Forcing the Tube

[RaceMedic]

I PM'd you, no need to HiJack the thread any further.

Race

[DwayneEMTP]

I received your reports but have decided not to act on the post as it was in response to one of mine. I'll leave it for one of the other mods, or Admin.

I can tell you though that if I hadn't read it I would have been more than comfortable deleting it based solely on the quality of the posters that reported it.

And for the record? At any get together that I'm involved in gays are more than welcome, but pigs....not so much.

Unfortunately Flaming, and this would not be within my power to do autonomously, though I have fought hard against banning even the likes of Crotchity at his worst, it is getting easier and easier to make the argument in your case. Just sayin'....

Dwayne

[txladymedic]

There are so many things to look at with this. Transport time, effectiveness of the patient's ventilatory effort, can you talk the patient through taking deeper and more frequent breaths, O2 sat, effectiveness of BLS airways...and on and on and on. Having worked in a system with no RSI...I personally would have gone with either a nasal airway and a BVM, might have considered a CPAP, and lastly nasal intubation. Nasal intubations are useful but can be difficult if you've never done one. You're right though, if you're going to intubate someone you should as least have the decency to give them some sedation.

Even with RSI I might have BLS'd the airway for a while to see if it was going to improve on it's own. I personally hate intubating elderly because of the risk of not being able to get them off a vent. I tend to try every other route before that one. If I am flying however, I tend to be more aggressive and secure an airway faster because I don't want to be in a situation of trying to secure an airway in a cramped aircraft.

[WelshMedic]

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.

Krysteen,

I think it's brave of you to put this out here. It is a classic situation where you have your back to the wall. I don't do RSI either, so I would have been facing the same problems. I have been in similar situations in the past but have usually been able to manage the airway to an acceptable degree with a BVM. I have never done nasal intubation (it's not taught here) but it's an interesting option. MY only other option would be to cric the pt. TO be honest, you know it's a last ditch thing but who really does have the guts to cut open someone's neck? I never have, in any case.

WM

[Krysteen]

Krysteen,

I think it's brave of you to put this out here. It is a classic situation where you have your back to the wall. I don't do RSI either, so I would have been facing the same problems. I have been in similar situations in the past but have usually been able to manage the airway to an acceptable degree with a BVM. I have never done nasal intubation (it's not taught here) but it's an interesting option. MY only other option would be to cric the pt. TO be honest, you know it's a last ditch thing but who really does have the guts to cut open someone's neck? I never have, in any case.

WM

You mean everyone else's calls are 100% perfect everytime?

Dwayne, loved hearing about your NTI experience. We use the BAM as well and I really just pictured you waiting oh so patiently for the next whistle on a RR of 6.

[DwayneEMTP]

...Dwayne, loved hearing about your NTI experience. We use the BAM as well and I really just pictured you waiting oh so patiently for the next whistle on a RR of 6.

Heh..yeah, waiting sucked. Waiting while me and likely everyone else knew that I was an idiot for being in that situation? Really, really sucked.

But it was an excellent lesson on intervention planning before implementation.

Dwayne

[WelshMedic]

Heh..yeah, waiting sucked. Waiting while me and likely everyone else knew that I was an idiot for being in that situation? Really, really sucked.

But it was an excellent lesson on intervention planning before implementation.

Dwayne

That sucky feeling changed something in you and you changed your practice. That's why these things happen, so that we can learn from them.

[Bieber]

Wow, this thread just blew up with activity! Thanks again for all the interaction guys, I swear I'll start replying to you guys individually tonight.

Hey Race, I'm out here in Wichita, though I've had the pleasure of speaking with the EMS director of Finney County EMS last year. He was trying to get me to come work out there, but I had to decline. Shoot me a PM sometime!

[Bieber]

All right, after having read some of the replies, I'll make one of my own. I know several of you were mentioning that the tube was (going to be) needed, and I completely agree. Regardless of her response to oxygen therapy, the ideal end game would be therapeutic hypothermia following proper sedation and intubation. But like Race said, without having RSI in my toolkit (much to my chagrin, rest assured), I believe (and I think the rest of you pretty much concurred) that ventilation via BVM or conscious sedation and THEN intubation were the proper method.

As far as the patient's condition currently, I haven't had a chance to follow up on her yet. Hopefully I'll be able to find out something in the next few days.

I think that a major component to the lack of fluidity and adherence of proper procedure that I see frequently around here is this persistent, misguided mentality that we've got to "go, go, go". Maybe it's just my service or region, but everyone seems to have such a strong "we've got to get going--NOW!" ideology to EMS care, and I personally am one for taking my time. Yes, even with post-resuscitation care. I am a firm believer that we take as much time as we need to to give the proper care that we are capable of giving, and THEN getting our patients to the next appropriate level of care. (Barring things which can be done en route without being detrimental to patient care.) Many a time during my internship I sat in the ambulance bay at the hospital still punishing a medication, and I regret not having given medications which were indicated because "we're already here" or whatever other excuse, as if brevity of transport was more important than taking a couple extra seconds, minutes, whatever to do what we're capable of and what's in the patient's best interests as opposed to buying into the mentality that skimping on our care is okay if it means the patient will get to the hospital sooner.

Wow, okay, I'll get off THAT soapbox for now... Haha.

Anyway, I think that's all I got. Oh, and by the way, we're supposedly not allowed to intubate nasally here. I say supposedly because that's what I've been told. Our policies and protocols are somewhat messy and incomplete, something which I believe they're planning on rectifying in the near future which'll make what we're permitted to do and how we're supposed to do it less ambiguous.

[systemet]

Many a time during my internship I sat in the ambulance bay at the hospital still punishing a medication, and I regret not having given medications which were indicated because "we're already here" or whatever other excuse, as if brevity of transport was more important than taking a couple extra seconds, minutes, whatever to do what we're capable of and what's in the patient's best interests as opposed to buying into the mentality that skimping on our care is okay if it means the patient will get to the hospital sooner.

I think you have a great attitude, but I just want to discuss one of the points you've made here.

I think the benefit of intervention by EMS has to be balanced against the benefit of getting the patient to definitive care. I've personally seen crews trying to do RSIs on multi-traumas within 5 minutes of a trauma center, on patients' whose airways were maintainable, and could be BVM ventilated to >90%. The vast majority of these patients are probably better waiting the 5-10 minutes to have their airways managed by an ED physician. I've also seen people try to intubate in the ambulance bay at the receiving hospital when there's far more skilled people a hundred meters away. Neither of these make sense to me.

I'm not saying there aren't instances where it's better to sit down and take some time, e.g. an MI patient, while organising a cathlab activation or doing thrombolysis, patients who need airway management who are a fair distance from a trauma center or are going to be transported to a minor hospital pending medevac. I just think we have to be careful to make sure that what we're doing in the field is always in the best interest of the patient.