intubation as a basic skill

[MeaganIV]

Sorry, but I have to respecfully disagree with this statement. Several recent studies have shown an equal efficiency by utlilizing a properly placed and sealed BVM with adequate ventilations of 10-12 / minute vs. immediate endotracheal intubation. Other than in the rare case of a patient who cannot physically be ventilated and thus requiring a surgical airway, endotracheal intubation itself is not a life or death item. Place an OPA/NPA and bag them. At the BLS level a combitube would be appropriate. For anyone who doubts the validity of this statement, you can refer to the current AHA standards for ACLS, PALS, and NRP. Advanced airway management in a full arrest now calls for intubation after the placement of an IV and after the initial administration of meds. There are enough Paramedics out there who can't successfully intubate because of the "stick the straw in the hole" mentality. What happens when you get a Cormick-Lehane grade IV airway with less than 10% POGO? What do you do now? No hole visible to stick it in!

On a quartely basis, I put on an advanced airway seminar. At the beginning of the class I give a pretest on the current trends and algorhythms of airway management. Here are 3 of the questions on the pretest.............

1. Describe the B.U.R.P. mneumonic.

2. You have a 12 year old, 40kg. patient. What size ET tube would you use to intubate this patient?

3. Which of the following are contraindications for the administration of Succinylcholine........

A. Myasthenia Gravis
B. A Potassium level of 7.2
C. Burns sustained 18 hours ago
D. A hypothermic patient
E. A and B
F. All of the above

The average grade.................46%

Now mind you, this is the average of the Paramedic grades. Experience varied from brand new patch to 20+ year medics.

Taking this information and adding it to recent studies which indicate a decrease in Paramedic intubation success rates in the "skill" of intubation, do you really want a BLS provider attempting it?????

Sorry, intubation should not be performed by EMT-B's.....................

Right there. Right there is every reason why EMRs should not and cannot perform ETs.

I shouldn't even be able to do it as an EMT-I under the supervision of a paramedic.

 

[MeaganIV]

We always employ the most basic maneouvers first. Thats the way it is. If I have a Pt who is in a hypoglycemic state and they can talk to me and follow commands and swallow I will administer oral glucose even though I do have D50W at my disposal and I have already established an IV line.

If I can secure the airway with an OPA or NPA then thats what I'll do. advanced airways are for enroute.. not for on scene.

 

[jeepmedic]

Ok I don't know who taught you folks how to intubate. I have pictures and video of my 3 year old intubating in a class this summer. And she is not even CPR certified. So NO IT IS NOT THAT HARD!!!!!!!

Flight LP as far as your little test.

1.Back up Right Pressure

2. You have to look at the pt. not a peace of paper.

3. If you don't use it you will not know. I don't so I don't care.

Now. If an EMT-B can't start an I.V. then how do you expect them to do a MAI? We are not talking about a Pt. that needs MAI we are talking about an unresponsive pt. that can't protect his/her airway. And yes if you do not do something they WILL DIE. Do you not remember that from First Aid. No Airway No Pt. you have a Body for the Funeral Home.

 

[MeaganIV]

Just because its "Easy" doesn't make it right!

dangerous things can happen with ETing. Things that as an EMR you cannot fix and WILL need a paramedic...


Thats the bottom line.

 

[jeepmedic]

Just because its "Easy" doesn't make it right!

dangerous things can happen with ETing. Things that as an EMR you cannot fix and WILL need a paramedic...


Thats the bottom line.

No just a competent EMT-B that was educated correctly. The airway is the first thing you should control. No air going in no O2 going in. IV's are missed more than Intubations. But I don't see you folks saying you should be a Dr. to start IV's. All you have to do is study, and try to understand what you are dealing with. I have seen Paramedics that could not put on a Traction Splint that could intubate. It is all about practice. The providers that miss the intubations are the one's that go back to the station after a call and sit on there arse and watch TV never studying or doing any practicals. When I was in class and even now we would get the dummys out and practice intubating, and do practicals to learn. We would also sit back and listen to the older Medics calls and ask questions. That is how we got to be where we are today. And yes we have EMT-B's that can intubate and do. We also have EMT-B's that can tell you the drugs in the drug box and what they are for. Why you ask? Because they ask questions and study what the medics are doing. I have one girl in my Dept. that just got her EMT-B that when we run codes she will hand me the drugs out of the box and she gets it right. She knows the drugs because she has studied and asked questions.

So to the ones who don't think an EMT-B can intubate you need to do some work and show them. How and Why. And for the ones who think it is to hard you need to get off the couch and practice.

