safetyparamedic

I see no problems with 18 year olds licensed as EMTs and then finishing paramedic at 19. Many companies will limit hiring to 23-25 for insurance reasons, but not because of the medical care given. I don't care if my new partner is 19 or 35, there will be a learning curve for them to realize that they are not EMTs anymore and there is a certain responsibility in working as a paramedic. It's my job as a FTO or preceptor to make sure that they realize that. Many small community ambulances could not function without their younger EMTs and Paramedic. And while I've had 20 year olds I've wanted to strangle because they won't follow directions, I've had 40 year olds that thought they knew everything and didn't need a preceptor once they got their shiny gold patch. Simply training new medics require a certain amount of patience regardless of the age.

I don't think that Medicare defines a combitube as an ALS intervention, but it is called an "Advanced Airway."

I've heard of a couple of situations where the Combitube was used in respiratory arrest after trauma, but they've been few and far between. Paramedic coverage is the gold standard, but many places cannot provide paramedic coverage due to cost or the inability to recruit paramedics. In Wisconsin, only 75% of the state is covered by ALS, and I think that just means they can start an IV. In places that cannot provide paramedic level coverage, the Combitube is better than the alternative of a simple airway. And I've never heard of a case where the Combitube was incorrectly placed, but that doesn't mean it doesn't happen. Again, education is the key. We have to re-cert every 6 months on Combitube.

What I think people need to realize is that the Combitube is not designed to replace the ETT. The Combitube is designed for non-ALS levels of EMS. In Wisconsin, which is the only state that I can really comment on) Combitubes are allowed all the way to the First REsponder level. Very simply, it provides a better airway and less chance of inflation of the stomache than an Oral Airway when using a BVM. The only time it is being used is during cardiac arrest. I disagree with the statement that improper placement causes death. Ok, that part is true, but the chance of an improper placement is pretty low. The Dual-Lumen system allows for placement in the esophogus (primary), but also allows for placement in the trachea. I believe that Kendal says that it will work in 95% of all patients. I agree that the Combitube does have some severe disadvantages, but I don't think that they override the advantage of providing some sort of advanced airway for the cardiac arrest patient in the BLS setting. Not to mention, there is no where near the risk of inexperienced or untrained personnel performing intubation. Not to mention, trauma to the oropharynx is the least of my concern during a cardiac arrest.

I like the Combitube as a great backup. The advantage of the ETT is that it can be placed in patients that have a gag reflex, works great for giving "definitive" protection, and can be inserted a variety of ways (oral, nasal, retrograde, etc.) The downside is there's no backup if it doesn't it. Also, there is a definite skill to doing it and it takes quite a bit of practice to do it right. Also, using the ETT to administer medication is quickly losing favor. It takes way too long for the medication to hit the circulation. Instead, IOs are gaining more favor if an IV can't be established.

I would keep the first responder training the same, about 40 hours. With the EMT Basics all having to become IV-Technicians, I would add about 70 hours (the same as the current IV Technician training) and more clinical time to the EMT-Basic curriculum. The paramedic training could stay the same. Granted, in my state, paramedics can have a pretty unlimited scope of practice with training in-house.

Wisconsin has 5. First Resonder EMT-Basic EMT-IV Technician (same skills as I-85 without as much training. I know Scary) EMT-I (1999) EMT-Paramedic For my 2 cents, I think we need 3. First Responder, IV Technician, and Paramedic