Endotracheal Tube or Combitube??

[Nate]

Wow! I sure didn't see that one coming.

That was an awful strange way to end a rant where you just gave a perfect example of why having a basic partner sucks! :?

:shock:

[Asysin2leads]

I am sorry, but for the life of me, I just cant think of ONE good reason a basic should be allowed to combitube someone. An effective seal via BVM with good Cricoid pressure with an OPA is optimum right before an ET tube goes into someones trachea. Look at all of the trauma that trachea has gone through already between you and your basic putting tubes in, and taking them out.

Combitubes are meant to be a BACK-UP airway, when you cant get the ET.

You have a 23 year old 300 lb linebacker who got drunk and fell down a flight of stairs, unresponsive, positive presence of CSF coming out of the ears, with occasional seizure activity. He now resides face down at the bottom of 3 flights of concrete stairs. You have him boarded and collared, and the nice firemen have provided a stokes basket to carry him out in. I would love to see you hold an effective jaw thrust seal with someone else holding adequate cricoid pressure as everyone huffs it up the stairs, out the door, through the yard, and into the ambulance, and then continue to hold it all the way to the hospital.

Oh, and screw the combi-tube. Eat, Drink, Intubate and be merry.

[firefighter523]

My friend Asysin2,

Lets get real,

I think you know exactly what I meant. Combitubes ARE in FACT back up airways! If you couldn't bag someone or ET tube someone, you would Combi tube someone, hence "face down in the bottom of a stairwell". That is another use for a back up airway, I did say BACK UP airway, didn't I?? Please don't insult my intelligence!

[AZCEP]

Combi-Tubes, LMA's, King LT-D, Cobra PLA's are all fine and good as initial alternatives to bag-mask ventilation, but as soon as an inexperienced operator destroys the soft tissue of the oro-laryngopharynx with a laryngoscope blade, the possibility of any of them working drops dramatically.

If you are thinking you need to use one of these alternates, you really have to consider using it before you attempt to visualize the vocal cords. Waiting until you realize you can't only sets up failure. Once the airway is full of the numerous fluids and materials that are possible, none of these devices are going to work too well.

The guy at the bottom of the stairs, might get a combi-tube until we can get him out, but I'm not going to leave it in place for too long. My EMT might be able to get a combi-tube placed while I am doing other things, but again, it is not going to stay in place very long.

[firefighter523]

" but I'm not going to leave it in place for too long. "

I can tell ya one thing, and I am sure I speak for many medics, If I have established a patent airway with a combitube, and some hotshot comes along and takes it out, and tries to intubate someone in front of me, their will be a problem. It probably got there for a good reason, why would you take a patent airway, and possibly throw it away. Regardless if a basic or advanced provider placed it (whatever your region allows), if they have equal rise and fall, with good breath sounds, and SPO2 numbers are good, as well as CO2 levels, there is no good reason to remove it.

[AZCEP]

Except for the fact that these devices do not secure the airway, or protect from aspiration as well as a properly placed endotracheal tube. You can cite SpO2 and CO2 numbers all day, but the fact remains that the only secured airway is a cuffed endotracheal tube.

These devices work best when no other trauma has happened to the airway. If there has not been a previous attempt to place a tube in the trachea, then I am going to attempt it before I accept that a patient has a secure airway without one.

[Thunderchild145]

Eh. Well I do know of cases where combitubes are used by basics in some states. They're not used by basics here. IMO, let's let basics do BLS skills, medics do ALS skills, let bygones be bygones and stop bickering. ;-)

After all, a good basic is more of a paramedic assistant than anything. Also, don't generalize. "Basics" aren't stupid, nor lacking in education. Well, lacking in education to perform ALS skills, but not to perform BLS or even assist with ALS. (IE, I know my partner has a ruetine. Shock, Tube, IV. As such, while he's shocking I get the laryngescope and tubes out. I also know he likes to use a Mac #3 and an 8 ETT. When he moves to tube, I set up his IV equipment. That's what I see my job as. Yes, I want to perform ALS skills, and (here it comes) THAT'S WHY I'M ENROLLED IN PARAMEDIC SCHOOL!)

As an EMT-B, there are only so many things you can do, and so many more that you can't do. It's just the SoP. Get used to it.

Lastly, in response to the original post, ETT versus combitube, the ruling is ETT by miles.

[medic001918]

"Basics" aren't stupid, nor lacking in education. Well, lacking in education to perform ALS skills, but not to perform BLS or even assist with ALS. (IE, I know my partner has a ruetine. Shock, Tube, IV. As such, while he's shocking I get the laryngescope and tubes out. I also know he likes to use a Mac #3 and an 8 ETT. When he moves to tube, I set up his IV equipment. That's what I see my job as. Yes, I want to perform ALS skills, and (here it comes) THAT'S WHY I'M ENROLLED IN PARAMEDIC SCHOOL!)

Basics are not stupid people, but they are limited by a very narrow window of education that largely leaves them underprepared for work in the field. Consider the curriculum and material covered in the current EMT-B program. Most new basics have a hard time determining when they really need ALS. Instead of viewing an EMT-B as a paramedic assistant, maybe they would be best served to focus at becoming profecient in their own skill set and knowledge base. The biggest difference an EMT and a paramedic is the knowledge behind the assessment. If any new EMT really wants to become proficient, take a couple semester of A&P and learn to assess your patients adequately. Then you'll truely be doing them a greater service.

Shane

NREMT-P

[Punisher]

No offense, but your average paramedic isn't that well versed in anatomy, physiology, pathophysiology, or any of the underpinnings of medical practice either. They know enough to function but are by no means educated in the true sense of the word. I mean look at the members of this board and some of the arguments against evidence based practice and other similar movements aimed at improving care. Most Basic EMT's (over 95% I would say) by comparison have just enough knowledge to be dangerous in the vast majority of cases.

[Ace844]

No offense, but your average paramedic isn't that well versed in anatomy, physiology, pathophysiology, or any of the underpinnings of medical practice either. They know enough to function but are by no means educated in the true sense of the word. I mean look at the members of this board and some of the arguments against evidence based practice and other similar movements aimed at improving care. Basic EMT's by comparison have just enough knowledge to be dangerous in the vast majority of cases.

It's definately a scary era to be a patient.....