The Gold Standard
Without an airway, a patient is dead, plain and simple. All of the splinting and backboarding in the world won't mean anything if he's blue because he can't breath. As an EMT I have been able to manage the airway with small cruved devices known as orophrangeal airways, I could drop small rubber tubes down the nose of a patient in order to facilitate forced resperations.
The basic airway adjuncts are all well and good, they have their place and they are usefull when they are all that is available. The only problem is that they do not prevent the person from inhaling vomitus or blood, not to mention any other lovelies that happen to be hanging out in the mouth of the unfournate. Even blindly inserted devices such as the CombiTube or Rhode Island's woefully outdated EOA do not totally isolate and therefore protect the airway.
In order to segregate and seal the airway, paramedics are trained and authorized to perform Endotracheal Intubation. Basically what this means is taking a lighted blade attached to a handle known as a Laryngscope and using it to open a patient's mouth by lifting the tongue and epiglottis out of the way of the trachea. By doing this, the paramedic is able to see the person's vocal chords. The vocal chords are jokingly refered to as the "pearly gates" as they are two white bands in a sea of pink flesh. After visualizing these chords, the medic takes a tube and passes it through the chords, dirrectly into the trachea. A plastic cuff on the tube is inflated inorder to seal the airway and a regular bag valve is fitted to the tube to provide ventilations.
While the procedure sounds fairly involved, it isn't the hardest part is forming the tube to the propper angle in order to pass into the trache and not the esophagus. The entire intubation procedure should take no longer than thirty seconds as that is about the limit an unconcious, unresponsive patient should be apenic.
Endotracheal intubation in the field is one of the most challenging and nerve wracking duties of a paramedic. In the textbook and the dummie lab the chords are always clearly visible, the dummy has not decided to end it all with a shotgun or plowed into the side of a mountain at a 100 miles an hour. The chords are pristine and visible quite readily. In real life they can be obscured by blood or foreign material. Sometimes all that is visible is a bubbling and the medic has to aim for that and hope for the best.
If the paramedic can not get the tube down because of severe trauma or something as simple as a poorly chewed lump of grandma's meat loaf, the medic has two options. The first is to find the crycoid cartilage, comonly known as the Adam's Apple and find the delicate membrane that lies just over the trachea. A fourteen gauge needle is inserted and the patient can be ventilated through the new opening. But a 14 guage needle, while huge as needles go, is still a very small airway. Another option is to make a surgical incision into the neck, insert a tube and ventilate in that manner. We praticed both options on extremely expensive dummies while hopping the turds would never hit that much of the turbine in the field.
EMS providers encounter people in various forms of distress, a person with altered mental status or a head injury may have their jaws clamped so tightly that normal intubation is impossible. Or they may still have a gag reflex but their ability to protect their airway is crumbling. In situations like that, paramedics can adminster paralytic drugs and essentially kill the person and breath for them.
The proceudre is known as Rapid Sequence Intubation and it was taken from the hospital setting and as is customary to fire/EMS bastardized to fit our needs. The patient is paralyzed so that they cannot breath on their own with the use of a parlytic known as succucolyne. Since this drug only parlyzes the person the amenisiac Versed is adminstered to make them forget the whole experience. Once the person is "knocked down" the tube is passed as normal. Well, hopefully. For some reason, the heart is untouched and continues its constant beat durring the entire procedure.
With just about seven months left in paramedic, there is alot more to learn and even more to do. Five hundred hours in a various hospital departments loom on the horrizon and countless more hours still remain.
The basic airway adjuncts are all well and good, they have their place and they are usefull when they are all that is available. The only problem is that they do not prevent the person from inhaling vomitus or blood, not to mention any other lovelies that happen to be hanging out in the mouth of the unfournate. Even blindly inserted devices such as the CombiTube or Rhode Island's woefully outdated EOA do not totally isolate and therefore protect the airway.
In order to segregate and seal the airway, paramedics are trained and authorized to perform Endotracheal Intubation. Basically what this means is taking a lighted blade attached to a handle known as a Laryngscope and using it to open a patient's mouth by lifting the tongue and epiglottis out of the way of the trachea. By doing this, the paramedic is able to see the person's vocal chords. The vocal chords are jokingly refered to as the "pearly gates" as they are two white bands in a sea of pink flesh. After visualizing these chords, the medic takes a tube and passes it through the chords, dirrectly into the trachea. A plastic cuff on the tube is inflated inorder to seal the airway and a regular bag valve is fitted to the tube to provide ventilations.
While the procedure sounds fairly involved, it isn't the hardest part is forming the tube to the propper angle in order to pass into the trache and not the esophagus. The entire intubation procedure should take no longer than thirty seconds as that is about the limit an unconcious, unresponsive patient should be apenic.
Endotracheal intubation in the field is one of the most challenging and nerve wracking duties of a paramedic. In the textbook and the dummie lab the chords are always clearly visible, the dummy has not decided to end it all with a shotgun or plowed into the side of a mountain at a 100 miles an hour. The chords are pristine and visible quite readily. In real life they can be obscured by blood or foreign material. Sometimes all that is visible is a bubbling and the medic has to aim for that and hope for the best.
If the paramedic can not get the tube down because of severe trauma or something as simple as a poorly chewed lump of grandma's meat loaf, the medic has two options. The first is to find the crycoid cartilage, comonly known as the Adam's Apple and find the delicate membrane that lies just over the trachea. A fourteen gauge needle is inserted and the patient can be ventilated through the new opening. But a 14 guage needle, while huge as needles go, is still a very small airway. Another option is to make a surgical incision into the neck, insert a tube and ventilate in that manner. We praticed both options on extremely expensive dummies while hopping the turds would never hit that much of the turbine in the field.
EMS providers encounter people in various forms of distress, a person with altered mental status or a head injury may have their jaws clamped so tightly that normal intubation is impossible. Or they may still have a gag reflex but their ability to protect their airway is crumbling. In situations like that, paramedics can adminster paralytic drugs and essentially kill the person and breath for them.
The proceudre is known as Rapid Sequence Intubation and it was taken from the hospital setting and as is customary to fire/EMS bastardized to fit our needs. The patient is paralyzed so that they cannot breath on their own with the use of a parlytic known as succucolyne. Since this drug only parlyzes the person the amenisiac Versed is adminstered to make them forget the whole experience. Once the person is "knocked down" the tube is passed as normal. Well, hopefully. For some reason, the heart is untouched and continues its constant beat durring the entire procedure.
With just about seven months left in paramedic, there is alot more to learn and even more to do. Five hundred hours in a various hospital departments loom on the horrizon and countless more hours still remain.
posted by Nick Stabile at 8:12 PM
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