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Intubation Attempts/provider


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#1 djs1183

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Posted 22 February 2012 - 04:24 PM

Our program is counting placing a laryngoscope blade past the teeth as one attempt. This is regardless of whether you have a tube in hand, bougie placed or anything else. We have two attempts per crew provided the pt spo2 is greater than 90%. Then it is down to one and placement of Adjunct device. Im curious what are some of the other programs out there doing for Intubation "attempts"

Thanks


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#2 sr_medic

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Posted 27 March 2012 - 05:12 PM

Our program is counting placing a laryngoscope blade past the teeth as one attempt. This is regardless of whether you have a tube in hand, bougie placed or anything else. We have two attempts per crew provided the pt spo2 is greater than 90%. Then it is down to one and placement of Adjunct device. Im curious what are some of the other programs out there doing for Intubation "attempts"

Thanks



Our CPG's state that every patient can get "three attempts by a qualified provider." So students, first-time intubators, etc. don't count. After that we go to a surgical/supraglotic airway. Hope that helps!
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#3 BrianACNP

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Posted 28 March 2012 - 01:47 AM

Our CPG's state that every patient can get "three attempts by a qualified provider." So students, first-time intubators, etc. don't count. After that we go to a surgical/supraglotic airway. Hope that helps!


Wow! Are you serious? An actual intubation attempt that doesn't count in "the numbers"? That's not putting the patient first...it's putting your numbers and statistics first.

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#4 sr_medic

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Posted 30 March 2012 - 01:17 AM

Wow! Are you serious? An actual intubation attempt that doesn't count in "the numbers"? That's not putting the patient first...it's putting your numbers and statistics first.

Brian


Don't shoot the messenger. It's not my rule.

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#5 old school

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Posted 30 March 2012 - 01:03 PM

Our CPG's state that every patient can get "three attempts by a qualified provider." So students, first-time intubators, etc. don't count. After that we go to a surgical/supraglotic airway. Hope that helps!


Wow! Are you serious? An actual intubation attempt that doesn't count in "the numbers"? That's not putting the patient first...it's putting your numbers and statistics first.


I don't think that's a bad policy. In fact, assuming common sense and good judgement are employed, I think it makes a lot of sense.

Quite a few times in my career I've been on a transport where someone (a paramedic student, a new flight nurse with no airway experience, or a paramedic or MD who was just having a bad day) has already tried and failed several times to intubate. In every one of those cases that I can remember, I was able to intubate easily and quickly, and I don't think it would have necessarily been in those patient's best interest to place an inferior airway just because some arbitrary number of intubation attempts had already been made.

Now I'm not talking about a scenario where you show up and the patient's airway is a mess and a very competent intubator has already been struggling with the airway for 10 minutes, and the patient is in or nearing extremis but you decide to get your three attempts in anyway because you are hoping to look like a hero. That's obviously a very different situation.
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#6 Jwade

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Posted 30 March 2012 - 04:55 PM

I don't think that's a bad policy. In fact, assuming common sense and good judgement are employed, I think it makes a lot of sense.

Quite a few times in my career I've been on a transport where someone (a paramedic student, a new flight nurse with no airway experience, or a paramedic or MD who was just having a bad day) has already tried and failed several times to intubate. In every one of those cases that I can remember, I was able to intubate easily and quickly, and I don't think it would have necessarily been in those patient's best interest to place an inferior airway just because some arbitrary number of intubation attempts had already been made.

Now I'm not talking about a scenario where you show up and the patient's airway is a mess and a very competent intubator has already been struggling with the airway for 10 minutes, and the patient is in or nearing extremis but you decide to get your three attempts in anyway because you are hoping to look like a hero. That's obviously a very different situation.



Unfortunately, I have seen too many flight crews do exactly what you described...........Happens every day.....

My question to you is: How do you qualify on scene if someone is a " Competent Intubator?" Do you ask them how long they have been a Paramedic / Nurse? Do you ask them how many intubations they have done in the last 3 months?

Just seems like an odd decision making tree to me.......

