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#21 brandon911

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Posted 16 July 2012 - 02:41 PM

I see no reason to jump into video scope intubation as the primary intubation device. Over the years I have seen the glidescope fail. I have seen direct laryngoscopy fail. I have seen blind insertion airway's fail. All these studies about video scope intubation being far superior to direct laryngoscopy in my opinion are not something we should be looking at. If I live in Indiana and videoscope intubation has far better outcomes in Maryland does that mean we should jump on it here? If your service has great first attempt success rate then why change it to videoscope for all attempts? If it's not broken then why change it? I truly believe videoscope intubation has its place in EMS / Critical Care medicine / Emergency Department / Surgery and so on. But we need to spend the money / time and effort to train absolutely everyone at how to be a better airway provider. Let me ask you this. Is your service going to remove the "old laryngoscope blades" off of your helicopter / ambulance? If so what happens if your video screen breaks? What if the pt vomits and you cannot get the lens cleaned or it shorts out? What if the cord on your Storz Cmac or glidescope gets cut or has a break or short in it? Do you just bag? Do you place a supraglottic airway even though you could have been able to intubate the pt with direct laryngoscopy? I think videoscope's should be for difficult airway only. We will all lose our airway skills IE: actual intubation and evaluation if we just blindly insert a camera and look for the hole. Why was there all the previous talk of how terrible intubation was in the field but not that were talking about videoscope intubation, intubation is a good thing again? Has anyone seen the video on youtube of the 4 yo little boy intubating the manikin head with the King Vision? So easy a kid can do it or making a joke of the skill some of us have worked so hard to accomplish the right way everytime? Also if we are going to go to strickly videoscope intubation why can EMT-B's not perform the skill? There is no real training required. Just put in the camera and find the 2 little white things with the hole in the middle. Slide the tube in past the black line and blow up the balloon. There ya go!!! Again my opinions. Call me whatever ya want. This is the way I feel. Don't punish the group for a few people that cannot perform the skill properly. Next thing ya know we will be using ultrasound to start IV's so we don't miss ever. Or just giving all medications nasally so we don't have to poke anyone anymore. First attempt success = whatever the clinicial is comfortable with.


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#22 Jwade

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Posted 16 July 2012 - 08:34 PM

I see no reason to jump into video scope intubation as the primary intubation device. Over the years I have seen the glidescope fail. I have seen direct laryngoscopy fail. I have seen blind insertion airway's fail. All these studies about video scope intubation being far superior to direct laryngoscopy in my opinion are not something we should be looking at. If I live in Indiana and videoscope intubation has far better outcomes in Maryland does that mean we should jump on it here? If your service has great first attempt success rate then why change it to videoscope for all attempts? If it's not broken then why change it? I truly believe videoscope intubation has its place in EMS / Critical Care medicine / Emergency Department / Surgery and so on. But we need to spend the money / time and effort to train absolutely everyone at how to be a better airway provider. Let me ask you this. Is your service going to remove the "old laryngoscope blades" off of your helicopter / ambulance? If so what happens if your video screen breaks? What if the pt vomits and you cannot get the lens cleaned or it shorts out? What if the cord on your Storz Cmac or glidescope gets cut or has a break or short in it? Do you just bag? Do you place a supraglottic airway even though you could have been able to intubate the pt with direct laryngoscopy? I think videoscope's should be for difficult airway only. We will all lose our airway skills IE: actual intubation and evaluation if we just blindly insert a camera and look for the hole. Why was there all the previous talk of how terrible intubation was in the field but not that were talking about videoscope intubation, intubation is a good thing again? Has anyone seen the video on youtube of the 4 yo little boy intubating the manikin head with the King Vision? So easy a kid can do it or making a joke of the skill some of us have worked so hard to accomplish the right way everytime? Also if we are going to go to strickly videoscope intubation why can EMT-B's not perform the skill? There is no real training required. Just put in the camera and find the 2 little white things with the hole in the middle. Slide the tube in past the black line and blow up the balloon. There ya go!!! Again my opinions. Call me whatever ya want. This is the way I feel. Don't punish the group for a few people that cannot perform the skill properly. Next thing ya know we will be using ultrasound to start IV's so we don't miss ever. Or just giving all medications nasally so we don't have to poke anyone anymore. First attempt success = whatever the clinicial is comfortable with.


brandon911


Brandon,

With all due respect, I completely disagree with your statement above.


