Posted by: medicblog999 | February 22, 2010

Paramedics are from Mars and Anaethetists are from Venus!

pillowsI took a patient into the A&E department of one of our major hospitals a couple of nights back.

The details of the patient aren’t important for this one, just the fact that he had a GCS of 5, was tolerating both an OPA and an NPA.

I was getting excellent air entry via BVM and his SaO2 was in the high 90`s throughout my time with him, once I had control of the airway.

We cannot RSI, and I decided not to try and intubate due to the short transfer time, the risk of laryngospasm and the fact that I was managing just fine with BVM thank you!

I got to the hospital and handed over the patient to the waiting team, they set to work and the A&E registrar tried to intubate her, but found that her larynx was indeed spasming as soon as the tube got anywhere near. Anaesthetics arrived a couple of minutes later and the consultant, a lady whom I used to work with when I was a theatre (OR) nurse, strode into the resus and proclaimed in a loud and proud voice…

“Right! The first thing I need is a good quality firm pillow! I cannot intubate this patient without a good firm pillow”

I looked up from my patient report form, mouth agape, looked at Sam, one of the A&E nurses and just smiled and shook my head.

As I said in the title chaps – two different worlds!!

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Responses

  1. haha! i love it!! your stories always make me laugh, 999.

  2. I am a great believer in pillows where airway management is concerned…when placed under the shoulder blades they are make wonderful adjuncts in keeping a person's head back.

  3. And I 100% completely agree!What I found amusing though was just imagining the next time I have an arrest with a patient trapped behind a tiny bathroom door or having to tube upside down, or in a smashed up car, in the rain, stopping and saying ” I need a firm good quality pillow…NOW!!”

  4. A nice story Mark – as ever.You appear not have noticed though that your patient underwent a full sex change on the way to hospital – that must be some ambulance ;-).Sorry I couldn't resist – I know you alter details for confidentiality reasons and I guess this one got altered once too often.Keep up the good work.Nick.

  5. We all get used to the different levels of expectations Mark, You know that. I'm surprised you even noticed that. We brought a patient in one time from a horrible car wreck and we were very pleased that she survived the trip to the hospital. The Doctor took one look at her and said 'My God, these wounds are filthy! Don't you people have any training in wound cleansing?' I just said “sorry doc, we were focused on keeping her airway and heartbeat, I guess we overlooked that detail”.

  6. I too have had on or two GOOD BLS airways fussed with. I half agree with the team in A&E.Yes an ET Tube is a damn good way to control an airway, but if the patient is for the moment “stable” with a patent airway and high O2 sats. A bit more care and foresight is always a good thing.

  7. *giggles*

  8. What I find interesting is the scorn you (rightfully) show the “consultant”, when you, yourself brought in a patient with an uncontrolled airway, in danger of aspirating the now air charged contents of their stomach. The fact that you somehow psychically predicted laryngospasm, doesn't adequately excuse the lack of proper airway control, and prevention of aspiration. A patient that was “tolerating both an OPA and an NPA” is a patient that will tolerate inhaling vomit. A combitube might have been a good tool to help you overcome your fear of intubating the patient.That said, funny story about the pillow. Ahh, if only we had the luxury of a completely controlled environment….

  9. Rookie?

  10. Whoops!! Always good to maintain confidentiality though!!

  11. Hi Chris,Thanks for your comment and thoughts.In this case, I left various parts of the patients presentation out as if I included them it would make this one uniquely identifiable. However, suffice to say that due to the presentation and the location of the incident to the hospital (less than 3 minutes drive), my clinical decision was to maintain a good BLS airway control whilst ensuring that on scene time was kept to a minimum.Yes there are risks to not placing a tube, but there also has to be recognition of the risks of intubating a patient with a GCS of 5 without anaesthetic drugs. This was a judgement call on my part, not a fear of placing a tube, and sometimes I feel that paramedics all to quickly go for the tube when it may not necessarily be the best thing for the patient, at that time!The situation was dynamic and very time critical. In hindisght and on reflection, I would do this same thing again. You may call it lucky, but seeing the difficulty that the A&E doc had trying to tube the pt before arrival of the anaethetist, then I am glad I didnt try in the back of the ambulance and waste valuable time.There is a time and a place for every intervention in out tool kit, I just felt that this was one of the times where BLS and diesel were the best options for the patient.Thank you again for bringing up the question though. They are always welcome here.

