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Paramedics and The ET Tube

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Ambulance Driver – Is It Time We Gave up the Endotracheal Tube? and Happy Medic – Thoughts on ETI have both recently posted about paramedics and intubation. Here are my thoughts on the subject:

My paramedic program required 10 live intubations in the OR. I did my first 9 with such ease that the anesthesiologist was recruiting me to join his practice. I then missed on my next 3 attempts all within 20 minutes of each other.

I got my first field intubation in 1993 during my ride time. It went in easy and caused me to do a funky moon walk break dance afterwards in the ED parking lot. I got a second ET while riding with another medic, but couldn’t get the job done on my only ET attempt while precepting. My first chance to intubate on my own, I missed and ended up having to use the bag valve mask all the way to the hospital where I delivered a very dead patient with a lot of air from difficult bag valve ventilation in her belly. Over the years I racked up well over 200 intubations, but as I have mentioned previously, I did not always get them on my first attempt. This I can say: the more I intubated the better I became. I attribute that to experience and a willingness to attend every airway class I could. Where my preceptor had to take over for me when I couldn’t get the tube, as a preceptor, I have on many occasions, had to step in and get the tube when my preceptees could not despite allowing the preceptees two tries.

Over the years I have been witness to and also heard many accounts of pass the larenygyscope codes, observed significant delays in compressions while ET was attempted and, while I have never done it, I have heard of and witnessed medics bringing into the ED patients with ETs in the belly (I have even seen this after the implementation of waveform capnography, although it is a much rarer occurance).

When I started we didn’t have supraglottic airways. We didn’t have backup airways. We didn’t have rescue airways. It was ET or bag. I believe if, when the world was young, there were King LTs, Combitubes and LMAs, the gods who created us, might never have given us the ET tube.
Does this mean I think paramedics should no longer be allowed to intubate? No, but I do think medics have to be retrained in how to think about airway management and to approach each airway encounter with an open mind to what will will be best way to ventilate a patient and pose the least risk to the patient.

Lately, in my job as a clinical coordinator, I have had a unique opportunity to sit in on regular SIM Lab airway sessions taught by two outstanding airway physicians and have really had my mind expanded into both the proper thinking and preparation that should go into each airway encounter. Three thoughts I have learned should always be in a paramedic’s mind when approaching an airway: 1) What is the best airway for this patient? 2) How can I maximize my chances for success on the first pass? and 3) What are my backup and my rescue plans should things not go the way I want?

I do believe there are situations where an ET tube is a critical option for the patient and it would be a shame not to have it available. But if it is available, paramedics have to have the training, equipment and medical oversight necessary to see that their patients get the best airway care possible. The days of handing a larengyscope to a new paramedic and telling him to go out and not kill anyone need to come to an end.

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Note:

Kelly Grayson, aka Ambulance Driver, mentioned one of his previous column’s in a comment to this post. Read The Airway Continuum in which he writes about what it takes to accomplish the necessary airway training. Excellent article.

Our annual airway training, which we are now instituting, for the RSI medics we sponsor includes a 4 hour diadactic class in airway management with review of all the services’s RSI attempts from the previous year, a 3 hour SIM Lab airway session, minimum 6 tubes per year(if you can’t document field tubes, the medic can go to the OR or SIM Lab to fill in the rest), and passage of an annual exam. Medics also have to participate in an annual skill session that includes intubation and surgical airway using pig tracheas.

I would like to see all services, RSI or not, be required to have an annual 4 hour airway session, annual skill sessions, and annual tube minimum that can be filled out with mannequin intubations if the number of field tubes are not reached.

The key to it all, I think is the class with an emphasis on ventilation not intubation. By all means read Kelly’s article.

Posted by on March 28, 2011 • Filed under: ems-topics • Tagged: , ,

Combitube!

8 comments

20 years ago when I was an EMT-Intermediate, we used a device called an EOA (esophageal obdurator airway). The airway was designed to occlude the esophagus, thus enabling supraglottic ventilation. The main problem with the EOA was sometimes instead of going in the esophagus, it ended up in the trachea and was not recognized. I was only an Intermediate for about a year before I became a medic and never got the opportunity to use one.

