There are contraindications for suxs but in the face of losing an airway they become relative rather than absolute. Any RSI protocol MUST have at least two if not three alternative airway methods. King, LMA, Bougie, BVM, or some type of trach are possibilities although I am very partial to the King. RSI requires strong medical control and close quality assurance measures to ensure success. If you will only use the protocol once or twice a year you should forget about it. There is a significant amount of literature that has been published on the subject and I'd strongly recommend that any protocol utilize an evidence based medicine approach. RSI should never be instituted in a casual manner. You can kill people if you don't do it correctly.

I've given platelets many times and I've never seen a reaction. We don't have a protocol for EMS but there are very few facilities outside the hospital around here that would give blood products. The cancer centers are attached to a hospital so any reactions would just go to the DEM. It seems that the staff had covered all the bases regarding treatment. The benadryl allergy limits treatment. I'm not sure I would have given epi because her vitals weren't all that bad and her heart rate was already fast. What was her saturation on oxygen? These types of reactions are not that common.

Well amicar just became the latest drug that we can't get any more so we are using tranexamic acid for our on-pump CABG patients. I've been gathering information and the Crash 2 and MATTERs trials are very interesting. I may try to add this to a couple services in my area as my doctoral dissertation.

One of our orthopedic surgeons just came back from a big meeting in Chicago and talked about using tranexamic acid for total joint replacements. Apparently the drug is injected into the drain at the end of surgery and the amount of drainage is drastically reduced. He is looking into using it for total knee replacements. We give amicar to all of our CABG patients that go on pump but nobody around here is using either for prehospital.

Blind nasal intubations is truly a lost art. I've done them on unconscious breathing patients that were not chemically paralyzed using an endotrol tube and a whistler in the OR and I always get strange looks from everybody because it is a rare technique.

Pennsylvania has state wide protocols but individual medical directors have some latitude in how far medics can go with their treatments. My service seldom has longer than a ten minute transport timeI to either a level one trauma center or a hospital with a cath lab. It seems this all goes back to the old "load and go" versus "stay and play" argument. Even with our short transport times our crews usually minimize on scene treatments. Our QA standards require a scene time of 20 minutes for medical and 10 minutes for trauma patients. It is rare to find these levels exceeded and it is usually related to difficult extrications. The bottom line is to do what is best for the patient in each situation. I've seen plenty of people that were supposed to be competent at airway management butcher an airway. Life isn't easy and no matter how good you think you are at managing an airway the next one might be a very humbling experience.

Tearing the cuff with the magills is why we use the glidescope and balloon inflation technique that I mentioned. ERDoc is right that nasal intubations are a lost art. Only paramedics do it because so many places in the U.S. do not allow RSI and they have no other option.