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RevMedic is not a name that signifies driving very fast - revving the engine - but that is what pops into my head every time I see his name. I know. I am by-passing St. Peter. I am not collecting 72 virgins. I am going straight to the great big tanning bed. This is not news.
RevMedic does all sorts of photography in the Newberg, Oregon area. If you need a photographer with some common sense, he seems like the guy to call.
Anyway RevMedic knows his stuff. Here is his comment on the post Prehospital Intubations and Mortality - comment from Herbie.
"I would much rather see medics using a BVM during their OR time, than intubating. Good BVM use is far more important than intubation skill."
Absolutely. I can't tell you how many times I've seen ineffectual ventilations with a BVM. There sits the EMT (at any level), blissfully unaware of the air blasting out from underneath the mask and not paying attention to the lack of a seal.
How is it that we graduate EMTs and medics, who are not skilled at airway management?
How is it that we graduate EMTs and medics, who do not understand airway management?
It isn't as if the courses suggest that there is a skill that comes before airway.
Excellent BVM use is all about assessment.
BVM excellence is the cornerstone of airway management.
Without excellence in the use of the BVM, the rest of airway management does not matter.
I prefer to do some of the bagging with patients who need ventilation. It is a skill that needs to be used, to be maintained. This also sets a good example for everyone else. This demonstrates to everyone else that, at least as far as I am concerned, skill with a BVM is a priority.
We also will find that some of the patients do not need to be intubated. Intubation should not be for the benefit of the medics. Intubation should be for the benefit of the patients.
There was another event where I was bagging the patient in preparation for intubation. I was having trouble getting an adequate seal, and asked for another set of hands. We had 4 PARAMEDICS in the rig, and the other three were solely concerned with getting the intubation equipment set up, preparing the drugs, etc. I had to repeat myself several times and finally loudly call one by name and DEMAND his/her assistance, before we achieved adequate ventilations.
One of the best uses for a separate pulse oximeter is to throw the machine at someone, when you need there attention. It can be very effective. It also demonstrates how little importance should be attached to the machine. It is just a tool, a slow tool, that should not be warning you that something happened, but should confirm what you already know from your continuous assessments.
One of the problems with these studies of systems that have horrible intubation success rates, is that their BVM use is probably just as bad. How much of the bad outcome is due to BVM incompetence, rather than the inability to put a tube in the right hole?
If we make the patient hypoxic enough in our focus on the intubation, does it matter if we are successful with the intubation?
No, it does not.
If we allow the patient to vomit and aspirate in our focus on the intubation, does it matter if we are successful with the intubation?
No, it does not.
RevMedic finishes up with:
BVM is the lost art of airway control.
There is only one appropriate response to that:
Amen.
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4 comments:
I love that you have been on this recent airway kick. It seems to be the one topic that gets me in trouble with our peers. I don't think I could pull out a BVM on a call without my partner grabing the intubation kit. It is almost as if it is being taught as one can not exist without the other. A good point to make is that no matter how good you are at BVM ventilations, and even with cric-pressure; you will still be putting some air into the belly. An NG tube is very usefull to mitigate this. Maybe a step by step BVM tutorial is at hand.
Recently within my department several of us were sent to the "The Difficult Airway Course" and being as the department sent us, we were charged with creating a training program update for the department from this. One of the most compelling parts of the information presented was a fluoroscopy with different BLS airway opening maneuvers. It was emphasized in this course (and the fluoroscopy illustrated it beautifully) is that to truly open the airway while utilizing a BVM the jaw must be dislocated forward. This is very difficult if not impossible to do so with 1 provider so their recommendation, and what became the recommendation in our training we provided to the department, is that whenever possible there BVM should be a 2 person job. This was just 1 piece of very good information taken away from this course and subsequently delivered to the department.
One of the best things I took away from my OR time was improved bag mask ventilation. Since we spent time in the PACU waiting for the tubes that we were there for, we were asked to assist the CRNAs with the daily ECT patients. Since they were paralyzed with Succinylcholine during the treatment, effective ventilation was a must. I learned a lot about how bad my technique was, how to correctly position the head and jaw, and how use of a basic OPA helps dramatically. Since many of the patients were older with difficult facial anatomy, this was often not easy - but after 10 or 20 of these, you begin to get more proficient. The anesthesiologists would ask to see you ventilate the patient with the bag prior to intubation in the OR, so not being able to demonstrate proficiency at this wouldn't look good when you were about to perform an advanced airway skill on a patient.
I agree that basic airway management is important. But why are we looking at taking away a skill (intubation) rather than looking at the system. We see there is a problem with some medics as far as intubation goes, but, why is it happening? Is there as oversaturation of ALS, leading to a decrease in the number of tubes, what is CME and recert time like, what about quality assurance?
In Ontario we have to have a minimum of 15 intubations to pass your O.R. phase of ALS training, we also have the chance to intubate during other hospital training phases, for example the E.R. and we also spend a day with an Respiratory Therapist. In most areas part of your yearly recert an 8 hour day in the hospital, 4 hours in OR and 4 hours in ER. We also have continuing QA. We work on ambulances with 1 ALS and one Intermediate. Our tiered response (fire dept.) are BLS-D. We do have a fairly high success rate.
Personally I am a bit of a crap magnet and in the summer averaged one tube in a block (4shifts on/ 4 days off). I also work part time at an all BLS service, where we have the KING LT, so I get lots of practice with basic airway management.
Lets not look at intubation as a problemm, but the system as a whole. Getting rid of intubation is like treating a symptom, rather then the cause of a disease.
I am not trying to protect the skill, but intubation is still the "gold standard" and if trained properly and with better Continuing Ed and recerts, maybe re thinking the deployment of ALS providers, we might see an improvment. As providers we should be looking at anyway to improve our care. Look for Airway courses etc. We have a chance to go to the cadaver lab, to practice. We have manequin heads available etc
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