Spock

We've had CPAP since December 1, 2007 and so far it is being used about once per week with great success. The hospital emergency rooms are doing a great job of having respiratory ready for us when we arrive. We give early notification because our transport times are usually less than 10 minutes. I review every trip sheet where CPAP has been used and all cases were appropriate.

Live long and prosper.

Spock

"Should EMS still have RSI?" I don't know the national or international percentage but I suspect the majority of paramedics are not permitted to use RSI at all. RSI by ground medics is prohibited in Pennsylvania. We do have a state protocol for etomidate only intubation but so far most medical directors have stayed away from it. Frankly etomidate only makes little sense since no ER doctor would do anything less than RSI.

I think the Star-Telegram is biased because they quoted Henry Wang. Dr. Wang thinks paramedics shouldn't be allowed to intubate anybody including cardiac arrests.

I've said before that any medication assisted intubation has to have close medical control and a very strict training and QA mechanism. It is not for everyone.

This topic has been discussed extensively before but since there is a poll attached I guess it is OK to bring it up again. Let's not beat a dead horse. If RSI is the standard in Texas then the poll applies to Texas.

Live long and prosper.

Spock

The University of Pittsburgh offers an EMS degree program (Bachelor of Science) and will give advanced standing to paramedics which I believe is around 40 credits. I might be wrong on the number but I do know you get advanced standing.

Duquesne University (in Pittsburgh) offers a second degree nursing program. Those with a bachelor's degree can earn a BSN in 12 months. Students go full time (40 hours/week) for a year without breaks and do all of their nursing clinicals and take the nursing classes. It's a good program and was 16 months when I went through it many years ago.

I would also recommend caution on any bridge program that is very short. If it sounds to good to be true it probably is. Make sure any program has the appropriate accreditation and be especially careful of any on line program from a school you never heard of. Research can prevent a lot of problems.

Good luck. Remember education is a never ending process. I'm thinking of starting on my third master's.

Live long and prosper.

Spock

Lots of good comments here and I have been on record as being a huge fan of the King. I've been using it in the OR for two years now as a primary airway (instead of an LMA) with minimal problems. I have had a few patients that I couldn't get the King placed but that is also true of the LMA. No device is 100% fool proof.

Flyin dutch makes a good point about evidence based literature and what is currently available is limited and biased because of manufacturer support. I do know of several studies that will soon be published that demonstrated subjects with minimal medical training can quickly place the King in a mannequin. Also, the latest edition of Prehospital Emergency Care is supposed to have an article about the King but I haven't seen it as of yet.

I do think if you can place an OP airway you can place a King. A monkey can be taught how to intubate or place a King or OP or combitube. The trick is you have to teach the monkey WHEN to do any of the above. Different story. I have said before that I thought the King could be a BLS skill but I now recognize the limitations of that because of the many comments on this site. You guys are right.

I used a King just the other night. 14 year old was unresponsive and had agonal respirations. I arrived on scene just as one of the medics was intubating. His skills stink and of course he put the tube in the goose. I took over and bagged her until her color improved and her sats came up. Scene time was already about 15 minutes and she wasn't doing well. We were on the second floor in a small bedroom and intubating was going to be difficult because of limited space. I thought about just bagging her while we carried her out in the reeves and then tubing her in the truck. Instead I placed a #3 King and was able to carry my end of the reeves while also bagging her while we went down the steps to the truck. In the truck I thought about changing the King for an ETT but her sats were 100%, ETCO2 was 36, we had good compliance and breath sounds were clear and equal. I figured the only thing I would do by changing the tube was make things worse so I left it alone.

I hate having to change a combitube in the ER and would much rather change a King. Most of our ER docs don't want to deal with it so they call anesthesia to change the things if the patient has survived to the point where they are admitted. If either a King or combitube is in a cardiac arrest patient they leave it alone as long as they are ventilating easily. If there is no ROSC they just call the code and leave whatever airway device is in place.

Live long and prosper.

Spock

Live long and prosper.

