1st intubation! Any advice?

[jwraider]

Hello...

A few nights ago during my internship I succussfully performed my first field intubation. It was a trauma arrest and a fairly messy scene. Multiple GSW victim in PEA with police performing CPR on arrival and alot of blood on the ground.

My preceptor had told me that during our first code my only job would be airway. Due to this I had everything setup before everyone else was done packaging the patient. My preceptor said go ahead and after some initial issues with my view (I did not set myself up well just sitting there on the ground behind the supine patient) I got it.

Normally you BLS a trauma victim to the ambulance unless you need to treat flail chest or tension pneumo or your BLS airway isn't good enough, correct? Someone on scene suggested next time that I intubate "at the back of the bus" or in othe words bringing the patient to the back like we are going to load them but stand there and intubate right before going in.

What do you guys think about doing it at this time? It seems to make sense to me with the only draw back being a slight delay to transport time. It provides a good angle (just like an OR intubation in a sense) and if it doesn't work you can just hop in and go.

What I don't like is it makes everyone else stop what they are doing to wait for you and delays transport time.

Thanks for your thoughts!

[Just Plain Ruff]

I always prefer intubating in a controlled environment and the area behind the ambulance is much more controlled than inside the ambulance going 65 miles per hour down the road.

If the time it takes you to intubate the patient is going to make the scant difference between life and death for this guy then he's dead already.

[ERDoc]

This guy is a traumatic arrest. You can fly him to the moon and back and then intubate him. The outcome is going to be the same. The best place to intubate is where you feel most comfortable. When you are comfortable, it should minimize the time it takes thus creating the least delay in transport. I've known medics that tube upside down in the dirty bathroom stall of a very small bar but couldn't hit the trachea in a nice controlled environment (ER, OR). It is all a matter of comfort.

[p3medic]

The controlled environment in the back of the truck would be my prefered spot, you have on board suction, good lighting, privacy, etc...The key is getting properly positioned for your best view.

[parapupp63727]

Intubation is always and will always be the paramedics judgement. Even in an arrest situation it is your judgement where and when to intubate. Especially now since the AHA has put so much effort into researching outcomes of arrest pt's. Now we find that people have better outcomes if we focus more on quality chest compressions. I'm not saying neglect the airway by any means. What I am saying is that if you are acheiving good chest rise and fall with a BVM and an oral airway. Intubation can fall a little later in the algorhythm and sometimes not at all if you are close to the ER. Just food for thought my friend. Good luck and congrats on your first field intubation!!!

[Flasurfbum]

Advice? Don't miss.

Seriously, do it where you want to, as long as it does not affect chest compressions.

I worked with medics that told me to keep doing compressions while the tube, others insist on stopping. It all depends on their skill, the pts difficulty, and how they are feeling that day.

Do what you feel best.

And congrats man, from one student to another!

[snakemedic]

you got the tube, congrats, everything else is academic. If you ever get a chance read wallis book on emergency airway management and consider taking his course.

[knhollenbeck]

I remember my first intubation, gets me excited everytime I think about it, I always load the patient into the ambulance, then I throw in the tube, The back of your rig is the safest place, but I work in Detroit, so we don't do things on the scene, but in the back of the rig..

[jwraider]

I'm in a similair city so I hear you on the scene safety thing =)

Thanks for the helpful replies everyone!

[Mateo_1387]

A few nights ago during my internship I successfully performed my first field intubation. It was a trauma arrest and a fairly messy scene. Multiple GSW victim in PEA with police performing CPR on arrival and alot of blood on the ground.

Great Job. Sounds like you performed well. You intubated as a student, under a very stressful situation. :thumbright:

Normally you BLS a trauma victim to the ambulance unless you need to treat flail chest or tension pneumo or your BLS airway isn't good enough, correct? Someone on scene suggested next time that I intubate "at the back of the bus" or in other words bringing the patient to the back like we are going to load them but stand there and intubate right before going in.

From my education....

With trauma time is critical. In your case your patient was coded before you got on scene, chances are so great that you will not get a return of pulses. Waiting to perform intubation is probably not a problem. But your patient was dead right there (DRT).

For a trauma patient with a pulse, when you arrive on scene, some things need to be done on scene. These may include intubation, chest decompression, and hemorrhage control. As I remember from trauma class, trauma patients cannot tolerate hypoxia and heat loss very well ( If I remember what Dr. Cambell wrote correctly). Irregardless of what the second "intolerable" was, I remember that hypoxia is not tolerable. It is recommended to intubate as early as possible to ensure adequate oxygenation, as well as airway protection. Even a small amount of time of hypoxia can be detrimental to a trauma patient.

Sometimes things do not go "as the book says." For whatever reason, you may need to defer intubation. For example you may need to perform drug assisted intubation, your safety may be in jeopardy, or your patient may be in a bad position to be intubated, such as in a rainy field with mud everywhere, in knee deep water, or whatever you want the situation to be. Waiting to get into your environment may be key in this case.

What do you guys think about doing it at this time? It seems to make sense to me with the only draw back being a slight delay to transport time. It provides a good angle (just like an OR intubation in a sense) and if it doesn't work you can just hop in and go.

If you intubate on scene or intubate while going into the back of the ambulance, there will be a slight increase of scene time. The main idea for trauma if we are presented with an unstable patient is to perform lifesaving measures on scene, and then transport to a truma facility. Our interventions may buy a little time for the patient, but that is only to get them to what the patient needs, a trauma surgeon.

What I don't like is it makes everyone else stop what they are doing to wait for you and delays transport time.

I would not worry so much about everyone else stopping to watch you intubate. The should probably be finding "something" to do on scene to be helpful rather than spectating. This procedure is about the patient and their survival, not the inconvenience of the rescuer. I mean, that is what we are paid for, right?