JEMS article regarding Medics and intubation

[spenac]

It isn't ETI-or-nothing. Come on.

BVM me while that bag is over my face. Give me a combi-tube, or an LMA, or a king. High flow O2 as well.

That kind of black and white thinking gets us in trouble. Where is the research (the evidence) that an intubated patient is better off than a bagged or rescue-airway'ed one? I just posted seven studies that suggest that patient might actually be WORSE with a tube in his throat.

That is where proper education comes into play. Not all patients need RSI, crics, etc. But when you can not provide a definitive, protected airway to a person that is unable to protect their airway you just killed them. If a BVM will do the job, fine but if I wait till the airway collapses completely, or they have aspirated, I just killed them. Proper education helps one to know when to go big or when to KISS(keep it simple stupid).

If I do not provide a definitive airway to a person that needs it, by the end of my long transport I can just divert to the funeral home.

[Dustdevil]

It isn't ETI-or-nothing. Come on.

BVM me. Give me a combi-tube, or an LMA, or a king. High flow O2 as well.

Ummm... none of those things are viable options when you still have a bag over your face.

Spenac didn't say you simply weren't breathing. He said you had a COMPROMISED AIRWAY. Different situation than what you are suggesting.

I appreciate what you are doing here, Fiz. Seriously. Always question the status quo. Believe half of what you see, and none of what you hear. Demand evidence. But you cannot let that train of thought blind you to the obvious. And you can't let your patients become nothing but statistics.

[fiznat]

But you cannot let that train of thought blind you to the obvious. And you can't let your patients become nothing but statistics.

I don't get this. What is obvious? Who needs to be intubated and who doesn't? I don't think its that obvious.

...And what makes our patients anything other than statistics? Everything else we do (or don't do) is driven by research! ACLS? Determined through research. Oxygen? Supported in the literature. C-spine? Derived from journals. Medicine is the practice of procedures laid out through the tough work of academic research, and (ideally) nothing more. Some ideas that are passed down from generation to generation without evidence of value are slowly getting weeded out as the profession becomes more precise. Nobody likes to change, but sometimes we really do find out that what "we've always done before" may not actually be the best thing for our patients. How do we find that out? Statistics.

[defib_wizard]

[fiznat wrote:

It isn't ETI-or-nothing. Come on.

BVM me. Give me a combi-tube, or an LMA, or a king. High flow O2 as well.

/quote]

OK break it down to the first rule of medicine "do no Harm"

Everything we do has a risk versus benefit.

BVM- benefit increased tidal volume and rate. Risk gastric insufflation= decreased tidal volume, aspiration = infection

Combi-tube - benefit some airway management. Risk cannot be used in burn pt. laryngospasm = occluded airway with adjunct in the way

cannot be used for long term. Aspiration is still an issue if distal cuff seal is compromised

LMA - benefit some airway management. Risk cannot be used in burn pt. laryngospasm = occluded airway with adjunct in the way

cannot be used for long term. Aspiration is still an issue as this just covers the opening to the larynx.

King airway see combi-tube except it may be fire medic proof. ( I doubt it though )

ETI Benefits cuffed seal prevents most aspiration ( post intubation only though ) . Tracheal suction can be performed. PEEP can be used. Laryngospasm is not a problem. Risks- ego of people attempting the procedure may prevent them from admitting they "missed " the trachea.

In summary Endotracheal intubation is the gold standard of airway control. All of the others are rescue devices that give you time until somebody can intubate the pt. So why not start with the best and use the others as back-ups.

It is not a terrible thing to admit you missed or cannot intubate a pt. I have used a combi-tube on more than one occasion. It is NEGLIGENCE to not pull a tube because your ego says you are in the trachea and you are not.

[frogman]

Hi Guys I'm new to this site but I would have to agree with Defib Wizard. Here in Ireland we are only roling out advanced airway management with ET intubation (3 yrs now ) and we find the same problems with some Doc's they feel we should be just left as van drivers.

I was at a lecture recently when the doctor who is the course director for our current Advanced Paramedic programme stated that the english paramedics are facing the possibility of loosing the ability to intubate under new guidelines.

The same Doc was very anoyed regarding this, he is very pro EMS prehospital care, and wants to push further into skills for Advanced Paramedics in Ireland.

[spenac]

OK break it down to the first rule of medicine "do no Harm"

Everything we do has a risk versus benefit.

