KosherMedic

Well, I have some comments.

I would like to preface them by saying that I am not even close to being an expert on this subject, so I may require considerable correction.

I recently attended the Critical Care Transport Medical Conference in San Antonio. While I was there I was shocked to hear that our American brothers fly in what I consider unsafe conditions. Many of the medical rotary-wing aircraft are flown by only one pilot and without Night Vision Goggle (NVG) capabilities. Further, the dispatch problems that naturally result from companies that are trying to scoop the flight and make some green when it is too dangerous to fly.

In Canada, I believe that all medevac helicopters that are part of the 911 dispatch system are twin-engine aircraft that have two pilots and NVG capability. I honestly thought that this was the standard of care. I have included links to a few of the organisations that provide this level of care here in Canada so you can get an idea of what I had expected to encounter when I visited the USA.

http://www.ornge.ca/...Operations.aspx

http://stars.ca/bins...asp?cid=3-16-37

Those were the BEST 76 hours of my life...

Negativity is contageous. Be very careful that you don't get infected.

That's a wise statement. Here's it said another way:

I can't count the number of times I foolishly associated with evil people and then, after a time, began acting in evil ways too.

My advice is get out of that situation if you can. Those people will suck the life out of you, as you probably will not be able to change the atmosphere there. You love caring for people, so find another place you can work without being sucked into slime.

In the mean time, make the best of what sounds like a terrible situation. It might be easier to deal with if you have an exit plan, as that plan will give you something better to look forward to.

An employee should pay for damage they cause? That's what insurance is for. That's the cost of doing business, as stuff happens. Any good manager budgets for things like this.

Where I come from, it is illegal for employers to take deductions from employees for damaging equipment. Isn't it bad enough that employers seriously underpay most EMS people that they have to think about docking paychecks?

Nothing but greed. The rich get richer by stealing from the poor.

I have seen three SB tubes. I have never put one in. In theory, they slide in like an OG. The one thing I have always wonder is how!! They are much more flacid than an oralgastric tube. How do you keep it from curling up. Just wondering.

http://en.wikipedia....-Blakemore_tube

This link says that those who have the SB tubes usually keep them in the refrigerator. They probably do that to make the tube more rigid.

I have not seen Walls' book.

It is unique, as it is a break from the traditional airway book we find for prehospital people that is based on anesthesiology. This book is based on prehospital studies and it attempts to tackle the issues we face "in the ditches".

If I have to intubate you, I can almost guarantee you'll be clean shaven when you wake up in the ICU and I'll swear that you gave me consent for the hair removal before the Versed.

Noooooooooooooooooo! I would NEVER give permission to shave my beard!

I might prefer a hole in my neck...

I don't know what the flight crew did. I would have a very hard time not tubing that patient if I were a member of that crew.

Loss of C.

Bleeding in an Airway.

Fractured Mandible.

Fracture Humerus.

This guy should be chewing on plastic (minimum) RSI or a surgical airway if he is going in by air in a small fling wing bird. There really is no down side to providing a secure airway, then "buddy" then can receive therapeutic doses of happy juice so he doesn't have too much pain.

In this situation with Loss of C and possibility of a head injury, well even small doses of analgesia in an unprotected airway could further comprise if just left to Basic Life Support (as in 3/4 prone) ... but that brings up another query if the patient is spinal restriction was he transported on his back with a fracture humerus and compromised airway from bleeding ?

Call for a Griffin / 412 ... LOL (inside joke)

I have worked on Pipeline and these are not light pieces of gear MOI is nasty squared, getting smacked with a 12 inch diamiter x 40 ft pipe, well "buddy" is lucky he is still alive.

BTW Does the destination / receiving facility have a Trauma Team notified ?

cheers

Sorry, sir. No Bell 412CF (CH-146 Griffon) is available for your medevac. The choppa that shows up is so sucky that the patient on the spine board cannot be turned to the side to aid drainage of blood from the oropharynx. Yep, you're going to have to suction that airway all the way to town. The ALS provider had to ask the pilot to touch down en route to empty their suction device (sigh).

