Re: More Evidence Agaisnt Intubation in TBI

[Guest guest]

i feel your pain. when i was in class, my instructor would

show up each morning and begin complaining about the

hospitals for the same reason. the funniest thing he would

always gripe about is how in the world did the CRNAs and

Anesthesiologist ever learn to intubate. cause they sure were

very willing to let us learn. our class was lucky though. we

had a couple of CRNAs that thought the right way, they said

that management was a waste of money and never came down to

the O.R. to see what really happened.

________________________________________

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OF GOLDSTAR EMS

[Guest guest]

i feel your pain. when i was in class, my instructor would

show up each morning and begin complaining about the

hospitals for the same reason. the funniest thing he would

always gripe about is how in the world did the CRNAs and

Anesthesiologist ever learn to intubate. cause they sure were

very willing to let us learn. our class was lucky though. we

had a couple of CRNAs that thought the right way, they said

that management was a waste of money and never came down to

the O.R. to see what really happened.

________________________________________

THIS EMAIL DOES NOT REFLECT THE VIEWS

OF GOLDSTAR EMS

[Guest guest]

Jane we see many of the same problems that you describe with the

Hospitals that we use as well. I sat in a meeting with several

anesthesiologists that our students have to work with in the O.R. and

was surprised at how broad of a difference in concern and attude that

was from one doctor to the next. What we have had to do is have the

same clinical coordinator at each rotation so that she knows which

doctors to use for the best out come for the students.

On the ambulance what I have noticed is that many of those we have

acting as preceptors have very little experience do to there limited

street time and they too want the tube because they have not had a

lot of attempts themselves. I hate the fact this is happening in our

area but the services have had a large turnover in the past several

years because of dissatisfaction.

Just my grumbling on a Wednesday

> " Require " and students actually " get " are two different stories.

This discussion has come up at the Education Committee, and it is at

least a statewide problem. While our students HAVE to have the

opportunities to learn on live patients in a precepted setting, most

programs in Texas are now having extreme difficulty getting these

exposures due to attitudes of nurses and physicians at the hospitals

and, yes, even attitudes by Paramedics in the field who are

precepting Intermediate and Paramedic students. I have had students

come back from OR rotations telling me they were told to sit in the

waiting room because they " weren't going to intubate in MY OR. " (And

then the next day I had a student with a differnent group who got 5

tubes.) Attempts to resolve the issues have gone without any change

and the issues had nothing to do with student appearance, contact

with the staff, or any prior problems with EMS students in those

locations. It is just attitude. I have had students on 911 trucks

in busy cities needing tubes who are told by the company designated

preceptors, " No student is going to get MY tube. " So the students

all across the state are struggling.

>

> Why???? Some, especially in the hospitals, blame it on potential

liability. Well, we have tried to explain that the anesthetist

precepting is covered as an " instructor " under our malpractice

insurance automatically. Doesn't faze them. Second, the response

is, " We are not a teaching hospital " - whatever that is. But the

hospital administration has willingly signed clinical affililation

agreements with the schools. (But of course, the administrations

seem to have very little control over the anesthesiologists who seem

to hold all the cards.) As for the other reasons, it mainly boils

down to attitude and due to upper management at the hospitals and EMS

agencies not properly teaching their personnel what is expected of

them when they are precepting ANY student. Since many of these sites

and agencies precept for multiple EMS, nursing, respiratory, and

other schools, you would think they would have good precepting

programs in house. And most are NOT willing to allow you to come in

and do it for your program because they don't have time for that.

>

> So is this possibly a part of the problem we are discussing???

Damn right it is. We are trying to be the best we can be but cannot

get hospitals especially to grasp what we need for our students to

get. And as for sending employees to these facilities for intubation

practice, NOT!

>

> Just my thoughts on a morning with an upper respiratory infection

starting..... Sorry. LOL

>

> Jane Hill

>

> --------- RE: More Evidence Agaisnt Intubation in TBI

>

>

> Funny... I was thinking 30 should be a minimum, and 50-100 more

adequate.

>

> ------------

> JRB

>

> Jeff Brosius,

> B.S., NREMT-P, FP-C

> Phoenix, AZ

> " Middle of the night, middle of nowhere, middle of a storm? Let's

get to

> work. "

>

>

>

>

>

>

>

[Guest guest]

Jane we see many of the same problems that you describe with the

Hospitals that we use as well. I sat in a meeting with several

anesthesiologists that our students have to work with in the O.R. and

was surprised at how broad of a difference in concern and attude that

was from one doctor to the next. What we have had to do is have the

same clinical coordinator at each rotation so that she knows which

doctors to use for the best out come for the students.

On the ambulance what I have noticed is that many of those we have

acting as preceptors have very little experience do to there limited

street time and they too want the tube because they have not had a

lot of attempts themselves. I hate the fact this is happening in our

area but the services have had a large turnover in the past several

years because of dissatisfaction.

Just my grumbling on a Wednesday

> " Require " and students actually " get " are two different stories.

This discussion has come up at the Education Committee, and it is at

least a statewide problem. While our students HAVE to have the

opportunities to learn on live patients in a precepted setting, most

programs in Texas are now having extreme difficulty getting these

exposures due to attitudes of nurses and physicians at the hospitals

and, yes, even attitudes by Paramedics in the field who are

precepting Intermediate and Paramedic students. I have had students

come back from OR rotations telling me they were told to sit in the

waiting room because they " weren't going to intubate in MY OR. " (And

then the next day I had a student with a differnent group who got 5

tubes.) Attempts to resolve the issues have gone without any change

and the issues had nothing to do with student appearance, contact

with the staff, or any prior problems with EMS students in those

locations. It is just attitude. I have had students on 911 trucks

in busy cities needing tubes who are told by the company designated

preceptors, " No student is going to get MY tube. " So the students

all across the state are struggling.

>

> Why???? Some, especially in the hospitals, blame it on potential

liability. Well, we have tried to explain that the anesthetist

precepting is covered as an " instructor " under our malpractice

insurance automatically. Doesn't faze them. Second, the response

is, " We are not a teaching hospital " - whatever that is. But the

hospital administration has willingly signed clinical affililation

agreements with the schools. (But of course, the administrations

seem to have very little control over the anesthesiologists who seem

to hold all the cards.) As for the other reasons, it mainly boils

down to attitude and due to upper management at the hospitals and EMS

agencies not properly teaching their personnel what is expected of

them when they are precepting ANY student. Since many of these sites

and agencies precept for multiple EMS, nursing, respiratory, and

other schools, you would think they would have good precepting

programs in house. And most are NOT willing to allow you to come in

and do it for your program because they don't have time for that.

>

> So is this possibly a part of the problem we are discussing???

Damn right it is. We are trying to be the best we can be but cannot

get hospitals especially to grasp what we need for our students to

get. And as for sending employees to these facilities for intubation

practice, NOT!

>

> Just my thoughts on a morning with an upper respiratory infection

starting..... Sorry. LOL

>

> Jane Hill

>

> --------- RE: More Evidence Agaisnt Intubation in TBI

>

>

> Funny... I was thinking 30 should be a minimum, and 50-100 more

adequate.

>

> ------------

> JRB

>

> Jeff Brosius,

> B.S., NREMT-P, FP-C

> Phoenix, AZ

> " Middle of the night, middle of nowhere, middle of a storm? Let's

get to

> work. "

>

>

>

>

>

>

>

[Guest guest]

A couple of comments: The average PM in the BioTel System (Dallas) gets

one intubation about every 2 years on the average. Talking with Dr

Racht the Austin area has the same problems with hospital intubations as

everyone else despite their reputation. We have a couple of options,

one is to introduce legislation to change this (make them let us in) the

problem is their lobby group will try to bully us on it. The second is

to utilize the Human Patient Simulator. These are being used almost

exclusively to train CRNA's and Anesthesiologists around the country.

The biggest problem with these are cost and complexity to use them.

They start about $38,000 and can go up to nearly $200,000 depending on

how fancy you want it. I know of very few places that the ability to do

intubations in the OR is not a big problem if not impossible. The same

can be said about OB also, it is a huge issue in our area to get any

exposure to live births or C-sections, again because of hospital staff

and physicians.

Just my 2 cents

Lee

RE: More Evidence Agaisnt Intubation in TBI

" Require " and students actually " get " are two different stories. This

discussion has come up at the Education Committee, and it is at least a

statewide problem. While our students HAVE to have the opportunities to

learn on live patients in a precepted setting, most programs in Texas

are now having extreme difficulty getting these exposures due to

attitudes of nurses and physicians at the hospitals and, yes, even

attitudes by Paramedics in the field who are precepting Intermediate and

Paramedic students. I have had students come back from OR rotations

telling me they were told to sit in the waiting room because they

" weren't going to intubate in MY OR. " (And then the next day I had a

student with a differnent group who got 5 tubes.) Attempts to resolve

the issues have gone without any change and the issues had nothing to do

with student appearance, contact with the staff, or any prior problems

with EMS students in those locat

Why???? Some, especially in the hospitals, blame it on potential

liability. Well, we have tried to explain that the anesthetist

precepting is covered as an " instructor " under our malpractice insurance

automatically. Doesn't faze them. Second, the response is, " We are not

a teaching hospital " - whatever that is. But the hospital

administration has willingly signed clinical affililation agreements

with the schools. (But of course, the administrations seem to have very

little control over the anesthesiologists who seem to hold all the

cards.) As for the other reasons, it mainly boils down to attitude and

due to upper management at the hospitals and EMS agencies not properly

teaching their personnel what is expected of them when they are

precepting ANY student. Since many of these sites and agencies precept

for multiple EMS, nursing, respiratory, and other schools, you would

think they would have good precepting programs

So is this possibly a part of the problem we are discussing??? Damn

right it is. We are trying to be the best we can be but cannot get

hospitals especially to grasp what we need for our students to get. And

as for sending employees to these facilities for intubation practice,

NOT!

Just my thoughts on a morning with an upper respiratory infection

starting..... Sorry. LOL

Jane Hill

--------- RE: More Evidence Agaisnt Intubation in TBI

Funny... I was thinking 30 should be a minimum, and 50-100 more

adequate.

------------

JRB

Jeff Brosius,

B.S., NREMT-P, FP-C

Phoenix, AZ

" Middle of the night, middle of nowhere, middle of a storm? Let's get

to

work. "

[Guest guest]

Trust me, as the Hiring Coordinator as well for my dept I'm very aware

that many of our students are our future employees.

However, patient care is of the utmost concern. When it comes down to

critical skills, our department needs to be performing them as often as

possible. If we were doing 200 intubations a year that may be and

probably is a different concern at the larger departments, and the

students there probably do get those opportunities.

Another thought, are the lawyers that the schools have going to cover

the student and clinical site (ie EMS) when the outcome was less then

desired and the problem was that the student was performing the most

critical skill? Probably not. I can tell you our County Attorney would

not be pleased with that either.

I know it is frustrating, it is frustrating on this side as well.

However, at some point the priority is the patient care and not the

opportunity for the student. We try to give every opportunity for

experience and education to the students that ride with us.

RE: More Evidence Agaisnt Intubation in TBI

" Require " and students actually " get " are two different stories. This

discussion has come up at the Education Committee, and it is at least a

statewide problem. While our students HAVE to have the opportunities to

learn on live patients in a precepted setting, most programs in Texas

are now having extreme difficulty getting these exposures due to

attitudes of nurses and physicians at the hospitals and, yes, even

attitudes by Paramedics in the field who are precepting Intermediate and

Paramedic students. I have had students come back from OR rotations

telling me they were told to sit in the waiting room because they

" weren't going to intubate in MY OR. " (And then the next day I had a

student with a differnent group who got 5 tubes.) Attempts to resolve

the issues have gone without any change and the issues had nothing to do

with student appearance, contact with the staff, or any prior problems

with EMS students in those locat

Why???? Some, especially in the hospitals, blame it on potential

liability. Well, we have tried to explain that the anesthetist

precepting is covered as an " instructor " under our malpractice insurance

automatically. Doesn't faze them. Second, the response is, " We are not

a teaching hospital " - whatever that is. But the hospital

administration has willingly signed clinical affililation agreements

with the schools. (But of course, the administrations seem to have very

little control over the anesthesiologists who seem to hold all the

cards.) As for the other reasons, it mainly boils down to attitude and

due to upper management at the hospitals and EMS agencies not properly

teaching their personnel what is expected of them when they are

precepting ANY student. Since many of these sites and agencies precept

for multiple EMS, nursing, respiratory, and other schools, you would

think they would have good precepting programs

So is this possibly a part of the problem we are discussing??? Damn

right it is. We are trying to be the best we can be but cannot get

hospitals especially to grasp what we need for our students to get. And

as for sending employees to these facilities for intubation practice,

NOT!

Just my thoughts on a morning with an upper respiratory infection

starting..... Sorry. LOL

Jane Hill

--------- RE: More Evidence Agaisnt Intubation in TBI

Funny... I was thinking 30 should be a minimum, and 50-100 more

adequate.

------------

JRB

Jeff Brosius,

B.S., NREMT-P, FP-C

Phoenix, AZ

" Middle of the night, middle of nowhere, middle of a storm? Let's get

to

work. "

[Guest guest]

Trust me, as the Hiring Coordinator as well for my dept I'm very aware

that many of our students are our future employees.