Eventually, the EOA was replaced by the Combitube. The Combitube had an answer for the EOA going in the trachea. It has two lumens. In most cases the tube ends up in the esophagus, but if it ends up in the trachea, it can be used like an ET tube and ventilated through the second of two ports. The problem with the Combitube is it has two ports, and you need to figure out which one to ventilate. Simple if you are playing with a mannequin, but the thought of figuring it out in the heat of the moment in a live patient is not quite as easy to dismiss if you have never used it before on a live patient.

In my first years as a medic we didn’t carry Combitubes. The service had a few intermediates and when they went out with basic partners they took the cardboard box holding the Combitube with them, but it was never left in the ambulance. A backup airway wasn’t in the paramedic parlance then. If you didn’t get the tube, you bagged the patient. If you were a self-respecting paramedic, you usually always got the tube. When you came in with the patient, the question was always “Did you get the tube?” not “How long did it take you to get the tube?” or “How many tries?” I went seven years in a row and always got the tube. But like I said, we didn’t count the number of times we tried or how long it took to get the tube.

Then we started carrying the Combitube regularly, but it was strictly a backup. It wasn’t in the in-house kit, it was it is that bulky cardboard box shoved deep in some cabinet.

Once a year at skills sessions, we could play with one if we wanted. I’d pick it up and look at the two ports and try to figure out which one was which. I’d figure it out enough to drop one in the airway head, but I didn’t think I would ever use one. Hey, after all, I’m a medic and the medic gets the tube. Ask me then which port you ventilated first, the blue one or the white one and I couldn’t have told you without more than a fifty-fifty chance of being right. Same with how much air you put in each balloon. One was 15, one was around 85.

In recent years we made the Combitube and the LMA alternative airways, not just backup airways. Still, I kept getting the tubes. Then we went to limiting ET attempts to 2, I started carrying the LMA in my in house back and last year used it a couple times with some success. I wrote about one such call in The Battle. I used an LMA again earlier this year as a first line airway in a cardiac arrest. It worked well. Meanwhile the Combitube was sitting on the shelf in its cardboard box.

So now I am back in the city. In the city, many of the inhouse bags have the Combitube in a flexible package rolled up in the in-house bag. The LMAs are in the cabinet. When I noticed this, I thought to myself, maybe if I get the chance, I’ll give this Combitube a try (if only I can remember which port is which.)

First cardiac arrest back in the city. Obese man on the second floor of a hoarder’s house, laying in bed in the corner of the room with a wall against the side and head of the bed and newspapers on the other sides, first responders standing on the bed, doing CPR. I looked at the round head, and no neck and crooked front teeth and I looked at the walls and the piles of hoard, and the picture in the bubble over my head was clear. “Combitube!”

I spread the teeth, pulled the tongue a little and shoved that tube on down to the teeth markings. Went in easy. I attached the capnography without hesitation to the blue tube and ventilated. On the monitor it read ETCO2 60 with a wave form. How easy was that! I did have to wonder aloud how much air I had to put in the balloon, but the other medic on scene who held the syringes stepped up and inflated them for me. (We talked about combitubes afterwards and he said he has had such success with them, he often uses them as his frontline airway).

No interruption to CPR, No having to reposition the unpositionable patient, no laying down on my belly to intubate, no staring down the throat hoping to see the chords. Just slide it down, attach the bag and ventilate. I did attach a tube holder, which was the most difficult part of the operation, but even that didn’t take more than ten seconds and didn’t interrupt CPR.

The tube was solid too. It held perfectly all during the getting the patient on a board and carried out of the cramped hoard-filled room and down the stairs and out to the front yard where the stretcher sat. Another medic told me once, you could drag someone out of a house by their Combitube it was that solid. I can see that. ETCO2 of 30 with perfect wave form all the way to the hospital.

My first Combitube use ever! Woo-hoo! I was impressed.