  12. I'm thinking just a jerk.

  13. There's always one (or more) in the crowd.

  14. I first read your title as ATHEISTS… lol…

  15. It's the way they're trained in the OR. In fact it's the way I was trained in the OR, but stopped doing in the field. There are some sound physiological reasons for raising the patient's head, but we can't always do that in the field. The truth is that we end up doing a number of things in the field that would cause doctors and nurses to faint away if they saw them. Just part of practicing (para)medicine in the real world.

  16. Not a rookie. EMT-P since 1987. Have worked high volume urban, sleepy rural, suburban, hospital based and west coast firefighter paramedic for 10 of those years. I am a proponent of aggressive, competent airway management. Medic-999's follow up explanation makes more sense than the original story, however, timidity (which, it appears, is not the case, here) in the face of an uncontrolled airway has, in my opinion become nearly epidemic. Yes, I am fully aware of the risks of intubation. Almost all of them are outweighed by the risks of aspiration, inadequate seal and bagging, and the lack of positive, controlled management of Co2 an O2 levels. In nearly every case, if the E.D. immediately intubates your patient, you dropped the ball. In systems that don't allow RSI, there is an understandable percentage of patients that will be paralyzed and intubated upon arrival, in the ED. Prehospital intubation is being downplayed, partially due to the poor success rates in some systems due to poor training and low volume. Personally, I don't let intubations “waste time” on my calls. A well oiled routine can get a tube down and secured in a couple of minutes, or en-route, if it works out that way.I realize that Medic999 posted the story to point out the humorous “requirements” of in-house folks who can't get a line without a team backing them up. I've got about a hundred of these stories, myself. I just internally shake my head, these days and laugh about it with my partner. I used the story as an opportunity to question, what I feel is becoming a kind of false bravado with the “I can get it done BLS, just fine” crowd. It is clear that Medic999 is not one of these people, and I think he gave a mature and satisfactory answer to the challenges I presented. There clearly are infinite variables in this profession, and we all have to live with our call, at the end of the shift.In answer to the peanut galley: The term is “dinosaur”, not rookie. And jerk? Eh, I've been called worse.Again, thanks to Medic999 for the great blog, and the fortitude and confidence to field tough questions.Chris B.

  17. Not a rookie. EMT-P since 1987. Have worked high volume urban, sleepy rural, suburban, hospital based and west coast firefighter paramedic for 10 of those years. I am a proponent of aggressive, competent airway management. Medic-999's follow up explanation makes more sense than the original story, however, timidity (which, it appears, is not the case, here) in the face of an uncontrolled airway has, in my opinion become nearly epidemic. Yes, I am fully aware of the risks of intubation. Almost all of them are outweighed by the risks of aspiration, inadequate seal and bagging, and the lack of positive, controlled management of Co2 an O2 levels. In nearly every case, if the E.D. immediately intubates your patient, you dropped the ball. In systems that don't allow RSI, there is an understandable percentage of patients that will be paralyzed and intubated upon arrival, in the ED. Prehospital intubation is being downplayed, partially due to the poor success rates in some systems due to poor training and low volume. Personally, I don't let intubations “waste time” on my calls. A well oiled routine can get a tube down and secured in a couple of minutes, or en-route, if it works out that way.I realize that Medic999 posted the story to point out the humorous “requirements” of in-house folks who can't get a line without a team backing them up. I've got about a hundred of these stories, myself. I just internally shake my head, these days and laugh about it with my partner. I used the story as an opportunity to question, what I feel is becoming a kind of false bravado with the “I can get it done BLS, just fine” crowd. It is clear that Medic999 is not one of these people, and I think he gave a mature and satisfactory answer to the challenges I presented. There clearly are infinite variables in this profession, and we all have to live with our call, at the end of the shift.In answer to the peanut galley: The term is “dinosaur”, not rookie. And jerk? Eh, I've been called worse.Again, thanks to Medic999 for the great blog, and the fortitude and confidence to field tough questions.Chris B.