"If it ain't broke, don't fix it" is the slogan of the complacent, the arrogant or the
scared. It's an excuse for inaction, a call to non-arms. It's a mind-set that
assumes (or hopes) that today's realities will continue tomorrow in a tidy, linear
and predictable fashion. Pure fantasy. In this sort of culture, you won't find
people who pro-actively take steps to solve problems as they emerge. Here's
a little tip: don't invest in these companies. GCP


The above quote was hammered into us during MBA school, and it is something I live by everyday, living with the status quo maybe ok for you, but, nothing in this world was ever accomplished by people being satisfied with the status quo.........Do you think Steve Jobs would have said ' If it ain't broke, don't fix it?'

JW
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John Wade MBA, CCEMT-P, FP-C, RN

"Have the courage to follow your heart and intuition, they somehow already know what you truly want to become" Steve Jobs

#23 brandon911

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Posted 16 July 2012 - 10:37 PM

Thank you for the quote Jwade. Do you have anything else to add other than the quote? I'll forget the fact that you called me arrogant and complacent. :). As for Steve Jobs....... I'm a blackberry user ;).

Thanks

brandon911
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#24 BrianACNP

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Posted 16 July 2012 - 10:53 PM

I see no reason to jump into video scope intubation as the primary intubation device. Over the years I have seen the glidescope fail. I have seen direct laryngoscopy fail. I have seen blind insertion airway's fail. All these studies about video scope intubation being far superior to direct laryngoscopy in my opinion are not something we should be looking at. If I live in Indiana and videoscope intubation has far better outcomes in Maryland does that mean we should jump on it here? If your service has great first attempt success rate then why change it to videoscope for all attempts? If it's not broken then why change it? I truly believe videoscope intubation has its place in EMS / Critical Care medicine / Emergency Department / Surgery and so on. But we need to spend the money / time and effort to train absolutely everyone at how to be a better airway provider. Let me ask you this. Is your service going to remove the "old laryngoscope blades" off of your helicopter / ambulance? If so what happens if your video screen breaks? What if the pt vomits and you cannot get the lens cleaned or it shorts out? What if the cord on your Storz Cmac or glidescope gets cut or has a break or short in it? Do you just bag? Do you place a supraglottic airway even though you could have been able to intubate the pt with direct laryngoscopy? I think videoscope's should be for difficult airway only. We will all lose our airway skills IE: actual intubation and evaluation if we just blindly insert a camera and look for the hole. Why was there all the previous talk of how terrible intubation was in the field but not that were talking about videoscope intubation, intubation is a good thing again? Has anyone seen the video on youtube of the 4 yo little boy intubating the manikin head with the King Vision? So easy a kid can do it or making a joke of the skill some of us have worked so hard to accomplish the right way everytime? Also if we are going to go to strickly videoscope intubation why can EMT-B's not perform the skill? There is no real training required. Just put in the camera and find the 2 little white things with the hole in the middle. Slide the tube in past the black line and blow up the balloon. There ya go!!! Again my opinions. Call me whatever ya want. This is the way I feel. Don't punish the group for a few people that cannot perform the skill properly. Next thing ya know we will be using ultrasound to start IV's so we don't miss ever. Or just giving all medications nasally so we don't have to poke anyone anymore. First attempt success = whatever the clinicial is comfortable with.


brandon911


1. Is there something different about Maryland patients versus Indiana patients? Just curious. I would think you can translate literature on the utility of video assisted airway adjuncts to patients in general and not just in the same geographical areas.

2. I will say that use of the glidescope and other video devices isn't as simple as "stick the camera in"..or whatever you said. I use the glidescope in my practice as well as maintaining my direct laryngoscopy skills. Use of the video devices does require some training and experience for competency. It's not a video game.

I do agree in general that it's important to keep the laryngoscopy skills as you mentioned and for some of the reasons you mentioned. That said, use of devices such as the glidescope will likely be the standard in the future, especially as the technology continues to improve over time. When something has been shown to consistently be safer for patient outcomes, then there will be a hard look to make it standard of care, much like ultrasound for CVL insertion. It's already excellent technology now and can work the majority of the time for most patients.....even the ones in Indiana. ;)

Brian
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Brian, MSN, ACNP, CCRN

#25 scottyb

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Posted 16 July 2012 - 10:59 PM

Thank you for the quote Jwade. Do you have anything else to add other than the quote? I'll forget the fact that you called me arrogant and complacent. :). As for Steve Jobs....... I'm a blackberry user ;).

