Intubation and proper BSI

[NoahG]

Hey all

I'm currently about to being my "live intubations" and clinical internship as a medic student and have received several mixed stories regarding proper BSI and Intubation.

My question is for you ALS providers when you intubate are you gloving only or using the glasses / masking?

Please be honest and if you do intubate with gloves only what is your reasoning for it? I'm hearing that several 10-20 yrd medics never use anything BSI wise other than gloves in the field. It sounds like 3 out of 5 I've spoken to say either no time to properly BSI or really no need. Yes I know someone coding does not have a gag reflex but an stomach full of air just could go wrong with as close as you have to get to preform the procedure (or at least as a student). I'm not a big fan of vomit let alone in my face so I'm curious as to what answers and why I'll receive.

Is it that taking an extra 30 seconds to grab the glasses or disposal mask would make you look like an idiot while everyone is waiting / expecting you to be on top of the tubing regardless , I mean personnel safety does come first am I right?

Anyways thank you in advance.

[HERBIE1]

Honest reply? I already wear glasses- I do not put on safety goggles over them. As for a mask- depends on the situation.

As for other providers, heck-I'd say maybe 50% use a mask/ face shield, or goggles.

Wrong- I suppose, but I also didn't even wear gloves when I started this business either.

[DwayneEMTP]

Hey Noah, welcome to the City!

Reaching for glasses won't make you look like an idiot, though you really should have them at hand on every call, but exposing yourself to unneeded risk will absolutely make you look like an idiot to every good provider I've ever known. The yahoos may moan, and the good providers may be disappointed if you take forever to find a vital piece of equipment, (yep, still talking goggles), but you need to become immune to the opinion of others when it comes to personal responsibility, morals or ethics. Set high standards and follow them and let the others do as they will.

I make fun of hose monkeys on a regular basis, but I was actually convinced of the need for goggles during intubation by a fire medic. I was a hotshot, had maybe 20 live intubations without a miss...a true hero in my own mind. On an arrest I intubated, got my tube no problem, was feeling good. After we transfered care of the pt the fire medic asked to speak to me privately. He said, "I'd like to ask you a favor. I notice you don't wear goggles when you intubate, next time would you use them, and then after, hold them up to the light? I'd like to know what you think." I told him I would, and I did. Next intubation was the same as the others, no trouble, no mess, no exchanged fluids. I got done and remembered to look at my goggles and I could have fainted. It looked as if they had been left in a barn for a few months, know what I mean? Covered with fly specs? They were filthy! Not heavy enough droplets that I could feel them making contact, nor enough to be able to feel wetness, but they were obviously terribly contaminated. And I had been taking that shit home to my family, kissing my wife with my dirty face. I was disgusted.

I didn't get the fire medics name, because I was confident when he said it that he was full of shit, so I didn't know how to find him. I spent the next week or so talking to every fireman and every medic describing him until I was able to identify him. I bought a bottle of wine and a card of thanks and took it to him. He set a standard for me not only for wearing goggles when necessary, but in watching out for our brother and sister coworkers...helping them when we see them putting themselves in danger.

So the answer for me is simple. If you purposely do things that could bring you or others harm then I have no interest in you or anything you choose to do. But, judging from your post, you had no intention of doing such foolish shit anyway. It seemed that you were actually looking for the silly reasons that others might actually justify such things....good question!!

Dwayne

[Just Plain Ruff]

Let's remember, safety first.

Protect yourself.

The eyes are great vecters for the passage of communicable diseases if you are exposed. Just go and take a look at your sclera in the mirror. See all those little blood vessels in there. It's easy for an organism to get through the thin lining of those vessels.

Why do you think we ask a person with a scratch on their eye or a foreign body in the eye if they are current on their tetanus status? Certainly not for our health.

I always wear a pair of goggles and if there is one available I put a full clear face shield on.

Consider what Dwayne said as the Truth. Do an experiment

On your next intubation - put on a pair of goggles.

On your next intubation after that, put on a full face shield.

Compare the two.

you will see a big difference.

And for the comment of a person coding not having a gag reflex - I disagree.

A full arrest might not have one but someone who it coding will still have a gag reflex and often will gag and fine small droplets will fly out of their mouths.

It's not the full arrests you need the face shield on(of course every patient you intubate you should wear protection) but it's the ones not to that point that you need the facial protection on. The drug overdoses, the trauma codes with all the blood and brain matter that comes with the territory and a myriad of other scenarios that we can all think of.

When in doubt - cover yourself.

[BAYAMedic]

I tend to read alot in my bus between calls, and as much as I hate to admit it my arms have gotten too short to read with out my cheaters. This last summer I was out at the local welding supply shop and discovered a pair of bifocal safety glasses that looked incredibly stylish (They were exactly how I brought sexy back). I broke my dollar store cheaters I had in my lunch box on accident so I used them as my bus readers. I tend to wear them on the top of my head most of the time and put them on, on all my calls. Apparantly those little details like veinus visualization became strangely easier. So Yeah, I use my cheaters as a multi use purpose.

Fireman1037

[scubanurse]

You will find often in the OR, doctors and NA's not wearing a mask or eye protection, but keep in mind these patients are most likely NPA for 8+ hours, they don't have much to vomit up. I would err on the side of safety and BSI up

[DwayneEMTP]

Honest reply? I already wear glasses- I do not put on safety goggles over them. As for a mask- depends on the situation.

