Spock

Fab makes some interesting points. We do a lot of OMF cases that require a nasal tube and at my hospital we have used and interesting technique with a glidescope (video laryngoscope). The tube is advanced through the nares and then the glidescope is inserted and the vocal cords are identified. The tube is advanced and then the balloon is inflated which elevates the tube such that the tip of the tube is placed into the trachea. The balloon is then deflated and the tube is advanced deeper into the trachea. It works well and beats the hell out of using the Magill forceps to place a nasal tube. I would never try this in a code situation nor would I choose a nasal intubation. Nasal airway and BVM as chbare suggests is the way to go.

Got a good laugh from that response Captain!

I would emphasize what others have already pointed out: you have to read the entire article before reaching any decision and what happens in Japan does not automatically apply to any other country. Good compressions and early defibrillation are the two most important interventions in cardiac arrest management. Airway management is not high on the list.

There are many good comments already and all I can do is confirm what has been said. Getting the nasal tube into the trachea was pure dumb luck and will happen once in a hundred times. There are many ways to manage an airway effectively and having a tube in the trachea is only one of them and it is not high on the list. The AHA ACLS materials have lowered the emphasis on getting the patient intubated because it all to often interrupts compressions. Requiring transport of a patient in asystole that has not responded to aggressive ALS interventions is also not recommended by the AHA. Obvious signs of death? Asystole and clenched jaws that can't be opened? Can anybody say rigor mortis?

Interesting discussion and many good comments. I think the thing to remember is that airway management means delivering your patient to the hospital ventilated and saturated. There are many ways to do that and what may be appropriate in one situation may not work in another. Good patient care is more than just doing procedures. It's been a while since I've checked out the site but I hope to be back on a more regular basis. Still some familiar names on the site. Spock May the tube be with you.

I'm with PA-1 DMAT and MA-1 was in Haiti when we were. I don't know specifics about MA-1 recruiting but we only recently have started accepting applications from EMT's and Paramedics mostly for logistics and communications slots. The good thing about DMAT is you are a federal employee but the bad thing is you work for the federal government. Just a joke. I've been on two deployments with DMAT and have found them interesting and challenging. Haiti was an experience that nobody can understand unless you were there. Good luck. Live long and prosper. Spock

I just got back from Haiti the other day after eight days in country. I was working for the Federal Government. Any one considering taking a job down there should be very careful about what you are getting into. That's the wild wild west all over again. It isn't pretty. Live long and prosper. Spock

Two for two in the field this year. I work at a level 1 trauma center as a nurse anesthetist and I don't know how many tubes I have in the hospital but I would guess about 400. Those are split between the OR, the floor, the ICU's and the ED. I just finished looking at our service and we had 53 intubations for the year with 5 being the most for any one medic. The data for Pennsylvania was reported in 2005 with the average of two per medic. Almost 40% of the medics in the state had zero intubations. As someone already pointed out the goal is to arrive at the hospital with a patient that is saturated and ventilated. How that occurs in not all that important. We do not automatically pull an alternative airway in the ED (I dislike the term rescue airway.) If the airway in place is working we use it. Most of the alternate airways are the King which is my favorite. The only time we change the King is if the patient is going to the OR or will be admitted to the ICU. I wish I knew how many intubations are needed to maintain proficiency but I don't. I'm not in favor of pulling ETI from the paramedic skill set but we need to get away from the idea that if we don't place an endo tube we have failed. Again, ventilation and saturation are the key. Live long and prosper. Spock Forgot one thing. I think the importance of regular mannequin practice cannot be underestimated. It gives you practice going through the many steps of intubation. It is no different than the checklists airline pilots go through for every step of a flight no matter how many times they have done it. A few years ago we started that in my service and though there was very poor compliance the medics that practiced every shift improved their success rates by 100%. May the tube be with you. Spock

Ventmedic covered the technical aspects of this question thoroughly and I won't add to that. I would suggest that if you are not an experienced laryngoscopist you should not experiment with new techniques until you have mastered the basics for which you have been taught. There is nothing wrong with practicing on a mannequin because it reinforces a procedure that is not done frequently. Airline pilots still go through their checklists no matter how many takeoffs and landings they have done. I check my airway equipment before every case. We have some left handed miller blades in my department and everytime I find one I toss it into the trash. Yes that makes me a jerk but I have tried to use these blades and have found them to be very difficult when used in a conventional manner. Live long and prosper. Spock