I don't agree with the arbitrary number either or delineation of what constitutes an attempt, I just don't understand your specific statement. Clearly, the majority of the time you are NOT going to know the ground crew on a personal basis, so, not sure how you would determine who is competent or not.


JW
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#7 old school

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Posted 30 March 2012 - 10:19 PM

So here's the thing: when I get into the back of an ambulance and am asked to take responsibility for and transport a patient who appears to require airway management, my responsibility is to assess that patient and decide on the safest, most appropriate plan of care. In order to do that, I have to gather as much information as possible. I gather that information by doing a rapid trauma survey, a focused airway assessment, gathering as much history as is available, and asking the person who already tried to intubate what they did, what they saw, and why their attempt(s) were not successful. If I know or suspect that the person who failed the intubation has significantly less airway experience than I do, then that piece of data becomes part of the equation.

After gathering all of that data and considering my protocols, I'll decide on a plan of care. That plan could include placing an LMA, performing a cric, letting the patient wake up if the sux is already wearing off, or making my own intubation attempt. Maybe I'll choose to consult with OLMC or go by ground to the ED that's right around the corner. Who knows?

It's important to understand that no SINGLE piece of information determines the plan of care, and the fact that someone was already unsuccessful at intubating is just one piece of information. An important piece, for sure, but probably not more important than the sum of the rest of the pertinent data. I've actually been faced with this scenario quite a few times, and I usually chose to make my own intubation attempt and that's usually worked out really well. I have absolutely no hesitation using an LMA or King if it's warranted, but that's just not usually the best option, in my judgement.
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#8 BrianACNP

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Posted 30 March 2012 - 11:13 PM

I don't think that's a bad policy. In fact, assuming common sense and good judgement are employed, I think it makes a lot of sense.

Quite a few times in my career I've been on a transport where someone (a paramedic student, a new flight nurse with no airway experience, or a paramedic or MD who was just having a bad day) has already tried and failed several times to intubate. In every one of those cases that I can remember, I was able to intubate easily and quickly, and I don't think it would have necessarily been in those patient's best interest to place an inferior airway just because some arbitrary number of intubation attempts had already been made.

Now I'm not talking about a scenario where you show up and the patient's airway is a mess and a very competent intubator has already been struggling with the airway for 10 minutes, and the patient is in or nearing extremis but you decide to get your three attempts in anyway because you are hoping to look like a hero. That's obviously a very different situation.


First, I didn't interpret that rule to include providers already on-scene prior to my arrival. In my opinion, those attempts do not count for my crew when talking about # o attempts before going to an alternative airway. I have to agree with John that I can't assume their experience level. Once I arrive, our crew would make the decisions on the best method to secure the airway. I would consider giving the student or the new flight nurse with no airway experience one attempt unless I was confident that this individual was able to secure it on the 2nd attempt (ie: they visualized the cords but had difficulty on 1st attempt, etc). If it was a situation of high acuity or high risk of failure, they would get, at the most, one chance. It's in the patient's best interest. Those kinds of situations are no time for anyone to practice their newly acquired skill.

My point, though, is about not counting an attempt. I recognize that the posting individual is "just the messenger", so my comments are geared towards the rule itself.....and I think it's ludricous. There's no shame to say that it took two or three attempts to secure an airway. We should strive to get it secured in one, but the reality is that flight crews intubate in some of the worst conditions. I understand that the purpose of the rule is to allow providers with new skillsets to intubate but keep the "real" attempts to a minimum of two or three. But what's the purpose of the rule if, at the end of the day, the patient was intubated on 4 or 5 attemtps...or that it took that long for the flight crew to decide to move to an alternative airway? It's false documentation, all in the name of allowing someone to practice and keeping the data within the "rule".

Sorry, Alan, you know I have GREAT respect for you, but I can't go along with your viewpoint.

Brian
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#9 Jwade

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Posted 30 March 2012 - 11:19 PM

So here's the thing: when I get into the back of an ambulance and am asked to take responsibility for and transport a patient who appears to require airway management, my responsibility is to assess that patient and decide on the safest, most appropriate plan of care. In order to do that, I have to gather as much information as possible. I gather that information by doing a rapid trauma survey, a focused airway assessment, gathering as much history as is available, and asking the person who already tried to intubate what they did, what they saw, and why their attempt(s) were not successful. If I know or suspect that the person who failed the intubation has significantly less airway experience than I do, then that piece of data becomes part of the equation.

