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Welcome to EMS Airway Clinic!

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Welcome to the first edition of the “EMS Airway Clinic.” I’m Charlie Eisele, your host, guide and pathfinder through the world of prehospital airway medicine. We created this site to do one thing: provide patients with the best care possible. We’ll do just that by targeting the folks who directly impact patient care: educators, medical directors, and street level, mud on your boots, stretcher carrying EMS providers. It doesn’t matter your level of training or how many letters you have after your name, you will leave this site with stuff you can put to use immediately.

When the title came across my desk, I just had to ask, “What the heck is an airway clinic?” Prince.edu gave me a couple of answers:

  1. A medical establishment run by a group of medical specialists;
  2. A meeting for diagnosis of problems and instruction or remedial work in a particular activity;
  3. A health-care facility for outpatient care; and
  4. A musical clinic is an informal meeting with a guest musician, where a small-to-medium sized audience questions the musician’s styles and techniques and also how to improve their own skill.

I immediately threw out the first and third. Number two has merit, but I really like number four. EMS Airway Clinic is an informal meeting with guests to provide a variety of styles and techniques to improve our skills.

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Here you’ll see articles, videos, podcasts and a variety of other vehicles to share best practices in airway management. I really like case studies. They’re a great way to gain experience without having to make mistakes yourself. Sometimes, you just want to know how something works, so there will be “how to” items. We will provide timely news stories that impact EMS airway management and previously published articles to download, and we’ll keep you up-to-date on relevant studies and journal articles.

Here’s a preview of upcoming topics:

  • The Glottis Is Not Your Friend
  • Quotes from My Airway Heroes
  • Video Interview with Dr. Jack Pacey
  • Roadmap to the Larynx
  • Sun Tzu: The Art of Airway Management

My vision is that this site be reader driven, so tell me what you want. What topics interest you? What tools and techniques have you found successful? I know you’ve got case studies and war stories; let’s hear them.

I’m a huge fan of professional, open discussions, so expect me to weigh in on controversial topics. Say, something like “should we intubate?”

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  1. I love this idea, and hope that it covers a variety of topics on respiratory calls and not just airway. My biggest pet peeves is the way that paramedics approach pneumonia and pulmonary edema. I feel that because there is not much other than supportive care that paramedics can do for pneumonia (or other respiratory infections – think SARS and H1N1) – it tends to frustrate them. As a result they try to use the tools that they have on these patients whether they are appropriate or not. I see so many paramedics that use Salbutamol (sorry I’m Canadian – albutarol?) and Ipratropium on pneumonia. Although I realize that the lung crap in pneumonia can cause some wheezing salbutamol is not always the best approach and Ipratropium is definitely not called for. Since it tends to dry up secretions and the secretions in pneumonia are often causing a consolidation anyway, that is really not a good idea in my mind. I also don’t agree with an anti-inflammatory in these situations (ie. dexamethasone). The inflammation in an infection is not the main problem. I could go on, but on to my second pet peeve.

    Salbutamol in pulmonary edema. I realize that sometimes the fluids that have backed up into the lung may cause some bronchial irritation that might lead to wheezing on top of the crackles. But if pulmonary edema is the main problem then getting rid of the fluid will also cure the wheezes, however, causing bronchial dilation to reduce the wheezes will also cause a decrease in the pulmonary pressure, so that theoretically the increased back pressure in the pulmonary circulation will be able to increase the fluid into the lungs.

    These are two of the respiratory topics that I think need to be talked about in these forums as I have found that more paramedics than not will give Salbutamol and Ipratropium in both pneumonia (or other lung infections) and pulmonary edema where they clearly don’t belong. However, I would be open to listening to new research that proves me wrong as well.

  2. This subject of pre hospital intubations now being in question as possibly ending greatly upsets me. This crucial skill needs to remain pre hospital. After all we are the ones who get the immediate need for it before anyone else don’t we? I am hoping I have come up with possible solution to keep endotracheal intubations in the field. Please look into my new product called the Stylite, which is a safe and cost effective hopeful solution to rising esophageal tubes. This item self illuminates with a burst of super bright light from a chemiluminescent tip that bounces off the natural phosphorous of our vocal cords which marks the trachea. This product makes what is sometimes a difficult skill, easy enough where I have had 6, 7, and 8 year old children properly intubate the trachea of my manikin. From the thousands of people who have tubed my manikin with my Stylite at the expos, they all perform this skill in seconds in the dark. Endotracheal Intubation needs to remain in the field for rapid airway patency. I hope I can play a part in keeping ETIs in the field. Pat Ramos

    • I found your subject on prehospital intubation utilising the styite really interesting and would love to somehow get to try this out in South Africa. I agree that endotracheal intubation needs to remain in the field and we get to intubate alot in our field. please would you forward any more information. I too hope I can play a part in keeping this skill in the field. Karen Romans