***

Here’s a Combitube video on a live patient where they use a larengyscope (interesting!):

And here’s some more information on the device:

Combitube

Posted by on March 21, 2011 • Filed under: ems-topics • Tagged: , ,

Division of Labor

3 comments

If you work commercial ambulance in a high volume system, and if one of you is a paramedic and one an EMT (the standard in our system), you and your partner are going to need to work out a way of dividing up the calls. In the course of your shift (Mine are 12 hours), you’ll do ALS, BLS, 911s and transfers. No two days are going to be alike.

My old partner Arthur used to talk with disdain about one paramedic he worked with. “He told me he didn’t do BLS,’” Arthur complained. Translated that meant Arthur teched all the transfers and all the BLS calls. The medic only did a call if it meant he had to pop in an IV or hook the patient up to the monitor, and this medic was not aggressive in his ALS care, which meant there were days Arthur did all the calls.

That’s not how I do it.

Here are my rules (guidelines) for division of labor.

I do all ALS (any call requiring a cardiac monitor, IV, advanced airway, medication, or anything only a medic can do), and whatever BLS I choose to do.

If we haven’t done ALS, and my partner has already done the first two BLS, I’ll do the third BLS, and then we’ll alternate provided we haven’t done any ALS in between.

Same with transfers. My partner does the first two transfers. If I haven’t done any calls yet, I’ll do the third.

I never have my partner get 3 calls ahead of me (unless he wants to do the calls).

Other circumstances may apply. If my partner is feeling sick, I may do more of the calls.

If one day I do all ALS all day, and the next day, it’s all BLS, and my partner wants to do the calls, that’s fine with me.

Here is the general mathematical formula, where “X” stands for the EMT and “y” for the paramedic.

X + 2 = y does the next call.

There you have it.

Posted by on March 14, 2011 • Filed under: ems-topics • Tagged: ,

Blogging (Repost)

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Below are my thoughts on blogging that I have previously posted and that can always be found under the Blogging page on the banner line. It is important to refreash my readers and myself what this blog is about.

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I occasionally have people ask me for advice about writing/blogging about EMS.

When I first considered starting a blog, I consulted with “the MacMedic,” a paramedic who at the time was working in my state. He gave me some advice as well as directing me to a blog post written by Tom Reynolds, an English EMT, and author of the blog, Random Acts of Reality. (Reyonlds turned excerpts from his blog into the book, Blood, Sweat & Tea: Real-Life Adventures in an Inner-City Ambulance.

Here is Reynolds’ post on blogging:

How To Blog And Not Lose Your Job

I followed Reynolds’s advice, as well as advice given to me by the Macmedic, and made certain my employers knew I was writing a blog. I emphasized to them I valued my job and was open to any changes or suggestions to prevent any problems. My policy is not to rank on anyone or the company, or at least not in a hateful way. I occasionally rail against the system, but not against any individuals. Generic subjects can be fair targets; identifiable ones are not. While in my books I used the real names of my partners and coworkers believing they deserved credit for the fine work they do, I have chosen for the most part not to follow that course on the internet. Consequently sometimes my posts appear as if I am the only responder there or if I have a partner, they are largely faceless, unless the story is centered around their involvement on the call.

I have also taken great strides to protect patient confidentiality. In addition to changing identifying details, I often use a randomized method of selecting sex and age to further obscure any case that might be known to the public. In only a few cases have I not written about a call for fear that I would reveal personal details that could be readily identified. In other cases, I have written about a call months out of sequence. It is easier for me to write about calls when I am working in the city and can respond to any of a number of towns beside the city, than when I was working in the one suburban town to which I was assigned.

I think it would be very difficult to write a blog in a small town with a low call volume and still protect confidentiality. The greater the population you serve, the easier it is to safely write about a call. I have heard many stories of small town bloggers offending fellow crew members or even town residents. I would advise anyone writing about a small service to be extremely careful in what they write, as you should even in a larger service. Write as if you were standing in front of the town, giving a public reading.