This lack of pride and professionalism is a constant source of irritation for me and at times I try to tell myself that I have set the bar to high. I don't know the solution but do believe pride comes from within and a strong mentor can bring it out for all to see. I never served in the military but do believe that EMS would be better off it it adopted more of the military training modules. Wear your uniform to paramedic class and stand inspection before the class starts. That would be interesting. I'm older than dirt. Live long and prosper. Spock

It would be quite unusual for anyone to turn down a Nobel Prize. Perhaps this reflects the low regard the American Government has had by the rest of the world over the last eight years. Live long and prosper. Spock

Look what you started Dust! You da man! Live long and prosper. Spock

The vast majority of prehospital intubations are in the cardiac arrest patient and this study only looked at trauma patients. The part I find unacceptable is the 12% of esophageal intubations. There is no excuse for this and if a service is going to allow their medics to intubate they should be required to have ETCO2. Pennsylvania mandates all ALS ambulances to have electronic capnography. I can't speak to the dipolma mills for paramedics because we don't have them here in Western PA but the idea of restricting advanced skills to certain medics with additional training has merit. Not every medic should be allowed to intubate. I also don't agree with counting "rescue airways" as failed intubations. While true that there is no endotracheal tube in the trachea if the patient is ventilated and saturated upon arrival then the medic has done their job well. I've said before that a better term would be alternative airways instead of rescue airways. I've also said that my experience tells me the King LT-D is the best of the bunch. The anesthesiologists that criticize paramedics really irritate me because they are the same people that will not allow medics into the operating room. The study identifies a problem but doesn't seem to recommend a solution. Live long and prosper. Spock

Thanks Dust! I've been around but have just been to darn busy as of late. Live long and prosper. Spock

Active cooling is much better than passive. The University of Pittsburgh Center for Emergency Medicine is doing a lot of research on this and they just did a big study using firefighters at a live burn. Data should be published soon. When I worked as an athletic trainer in the NFL back in the 80's the most effective way to cool a player post practice was cold immersion. I kept a whirlpool bath filled with cold water and the players would dunk themselves for a few minutes and they loved it. Incidence of heat illness dropped dramatically. Live long and prosper. Spock

We started a hypothermia protocol a few months ago. If we get pulses back we infuse two liters of cold saline as fast as possible and support the BP with dopamine. Valium is given for shivering. We have used it twice now but both patients still died at the hospital some time later. We keep the saline in a cooler with freeze packs which are rotated every 12 hours. The City of Pittsburgh started this long before we did and they put small refrigerators in their trucks. The recommendations for hypothermia were initially made in the ACLS update in 2000 and was given greater emphasis in the 2005 update because of the good results in the hospital setting. Taking it prehospital seems to make sense but I agree more data is needed. Live long and prosper. Spock

We have a tactical team of medics that respond with our regional SWAT team. They are trained to make entry with SWAT but are unarmed because Pennsylvania does not permit medics to be armed. It is clearly understood that medics entering with SWAT would be a rare instance. The big advantage is that SWAT is working with a small group of medics that they know well and trust. The importance of that can not be underestimated. We have also trained SWAT in basic trauma care so they can help each other in the hot zone. This is a good team and its value is recognized by SWAT. All of that said I have to agree that tactical medics should be armed which is why I am not on the team although I have helped them develop an airway protocol similar to the one we use on our county haz mat medical team. Live long and prosper. Spock

We use this rule for our firefighter rehab program. Any FF that hits 80% of his max heart rate does not return to duty until the heart rate is less than 100. It works well because it is objective and FF's that reach this level usually feel like crap and don't want to return to duty. It gives them an out and they are usually glad to take it. Live long and prosper. Spock

If you need to replace the equipment you have currently the extra expense of the fiberoptic scopes is well worth it. I have yet to find a disposable laryngoscope that I thought was worthwhile but that doesn't mean they don't exist. Live long and prosper. Spock

We don't allow minors to sign a refusal and make every attempt to contact the parents. We also require command consult for refusals. If we can't contact the parents the minor goes to the hospital. If I remember correctly there were several high school football players that died from heat illness in North Carolina last year and a football coach has been charged in the death of one player. Live long and prosper. Spock