After gathering all of that data and considering my protocols, I'll decide on a plan of care. That plan could include placing an LMA, performing a cric, letting the patient wake up if the sux is already wearing off, or making my own intubation attempt. Maybe I'll choose to consult with OLMC or go by ground to the ED that's right around the corner. Who knows?

It's important to understand that no SINGLE piece of information determines the plan of care, and the fact that someone was already unsuccessful at intubating is just one piece of information. An important piece, for sure, but probably not more important than the sum of the rest of the pertinent data. I've actually been faced with this scenario quite a few times, and I usually chose to make my own intubation attempt and that's usually worked out really well. I have absolutely no hesitation using an LMA or King if it's warranted, but that's just not usually the best option, in my judgement.



Old School.

Would you make the same decision if you responded to a rural ER where the local MDA or CRNA has not been able to obtain an ET tube for whatever reason? Clearly, both of them are going to have vastly more Airway experience than yourself......

So, what I am hearing you say above, is essentially, no matter what, you're going to do a D.L. just to satisfy your own curiosity.........and once you confirm what the medic or ER doc just told you, then you would place an LMA or KING?

I am just curious, because, I had a case where we couldn't intubate a patient due to gnarly dentition and barely a lower jaw, but we could easily ventilate.....When we walked into the ER at the trauma center, the MDA was waiting, and after listening to my report, he did not bother to even look at the airway, and simply called for the glidescope from the OR. That left a huge impression on me that day to say the least........I was pretty impressed with his decision making tree.

I've seen plenty of flight crew screw-ups sitting on QA teams, and to me it seems like EGO gets the best of them every time, where in reality, less is more sometimes........

JW
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#10 old school

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Posted 31 March 2012 - 01:11 PM

Old School.

Would you make the same decision if you responded to a rural ER where the local MDA or CRNA has not been able to obtain an ET tube for whatever reason? Clearly, both of them are going to have vastly more Airway experience than yourself......

If a CRNA who has years of advanced education and does a couple hundred airways a year of all types using all kinds of adjuncts tells the me that the patient needs an LMA placed, that is very different than hearing the same thing from a paramedic who likely only does a handful of intubations per year or less.

Are you suggesting, John, that I should always blindly defer to the advice of whoever happens to have gotten to the patient before me, regardless of whether or not I disagree with their assessment?

Why even do an assessment then? Why not just ask the ground paramedic to write down the orders he'd like me to follow during transport?


So, what I am hearing you say above, is essentially, no matter what, you're going to do a D.L. just to satisfy your own curiosity.........and once you confirm what the medic or ER doc just told you, then you would place an LMA or KING?


Well I guess you are hearing what you want John, because that's not at all what I wrote...
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#11 old school

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Posted 31 March 2012 - 01:51 PM

My point, though, is about not counting an attempt. I recognize that the posting individual is "just the messenger", so my comments are geared towards the rule itself.....and I think it's ludricous. There's no shame to say that it took two or three attempts to secure an airway. We should strive to get it secured in one, but the reality is that flight crews intubate in some of the worst conditions. I understand that the purpose of the rule is to allow providers with new skillsets to intubate but keep the "real" attempts to a minimum of two or three. But what's the purpose of the rule if, at the end of the day, the patient was intubated on 4 or 5 attemtps...or that it took that long for the flight crew to decide to move to an alternative airway? It's false documentation, all in the name of allowing someone to practice and keeping the data within the "rule".

Sorry, Alan, you know I have GREAT respect for you, but I can't go along with your viewpoint.

Brian


Brian, I think you and I are actually on the same page for the most part.

Maybe i misunderstood what Idaho meant, but my interpretation of his statement that "first time intubator's attempts don't count" wasn't that they actually don't count - or that they don't get documented - but rather, that the policy just allows for more flexibility when the first and second attempt is done by someone with no or very little experience.