However, patient care is of the utmost concern. When it comes down to

critical skills, our department needs to be performing them as often as

possible. If we were doing 200 intubations a year that may be and

probably is a different concern at the larger departments, and the

students there probably do get those opportunities.

Another thought, are the lawyers that the schools have going to cover

the student and clinical site (ie EMS) when the outcome was less then

desired and the problem was that the student was performing the most

critical skill? Probably not. I can tell you our County Attorney would

not be pleased with that either.

I know it is frustrating, it is frustrating on this side as well.

However, at some point the priority is the patient care and not the

opportunity for the student. We try to give every opportunity for

experience and education to the students that ride with us.

RE: More Evidence Agaisnt Intubation in TBI

" Require " and students actually " get " are two different stories. This

discussion has come up at the Education Committee, and it is at least a

statewide problem. While our students HAVE to have the opportunities to

learn on live patients in a precepted setting, most programs in Texas

are now having extreme difficulty getting these exposures due to

attitudes of nurses and physicians at the hospitals and, yes, even

attitudes by Paramedics in the field who are precepting Intermediate and

Paramedic students. I have had students come back from OR rotations

telling me they were told to sit in the waiting room because they

" weren't going to intubate in MY OR. " (And then the next day I had a

student with a differnent group who got 5 tubes.) Attempts to resolve

the issues have gone without any change and the issues had nothing to do

with student appearance, contact with the staff, or any prior problems

with EMS students in those locat

Why???? Some, especially in the hospitals, blame it on potential

liability. Well, we have tried to explain that the anesthetist

precepting is covered as an " instructor " under our malpractice insurance

automatically. Doesn't faze them. Second, the response is, " We are not

a teaching hospital " - whatever that is. But the hospital

administration has willingly signed clinical affililation agreements

with the schools. (But of course, the administrations seem to have very

little control over the anesthesiologists who seem to hold all the

cards.) As for the other reasons, it mainly boils down to attitude and

due to upper management at the hospitals and EMS agencies not properly

teaching their personnel what is expected of them when they are

precepting ANY student. Since many of these sites and agencies precept

for multiple EMS, nursing, respiratory, and other schools, you would

think they would have good precepting programs

So is this possibly a part of the problem we are discussing??? Damn

right it is. We are trying to be the best we can be but cannot get

hospitals especially to grasp what we need for our students to get. And

as for sending employees to these facilities for intubation practice,

NOT!

Just my thoughts on a morning with an upper respiratory infection

starting..... Sorry. LOL

Jane Hill

--------- RE: More Evidence Agaisnt Intubation in TBI

Funny... I was thinking 30 should be a minimum, and 50-100 more

adequate.

------------

JRB

Jeff Brosius,

B.S., NREMT-P, FP-C

Phoenix, AZ

" Middle of the night, middle of nowhere, middle of a storm? Let's get

to

work. "

[Guest guest]

For some reason I just now read Dr. Bledsoe's post of 11/02/2004 on Airway

Skills. I would like to place some comments on his statements and add some

comments of my own.

As some of you know, airway is one of my interests as a member of TeamSLAM,

the best advanced airway program in existence (he said, modestly).

There are SO many things about airway management that are not being taught in

paramedic courses that would greatly enhance a paramedic's abilities to

successfully manage the difficult airway. These techniques are well known, and

there are very simple and cheap adjuncts that are readily available, yet medics

are not taught them.

That's why I question the studies that say that intubation ought not be

attempted in this patient or that, because the studies do not take into

consideration the level of training that the practitioner has had. Read down,

please,

GG

>

> I think, that with the literature coming in as it is, medical directors may

> have to make decisions whether to allow paramedics to intubate children and

> patients with traumatic brain injuries. It may be hard to defend in court

> otherwise. But, before we commit hari-kari, we need a randomized-controlled

> trial to sort out the problems. Gene may get on me for this, but I think the

> problems are these:

>

GG: I agree with you 100%, . You are completely correct in each and

every stated problem.

GG

>

> 1. EMTS develop poor airway skills because the skills are not adequately

> emphasized or instructor accept CPR cards as evidence of aiway competency.

>

Correct. Consider this: Airway maintenance is the most important aspect

of patient care. As SLAM teaches, " If your patient cannot breathe, nothing

else matters. " Why would we relegate airway training to a short module where

the student only needs to demonstrate that s/he can hook up an oxygen cylinder,

pick out a delivery device and put it on the patient, and deliver X lpm; bag

a patient with the BVM for a minute (seldom enforced), do a little suctioning,

stick a tube into a manikin that the student has practiced on and whose

airway paramaters never change, stick in a Combitube once, and that's it.

Airway ought to be the most emphasized skill, and it should be taught,

retaught, retaught, practiced, and retaught ad infinitum. But the training has

to

be good to begin with. Practicing bad technique only makes you proficient in

bad airway technique.

> 2. Paramedics are not getting enough intubation practice (programs have too

> few hours and curriculum enhanced)

>

Correct again. See above.

> 3. Inadequate operating room exposure (thanks to the trial lawyers)

>

Not just thanks to trial lawyers, although that's a part of it, but thanks to

the LMA and the fact that Medicare and other insurance companies have scared

the crap out of anesthesiologiests and CRNAs for filing for compensation for a

prodecure that they did not do personally. Hell, even residents cannot get

adequate skill practice because of this. Trial lawyers are a small part of

it. Medical bureaucracy and insurance companies are the worst.

So many gas passers just do not drop a lot of tubes now because of the LMA

that it's hard to get tubes even with docs who want to cooperate.

> 4. Failure to recognize skill decay ( " I can intubate as good as

> anybody--regardlessmif I haven't done it in 6 momths " )

>

Some medics just do not encounter patients who need to be intubated often.

We cannot change that. But we CAN show medics how to enhance their

intubation skills so that when they do have to do it, they can accomplish the

task even

if they are not in practice. The gum elastic bougie is the one cheap and

easy item that can make all the difference in the world for those people. Yet,

they're not trained to use it, not supplied with it, and don't even know

about it. Attendance at a cadaver lab can give one the opportunity to become

familiar with the airway structures and to practice many different techniques.

Cadaver practice should be mandatory.

> 5. Ego

>

In SLAM we teach that Einstein (you DO know who Einstein was?) said that

doing the same thing over and over and expecting a different result is insanity.

So if you try to intubate with a Mac 4 and can't get it done, don't just keep

trying with your Mac 4. Get a and try. Stick the bougie in, or if

none of those work, put the Combitube in or an LMA. The cases where you

cannot get an airway SOME WAY are practically non-existent. It is those people

who egotistically refuse to try a disciplined series of different techniques

who fail. Guilt for this sin spreads across the whole spectrum of providers.

I have seen doctors who tried to intubate for 10 minutes without ever

ventilating their patient, never tried another blade or technique, and

paramedics who

followed their teachings. All bad.

Remember that a dog that can only do one trick will not do well at the show.

The dog that can do 15 tricks will win. Have more than one trick, and if

your first trick doesn't work, immediately try the next one.

It is NOT a loss of face to fail to place an endotracheal tube, recognize

that you're probably not going to be successful and then successfully place a

Combitube, ventilate your patient adequately, and all is well.

The greatest loss of face ought to be failure to ventilate your patient by

any means and lose him or her; not failure to endotracheally intubate.

> 6. Adrenalin (paramedics tend to not adequately ventilate and oxygenate

> prior to ET placement and tend to hyperventilate the patient once intubated.

>

Getting in too big a hurry is a terrible problem. Take a deep breath.

Relax. Look at your patient and think what's happening. Form a plan. Get

your patient adequately pre-oxygenated, then try your first trick. If that

doesn't work, re-oxygenate and go to your second trick.

Then, once the patient has an airway, whether it is an ET tube, Combitube,

LMA, or whatever, control yourself. Count 1-1000, 2-1000, 3-1000-,4-1000,

5-1000, 6-1000 BREATHE. We are overventilating our patients to the point that

we're creating increased pulmonary pressures, medistinal pressures, and actually

causing a drop in preload and cardiac output through these increased

pressures. You can actually improve both your Sat% and CO2 output by slowing

ventilations rather than increasing them.

> 7. Inadequte use of wave-form capnography.

>

This will be the standard of care in a short time. It is scientifically the

standard of care now, and it will be the legal standard of care as soon as a

sufficient number of practitioners begin to use it.

The advantages of this process are that it can not only tell you whether or

not your airway is adequately managed and provide legal proof of it, but it

can show you when you need to intubate a breathing patient long before s/he

crashes. Services that don't have capnography are gambling against their

futures.

> 8. Lack of research that would have shown light on the problem before the

> practice was so well-entrenched.

>

Research is difficult if not impossible to implement in the system that we

have. The legal concerns surrounding uninformed consents that are attendant in

non-responsive patients, the difficulty in maintaining controls in the

pre-hospital setting, and, above all, lack of any sort of funding for EMS based

research makes it unlikely that we will have the evidence upon which to base

airway practices such as RSI, intubation of TBI patients and pedis any time

soon.

We will continue to use empirical and intuitive considerations in doing what

we do.

" Evidence based medicine " is a great buzzword. I truly want everything that

is done to me to be evidence based. Yet, I know that when prehospital

interventions are involved, the acquisition of evidence upon which to base an

intervention is damn near impossible given our present laws.

> 9. Paramedics think that failure to place an ET tube is a sign of failure

> and are thus reluctant to use other airway devices.

>

See above. The REAL sign of failure is to lose a patient due to failure to

ventilate when you had alternative devices at hand which could have been

readily employed. Failure to use alternative devices is malpractice. Period.

No defense.

The greatest loss of face ought to be failure to ventilate a patient, not

failure to place an ET tube.

> 10. Paramedics are poorly prepared to manage the difficult airway and not

> familiar with other techniques (gum elastoc bougie, retrograde intubation)

> and so on.

>

100% correct. The Gum Elastic Bougie is the greatest thing since Popsicles.

It's cheap enough that even rural Paramedics can buy one, and no EMT-I or

Paramedic should ever go to work without one available at fingertip. The

bougie can help you turn an impending disaster into a resounding triumph.

Believe me, I've done it. The bougie has saved my patient and me many times.

Also, if you can't stick a 14 into the cricothyroid membrane, grab the BVM

adaptor off of a #3 ET tube, stick it into the hub of the 14 and ventilate

your patient for 5 minutes while you're figuring out what your next move is

going

to be, you're going to lose that patient. Use of a needle crich can buy you

enough time to get yer act together and do a PerTrach, Cook Melker, or

surgical crich. Or a retrograde. Haven't practiced these techniques? Don't

know

how to do them? Don't have a clue? You're a walking liability. Be sure

your insurance is paid. Or be ready for a million dollar judgment to be

filed against you and hook on to everything you own, prevent you from buying

anything, and generally making your life a cesspool.

Better learn what airway standard of care is, and it AIN'T just ET

intubation.

>

> When I went to paramedic school in 1975 (and taught it from 1979-1983), we

> often got the ET mannikins out and required prtactice and check-offs, This

> may not be occurring.

>

> This begs the question: are the negative outcome studies seen with

> prehospital RSI a function of basically poor airway skills or of the

> procedure itself. I am beginning to think the former.

>

My considered opinion is that, as Dr. Bledsoe says, it is the former. I

firmly believe that we can teach average folks to do advanced airway skills with

a high degree of competency. But we cannot do it without a stated commitment

to doing it. It requires much more than is taught in most courses.

There's no excuse for that. There is a lot of money floating around for grants

these days.

If you're a medic who has never been exposed to the " tricks of the trade " and

practiced on cadavers, the hold up the 7-11, rob the bank, sell your dog, or

do what's necessary to learn how to manage the impossible airway. The

training is available.

RSI? Great when you need it and know how to do it. Are you allowed to do

it? When is the last time you practiced it on a manikin in real time? When

is the last time you actually drew up the drugs, had them all lined up, kept

your patient ventilated manually while getting ready, gave the drugs in

sequence and within the time frame, and then intubated using whatever it took to

do

it? Rehearsal is absolutely required, at least twice a year.

Do you know what to do when you paralyze your patient, take a look with the

laryngoscope and see a Cormack-Lahane IV view? If you cannot answer that

question, you have no business ever doing RSI. But if you don't know the

answer,

you can quite easily learn it. But will you do it?

Do you know that any Cormack-Lahane can be moved up one number with BURP

usually, but after you paralyze your patient your number will generally decrease

one? Know what I'm talking about? If so, good for you. If not, better

call your lawyer, pay your insurance premium, and then sign up for a class.

I have the greatest confidence that ordinary Paramedics and EMT-Intermediates

can give state of the art airway management. There's nothing even remotely

hard to understand about it. It only requires teaching and practice under

the right conditions.

Sadly, most EMT-I and Paramedic students are not being afforded this

education, training, and practice. So we take the hits for airway failures.

GG

>

>

> E. Bledsoe, DO, FACEP

> Midlothian, TX

>

> Re: More Evidence Agaisnt Intubation in TBI

>

>

> So is more training necessary or less excitement while on scene?

>

Both, Danny. Yes, more training. More training will result in less

excitement on the scene. The calm practitioner is the one who is confident

with

his/her skills, confident that s/he can manage the difficult airway, and

prepared to ventilate any patient.