 

[Flight-LP]

Ok I don't know who taught you folks how to intubate. I have pictures and video of my 3 year old intubating in a class this summer. And she is not even CPR certified. So NO IT IS NOT THAT HARD!!!!!!!

Flight LP as far as your little test.

1.Back up Right Pressure

2. You have to look at the pt. not a peace of paper.

3. If you don't use it you will not know. I don't so I don't care.

Now. If an EMT-B can't start an I.V. then how do you expect them to do a MAI? We are not talking about a Pt. that needs MAI we are talking about an unresponsive pt. that can't protect his/her airway. And yes if you do not do something they WILL DIE. Do you not remember that from First Aid. No Airway No Pt. you have a Body for the Funeral Home.

Perhaps a little less emotion may be in order, after all you are getting kind of freaked out over words written in an online forum!

How you can remotely coorelate a success rate of intubation between a live person and a lifeless, stiff, perfect anatomy mannequin is irrelevant. You are comparing apples to oranges my friend.............

I NEVER said anything about "not doing something". I said that an appropriately used BVM with airway adjuncts can effectively ventilate most patients initially. There is a distinct difference.............

I also never said anything about an EMT-B performing RSI / PAI/ MAI/ DAI (what ever your agency refers it as). The remote thought is horrific.........

As far as my "little test"...........

The reason that most people have difficulty with intubation is not due to the skill itself, but the assessment, evaluation, and delivery of the two. Failure to identify a need, waiting too long and then getting hurried, not properly evaluating and assessing a difficult airway (i.e the 3-3-2 rule, Mallampati classification), and failing to maintain an advanced airway are all causitive agents in why intubation fails and the bottom line is that too few know or realize it. Many have the exact attitude that you have "its easy and you just stick it in the hole". And that attitude is why current literature shows an increase in out of hospital death or neurological deficit post "intubation". It is also the reason why the AHA no longer recommends pre-hospital intubation of children (fyi - a documented 46% FAILURE rate).

Your response tells me all I need to know about your view of the subject so there will be no further debate from me, you are entitled to your beliefs and I'll leave it at that...............

BTW, You scored a 33% and Dr. Paul Pepe walked me through my first live intubation (since you wondered who taught me).................

 

[jeepmedic]

The reason that most people have difficulty with intubation is not due to the skill itself, but the assessment, evaluation, and delivery of the two. Failure to identify a need, waiting too long and then getting hurried, not properly evaluating and assessing a difficult airway (i.e the 3-3-2 rule, Mallampati classification), and failing to maintain an advanced airway are all causitive agents in why intubation fails and the bottom line is that too few know or realize it. Many have the exact attitude that you have "its easy and you just stick it in the hole". And that attitude is why current literature shows an increase in out of hospital death or neurological deficit post "intubation". It is also the reason why the AHA no longer recommends pre-hospital intubation of children (fyi - a documented 46% FAILURE rate).

Your response tells me all I need to know about your view of the subject so there will be no further debate from me, you are entitled to your beliefs and I'll leave it at that...............

BTW, You scored a 33% and Dr. Paul Pepe walked me through my first live intubation (since you wondered who taught me).................

I too think that the main reason for Failed intubation is not acting. But this is also true all the way up and down the Health Care system. The failure to act only makes a pt.'s condition worse. My point is and will continue to be that you educate Providers on the why of a skill before teaching them the skill. The physical skill is very easy most of the time. The problem with most providers is just getting them to see and act on a condition before it gets worse. I prefer to be proactive instead of reactive. Its like on the CO2 thread. Someone there said that you could see the changes in the waves before the pt. had a period of apnea. They bagged him and kept him from having that period. They saw a need and addressed it before it got worse. The same with Airway and Intubation if an EMT-B can see the need and can address it before I get there then great we are one step ahead of the game. It is not the EMT-B who can't intubate it is the provider.

 

[jeepmedic]

We always employ the most basic maneouvers first. Thats the way it is. If I have a Pt who is in a hypoglycemic state and they can talk to me and follow commands and swallow I will administer oral glucose even though I do have D50W at my disposal and I have already established an IV line.

If I can secure the airway with an OPA or NPA then thats what I'll do. advanced airways are for enroute.. not for on scene.

Ok if you have a Pt. that can talk and is just hypoglycemic and can follow commands, Why did you Start an IV in the first place? And if you have an IV then is quicker to give D-50. Or if no IV and they are talking to you why not fix them some breakfast? (this is not a sarcastic comment and the one who did this knows what I am talking about.)

You should not intubate in a moving ambulance. What happens if you have a sudden stop, or a bump?

Can a Pt still aspirate with a OPA or NPA? yes. So the airway is not secure.