  3. R. L. Shields NREMTP, AAPsy, C.O.S.S.

    Just a note to say; I have enjoyed reading this,and subsequent article concerning the debate of “Should we Intubate”. I am of the old school; in that I believe it is easier to wean someone off of the Ventilator (even considering ARDS and respiratory infections) than to chance a compromised airway. At the risk of sounding ancient, I can’t seem to get past the importance of the “A” in the A,B,C,D’s, of pre-hospital care and patient management. One thing I learned many years ago; Concerning “When to Intubate”, a pre-hospital provider could get caught up in the placement of the ETT, that they loose sight on the larger scope of care. Too many times a Medic will make numerous attempts to Intubate, followed by frustration when the Tube is inserted into the Epi-Gastric canal on a difficult and sometimes challenging task; i.e. Trauma, Anterior structure, or any other obstacle place in the way of successful intubation. I have learned to leave the first “Misplaced ETT” where it falls, and then the second attempt is more likely to be place properly. Given that the ETT would more than likely not be inserted into the Epi-Gastric canal due to the previous land mark of first ETT. This can subsequently be extubated after confirmation and positive sign/symptoms are evident. This has proven to be helpful in saving time and reducing patient detriment in care provided. Just a thought that probably most of your readers have knowledge and practice of, however; if even one patient benefits from this little tidbit, my conscience has been calmed. Thanks for the time and opportunity afforded to air this concern. And as you can tell, I am all for Intubation in the right circumstances and application. I do not think that this should be the first line of airway management in all applications. This should be discussed further given the different etiologies introduced into the pre-hospital setting; such as designer drugs and certain overdoses. Thanks again…

  4. I have read numerous articles debating the subject of pre-hospital intubations, yet have heard of Field Studies documenting the fact that superglottic airway devices create a wall. When stomach contents are forced out, the superglottic devices seem to push gastric contents into the lungs (aspiration).
    If the patient does not have a secured airway with an ET Tube, we cannot control what does / does not enter the lungs. There are certain patients (Burn Patients, Trauma Patients, etc) that need a secured airway, and if they wait until the hospital it may be too late.
    Video LaryngoScopy has created a pathway to fast, effective ET placement allowing us to concentrate on patient care, compressions and getting the patient to the hospital much faster. What about the patients you cannot ventilate – just go to surgical airway? I think Video Laryngoscopy gives us more options… that is probably why over 90% of ED’s in USA use them, why shouldn’t we?
    Are they really THAT expensive? We have the LifePak, Electric Cots, Thumpers, Easy I/O…

  5. Pre-hospital endotracheal intubation (ETI) needs to be revisited, an evidence based risk/benefit analysis performed, and the indications refined.

    There is mounting evidence, not opinion, that in some situations, ETI does more harm than good. An example is cardiac arrrest. The ET tube provides a fantastic conduit to provide super saturation of O2, and increased intrathoracic pressures during CPR.

    It is quite possible that super saturation of O2 does more harm than good in a cardiac arrest. The intrathoracic pressures, if you really think about it, would decrease the capability for CPR to work optimally.

    This issue is a paramedic (20 year veteran here) ego-centric issue many times. Paramedics, statistically, are pretty good at ETI. But that isn’t the issue. Medicine needs to be evidence based; so do our practices, or we are not a bona fide profession. It is time for a real good hard look, and an evidenced based risk/benefit analysis of pre-hospital ETI.

    • The endotracheal tube can indeed be a conduit for hyperoxemia and increased intrathoracic pressure. My humble opinion is that the endotracheal tube is and will always be the gold standard of airway management. We really need to focus on controlling the rate of ventilations and the titration of oxygen delivered in order to prevent these two pitfalls, hyperoxemia and increased intrathoracic pressure, from occurring in cardiac arrest. In reality we should probably only ventilate a cardiac arrest patient 4 times/minute when we have an endotracheal tube in place( as long as we can deliver good tidal volume) and in post arrest, we should decrease the oxygen flow to 4-6 lpm (titrating for a 94% to 98% oxygen saturation).

  6. As a CCEMTP thats has been serving since 1981 , I look forward to seeing any evidence based information that helps me to continue to deliver quality Patient care , Thanks for providing a new source for information .

