Jake Almand

This topic is interesting and very diverse. The issues invovled with the current state and the future of prehospital intubation are multifaceted. Like any other treatment we are discussing there are several questions that should be answered before we begin using it. To me, we as clinicians need to first look at available evidence to determien what is the best treatment for our common patients' conditions. Then we need to evaluate that treatment to determine if it can be accomplished safely and effectively in the pre-hospital environment. If it can be, then we must develop a evidence based protocols and a QA/QI process to monitor it's use. If it can not, then we shold look for the next best treatment for the given condition that can be safely performed and then develop a protocl and QA/QI process. These basic steps should be evaluated for more then just intubation. Really we should look at everything we do using this method. Our goal shuold be patient outcome. In my opinion after evaluating evidence, There are certain patients (Trauma Patients with decreased GCS, respiratory failure, etc...) for whom intubation using RSI is the best treatment. However, it can only be performed safely and effectively in the field if it is afforded a suitable amount of education and ongoing practice. If these two things are not present then intuabtion should not be an option for EMS providers and SGA's should be the next best option (and the only option for CPR, pending further research on this). Now, the piece of this whole conversation that got me interested was the discussion on paralysis vs. sedation & analgesia for post intubation management. In my experience, including several years as a flght paramedic, I have seen many providers use unnecessary paralysis. Generally they use the excuse that it is for flight safety or because the patient "can't be sedated". Too many times though I have seem patients who are simply under-sedated and the provider uses paralysis to make their life easier instead of properly sedating and providing pain relief. Often these providers move immediately to long term paralysis post intubation and then neglect the sedation that must accompany it. This usually results in patients who lay perfectly still (so the crew is happy) but are under-sedated and in pain (the patient is being tortured). I generally will push to use liberal sedation and analgesia and try to avoid vec unless absolutely necessary. Like someone else mentioned, there are issues with completely making someone vent dependant even for a short time. These patients generally do better if allowed to mantain their own respiratory drive and are placed on "support" instead of mandatory ventilation.

My ground EMS employer is implementing a policy that will not allow crews to leave a patient in the ER with any of the following pieces of equipment in place: Traction Splint Vacuum Splint Pediatric Immobilizer KED The policy is designed to prevent our reusable medical equipment from being lost/destroyed. There are only two exceptions covered in the policy, otherwise our crews are expected to retrieve the equipment before leaving the hospital. One exception would be if we are in overload and need to get back in service immediately. The only other exception is we can leave a traction splint on a patient going to surgery. Otherwise, we are required to retrieve our equipment from the Pt prior to leaving the ER. Has anyone experienced such a policy? How do most systems handle equipment that is left with a patient at the hospital? Would your hospitals be open to removing equipment earlier in the course of care than what they currently do? This was put out recently without going to our EMS advisory board and I am looking at bringing up at our next meeting. My opinion is that this policy is inappropriate and places undue risk on patients and EMS providers. I can foresee an issue arising between ER staff and our Paramedics when they tell them they have to remove our splint so we can leave? I have routinely transported multi trauma patients with vacuum splints in place that are not removed prior to them going to the OR and I don't want to be the first person to ask a trauma team to remove my splint so I can leave. Here is the policy with all reference to my employer removed. 648.1 Purpose To establish guidelines to follow regarding EMS equipment left at a hospital. 648.2 Procedures A. The following equipment shall not be left at a hospital; if possible: 1. Pedi Immobilizer 2. XP1 (KED) 3. Vacuum Splints 4. Sager Traction Splint B. In the event of ambulance overload contact the EMS Officer to advise of equipment at the hospital so that your unit can return to service as soon as possible. Advise the hospital personnel that you need to get back in service and give them your unit contact information, along with EMS Officer's contract information. THE SAGER TRACTION SPLINT IS THE ONLY ITEM THAT CAN BE LEFT AT THE HOSPITAL WHILE NOT IN AMBULANCE OVERLOAD. THE ONLY CONDITION THAT THIS CAN HAPPEN IS IF THE PATIENT IS GOING TO SURGERY WITH THE SPLINT. C. Each time an EMS crew transports to a hospital they should check in the designated area at that ER for EMS equipment and return it to their station. D. Anytime equipment is picked up from a hospital, the paramedic in charge needs to contact all EMS Officers, along with all personnel that are assigned to that station by email and advise what was picked up. E. All equipment picked up should be cleaned prior to returning it to service. F. If something has to be left at the hospital, send an e-mail to all paramedics and EMS Officers stating where the equipment was left, contact information with which the equipment was left with and an incident number. G. The EMS Officer should make every opportunity to retrieve the equipment from the hospital within 24 hours.