Spock

Those are some good points guys and I think I need to clarify something. 97% of our patients that had an intubation attempt were eventually intubated. I've been looking at first time success rates. My theory is that if there are multiple attempts something else isn't getting done and since most of these patients are cardiac arrests what isn't getting done is probably compressions which we know is more important.

We don't have a true RSI and PA just approved etomidate only assisted intubation. I doubt our medical command system will allow it and I wouldn't let most of our paramedics any where near the drug. Most of the airway evaluation techniques have never been validated scientifically. The best measure of airway evaluation I have seen is the straight edge rule. Take any straight object (such as a pencil) and if the nose, lips and chin don't all touch the straight edge you will have difficulty intubating. A corollary is if the patient can't bite his upper lip you will also have problems. Try it.

I'm not yet at the point where I think medics shouldn't intubate but I can see why some doctors think so and if people don't put more emphasis on airway management it may come to pass.

I would mention that I almost never intubate in the ambulance until someone else has tried. I don't want to take tubes from those that need to perform the skill but after one miss I can't justify not taking over.

Live long and prosper.

Spock.

Spock:

You mentioned that the five who adhered to your study's protocol improved their success rates by 100%. What were their success rates pre and post study? And was that improvement based on non-lab, real-life intubations?

How would it work if you offered an incentive for those who agree to participate yet fail to follow the guidelines? I suppose buying participation could be questionable. But if colleges/universities can compensate for study participation why couldn't you? (Or you could just threaten to remove their ability to intubate in the field for failing to live up to their end of the bargain;) ).

Sounds interesting.

-be safe

The medics that improved went from around 40% to 80% on real patient intubations. Yes 40% wasn't very good to start with but the only variable that I could see was the mannequin intubations. The medics that did not participate showed no improvement. One medic was participating but stopped half way through for an unexplained reason (I suspect peer pressure.) His states went into the tank as he then missed his next four tubes. Not sure if stopping the mannequin intubations was the cause but it was interesting.

The power analysis showed we needed 48 tubes in order to show a 15% improvement which we met with 54 tubes for the study period. Yes the comparisons were based on the study year and the preceding year.

Incentives may be a problem for future studies but paying subjects to participate in a study has been done before. I'm not sure if it will make a difference here.

The current issue of JEMS has a brief article on OR intubations and RSI success. It suggests that OR intubations do not make a difference in success rates. I didn't like their definition of intubation attempt (passing the tube beyond the teeth) and they didn't require capnography.

Certainly an area for further study. Frankly one of the reasons for the lack of participation was no support from administration. We have two supervisors that had a ZERO success rate over two years! Go figure.

Ago porro quod prospicio. Thanks scott33--I love it.

Spock

Back to the research topic. I recently completed a prehospital research study on inproving intubation success rates. Everything I have read suggests that paramedic intubation success rates are in the 50-60% range. My service was no better and experience led me to believe the reason medics miss the first time is that they do not have everything ready before putting the blade in the mouth. I postulated that regular practice would improve first time intubation success rates.

I got 25 medics in my service to sign up and agree to intubate the mannequin every shift. We developed a check list they had to follow and intubate the mannequin within 30 seconds. The study ran for 12 months with 4 mannequin tubes each shift for the first 2 months and then 2 per shift the last 10 months. All the medics thought it was a great ideas and pledged to follow the study protocol.

The results were disappointing to say the least. Most of the medics just blew it off saying they didn't have time to intubate the mannequin. I should note we have an airway lab in our training center and the mannequins and equipment were readily available. They couldn't take ten minutes to do the tubes during a 24 hour shift but they had plenty of time to watch TV, smoke in the garage and surf fire department web sites.

I had planned to compare the service intubation success rates for the study year and the year preceding but the poor compliance prevented that. I was able to compare 5 medics that were diligent in following the study protocol and all 5 improved their success rates on the order of 100%. The statistician has the data and if it rises to statistical significance I intend to submit it for publication. I may submit it even if it doesn't have statistical significance but I'm not sure it will be published. Time will tell.

The study did generate some interest from a larger EMS system in the area and I might try to repeat the study with incentives for participation since the large system is interested in perhaps funding it. My mistake was staying small and believing the medics in my service were dedicated professionals. My fault.