I'm going to come down on the side of removing pediatric intubations because it is easy to bag a kid but not necessarily easy to intubate. PALS recommends that intubation be left to only the most experienced and promotes BVM ventilation. As mentioned if you can ventilate the kid you can most likely avoid the cardiac arrest. The comment about the saturation staying in the 90's for a few minutes of apnea only applies to a healthy patient. Plus there are very few alternative airways for kids. LMA's do come in pediatric sizes all the way down to the neonate but the King has no sizes for under three feet and the combitube has no pediatric sizes. Most paramedics so not have the LMA available to them. My service MIGHT see one pediatric intubation in a year. Hardly enough to maintain proficiency. I work in an adult trauma center and do maybe 6 pediatric intubations in a year (mostly burns.) Is that enough for me to maintain proficiency? I don't know. Live long and prosper. Spock

I really am not trying to get into the middle of this but I have to agree with VentMedic. I will do a nasal in the OR for maxilofacial cases and place a nasal RAE tube under direct laryngoscopy with magill forceps. These patients are usually extubated in the OR after the case or in the PACU within an hour. Blind NTI is a lost art in the hospital although I have done it on rare occasions using an endotrol tube and a whistler. NTI will remain a tool for prehopital use because RSI is not available everywhere and I would favor NTI over a needle cric any day. We don't do true surgical airways in my region and we don't have RSI or even etomidate. Using benzo's for intubation is a poor choice although sometimes the only one available. Live long and prosper. Spock

I would suggest that everyone read the Bledsoe/Gandy article closely. The article is well written and is the best review of the literature in one place that I have seen in a long time. The most important point they make is that managing an airway is about ventilating the patient and not just putting the tube in the right hole. As I have said before you can teach a monkey to intubate but not when to intubate. That is the difference between training and education. Most of the medics I know cry that ETI may be taken away from them but they aren't willing to take the steps necessary to maintain their skills. I couldn't agree more with ventmedic's comment on intubating the manequin. It requires you to go through the steps of ETI in an orderly fashion so that when you have to intubate a patient it is second nature. Checklists are one of the reasons the airline industry has such a good safety record. After that plane crashed in the Hudson River the pilot left the cockpit to see that the passengers were evacuating while the copilot stayed in his seat and went through the evacuation checklist. That is professionalism and bravery all at once! I don't know where ETI is heading in the future for EMS but at the least we must think about restricting the skill to only those that will do it often enough to maintain proficiency. That means at least 15-20 tubes per year. Very few medics will be able to attain those numbers. On a personal note I will say that I will never be burned by an esophageal intubation by a medic again. The next time they bring a tubed patient into the trauma bay without wave form capnography to verify tube placement I will get my scope and look for myself. No more giving the medic the benefit of the doubt. I will also rip him an new hole for not using capnography and putting the tube in the goose. If you are doing a procedure you must do it correctly or not at all. Live long and prosper. Spock

Freedom House Ambulance was established in Pittsburgh in the late 60's (Sorry but I don't know the exact year) to serve a largely black community in the city (the Hill District) because the ambulances run by the funeral homes would not respond there. The crews were mostly Vietnam vets and many had been combat medics. They were trained by several doctors most notably Dr. Peter Safar. They originally only responded into the Hill but when the police saw what they could do they started calling them to other parts of the city. At that time the cops would take people to the hospital by tossing them into the back of the van and driving like hell to the hospital with both officers up front. Pittsburgh EMS grew out of this and one of the assistant chiefs is a Freedom House vet. I would be interested to know which US city had the first paramedic service. Good topic. Live long and prosper. Spock

I may be crazy but there is nothing better than getting a stat page for a leaking aortic aneurysm other than maybe a GSW to the chest. We put the NIBP on the right and the arterial line in the left. Why? Because the NIBP unit is on the right and the art line transducer is on the left. No other reason. We do compare the values and if there is a big difference we also will put in a femoral art line if we have time which we frequently do not. I have never heard of the BP cuff on the left being a problem and can't think of any good reason why that would be a problem. The issue is the exact location of the aneurysm which is determined by CT, CT angio and transesophageal echo. If it is above the aortic valve but before the arch the surgeon can usually get a clamp on it and we can go on bypass in the usual manner. If it goes into the arch the surgeon canulates the left femoral artery and vein for bypass and we do a circulatory arrest which means we cool the patient to around 18 degrees centigrade and shut off the pump. The surgeon then sews in a new arch. Descending aneurysms are done through a left lateral approach and we put in a double lumen endo tube and deflate the left lung. Challenging cases all the way around and that is why I love doing cardiac. Anyone that wants to call me a sick SOB feel free because you are correct. Live long and prosper. Spock