Thanks

brandon911

I remember when I had a Blackberry..... :huh:
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Scott Bild RN, FP-C

#26 Jwade

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Posted 17 July 2012 - 12:32 AM

Thank you for the quote Jwade. Do you have anything else to add other than the quote? I'll forget the fact that you called me arrogant and complacent. :). As for Steve Jobs....... I'm a blackberry user ;).

Thanks

brandon911



I am truly sorry you are a BB user still......It must be very disappointing for you to see the company on it's death bed. BUT, hey the status quo is always good, just ask the RIM CEO's who failed to look forward and instead stuck with the " If it isn't broke, don't fix it" approach.............

BlackBerry U.S.A Market Share MAY 2007 41%

JUNE 2007 IPHONE LAUNCHED

BlackBerry USA Market Share, July 2012 < 4%

BlackBerry Stock Price July 2011 = >$30

BlackBerry Stock Price July 2012 = $7.09

B) B)
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John Wade MBA, CCEMT-P, FP-C, RN

"Have the courage to follow your heart and intuition, they somehow already know what you truly want to become" Steve Jobs

#27 onearmwonder

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Posted 17 July 2012 - 01:16 AM

On a little different note... We have been using the First Passed Success Rate as a QA/QI marker to justify how good our care was for the patient in regards to taking care of the airway. I believe this is appropriate, but it's still missing something and I think we can do better at this in regards to patient care. Is getting the tube passed on the first try really a success? What about oxygen saturation, bradycardia, hypotension on the first try as well? Does letting an SPO2 go from 88% to 50% on that first pass constitute a success? Especially if you're messing around in the airway too long for what ever reason. Absolutely not... Now I know that there will be times that no matter what we prepare for or how well we try to pre oxygenate our patients with positioning or extraglottic devices that it will be inevitable to maintain their sats at the same levels prior to RSI or a crash airway intubation. Even if it was inevitable I don't think we can call that a success. It's not that we did anything wrong, there was a good chance it was going to happen anyways, and we tried everything to avoid it, but we still can't call it a success. So from a QA/QI standpoint I think this is a poor qualifier to say this was a success. Let's also look at other things during and RSI or Awake Intubation, or Crash Airway Intubation that actually harms a patient right now or in the longterm. Because we all know that the more you place rigid devices in the airway the more trauma you cause wether it's a little to major trauma which decreases our chances of actually passing the tube through the cords on the second and third trys . Just a thought... What are yours?

Thanks,

Matt
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#28 SerendepitySaki

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Posted 17 July 2012 - 01:23 AM

would this be a bad time to mention i'm STILL rocking a Palm Tungsten? :P
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LET THE WILD RUMPUS BEGIN !!!!!!
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#29 Macgyver

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Posted 17 July 2012 - 02:03 AM

we need to spend the money / time and effort to train absolutely everyone at how to be a better airway provider


And we finally get to the root of the problem with intubation success rates - declining standards in training and ongoing clinical competency evaluation. Yes - people are supersizing - but there have always been difficult intubations. All the new toys should do is make THESE cases more likely to have succssfull outcomes.

However making this the first pass device will erode the (already minimal) skill base. What needs to be done is better initial and ongoing intubation training for providers be they Medic, RN, PA, NP, MD or whatever. The only groups that get it right are the CRNA and Anesthesiolgists. Everyone else is on a race to the bottom to "certify" providers as intubators as quickly and cheaply as possible.

DISCLAIMER: My bias = from an AD medic program in Canada, about 100 classroom and lab hours devoted specifically to airway management and 2 weeks in the OR (x10hrs a week), my class all had between 100-130 live human tubes including pedes and a few neo's before graduation. RSI with paralytics in-scope for new grads on ground EMT/Medic units fresh out of school even in rural areas with no backup medics available (and this was over 20 years ago...) And about a 93-95% 1st attempt success rate province wide over the years.
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Ken BHSc, RN, REMT-P

#30 rick k

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Posted 17 July 2012 - 02:21 AM