Also, I must comment about the use of the term " on scene. " The only things

that should be done " on scene " are airway management, hemorrhage management,

spinal immobilization, and such other interventions that cannot be managed as

well in the ambulance enroute to the hospital.

Staying and playing is only justified when your patient will not survive

being moved to the ambulance.

GG

>

> Danny L.

> Owner/NREMT-P

> Panhandle Emergency Training Services And Response

> (PETSAR)

> Office

> FAX

>

>

>

[Guest guest]

For some reason I just now read Dr. Bledsoe's post of 11/02/2004 on Airway

Skills. I would like to place some comments on his statements and add some

comments of my own.

As some of you know, airway is one of my interests as a member of TeamSLAM,

the best advanced airway program in existence (he said, modestly).

There are SO many things about airway management that are not being taught in

paramedic courses that would greatly enhance a paramedic's abilities to

successfully manage the difficult airway. These techniques are well known, and

there are very simple and cheap adjuncts that are readily available, yet medics

are not taught them.

That's why I question the studies that say that intubation ought not be

attempted in this patient or that, because the studies do not take into

consideration the level of training that the practitioner has had. Read down,

please,

GG

>

> I think, that with the literature coming in as it is, medical directors may

> have to make decisions whether to allow paramedics to intubate children and

> patients with traumatic brain injuries. It may be hard to defend in court

> otherwise. But, before we commit hari-kari, we need a randomized-controlled

> trial to sort out the problems. Gene may get on me for this, but I think the

> problems are these:

>

GG: I agree with you 100%, . You are completely correct in each and

every stated problem.

GG

>

> 1. EMTS develop poor airway skills because the skills are not adequately

> emphasized or instructor accept CPR cards as evidence of aiway competency.

>

Correct. Consider this: Airway maintenance is the most important aspect

of patient care. As SLAM teaches, " If your patient cannot breathe, nothing

else matters. " Why would we relegate airway training to a short module where

the student only needs to demonstrate that s/he can hook up an oxygen cylinder,

pick out a delivery device and put it on the patient, and deliver X lpm; bag

a patient with the BVM for a minute (seldom enforced), do a little suctioning,

stick a tube into a manikin that the student has practiced on and whose

airway paramaters never change, stick in a Combitube once, and that's it.

Airway ought to be the most emphasized skill, and it should be taught,

retaught, retaught, practiced, and retaught ad infinitum. But the training has

to

be good to begin with. Practicing bad technique only makes you proficient in

bad airway technique.

> 2. Paramedics are not getting enough intubation practice (programs have too

> few hours and curriculum enhanced)

>

Correct again. See above.

> 3. Inadequate operating room exposure (thanks to the trial lawyers)

>

Not just thanks to trial lawyers, although that's a part of it, but thanks to

the LMA and the fact that Medicare and other insurance companies have scared

the crap out of anesthesiologiests and CRNAs for filing for compensation for a

prodecure that they did not do personally. Hell, even residents cannot get

adequate skill practice because of this. Trial lawyers are a small part of

it. Medical bureaucracy and insurance companies are the worst.

So many gas passers just do not drop a lot of tubes now because of the LMA

that it's hard to get tubes even with docs who want to cooperate.

> 4. Failure to recognize skill decay ( " I can intubate as good as

> anybody--regardlessmif I haven't done it in 6 momths " )

>

Some medics just do not encounter patients who need to be intubated often.

We cannot change that. But we CAN show medics how to enhance their

intubation skills so that when they do have to do it, they can accomplish the

task even

if they are not in practice. The gum elastic bougie is the one cheap and

easy item that can make all the difference in the world for those people. Yet,

they're not trained to use it, not supplied with it, and don't even know

about it. Attendance at a cadaver lab can give one the opportunity to become

familiar with the airway structures and to practice many different techniques.

Cadaver practice should be mandatory.

> 5. Ego

>

In SLAM we teach that Einstein (you DO know who Einstein was?) said that

doing the same thing over and over and expecting a different result is insanity.

So if you try to intubate with a Mac 4 and can't get it done, don't just keep

trying with your Mac 4. Get a and try. Stick the bougie in, or if

none of those work, put the Combitube in or an LMA. The cases where you

cannot get an airway SOME WAY are practically non-existent. It is those people

who egotistically refuse to try a disciplined series of different techniques

who fail. Guilt for this sin spreads across the whole spectrum of providers.

I have seen doctors who tried to intubate for 10 minutes without ever

ventilating their patient, never tried another blade or technique, and

paramedics who

followed their teachings. All bad.

Remember that a dog that can only do one trick will not do well at the show.

The dog that can do 15 tricks will win. Have more than one trick, and if

your first trick doesn't work, immediately try the next one.

It is NOT a loss of face to fail to place an endotracheal tube, recognize

that you're probably not going to be successful and then successfully place a

Combitube, ventilate your patient adequately, and all is well.

The greatest loss of face ought to be failure to ventilate your patient by

any means and lose him or her; not failure to endotracheally intubate.

> 6. Adrenalin (paramedics tend to not adequately ventilate and oxygenate

> prior to ET placement and tend to hyperventilate the patient once intubated.

>

Getting in too big a hurry is a terrible problem. Take a deep breath.

Relax. Look at your patient and think what's happening. Form a plan. Get

your patient adequately pre-oxygenated, then try your first trick. If that

doesn't work, re-oxygenate and go to your second trick.

Then, once the patient has an airway, whether it is an ET tube, Combitube,

LMA, or whatever, control yourself. Count 1-1000, 2-1000, 3-1000-,4-1000,

5-1000, 6-1000 BREATHE. We are overventilating our patients to the point that

we're creating increased pulmonary pressures, medistinal pressures, and actually

causing a drop in preload and cardiac output through these increased

pressures. You can actually improve both your Sat% and CO2 output by slowing

ventilations rather than increasing them.

> 7. Inadequte use of wave-form capnography.

>

This will be the standard of care in a short time. It is scientifically the

standard of care now, and it will be the legal standard of care as soon as a

sufficient number of practitioners begin to use it.

The advantages of this process are that it can not only tell you whether or

not your airway is adequately managed and provide legal proof of it, but it

can show you when you need to intubate a breathing patient long before s/he

crashes. Services that don't have capnography are gambling against their

futures.

> 8. Lack of research that would have shown light on the problem before the

> practice was so well-entrenched.

>

Research is difficult if not impossible to implement in the system that we

have. The legal concerns surrounding uninformed consents that are attendant in

non-responsive patients, the difficulty in maintaining controls in the

pre-hospital setting, and, above all, lack of any sort of funding for EMS based

research makes it unlikely that we will have the evidence upon which to base

airway practices such as RSI, intubation of TBI patients and pedis any time

soon.

We will continue to use empirical and intuitive considerations in doing what

we do.

" Evidence based medicine " is a great buzzword. I truly want everything that

is done to me to be evidence based. Yet, I know that when prehospital

interventions are involved, the acquisition of evidence upon which to base an

intervention is damn near impossible given our present laws.

> 9. Paramedics think that failure to place an ET tube is a sign of failure

> and are thus reluctant to use other airway devices.

>

See above. The REAL sign of failure is to lose a patient due to failure to

ventilate when you had alternative devices at hand which could have been

readily employed. Failure to use alternative devices is malpractice. Period.

No defense.

The greatest loss of face ought to be failure to ventilate a patient, not

failure to place an ET tube.

> 10. Paramedics are poorly prepared to manage the difficult airway and not

> familiar with other techniques (gum elastoc bougie, retrograde intubation)

> and so on.

>

100% correct. The Gum Elastic Bougie is the greatest thing since Popsicles.

It's cheap enough that even rural Paramedics can buy one, and no EMT-I or

Paramedic should ever go to work without one available at fingertip. The

bougie can help you turn an impending disaster into a resounding triumph.

Believe me, I've done it. The bougie has saved my patient and me many times.

Also, if you can't stick a 14 into the cricothyroid membrane, grab the BVM

adaptor off of a #3 ET tube, stick it into the hub of the 14 and ventilate

your patient for 5 minutes while you're figuring out what your next move is

going

to be, you're going to lose that patient. Use of a needle crich can buy you

enough time to get yer act together and do a PerTrach, Cook Melker, or

surgical crich. Or a retrograde. Haven't practiced these techniques? Don't

know

how to do them? Don't have a clue? You're a walking liability. Be sure

your insurance is paid. Or be ready for a million dollar judgment to be

filed against you and hook on to everything you own, prevent you from buying

anything, and generally making your life a cesspool.

Better learn what airway standard of care is, and it AIN'T just ET

intubation.

>

> When I went to paramedic school in 1975 (and taught it from 1979-1983), we

> often got the ET mannikins out and required prtactice and check-offs, This

> may not be occurring.

>

> This begs the question: are the negative outcome studies seen with

> prehospital RSI a function of basically poor airway skills or of the

> procedure itself. I am beginning to think the former.

>

My considered opinion is that, as Dr. Bledsoe says, it is the former. I

firmly believe that we can teach average folks to do advanced airway skills with

a high degree of competency. But we cannot do it without a stated commitment

to doing it. It requires much more than is taught in most courses.

There's no excuse for that. There is a lot of money floating around for grants

these days.

If you're a medic who has never been exposed to the " tricks of the trade " and

practiced on cadavers, the hold up the 7-11, rob the bank, sell your dog, or

do what's necessary to learn how to manage the impossible airway. The

training is available.

RSI? Great when you need it and know how to do it. Are you allowed to do

it? When is the last time you practiced it on a manikin in real time? When

is the last time you actually drew up the drugs, had them all lined up, kept

your patient ventilated manually while getting ready, gave the drugs in

sequence and within the time frame, and then intubated using whatever it took to

do

it? Rehearsal is absolutely required, at least twice a year.

Do you know what to do when you paralyze your patient, take a look with the

laryngoscope and see a Cormack-Lahane IV view? If you cannot answer that

question, you have no business ever doing RSI. But if you don't know the

answer,

you can quite easily learn it. But will you do it?

Do you know that any Cormack-Lahane can be moved up one number with BURP

usually, but after you paralyze your patient your number will generally decrease

one? Know what I'm talking about? If so, good for you. If not, better

call your lawyer, pay your insurance premium, and then sign up for a class.

I have the greatest confidence that ordinary Paramedics and EMT-Intermediates

can give state of the art airway management. There's nothing even remotely

hard to understand about it. It only requires teaching and practice under

the right conditions.

Sadly, most EMT-I and Paramedic students are not being afforded this

education, training, and practice. So we take the hits for airway failures.

GG

>

>

> E. Bledsoe, DO, FACEP

> Midlothian, TX

>

> Re: More Evidence Agaisnt Intubation in TBI

>

>

> So is more training necessary or less excitement while on scene?

>

Both, Danny. Yes, more training. More training will result in less

excitement on the scene. The calm practitioner is the one who is confident

with

his/her skills, confident that s/he can manage the difficult airway, and

prepared to ventilate any patient.

Also, I must comment about the use of the term " on scene. " The only things

that should be done " on scene " are airway management, hemorrhage management,

spinal immobilization, and such other interventions that cannot be managed as

well in the ambulance enroute to the hospital.

Staying and playing is only justified when your patient will not survive

being moved to the ambulance.

GG

>

> Danny L.

> Owner/NREMT-P

> Panhandle Emergency Training Services And Response

> (PETSAR)

> Office

> FAX

>

>

>

[Guest guest]

For some reason I just now read Dr. Bledsoe's post of 11/02/2004 on Airway

Skills. I would like to place some comments on his statements and add some

comments of my own.

As some of you know, airway is one of my interests as a member of TeamSLAM,

the best advanced airway program in existence (he said, modestly).

There are SO many things about airway management that are not being taught in

paramedic courses that would greatly enhance a paramedic's abilities to

successfully manage the difficult airway. These techniques are well known, and

there are very simple and cheap adjuncts that are readily available, yet medics

are not taught them.

That's why I question the studies that say that intubation ought not be

attempted in this patient or that, because the studies do not take into

consideration the level of training that the practitioner has had. Read down,

please,

GG

>

> I think, that with the literature coming in as it is, medical directors may

> have to make decisions whether to allow paramedics to intubate children and

> patients with traumatic brain injuries. It may be hard to defend in court

> otherwise. But, before we commit hari-kari, we need a randomized-controlled

> trial to sort out the problems. Gene may get on me for this, but I think the

> problems are these:

>

GG: I agree with you 100%, . You are completely correct in each and

every stated problem.

GG

>

> 1. EMTS develop poor airway skills because the skills are not adequately

> emphasized or instructor accept CPR cards as evidence of aiway competency.

>

Correct. Consider this: Airway maintenance is the most important aspect

of patient care. As SLAM teaches, " If your patient cannot breathe, nothing

else matters. " Why would we relegate airway training to a short module where

the student only needs to demonstrate that s/he can hook up an oxygen cylinder,

pick out a delivery device and put it on the patient, and deliver X lpm; bag

a patient with the BVM for a minute (seldom enforced), do a little suctioning,

stick a tube into a manikin that the student has practiced on and whose

airway paramaters never change, stick in a Combitube once, and that's it.

Airway ought to be the most emphasized skill, and it should be taught,

retaught, retaught, practiced, and retaught ad infinitum. But the training has

to

be good to begin with. Practicing bad technique only makes you proficient in

bad airway technique.

