The final word on combitubes

[Asysin2leads]

First, I apologize for bringing this up, but I was reviewing some airway stuff the other day and I thought back to the long, exhaustive, and tedious battles that have occured on this board over BLS and combitubes. Since I am of the school of know what you're doing before doing it, I have never been in favor of basics and invasive procedures. That's not what I want to get into. What I was thinking about is, how effective will the combitube really be in absence of ALS procedures.

In short, conscious people do not like having things put down their throats. You have to be either unconscious, in arrest, or sedated to let someone put an OPA, let alone an ETT or a combitube in your throat.

Now the biggest instance where BLS claims combitubes should be put into practice is in traumas, where a BLS unit rapidly transporting a patient with a patient with a combitube is preferable to waiting for ALS intercept.

However, again, unless a person has suffered a head injury and is unconscious, they will still need to be sedated to effectively manage their airway, even with a combitube.

So, in my opinion, given my knowledge of airway management and EMS capabilities and experience in the field, the number of patients who can can have their airways effectively managed with a combitube and BLS procedures, in my mind, is very limited. To sum up, really the only people who can be intubated or combitubed without sedation are people who are dead, or people who are unconscious. If you are dead, the combitube isn't going to help, and if you are unconscious, you typically need ALS intervention beyond airway managment. Given these facts alone, I think combitubes and BLS don't mix, combitubes should be utilized as a back up to proper intubation.

That's my opinion. Let's hear yours.

[spenac]

In those limited cases where they're unable to bag effectivly, I have no problem with the basic using a combi. It's life over limb. If person will die w/o it at least they have a shot with it. Yes some BS people will be to dumb to confirm they are bagging proper tube, but sadly we have all to many AS people that are to dumb to check proper placement of tube and reconfirm after moves, etc. I'ld like to say combi is idiot proof but it gets used wrong by BS and AS providers alike, just like so many other so called idiot proof tools.

So my vote is to allow basics to use combi. But keep in mind my area may have a BS crew only on duty and no AS until the hospital 90 miles down the road.

[Just Plain Ruff]

Spenac, haven't you heard this saying

If you build something that is idiot proof, they will just build a better idiot.

[spenac]

Spenac, haven't you heard this saying

If you build something that is idiot proof, they will just build a better idiot.

hahahahahahahahahahahahahaha :laughing3: :notworthy: Definitly seems some schools are working hard at proving you right.

[Just Plain Ruff]

I think I've worked with at least one from each school.

[VentMedic]

I don't particularly like the CombiTube. However, if properly trained and competency is maintained, it's another skill.

However, I do have a problem with EMT-Ps using it due to laziness or not keeping their intubation skills at a competent level.

This device makes me a little extra money when the attorneys need an "expert". It also drags me and the ER doctor into the deposition room to give a statement when "CombiTube goes very wrong" in the field and is brought into the hospital I'm working at. Misplaced ETTs are one thing. This thing can tear up the esophagus and totally relocate the vocal cords to another zip code if used by idiots.

[ccmedoc]

Totally agree with Ventmedic. If the ET is not available or otherwise able to be used, there are other options that are not as traumatic to the soft tissue. It is not idiot-proof, but is most often seen this way and used this way..

Ventmedic, do you have a preference of alternatives.? (King,LMA, etc...). Not for medics, but for BLS.. :wink:

[spenac]

This device makes me a little extra money when the attorneys need an "expert".

Wow I've met several "expert" witnesses that say that for basics it is the minimum standard of care for patient unable to maintain airway and for Paramedics it is a viable option for a difficult intubation. Guess it depends on who's paying as to what is proper minimum standard.

Definition of expert ( pronounced ex - spurt ) is old drip under pressure. :twisted:

[VentMedic]

Ventmedic, do you have a preference of alternatives.? (King,LMA, etc...). Not for medics, but for BLS.. :wink:

I like the LMA personally but I also use it frequently in the hospital for conscious sedation. I think it is a viable option for ALS though it may be more difficult to maintain placement while moving. Due to cost, not all ALS providers are aware of the many versions of the LMA and the potential benefits.

The King is like a remake of the old EOA. I do like some of the options on it and the fact that you are aiming for the esophagus. Probably for BLS, this would be my choice.

[VentMedic]

Wow I've met several "expert" witnesses that say that for basics it is the minimum standard of care for patient unable to maintain airway and for Paramedics it is a viable option for a difficult intubation. Guess it depends on who's paying as to what is proper minimum standard.

It has be an event that warrants litigation. My area has several government ALS services so they fall into whole other set of processes for fact finding before the courts are petitioned for the actual lawsuit to be allowed into the system. This is not to say the patient is SOL nor the paramedic is off the hook.

It doesn't have as much to do with "proper minimum standard" as following the minimum standard. If the device is in the protocols, then that's the device to use if there are no other options. For my area, it is the backup device for Paramedics. If the ETT was not ATTEMPTED, we want to know why. How was the paramedic trained on the device? If there is not record of competency maintained by the employer on this employee's use of this device, why? What role did the Medical Director have in training the paramedic on the use and protocols? How many times had the paramedic used this device in the field?

If competency and records are maintained and the paramedic has a valid reason for not bringing out the laryngoscope and ETT, then the paramedic may have no problem in court. Complications happen. However, since the paramedic has options, he/she may be held to a higher standard.

It is unfortunate in some services, when a paramedic screws up with the CombiTube, the EMT-B loses access to the skill and not the EMT-P.