I completely agree that we need to strive to place an ETT on the first attempt. And in reality, at MCA we do achieve that a large majority of the time (something like 86% of our intubations, I think?).

I also understand the reason behind the "3 attempts max" rule. Without that in writing, some providers will try all day to place an ETT before moving on to something else. I've seen it lots of times and was even guilty of it myself earlier in my career (though in my defense, when I used to do that it was largely because our backups weren't nearly as good as what we have now). And also, medical directors need to CYA.

I actually think "3 attempts" is a good guideline. If the same experienced person has missed 3 attempts, then they need to seriously re-assess whether an ETT is the best option, and there's a really good chance it's not at that point.

But at the same time, these situations are often too complicated to be adequately governed by such a very simple rule. Again, I think "3 attempts" is a decent basic guideline, it's just that I don't agree that the simple fact that 3 attempts have already been made, automatically necessitates, in every case, that the best thing to do for the patient is to place a backup.

King's and LMA's are great tools and we should be quick to use them when the clinical situation warrants.
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#12 old school

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Posted 31 March 2012 - 02:00 PM

Apologies if I'm taking this thread off-topic (Brian please move this post to a new thread if you think that's the case), but I think what I'm about to address is quite relevant to the topic at hand.

Whenever we talk about pre-hospital airway management - and especially when we talk about failed attempts - it seems like there's this 400# gorilla in the corner that many of us like to pretend isn't there.

Does anyone else know what I'm referring to?
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#13 sr_medic

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Posted 31 March 2012 - 09:22 PM

Brian, I think you and I are actually on the same page for the most part.

Maybe i misunderstood what Idaho meant, but my interpretation of his statement that "first time intubator's attempts don't count" wasn't that they actually don't count - or that they don't get documented - but rather, that the policy just allows for more flexibility when the first and second attempt is done by someone with no or very little experience.


I completely agree that we need to strive to place an ETT on the first attempt. And in reality, at MCA we do achieve that a large majority of the time (something like 86% of our intubations, I think?).

I also understand the reason behind the "3 attempts max" rule. Without that in writing, some providers will try all day to place an ETT before moving on to something else. I've seen it lots of times and was even guilty of it myself earlier in my career (though in my defense, when I used to do that it was largely because our backups weren't nearly as good as what we have now). And also, medical directors need to CYA.

I actually think "3 attempts" is a good guideline. If the same experienced person has missed 3 attempts, then they need to seriously re-assess whether an ETT is the best option, and there's a really good chance it's not at that point.

But at the same time, these situations are often too complicated to be adequately governed by such a very simple rule. Again, I think "3 attempts" is a decent basic guideline, it's just that I don't agree that the simple fact that 3 attempts have already been made, automatically necessitates, in every case, that the best thing to do for the patient is to place a backup.

King's and LMA's are great tools and we should be quick to use them when the clinical situation warrants.


Old School hit the nail right on the head. The guideline is in place to help eliminate endless and futile attempts at intubation; when an otherwise equally effective alternative exists. With so many airway mishaps occurring in the industry right now, I think we are better off to self-police ourselves and keep ourselves out of the spot light.

I don't believe the guideline has anything to do with trying to shame someone into getting the tube on the first or second or even third attempt. It's there to help people stay in a quality clinical mindset and avoid tunnel vision. As a clinician, I have it in my mind that if 3 quality attempts have been made, we as a team need to re-evaluate the airway (Combi/King/Glidescope/Surgical). I can think of more than a couple situations over the 7 years I've been in EMS where the number of intubation attempts has become very vague. After the first person doesn't get it, then then another person has to try and so on. Before long there have been so many attempts made we have all lost track, all the while the patients 02 sats are like a roller-coaster.

I realize that what I have said will probably get chewed up and spit out- as a new member I'm pretty used to that. The point I am trying to make is that the guideline is there to help us and the patient- not back anyone into a corner.
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#14 sr_medic

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Posted 31 March 2012 - 09:29 PM

Wow! Are you serious? An actual intubation attempt that doesn't count in "the numbers"? That's not putting the patient first...it's putting your numbers and statistics first.

