Re: on-scene vs. aircraft intubations

[SUllrich@att.net]

Janet, I have also watched this debate with interest and 
I have had many discussions with partners related to 
this issue.  My personal opinion is to tube early.  If 
it needs to be done, do it on scene.  You never know 
when that patient is going to decompensate. The value of 
a secure airway and oxygenation cannot be stressed 
enough.  Another aspect that has not been discussed it 
the issue of ventilation.  We all know that just because 
a person's Sats are good, they may not be ventilating 
and are retaining CO2. Another reason to get control of 
the airway quickly.  I think we also overlook the value 
early sedation and paralysis have on ICP. I feel the 
bottom line is put 'em down and keep 'em down.  Why wait.

Steve 
> Hi all,
> 
> I have read with interest all the discussion that this topic has generated.  
> David and I have discussed this dilemma at length in the past.  I think there 
> are several key elements:  patient's current airway management (or lack of), 
> clinician's judgement of the situation, and safety of the flight crew.  As we 
> all know, it is nearly impossible to plug our "gray" patients into a "black 
> and white" system.  All patients and scenarios will differ and we must use 
> our clinical assessment skills and judgement to make the best decision 
> possible for the best patient outcome.  
> 
> If the patient is maintaining an adequate airway and can be safely packaged 
> and transported to the helicopter, then a tube should be placed in flight.  
> However, I recently did a scene response involving a teenage male, 
> head-injured from a roll-over.  
> He was in the back of the local EMS ambulance, c-collar, LBB, one IV line in 
> place, saturations were 67% on a NRB.  GCS of 6.  Spontaneous respirations 
> but gurgling from all the blood in his oropharynx, moaning on expiration, 
> bilateral pupils blown.  I opted to stay and RSI on scene.  My partner and I 
> identified the patient as being hypoxic with poor airway control.  To have 
> delayed tube placement for an additional 5 to 7 minutes would have been, in 
> my opinion, not in this patient's best interest and legally negligent on my 
> part.  I understand that many feel legal issues should not necessarily 
> determine the clinician's course of action.  However, the patient's medical 
> chart is no longer just a "medical chart" but a "medicolegal" chart. Our 
> decisions, actions, and documentation often come under the legal microscope.  
> What would I have done if not able to tube?  Combitube and scoot.  It does 
> you and your patient very little good to arrive at the trauma center in 
> record time with a dead patient from lack of airway management.  
> 
> In our industry there is a lot of pressure placed upon us to deliver fast, 
> expediate care.  Some of that pressure stems from competing airmedical 
> services.  "if they can do on-scene times of < 10" so can you."  We need to 
> resist those pressures and focus on what is best for our patients and the 
> safety of our crew.  
> 
> Thanks for lending an ear.......
> 
> Janet
> Flight Nurse

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