I see no reason to jump into video scope intubation as the primary intubation device. Over the years I have seen the glidescope fail. I have seen direct laryngoscopy fail. I have seen blind insertion airway's fail. All these studies about video scope intubation being far superior to direct laryngoscopy in my opinion are not something we should be looking at. If I live in Indiana and videoscope intubation has far better outcomes in Maryland does that mean we should jump on it here? If your service has great first attempt success rate then why change it to videoscope for all attempts? If it's not broken then why change it? I truly believe videoscope intubation has its place in EMS / Critical Care medicine / Emergency Department / Surgery and so on. But we need to spend the money / time and effort to train absolutely everyone at how to be a better airway provider. Let me ask you this. Is your service going to remove the "old laryngoscope blades" off of your helicopter / ambulance? If so what happens if your video screen breaks? What if the pt vomits and you cannot get the lens cleaned or it shorts out? What if the cord on your Storz Cmac or glidescope gets cut or has a break or short in it? Do you just bag? Do you place a supraglottic airway even though you could have been able to intubate the pt with direct laryngoscopy? I think videoscope's should be for difficult airway only. We will all lose our airway skills IE: actual intubation and evaluation if we just blindly insert a camera and look for the hole. Why was there all the previous talk of how terrible intubation was in the field but not that were talking about videoscope intubation, intubation is a good thing again? Has anyone seen the video on youtube of the 4 yo little boy intubating the manikin head with the King Vision? So easy a kid can do it or making a joke of the skill some of us have worked so hard to accomplish the right way everytime? Also if we are going to go to strickly videoscope intubation why can EMT-B's not perform the skill? There is no real training required. Just put in the camera and find the 2 little white things with the hole in the middle. Slide the tube in past the black line and blow up the balloon. There ya go!!! Again my opinions. Call me whatever ya want. This is the way I feel. Don't punish the group for a few people that cannot perform the skill properly. Next thing ya know we will be using ultrasound to start IV's so we don't miss ever. Or just giving all medications nasally so we don't have to poke anyone anymore. First attempt success = whatever the clinicial is comfortable with.


brandon911


While the statistics had pointed out that our success rate wasn't great, I would have thought that education would have been the more appropriate thing to do versus adding more equipment to an already fully stocked aircraft. We have put them in service and it is the first line intubation device.
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Rick Kantor
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#31 brandon911

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Posted 17 July 2012 - 04:46 AM

Ok I must come clean........ I use a blackberry for work and I own an Iphone. Thank the lord for Steve Jobs!!!! I can listen to my ipod tunes while watching my porn at any altitude.....Fantastic!!!! LOL.. JK!!!

Rick.....What device do you use at your service? Do you still have your regular intubation equipment on the helicopter? If your video device fails on the first, second attempt what do you do?

Jwade......If I really bothered you with my " if it ain't broke don't fix it " comment allow me to apologize. Again just my opinion. Right or wrong I am entitled to it. Although I did sound like a bit of a hillbilly with that comment ahaha!!

Onearmwonder......I absolutely agree with you. That was an excellent reply. There are lots of other things to consider with an RSI intubation or any intubation. Any rigid device can cause trauma to the airway. Please watch Rapid Sequence Induction AOD.MP4 on youtube. Tell me that wasn't as forceful or more forceful that conventional intubation. Also watch King Vision Channel Scope Intubation AOD.mov. See how long it takes to actually pass the tube and get it out of the channel and begin ventilation. Almost a whole minute from the time the scope enters the mouth.

As I have said before I truly believe Video Scope Intubation has it's place. No doubt. But I believe it is and should be a difficult airway tool. We have to keep up our skills as clinicians in order to be able to provide people with the most important thing we can.....an airway.

Thanks for all the replies. Keep em coming!!!
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#32 brandon911

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Posted 17 July 2012 - 05:16 AM

Brian ACNP.......I disagree about needing skill and training to use a video scope. Please see 4 year old boy video scope intubation on youtube. Also see 8 year old boy video scope intubation on youtube. I especially like the part when he places the tube and everyone says.........congratulations you are a paramedic!!!!!! Again so easy a child can do it or making a joke of the skill we have trained so hard to be good at? I hear all the time about nurses / rt's / physicians intubating patients in very small hospitals with a glide scope / video scope because there is " no training " needed. The only training you really need is to know what you are looking at. Vocal Cords vs. Esophagus so you know where to put your tube. And it kinda is like a video game.....isn't the points you get for passing the tube through the cords written on the side of the ET Tube? :)

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#33 rick k

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Posted 17 July 2012 - 08:38 AM

We still have the traditional laryngoscopy equipment along with the King LT-D for backup. We have implemented the C-MAC by Storz. When there is a failure of this new equipment for some reason or another (dead battery, environmental extremes..) I hope the theory of remembering to ride the bicycle works well. Of course, one good thing about it is you don't have to utilize the video screen. Just use it like a traditional laryngoscope, as long as you prefer a Mac blade......
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Rick Kantor
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Eastcare Transport

#34 brandon911

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Posted 17 July 2012 - 01:30 PM