BVM- benefit increased tidal volume and rate. Risk gastric insufflation= decreased tidal volume, aspiration = infection

Combi-tube - benefit some airway management. Risk cannot be used in burn pt. laryngospasm = occluded airway with adjunct in the way

cannot be used for long term. Aspiration is still an issue if distal cuff seal is compromised

LMA - benefit some airway management. Risk cannot be used in burn pt. laryngospasm = occluded airway with adjunct in the way

cannot be used for long term. Aspiration is still an issue as this just covers the opening to the larynx.

King airway see combi-tube except it may be fire medic proof. ( I doubt it though )

ETI Benefits cuffed seal prevents most aspiration ( post intubation only though ) . Tracheal suction can be performed. PEEP can be used. Laryngospasm is not a problem. Risks- ego of people attempting the procedure may prevent them from admitting they "missed " the trachea.

In summary Endotracheal intubation is the gold standard of airway control. All of the others are rescue devices that give you time until somebody can intubate the pt. So why not start with the best and use the others as back-ups.

It is not a terrible thing to admit you missed or cannot intubate a pt. I have used a combi-tube on more than one occasion. It is NEGLIGENCE to not pull a tube because your ego says you are in the trachea and you are not.

Excellent post. In fact IMHO your best yet.

[tniuqs]

I have said this over and over:

1- Rescue airways are reactive medicine, not Proactive medicine do you see rescue adjuncts in ER?

2- Using technology/invention over training and education is a backward step.

3- Lets compare ETI with the Doctors first pass success rates, for good measure shall we ?

(I have worked in hospital too, not as good as they make out to be, especially rural areas)

Funny thing the OPALS studies are oft time quoted: ALS vs BLS (and poorly presented) but without the availability of paralytics for the Ontario ACP the success rate was 73 % on first pass. hmmm interesting isnt it ? So give us the same tools in the tool box is all I am saying, retrain those that are in need dont lump the rest of us with the failures. The OPAL studys also strongly suggest that the ACP makes a huge difference in outcome studies in the comprimized breathing group (proactive paramedicine)

Just look to the education proccess to explain the rather obvious differences.

ps I have all the tools in my toolbox btw, take them away from me so that I can not perform to my full scope and for my good of my patient and I will find another job.

cheers

[chbare]

Nearly every ER I have experienced had a supraglottic device in their airway cart or difficult airway set up. I even worked in a five bed ER out in the middle of nowhere that had LMA's in their failed airway cart.

Using technology to replace adequate education is indeed a step back.

We cannot point to the bad behavior of other professions to justify our own problems.

Like Fiznat, I am not against ETI; however, the burden is on us to prove that RSI and ETI can be used safely and effectively by pre-hospital providers. He brings up some great points.

Take care,

chbare.

[Ridryder 911]

Nearly every ER I have experienced had a supraglottic device in their airway cart or difficult airway set up. I even worked in a five bed ER out in the middle of nowhere that had LMA's in their failed airway cart.

.

You were lucky then. I still do not know of any ER's in my area that has LMA's (except in OR) or King/ Combitubes, etc. Nor does most of the ER physicians (yes they are board cert ER docs) know anything about them. I wished I could say it is a regional thing, but they come from all over from different states.

I have seen more my fair share of botched up airways. One attempted to perform a crich after a failed intubation using a Melker crich kit. He inserted it with the curvature upwards and refused to listen to Paramedics on the proper placement. Another attempted intubated with an NG tube then attempted slide the ETT over it alike a bougie device.. except the NG tube was too big so he then placed KY and attempted with no avail... Again, different ER's and no these were not small ones either. My opinion is let's start at the top and clean it up..

Personally, would like to see the performance level of Dr. Wang on airways from hell.

R/ r911

[spenac]

You were lucky then. I still do not know of any ER's in my area that has LMA's (except in OR) or King/ Combitubes, etc. Nor does most of the ER physicians (yes they are board cert ER docs) know anything about them. I wished I could say it is a regional thing, but they come from all over from different states.

I have seen more my fair share of botched up airways. One attempted to perform a crich after a failed intubation using a Melker crich kit. He inserted it with the curvature upwards and refused to listen to Paramedics on the proper placement. Another attempted intubated with an NG tube then attempted slide the ETT over it alike a bougie device.. except the NG tube was too big so he then placed KY and attempted with no avail... Again, different ER's and no these were not small ones either. My opinion is let's start at the top and clean it up..

Personally, would like to see the performance level of Dr. Wang on airways from hell.

R/ r911

I have actually had to go out to the ambulance and get a combitube and place it for the ER doc when he could place a tube. In my area it seems only options in ER are ETI or cric.