Experience Matters in EMS Intubation

[docB]

Really?

Yeah. Getting funding for anything like that is tough.

Our group is always reluctant to buy stuff because they want the hospital to buy it. We don't get a break on med mal from equipment. We're self insured and the stuff our insurance end primarily seems to care about is computer based quizzes about EMTALA and patients who leave AMA.

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[proman]

Yeah. Getting funding for anything like that is tough.

Our group is always reluctant to buy stuff because they want the hospital to buy it. We don't get a break on med mal from equipment. We're self insured and the stuff our insurance end primarily seems to care about is computer based quizzes about EMTALA and patients who leave AMA.

I understand how hard capital expenditures can be. If I had to spend my own money on a backup airway device, it would be the disposable Glidescope.

So what are you using the ultrasound for? Vascular access?

 

[docB]

I understand how hard capital expenditures can be. If I had to spend my own money on a backup airway device, it would be the disposable Glidescope.

So what are you using the ultrasound for? Vascular access?

We do the full range of EM ultrasound. Vascular access, gallbladders, aortas, gyn exams, FAST exams for trauma, focused cardiac exams looking of EMD and pericardial effusions, pneumothorax, abscesses, fbs, etc.

 

[proman]

I'm surprised you didn't have access to an ultrasound already.

 

[docB]

Yeah, we're definitely behind the times on a number of fronts.

 

[jbar]

Not that it should be the primary means of tube placement confirmation, but you can use the ultrasound to visualize an empty esophagus and the ET tube in the trachea. Neat trick when you aren't sure you're in but the sats haven't started dropping yet.

 

[proman]

Not that it should be the primary means of tube placement confirmation, but you can use the ultrasound to visualize an empty esophagus and the ET tube in the trachea. Neat trick when you aren't sure you're in but the sats haven't started dropping yet.

You can easily image the tube in the trachea but how do you image the esophagus? Normally the air in the trachea obliterates the ultrasound beam.

 

[EMS5]

I would agree with that. With CPAP / BiPAP the need for RSI is significantly decreased IMO (yes I know there are still situations where RSI is needed, but they are generally few and far between).

I really liked the glidescope, but unfortunately the cost per unit was deemed to be too high...for now.

CPAP has definitely been an asset on the ambo. Before it became standard protocol especially with CHF'ers, I would say we had at least one or two patients per week who could have been justified in the use of RSI. Since CPAP was made operational on all of our units, the number of assisted ventilation and intubated patients has gone wayyyy down.

Unfortunately my agency doesn't allow providers to perform RSI, which is a mixed blessing IMO. Only agencies locally that allow it are another city about 30 minutes away and flight paramedics.

 

[docB]

I think we should be expanding the use of CPAP in EMS and I think it will cut down on intubations.

I think we should be intubating fewer people prehospital. The data is shaping up that way. I do, however, think that RSI should be available because the data is conclusive that if you're going to be intubating RSI is superior.

 

[EMS5]

I think we should be expanding the use of CPAP in EMS and I think it will cut down on intubations.

I think we should be intubating fewer people prehospital. The data is shaping up that way. I do, however, think that RSI should be available because the data is conclusive that if you're going to be intubating RSI is superior.

Absolutely. With a provider properly trained in RSI, you are creating a more controlled environment, allowing for proper pre-oxygenation before induction. Now that ACLS is even starting to shy away from intubation, there is going to be less and less field intubating. There definitely needs to be more CPAP education in ALS training. When I went through EMT-I, we spent maybe one lecture (2-3 hours) on CPAP and respiratory physiology and about 2 hours of lab on CPAP indications/administration/usage.

I would also like to see more alternative airway solutions. I don't have any experience with any, but King, LMA, etc would be a nice alternative to intubation and combitube.

 

[Paseo Del Norte]

Absolutely. With a provider properly trained in RSI, you are creating a more controlled environment, allowing for proper pre-oxygenation before induction. Now that ACLS is even starting to shy away from intubation, there is going to be less and less field intubating. There definitely needs to be more CPAP education in ALS training. When I went through EMT-I, we spent maybe one lecture (2-3 hours) on CPAP and respiratory physiology and about 2 hours of lab on CPAP indications/administration/usage.