Brian


Brian-
I don't know if I have misunderstood what you are trying to say. In short... on our PCR all attempts get documented. In no way was I implying that we are 'cheating' on our number of attempts in order to put our numbers first. The basis of the rule is that if a patient has had three attempts at intubation by a qualified provider; try something else- there must be a reason why it's not working. In that same hand, I would say that if after those three attempts you discover an equipment problem or patient problem, and can fix it- by all means do what is most appropriate.
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#15 Jwade

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Posted 31 March 2012 - 09:39 PM

If a CRNA who has years of advanced education and does a couple hundred airways a year of all types using all kinds of adjuncts tells the me that the patient needs an LMA placed, that is very different than hearing the same thing from a paramedic who likely only does a handful of intubations per year or less.

Are you suggesting, John, that I should always blindly defer to the advice of whoever happens to have gotten to the patient before me, regardless of whether or not I disagree with their assessment?

Why even do an assessment then? Why not just ask the ground paramedic to write down the orders he'd like me to follow during transport?




Well I guess you are hearing what you want John, because that's not at all what I wrote...


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#16 Jwade

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Posted 31 March 2012 - 09:51 PM

If a CRNA who has years of advanced education and does a couple hundred airways a year of all types using all kinds of adjuncts tells the me that the patient needs an LMA placed, that is very different than hearing the same thing from a paramedic who likely only does a handful of intubations per year or less.

Are you suggesting, John, that I should always blindly defer to the advice of whoever happens to have gotten to the patient before me, regardless of whether or not I disagree with their assessment?

Why even do an assessment then? Why not just ask the ground paramedic to write down the orders he'd like me to follow during transport?




Well I guess you are hearing what you want John, because that's not at all what I wrote...



So, to follow your current logic to it's predictive conclusion, If I ( or any other experienced HEMS provider) just happen to be working the ground that day on our days off from flying, you would still dismiss our report of a difficult airway and proceed to do yet another attempt just because, by default, we are a paramedic, who, by your own assumptions, probably only does a handful of intubations a year or less? I would say your logic is flawed at best.

Just an FYI, I am using what they call " I statements" I am concerned, I am confused, What I am hearing you say is: These are Critical Thinking / Psych / Counseling 101 concepts which are used to prevent assumptions from being made. The benefit to these statements allow for facts to be checked out with the person who initially made the statements so there is no confusion / misunderstanding..........Hence my statement to you. I was simply asking for clarification on your end.

Do you routinely remove alternative airways on scene as well, so you can try to get the intubation?

JW
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#17 old school

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Posted 01 April 2012 - 01:08 AM

Do you routinely remove alternative airways on scene as well, so you can try to get the intubation?


Yes John. I always do that. Because I'm a cowboy, and I'm not nearly as smart or experienced as you.

There, I finally admitted what you've apparently been trying to prove for a long time.

I feel so much better now. B)
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#18 Jwade

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Posted 01 April 2012 - 02:43 PM

Yes John. I always do that. Because I'm a cowboy, and I'm not nearly as smart or experienced as you.

There, I finally admitted what you've apparently been trying to prove for a long time.

I feel so much better now. B)



Tsk Tsk........No need to get personal Old School....I am not the one resorting to ad hominem attacks, i am trying to engage in a healthy discussion / debate to further understand why you do things the way you do. Now, if you can't or won't engage in this non-personal debate, then just say so......I certainly respect your opinion, even if I happen to disagree with your logic.

I was simply following your logic to it's flawed conclusion. You stated multiple times you would further attempt intubation simply due to the fact a paramedic was telling you it was a difficult airway and then followed up with if a CRNA told you the same thing, you would certainly listen to them which further proves your decision making algorithm is biased and flawed.

I am not making this stuff up, you clearly stated everything i have just said.

I am simply asking you to explain why your bias is so prevalent towards people who you are CLEARLY making a 100% assumption about in regards to experience, ability, and airway management skills.

