Forcing the Tube

[usalsfyre]

Crap, why didn't I think of nasal intubation? I guess I've been spoiled by spending most of my career in systems that had RSI.

[Krysteen]

No offense taken here on the halfassery comment:) Beat myself up on this call enough. Usa, you said so yourself you have that luxury of RSI. I on the other hand do not. There was talk on RSI and utilizing it. Here were my thoughts and you can do a double take, I know my limitations. For as much as I would love it in situations like these, unless I can guarantee a spot quarterly in the OR keeping up those skills and that I have a Paramedic partner to assist I will pass. Now with that being said I have heard the largest ground EMS agency may be losing that privilege due to misuse. Which isn't good because I could use them as intercept. You never know what you are missing til its not there anymore.

Dwayne you are my hero:) I am quite close to your location also. I enjoy reading your posts, learn, and agree with you on many scenerios. The patient exhibited cheyne-stokes. Classic Cushings Triad, not sure if I will ever come across it again. Thank you for saying this call sucked.

Here is what happened. Risk of aspiration was already there. Vomit was being expelled through clenched teeth of what may have been beer and pizza for all I knew. I know that versed most likely would not have the effect I wanted on the trismus, but it was worth a shot. Pt was already vomiting when I grabbed it. I was debating nasal intubation, and chose not because of head injury. So I pushed a little versed with no effect obviously. All I could do was roll the board and suction. Pts vitals did not change significantly. I informed them no definitive airway, and that I do not have RSI capability. First thing asked was, "did you administer anything to facilitate intubation". At least I was able to say yes to that.

Dwayne, per my medical director review. He said nasal would have been the choice. He would have backed me on that one. Now it depends on which doc you ask. All have different opinions. Now, if I am ever presented with this again I know which route I am heading. This also lead to a Trauma Review with the receiving facility. I was terrified, but in the end the ER also had their struggles. The physician on review did not agree with nasal and not once was cric mentioned. Versed was just a waste as I held back on giving enough to possibly see any effect. The end thought was to request for intercept of the said agency above.

I was ready to take an ass chewing, but to my surprise I was commended on what we Paramedics face out in rural country without a controled environment or a trauma team at our disposal. This patients prognosis was poor even before I arrived. On a good note, this patient may have saved lives as their organs were donated.

[DwayneEMTP]

Krysteen, it's good to have you here!

And good on your for having the balls/ovaries to put out your call review.

And I've had RSI protocols once, overseas, but never domestically, so nasally intubating came more naturally for me than RSI, as well I noted that you didn't have it there either. And when I did have it, like with the pt below, I'd no experience with it so didn't use it like I maybe should have.

The first time I tried to nasally intubate I'd been chomping at the bit to do it. All of the best medics I'd known seemed to do it 3-4 times a day before they'd finished their coffee in the morning, to hear them talk. I friggin' had to check this off of my list!

The indications seemed to be there...I was so stoked..but. The reason I asked about resp rate in your post is that I didn't consider it my first time. The patient was only breathing about 6 BPM spontaneously.

I was ready man, prepped his upper airway, lubed my tube, placed my BAM whistle, the guy had nares I could have put my leg in, everyone was watching...this scenarui couldn't have been more perfectly staged to exhibit my previously unrecognized heroism!

I passed the tube through the nares, got a decent/half assed whistle, pushed in forward...and...yeah, you know...nothing. So I waited, and waited, and finally, after about 3 days, it whistled again! I tried to follow it, but wasn't sure really how to read it, and.....Nothing. I finally pushed it down far enough to bag over it, waited, tried again.

After about two or three cycles of this it was obvious that I had totally screwed the pooch when I'd made this decision. I decided to just align things as perfectly as I could and see if the EMS Gods would smile upon me and let me pass it blind. I lined him up dead center, pushed forward gently, felt a tiny bit of resistance, advanced a bit, verified, missed. Did it again and on the second attempt got good lung sounds with good cap waves.

What a dipshit. And unfortunatly I'm not much brighter now.

But anyway...great scenario. Thanks for participating. I always thing that you know that you've done well when you get most of the strong providers in a thread, and Beiber has knack for doing that.

Dwayne

Edit. Where are you near the Springs? No worries if you're not comfortable mentioning it, or you can PM if you like.

Upon review, did the physician mention why he was opposed to nasally intubating? What did he see as viable options?