I would also like to see more alternative airway solutions. I don't have any experience with any, but King, LMA, etc would be a nice alternative to intubation and combitube.

Agreed with CPAP.

However, when looking at all the other alternative airways, I am not sure I could say with any level of objective confidence that one airway is better than another. The Combitube may not be the latest and greatest device; however, it has been around for a while and has been extensively used. We have a fair amount of literature on this device and it's pros and cons are well known. So, I do not see these newer modalities, not that the LMA is new, as a better alternative to the combitube at this point.

On a side note, the medical director of a large ground service in my area of the world has instituted a three month study. All patients who would have been traditionally intubated will be managed with the King LTDS. Clearly, there will be exclusion criteria and so on. Following the three month trial, the data will be compared to data that has been pulled from the past. I assume, similar patients with similar conditions and or patters will be compared to their King managed counterparts. We will see how it goes.

My personal bias is that outcomes will probably not change as this service does not use RSI and most of the intubations are the typical crash airway of an arrest patient. We will se however. I am happy to see a medical director taking such proactive steps regarding the airway management situation.

 

[DitchDoc73]

Agreed with CPAP.

However, when looking at all the other alternative airways, I am not sure I could say with any level of objective confidence that one airway is better than another. The Combitube may not be the latest and greatest device; however, it has been around for a while and has been extensively used. We have a fair amount of literature on this device and it's pros and cons are well known. So, I do not see these newer modalities, not that the LMA is new, as a better alternative to the combitube at this point.

On a side note, the medical director of a large ground service in my area of the world has instituted a three month study. All patients who would have been traditionally intubated will be managed with the King LTDS. Clearly, there will be exclusion criteria and so on. Following the three month trial, the data will be compared to data that has been pulled from the past. I assume, similar patients with similar conditions and or patters will be compared to their King managed counterparts. We will see how it goes.

My personal bias is that outcomes will probably not change as this service does not use RSI and most of the intubations are the typical crash airway of an arrest patient. We will se however. I am happy to see a medical director taking such proactive steps regarding the airway management situation.

Having used all 3 alternative airways being discussed, I definitely prefer the King Tube, followed by Combitube, and lastly the LMA...LMA is a good airway, but it is difficult to properly secure in a prehospital environment with all of the Pt movements...Just my opinion...

 

[jbar]

You can easily image the tube in the trachea but how do you image the esophagus? Normally the air in the trachea obliterates the ultrasound beam.

First of all if you see tracheal ring artifact and also see ET tube artifact in a separate structure you are in the esophagus. I'm not an expert on ultrasound but picked up an esophageal intubation with US. Also a lecture at SAEM on US said that you can usually see the empty esophagus, as it should have some air in it that distinguishes if from surrounding tissue. Probably some studies need to be done on the sensitivity and specificity of US for confirming tube placement but it's an interesting concept at the least.

 

[Paseo Del Norte]

Agreed with CPAP.

However, when looking at all the other alternative airways, I am not sure I could say with any level of objective confidence that one airway is better than another. The Combitube may not be the latest and greatest device; however, it has been around for a while and has been extensively used. We have a fair amount of literature on this device and it's pros and cons are well known. So, I do not see these newer modalities, not that the LMA is new, as a better alternative to the combitube at this point.

On a side note, the medical director of a large ground service in my area of the world has instituted a three month study. All patients who would have been traditionally intubated will be managed with the King LTDS. Clearly, there will be exclusion criteria and so on. Following the three month trial, the data will be compared to data that has been pulled from the past. I assume, similar patients with similar conditions and or patters will be compared to their King managed counterparts. We will see how it goes.

My personal bias is that outcomes will probably not change as this service does not use RSI and most of the intubations are the typical crash airway of an arrest patient. We will se however. I am happy to see a medical director taking such proactive steps regarding the airway management situation.

Scrap that. A crew had problems and decided on bag mask ventilation and transporting an arrest without any advanced airway. The receiving ER doc lost the plot, had a fit and now the study has been terminated. So much for progress...

 

[MedicFL]

Scrap that. A crew had problems and decided on bag mask ventilation and transporting an arrest without any advanced airway. The receiving ER doc lost the plot, had a fit and now the study has been terminated. So much for progress...