Yeah, that patient should have had their airway captured. The provider did not do that.

The facility you're en route to is only a small town hospital. Your patient is to be eventually picked up by a fixed wing air ambulance and flown about 2 hours to a trauma centre.

You have a patient who was struck in the left side of the head by a heavy section of pipe on a pipeline project about 30 mins by helicopter from the nearest hospital. The patient was guiding the pipe that a backhoe was moving without a tag line when the backhoe tipped a bit because of uneven ground causing the heavy pipe to strike the patient.

The patient presented alert after being initially unconscious, bleeding profusely from mouth with many missing teeth, suspected jaw fracture, and periorbital bruising on left side. Patient is normotensive and not exhibiting signs of shock. Patient has closed fracture of left humerus. Patient is maintaining own airway and welcomes your frequent suctioning. Verbal communication with patient is very difficult. Patient is brought to your remote worksite clinic by the EMT on scene with full spinal precautions in place.

The helicopter is on it's way, but it is just a pilot and you will have to accompany patient to the hospital.

You are an advanced life support provider. What do you do for this patient?

(This is a real situation that I was not involved with that happened recently.)

Imagine a piece of 12" x 40' pipe being lifted by that machine and the pipe swinging into the face/side of your patient. Ouch!

Belonging to this discussion group is helping to open my eyes. I had no idea that paramedic training in other parts of the world is so different. I have heard that some paramedic programs in the USA are only 90 hours. Is that really true?

I was reading what KiwiMedic said about their training in New Zealand and their Intensive Care Paramedic is comparable to the training I received here in Alberta, Canada. Though, our program is a two year technologist diploma that follows a one year technician diploma. Also, our training focuses on the actual skills and knowledge needed for critically injured patients and doesn't include the professional courses like:

Psychology and Lifespan Development

Knowledge, Enquiry and Communication

Health and Environment

Professional Practice and Ethics

Health Law & Policy

Disaster Theory

Emergency Planning

We do have four year degree programs that cover that material for people who want a professional degree. However, most get their Emergency Medical Technician (year one) and then go back for their Emergency Medical Technologist - Paramedic (years two and three) after getting some experience.

Would I think that a nurse/EMT crew would be better than a paramedic/EMT team? Not unless that nurse was also a paramedic. There are things you need to know about working on an ambulance that you cannot learn from a book. And, unless that nurse is allowed to perform the same kinds of advanced airway techniques a Paramedic can then what's the point of them trying to take a paramedic spot?

I've worked in remote nursing stations where the nurses thought they could be the local ambulance people too. The vast majority of nurses just don't have the skill sets and experience with pre-hospital patient care they need to function in a prehospital environment - but, you try telling them that. If they want to be ambulance personnel then they should go to school and learn how to do it properly. If a nurse wants to learn how to board a patient in a ditch, goes to the OR and learns how to intubate, and passes a full ALS practicum on ambulance then they've earned the right to take a paramedic spot.

Do any of you nice paramedic or paramedic students in Alberta know where I can find some good quality prep exams or material for the ACoP paramedic exam?

Are you in school in Alberta? If so, your school will probably have a good review course or materials.

....and IMHO, I can cut the neck (and have) pretty quick.

Can I call you Speedy Gonzales?

"¡Ándale! ¡Ándale! ¡Arriba! ¡Arriba!"

If the ETT can make it through the cords and you still have a problem oxygenating and/or ventilating, a cric may not make a difference.

Actually, the scenario I was discussing is where one cannot get an ETT and they need to move on to another way to capture the airway of a patient who is suffocating. So, since they cannot get the ETT tube through the cords they need to move on. If I were the person in the vehicle you wouldn't be able to use a BVM on me very well because of my big beard. People who have a difficult airway have a difficult airway and they may need their neck cut to save their life.

I hope the Paramedic who may one day cut my neck open does as little damage as possible. I'd be very happy that they saved my life each time I looked at my scar in the mirror.

