The final word on combitubes

[flight-lp]

Interesting perspectives from all around. Personally, I believe that a Combitube is a great rescue airway, but should be limited to that use alone. Three unsuccessful attempts at definitive management would be an indication for use. However, what really surprises and in some ways disturbs me is the way that people see an indicated use at the BLS level. The very same people (general descriptive statement for several EMS forums) that always scream "BLS before ALS" are the ones suggesting misuse of a Combitube. What ever happened using a good 'ol BVM with a proper seal and appropriate ventilations? Need to keep an airway open, then place some pharyngeal airways. All of this, well what about if xxxxx happens, well, the reality is that definitive airway managment is not appropriately performed at a BLS level. You need ALS providers, period. People need to stop making excuses and justifications as to why some things are perceived as acceptable and start offering a level of care that could provide the minimal level of appropriate care. Sorry to rant, but I've seen more EMT's screw up things they shouldn't be doing in the first place than I have seen Paramedics not being proficient enough to perform at the ALS level. Thats my perspective, take it as you wish............

No apology needed Asys, great topic to bring up. Hopefully it will shed some new perspective on this topic and will help in closing a topic that has really been beaten to death........

[croaker260]

So, in my opinion, given my knowledge of airway management and EMS capabilities and experience in the field, the number of patients who can can have their airways effectively managed with a combitube and BLS procedures, in my mind, is very limited. To sum up, really the only people who can be intubated or combitubed without sedation are people who are dead, or people who are unconscious. If you are dead, the combitube isn't going to help, and if you are unconscious, you typically need ALS intervention beyond airway management. Given these facts alone, I think combitubes and BLS don't mix, combitubes should be utilized as a back up to proper intubation.

That's my opinion. Let's hear yours.

And that is the only role for combitubes at the BLS level. I dont think anyone ever suggested that BLS levels use it for anything else. considering that in many rural areas of the country with out the skill set, skill practice, training resources or call volume to support a medic. I wish more services , including major metro services, would either go to a tiered response system to promote truely ADVANCED life support, or get offf the pot so to speak...and focus their paltry efforts to BLS.

Idaho is full of areas like this, frontier areas where the ONLY ALS is by air, and often grounded in winter due to weather. Whether 5 minutes and 5 hours from hospital (usualy a PA staffed clinic), having these skills in an ALS poor environment, to get them to ALS or to get them to the local clinic or hospital, is essential .

I would rather have a well trained EMT-B/I with a combitube that a poorly trained medic with an ETT. To suggest otherwise that it is better to have a medic when you know that medic isnt going to get the training support or calls needed to stay proficient, is the real cop out and excuse..that "ALS is the standard of care". It is not.

It (ALS ) should only be there for systems that can prove the need, and more importantly IMHO the ability to support paramedic level care. The simple fact is that if you move out to the wilderness, and you chose to not support your community on providing GOOD paramedic service, then you not only deserve BLS/ILS care, but are in all seriousness, are probably better served by it.

Having worked in TN with combitubes and PTLAs at the BLS level, as well as a Paramedic there, I do think they are a valuable tool for BLS.

Medics should have the combitube (or airway de jour) as a rescue airway, with extensive (read: lots more than most services require) airway training and RSI. if a service choses not to support a true advanced level of care...then those agencies should function at a BLS or mother may I ILS level, tubing only dead floppy patients. I dont careif you are DC metro or BFE Idaho.

besides in most cases BLS or ILS is all thats needed.

[island emt]

Large round of applause for Steve!!!!!!!!

[AZCEP]

Expecting the combitube to "rescue" an airway is one of the great errors that we make.

It's very design will not allow it to work very well once the friable tissue of the laryngopharynx has been traumatized by bad laryngoscope technique. Where an ETT can still be placed through vomitus, or blood, the combitube tries to seal these substances off. When they fill the area around the glottis, the combitube can't perform effectively.

Yes, it is a useful tool. As long as those using it understand when it will and won't work.

[Dustdevil]

I'm disappointed in you, Steve.

I've never known you to get all caught up in "tools" and "skills."

You know that is not what the practice of EMS is about.

[croaker260]

Dust,

I am confused how you got that I am focused on skills when I mentioned the requirements of training (and my thoughts on that) several times related to airway management..