As for other providers, heck-I'd say maybe 50% use a mask/ face shield, or goggles.

Wrong- I suppose, but I also didn't even wear gloves when I started this business either.

You know, I was typing the same time as Herbie so didn't see his post before posting mine. The reason I mention this is that as I review the thread it appears to me as if I created my post as a snotty contrast to his. And that is just not the case.

Herbie has been doing this for a few weeks, me, only a few days in comparison. We came up in completely different EMS cultures and that makes a difference when debating these types of topics. The vast majority of people, at least that is my belief based on casual observation, that come to EMS in the more recent years consider BSI to be a higher priority at times than nearly anything. The earlier cultures were much more macho and pt over provider focused I believe.

So all I'm really saying is that if I disagreed with Herbie, which is uncommon, I certainly wouldn't have stated my disagreement in such a way...I hope. (Sometimes I screw the pooch on tact.) We're fortunate to have members such as him that give the honest answers that allows us to compare and contrast as well as learn about the history and common changes in EMS instead of the politically correct answer that was likely to have a bunch of people hitting his + button.

Well then, for what it's worth, there you have it.

[DwayneEMTP]

You will find often in the OR, doctors and NA's not wearing a mask or eye protection, but keep in mind these patients are most likely NPA for 8+ hours, they don't have much to vomit up. I would err on the side of safety and BSI up

We get lost a little bit I think when we focus our concern on stomach contents. In fact I don't think that I've ever really considered protecting myself from the stomach during intubation. There are plenty of evil looking little critters living in the lungs too! (Think TB, HEP/HIV infected blood from diseased lungs, etc.) And they can, during intubation, vomit nearly as well as the stomach!

I had a younger man that O.D'd on a whole pharmacy of things..When I listened to his lungs they sounded something like what you'd expect from a really old cement mixer. They were really, really nasty with what I assumed was aspirated...something. I decided to nasally intubate him instead of trying to wake him up and then let the doc figure it out in the ER. I got my tube with little trouble but when I asked my partner to bag so that I could verify lung sounds I couldn't hear anything on the first breath. The second breath was the same and I was becoming concerned that I had missed my tube. On the third attempt at ventilation I'm not sure if the tube move down a little bit, I don't know, but a blast of nasty shit came up the tube, into the BVM and sprayed out of the BVM vent all over the pts head. Yeah...it was disgusting. I could immediately hear lung sounds following the eruption and called it good as his SATs began to climb and we drove him the few minutes to the hospital.

It turned out that he HAD ODd, but that he was unresponsive due to a CVA, at 28 years old. Not only a stroke but he was HEP +, HIV +, and one or two other things...I can't remember now. But I really, really don't like to think of the post exposure treatments that would have been necessary had that sprayed in my mouth and eyes.

Since, I've kind of come to regard the ETT as a loaded gun. Even with the safety on (face shield/goggles) I don't point it at me or my partners if at all possible.

Great conversation!

Dwayne

Edited to fix those typos that seem to be invisible until after I hit the post button. No contextual changes made.

Edited October 26, 2010 by DwayneEMTP

[HERBIE1]

You know, I was typing the same time as Herbie so didn't see his post before posting mine. The reason I mention this is that as I review the thread it appears to me as if I created my post as a snotty contrast to his. And that is just not the case.

Herbie has been doing this for a few weeks, me, only a few days in comparison. We came up in completely different EMS cultures and that makes a difference when debating these types of topics. The vast majority of people, at least that is my belief based on casual observation, that come to EMS in the more recent years consider BSI to be a higher priority at times than nearly anything. The earlier cultures were much more macho and pt over provider focused I believe.

So all I'm really saying is that if I disagreed with Herbie, which is uncommon, I certainly wouldn't have stated my disagreement in such a way...I hope. (Sometimes I screw the pooch on tact.) We're fortunate to have members such as him that give the honest answers that allows us to compare and contrast as well as learn about the history and common changes in EMS instead of the politically correct answer that was likely to have a bunch of people hitting his + button.

Well then, for what it's worth, there you have it.

No offense taken, bud. Problem is, there really is no justification to NOT take all those precautions.

I was certainly not bragging about the good ole days, just pointing out a fact. When I started, I was in college, doing volunteer work as a newly minted EMTA (now EMTB) We would do stand bys for road races and other special events as well as disaster assessment through the Red Cross. We had a team of 3 guys, we bought all our own supplies- via the school's health service, LOL) and had a great time. Many times we were up to our elbows in blood, we loved every minute of it, and it was even a badge of honor. Of course, this was also pre-HIV days, so we honestly did not worry too much about BSI. Even as a new medic, I often took off a glove to get a better feel for a vein on a tough stick. Again- not saying it's right, just a fact.

Times do change, us old timers SHOULD change, but too often old habits die hard.

[mobey]

My honest answer:

I always wear safety glasses, so that is a given.

IF the pt has a temp, I will wear a mask for long transports, intubating, and nebulizing meds. I always wear gloves of course.

I have never worn a full faceshield, although I have thought of it a few times. The reality is, we keep it in a hard to reach spot, and I usually don't think about it till 2 sec before the tube goes in, by that time it is lazyness/fear, once the succ is pushed I just wanna secure the friggin airway!

I have noticed the spots on the glasses Dwayne is attesting too, especially on edema/infection filled lungs when the pt is still breathing with direct laryngoscopy.

Do what you think is best for yourself, your patient, and your profession, and you cannot go wrong.