> 2. Paramedics are not getting enough intubation practice (programs have too

> few hours and curriculum enhanced)

>

Correct again. See above.

> 3. Inadequate operating room exposure (thanks to the trial lawyers)

>

Not just thanks to trial lawyers, although that's a part of it, but thanks to

the LMA and the fact that Medicare and other insurance companies have scared

the crap out of anesthesiologiests and CRNAs for filing for compensation for a

prodecure that they did not do personally. Hell, even residents cannot get

adequate skill practice because of this. Trial lawyers are a small part of

it. Medical bureaucracy and insurance companies are the worst.

So many gas passers just do not drop a lot of tubes now because of the LMA

that it's hard to get tubes even with docs who want to cooperate.

> 4. Failure to recognize skill decay ( " I can intubate as good as

> anybody--regardlessmif I haven't done it in 6 momths " )

>

Some medics just do not encounter patients who need to be intubated often.

We cannot change that. But we CAN show medics how to enhance their

intubation skills so that when they do have to do it, they can accomplish the

task even

if they are not in practice. The gum elastic bougie is the one cheap and

easy item that can make all the difference in the world for those people. Yet,

they're not trained to use it, not supplied with it, and don't even know

about it. Attendance at a cadaver lab can give one the opportunity to become

familiar with the airway structures and to practice many different techniques.

Cadaver practice should be mandatory.

> 5. Ego

>

In SLAM we teach that Einstein (you DO know who Einstein was?) said that

doing the same thing over and over and expecting a different result is insanity.

So if you try to intubate with a Mac 4 and can't get it done, don't just keep

trying with your Mac 4. Get a and try. Stick the bougie in, or if

none of those work, put the Combitube in or an LMA. The cases where you

cannot get an airway SOME WAY are practically non-existent. It is those people

who egotistically refuse to try a disciplined series of different techniques

who fail. Guilt for this sin spreads across the whole spectrum of providers.

I have seen doctors who tried to intubate for 10 minutes without ever

ventilating their patient, never tried another blade or technique, and

paramedics who

followed their teachings. All bad.

Remember that a dog that can only do one trick will not do well at the show.

The dog that can do 15 tricks will win. Have more than one trick, and if

your first trick doesn't work, immediately try the next one.

It is NOT a loss of face to fail to place an endotracheal tube, recognize

that you're probably not going to be successful and then successfully place a

Combitube, ventilate your patient adequately, and all is well.

The greatest loss of face ought to be failure to ventilate your patient by

any means and lose him or her; not failure to endotracheally intubate.

> 6. Adrenalin (paramedics tend to not adequately ventilate and oxygenate

> prior to ET placement and tend to hyperventilate the patient once intubated.

>

Getting in too big a hurry is a terrible problem. Take a deep breath.

Relax. Look at your patient and think what's happening. Form a plan. Get

your patient adequately pre-oxygenated, then try your first trick. If that

doesn't work, re-oxygenate and go to your second trick.

Then, once the patient has an airway, whether it is an ET tube, Combitube,

LMA, or whatever, control yourself. Count 1-1000, 2-1000, 3-1000-,4-1000,

5-1000, 6-1000 BREATHE. We are overventilating our patients to the point that

we're creating increased pulmonary pressures, medistinal pressures, and actually

causing a drop in preload and cardiac output through these increased

pressures. You can actually improve both your Sat% and CO2 output by slowing

ventilations rather than increasing them.

> 7. Inadequte use of wave-form capnography.

>

This will be the standard of care in a short time. It is scientifically the

standard of care now, and it will be the legal standard of care as soon as a

sufficient number of practitioners begin to use it.

The advantages of this process are that it can not only tell you whether or

not your airway is adequately managed and provide legal proof of it, but it

can show you when you need to intubate a breathing patient long before s/he

crashes. Services that don't have capnography are gambling against their

futures.

> 8. Lack of research that would have shown light on the problem before the

> practice was so well-entrenched.

>

Research is difficult if not impossible to implement in the system that we

have. The legal concerns surrounding uninformed consents that are attendant in

non-responsive patients, the difficulty in maintaining controls in the

pre-hospital setting, and, above all, lack of any sort of funding for EMS based

research makes it unlikely that we will have the evidence upon which to base

airway practices such as RSI, intubation of TBI patients and pedis any time

soon.

We will continue to use empirical and intuitive considerations in doing what

we do.

" Evidence based medicine " is a great buzzword. I truly want everything that

is done to me to be evidence based. Yet, I know that when prehospital

interventions are involved, the acquisition of evidence upon which to base an

intervention is damn near impossible given our present laws.

> 9. Paramedics think that failure to place an ET tube is a sign of failure

> and are thus reluctant to use other airway devices.

>

See above. The REAL sign of failure is to lose a patient due to failure to

ventilate when you had alternative devices at hand which could have been

readily employed. Failure to use alternative devices is malpractice. Period.

No defense.

The greatest loss of face ought to be failure to ventilate a patient, not

failure to place an ET tube.

> 10. Paramedics are poorly prepared to manage the difficult airway and not

> familiar with other techniques (gum elastoc bougie, retrograde intubation)

> and so on.

>

100% correct. The Gum Elastic Bougie is the greatest thing since Popsicles.

It's cheap enough that even rural Paramedics can buy one, and no EMT-I or

Paramedic should ever go to work without one available at fingertip. The

bougie can help you turn an impending disaster into a resounding triumph.

Believe me, I've done it. The bougie has saved my patient and me many times.

Also, if you can't stick a 14 into the cricothyroid membrane, grab the BVM

adaptor off of a #3 ET tube, stick it into the hub of the 14 and ventilate

your patient for 5 minutes while you're figuring out what your next move is

going

to be, you're going to lose that patient. Use of a needle crich can buy you

enough time to get yer act together and do a PerTrach, Cook Melker, or

surgical crich. Or a retrograde. Haven't practiced these techniques? Don't

know

how to do them? Don't have a clue? You're a walking liability. Be sure

your insurance is paid. Or be ready for a million dollar judgment to be

filed against you and hook on to everything you own, prevent you from buying

anything, and generally making your life a cesspool.

Better learn what airway standard of care is, and it AIN'T just ET

intubation.

>

> When I went to paramedic school in 1975 (and taught it from 1979-1983), we

> often got the ET mannikins out and required prtactice and check-offs, This

> may not be occurring.

>

> This begs the question: are the negative outcome studies seen with

> prehospital RSI a function of basically poor airway skills or of the

> procedure itself. I am beginning to think the former.

>

My considered opinion is that, as Dr. Bledsoe says, it is the former. I

firmly believe that we can teach average folks to do advanced airway skills with

a high degree of competency. But we cannot do it without a stated commitment

to doing it. It requires much more than is taught in most courses.

There's no excuse for that. There is a lot of money floating around for grants

these days.

If you're a medic who has never been exposed to the " tricks of the trade " and

practiced on cadavers, the hold up the 7-11, rob the bank, sell your dog, or

do what's necessary to learn how to manage the impossible airway. The

training is available.

RSI? Great when you need it and know how to do it. Are you allowed to do

it? When is the last time you practiced it on a manikin in real time? When

is the last time you actually drew up the drugs, had them all lined up, kept

your patient ventilated manually while getting ready, gave the drugs in

sequence and within the time frame, and then intubated using whatever it took to

do

it? Rehearsal is absolutely required, at least twice a year.

Do you know what to do when you paralyze your patient, take a look with the

laryngoscope and see a Cormack-Lahane IV view? If you cannot answer that

question, you have no business ever doing RSI. But if you don't know the

answer,

you can quite easily learn it. But will you do it?

Do you know that any Cormack-Lahane can be moved up one number with BURP

usually, but after you paralyze your patient your number will generally decrease

one? Know what I'm talking about? If so, good for you. If not, better

call your lawyer, pay your insurance premium, and then sign up for a class.

I have the greatest confidence that ordinary Paramedics and EMT-Intermediates

can give state of the art airway management. There's nothing even remotely

hard to understand about it. It only requires teaching and practice under

the right conditions.

Sadly, most EMT-I and Paramedic students are not being afforded this

education, training, and practice. So we take the hits for airway failures.

GG

>

>

> E. Bledsoe, DO, FACEP

> Midlothian, TX

>

> Re: More Evidence Agaisnt Intubation in TBI

>

>

> So is more training necessary or less excitement while on scene?

>

Both, Danny. Yes, more training. More training will result in less

excitement on the scene. The calm practitioner is the one who is confident

with

his/her skills, confident that s/he can manage the difficult airway, and

prepared to ventilate any patient.

Also, I must comment about the use of the term " on scene. " The only things

that should be done " on scene " are airway management, hemorrhage management,

spinal immobilization, and such other interventions that cannot be managed as

well in the ambulance enroute to the hospital.

Staying and playing is only justified when your patient will not survive

being moved to the ambulance.

GG

>

> Danny L.

> Owner/NREMT-P

> Panhandle Emergency Training Services And Response

> (PETSAR)

> Office

> FAX

>

>

>

[Guest guest]

Outstanding comments Gene! Hopefully folks will take heed!

Re: More Evidence Agaisnt Intubation in TBI

>

>

> So is more training necessary or less excitement while on scene?

>

Both, Danny. Yes, more training. More training will result in less

excitement on the scene. The calm practitioner is the one who is

confident with

his/her skills, confident that s/he can manage the difficult airway, and

prepared to ventilate any patient.

Also, I must comment about the use of the term " on scene. " The only

things

that should be done " on scene " are airway management, hemorrhage

management,

spinal immobilization, and such other interventions that cannot be

managed as

well in the ambulance enroute to the hospital.

Staying and playing is only justified when your patient will not

survive

being moved to the ambulance.

GG

>

> Danny L.

> Owner/NREMT-P

> Panhandle Emergency Training Services And Response

> (PETSAR)

> Office

> FAX

>

>

>

[Guest guest]

Outstanding comments Gene! Hopefully folks will take heed!

Re: More Evidence Agaisnt Intubation in TBI

>

>

> So is more training necessary or less excitement while on scene?

>

Both, Danny. Yes, more training. More training will result in less

excitement on the scene. The calm practitioner is the one who is

confident with

his/her skills, confident that s/he can manage the difficult airway, and

prepared to ventilate any patient.

Also, I must comment about the use of the term " on scene. " The only

things

that should be done " on scene " are airway management, hemorrhage

management,

spinal immobilization, and such other interventions that cannot be

managed as

well in the ambulance enroute to the hospital.

Staying and playing is only justified when your patient will not

survive

being moved to the ambulance.

GG

>

> Danny L.

> Owner/NREMT-P

> Panhandle Emergency Training Services And Response

> (PETSAR)

> Office

> FAX

>

>

>

[Guest guest]

Outstanding comments Gene! Hopefully folks will take heed!

Re: More Evidence Agaisnt Intubation in TBI

>

>

> So is more training necessary or less excitement while on scene?

>

Both, Danny. Yes, more training. More training will result in less

excitement on the scene. The calm practitioner is the one who is

confident with

his/her skills, confident that s/he can manage the difficult airway, and

prepared to ventilate any patient.

Also, I must comment about the use of the term " on scene. " The only

things

that should be done " on scene " are airway management, hemorrhage

management,

spinal immobilization, and such other interventions that cannot be

managed as

well in the ambulance enroute to the hospital.

Staying and playing is only justified when your patient will not

survive

being moved to the ambulance.

GG

>

> Danny L.

> Owner/NREMT-P

> Panhandle Emergency Training Services And Response

> (PETSAR)

> Office

> FAX

>

>

>

[Guest guest]

Gene,

As Lee said, excellent comments......

When I grow up, I want to be just like you.......except I want

hair....

Mike

'Tater Salad' Hatfield EMT-P

" Si hoc legere scis nimium eruditiones habes. "

EMStock 2005, it's never to early to plan!!!

www.emstock.com

www.temsf.org

From: wegandy1938@...

Airway ought to be the most emphasized skill, and it should be taught,

retaught, retaught, practiced, and retaught ad infinitum. But the

training has to

be good to begin with.

[Guest guest]

Gene,

As Lee said, excellent comments......

When I grow up, I want to be just like you.......except I want

hair....

Mike

'Tater Salad' Hatfield EMT-P

" Si hoc legere scis nimium eruditiones habes. "

EMStock 2005, it's never to early to plan!!!

www.emstock.com

www.temsf.org

From: wegandy1938@...

Airway ought to be the most emphasized skill, and it should be taught,

retaught, retaught, practiced, and retaught ad infinitum. But the

training has to

be good to begin with.

[Guest guest]

Mike,

Be careful what you wish for!!!

Now, I really DO have hair, lots of it. I just choose not to have it.

Thanks for the kind words.

GG

>

> Gene,

>

> As Lee said, excellent comments......

>

> When I grow up, I want to be just like you.......except I want

> hair....

>

> Mike

>

>

>

>

> 'Tater Salad' Hatfield EMT-P

>

> " Si hoc legere scis nimium eruditiones habes. "

>

> EMStock 2005, it's never to early to plan!!!

> www.emstock.com

> www.temsf.org

>

>

>

> From: wegandy1938@...

>

> Airway ought to be the most emphasized skill, and it should be taught,

> retaught, retaught, practiced, and retaught ad infinitum.   But the

> training has to

> be good to begin with.  

>

>

>

>

>

>

>

[Guest guest]

Mike,

Be careful what you wish for!!!