BVESBC--If you can't run with the big dogs stay on the porch. Res ispa loquitor.

Live long and prosper. (Anybody know how to say that in Latin?)

Spock

When I first started working Penn State football games I was on a medic unit dispatched to one of the parking lots for a 23 year old male unconscious. When we arrived we found this guy unconscious as dispatched. His friends all swore he only had two beers and there must be something really wrong with him. They also identified themselves as paramedics and nurses from a large city. I was skeptical about the two beers but decided to give them the benefit of the doubt. We loaded him into the truck but needed the police to keep them from getting into the truck. High flow oxygen, nasal airway, glucose check, IV and narcan but he was still unconscious. We arrived at the local community hospital two miles away and I gave the ER staff my report. A nurse looked at me and said "Why the hell did you do all that treatment. He's drunk." She went on to say the only thing I did by giving fluids was to lessen the hangover. Their treatment for drunks is to put them in a room with a pulse oximeter and let them sleep it off.

I don't quite comprehend that philosophy but it turned out the guy's BAC came back at 250. I wouldn't treat the guy any differently even after working the games for ten years but I now ask how large were the two beers!

Live long and prosper.

Spock

Do the paramedics in the areas that are considering this procedure getting enough airway management practice to maintain their ability?

If they aren't, and most places don't, adding one more set of providers with an advanced skill that will not be practiced enough is not the answer. Educate the medics that need more practice so the EMT's won't need another add on skill.

I couldn't agree more with this and it is a national problem. I'm not suggesting that if an EMT and a paramedic crew arrive on scene of an arrest the EMT should place a King instead of the medic intubating. I do think that a BLS ambulance or BLS first responder unit that arrives on scene before an ALS unit can start CPR, use an AED and place a King airway. When the ALS unit arrives they could change the King only if ventilations are inadequate.

Will this cut the number of intubations by medics? Most definitely yes in some systems. This may be in our patient's best interest because we know now how interruptions in CPR are to be avoided and ETI results in stopping CPR for an unacceptable amount of time. Many medics have poor intubation skills to begin with and asking them to hit a moving target really puts them behind the eight ball.

I realize that many of you work in systems that place a high emphasis on intubation and have good con ed and QI programs. Consider yourself lucky and thank your medical director because I run in an area that does none of these things.

Live long and prosper.

Spock

Well, I agree with you on the first responder thing. I equate them with EMTs. No real difference to me. That's why BLS and EMT are not synonymous.

I equate BLS with anything that does not require a physicians order, regardless of who is applying it. After all, physicians, nurses, and paramedics apply BLS too.

I'm not saying EMTs cannot apply ALS. I'm saying that if it requires a physicians order, it is ALS, regardless of who is applying it. That is indisputable fact.

I think we are arguing over semantics. For instance: I arrive on scene of a cardiac arrest and start CPR and ALS interventions. I may talk to the doctor enroute to the hospital but I am not required to do so unless I want to call the code on scene. I never get a physicians order for any of my interventions because I am working under established protocols. Why can't the same hold true for EMT's using a King airway? Of course there has to be sufficient training and a close QI program to support it. We already have BLS protocols that apply to all EMS providers and I don't see why the King can't be added.

I do agree that it should only be used in the cardiac arrest patient.

Live long and prosper.

Spock

All sarcasm aside I equate BLS with EMT. First responders may be a different story although if they can place an oral airway and use a BVM I don't see why they couldn't use a King.

Live long and prosper.

Spock

I've been using the King LTS and LT as a primary airway in the OR for almost 2 years and have used it at least 100 times. As soon as PA approved it for prehospital use last year my service replaced the combitube with the King as a rescue airway. So far it has been used 5 times with good success. My experience tells me this could and should be a BLS skill (sorry Dust). I would also be interested in the Iowa study if it has been published.

I'm not going to get deep into the 70 second intubation discussion except to say I am not surprised. A study in Critical Care Medicine in August 2005 reported that almost 40% of PA paramedics had ZERO intubations during the study year. If you perform a skill rarely you will struggle with it.

