RE: on-scene vs. aircraft intubations

["Pufahl, Jo" <JPufahl@smdc.org>]

I say a hearty AMEN to that.  I have been flying for 13 years and I have yet to see any two flights the same.  The variables are too many to count, and we need to be alert, flexible, safe, aggressive and efficient provide the best possible care for the patient.  To do less is negligence from many angles.  If I am injured/ill, my life is in the hands of the person beside me - not in the hands of the medical director/management back home in the easy chair of the office or home.

 

Jo Pufahl, SMDC LifeFlight, Duluth, MN

-----Original Message-----
From: Jsscharm@aol.com [mailto:Jsscharm@aol.com]
Sent: Wednesday, March 06, 2002 12:15 AM
To: flightmed@flightweb.com
Subject: on-scene vs. aircraft intubations

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