Now, I really DO have hair, lots of it. I just choose not to have it.

Thanks for the kind words.

GG

>

> Gene,

>

> As Lee said, excellent comments......

>

> When I grow up, I want to be just like you.......except I want

> hair....

>

> Mike

>

>

>

>

> 'Tater Salad' Hatfield EMT-P

>

> " Si hoc legere scis nimium eruditiones habes. "

>

> EMStock 2005, it's never to early to plan!!!

> www.emstock.com

> www.temsf.org

>

>

>

> From: wegandy1938@...

>

> Airway ought to be the most emphasized skill, and it should be taught,

> retaught, retaught, practiced, and retaught ad infinitum.   But the

> training has to

> be good to begin with.  

>

>

>

>

>

>

>

[Guest guest]

Mike,

Be careful what you wish for!!!

Now, I really DO have hair, lots of it. I just choose not to have it.

Thanks for the kind words.

GG

>

> Gene,

>

> As Lee said, excellent comments......

>

> When I grow up, I want to be just like you.......except I want

> hair....

>

> Mike

>

>

>

>

> 'Tater Salad' Hatfield EMT-P

>

> " Si hoc legere scis nimium eruditiones habes. "

>

> EMStock 2005, it's never to early to plan!!!

> www.emstock.com

> www.temsf.org

>

>

>

> From: wegandy1938@...

>

> Airway ought to be the most emphasized skill, and it should be taught,

> retaught, retaught, practiced, and retaught ad infinitum.   But the

> training has to

> be good to begin with.  

>

>

>

>

>

>

>

[Guest guest]

Todd,

I'll be glad to. Malampatti's classification system is done with the

patient sitting up and opening their mouth. You look in and grade what you see

I-IV.

Cormack and Lehane developed a similar scoring system for what you see with

direct laryngoscopy with I being the best view (full view of the cords) and IV

being the worst (tongue and uvula only). Modifications have been made to

their original descriptions so that now the system is referred to as Modified

Cormack Lehane Scoring System (MCLS).

By using the BURP technique (backward, upward, rightward pressure on the

tyroid cartilege) it is often possible to upgrade a MCLS one classification.

This is important since, if you have only a grade IV view, if you can use BURP

to

improve it to a III, you can usually place your gum elastic bougie correctly

and get the intubation.

Gene

>

>

> OK, I will bite.  I have never heard of the " Cormack-Lahane IV view " .  I

> asked one of our ER Docs and they haven't either.  I took a SLAM class a few

> years ago and I don't remember it there either.  Enlighten this brain dead

> old guy.

>

> Thanks

>

>

>

> Todd D.

>

> EMS Manager

>

> 304 S. Daugherty

>

> PO Box 897

>

> Eastland, Texas 76448

>

> ext. 408

>

> Cell

>

> Fax

>

> ems@...

>

>

>

>   _____ 

>

> From: wegandy1938@...

> Sent: Friday, November 12, 2004 10:08 PM

> To: bbledsoe@...; ;

> Paramedicine ; EMS_Research

> Subject: Re: More Evidence Agaisnt Intubation in TBI

>

>

>

> For some reason I just now read Dr. Bledsoe's post of 11/02/2004 on Airway

> Skills.   I would like to place some comments on his statements and add some

>

> comments of my own.  

>

> As some of you know,   airway is one of my interests as a member of

> TeamSLAM,

> the best advanced airway program in existence (he said, modestly).

>

> There are SO many things about airway management that are not being taught

> in

> paramedic courses that would greatly enhance a paramedic's abilities to

> successfully manage the difficult airway.   These techniques are well known,

> and

> there are very simple and cheap adjuncts that are readily available, yet

> medics

> are not taught them.

>

> That's why I question the studies that say that intubation ought not be

> attempted in this patient or that, because the studies do not take into

> consideration the level of training that the practitioner has had.   Read

> down, please,

>

> GG

>

>

>

> >

> > I think, that with the literature coming in as it is, medical directors

> may

> > have to make decisions whether to allow paramedics to intubate children

> and

> > patients with traumatic brain injuries. It may be hard to defend in court

> > otherwise. But, before we commit hari-kari, we need a

> randomized-controlled

> > trial to sort out the problems. Gene may get on me for this, but I think

> the

> > problems are these:

> >

> GG:   I agree with you 100%, .   You are completely correct in each and

>

> every stated problem.

> GG

> >

> > 1. EMTS develop poor airway skills because the skills are not adequately

> > emphasized or instructor accept CPR cards as evidence of aiway competency.

> >

> Correct.   Consider this:   Airway maintenance is the most important aspect

> of patient care.   As SLAM teaches, " If your patient cannot breathe, nothing

>

> else matters. "    Why would we relegate airway training to a short module

> where

> the student only needs to demonstrate that s/he can hook up an oxygen

> cylinder,

> pick out a delivery device and put it on the patient, and deliver X lpm; bag

>

> a patient with the BVM for a minute (seldom enforced), do a little

> suctioning,

> stick a tube into a manikin that the student has practiced on and whose

> airway paramaters never change, stick in a Combitube once, and that's it.

>

> Airway ought to be the most emphasized skill, and it should be taught,

> retaught, retaught, practiced, and retaught ad infinitum.   But the training

> has to

> be good to begin with.   Practicing bad technique only makes you proficient

> in

> bad airway technique.

>

> > 2. Paramedics are not getting enough intubation practice (programs have

> too

> > few hours and curriculum enhanced)

> >

> Correct again.   See above.

>

> > 3. Inadequate operating room exposure (thanks to the trial lawyers)

> >

> Not just thanks to trial lawyers, although that's a part of it, but thanks

> to

> the LMA and the fact that Medicare and other insurance companies have scared

>

> the crap out of anesthesiologiests and CRNAs for filing for compensation for

> a

> prodecure that they did not do personally.   Hell, even residents cannot get

>

> adequate skill practice because of this.   Trial lawyers are a small part of

>

> it.   Medical bureaucracy and insurance companies are the worst.

>

> So many gas passers just do not drop a lot of tubes now because of the LMA

> that it's hard to get tubes even with docs who want to cooperate.

>

> > 4. Failure to recognize skill decay ( " I can intubate as good as

> > anybody--regardlessmif I haven't done it in 6 momths " )

> >

> Some medics just do not encounter patients who need to be intubated often.

>

> We cannot change that.   But we CAN show medics how to enhance their

> intubation skills so that when they do have to do it, they can accomplish

> the task even

> if they are not in practice.   The gum elastic bougie is the one cheap and

> easy item that can make all the difference in the world for those people.

> Yet,

> they're not trained to use it, not supplied with it, and don't even know

> about it.   Attendance at a cadaver lab can give one the opportunity to

> become

> familiar with the airway structures and to practice many different

> techniques.  

> Cadaver practice should be mandatory.

>

> > 5. Ego

> >

> In SLAM we teach that Einstein (you DO know who Einstein was?) said that

> doing the same thing over and over and expecting a different result is

> insanity.  

> So if you try to intubate with a Mac 4 and can't get it done, don't just

> keep

> trying with your Mac 4.   Get a and try.   Stick the bougie in, or if

>

> none of those work, put the Combitube in or an LMA.   The cases where you

> cannot get an airway SOME WAY are practically non-existent.   It is those

> people

> who egotistically refuse to try a disciplined series of different techniques

>

> who fail.   Guilt for this sin spreads across the whole spectrum of

> providers.  

> I have seen doctors who tried to intubate for 10 minutes without ever

> ventilating their patient, never tried another blade or technique, and

> paramedics who

> followed their teachings.   All bad.  

>

> Remember that a dog that can only do one trick will not do well at the show.

>

> The dog that can do 15 tricks will win.   Have more than one trick, and if

> your first trick doesn't work, immediately try the next one.  

>

> It is NOT a loss of face to fail to place an endotracheal tube, recognize

> that you're probably not going to be successful and then successfully place

> a

> Combitube, ventilate your patient adequately, and all is well.

>

> The greatest loss of face ought to be failure to ventilate your patient by

> any means and lose him or her; not failure to endotracheally intubate.

>

> > 6. Adrenalin (paramedics tend to not adequately ventilate and oxygenate

> > prior to ET placement and tend to hyperventilate the patient once

> intubated.

> >

> Getting in too big a hurry is a terrible problem.   Take a deep breath.  

> Relax.   Look at your patient and think what's happening.   Form a plan.

> Get

> your patient adequately pre-oxygenated, then try your first trick.   If that

>

> doesn't work, re-oxygenate and go to your second trick.  

>

> Then, once the patient has an airway, whether it is an ET tube, Combitube,

> LMA, or whatever, control yourself.   Count 1-1000, 2-1000, 3-1000-,4-1000,

> 5-1000, 6-1000 BREATHE.   We are overventilating our patients to the point

> that

> we're creating increased pulmonary pressures, medistinal pressures, and

> actually

> causing a drop in preload and cardiac output through these increased

> pressures.   You can actually improve both your Sat% and CO2 output by

> slowing

> ventilations rather than increasing them.  

>

> > 7. Inadequte use of wave-form capnography.

> >

> This will be the standard of care in a short time.   It is scientifically

> the

> standard of care now, and it will be the legal standard of care as soon as a

>

> sufficient number of practitioners begin to use it.  

> The advantages of this process   are that it can not only tell you whether

> or

> not your airway is adequately managed and provide legal proof of it, but it

> can show you when you need to intubate a breathing patient long before s/he

> crashes.   Services that don't have capnography are gambling against their

> futures.

>

> > 8. Lack of research that would have shown light on the problem before the

> > practice was so well-entrenched.

> >

> Research is difficult if not impossible to implement in the system that we

> have.   The legal concerns surrounding uninformed consents that are

> attendant in

> non-responsive patients, the difficulty in maintaining controls in the

> pre-hospital setting, and, above all, lack of any sort of funding for EMS

> based

> research makes it unlikely that we will have the evidence upon which to base

>

> airway practices such as RSI, intubation of TBI patients and pedis any time

> soon.  

> We will continue to use empirical and intuitive considerations in doing what

>

> we do.  

>

> " Evidence based medicine " is a great buzzword.   I truly want everything

> that

> is done to me to be evidence based.   Yet, I know that when prehospital

> interventions are involved, the acquisition of evidence upon which to base

> an

> intervention is damn near impossible given our present laws.

>

> > 9. Paramedics think that failure to place an ET tube is a sign of failure

> > and are thus reluctant to use other airway devices.

> >

> See above.   The REAL sign of failure is to lose a patient due to failure to

>

> ventilate when you had alternative devices at hand which could have been

> readily employed.   Failure to use alternative devices is malpractice.

> Period.  

> No defense.

>

> The greatest loss of face ought to be failure to ventilate a patient, not

> failure to place an ET tube.

>

> > 10. Paramedics are poorly prepared to manage the difficult airway and not

> > familiar with other techniques (gum elastoc bougie, retrograde intubation)

> > and so on.

> >

> 100% correct.   The Gum Elastic Bougie is the greatest thing since

> Popsicles.

>   It's cheap enough that even rural Paramedics can buy one, and no EMT-I or

> Paramedic should ever go to work without one available at fingertip.   The

> bougie can help you turn an impending disaster into a resounding triumph.  

> Believe me, I've done it.   The bougie has saved my patient and me many

> times.  

>

> Also,   if you can't stick a 14 into the cricothyroid membrane, grab the BVM

>

> adaptor off of a #3 ET tube, stick it into the hub of the 14 and ventilate

> your patient for 5 minutes while you're figuring out what your next move is

> going

> to be, you're going to lose that patient.  Use of a needle crich can buy you

>

> enough time to get yer act together and do a PerTrach, Cook Melker, or

> surgical crich.   Or a retrograde.   Haven't practiced these techniques?

> Don't know

> how to do them?   Don't have a clue?   You're a walking liability.   Be sure

>

> your insurance is paid.   Or be ready for a million dollar judgment to be

> filed against you and hook on to everything you own, prevent you from buying

>

> anything, and generally making your life a cesspool.  

>

> Better learn what airway standard of care is, and it AIN'T just ET

> intubation.

>

> >

> > When I went to paramedic school in 1975 (and taught it from 1979-1983), we

> > often got the ET mannikins out and required prtactice and check-offs, This

> > may not be occurring.

> >

> > This begs the question: are the negative outcome studies seen with

> > prehospital RSI a function of basically poor airway skills or of the

> > procedure itself. I am beginning to think the former.

> >

> My considered opinion is that, as Dr. Bledsoe says, it is the former.   I

> firmly believe that we can teach average folks to do advanced airway skills

> with

> a high degree of competency.   But we cannot do it without a stated

> commitment

> to doing it.   It requires much more than is taught in most courses.  

> There's no excuse for that.   There is a lot of money floating around for

> grants

> these days.  

>

> If you're a medic who has never been exposed to the " tricks of the trade "

> and

> practiced on cadavers, the hold up the 7-11, rob the bank, sell your dog, or

>

> do what's necessary to learn how to manage the impossible airway.   The

> training is available.  

>

> RSI?   Great when you need it and know how to do it.   Are you allowed to do

>

> it?   When is the last time you practiced it on a manikin in real time?