Thanks Rick. I was wondering if you can use the Storz as a " regular " intubation blade. We have been looking at purchasing the King Vision for difficult intubation. I haven't seen to many Storz Cmac videos on youtube. If you can't tell I really like youtube videos. :)

brandon911
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#35 BrianACNP

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Posted 17 July 2012 - 02:02 PM

Brian ACNP.......I disagree about needing skill and training to use a video scope. Please see 4 year old boy video scope intubation on youtube. Also see 8 year old boy video scope intubation on youtube. I especially like the part when he places the tube and everyone says.........congratulations you are a paramedic!!!!!! Again so easy a child can do it or making a joke of the skill we have trained so hard to be good at? I hear all the time about nurses / rt's / physicians intubating patients in very small hospitals with a glide scope / video scope because there is " no training " needed. The only training you really need is to know what you are looking at. Vocal Cords vs. Esophagus so you know where to put your tube. And it kinda is like a video game.....isn't the points you get for passing the tube through the cords written on the side of the ET Tube? :)

brandon911


It isn't very difficult on normal anatomy once you are trained to use it...there are idiosyncracies to each device that one must learn. I'll just leave it there since you disagree. I'm coming from my experience with the device, though.

Brian
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Brian, MSN, ACNP, CCRN

#36 brandon911

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Posted 17 July 2012 - 02:24 PM

Brian. Do you still use direct laryngosopy? If so when and what types of patients? If you expect a difficult airway do automatically go to video scope? And I'm sorry I'm not sure what setting you are in. I apologize.

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#37 BrianACNP

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Posted 17 July 2012 - 04:37 PM

Brian. Do you still use direct laryngosopy? If so when and what types of patients? If you expect a difficult airway do automatically go to video scope? And I'm sorry I'm not sure what setting you are in. I apologize.

brandon911


I work in the ICU setting as an advanced practice provider. I do still use direct laryngoscopy, which is a skill that I have been proficient for about 20 years. I do have significant prehospital experience (12 years EMS in a high volume system and 8 years aeromedical) and used direct laryngoscopy during that time. I use a combination of approaches when I perfom airway management. If I do have patients who I deem to be difficult, then I will proceed to video-assisted laryngoscopy. However, because of my expertise in direct laryngoscopy, I'm not afraid to use that skill if the glidescope were to fail.

What type of experience do you have?

Brian
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Brian, MSN, ACNP, CCRN

#38 Jwade

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Posted 17 July 2012 - 05:19 PM

Brian. Do you still use direct laryngosopy? If so when and what types of patients? If you expect a difficult airway do automatically go to video scope? And I'm sorry I'm not sure what setting you are in. I apologize.

brandon911



Brandon,

Having worked in the O.R. for 8 years and married to an MDA, I can say without hesitation, if they even remotely expect a difficult airway after performing an airway exam, or encountering a patient with a known difficult airway in the past, Anesthesia will use the video scope without issue. They do thousands of Direct Laryngoscopy every year, ( far more than pre-hospital providers) but, yet, will flip to the video immediately to give themselves the best avenue to obtain airway access the first attempt........

Personally, I think it boils down to EGO more than anything..........It's not about us, it's about the patient so whatever method that enables the best chance should be used IMO......

I suspect Brian operates the same way as a Nurse Practitioner on the Trauma / Critical Care ICU.........

JW
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John Wade MBA, CCEMT-P, FP-C, RN

"Have the courage to follow your heart and intuition, they somehow already know what you truly want to become" Steve Jobs

#39 brandon911

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Posted 17 July 2012 - 06:56 PM

I disagree that it boils down to ego. But it's your opinion and you are entitled to it. I want to do what is best for patient's. I know that we all want to. I just don't always think that is the best way. I have no ego.

I have been a paramedic supervisor at a busy 911 service here in Indiana for the last 6 years. 16,000-20,000 calls per year. RSI capabilities. I have performed lots of intubations. In the field, ED and OR. Not nearly as many as you have Brian.

I have been in the Aeromedical Industry for the last 3 years. All with RSI capabilities. None of which have video scope intubation. I also feel that I am very profecient in Airway management especially Intubation. I never brag about myself but I believe my peers and medical directors would agree.

I would have no problem grabing a video scope if I anticipated a difficult airway or was having trouble intubating a patient. I just don't agree with using them first attempt on every intubation. Especially from a cost stand point for us as prehospital providers depending on what scope we decide to go with.

Advanced Practice Provider? If I sound like an idiot I'm sorry. Are you a nurse? CRNA?
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#40 brandon911

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Posted 17 July 2012 - 06:59 PM

Acute Care Nurse Practitioner. See I am smart!!!

brandon911
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