The one area where people seem to get in the most trouble is with photos. When I first started, I was tempted a number of times to post a photo of an accident scene, even once going so far as uploading a photo of one mangled car very relevant to the story, but was unable to push the publish button out of fear I was crossing a line. A newspaper or TV station can show the pictures, but health care providers cannot. I would think the only way you could post the photos safely would be to show a photo that does not in any way identify a person or specific car or accident scene and post it at a date different than that on which it occurred. When in doubt I would always first check with your company’s policy. Many companies now have policies prohibiting both the taking of photos unless taken with an officially issued camera and then only for patient care purposes. If your company doesn’t have a policy, you might want to work with them to develop one.

As important as I believe blogging is in spreading the word about what life is like in EMS, I don’t think it is ever worth losing your job over.

As far as a personal policy, I would say this:

Don’t use writing to put someone else down, particularly someone who cannot properly defend themselves. Don’t be cruel. Write to elevate what we do. Write to elevate the spirit you have seen in people you have cared for — in their worst and best moments. Write to share your human experience with those who can benefit from it. Record your stories, your thoughts, and your revelations. Use your writing to try to understand the world, not to condemn it. Share your victories, your defeats, your frustrations and your hopes. Write to show that you have walked down the EMS streets.

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Some final thoughts. Blogging about EMS is an excellent way to stay fresh. By looking for material, I can see interesting things I might not have noticed. It keeps me from falling into a rut.

Blogging can be particularly useful for a new medic. Writing about a call can enable you to think about it in a new way, as well as to learn from the comments of readers. The experiences we have that can seem isolated to ourselves we learn are actually fairly universal.

Everyone should find their own angle so that they are writing about what interests them. Some blogs are story-centered, some medically centered, some are very introspective, and others go for the humor. Write what you enjoy.

It is not a bad idea if you are thinking of starting a blog to read the work of others.

I have quite a number of blogs listed in my blogroll. While I don’t read them all everyday, I periodically check in on them to see how they are doing. They all have their own voice and are worth a listen. Find someone with a style that matches yours and learn from that blogger.

There are many excellent bloggers out there waiting to be discovered. If you start a new EMS blog, don’t hesitate to send me a link, and I will add you to my blogroll.

Note: My Blogroll has been broken for awhile but I hope to get it repaired soon.

Together, we, as EMS bloggers, are painting a fresh immediate portrait of what our work and world is really like that you can’t find anywhere else. Our contributions help others; both fellow EMSers and members of the public understand our unique and extremely important profession.

Keep up the writing and stay safe!

Posted by on March 10, 2011 • Filed under: ems-topics

Splinting (Update)

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My quest to be the Architectural Digests’ Best Splint Ever Winner, as well as getting an award for Most Improved Splinter continues.

Since I posted — Splinting — I have had three opportunities to splint.

1. A call almost identical to my previous post. Man fallen with lower tibia pain and deformity at the ankle. In addition to elevation, ice, and padding, I used a cardboard splint and cravats instead of a pillow. I used pillow cases to fill any void. No change in pain. 100 ugs of Fentanyl later and the patient was feeling better. At the ED, they undid the splint to examine the injury. When I went to say good bye to the patient, splint undone, his foot was elevated on a pillow, he was starting to feel some more pain. Fortunately, a nurse came in then with some more Fentanyl and all was well again.

2. Patient with anterior shoulder dislocation moaning to the Lord Jesus to help her with her pain. Now, if I ever were to suddenly go mad — me — a stark raving lunatic shouting on a street corner, after this call, there is no way I could ever claim that I was the Lord Jesus because nothing I could do helped this poor woman with her pain. Applying a sling and swath (see picture from previous post) on a practice patient is one thing, applying it on someone who feels excruciating pain just being breathed on, is another. I have done many sling and swaths in my time, but sometimes the patient won’t stop moving and what is left does not resemble what you started with. I gave her some Fentanyl IM, then tried to splint again. We managed to get it on, also using a pillow, but had no luck finding any kind of position of comfort. After getting an IV, I eventually drained my standing order limit of Fentanyl and called for more. “Lord Help me Jesus!” she screamed as I spoke with the doc. No relief. Ice, padding, pillows, sling and swath, 200 ugs of Fentanyl. I considered getting on my new I-phone and Googling to see if there was any online way to get a medical degree in 5 minutes so I could learn how to reduce a dislocation (not in our paramedic scope of practice) and legally do it in the field because that was likely the only thing that was going to help her pain. But no luck finding such a course. In the ED, she got a milligram of dilaudid. She was still crying and rocking back and forth as I left. It was a sorrowful haunting, tear-strewn cry – a cry I have heard in many EDs. “Help me, help me, Jesus!” Despite all our efforts, sometimes we just don’t have the tools to take away the pain. (In retrospect, I might have called for a touch of Ativan).