> When

> is the last time you actually drew up the drugs, had them all lined up, kept

>

> your patient ventilated manually while getting ready, gave the drugs in

> sequence and within the time frame, and then intubated using whatever it

> took to do

> it?   Rehearsal is absolutely required, at least twice a year.

>

> Do you know what to do when you paralyze your patient, take a look with the

> laryngoscope and see a Cormack-Lahane IV view?   If you cannot answer that

> question, you have no business ever doing RSI.   But if you don't know the

> answer,

> you can quite easily learn it.   But will you do it?  

>

> Do you know that any Cormack-Lahane can be moved up one number with BURP

> usually, but after you paralyze your patient your number will generally

> decrease

> one?   Know what I'm talking about?   If so, good for you.   If not, better

> call your lawyer, pay your insurance premium, and then sign up for a class.

>

> I have the greatest confidence that ordinary Paramedics and

> EMT-Intermediates

> can give state of the art airway management.   There's nothing even remotely

>

> hard to understand about it.   It only requires teaching and practice under

> the right conditions.  

>

> Sadly,   most EMT-I and Paramedic students are not being afforded this

> education, training, and practice.   So we take the hits for airway

> failures.  

>

> GG

> >

> >

> > E. Bledsoe, DO, FACEP

> > Midlothian, TX

> >

> > Re: More Evidence Agaisnt Intubation in TBI

> >

> >

> > So is more training necessary or less excitement while on scene?

> >

> Both, Danny.   Yes, more training.   More training will result in less

> excitement on the scene.   The calm practitioner is the one who is confident

> with

> his/her skills, confident that s/he can manage the difficult airway, and

> prepared to ventilate any patient.  

>

> Also, I must comment about the use of the term " on scene. "    The only things

>

> that should be done " on scene " are airway management, hemorrhage management,

>

> spinal immobilization, and such other interventions that cannot be managed

> as

> well in the ambulance enroute to the hospital.

>

> Staying and   playing is only justified when your patient will not survive

> being moved to the ambulance.  

>

> GG

> >

> > Danny L.

> > Owner/NREMT-P

> > Panhandle Emergency Training Services And Response

> > (PETSAR)

> > Office

> > FAX

> >

> >

> >

[Guest guest]

OK, I will bite. I have never heard of the " Cormack-Lahane IV view " . I

asked one of our ER Docs and they haven't either. I took a SLAM class a few

years ago and I don't remember it there either. Enlighten this brain dead

old guy.

Thanks

Todd D.

EMS Manager

304 S. Daugherty

PO Box 897

Eastland, Texas 76448

ext. 408

Cell

Fax

ems@...

_____

From: wegandy1938@...

Sent: Friday, November 12, 2004 10:08 PM

To: bbledsoe@...; ;

Paramedicine ; EMS_Research

Subject: Re: More Evidence Agaisnt Intubation in TBI

For some reason I just now read Dr. Bledsoe's post of 11/02/2004 on Airway

Skills. I would like to place some comments on his statements and add some

comments of my own.

As some of you know, airway is one of my interests as a member of

TeamSLAM,

the best advanced airway program in existence (he said, modestly).

There are SO many things about airway management that are not being taught

in

paramedic courses that would greatly enhance a paramedic's abilities to

successfully manage the difficult airway. These techniques are well known,

and

there are very simple and cheap adjuncts that are readily available, yet

medics

are not taught them.

That's why I question the studies that say that intubation ought not be

attempted in this patient or that, because the studies do not take into

consideration the level of training that the practitioner has had. Read

down, please,

GG

>

> I think, that with the literature coming in as it is, medical directors

may

> have to make decisions whether to allow paramedics to intubate children

and

> patients with traumatic brain injuries. It may be hard to defend in court

> otherwise. But, before we commit hari-kari, we need a

randomized-controlled

> trial to sort out the problems. Gene may get on me for this, but I think

the

> problems are these:

>

GG: I agree with you 100%, . You are completely correct in each and

every stated problem.

GG

>

> 1. EMTS develop poor airway skills because the skills are not adequately

> emphasized or instructor accept CPR cards as evidence of aiway competency.

>

Correct. Consider this: Airway maintenance is the most important aspect

of patient care. As SLAM teaches, " If your patient cannot breathe, nothing

else matters. " Why would we relegate airway training to a short module

where

the student only needs to demonstrate that s/he can hook up an oxygen

cylinder,

pick out a delivery device and put it on the patient, and deliver X lpm; bag

a patient with the BVM for a minute (seldom enforced), do a little

suctioning,

stick a tube into a manikin that the student has practiced on and whose

airway paramaters never change, stick in a Combitube once, and that's it.

Airway ought to be the most emphasized skill, and it should be taught,

retaught, retaught, practiced, and retaught ad infinitum. But the training

has to

be good to begin with. Practicing bad technique only makes you proficient

in

bad airway technique.

> 2. Paramedics are not getting enough intubation practice (programs have

too

> few hours and curriculum enhanced)

>

Correct again. See above.

> 3. Inadequate operating room exposure (thanks to the trial lawyers)

>

Not just thanks to trial lawyers, although that's a part of it, but thanks

to

the LMA and the fact that Medicare and other insurance companies have scared

the crap out of anesthesiologiests and CRNAs for filing for compensation for

a

prodecure that they did not do personally. Hell, even residents cannot get

adequate skill practice because of this. Trial lawyers are a small part of

it. Medical bureaucracy and insurance companies are the worst.

So many gas passers just do not drop a lot of tubes now because of the LMA

that it's hard to get tubes even with docs who want to cooperate.

> 4. Failure to recognize skill decay ( " I can intubate as good as

> anybody--regardlessmif I haven't done it in 6 momths " )

>

Some medics just do not encounter patients who need to be intubated often.

We cannot change that. But we CAN show medics how to enhance their

intubation skills so that when they do have to do it, they can accomplish

the task even

if they are not in practice. The gum elastic bougie is the one cheap and

easy item that can make all the difference in the world for those people.

Yet,

they're not trained to use it, not supplied with it, and don't even know

about it. Attendance at a cadaver lab can give one the opportunity to

become

familiar with the airway structures and to practice many different

techniques.

Cadaver practice should be mandatory.

> 5. Ego

>

In SLAM we teach that Einstein (you DO know who Einstein was?) said that

doing the same thing over and over and expecting a different result is

insanity.

So if you try to intubate with a Mac 4 and can't get it done, don't just

keep

trying with your Mac 4. Get a and try. Stick the bougie in, or if

none of those work, put the Combitube in or an LMA. The cases where you

cannot get an airway SOME WAY are practically non-existent. It is those

people

who egotistically refuse to try a disciplined series of different techniques

who fail. Guilt for this sin spreads across the whole spectrum of

providers.

I have seen doctors who tried to intubate for 10 minutes without ever

ventilating their patient, never tried another blade or technique, and

paramedics who

followed their teachings. All bad.

Remember that a dog that can only do one trick will not do well at the show.

The dog that can do 15 tricks will win. Have more than one trick, and if

your first trick doesn't work, immediately try the next one.

It is NOT a loss of face to fail to place an endotracheal tube, recognize

that you're probably not going to be successful and then successfully place

a

Combitube, ventilate your patient adequately, and all is well.

The greatest loss of face ought to be failure to ventilate your patient by

any means and lose him or her; not failure to endotracheally intubate.

> 6. Adrenalin (paramedics tend to not adequately ventilate and oxygenate

> prior to ET placement and tend to hyperventilate the patient once

intubated.

>

Getting in too big a hurry is a terrible problem. Take a deep breath.

Relax. Look at your patient and think what's happening. Form a plan.

Get

your patient adequately pre-oxygenated, then try your first trick. If that

doesn't work, re-oxygenate and go to your second trick.

Then, once the patient has an airway, whether it is an ET tube, Combitube,

LMA, or whatever, control yourself. Count 1-1000, 2-1000, 3-1000-,4-1000,

5-1000, 6-1000 BREATHE. We are overventilating our patients to the point

that

we're creating increased pulmonary pressures, medistinal pressures, and

actually

causing a drop in preload and cardiac output through these increased

pressures. You can actually improve both your Sat% and CO2 output by

slowing

ventilations rather than increasing them.

> 7. Inadequte use of wave-form capnography.

>

This will be the standard of care in a short time. It is scientifically

the

standard of care now, and it will be the legal standard of care as soon as a

sufficient number of practitioners begin to use it.

The advantages of this process are that it can not only tell you whether

or

not your airway is adequately managed and provide legal proof of it, but it

can show you when you need to intubate a breathing patient long before s/he

crashes. Services that don't have capnography are gambling against their

futures.

> 8. Lack of research that would have shown light on the problem before the

> practice was so well-entrenched.

>

Research is difficult if not impossible to implement in the system that we

have. The legal concerns surrounding uninformed consents that are

attendant in

non-responsive patients, the difficulty in maintaining controls in the

pre-hospital setting, and, above all, lack of any sort of funding for EMS

based

research makes it unlikely that we will have the evidence upon which to base

airway practices such as RSI, intubation of TBI patients and pedis any time

soon.

We will continue to use empirical and intuitive considerations in doing what

we do.

" Evidence based medicine " is a great buzzword. I truly want everything

that

is done to me to be evidence based. Yet, I know that when prehospital

interventions are involved, the acquisition of evidence upon which to base

an

intervention is damn near impossible given our present laws.

> 9. Paramedics think that failure to place an ET tube is a sign of failure

> and are thus reluctant to use other airway devices.

>

See above. The REAL sign of failure is to lose a patient due to failure to

ventilate when you had alternative devices at hand which could have been

readily employed. Failure to use alternative devices is malpractice.

Period.

No defense.

The greatest loss of face ought to be failure to ventilate a patient, not

failure to place an ET tube.

> 10. Paramedics are poorly prepared to manage the difficult airway and not

> familiar with other techniques (gum elastoc bougie, retrograde intubation)

> and so on.

>

100% correct. The Gum Elastic Bougie is the greatest thing since

Popsicles.

It's cheap enough that even rural Paramedics can buy one, and no EMT-I or

Paramedic should ever go to work without one available at fingertip. The

bougie can help you turn an impending disaster into a resounding triumph.

Believe me, I've done it. The bougie has saved my patient and me many

times.

Also, if you can't stick a 14 into the cricothyroid membrane, grab the BVM

adaptor off of a #3 ET tube, stick it into the hub of the 14 and ventilate

your patient for 5 minutes while you're figuring out what your next move is

going

to be, you're going to lose that patient. Use of a needle crich can buy you

enough time to get yer act together and do a PerTrach, Cook Melker, or

surgical crich. Or a retrograde. Haven't practiced these techniques?

Don't know

how to do them? Don't have a clue? You're a walking liability. Be sure

your insurance is paid. Or be ready for a million dollar judgment to be

filed against you and hook on to everything you own, prevent you from buying

anything, and generally making your life a cesspool.

Better learn what airway standard of care is, and it AIN'T just ET

intubation.

>

> When I went to paramedic school in 1975 (and taught it from 1979-1983), we

> often got the ET mannikins out and required prtactice and check-offs, This

> may not be occurring.

>

> This begs the question: are the negative outcome studies seen with

> prehospital RSI a function of basically poor airway skills or of the

> procedure itself. I am beginning to think the former.

>

My considered opinion is that, as Dr. Bledsoe says, it is the former. I

firmly believe that we can teach average folks to do advanced airway skills

with

a high degree of competency. But we cannot do it without a stated

commitment

to doing it. It requires much more than is taught in most courses.

There's no excuse for that. There is a lot of money floating around for

grants

these days.

If you're a medic who has never been exposed to the " tricks of the trade "

and

practiced on cadavers, the hold up the 7-11, rob the bank, sell your dog, or

do what's necessary to learn how to manage the impossible airway. The

training is available.

RSI? Great when you need it and know how to do it. Are you allowed to do

it? When is the last time you practiced it on a manikin in real time?

When

is the last time you actually drew up the drugs, had them all lined up, kept

your patient ventilated manually while getting ready, gave the drugs in

sequence and within the time frame, and then intubated using whatever it

took to do

it? Rehearsal is absolutely required, at least twice a year.

Do you know what to do when you paralyze your patient, take a look with the

laryngoscope and see a Cormack-Lahane IV view? If you cannot answer that

question, you have no business ever doing RSI. But if you don't know the

answer,

you can quite easily learn it. But will you do it?

Do you know that any Cormack-Lahane can be moved up one number with BURP

usually, but after you paralyze your patient your number will generally

decrease

one? Know what I'm talking about? If so, good for you. If not, better

call your lawyer, pay your insurance premium, and then sign up for a class.

I have the greatest confidence that ordinary Paramedics and

EMT-Intermediates

can give state of the art airway management. There's nothing even remotely

hard to understand about it. It only requires teaching and practice under

the right conditions.

Sadly, most EMT-I and Paramedic students are not being afforded this

education, training, and practice. So we take the hits for airway

failures.

GG

>

>

> E. Bledsoe, DO, FACEP

> Midlothian, TX

>

> Re: More Evidence Agaisnt Intubation in TBI

>

>

> So is more training necessary or less excitement while on scene?

>

Both, Danny. Yes, more training. More training will result in less

excitement on the scene. The calm practitioner is the one who is confident

with

his/her skills, confident that s/he can manage the difficult airway, and

prepared to ventilate any patient.