Dude, I think we are probably on the same sheet of music, just at different parts of the symphony....

AZCEP, As for the combitube, well I wont disagree that their are not the best rescue airway out there, and "rescue airway" is the common term these days, is it not?..anyway, hence I mentioned "airway de jour"...I myself am NOT a fan of the LMA....the King LTD shows a lot of promise but I haven't actually laid on hands with it yet...but having used the combitube (and the PTLA, and the old EGTA)as a BLS/ILS and a medic....as well as wrestling with the issues of training and standardizing response in a system with several agencies wanting to use this, I am a fan of the combitube because of the ease of training, the trouble shooting procedure is simple, and durability. Is it perfect, no, but its a good fit for the BLS/ILS level I believe, who in most systems will use this far less..like 1-3% of call volume...than other skills.

and while I may be stoned for this, from the beginning I did not think that ET was a good fit for the BLS/ILS level..we have a hard enough time getting medics to do that skill right in the field.

And yes I recognize that there are other rescue techniques out there, including retrograde and the various versions of a needle/surgical airway. There is also the bougie (which is AWESOME! Love it!).

DO I think it is a replacement for the ETT at the ALS level? No, But I would rather a medic go through his ABC difficult airway approach (A-Alternate -provider/blade, B- Blind airway/BVM/Bougie, C- Cric) systematically, and get sometype of airway control or decision in under 7-10 minutes (or much less preferably) than sit on scene or in the rig for 30 minutes dicking around with the airway while the patient stayed hypoxic....which I have seen happen (including by a flight crew).

[Dustdevil]

I would rather have a well trained EMT-B/I with a combitube that a poorly trained medic with an ETT. To suggest otherwise that it is better to have a medic when you know that medic isnt going to get the training support or calls needed to stay proficient, is the real cop out and excuse..that "ALS is the standard of care". It is not.

It (ALS ) should only be there for systems that can prove the need, and more importantly IMHO the ability to support paramedic level care. The simple fact is that if you move out to the wilderness, and you chose to not support your community on providing GOOD paramedic service, then you not only deserve BLS/ILS care, but are in all seriousness, are probably better served by it.

It seemed to me that the point you were making/conclusing you were drawing was that it's just fine to run a system without paramedics, so long as the basics can perform ALS skills.

Now it seems that you are equating training with education, which also disappoints me.

Sorry if I misunderstood you.

[croaker260]

You have misunderstood me. I am not saying that just fine to run a system without paramedics, so long as the basics can perform ALS skills. What I am saying that it is better to run a good BLS or ILS system than a poor ALS system. I also believe that many urban areas as well as rural areas would be better served by more BLS/ILS and reduced ALS. I think where some confusion develops on the fact that many so called ALS systems only run at what is basically a ILS level. Their medics simply dont do much.

Perhaps our view of ALS, ILS , and BLS may differ a bit. I came from a state wide system where even in the early 90s combitubes/PTLA were BLS always thought of them that way, while i think that ETT should only be ALS, depsite the "ETT modules" that came out inthe 90s for EMT-B. While this is a different thread, I believe fully tthat benadryl and glucagon should be BLS scope, unless the state in question allows a EMT-I level. I just dotn think that you need a medic to administer benadryl , epi, or nebs. sue me.

of course I believe also that EMT basic should be at least a 200 hour course before adding scope.... Again a different thread.

And I fully recognize the difference between education and training, thankyourverymuch!

[Dustdevil]

of course I believe also that EMT basic should be at least a 200 hour course before adding scope....

And I fully recognize the difference between education and training, thankyourverymuch!

LOL!

Do you not realise how contradictory those two statements right there were?

Apparently you do not recognise the difference after all.

[brentoli]

I have used a combi-tube but have not used a OPA in the field. There for I can't really judge it based on experience, I do know though, the one combi-tube I placed, the medic's first action was to cut the bladders and try to intubate, which failed all the way to the hospital.

I belive it was a DRT paitent anyway and it didn't have an effect on the outcome, however, the medic did not even check the tube placement or even did anything else. His first action in the door was to remove the combitube.

Our placement was good, bi-lateral breath sounds and nothing in the abdomen. The first 3 pumps on the bag filled up the belly.

What are some ALS thoughts on this?