......rules and ramblings

[Guest guest]

 

I was going to stick my 50 cents worth into this very technical discussion but

had second thoughts and will just stick to maintaining the airway and keep the

breathing going as best I can with what I have...!

 

P

From: Ric wilkinson <wilkinsonric@...>

Subject: RE: Intubation rules and ramblings

Date: Friday, 1 August, 2008, 4:09 PM

I agree with many points ,coming from the state of florida where RSI is the

standard of care in ems to offshore in the gom with nothing more than ms04 and

valium and know working in alabama without ms04 on the ambulance.

I teach the difficult airway course statewide to try to improve standards by

education and not letting the powers to be, think we cannot be taught thre right

way just because they are scared of it.

I think performing pre hosp ett in any out the hosp envir. Should never be

taking away from the paramedic this will only increase death.

Just a comment about money remember aha 2000 when cordarone come out and

lidocaine all of a sudden stopped being given

Lido 1.10 dollar a box 100 mg

Cordarone 300 dollars a dose 300 mg

I might see a pattern too

Have safe day to and a great topic

ric

Re: [Remotemedics. co.uk] Intubation rules and ramblings

Dear Rod:

I find this information very discouraging and disheartening, (the concept to

dummy down training) my rational being that the evidence based research is very

jaded towards the JUST the street medic and JUST in urban communities, those

with are very short transport distances and accompanied by a trained partner.

So to that end a bit of a dissection shall we just for entertainment:

1- So why NOT provide the essential drugs to accomplish more successful

intubation possibilities to the paramedics, their is lots of research to

indicate that this situation/ reputation is " quite repairable " out of the US.

supported by ER docs that are advocates of Paralytics being carried on Car. I

find it a rather unfair playing field that MDs have all the tools in ER to

improve their success rates in a controlled, warm, well lighted environment with

a ton of back up. So why NOT give ALL the paramedics the tools in the toolbox

that are the standard accepted practice now .... Don't just dummy it down,

improve the education/ practice opportunities, and Don't change the rules of

engagement because of less than optimal stats and poor inclusion criteria, FIX

the initial problem don't just complicate issues with a new unproven plastic

toy's.

Hey we could just remove paralytics from the ER .... just to keep things on a

level playing field is all, AS IF that is reality ? If the ER docs didn't have

all the tools, I just bet there would be one hell of a hullabaloo, these airways

were developed as a rescue tools only and NOT a primary means of ventilation for

Paramedics ... we are so going down the wrong road !

ps maybe take that fiberoptic scope out of ER too ? (just another a friendly

dig)

So could the researchers and investors of these rather " expensive rescue

devices " influence the recommendations just a tad or is that just my outside

voice again ? So tell me it isn't so under the very suspicious " what's best for

the patient false rationalization " by the makers of these toys, they do stand a

lot to gain economically don't they ?

Bottom Line for me:

Give me SUX and PAV/ROC/VEC or give me death, BECAUSE in a remote environment

this WILL be the outcome, when " buddy " is circling the drain and his pressure is

in his boots.

Just try doing an RSI with just versed and fentanyl alone (and by oneself) then

transport by helo or fixed wing a thousand kms ? I submit that the outcome

studies in this situation will indicate something completely different, it keeps

one rather busy JUST doing airway control, just securing the mask against leaks

and then one can't do much else so one is hooped providing any other kinda

important care like pulling up meds ... maybe get the first officer flying to

assist too? The LMA and the Combi Tube or LT King tube are just not the answer

here and gas exchange IS influenced by the increased deadspace ventilation ...

just in passing. Why oh why use a these tubes/gadgets as a replacement for good

education and practice ? This degrades us all and sets us back a thousand years,

besides this evidence is based on RESUS attempts NOT elective airway control

BEFORE arrest. This is simply comparing bloody apples to oranges, almost nuf

said. Well accept that the

LMA is great for short term surgical procedures (with an empty belly) when the

move is a roll from one bed to another and not from clinic/sickbay/ doghouse/

bush/ floor to helo pad and then .... far beyond. This device is SO highly

overrated by the MDs themselves, in passing I had a Topside a " General

Practitioner " simply rave about the " Vagina on a Stick " and when queried he had

NEVER used one himself, " cough due to cold clinic type setting " is not the

Topside MD that I want .... a topic unto its own.

2- Yes, exactly the ongoing appraisal of skill sets and practice ! Kudos

therefore: if one is an topside director then should not the competency of those

under his/her direction be evaluated on an ongoing basis in the first place ?

Very poor QA/QC from the get go, one could switch gears and point DIRECTLY at

some Medical Directors sitting on their arses and not reacting in a timely

manner, I dare say possible incoming ??

3- So is ETT really going to be excluded from to be mandatory curriculum in the

UK this would be a true pity in unto itself, just an anecdotal note but working

in ER and many ICU's settings for more than a decade, I would personally suggest

that these rescue tubes DO affect " to door discharge outcomes " why you say ?

Because for a " second time " expose the patient to possibility of aspiration,

(reintubating properly) ventilators do need a closed system to work well, I

wonder if this situation has really been studied, a viable patient needing yet

another invasive procedure ... I bet ca$h NOT !

And No ETCO2 detection or Bougie available on car in the UK ? WTF EH ? .... and

here I thought that Canukistanians were backwards.

So in conclusion I feel somewhat obligated to propose a question for the group :

Would a change's in scope of practice in one countries curriculum i.e. " UK

Paramedics " affect the employability for offshore or remote practitioner from

another, like say from the backward colony(s) like Canada or OZ or even the US

(those dang rebels) j/k.

I forgot to mention Bougie tubes are about 10 bucks here, not a 100 bucks as is

the Combi, then x 2 and one heck of a lot lighter to pack around in kits too

.....

Rod ..... I could send a few your way .... for a just minor fee ?

Clearly I am NOT trying to start a war of the worlds here, this post is NOT

intended to SLAG any group, just friendly international banter and debate is

all.

Cheers and Argh.

Wilf :>(

[Remotemedics. co.uk] Intubation rules

Interesting and important words from the Joint Royal College Ambulance

Liaison Committee that will be interest to all us paramedics in the UK!

It would have appeared to have caused some upset already in the UK:

Airway management - JRCALC recommendations July 2008.

Introduction.

At the main committee meeting held in London on 9 July 2008 JRCALC

members were able to study the final version of its commissioned working

group

report entitled " A Critical Reassessment of Ambulance Service Airway

Management in Pre-Hospital Care " (the report can be seen in its entirety on

the

JRCALC website www.jrcalc.org. uk). JRCALC had recommended that this area

of clinical practice be examined in more detail to produce guidance and

recommendations for future practice. This has already been explained in more

detail in the " Airway Management Update following committee meeting on 12

March 2008 " to be found on the JRCALC website homepage. Three main points

had therefore been scrutinised: 1) a current assessment of the benefit on

patient

outcome of tracheal intubation without drugs, 2) an appraisal of the

adequacy of

current training requirements for competency in tracheal intubation and 3)

an

assessment of the adequacy of ensuring ongoing competency in the

intervention.

After careful consideration of the document and its accompanying evidence

the

committee have accepted the group's conclusion that " .paramedic intubation

can no longer be recommended as a mandatory component of paramedic

practice and should not be continued to be practiced in its current format " ,

and

that " .for the majority of paramedics . greater emphasis should be placed on

airway management using an appropriate supraglottic device (SAD) " .

Recommendations.

..