Also, I must comment about the use of the term " on scene. " The only things

that should be done " on scene " are airway management, hemorrhage management,

spinal immobilization, and such other interventions that cannot be managed

as

well in the ambulance enroute to the hospital.

Staying and playing is only justified when your patient will not survive

being moved to the ambulance.

GG

>

> Danny L.

> Owner/NREMT-P

> Panhandle Emergency Training Services And Response

> (PETSAR)

> Office

> FAX

>

>

>

[Guest guest]

OK, I will bite. I have never heard of the " Cormack-Lahane IV view " . I

asked one of our ER Docs and they haven't either. I took a SLAM class a few

years ago and I don't remember it there either. Enlighten this brain dead

old guy.

Thanks

Todd D.

EMS Manager

304 S. Daugherty

PO Box 897

Eastland, Texas 76448

ext. 408

Cell

Fax

ems@...

_____

From: wegandy1938@...

Sent: Friday, November 12, 2004 10:08 PM

To: bbledsoe@...; ;

Paramedicine ; EMS_Research

Subject: Re: More Evidence Agaisnt Intubation in TBI

For some reason I just now read Dr. Bledsoe's post of 11/02/2004 on Airway

Skills. I would like to place some comments on his statements and add some

comments of my own.

As some of you know, airway is one of my interests as a member of

TeamSLAM,

the best advanced airway program in existence (he said, modestly).

There are SO many things about airway management that are not being taught

in

paramedic courses that would greatly enhance a paramedic's abilities to

successfully manage the difficult airway. These techniques are well known,

and

there are very simple and cheap adjuncts that are readily available, yet

medics

are not taught them.

That's why I question the studies that say that intubation ought not be

attempted in this patient or that, because the studies do not take into

consideration the level of training that the practitioner has had. Read

down, please,

GG

>

> I think, that with the literature coming in as it is, medical directors

may

> have to make decisions whether to allow paramedics to intubate children

and

> patients with traumatic brain injuries. It may be hard to defend in court

> otherwise. But, before we commit hari-kari, we need a

randomized-controlled

> trial to sort out the problems. Gene may get on me for this, but I think

the

> problems are these:

>

GG: I agree with you 100%, . You are completely correct in each and

every stated problem.

GG

>

> 1. EMTS develop poor airway skills because the skills are not adequately

> emphasized or instructor accept CPR cards as evidence of aiway competency.

>

Correct. Consider this: Airway maintenance is the most important aspect

of patient care. As SLAM teaches, " If your patient cannot breathe, nothing

else matters. " Why would we relegate airway training to a short module

where

the student only needs to demonstrate that s/he can hook up an oxygen

cylinder,

pick out a delivery device and put it on the patient, and deliver X lpm; bag

a patient with the BVM for a minute (seldom enforced), do a little

suctioning,

stick a tube into a manikin that the student has practiced on and whose

airway paramaters never change, stick in a Combitube once, and that's it.

Airway ought to be the most emphasized skill, and it should be taught,

retaught, retaught, practiced, and retaught ad infinitum. But the training

has to

be good to begin with. Practicing bad technique only makes you proficient

in

bad airway technique.

> 2. Paramedics are not getting enough intubation practice (programs have

too

> few hours and curriculum enhanced)

>

Correct again. See above.

> 3. Inadequate operating room exposure (thanks to the trial lawyers)

>

Not just thanks to trial lawyers, although that's a part of it, but thanks

to

the LMA and the fact that Medicare and other insurance companies have scared

the crap out of anesthesiologiests and CRNAs for filing for compensation for

a

prodecure that they did not do personally. Hell, even residents cannot get

adequate skill practice because of this. Trial lawyers are a small part of

it. Medical bureaucracy and insurance companies are the worst.

So many gas passers just do not drop a lot of tubes now because of the LMA

that it's hard to get tubes even with docs who want to cooperate.

> 4. Failure to recognize skill decay ( " I can intubate as good as

> anybody--regardlessmif I haven't done it in 6 momths " )

>

Some medics just do not encounter patients who need to be intubated often.

We cannot change that. But we CAN show medics how to enhance their

intubation skills so that when they do have to do it, they can accomplish

the task even

if they are not in practice. The gum elastic bougie is the one cheap and

easy item that can make all the difference in the world for those people.

Yet,

they're not trained to use it, not supplied with it, and don't even know

about it. Attendance at a cadaver lab can give one the opportunity to

become

familiar with the airway structures and to practice many different

techniques.

Cadaver practice should be mandatory.

> 5. Ego

>

In SLAM we teach that Einstein (you DO know who Einstein was?) said that

doing the same thing over and over and expecting a different result is

insanity.

So if you try to intubate with a Mac 4 and can't get it done, don't just

keep

trying with your Mac 4. Get a and try. Stick the bougie in, or if

none of those work, put the Combitube in or an LMA. The cases where you

cannot get an airway SOME WAY are practically non-existent. It is those

people

who egotistically refuse to try a disciplined series of different techniques

who fail. Guilt for this sin spreads across the whole spectrum of

providers.

I have seen doctors who tried to intubate for 10 minutes without ever

ventilating their patient, never tried another blade or technique, and

paramedics who

followed their teachings. All bad.

Remember that a dog that can only do one trick will not do well at the show.

The dog that can do 15 tricks will win. Have more than one trick, and if

your first trick doesn't work, immediately try the next one.

It is NOT a loss of face to fail to place an endotracheal tube, recognize

that you're probably not going to be successful and then successfully place

a

Combitube, ventilate your patient adequately, and all is well.

The greatest loss of face ought to be failure to ventilate your patient by

any means and lose him or her; not failure to endotracheally intubate.

> 6. Adrenalin (paramedics tend to not adequately ventilate and oxygenate

> prior to ET placement and tend to hyperventilate the patient once

intubated.

>

Getting in too big a hurry is a terrible problem. Take a deep breath.

Relax. Look at your patient and think what's happening. Form a plan.

Get

your patient adequately pre-oxygenated, then try your first trick. If that

doesn't work, re-oxygenate and go to your second trick.

Then, once the patient has an airway, whether it is an ET tube, Combitube,

LMA, or whatever, control yourself. Count 1-1000, 2-1000, 3-1000-,4-1000,

5-1000, 6-1000 BREATHE. We are overventilating our patients to the point

that

we're creating increased pulmonary pressures, medistinal pressures, and

actually

causing a drop in preload and cardiac output through these increased

pressures. You can actually improve both your Sat% and CO2 output by

slowing

ventilations rather than increasing them.

> 7. Inadequte use of wave-form capnography.

>

This will be the standard of care in a short time. It is scientifically

the

standard of care now, and it will be the legal standard of care as soon as a

sufficient number of practitioners begin to use it.

The advantages of this process are that it can not only tell you whether

or

not your airway is adequately managed and provide legal proof of it, but it

can show you when you need to intubate a breathing patient long before s/he

crashes. Services that don't have capnography are gambling against their

futures.

> 8. Lack of research that would have shown light on the problem before the

> practice was so well-entrenched.

>

Research is difficult if not impossible to implement in the system that we

have. The legal concerns surrounding uninformed consents that are

attendant in

non-responsive patients, the difficulty in maintaining controls in the

pre-hospital setting, and, above all, lack of any sort of funding for EMS

based

research makes it unlikely that we will have the evidence upon which to base

airway practices such as RSI, intubation of TBI patients and pedis any time

soon.

We will continue to use empirical and intuitive considerations in doing what

we do.

" Evidence based medicine " is a great buzzword. I truly want everything

that

is done to me to be evidence based. Yet, I know that when prehospital

interventions are involved, the acquisition of evidence upon which to base

an

intervention is damn near impossible given our present laws.

> 9. Paramedics think that failure to place an ET tube is a sign of failure

> and are thus reluctant to use other airway devices.

>

See above. The REAL sign of failure is to lose a patient due to failure to

ventilate when you had alternative devices at hand which could have been

readily employed. Failure to use alternative devices is malpractice.

Period.

No defense.

The greatest loss of face ought to be failure to ventilate a patient, not

failure to place an ET tube.

> 10. Paramedics are poorly prepared to manage the difficult airway and not

> familiar with other techniques (gum elastoc bougie, retrograde intubation)

> and so on.

>

100% correct. The Gum Elastic Bougie is the greatest thing since

Popsicles.

It's cheap enough that even rural Paramedics can buy one, and no EMT-I or

Paramedic should ever go to work without one available at fingertip. The

bougie can help you turn an impending disaster into a resounding triumph.

Believe me, I've done it. The bougie has saved my patient and me many

times.

Also, if you can't stick a 14 into the cricothyroid membrane, grab the BVM

adaptor off of a #3 ET tube, stick it into the hub of the 14 and ventilate

your patient for 5 minutes while you're figuring out what your next move is

going

to be, you're going to lose that patient. Use of a needle crich can buy you

enough time to get yer act together and do a PerTrach, Cook Melker, or

surgical crich. Or a retrograde. Haven't practiced these techniques?

Don't know

how to do them? Don't have a clue? You're a walking liability. Be sure

your insurance is paid. Or be ready for a million dollar judgment to be

filed against you and hook on to everything you own, prevent you from buying

anything, and generally making your life a cesspool.

Better learn what airway standard of care is, and it AIN'T just ET

intubation.

>

> When I went to paramedic school in 1975 (and taught it from 1979-1983), we

> often got the ET mannikins out and required prtactice and check-offs, This

> may not be occurring.

>

> This begs the question: are the negative outcome studies seen with

> prehospital RSI a function of basically poor airway skills or of the

> procedure itself. I am beginning to think the former.

>

My considered opinion is that, as Dr. Bledsoe says, it is the former. I

firmly believe that we can teach average folks to do advanced airway skills

with

a high degree of competency. But we cannot do it without a stated

commitment

to doing it. It requires much more than is taught in most courses.

There's no excuse for that. There is a lot of money floating around for

grants

these days.

If you're a medic who has never been exposed to the " tricks of the trade "

and

practiced on cadavers, the hold up the 7-11, rob the bank, sell your dog, or

do what's necessary to learn how to manage the impossible airway. The

training is available.

RSI? Great when you need it and know how to do it. Are you allowed to do

it? When is the last time you practiced it on a manikin in real time?

When

is the last time you actually drew up the drugs, had them all lined up, kept

your patient ventilated manually while getting ready, gave the drugs in

sequence and within the time frame, and then intubated using whatever it

took to do

it? Rehearsal is absolutely required, at least twice a year.

Do you know what to do when you paralyze your patient, take a look with the

laryngoscope and see a Cormack-Lahane IV view? If you cannot answer that

question, you have no business ever doing RSI. But if you don't know the

answer,

you can quite easily learn it. But will you do it?

Do you know that any Cormack-Lahane can be moved up one number with BURP

usually, but after you paralyze your patient your number will generally

decrease

one? Know what I'm talking about? If so, good for you. If not, better

call your lawyer, pay your insurance premium, and then sign up for a class.

I have the greatest confidence that ordinary Paramedics and

EMT-Intermediates

can give state of the art airway management. There's nothing even remotely

hard to understand about it. It only requires teaching and practice under

the right conditions.

Sadly, most EMT-I and Paramedic students are not being afforded this

education, training, and practice. So we take the hits for airway

failures.

GG

>

>

> E. Bledsoe, DO, FACEP

> Midlothian, TX

>

> Re: More Evidence Agaisnt Intubation in TBI

>

>

> So is more training necessary or less excitement while on scene?

>

Both, Danny. Yes, more training. More training will result in less

excitement on the scene. The calm practitioner is the one who is confident

with

his/her skills, confident that s/he can manage the difficult airway, and

prepared to ventilate any patient.

Also, I must comment about the use of the term " on scene. " The only things

that should be done " on scene " are airway management, hemorrhage management,

spinal immobilization, and such other interventions that cannot be managed

as

well in the ambulance enroute to the hospital.

Staying and playing is only justified when your patient will not survive

being moved to the ambulance.

GG

>

> Danny L.

> Owner/NREMT-P

> Panhandle Emergency Training Services And Response

> (PETSAR)

> Office

> FAX

>

>

>

[Guest guest]

OK, I will bite. I have never heard of the " Cormack-Lahane IV view " . I

asked one of our ER Docs and they haven't either. I took a SLAM class a few

years ago and I don't remember it there either. Enlighten this brain dead

old guy.

Thanks

Todd D.

EMS Manager

304 S. Daugherty

PO Box 897

Eastland, Texas 76448

ext. 408

Cell

Fax

ems@...

_____

From: wegandy1938@...

Sent: Friday, November 12, 2004 10:08 PM

To: bbledsoe@...; ;

Paramedicine ; EMS_Research

Subject: Re: More Evidence Agaisnt Intubation in TBI

For some reason I just now read Dr. Bledsoe's post of 11/02/2004 on Airway

Skills. I would like to place some comments on his statements and add some

comments of my own.

As some of you know, airway is one of my interests as a member of

TeamSLAM,

the best advanced airway program in existence (he said, modestly).

There are SO many things about airway management that are not being taught

in

paramedic courses that would greatly enhance a paramedic's abilities to

successfully manage the difficult airway. These techniques are well known,

and

there are very simple and cheap adjuncts that are readily available, yet

medics

are not taught them.

