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Thu Apr 6 13:52:22 BST 2006

With all due respect, I have a different suggestion - how about
anesthetists and anesthesiologists willingly sharing their knowledge and
giving paramedics more chances to practice intubation in a controlled
setting (i.e., consider us as important to train as you do residents,
and stop giving the residents all the tubes).  Last time I was in the OR
for ET practice, I got 0 chances out of an 8 hour day.  Why?  Because
anesthesia always found a reason to say no -  No, this patient has caps
on her teeth.  No, this patient is in for elective surgery.  No, we want
the resident to get some experience.  Not a very effective investment of
my time.  And not a very appropriate way to behave, to my thinking.

Experienced paramedics can intubate quite successfully - and quickly. 
The determining factor is not whether you have an MD or other degree -
it is the experience.   Experience in controlled settings helps you
anticipate the problems in the uncontrolled environment - and helps you
understand when you will be able to get the tube, and when you just
secure whatever airway you can get and run.

Patients may or may not have already aspirated - often they haven't,
and the reason they aspirate is because someone is thumping and pumping
on them.  Having an ET in place saves these patients significant
morbidity and mortality - and isn't that what this EMS is all about??? 
No, paramedics shouldn't spend 10 minutes on the scene trying to get an
ET tube in.  That is not the same thing as saying that ET in the field
is inappropriate.  If you can get a tube quickly, without undue
deprivation of oxygen, do it.  If you can't, acknowledge you are human,
use an alternative, and get the patient to definitive care.

The debate about ET in the field is really a question of ensuring
appropriate training and experience.  There are lots of medics out there
who would be very happy to have more experience in controlled settings. 
Any anesthetists/anesthesiologists willing to help???

P.S.  If you prohibit pre-hospital intubation absent hundreds of
intubations (in what time period?), don't forget that residents in the
EMS fellowships  and flight nurses, etc. won't be able to tube either,
until they get that many tubes.  In that case, paramedics should have
the chance to accomplish the same criteria, and we are back where I
started - it all comes down to providing opportunities for experience.

My .02 worth
Melissa

>>> SeppelI at wahs.nsw.gov.au 4/5/2006 8:52:48 PM >>>
What say the anaesthetists? Speaking as both an anaesthetist and an
intensivist, I have no problem with what you are saying in principle,
but we are discussing totally different things.

I use nasotracheal tubes in appropriate patients (the risk of
sinusitis
is often grossly overstated). I have done digital intubation as well,
but that is not something to recommend to an inexperienced operator
and
not a situation I want to be in again. Your key word is "- with
experience". With the right experience you can do anything you like,
but
for the majority of people out there with less experience what you
propose is pretty impractical, whereas there is a lot of data out
there
that the LMA is readily inserted to provide a relaible airway by even
the most inexperienced people with a minimum training. And it's pretty
good for experienced people too, while your heart rate comes down, the
patient's heart rate comes back up, and you think of your next option.

Nobody has ever called an LMA a "definitive airway" per the ATLS
definition of "piece of cuffed plastic in the trachea". What we are
talking about is 'rescue technique of choice for failed intubation'.
And
in that context aspiration is irrelevant - I'll deal with the
aspiration
later in the ICU, and most of these patients have aspirated anyway,
prior to attempts to intubate.

A whole different question, which Ken Harrison raised, is whether 'non
experts' (and by that I mean the experience of HUNDREDS of in hospital
intubations first including a fair number of difficult ones) should
even
be attempting to intubate pre hospital, as opposed to simple airway
manouvres and driving fast. The data just isn't there at present to
support prehospital intubation, and things like the Los Angeles study
show that by trying to intubate you waste a lot of time without doing
anything to improve outcomes.

Food for thought, isn't it?

Cheers, Ian

Ian Seppelt FANZCA FJFICM
Staff Specialist in Intensive Care Medicine
The Nepean Hospital, 
PO Box 63, Penrith NSW 2751
Clinical Lecturer, University of Sydney

>>> bensonblues at comcast.net 6/04/2006 3:38am >>>
As a wayward Yankee ER doc, I've been enlightened by the LMA
discussion. Haven't used one, but I know they're used in the OR for
short cases, dificult intubations, etc. But, they can't be considered
definitive (do not secure the airway against aspiration). In my
training
at Detroit Receiving Hospital (ca 1980's) almost all of the trauma
patients requiring intubation in the ED received nasotracheal tubes
(NTI). Archaic, eh? But, we were good at it, and rarely was NTI
unsuccessful in the spontaneously breathing patient (ketamine being an
excellent agent to facilitate the procedure, and use a 6.5 - 7.5
cuffed
tube). Even in the apneic pt, NTI can be quite successful and fairly
easy to perform - with experience. I still use NTI in dificult
airways,
and "rescued" one apneic fellow with no neck just the other day (the
intensivists groan, because of risk of sinusitis). Another technique
is
digital - by placing your 2nd and 3rd fingers in the hypopharynx volar
side up, I have also been able to guide the tube into the glottis (I
would not use this if they are awake!). These two techniques, if
practiced, seem to me to be reasonable options for prehospital
personnel
in whose patients direct laryngoscopy and intubation are difficult.
What
say the anesthetists? DB
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