Live long and prosper.

Spock

Congratulations and good luck AZCEP!

Now my story. I was an athletic trainer for 15 years (including 5 years in the NFL) when I decided to switch careers. I found a second degree BSN program which took 16 months to complete ( I already had a BA and an MEd.) I worked a year in an ICU. They hired me right out of nursing school because I was a medic and that hospital valued prehospital experience. Not all nursing departments do. I went to a CRNA program and got an MS. The program is difficult and time consuming. I worked as a medic while training as a CRNA because the pay difference between EMT-P and ICU RN was small plus I was able to study while working as a medic which was not possible while working as an RN. I have worked at a level one trauma center for 10 years but still find time to run on my community EMS agency.

Doczilla has many good recommendations especially the part about continuing your education. Don't stop taking classes even if you are not sure where you eventually want to go. Take classes that will apply to any higher education program.

I do disagree with Doczilla's opinion that working as a CRNA is boring. There are many different work settings and you make the most of what you have. I still find my work stimulating and enjoyable and yes the money isn't bad. We get paid well because we are valuable and in short supply. My work is not the same every day in that I may start the day doing a CABG and finish with a craniotomy. Yes I would be bored if I did gall bladders or hips all day but fortunately I work in a hospital that has a large variety and thankfully does not do transplants. Those are really boring!

Surgeons frequently tell me they want me or another CRNA in the room and not an anesthesiologist. I do the difficult airways where I work and the anesthesiologist pretty much stays out of the way. That is not the case everywhere. In fact, many hospitals in the US do not have anesthesiologists but only CRNA's.

I have the greatest respect for EMT's and paramedics that choose EMS as a career but I see many of them become frustrated because of low pay and little respect from other health care providers and the general public.

Good luck with your future education.

Live long and prosper.

Spock

Great picture!

I agree with others in that I don't see much value in starting a saline lock. Vicki: You might be more valuable to your patients by focusing on AED use and whatever airway interventions Kansas allows for EMT's. Good CPR and an AED will benefit your cardiac arrest patients the most.

I looked at the website ventmedic mentioned which lists the credentials of 50 states and territories. The list for Pennsylvania was incomplete in that it didn't list PHRN's or prehospital MD's. Not sure why PA didn't provide the most accurate information.

Live long and prosper.

Spock

My CPA has me deduct mileage for my responses to calls and the station for next out crew. I know it is a bad word but I am a volunteer if that makes any difference.

Live long and prosper.

Spock

Calcium is not a standard premedication for intubation. In the world of anesthesia calcium is very frequently used to raise the BP in conjunction with other meds (ephedrine and neosynephrine.) Calcium will increase contractility and hence cardiac output which is why we use it. We consider it a vasopressor and I use it when coming off bypass for the CABG patient.

I wouldn't recommend paramedics using it unless they have hyperkalemic arrest patient (renal patients) in which case you would also give bicarb. I agree with chbare regarding calcium when succynlcholine is given in the face of hyperkalemia.

Live long and prosper.

Spock

We carry dopamine and dobutamine premix on the truck and could mix an epi drip if needed. We don't carry levophed but I do use it in the OR if the SVR is low. I'm trained as a cardiac anesthetist so I prefer epi. Dopamine just makes them tachycardic at low doses and dobutamine is a great vasopressor when you don't need one. That's why I like epi. Put 4mg of 1::1000 in a 250cc bag and run at 15cc/hr which gives you 4 mcg/min. If you can't run with the big dogs stay on the porch!

We use vasopressin or isuprel as last ditch pressors. Those patients do not do well.

Live long and prosper.

Spock

Dust is right about the survival rates with amiodarone in the cardiac arrest patient. If you read the original research that lead to the inclusion of amio for cardiac arrests you will see that the incidence of ROSC was higher with amio than lido but the survival rates were the same. One study did not follow the patients through to discharge. Suboptimal research did not prevent the inclusion in the AHA guidelines because they were looking for a replacement for bretylium which went off the market.