3. Fall with hip fracture. Man on ground with 7 of 10 pain. Now a recent post there was a comment about how much you can learn working with another medic. Since for many years I have worked solo, it was with great delight, I got to work with another medic on this call. (He responded in a fly car while I was in the transport ambulance). The medic suggested we try a reverse KED splint. Having never heard of a reverse KED for a hip fracture, I was instantly intrigued. “Tell me more!”

After I premedicatied the patient with 50 mgs of Fentanyl, we carefully lifted the man’s torso and legs and slid the upside down KED underneath him. We wrapped the main part around his hips using the three chest straps. The head pillow was folded and placed between his legs and then his legs were wrapped around it with the head straps. It was AWESOME!

We carried the patient, who we also backboarded, down three flights of stairs with no discomfort. Pain free on arrival at the hospital. “Behold the Reverse KED!” I declared. The ED staff was very impressed. “I call it ‘The Canning,’” I said. “I thought of it myself!”

Actually, I call it “The Dennis.” Kudos to a great medic. Thanks for passing on a tip of the trade! Never too old to learn.

Posted by on March 8, 2011 • Filed under: ems-topics • Tagged: , , ,

The Heart of Health Care

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Last week, as I stood in an ED room for the first time in many years getting ready to take a patient out instead of bringing a patient in, the nurse walked in to say goodbye to the elderly patient as we spread out a clean white sheet on our stretcher.

The nurse said, “Well, good luck Mr. Jones. I hope you are feeling better.”

“Thank you, Joe,” the old man said to the nurse. “You were very nice to me. You have a comforting bedside manner. You are a good guy, and I appreciate it.”

You have these moments in life. Sometimes you see something for the first time. Other times you are just reminded of basic truths. This was such a moment for me when you see the world very clearly.

I spoke up then, and said to the nurse. “What a high compliment he just gave you. You should be very proud of that.”

The nurse blushed and lowered his eyes and said, “Thank you, most people think I tell bad jokes.”

***

So we put the man on our stretcher, fluffed his pillow and wrapped him against the cold, and we drove him through the city streets to the highway, where we headed north to his town. When we found his small house on a quiet residential street, we backed into the drive, and then went and got the door open and ready before we took him out of the back, where the heat was keeping him warm. We carried him into the house on our stretcher and then went out and got the stair chair and carried him up the stairs to his bedroom, where his wife of fifty-three years was preparing his room. “This beautiful woman can’t possibly be your wife,” I said, “Unless of course you are a lucky man, which I now see you are.” The wife smiled broadly and the man laughed and they looked at each other in the way people do who have spent their lives together through good and bad, and know they have never lost their faith or their sense of humor. We got him settled into bed and and we joked some more and exchanged well wishes with them. And then the man and his wife thanked us again for helping them.

And my partner and I left and drove back to the city.

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I mentioned in my last post I am reading this book called Outliers: The Road to Success. The book examines the lives of people like Bill Gates, and professional hockey players, concert violinists, top Wall Street lawyers and children from disadvantaged neighborhoods who have gone on to be the first member of their family to go to college and others who have risen to the top of their fields. The one overriding theme in all of their lives is that effort equals reward. People who are most satisfied with their work and lives are those in fields where they can see the result of their labor.

What I like about EMS and health care is that if you view the work not as about saving lives, but as about treating people well, then on a day to day basis, your effort will be rewarded. And the reward is more than a check that is good at the bank at the end of the week, it is the simple feeling about being happy with your life’s work — taking care of people. This is not a thankless job. The people who matter — our patients (most of them anyway) — appreciate what we do. And of course, we get to tell bad jokes.

Posted by on March 1, 2011 • Filed under: ems-topics