RSI

[AnthonyM83]

Are you saying they do not intubate pediatrics in LA county?

Yes. Sir.

[captainstandup]

Now were ready for that "state" to break off and simply float away.

[Aussieaid]

I have to say I couldn't believe it either the first time they took off my ETCO2 monitor with a perfect waveform and put on an Ezycap in the ER. Hmmm I guess you can't trust our equipment because it is prehospital equipment? :roll:

[chbare]

Yep, I have this occur on occasion at well. We are talking at a level I trauma center. Then again, we all have strange habits. I almost always carry an esophageal bulb. With every move of the patient, I throw on the bulb. I look at it this way, 2 objectives are better than one.

Take care,

chbare.

[VentMedic]

I have to say I couldn't believe it either the first time they took off my ETCO2 monitor with a perfect waveform and put on an Ezycap in the ER. Hmmm I guess you can't trust our equipment because it is prehospital equipment? :roll:

Maybe they do trust your equipment and that is why they're not using their technology.

I would love to have an ETCO2 monitor for every ventilator patient but we run over 100 ventilators per day in the hospital. 6 of those can be in the ED at any given time waiting for an ICU bed. If your equipment looks good, I go with it (at least a waveform check but not the numbers) and do a 2nd (EZCAP) quick check to compliment the rest of my assessment for documentation. We do keep a couple ETCO2 monitors near the resuscitation beds. Depending on the patient, not every patient is going to need all the bells and whistles. Ensuring that all the monitors are current on the cals as well as all of the QA/QI paperwork on each machine can get time consuming. There are probably better ETCO2 uses for a hospital with a limited monitor supply.

How did the paramedic ever do the job before RSI, pulse oximetry and ETCO2 monitoring?

[Aussieaid]

I work in a large hospital that has probably 100 ventilators or more and practically every ventilated pt (except for the long term rehab pts) has an ETCO2 monitor on. Occasionally they won't run it on a pt but that is the exception rather than the rule. A lot of the ventilators have it built in so it is just cheap of the hospital to not be paying for it to be used. It is the safest thing to have the pt on continuous ETCO2 monitoring but not all the "budget minded" individuals put the pt safety over the $$$.

I have been in a lot of hospitals that don't have it on, especially in the ER's but I think it is a substandard level of care. (Talking about the hospitals here not in pre-hospital environment).

Why would you check the waveform and not the numbers? If the number is where you want it then you have a good idea where to start with your vent settings.

Checking with the EZCAP is just redundant really but I guess people should do whatever makes them feel comfortable. The EZCAP is really a less ideal alternative if you don't have capnography available. We do use it after initial intubation if our ETCO2 monitor hasn't been plugged in or is warming up. Some people use it anyway. But once you have a good waveform on the monitor the EZCAP is redundant.

How did they ever run codes before defibrillators, or treat arrhythmias without EKG's...scientific advances mostly result in improved pt care and outcomes. People do their job to the best of their ability with the tools and science that is available to them at the time. Morbidity and mortality rates improve generally with advances so just because you used to do something "such and such a way" in the good old days doesn't mean that improvements can't be made. I say if the technology is available and it improves pt's safety and morbidity/mortality then you should be using it.

Anyway this is not a rant more of a thinking out loud. I don't have strong feelings on the subject and the ER people who have done it have really done it out of a real lack of understanding of what they were doing.

Cheers

[VentMedic]

I work in a large hospital that has probably 100 ventilators or more and practically every ventilated pt (except for the long term rehab pts) has an ETCO2 monitor on. Occasionally they won't run it on a pt but that is the exception rather than the rule. A lot of the ventilators have it built in so it is just cheap of the hospital to not be paying for it to be used. It is the safest thing to have the pt on continuous ETCO2 monitoring but not all the "budget minded" individuals put the pt safety over the $$$.