  7. I’ve been an NYS EMT since 95 and a NYS EMT-P since 98. I’ve been teaching in a Paramedic Program since 02. I’ve worked in several 911 systems as a Paramedic: NYC, Westchester, Rockland, and Orange Counties. I’ve noticed a trend of EMTs coming into the Paramedic Program and it’s not for the better. I’ve noticed the EMTs to be worst as EMTs from 02 to now. It’s not getting better; it’s getting worst. I feel that the EMT Programs are not informational at all. There are many BLS Skills that have to be re-taught to them. Many come to the Program just finishing their EMT. I have been proposing change in NYS but it has gone to deaf ears. I sent letters to NYS DOH EMS, NYS Assembly, and NYS Senate and nothing has been addressed. I offered my services to assist in this change; my free time to get this changed. I’ve emailed the NSTHB and DOT regarding EMS Certification change. I believe EMS is not progressive; well it is not in NYS.

    My proposal is simple. Increase rotation time for EMTs. In NYS, the EMT student needs to do one 8hr rotation on the Ambulance or the ER. Didactic hours need to be increased. Skills like Aspirin, Albuterol, and Epinephrine need to be a mandatory skill in the course. The EMT-I85 needs to be eliminated and keep the EMT-I99. There is no need for two types of EMT-Is. In NYS; we have the EMT-CC (Critical Care); which is below a Paramedic. We can merge the EMT-I99 and the EMT-CC and have just the EMT-I99. They are not far apart in skill set. The NYS EMT-P must be an Associates Degree, with the elimination of the Certificate Courses. It should only be available in Colleges and Universities. I’ve even proposed that the CCEMTP should be incorporated into the NYS EMT-P curriculum.

    I feel all the hours taken out of the various EMS Certification Curriculum, have hinder EMS care. I feel the older Paramedics are a dying breed. We didn’t have Capnography back then; we just had visualization of the tube passing the vocal cords, condensation in the tube, no resistance in ventilation with the BVM, lungs sounds to all fields, no epigastric breathe sounds, and reassessing every few minutes. I’ve intubated dozens of patients and never had an Esophageal Intubation. I knew if it was not in the trachea; I would extubate, insert an OPA, ventilate with a BVM.

    All the best…

  8. As a long time Paramedic, I have had great success with ET but I have seen others struggle.

    One thing I have learned is that most field practitioners intubate incorrectly. I routinely see the laryngoscope pushed up with superhuman effort in an attempt to visualize the cords. The tube is sometimes then, still, inserted blindly. I have seen other providers lift the patient by the arms in an attempt to assist with visualization. I have seen the Selleck maneuver overused when it wasn’t necessary.

    When I did my OR rotation for Paramedic school I was already released to practice ALS at the EMT-Cardiac (VA) level. The nurse anesthetist was horrified to see me remove the head block and intubate as I was taught, and accustomed to doing. While my intubation was successful, he explained that the head block allowed for the ‘sniffing position’ instead of having to re-create it by force. On my next intubation I used the head block and found the intubation much easier. I could move the laryngoscope toward the feet and up instead of attempting to left the entire head. Now all my field intubations are done only after placing a towel under the patient’s head. I also spread this knowledge to other providers. A proper head intubation block should be required equipment on an ALS ambulance for use with laryngoscope intubations.

    While there are a number of interesting new intubation aids on the market, and none are ‘perfect’, so far I like the SALT airway the best. Unless experience unearths some significant negatives, it looks like a true KISS miraculous innovation for intubation both in and out of the hospital setting.

    • I believe the SALT device is a vomit comit. everyone airway is different and we have had multiple failures. It has been removed from our equipment list. Just learn to intubate. Contact your local air medical provider and tell them you want cadaver lab training for your employees. Mandate the Bougie and make these people practice each shift. This is not a difficult skill at all with the proper training

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  12. i am looking forward to this site. I am both a paramedic and RRT I teach in 2 year respiratory care program. As to a need for hospital intubation? yes
    As to a need for more training and over site most- definitely yes. It a skill that needs to be practiced to be be done well most service that I see just do not have the calls or training times – manikins do not count.

  13. Hello. Thank you for this interesting information! Why are people still using BVM devices? Isn’t it true that 2/3 of the people using these are giving too many breaths or making other errors that can harm the patient further? There are automated ventilators that are never affected by high-stress environments and can deliver the correct amount of breaths in the right amount of time every time. Does anyone here have any experience and/or feedback with the SAVe (simplified automated ventilator) ventilator? If so, please comment. Thank you and thanks for helping to educate and inform, it’s appreciated !- Sean

  14. I think the one thing that we need to remember; just because you can, doesn’t mean you should!!! Unfortunately we see a lot of EMS services that attempt RSI &/or intubation in the field and are a couple of blocks from a healthcare facility. I think we all need to STOP for a moment and go back to the basics of ABC. Establishing an airway and ventilating/oxygenating the patient takes precidence over any type of advanced procedure. Thanks, Glennita

    • Glennita, I could not agree with you more on your post. Every ALS provider out there should think, think ahead. Just because this is one of your skilled sets, doesn’t mean it should be done all the time.

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