' I am concerned', again, you clearly made another assumption with my last question about removing alternative airways. This was a legit question, as I have watched more than a few flight crews ( Including a couple of former partners ) remove a perfectly good airway only to get themselves into a " ClusterF$ck".......Furthermore, a secondary reason i ask the question, is in Paramedic school, we were actually taught to intubate around the combitube by deflating the large cuff while leaving the small inflated. Then remove the combitube once intubated......I am not sure, I would ever attempt this, as I would have a hard time justifying why I screwed with a perfectly good airway in court. I am wondering what your experience with alternative airways in place has been in your neck of the woods......

Thoughts?
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#19 old school

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Posted 02 April 2012 - 07:30 PM

You stated multiple times you would further attempt intubation simply due to the fact a paramedic was telling you it was a difficult airway.....


You are mischaracterizing what I wrote. I never stated that I always or would definitely "further attempt intubation simply due to the fact that a paramedic was telling me it was a difficult airway". What I wrote was, I may choose to make another intubation attempt, if, in my judgment, it's the right thing for the patient/situation. A backup airway is often the best choice, but it isn't always the best choice.

I don't know about you or anyone else, but I never base my assessment and plan of care solely on what I'm told in report, whether it comes from an EMT, paramedic, RN, or MD. Both ethically and legally, I am always responsible for performing my own assessment of the patient and situation and practicing to the standards to which I've been educated and to the protocols I've been supplied with.


Answer me this, John: Do you always formulate your plan of care based solely to what you are told on report?

What if you are preparing a CHF patient for transport, and the referring nurse tells you "this guy doesn't need CPAP or intubation; he'll be fine for transport." Do you decide then and there that you aren't going to use the LTV, based solely on what you were told, or do you assess the patient and decide for yourself?

What if you are preparing a STEMI patient for transport, and the referring doctor tells you "the patient doesn't need his nitro turned up; it's a short transport." Do you decide then and there not to titrate the nitro, based solely on what you were told, or do you assess the patient, consider your protocols and the stresses of transport, and decide for yourself?

What if you are at a scene, and the referring paramedic tells you "this guy has no veins, we already tried a couple times and couldn't get an IV." Do you decide then and there not to attempt an IV, or do you assess the patient, look for veins, and decide for yourself?


So you can do things differently if you want, but when I get in the back of an ambulance and they are trying to bag a patient who is breathing against them, and when I ask what's up and the paramedic tells me that he just missed his second or third attempt because this guy is "really hard" and that the 100kg patient's jaw never fully relaxed after the 50mg or 75mg of sux they gave him, and all the intubating stuff is laying right there and there's nothing about the outward anatomy that indicates that it's going to be a hard intubation, then yeah, I am probably gonna give a proper dose of etomidate and sux and take a quick look myself before I place a supraglottic airway that doesn't protect the trachea as well as an 8.0 does. And 8 or 9 out of 10 times that won't be a hard intubation and I'll have the ETT secured just as quickly as I would an LMA. Sorry if you find that "flawed" or if that makes me a cowboy.



...and then followed up with if a CRNA told you the same thing, you would certainly listen to them which further proves your decision making algorithm is biased and flawed.


Are you really trying to equate a paramedic to a CRNA or MDA in terms of their ability to judge and secure an airway? Keeping in mind, of course, that a typical paramedic might do 5 or less intubations during their initial training and less than that annually thereafter, whereas a typical CRNA does hundreds during their initial training, and may do hundreds annually thereafter, using all manner of adjuncts and techniques.

I guess my decision making is "biased and flawed" all the way around then, because I would also give more weight to the opinion of a cardiologist than a paramedic when it comes to assessing a heart failure patient, and would have more regard for the opinion of a neurologist than a paramedic when it comes to assessing and managing a hemorrhagic stroke patient.
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bring it in for the real thing

#20 rick k

rick k

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Posted 09 April 2012 - 03:48 AM

As an answer to the OP's question, 1 attempt period for scene response trauma. 2 attempts total for medical. An attempt is passing the teeth with the blade. I have been told we are getting ready to implement the C-MAC from Storz as the primary intubation device.
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Rick Kantor
Critical Care Paramedic
Eastcare Transport