VentMedic - You're an RRT and EMT-P, right? What do you think of Walls' manual? Do you think that there are good recommendations for EMS personnel in there?

Continued...

Walls says that a patient like that needs a cric. However, if your partner manages to get a supraglottic airway in place first then that should work fine.

"On your mark, get set, GO!"

Whoever gets their airway intervention first causes the patient to win and their partner has to buy lunch.

Does this make sense to you? I think it makes sense. Concurrent activity. Why should the EMT sit around and watch the Paramedic prep for a cric when they can be trying a supraglottic airway?

LOL....good topic but I wouldn't do it unless I had fingers like John Holmes!!

Haha... nice. I'll pretend that I don't know who he is.

But if you are going to do both a cric and a supraglottic airway, then focus your rescources and just do the cric, because you will have the first incision before you get the supra-glottic airway out of the package. Again, not what I would reccommend, but once you cut into the trach, the supra-glottic airway becomes useless.

Do the supraglotic airway de jour quickly, and if it is ineffective, or contraindicated, either BVM them or if that is not an option, then chose to do the cric... quickly.

That is my point.

Thank you.

To add...

All things being equal, I don't think that I would be dissecting to the cric membrane before my partner has the supraglottic airway out of the packaging. I would be examining the patient's neck for contraindications to a cric, landmarking, prepping the skin, taking the scalpel out, and rechecking my landmarks carefully. I imagine that my partner would have tried the supraglottic airway by then. If they failed I would incise the area.

And, just so you know, the scenario I am discussing is one where ETT and BVM have failed to oxygenate the seriously injured and unconscious patient who is trapped in a vehicle. Walls does not recommend the use of a supraglottic airway in a patient like this unless it is done while a cric is being readied. As a Paramedic, I would not waste my time on a supraglottic airway that my capable EMT partner is able to utilise.

I am familier with the worthy text by Walls and the algorythm, but I think you misunderstand me. I was using the example of an ETT as a reasons why doing a cric and an ETT simultanously is counter productive, and comparing the ETT to the supraglottic airways (wich use higher airway pressures) to explain that doing a cric AND a supraglottic airway simultanously is even more counter productive.

In short, the alteration of the integrity of the lower airway will render the supra-glottic airway ineffective. But if you are going to do both a cric and a supraglottic airway, then focus your rescources and just do the cric, because you will have the first incision before you get the supra-glottic airway out of the package. Again, not what I would reccommend, but once you cut into the trach, the supra-glottic airway becomes useless.

Do the supraglotic airway de jour quickly, and if it is ineffective, or contraindicated, either BVM them or if that is not an option, then chose to do the cric... quickly.

That is my point.

Thank you.

Why would the Paramedic cut into the neck of the patient if his EMT partner got the Combitube in place and was successfully ventilating the patient? He wouldn't. The whole point of them trying their interventions at the same time is to increase their chances of getting an airway in a patient who is suffocating and terribly injured.

I'm thinking vent may or may not be able to back me up on this, but here are my thoughts....

I know that the concept of using a rescue airway or attempting ETT at the same time as cricing seems like a good use of limited time, and in some cases it would be, such as laryngeoscopy while attempting a retrograde ETT....

But I also know that in the case of a fractured larynx you must intubate PAST the fracture with an ETT. And the airway pressures for a supra-glottic airway are even higher. Therefore I think that altering the integrity of the lower airway with an attempted cric, and using a combitube or a LMA (or a king, PTL, EGTA, what ever) instead is a recipe for (at the least) SQ air; if not very poor ventilation or even complete airway obstruction. The airway pressures for a supra glottic airway must by nature be higher than that of an ETT to provide effective ventilations, so the concept of doing both seems like something that "sounded good at the time" but actually isnt.

At least if you use the ETT, you an advance it past the incision and still ventilate until the surgeon can repair the incision (this is what a friend had to do with a Fx larynx one time on a ped)

Finally, if a combitube (or what ever) was a realistic consideration (or BVM) then I would have some strong thoughts about even attempting the cric. IMHO, the cric is strictly reserved for the known CICV situation.