Have your RT department PM me. I would love to have ETCO2 monitors everywhere. For 100 ventilators to be dressed out with ETCO2 that would cost an additional $1.2 million. Each vent averages $35 - 45,000 "naked". A few cost $60,000+. You also have to figure in the software upgrade, maintenance contracts, supplies, etc. I would rather have a dozen more FTE hired if I have to choose between them and more machinery. If there is anything left, I would prefer it goes to more education time.

We have monitoring capabilities for everything else from bowel movements to expensive CR and hemodynamic monitors. I would have more humans around. Speaking of a hospital environment of course.

I have been in a lot of hospitals that don't have it on, especially in the ER's but I think it is a substandard level of care. (Talking about the hospitals here not in pre-hospital environment).

Substandard care is relying on technology and forgetting how to assess. Technology will not make a better clinician.

Why would you check the waveform and not the numbers? If the number is where you want it then you have a good idea where to start with your vent settings.

I don't know when you last calibrated your machine. I don't know your drift factor. Those numbers also do not tell me how fast you were ventilating or the VT you used or the IBW.

Checking with the EZCAP is just redundant really but I guess people should do whatever makes them feel comfortable. The EZCAP is really a less ideal alternative if you don't have capnography available. We do use it after initial intubation if our ETCO2 monitor hasn't been plugged in or is warming up. Some people use it anyway. But once you have a good waveform on the monitor the EZCAP is redundant.

Depends on your P&P. At many teaching hospitals, 3 confirmations are taught, one has to be phyical assessment.

How did they ever run codes before defibrillators, or treat arrhythmias without EKG's...scientific advances mostly result in improved pt care and outcomes. People do their job to the best of their ability with the tools and science that is available to them at the time. Morbidity and mortality rates improve generally with advances so just because you used to do something "such and such a way" in the good old days doesn't mean that improvements can't be made. I say if the technology is available and it improves pt's safety and morbidity/mortality then you should be using it.

Clinical skills and education improves patient safety. At any deposition, you will hear, "didn't hear the alarm because of all of the other alarms".

And I am definitely one for change which is why I got more degrees to work in other areas with more gadgets and technology than one can ever imagine. However, when it comes to a sick or injured patients, the technology may be an adjunct but my skills and knowledge are what I will use the most. During a code, I like to spend more time utilizing my other skills to quickly get the job at hand done. This can be in a nice ICU, ER, med-surg room or on the street. My physical assessments skills are mobile and I won't leave them in the truck.

ETCO2 definitely has it place in prehospital. I just hate seeing it used as a crutch like the pulse oximeter has become.

Anyway this is not a rant more of a thinking out loud. I don't have strong feelings on the subject and the ER people who have done it have really done it out of a real lack of understanding of what they were doing.

Are referring to ETCO2 monitoring or RSI? Although yes to either wouldn't be good.

Again education and clinical skills are essential. I can also ask several professionals to tell me what they see by the waveforms. It is sad but many only use that expensive piece of technology to "get a wave".

I enjoyed your post but I have to balance reality with budget and technology.

My rant is someone who can not tell me if a patient is breathing effectively without first looking at a pulse oximeter or ETCO2. And yes, a patient can become intubated with an SpO2 of 100% and ETCO2 of 40. Of course you'll always hear "but the numbers look good".

I apologize for my rant but that's a very sore subject for me especially with November approaching.

I mean no offense to anyone, but hospital workers also have to manage with what our healthcare system deals us. Just because we don't have all the latest and greatest that technology has to offer doesn't mean we don't care or that patient safety is taking a back seat. Our priorities are different because we do have other technology to assist us.

[captainstandup]

The problem is there is no standard of care in the US, and for that matter there certainly isnt a international standard of care. Medical Directors are afforded a great deal of power in determining which skills are worthy of his / her risk. Since the day the white paper was released there hasnt been enough continuity in pre-hospital care to fill a paragraph,

[Scaramedic]

I apologize for my rant but that's a very sore subject for me especially with November approaching.

:?: :?: :?: :?: :?:

[VentMedic]

1. Budget meetings

2. Florida's "snow bird season" starts officially