flyin dutch

Not sure if same stuff applies to you in Canada but AHA is coming with new guidelines in 2010. I've heard rumors of "optional" ventilations, not sure what else.

Hi all . . . Looking for input for developing protocols on firefighter "rehab" after exiting a fire in which air packs have been used. This is for a volunteer ambulance and fire department, separate entities but same community, ambulance dispatched simultaneously for all structure fires, etc. Firefighters have a limit of 2 times in total with packs on, and have to be evaluated by EMT's after exiting the fire each time. What systolic and/or diastolic BP, heart rate, signs/symptoms should put them in a "time-out," what warrants treatment/transport? Remembering that BP, heart rate normally elevated somewhat in these situations. Have considered having a list of baseline vitals, updating yearly, not allowing said firefighter back in if greater than X% above baseline . . . Any ideas, thoughts welcome.

I agree, too--in a perfect world, everyone WOULD have paramedics and we wouldn't be having this discussion . . . but as we all know, this isn't a perfect world. Many of the places I fly have only a clinic with maybe an MD but most of the time a PA-C or NP is the highest level of provider. And then to expect that same community to be staffed with paramedics? It's not going to happen! Regards

Taking RSI/ALS away is not at all what I was suggesting, not sure about anyone else :oops: Rather, I was emphasizing that in some places, the best care available is an intermediate level, and why shouldn't they be able to use a Combi/King. I personally had never had any dealings with the EOA, it was gone long I started in EMS. Until later . . .

These are hillariously true . . . And if you've every done CPR straddling the patient in a Stoke's being pulled behind a snowmobile . . . you might be a rural EMT!

The only training is: if the patient wakes up, DEFLATE and remove that puppy ASAP! I'm sure none of us would be too happy to awaken with that gob of PVC in our throat. On to the patient who survives, but doesn't wake up and does tolerate the Combi--what to do in hospital??? I think the onus of changing out an intermediate airway to a definitive airway falls to the OR/Anesthsia staff at the receiving hospital. I'm sure there will be an outcry for my saying this, but the fact remains . . . these Combitubes are out there and being inserted by FR's, EMT-B's, etc, and I don't think that will be changing anytime soon (especially in rural EMS). Let me defend that comment . . . I have seen an ER physican insist on changing out a working, adequately-ventilating Combi for an ETT in the ER only to fail to place the ETT and send the previously quite viable patient into full arrest :shock: :evil: Good point on the cadavers, though--the majority of the time the Combi-tube is just one more thing the coroner gets to remove during the exam. Ya . . . when I first started checking into the King tube, the FDA/OPA thing is what I was told. The State of Iowa has no protocol regarding the King tube and I haven't gotten a commitment on whether they're going to write one. And so, if the state requires "documentation of training" and "medical director's approval" to use the King tube, where do I get training that is adequate and accurate. All of the above pending that I find enough evidence to support replacing the Combi with the King? In the limited experience I have with them, I do think that the King tube is more "user-friendly" than the Combi and less barbaric to the patient. I do have a question though . . . is there research out there showing that use of a Combi or some other intermediate airway has been detrimental to patient outcomes when there is no advanced airway management immediately available? That last part is the operative phrase . . . Because there is A LOT of rural EMS where they don't have any ALS available and in their cases, I do believe the Combi/King IS the next best thing. That being said . . . a BLS service with GOOD skills (oral, nasal airways and BVM) is far better than an ALS service with POOR skills (and I'm sorry, but it's very difficult to be good at ALS when you get 1 intubation a year!!!!!). I think there's quite a few rural EMS squad who have 1 or 2 ALS providers and see only a few runs a year--how do they keep up their skills? In those cases I'd rather see them dump in a Combi/King, etc than fail an intubation because they haven't done one for a year and a half. Anyway, that's just my $.02 on that. Thanks for your help with the research . . .

Hmmm . . . so I'm not sure I want to get into this argument but I'm looking for some information. Let me explain my background a little. I work full time as a flight nurse but also am a volunteer EMT-B (conditional "I" through RN exception) for a rural ambulance service in Iowa. Currently, on flights, our back-ups for RSI include the Combi-tube and then the Melker cric kit. Now that the King Lts-D has come out, there's some rumblings about changing to the King tube instead of the Combi-tube. At the same time, the medical director of the volunteer BLS squad approached us about changing to the King tube instead of Combi-tube as well. Currently, the Combi-tube is part of our standing orders for any cardiac or respiratory arrest (trauma or medical) that aren't excluded by the Combi-tube contraindications. What I am looking for is some PUBLISHED studies on the efficacy of the King tube--you know, evidence-based medicine? I've handled the King tube and placed one in a dummy, appreciate the features and everything seems a-ok. But I want evidence before we put them into practice! The King Lts-D is acutally classified by the FDA as an OPA, putting them in every EMS provider's scope of practice. However, the state of Iowa also requires documentation of training and the medical director's approval. Some more food for thought--thanks in advance if any of you have any info on published studies!! flyin dutch