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David,
- From: HFD181@aol.com
- Date: Mon, 4 Mar 2002 16:42:26 EST
Based on your listing (as well as the subject header) I am guessing that you are talking about inflight intubations specifically with trauma patients from scene flights. I agree with you that the load and go approach probably isn't the best idea.
In his reply, Jeff Hameister made some strong points that I agree with. Airway control is obviously paramount. As Jeff stated we generally do not do anything but airway and packaging. Now all we have to do is decide what course of action is best in that particular situation regarding patient (airway) management. This was the single most challenging task for me when I was making the transition from a ground medic to a flight medic. Does this patient require intubation? If not, will the patient require intubation before I arrive at the trauma center? Which patients actually require intubation? How have these requirements changed now that my ambulance has blades instead of wheels? These are questions that everyone in our profession has asked themselves at one time or another.
In my service's operational area, we find ourselves responding to about 60% scene flights. Generally the transport time back to the trauma center is less than 30 minutes. Most of the ground units in the region have ALS staffing however do not have RSI capabilities. What we find more often than not when we make contact with the patient is a well packaged victim with IV's placed and a BLS airway. I routinely find myself rapidly assessing the patient with one primary concern; do I need to intubate? Yes/no, then either secure an airway then transport, or just transport. Obviously, all calls don't play out like this. Just like everyone else, we fly into some real clusters. I find that for the most part however, once things start to shape up and get organized, it's time to decide on airway control then transport considerations.
The crews that operate in my service are lucky to have a good guideline to work with regarding airway control. Our medical director and his staff are excellent both during the flight as well as on follow ups and during training sessions. We have all the tools we need. A good RSI protocol with backup medications. Equipment backups such as the Combitube, LMA, trans-tracheal, retrograde, and surgical intubation. Currently, the intubation protocol does not specify whether or not we intubate on the ground or in the air. The decision is left up to the judgment of the crew and the medical control doc.
Our service operates BO-105's. Our first in-air intubation (that I am aware of) was successfully performed about a year ago. I'm not too certain on the specific details regarding the patient. At the time it was a popular topic to discuss amongst different providers within our service. I think it was a big step for us to realize that it was possible to drop a tube during flight in a 105. It was at that time that crews started to consider changing their own ideas pertaining to the questions that I addressed earlier. Does this patient require intubation? If not, will they require it before I get to the trauma center? etc. "Now maybe we can get the patient to the trauma center sooner if we can scoop and run then intubate during flight" You get the picture...
Let's go back and look at why we are intubating these patients. I think everyone is on the same page when it comes to airway control in trauma patients. Now lets add aircraft transport considerations in the mix. Safety should be your number one priority. First yours, then that of the crew, then the aircraft, then the patient. Hopefully we all consider the ramifications of getting a combative patient in the aircraft. Think about it, how many trauma patients have you seen that needed airway control but didn't have the potential to get away from you physically. I tend to hear a lot of conversation regarding the type and size of aircraft that a service is using when one justifies his/her decision to intubate in the air or not. This is not a size/space issue, the crews operating in our environment should have the background and experience to work an airway in poor conditions. It's a safety issue! If you have a head injured intoxicated patient who wants to get out at 1000 AGL, do you really think it matters whether you are in a LongRanger or an S-76? Talk to your pilots, you might be surprised to hear what they have to say. I actually heard a flight nurse recently tell a story about a flight where the pilot questioned the crew's judgment as to why they hadn't intubated a somewhat combative patient for the flight. I thought to myself "if the pilot realized there was a problem, then you missed the boat somewhere in your assessment and treatment plan," I felt embarrassed for the nurse. A few years ago, the Flight Medic who hired me and provided my field training told me something that made sense then and makes sense now; Good Assessment, Good Anticipation, Good Plan, Good Flight...
Obviously the other side of the argument is scene time considerations. We've all been there when that little man who stands on your shoulder whispers in your ear "we need to get going." You missed the IV, can't get the tube, after 200 of Sux the patient is still chewing on the blade, whatever. Even a perfect RSI will add a few minutes to the scene time. At some point, I think we probably have to except this more as a trade off rather than a problem that needs to be fixed. Here's a question for you. How much scene time is an airway worth? 1min, 5min, 20min? I don't think there is a correct answer. It is all situational dependent. If you are presented with an altered suspected head injured patient that you can't brief on aircraft safety issues prior to flight due to his inability to process information, that patient probably isn't flyable until they are RSI'd. Say it's a perfect intubation and it adds 7 minutes to your scene time. I'm betting that most people won't be alarmed or concerned with this. Now take the same patient and add severe upper extremity injury's that will complicate IV access. The patient still can't understand the aircraft safety briefing, but he will take longer to intubate, say 18 minutes by the time you blow a couple of lines and then you dig out the sternal IO. Is this the patient that we want to scoop and run with?
One last area to touch on, legal issues. David, in section 3 of you posting you refer to a concern for increased liability once you make a choice to intubate someone. If we as airmed crews at the scene of an incident start to make patient care choices based on liability fears rather than our training and experience, we are all in trouble! Ultimately it will lead to poor patient care...
In conclusion, I am obviously a fan of securing the patient's airway before they are in the aircraft. I think that intubating in the aircraft is an important skill and we should be confident that we can do it. There may be situations when an apparent stable patient crumps or we displace a tube in flight. This is the time to drop the tube in the air. I feel very strongly that if you look at a patient and say to yourself "this guy needs a tube, but I can get it in the air" you are making a mistake for a number of reasons, the most important being your safety.
Ross Hoham, CC/NREMT-P
Flight Paramedic