Taking Away Paramedic and Pre-hospital Intubation

[VentMedic]

Definitely agree that BLS is often forgotten even in the hospital setting.

Sorry to disagree about the 2 nasal airways. This you can prove on yourself.

Putting 2 nasal airways into the nares was big in the 70s and early 80s. Through pulmonary testing for nasal resistance it was found that the resistance for both tubes can increase by 4 - 8x. Thus, instead of very patent nasal airways, you had two partially occluded airways. The same can be demonstrated with a lg NG tube and nasal airway with attempts to sx through the nasal airway. Small nares may have significantly increased resistance. We do occasionally use 1 nasal and an oral to pre oxygenate/ventilate in the hospital setting for intubation.

Besides the OR, your company can always see if your local Medical University will give you some cadaver time. If you can tube a stiff cadaver a few times... We will sometimes chalk the teeth of the cadaver to check technique. There are a couple programs in Florida that do this routinely just for their yearly check offs.

Of course, there are the doctors that will pull the curtain and let you get a few passes after the "code is called" if you express an interest provided it is not an ME case.

How involved are your medical directors? How much involvement do they have in seeing that your intubation skills are up to par? I do know a few EMT-Ps that do inter-facility transports that have not intubated in 5 years (since paramedic school) and yet they are considered ALS. It is just assumed that since they are a paramedic they'll be able to intubate if needed. The medical director of that company seems to be fine with that. The medical directors in the hospitals are not so happy wilth it.

[OzMedic]

Through pulmonary testing for nasal resistance it was found that the resistance for both tubes can increase by 4 - 8x.

This does interest me as it seems to be something that is practiced according to the individual as opposed to any real evidence so if you could add a link to the evidence or post it on here it would be appreciated

[VentMedic]

OzMedic,

This is one that is much better at a personal sense than "read about" to be fully appreciated.

You can try on yourself or someone near you. Medical interns or aspiring medics are my favorite choices. :wink: 2 nasal tubes - each should be able to pass at least a #14 fr suction catheter for adequate air flow with least resistance in an adult. After the nasal tubes are in, see if you can pass the 14 fr sx cathether through each without difficulty. No lubication. That's cheating. If you have very big nares...it may work. However many people have deviated septums or swollen turbinates. The turbinates may also need some neosynephrine to dilate the passages enough to pass the tubes without causing damage. You can also see if the PFT lab at your hospital will do a nasal resistance test on you with the 2 tubes. If your hospital does alot of rhinoplasty or facial trauma reconstruction, they may do still do the test. We did alot of NRTs in the 80s when rhinoplasty was vogue...to get insurance to pay for the nose job. The new software on our Medgraphics PFT machines is still setup for it, but it's not that popular now (and nobody can remember the CPT code). You can also simulate the lab with a tube attached to a manometer. Place the tube snugly into one nare, occlude the other nare. You can also see how much air can be passed though the nare with a device that measures volume like a Wright's spirometer. The advantage of the PFT software; it would do the resistance calculations for you.

We run into the 2 different tubes up the nose in the hospital frequently. I'll get a tube in that I can easily sx through and a nurse will drop an NGT. There goes my 14 fr cathether access. I may have to go all the way down to a 10 fr which defeats the task secretion removal in an adult. Of course, it doesn't have to be a nasal trumpet. We will change a nasal ETT quickly if we meet any resistance when passing a suction catheter. Nasal ETTs are usually changed out quickly anyway in alot of hospitals with various Vent Assoc. PNA protocols.

Every nare is a little different. There are some adults that I can not pass a #8 catheter through either nare no matter how much we try to dilate them. A lot of bronchoscopies have to be done orally due to limitations of the nares. Then there are some nares that could hold a bus in each side. And of course there are those that have little or no septum for various reasons.

I do have my students and med interns put nasal trumpets into each other' nares. I haven't asked them to do two at the same time. Usually one is enough to get the idea. Also, I don't want to be sued if they damaged each other.

What experiences 30 years of paramedicine and with a sputum specialty will give!

I also think the polysomnographers/sleep medicine are big into nasal resistance when they are determining if a patient can use different naal devices for sleep. Their equipment has evolved in a big way.

My OLD textbooks discussed nasal resistance in great detail. Two books come to mind, Shapiro and Burton,early editions. I may still have these around somewhere to quote for you later.

But until then, give the above things a try and get back to me.

Have a great evening!

[1EMT-P]

I have to agree with AZCEP on this one. The University of Pittsburgh did a study that involved 42 EMS agencies over an 18 month period. There were 1,941 cases, with more than 30% requiring multiple intubation attempts. They concluded that pre-hospital providers often require multiple attempts to intubate. They recommended limiting pre-hospital intubation to 3 attempts.

Wang HE. Yealy DM. "How Many Attempts Are Required to Accomplish Out-of-Hospital Endotracheal Intubation?" Academic Emergency Medicine. 2006;13:372-377

[scratrat]

No kidding. What I'm saying is, if you can put 3 airways in someone, then they need to be tubed. A secure airway is one with an endotracheal tube in it. Not BLS airways. Yes, you ventilate with them prior to intubation, I never said to skip BLS procedures. I understand your passage, but what my point was, was that if they can tolerate the airways without a gag, intubation is in order. That's all I was getting at.