Amiodarone is superior to many other meds for patients not in cardiac arrest. We start it for all CABG patients over 60 or CABG/valve patients because it has been proven to reduce the occurence of postop A-Fib. Amio is effective for just about every arrythmia except blocks. It is a good drug when used properly.

Live long and prosper.

Spock

When I worked on a hospital response truck the only time I had to beach the truck was when the ambulance showed up with only one person. That happened quite a bit. The police would make sure it was in a safe spot and keep an eye on it until the ambulance returned me to the truck.

We rarely have to leave the supervisors Suburban or the rescue truck because there is usually a FD QRS vehicle with two firefighters on these calls and they will take the truck back to their station. When I respond in my own car to calls I can count on the FD taking my car to their station. I just give the Chief my keys and he takes care of it. If I do have to leave my car at the scene we tell the police and again they will watch the car. We have never had a problem and an added benefit is most of the police in this area know me and my car. Never can tell when that may come in handy!

Live long and prosper.

Spock

I mix amiodarone with saline all the time and have never had a problem although the AHA ACLS guidelines mention using D5W to dilute it.

I think Dust was joking about giving both but I could be wrong. I have given both but not at the same time. I usually give amio and then wait for an effect before going to lidocaine. I also use magnesium with the amio. This is done in the context of v-fib during the rewarming phase of an open heart procedure. In the ambulance we go with amio and have gotten away from using lidocaine although we still carry it.

I did have a cardiologist tell me he had seen several cases of asystolic arrest after simultaneous administration of amio and lido. Lido stabilizes membranes by blocking sodium channels while amio prolongs repolarization without altering the resting membrane potential. Lidocaine works on sodium channels in phase 0 and phase 4 (in high doses) while amio works on sodium channels in phases 2 and 3. So, his theory was that if you give both simultaneously you wipe out all phases of the cardiac action potential and asystole results. Interesting theory that may have merit.

I think a big advantage of amio over lido is in the patient with an aberrant SVT. Lido doesn't work on SVT but amio does. So if you aren't sure if it's VT or an aberrant SVT amio is the drug of choice.

Live long and prosper.

Spock

I've been using the King in the OR for over 18 months as a primary airway and feel it is much better than the LMA or combitube. My EMS agency switched to the King from the combitube as a rescue device in April. It has been used 6 times since then with good results. Unfortunately that also means we have a bunch of medics that can't intubate.

Look at the King closely and I think you will like it. I didn't know the EOA still existed.

Live long and prosper.

Spock

I got a few chuckles out of the posts so far. I also don't think it should be a standard of care for EMS for all of the reasons outlined.

ER Doc is almost correct on the anesthesiologists ABC's. They have progressed to the point where now the book has been replaced by surfing the internet planning their next vacation! When I'm on call most of my anesthesiologists are smart enough to stay in bed and not get in my way.

On a serious note and off topic I do wish ER's would get wave form capnography. Only two of the ER's in this area have it and one never uses it. This is becoming the standard of care in the ambulances and should be in all critical care areas of the hospital. I am always amazed when I bring an intubated patient into the ER with good wave form on my LP-12 and they check my tube placement with an Easy Cap. Incredible!

Live long and prosper.

Spock

The best treatment I know of for motion sickness is a scopolamine patch. The onset of action limits its use in the prehospital setting. Zofran may help but won't completely prevent nausea from motion sickness.

Live long and prosper.

Spock

I have to agree with ventmedic about the training. The first week it was implemented in our area I was at the ED and saw another service bringing in a patient on CPAP and in a supine position. That struck me as odd and I later went by her exam room and saw her sitting up an on a nasal cannula calmly talking with the nurse.

I'm reviewing every use in my service in order to stop misuse. So far every time it has been used has seemed warranted although I do not have access to hospital records. Time will tell.

Live long and prosper.

Spock

Before Zofran went generic (ondansetron) we also got the happy grams reminding us of the cost when we used it in the OR. Now it is so cheap just about every patient getting a general anesthetic gets Zofran for nausea prophylaxis.

I can't see any reason why you would give phenergan before Zofran. Zofran is more effective and has fewer side effects. Maybe your command system is still paying the brand name cost.

Live long and prosper.

Spock