How can one doctor cause the study to be shut down? Were they the medical director or the study PI? ACLS has been downplaying the need to advanced airway as long as the BLS airway is working. Compressions Compressions. I wouldnt just give up on the study, I think it has good merit to it..

 

[Paseo Del Norte]

How can one doctor cause the study to be shut down? Were they the medical director or the study PI? ACLS has been downplaying the need to advanced airway as long as the BLS airway is working. Compressions Compressions. I wouldnt just give up on the study, I think it has good merit to it..

No, was not a medical director and not involved with the study.

 

[docB]

How can one doctor cause the study to be shut down? Were they the medical director or the study PI? ACLS has been downplaying the need to advanced airway as long as the BLS airway is working. Compressions Compressions. I wouldnt just give up on the study, I think it has good merit to it..

But one can easily imagine a hot head doc who'se angry over getting a crumpy patient and threatens to go to some oversight agency about it. Next thing you know, no more study.

 

[docB]

I was reviewing old threads because I'm giving a talk on prehospital intubation. I noticed this part about the doc who got annoyed that a code showed up without being intubated. We recently had a case where a crew didn't tube the patient and were not bagging the patient who was under CPR. They had put an NRB on and one was managing the gurney and the other was doing CPR. They did this based on the a new local protocol that is trying to adhere to the AHA guidelines. The doc who received the case flipped out and created a huge stink. It's taken weeks to calm it all down.

 

[Paseo Del Norte]

I was reviewing old threads because I'm giving a talk on prehospital intubation. I noticed this part about the doc who got annoyed that a code showed up without being intubated. We recently had a case where a crew didn't tube the patient and were not bagging the patient who was under CPR. They had put an NRB on and one was managing the gurney and the other was doing CPR. They did this based on the a new local protocol that is trying to adhere to the AHA guidelines. The doc who received the case flipped out and created a huge stink. It's taken weeks to calm it all down.

Yikes! Even the 2010 guidelines recommend that healthcare providers perform 30:2 compressions to ventilation. I think the benefit of ventilation in an arrest could be debated, but when you have international consensus, it would be an uphill battle for someone like an EMS professional.

I want to emphasise that the patient from my prior post was receiving bag mask ventilations and compressions at a 30:2 ratio. I guess I was pretty upset because I was very excited to see where this study could have gone and also excited that a medical director was being progressive IMHO. Especially, since many of us do training up north where a fairly well known ER physician and medical director of a flight service is being quite progressive, to include writing and publishing case studies on a newer concept that he coined rapid sequence airway (RSA). It basically evolved from a crew that called him with a trauma patient that was crashing in turbulent conditions and the crew was not confident with intubation. He directed them to do an RSI procedure, but use a supraglottic airway instead of conventional intubation.

The risks and benefits of this are debatable for sure, but it is nice to see a physician take such an active role.

 

[Dwindlin]

This may be way off base but wasn't there some research recently that showed simply placing a mask on a patient then doing good CPR will naturally draw some O2 into the lungs? Or am I hallucinating again?

 

[Paseo Del Norte]

This may be way off base but wasn't there some research recently that showed simply placing a mask on a patient then doing good CPR will naturally draw some O2 into the lungs? Or am I hallucinating again?

Not necessarily, in fact hands only CPR with no airway interventions is now acceptable for the lay provider. I'm not sure exactly how effective airway interventions are in the arrest patient when considering the big picture. However, unless the providers had hands only protocols that allowed them to do CPR with a NRM on, I can understand why a physician may be upset.

 

[docB]

That's what the protocol says. It's designed to allow 2 man crews to have one man manage the gurney and the other do uninterrupted CPR. Even though it was per protocol the doc had a fit. He then stepped on a lot of toes and having his fit and, like I said, it took a lot of calls to chill everyone out.

 

[Paseo Del Norte]

That's what the protocol says. It's designed to allow 2 man crews to have one man manage the gurney and the other do uninterrupted CPR. Even though it was per protocol the doc had a fit. He then stepped on a lot of toes and having his fit and, like I said, it took a lot of calls to chill everyone out.

I stand corrected and it is good to hear that they have a protocol that takes their operating environment into consideration.