[NREMT-Basic]

In the interest of my own education...

As an EMT-B, obviously ETTs are not of concern to me, except insofar as they involve whatever assistance I might give the medic. But consider if you will, the following for my edification:

If we say that a truly patent/protected airway is one that is a)held by the patient or b)held by ETT, if we have a six minutes transport time from just about anywhere in my area to the nearest facility, what is the medics best and most viable option? Multiple pharyngeal airways? ETT? I guess what I am asking is if we are 6 minutes out, is it in the pts best interest to attempt an ETT given the information by another poster that most ETTs require at least 2 attempts?

Notice I dont even bring up Combitubing. When I first got my EMT, I was very excited about the possibility that at my level of training, an instrument had been devised to allow me (not for reasons of prestige or ego)to "tube" a patient. After having done three in the field now, since my local volly department runs BLS, I see them as a "lube, cram and jam" procedure of last resort. I still hold that they are a wonderful asset, but as a last resort which is carries a very high risk of causing esophegeal and/or tracheal damage. I have also just about reached the conclusion that if I were to get a perfectly placed (ie tracheal) Combi, I would probably still trash the cords since Combitubing is blind. I would also be interested if someone had statistics on damage done by Combitubing in the field.

So, if we take our old friend Combi out of the picture, what is the best option if an ETT is not plausible because of time, difficult intubation field, etc?

Im hoping not to get trashed for asking this since it is a sincere question with no motive other than to educate myself. And I say hoping not to get trashed, because I have noticed an alarming trend of certain posters blasting anyone with whom they disagree even when the question is not intended to incite controversy. As a side bar, it would be really great if we could return to the days of yore when questions were just that...a means of education and not an invitation for a bare knuckled bar brawl.

Thanks.

[AZCEP]

NREMT-B, Your question is a valid one.

With a short transport time, and I will assume multiple providers, the ETT should be attempted by the provider most likely to place it with a bare minimum of attempts. If this is not possible, the Combitube is a viable option. The risk of damage to soft tissue is very real, but not placing the device due to this fear is near negligent. The combitube will actually work better if it is used earlier in the progression of the situation. Once multiple ETT attempts are made, the combitube is less able to seal properly.

The BLS adjuncts are more than capable of providing some degree of airway maintenance for the short term. Providing the individual doing the ventilating is careful about the volumes and pressures they generate.

Also considering the amount of time spent on the scene prior to transport will generally be 10-15 minutes regardless, securing an airway should be a priority, but can't detract from the moving of the patient to definitive care.

[emt322632]

I'm hearing alot of the same things from other people that I went through in my OR rotations. Docs or RNs fearful of giving the opportunity to a student due to fear of a lawsuit or damage to the patient.

This doesn't seem like an isolated incident, which to me says something about the state of EMS education in the US. I did have a rotation with an RN who allowed me the tube without any hesitation, but this was one day out of 5 or 6 mind you.

Also, the hospital I went to for OR time, (the ONLY hospital in my area that would allow EMS students in the OR), was and is currently moving away from ETT in favor of LMA. I have been told that the class now going through clinicals have had very few attempts at intubations, or none at all.

Something needs to change, practicing on mannequins is not enough.

[kevkei]

Intubation itself is being measured and debated. It is not a matter of someone wanting to steal away our tools. The outcome, I predict will be a "urinate or get off the pot" conclusion. Do it, do it well or you will be killing your patient and held accountable. (Medical Directors, mostly)

=D> =D> =D>

The most to the point response. I don' think the issue is whether or not intubation is successful. Our system reports an intubation success rate of 92%. At the surface, that sounds pretty good but there are more questions to ask: how many attempts did it take? What do you classify as an 'attemt'?

Compare this to cardiac arrest data. If someone has a 50% 'success' rate in ROSC, they are probably not using Utstein criteria. What has to be considered is patient outcome.

Each of us here that defend prehospital intubation are probably aware of the complications and the morbidity caused by the procedure and how to minimize the effects of the same. However, what percentage of our fellow practitioners can say the same? With the wide variety of educational and clinical requirements, the monkey skill that we can do can and does do more harm than good.

Consider a traumatic brain injury. Any result in one or more of hypoxia, hypotension or hypercapnea signifcantly increases both morbidity and mortality. What do we often do with these patients? RSI them right. So now we give a bunch of medications that typically have hemodynamic effects, take away their ability to breathe and they end up hypoventilating, become hypoxic and hypercapnic.

If you aren't aware of these issues and how to observe for them and how to mitigate, then you shouldn't be touching a laryngoscope blade.

So what if you as an individual have a 100% intubation success rate on your first attempt if it takes you over 1 minute to pass the tube.

[NREMT-Basic]

I guess that begs my next question, which is in fact about the use of the Combitube. Given that the risk of soft tissue/cord damage is high, is it considered enough of a known complication/risk that if we do it we are going to be somewhat protected against litigation. And I make no claim that it speaks to anything other than my experience, but out of the three Combis I have dropped in the field, one actually went into the trachea and to be honest, since I saw no blood gushing into the airway, I have no idea what damage may or may not have been done, only that we achieved a patent airway (or a Combi-airway if you are of the mind that a patent airway can only be achieved with an ETT, which I say to allow for both sides of the debate and not to slam someone who feels one way or another).