 

[MeaganIV]

Ok if you have a Pt. that can talk and is just hypoglycemic and can follow commands, Why did you Start an IV in the first place? And if you have an IV then is quicker to give D-50. Or if no IV and they are talking to you why not fix them some breakfast? (this is not a sarcastic comment and the one who did this knows what I am talking about.)

You should not intubate in a moving ambulance. What happens if you have a sudden stop, or a bump?

Can a Pt still aspirate with a OPA or NPA? yes. So the airway is not secure.

Very good question. We start an IV of NS, TKVO incase we do need to administer drugs via IV line.

We only admininster D50W if the Pt is unconsciouse. IF they are able to swallow, we always implement the simplest solution because there are certain risks with D50W. After the administration of oral glucose, dextrose, or glucagon we do have food ready for them. They're hypoglycemic. They need food.

A pt can still aspirate any time! thats what happens! Intubation isn't going to stop them from throwing up and sucking it back in. Thats always a precaution. Always.

 

[jeepmedic]

A pt can still aspirate any time! thats what happens! Intubation isn't going to stop them from throwing up and sucking it back in. Thats always a precaution. Always.

Yes it will.

 

[JavaMedic]

THe thing about intubation is that it actually does require more skill then you think.

Its dangerous, invasive, and has consequenses especially when trying to place it.


It should not be a basic skill because it is NOT basic.

It's about as basic as you can get. See the cords. Drop the tube. I've been through EMT-B, EMT-I, EMT-P and CCP. The training I received for intubation was more indepth in the basic class than any other class with the exception of RSI. I've had more in field tubes than years I've been on this earth. I've missed my share and am damn glad that my "just a basic" partner was there to bail me out. Some basics have way more experience at intubation than a lot of street medics out there.

 

[MeaganIV]

It's about as basic as you can get. See the cords. Drop the tube. I've been through EMT-B, EMT-I, EMT-P and CCP. The training I received for intubation was more indepth in the basic class than any other class with the exception of RSI. I've had more in field tubes than years I've been on this earth. I've missed my share and am damn glad that my "just a basic" partner was there to bail me out. Some basics have way more experience at intubation than a lot of street medics out there.

I'm really not debating that. Truely. I just really think the skill needs to be done with a paramedic present.


I'm sorry. Thats how I feel..

 

[JavaMedic]

You feel that intubation is above you yet you'll start an IV. Can't get more invasive than that. A myriad of dangerous consequences follows IV cannulation including overload, aterial puncture, catheter shear, allergic reactions, local infections, air embolism, necrosis...etc. The list goes on. Sounds like that should be a medic only skill as well then.

 

[MeaganIV]

ohhhkay. Thats fair. I'm not going to argue my point. I think it has been made.

I think that IV's are easier and less invasive but thats my opinion.


To each his/her own right?


Gotta get back to this here studying, have a gooder all!

 

[JavaMedic]

I agree to each his/her own. But regardless of what level you are at learn EVERYTHING that you can about the next one up. The more that you know and the more aggressive that you are means a much better partner that you will become and a much better advocate for your patients.

 

[jeepmedic]

You feel that intubation is above you yet you'll start an IV. Can't get more invasive than that. A myriad of dangerous consequences follows IV cannulation including overload, aterial puncture, catheter shear, allergic reactions, local infections, air embolism, necrosis...etc. The list goes on. Sounds like that should be a medic only skill as well then.

thats what I wanted to say.

 

[Bandaid]

I agree with R/R. I mean, intubating takes skill. Its a highly invassive procedure and needs a great deal of know how. I'm not allowed to do it as an EMT-A but with the supervision of a paramedic I'm allowed.


A lot can go wrong with tubing such as insertion. The tube could be placed in the esophogus and create gastric distension, even though the placement isn't blind. It could be placed in to far and will only inflate the right lung.

it can also hit the vagus nerve and mess up the heart rate leading to dangerous arrythmias.

ugh.

Have you even intubated before?

 

[MeaganIV]

Have you even intubated before?

Nope. Haven't needed to.

 

[Fedmedic]

If a pt. is properly intubated and the tube properly secured. There is no chance of aspiration unless someone pours something down the tube.

 

[MedicPrincess]

Meagan-

First I will tell you I am going to be starting my fourth 48 hour shift in 2 weeks tomorrow, so it may be day or two before I can read your response....

I understand your point that ET intubation should be a paramedic procdure. Its an ALS skill, Medics are ALS. But what I would like you to help me understand is your belief that intubation is harder than starting IV's, because in most cases I would strongly disagree with that.