I hope this is making sense....good discussion.

I'm not talking about EET at the same time as a cric. I'm talking about a patient who NEEDS an immediate airway, an ETT is not possible, and their oxygenation cannot be maintained with a BVM. Dr. Walls recommends going for an alternative airway at the same time as a cric. Please, check out "The Manual of Emergency Airway Management". Check out the "Failed Airway Algorithm" on page 18ff.

http://books.google....page&q=&f=false

Not everyone will agree with the recommendations contained in "The Manual of Emergency Airway Management", but many in the EMS world follow these recommendations which are based on pre-hospital research.

Mr Nash added an additional line in the late 1960s:

We can still hang together, discuss the ways of the EMS world, perhaps belly up to the bar in a pub together. At least I know you won't try to steal my bacon cheeseburgers (right religion, but non observant of the dietary laws)!

L'chaim!

Perhaps you could just stick to drinking with him.

He does that well.

Yes, he does.

The last time I was at his place he served me some kosher rhum with orange juice and some Pringles.

Thanks a lot for the warm welcome, my EMS brothers!

I'm an ex-military Medical Assistant and an EMT-P in Alberta. I have a keen interest in flight medicine and furthering my understanding of critical care. Perhaps I will learn a thing or two if I sit at the feet of tniuqs and feast on his crumbs, but I'll never do that because he doesn't eat kosher and I do.

Please forgive me if I haven't been clear. I was talking about a patient who I needed to "help ... get the oxygen they desperately need". A patient who cannot be ventilated successfully with a BVM or intubated, yet is unconscious is in need of an immediate airway. My point was that I would attempt the Combitube and cric at the same time in a patient who I was not able to intubate and was in desperate need of an immediate airway. This idea of attempting to use a device like the Combitube at the same time you attempt a cric is taught in "The Manual of Emergency Airway Management" and I think it makes sense.

http://volusia.org/ems/COMPLETE%20RSI%20INSERVICE.pdf

Thanks again for your response and the learning opportunities.

i think a lma/combitube would be more effective in these situations besides going straight for the cric. Especially where space and access might be an issue. That's just me though.

I've been taught to go for an alternative airway at the same time I go for the cric. Basically, my partner would try something like a Combitube and I would try a cric. Whoever wins the race gets to help the patient get the oxygen they desperately need. I don't think it's a good idea to try a Combitube and then try a cric. My BLS partner can do a Combitube, so it makes sense that they try that while I try for a cric.

Wow... the Advanced Paramedic website is fancy.

http://www.apl4911.ca/

Now we have an idea of where the owner has been spending some of the money he's made off of exploiting those poor people who just want to fly into the blue yonder with critically ill patients under their care.

On the Alberta College of Paramedics job postings I see that Advanced Paramedic is hiring for what looks like all positions. Would those who take those positions be considered "scabs"? Mind you, if you want to fly for peanuts then now is your chance to get on with them...

If you are considering digital intubation, you should have some access to the cords and therefore it would be very difficult to justify doing a cric.

Thanks for your informative post.

If my only option was digital intubation I would prefer a cric. Of course, it all depends on the situation. We should only cric people who we cannot intubate another way and have low oxygen saturation. I envision a situation where, as a previous poster considered, a patient is in a twisted hunk of metal and very seriously hurt. This person likely has a decreased LOC and shock, so I need to capture their airway. Yes, I could try to utilise a bougie tube to accomplish a digital intubation and I might. However, I wouldn't hesitate to move to a cric if the situation warranted it.

I haven't done any digital intubations other than on mannequins. I also haven't done any crics. When it comes to the two procedures I would be more comfortable doing the cric, as I am much more confident with that procedure. This discussion has shown me that I should study the digital intubation procedure more so I can become more comfortable with it.

On a related topic, what do you think of "The Manual of Emergency Airway Management" by Walls?

No, I haven't. I would likely cric someone if my only other option was digital intubation.

I'm one of the new guys around here and I'm looking forward to having some meaningful and enjoyable exchanges with you folks.

Shalom,

KosherMedic