[FireEMT2009]

As a student you belong in this conversation as much, or even more so, arguably, than anyone else. Good on you for having the balls to jump in.

A couple of questions Mr. student man... :-)

Mobey mentioned that his rationale for intubation was patient exhaustion. And I completely agree with that now, after his explanation, so assisted ventilations at a minimum would seem manatory, right?

I also thought that bagging was a viable option, and bagging in a neb treatment even more so. But lets assume the transport time is 5 minutes. Do still feel the same? How about 30 minutes? 60 minutes?

Does your feeling on maintaing this patients ventilation status change in each scenario? What might the issues be should you choose to bag in each instance instead of intubate?

I haven't noticed you posting for a bit...good to see you here!

A friendly note to you, and others...simply for the ease of reading, paragraphs help. I sometimes, and I know others do as well, simply pass up posts that are in a giant block. Though sometimes you end up breaking parahraphs in illogical places, reading in pieces is much easier online.

Dwayne

Edited to correct spelling errors only.

For all the times:

Attempt to sedate the patient with versed, ativan, whatever sedative you have available and with an OPA and BVM with nebulizer. If the sedatives work as I would hope them to then I would attempt to reintubate and continue my neb treatments. As long as you have an OPA and BVM you have an airway of some sort.

I hope you are not planning on using versed alone for RSI, are you stating that you will just use it for those who fight the tube, after intubation ?

RSI needs sedative/anesthetics and paralytics. I would use it as a sedative assisted intubation to help the gag reflex and to ease the patient's suffering on the tube. I would use the versed or whatever sedative you have available at your disposal to help facilitate better airway management for my patients.

[RaceMedic]

Hey Dwayne, You ever been through Garden City KS ?

[DwayneEMTP]

Hey Dwayne, You ever been through Garden City KS ?

I'm not sure. Not for any appreciable length of time.

Why do you ask?

[Asysin2leads]

Bieber, first off, your captain was completely and utterly flat assed wrong, and you can tell him I said that. Unfortunately, working under supervisors who lack the medical knowledge and training to adequately discharge their duties is just one of the many joys of working EMS.

He was wrong on many levels. First off, as people have pointed out, having a patient with an ETT tube in place without some form of sedation is inhumane, and tantamount to torture in my mind. Secondly, what the hell is he talking about "respiratory drive"? You know that thing called the BVM? That's the patient's respiratory drive. Unless we do something to permanently alter the patient's physiology, once they have a secured airway, we can depress the respiratory functions all we want. We can even paralyze it. That's what paralytics like succinylcholine do.

The dilemma that EMS runs into is that administrative hierarchy vs. medical hierarchy, especially in a paramilitary themed service. While the captain/lieutenant/commodore/admiral of your service may be the one who will be making your life miserable when you go and pretty disorder, ultimately, patient care will fall on you, and your orders rely on what the doctor and your protocols tell you. The advice I always give is that you want to serve medical hierarchy first. Not only is in the realm of good ethics to disobey an order that is contrary to the patient's best interest (even the Uniform Code of Military Justice basically says that disobeying an illegal order is as much of duty as obeying direct orders is), but from a practical, selfish standpoint, the worse thing that can happen if you disobey a supervisor is you that you get fired. It happens. You can get another job. If you disobey a medical order or act against the patient's best interests, you can lose your entire certification and your career in EMS.

The best thing to do in a situation like that is politely state to your superior that you don't feel comfortable and would like to contact telemetry with how to proceed. Do it diplomatically. But there is no captain or chief or supreme allied commander who will go against a director order from a physician. Everybody answers to somebody, and everybody fears the physician.

Edited October 22, 2011 by Asysin2leads

[DwayneEMTP]

...While the captain/lieutenant/commodore/admiral of your service...captain or chief or supreme allied commander...

LMFAO...

Great advice, but funny as hell too...

Dwayne

[RaceMedic]

I'm not sure. Not for any appreciable length of time.

Why do you ask?

Thats where i live, about 4hrs SE of your home city. you mentioned CO Springs .. never put two and two together until you asked Krysteen. I drive though on my way to Denver several times a yr.

Race

[DwayneEMTP]

Nice! Lets make some time to get together when you come through, ok? Or we can meet in the middle. Do you usually know when you're going to Denver?

Dwayne