That's why I question the studies that say that intubation ought not be

attempted in this patient or that, because the studies do not take into

consideration the level of training that the practitioner has had. Read

down, please,

GG

>

> I think, that with the literature coming in as it is, medical directors

may

> have to make decisions whether to allow paramedics to intubate children

and

> patients with traumatic brain injuries. It may be hard to defend in court

> otherwise. But, before we commit hari-kari, we need a

randomized-controlled

> trial to sort out the problems. Gene may get on me for this, but I think

the

> problems are these:

>

GG: I agree with you 100%, . You are completely correct in each and

every stated problem.

GG

>

> 1. EMTS develop poor airway skills because the skills are not adequately

> emphasized or instructor accept CPR cards as evidence of aiway competency.

>

Correct. Consider this: Airway maintenance is the most important aspect

of patient care. As SLAM teaches, " If your patient cannot breathe, nothing

else matters. " Why would we relegate airway training to a short module

where

the student only needs to demonstrate that s/he can hook up an oxygen

cylinder,

pick out a delivery device and put it on the patient, and deliver X lpm; bag

a patient with the BVM for a minute (seldom enforced), do a little

suctioning,

stick a tube into a manikin that the student has practiced on and whose

airway paramaters never change, stick in a Combitube once, and that's it.

Airway ought to be the most emphasized skill, and it should be taught,

retaught, retaught, practiced, and retaught ad infinitum. But the training

has to

be good to begin with. Practicing bad technique only makes you proficient

in

bad airway technique.

> 2. Paramedics are not getting enough intubation practice (programs have

too

> few hours and curriculum enhanced)

>

Correct again. See above.

> 3. Inadequate operating room exposure (thanks to the trial lawyers)

>

Not just thanks to trial lawyers, although that's a part of it, but thanks

to

the LMA and the fact that Medicare and other insurance companies have scared

the crap out of anesthesiologiests and CRNAs for filing for compensation for

a

prodecure that they did not do personally. Hell, even residents cannot get

adequate skill practice because of this. Trial lawyers are a small part of

it. Medical bureaucracy and insurance companies are the worst.

So many gas passers just do not drop a lot of tubes now because of the LMA

that it's hard to get tubes even with docs who want to cooperate.

> 4. Failure to recognize skill decay ( " I can intubate as good as

> anybody--regardlessmif I haven't done it in 6 momths " )

>

Some medics just do not encounter patients who need to be intubated often.

We cannot change that. But we CAN show medics how to enhance their

intubation skills so that when they do have to do it, they can accomplish

the task even

if they are not in practice. The gum elastic bougie is the one cheap and

easy item that can make all the difference in the world for those people.

Yet,

they're not trained to use it, not supplied with it, and don't even know

about it. Attendance at a cadaver lab can give one the opportunity to

become

familiar with the airway structures and to practice many different

techniques.

Cadaver practice should be mandatory.

> 5. Ego

>

In SLAM we teach that Einstein (you DO know who Einstein was?) said that

doing the same thing over and over and expecting a different result is

insanity.

So if you try to intubate with a Mac 4 and can't get it done, don't just

keep

trying with your Mac 4. Get a and try. Stick the bougie in, or if

none of those work, put the Combitube in or an LMA. The cases where you

cannot get an airway SOME WAY are practically non-existent. It is those

people

who egotistically refuse to try a disciplined series of different techniques

who fail. Guilt for this sin spreads across the whole spectrum of

providers.

I have seen doctors who tried to intubate for 10 minutes without ever

ventilating their patient, never tried another blade or technique, and

paramedics who

followed their teachings. All bad.

Remember that a dog that can only do one trick will not do well at the show.

The dog that can do 15 tricks will win. Have more than one trick, and if

your first trick doesn't work, immediately try the next one.

It is NOT a loss of face to fail to place an endotracheal tube, recognize

that you're probably not going to be successful and then successfully place

a

Combitube, ventilate your patient adequately, and all is well.

The greatest loss of face ought to be failure to ventilate your patient by

any means and lose him or her; not failure to endotracheally intubate.

> 6. Adrenalin (paramedics tend to not adequately ventilate and oxygenate

> prior to ET placement and tend to hyperventilate the patient once

intubated.

>

Getting in too big a hurry is a terrible problem. Take a deep breath.

Relax. Look at your patient and think what's happening. Form a plan.

Get

your patient adequately pre-oxygenated, then try your first trick. If that

doesn't work, re-oxygenate and go to your second trick.

Then, once the patient has an airway, whether it is an ET tube, Combitube,

LMA, or whatever, control yourself. Count 1-1000, 2-1000, 3-1000-,4-1000,

5-1000, 6-1000 BREATHE. We are overventilating our patients to the point

that

we're creating increased pulmonary pressures, medistinal pressures, and

actually

causing a drop in preload and cardiac output through these increased

pressures. You can actually improve both your Sat% and CO2 output by

slowing

ventilations rather than increasing them.

> 7. Inadequte use of wave-form capnography.

>

This will be the standard of care in a short time. It is scientifically

the

standard of care now, and it will be the legal standard of care as soon as a

sufficient number of practitioners begin to use it.

The advantages of this process are that it can not only tell you whether

or

not your airway is adequately managed and provide legal proof of it, but it

can show you when you need to intubate a breathing patient long before s/he

crashes. Services that don't have capnography are gambling against their

futures.

> 8. Lack of research that would have shown light on the problem before the

> practice was so well-entrenched.

>

Research is difficult if not impossible to implement in the system that we

have. The legal concerns surrounding uninformed consents that are

attendant in

non-responsive patients, the difficulty in maintaining controls in the

pre-hospital setting, and, above all, lack of any sort of funding for EMS

based

research makes it unlikely that we will have the evidence upon which to base

airway practices such as RSI, intubation of TBI patients and pedis any time

soon.

We will continue to use empirical and intuitive considerations in doing what

we do.

" Evidence based medicine " is a great buzzword. I truly want everything

that

is done to me to be evidence based. Yet, I know that when prehospital

interventions are involved, the acquisition of evidence upon which to base

an

intervention is damn near impossible given our present laws.

> 9. Paramedics think that failure to place an ET tube is a sign of failure

> and are thus reluctant to use other airway devices.

>

See above. The REAL sign of failure is to lose a patient due to failure to

ventilate when you had alternative devices at hand which could have been

readily employed. Failure to use alternative devices is malpractice.

Period.

No defense.

The greatest loss of face ought to be failure to ventilate a patient, not

failure to place an ET tube.

> 10. Paramedics are poorly prepared to manage the difficult airway and not

> familiar with other techniques (gum elastoc bougie, retrograde intubation)

> and so on.

>

100% correct. The Gum Elastic Bougie is the greatest thing since

Popsicles.

It's cheap enough that even rural Paramedics can buy one, and no EMT-I or

Paramedic should ever go to work without one available at fingertip. The

bougie can help you turn an impending disaster into a resounding triumph.

Believe me, I've done it. The bougie has saved my patient and me many

times.

Also, if you can't stick a 14 into the cricothyroid membrane, grab the BVM

adaptor off of a #3 ET tube, stick it into the hub of the 14 and ventilate

your patient for 5 minutes while you're figuring out what your next move is

going

to be, you're going to lose that patient. Use of a needle crich can buy you

enough time to get yer act together and do a PerTrach, Cook Melker, or

surgical crich. Or a retrograde. Haven't practiced these techniques?

Don't know

how to do them? Don't have a clue? You're a walking liability. Be sure

your insurance is paid. Or be ready for a million dollar judgment to be

filed against you and hook on to everything you own, prevent you from buying

anything, and generally making your life a cesspool.

Better learn what airway standard of care is, and it AIN'T just ET

intubation.

>

> When I went to paramedic school in 1975 (and taught it from 1979-1983), we

> often got the ET mannikins out and required prtactice and check-offs, This

> may not be occurring.

>

> This begs the question: are the negative outcome studies seen with

> prehospital RSI a function of basically poor airway skills or of the

> procedure itself. I am beginning to think the former.

>

My considered opinion is that, as Dr. Bledsoe says, it is the former. I

firmly believe that we can teach average folks to do advanced airway skills

with

a high degree of competency. But we cannot do it without a stated

commitment

to doing it. It requires much more than is taught in most courses.

There's no excuse for that. There is a lot of money floating around for

grants

these days.

If you're a medic who has never been exposed to the " tricks of the trade "

and

practiced on cadavers, the hold up the 7-11, rob the bank, sell your dog, or

do what's necessary to learn how to manage the impossible airway. The

training is available.

RSI? Great when you need it and know how to do it. Are you allowed to do

it? When is the last time you practiced it on a manikin in real time?

When

is the last time you actually drew up the drugs, had them all lined up, kept

your patient ventilated manually while getting ready, gave the drugs in

sequence and within the time frame, and then intubated using whatever it

took to do

it? Rehearsal is absolutely required, at least twice a year.

Do you know what to do when you paralyze your patient, take a look with the

laryngoscope and see a Cormack-Lahane IV view? If you cannot answer that

question, you have no business ever doing RSI. But if you don't know the

answer,

you can quite easily learn it. But will you do it?

Do you know that any Cormack-Lahane can be moved up one number with BURP

usually, but after you paralyze your patient your number will generally

decrease

one? Know what I'm talking about? If so, good for you. If not, better

call your lawyer, pay your insurance premium, and then sign up for a class.

I have the greatest confidence that ordinary Paramedics and

EMT-Intermediates

can give state of the art airway management. There's nothing even remotely

hard to understand about it. It only requires teaching and practice under

the right conditions.

Sadly, most EMT-I and Paramedic students are not being afforded this

education, training, and practice. So we take the hits for airway

failures.

GG

>

>

> E. Bledsoe, DO, FACEP

> Midlothian, TX

>

> Re: More Evidence Agaisnt Intubation in TBI

>

>

> So is more training necessary or less excitement while on scene?

>

Both, Danny. Yes, more training. More training will result in less

excitement on the scene. The calm practitioner is the one who is confident

with

his/her skills, confident that s/he can manage the difficult airway, and

prepared to ventilate any patient.

Also, I must comment about the use of the term " on scene. " The only things

that should be done " on scene " are airway management, hemorrhage management,

spinal immobilization, and such other interventions that cannot be managed

as

well in the ambulance enroute to the hospital.

Staying and playing is only justified when your patient will not survive

being moved to the ambulance.

GG

>

> Danny L.

> Owner/NREMT-P

> Panhandle Emergency Training Services And Response

> (PETSAR)

> Office

> FAX

>

>

>

[Guest guest]

I don't feel so bad now. I had to look it up. Gotta love Google when the

brain slows!

Mike

Longview

Re: More Evidence Agaisnt Intubation in TBI

> >

> >

> > So is more training necessary or less excitement while on scene?

> >

> Both, Danny. Yes, more training. More training will result in less

> excitement on the scene. The calm practitioner is the one who is

confident

> with

> his/her skills, confident that s/he can manage the difficult airway, and

> prepared to ventilate any patient.

>

> Also, I must comment about the use of the term " on scene. " The only

things

>

> that should be done " on scene " are airway management, hemorrhage

management,

>

> spinal immobilization, and such other interventions that cannot be managed

> as

> well in the ambulance enroute to the hospital.

>

> Staying and playing is only justified when your patient will not survive

> being moved to the ambulance.

>

> GG

> >

> > Danny L.

> > Owner/NREMT-P

> > Panhandle Emergency Training Services And Response

> > (PETSAR)

> > Office

> > FAX

> >

> >

> >

[Guest guest]

I don't feel so bad now. I had to look it up. Gotta love Google when the

brain slows!

Mike

Longview

Re: More Evidence Agaisnt Intubation in TBI

> >

> >

> > So is more training necessary or less excitement while on scene?

> >

> Both, Danny. Yes, more training. More training will result in less

> excitement on the scene. The calm practitioner is the one who is

confident

> with

> his/her skills, confident that s/he can manage the difficult airway, and

> prepared to ventilate any patient.

>

> Also, I must comment about the use of the term " on scene. " The only

things

>

> that should be done " on scene " are airway management, hemorrhage

management,

>

> spinal immobilization, and such other interventions that cannot be managed

> as

> well in the ambulance enroute to the hospital.

>

> Staying and playing is only justified when your patient will not survive

> being moved to the ambulance.

>

> GG

> >

> > Danny L.

> > Owner/NREMT-P

> > Panhandle Emergency Training Services And Response

> > (PETSAR)

> > Office

> > FAX

> >

> >

> >

[Guest guest]

I don't feel so bad now. I had to look it up. Gotta love Google when the

brain slows!

Mike

Longview

Re: More Evidence Agaisnt Intubation in TBI

> >

> >

> > So is more training necessary or less excitement while on scene?

> >

> Both, Danny. Yes, more training. More training will result in less

> excitement on the scene. The calm practitioner is the one who is

confident

> with

> his/her skills, confident that s/he can manage the difficult airway, and

> prepared to ventilate any patient.

>

> Also, I must comment about the use of the term " on scene. " The only

things

>

> that should be done " on scene " are airway management, hemorrhage

management,

>

> spinal immobilization, and such other interventions that cannot be managed

> as

> well in the ambulance enroute to the hospital.

>

> Staying and playing is only justified when your patient will not survive

> being moved to the ambulance.

>

> GG

> >

> > Danny L.

> > Owner/NREMT-P

> > Panhandle Emergency Training Services And Response

> > (PETSAR)

> > Office

> > FAX

> >

> >

> >