  18. I believe there was a misunderstanding. I am in full agreement with needing intubation with any unconcsious patient. A controlled airway is part of the basic ABC's. I however disagree with needing a pillow, which is what I apparently thought you meant, lol. Sure, a pillow to help hold sniffing position every time you intubate would be great, but it just isn't feasible most times. At least not in the field. I've been in EMS about as long, and I'm sure we've both seen many changes and advances. Dinosaur? possibly, but not extinct. Hopefully there's still a need for us, lol.

  19. Not a rookie. EMT-P since 1987. Have worked high volume urban, sleepy rural, suburban, hospital based and west coast firefighter paramedic for 10 of those years. I am a proponent of aggressive, competent airway management. Medic-999's follow up explanation makes more sense than the original story, however, timidity (which, it appears, is not the case, here) in the face of an uncontrolled airway has, in my opinion become nearly epidemic. Yes, I am fully aware of the risks of intubation. Almost all of them are outweighed by the risks of aspiration, inadequate seal and bagging, and the lack of positive, controlled management of Co2 an O2 levels. In nearly every case, if the E.D. immediately intubates your patient, you dropped the ball. In systems that don't allow RSI, there is an understandable percentage of patients that will be paralyzed and intubated upon arrival, in the ED. Prehospital intubation is being downplayed, partially due to the poor success rates in some systems due to poor training and low volume. Personally, I don't let intubations “waste time” on my calls. A well oiled routine can get a tube down and secured in a couple of minutes, or en-route, if it works out that way.I realize that Medic999 posted the story to point out the humorous “requirements” of in-house folks who can't get a line without a team backing them up. I've got about a hundred of these stories, myself. I just internally shake my head, these days and laugh about it with my partner. I used the story as an opportunity to question, what I feel is becoming a kind of false bravado with the “I can get it done BLS, just fine” crowd. It is clear that Medic999 is not one of these people, and I think he gave a mature and satisfactory answer to the challenges I presented. There clearly are infinite variables in this profession, and we all have to live with our call, at the end of the shift.In answer to the peanut galley: The term is “dinosaur”, not rookie. And jerk? Eh, I've been called worse.Again, thanks to Medic999 for the great blog, and the fortitude and confidence to field tough questions.Chris B.

  20. Not a rookie. EMT-P since 1987. Have worked high volume urban, sleepy rural, suburban, hospital based and west coast firefighter paramedic for 10 of those years. I am a proponent of aggressive, competent airway management. Medic-999's follow up explanation makes more sense than the original story, however, timidity (which, it appears, is not the case, here) in the face of an uncontrolled airway has, in my opinion become nearly epidemic. Yes, I am fully aware of the risks of intubation. Almost all of them are outweighed by the risks of aspiration, inadequate seal and bagging, and the lack of positive, controlled management of Co2 an O2 levels. In nearly every case, if the E.D. immediately intubates your patient, you dropped the ball. In systems that don't allow RSI, there is an understandable percentage of patients that will be paralyzed and intubated upon arrival, in the ED. Prehospital intubation is being downplayed, partially due to the poor success rates in some systems due to poor training and low volume. Personally, I don't let intubations “waste time” on my calls. A well oiled routine can get a tube down and secured in a couple of minutes, or en-route, if it works out that way.I realize that Medic999 posted the story to point out the humorous “requirements” of in-house folks who can't get a line without a team backing them up. I've got about a hundred of these stories, myself. I just internally shake my head, these days and laugh about it with my partner. I used the story as an opportunity to question, what I feel is becoming a kind of false bravado with the “I can get it done BLS, just fine” crowd. It is clear that Medic999 is not one of these people, and I think he gave a mature and satisfactory answer to the challenges I presented. There clearly are infinite variables in this profession, and we all have to live with our call, at the end of the shift.In answer to the peanut galley: The term is “dinosaur”, not rookie. And jerk? Eh, I've been called worse.Again, thanks to Medic999 for the great blog, and the fortitude and confidence to field tough questions.Chris B.

  21. I believe there was a misunderstanding. I am in full agreement with needing intubation with any unconcsious patient. A controlled airway is part of the basic ABC's. I however disagree with needing a pillow, which is what I apparently thought you meant, lol. Sure, a pillow to help hold sniffing position every time you intubate would be great, but it just isn't feasible most times. At least not in the field. I've been in EMS about as long, and I'm sure we've both seen many changes and advances. Dinosaur? possibly, but not extinct. Hopefully there's still a need for us, lol.


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