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Rescue Airway Techniques

Ben Reynolds aneurysm_42 at yahoo.com
Thu Apr 6 19:21:59 BST 2006


I think it's great that you want to make a change.

But your approach would assume to know exactly what it
is about prehospital intubation that is bad.  You
argue that we should increase the training of the
EMTs.  What if it has nothing to do with training?  As
it stands now, Americans EMTs and paramedics have some
of the best training in the world.  The indications
and technique for intubating a patient in the hospital
aren't that different from intubating a patient in the
field.  The answer is that we don't the answer.  

And if you don't know the answer the safer approach
would be to aggressively apply the scientific method
to the problem:  A prospective, randomized, blinded,
controlled, multicenter trial.  Instead of repeating
potentially fatal mistakes over and over again by
making changes which potentially have little or no
impact which is measurable, get the numbers and let
the arithmetic answer itself.   

Ben Reynolds, PA-C
Pittsburgh, Pa 

--- Michael Ferker <xg2k2 at yahoo.com> wrote:

> Alot of the points brought up here could be
> addressed by providing EMTs with more training on
> exactly when to intubate and when to take a more
> steady course. The ability of EMTs to completely
> assess a patient's ABCs both anatomically and
> physiologically are limited, especially when they're
> trying to institute as much life support as possible
> on the pt's way to the hospital. Sometimes
> intubation is performed when necessary, othertimes,
> intubation is neglected when it should have been the
> appropriate course of action. I think such issues
> can be addressed by the EMTs being trained more.
> It'd be better for us to find a way to enhance
> paramedic training instead of limiting intubations
> altogether.
>    
>   -Mike F
> 
> Ben Reynolds <aneurysm_42 at yahoo.com> wrote:
>   There is an evolving body of literature which
> argues
> exactly the OPPOSITE, that in fact prehospital
> intubation as an independent event in severe head
> injury*, hypovolemic shock** AND in pediatric
> patients*** is associated with HIGHER morbidity and
> mortality.
> 
> 
> Ben Reynolds, PA-C
> Pittsburgh, PA
> 
> *Bochicchio GV, Ilahi O, Joshi M, Bochicchio K,
> Scalea
> TM. Endotracheal intubation in the field does not
> improve outcome in trauma patients who present
> without
> an acutely lethal traumatic brain injury. J Trauma.
> 2003 Feb;54(2):307-11.
> 
> *Davis DP, Peay J, Sise MJ, Vilke GM, Kennedy F,
> Eastman AB, Velky T, Hoyt DB. The impact of
> prehospital endotracheal intubation on outcome in
> moderate to severe traumatic brain injury. J Trauma.
> 2005 May;58(5):933-9.
> 
> *Sen A, Nichani R. Best evidence topic report.
> Prehospital endotracheal intubation in adult major
> trauma patients with head injury. Emerg Med J. 2005
> Dec;22(12):887-9.
> 
> *Wang HE, Peitzman AB, Cassidy LD, Adelson PD, Yealy
> DM. Out-of-hospital endotracheal intubation and
> outcome after traumatic brain injury. Ann Emerg Med.
> 2004 Nov;44(5):439-50.
> 
> *Davis DP, Stern J, Sise MJ, Hoyt DB. A follow-up
> analysis of factors associated with head-injury
> mortality after paramedic rapid sequence intubation.
> J
> Trauma. 2005 Aug;59(2):486-90.
> 
> **Shafi S, Gentilello L. Pre-hospital endotracheal
> intubation and positive pressure ventilation is
> associated with hypotension and decreased survival
> in
> hypovolemic trauma patients: an analysis of the
> National Trauma Data Bank. J Trauma. 2005
> Nov;59(5):1140-5; discussion 1145-7.
> 
> ***DiRusso SM, Sullivan T, Risucci D, Nealon P, Slim
> M. Intubation of pediatric trauma patients in the
> field: predictor of negative outcome despite risk
> stratification. J Trauma. 2005 Jul;59(1):84-90;
> discussion 90-1.
> 
> 
> --- stefmazur at ausdoctors.net wrote:
> 
> > Melissa,
> > 
> > What is the evidence that shows having an ET tube
> > placed pre-hospital saves these patients
> > "significant mortality and morbidity"?
> > 
> > My reading (admittedly limited) seems to suggest
> the
> > opposite, so would be interested in what evidence
> > has lead you to your conclusion.
> > 
> > Cheers,
> > Stefan Mazur
> > Emergency Physician
> > 
> > >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
> 
=== message truncated ===



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