Curious as to how many people feel they received or have adequate knowledge of alternative airway devices. Even after many studies have shown these devices to be effective alternatives to conventional intubation, the AHA seal of approval, and now, a push for increased utilization of these devices in the pre-hospital environment instead of conventional intubation, (Aside from being used frequently in the OR.) it appears many of us may not be up to date with current recommendations and general knowledge of these devices.
I have been in larger ER's where the difficult/failed airway strategy was simply to cric. I have also pulled patients out of hospitals where several unsuccessful attempts at intubation were documented with absolutely no attempt at rescue device utilization. In addition, I have even been in ER's where the nurses would teach new team members the "proper" way to deal with a patient who came into the ER by EMS with a combitube in place. They advocated a technique that involved cutting off both pilot balloons at the same time, thus deflating both cuffs at the same time for rapid removal. You cannot make this stuff up.
-How many of you have some sort of difficult and failed airway plan in place?
-Does it involve alternative/backup/supraglottic devices such as LMA's, combitubes, Kings's, etc?
-Do you feel comfortable using a backup airway?
-Do you feel comfortable assessing a patient with a backup placed?
-Do you feel comfortable managing a patient with a backup airway placed?
-Are your ER physicians familiar with these devices and would they actually consider using them as part of the airway management strategy?
I get the feeling that many people are still in that intubate at any cost mentality?
I would not support an airway class based on the EMT NCS with a NREMT like psychomotor station. This is due to the fact that the typical ER RN functions in a different capactity and environment. The ideal course should focus on the following:
1) Airway assessment and anticipating problems/difficulty
2) Review of the pharmacology
3) Preparing for intubation and positioning
4) Assisting with intubation, placement verification, & securing methods
5) What to do when plan A fails
-difficult airway
-failed airway
-emphasis on adjuncts, positioning, suctioning, and mask technique
-awake technique and intubation adjunct overview (Bougie, fiberoptics, etc)
6)Airway A&P overview and review of indications/cautions and medical/legal problems associated with airway management.
I envision a two day course with one day dedicated to didactic lecture and case studies. The second day would be a clinical lab exercise.
I agree that the focus should not be on RN's intubating, but rather how to prepare, assess, and respond when things do not go as planned. However, I think the RN should demonstrate proper BLS techniques and be able to properly insert, assess, and manage a supra-glottic airway.
Thus, I see skills labs emphasizing the following:
1) Airway assessment techniques, positioning, and protection
2) Setting up for intubation, monitoring the patient, and medication administration
3) Placement verification and securing
4) BLS techniques to maintain ventilation and oxygenation
5) Recognizing the failed or difficult airway situation
at my hospital we have annual "housewide mandatories" that every staff member has to complete. one of the stations is an airway station where they go over most of things you have listed. nurses should be able to properly assess an airway without a class like this, but i understand what you're getting at. the ED has "mandatories" as well where we, again, go over the alternative airway equipment, assessing who and when a pt. needs it, etc. i wonder if there are any RT classes that would be good to emulate for developing something for nurses? it seems that one of the biggest pit falls to having a large "team approach" to patient care is that we, as nurses, can lose valuable skills and assessment techniques if we are no longer using them. for instance....where i work our RT's do EVERYTHING respiratory, save for opa/npa and initial oxygen placement. we give the drugs for rsi and so forth, but generally there are at least 2 (or more) RT's at each code or critical resp pt. they do all the breathing treatments, n/t suctionin, tube stabilization and even abg's. half of the nurses i work with don't even carry a steth which totally drives me crazy! their excuse is that ER assessments are complaint based, which can be true......but.....ugh! anyway....obviously a pet peeve of mine:) my point is that if you start in a hospital like that....while it's nice to have all that support....you will lose very important skills. i was used to doing my own abg's, checking for tube placement, breathing treatments, etc. now it's a rarity. if you're a new grad at my hospital you'll be able to say, "well....i've SEEN it done several times, but have never done one myself".
Cutting the pilot tube as a student will get you a very poor eval and kicked out of the OR to go look up articles.
Cutting the pilot tube is darned near malpractice. The pilot tube on endotracheal tubes made since about 1974 are NOT elastic and self deflating. if you cut the tube and remove the tube... guess what? You are deflating it against the cords.. Medline some articles about vocal cord injuries and ET tube removal.
i was used to doing my own abg's, checking for tube placement, breathing treatments, etc. now it's a rarity. if you're a new grad at my hospital you'll be able to say, "well....i've SEEN it done several times, but have never done one myself".
I work in a freestanding ED -- no RTs, no anesthesiologists, nada. We do the ABGs, check tube placement, manage the vents, do breathing treatments ... heck, we mix our own drips most of the time, too. But it's great because we don't lose those skills. :)
I would be interested in a class like this. We also have respiratory staff that do most of the intubating, venilator settings, ect. About the only time I extubate is on a dead pt going to the morgue. We never use the alternative airways. Occasionally they will come in with one from the medics and we just leave it alone. We never initiate anything but a standard ET. I think your class should include ventilator settings and CPAP/BIPAP. Vents are something I never mess with due to respiratory doing it and I don't really understand them. We have been using CPAP a lot more recently and I have found it to be a great alternative to intubating on a CHF/COPD pt. I've seen several people get better quickly and avoid the tube altogether.
I work in a freestanding ED -- no RTs, no anesthesiologists, nada. We do the ABGs, check tube placement, manage the vents, do breathing treatments ... heck, we mix our own drips most of the time, too. But it's great because we don't lose those skills. :)
we mix our own meds, but the other stuff is pretty much RT. sometimes it's nice, but other times i'm like...ugh, just let me do it! but it's actually hospital policy! rt's are the only ones who are even able to access neb meds in the pyxis!
but like i said before, it is nice to have the support. i just have to remember to keep up on the stuff myself so i don't lose it!
I would be interested in a class like this. We also have respiratory staff that do most of the intubating, venilator settings, ect. About the only time I extubate is on a dead pt going to the morgue. We never use the alternative airways. Occasionally they will come in with one from the medics and we just leave it alone. We never initiate anything but a standard ET. I think your class should include ventilator settings and CPAP/BIPAP. Vents are something I never mess with due to respiratory doing it and I don't really understand them. We have been using CPAP a lot more recently and I have found it to be a great alternative to intubating on a CHF/COPD pt. I've seen several people get better quickly and avoid the tube altogether.
we use a lot of bipap for our chf/copd pts. a lot of times we attempt that until an abg result comes in....then when the doctor sees the high co2 we intubate:)
Oddly enough, I just got a brochure in the mail today for "The Difficult Airway Course: EMS" which made me think of this discussion thread. According to the brochure, the target audience is EMS, as well as critical care transport professionals. Looks like they also have a course for docs, too. If anyone is interested, the website is http://www.theairwaysite.com -- looks like they're having courses all over the U.S. this year. Unfortunately it's $350-$375 for two days. Ouch.
Lunah, see if your hospital will pay for it, or at least the days you attend. You can easily argue that it will be largely beneficial to your ED practice.
Mine paid for the days when I did paramedic refresher since BLS, ACLS, and PALS were rolled into it. As long as we could argue that something required for the ED was in there, they were cool with it.
Couldn't hurt to ask!
Where do you work? It sounds like a good environment for a paramedic/nurse - used to doing the skills directly.
I'm already having them pay for my RN-BSN, CEN, and TNCC! But it's worth a try!
I work in a freestanding ED in Northern Virginia -- there are a few in the DC metro area. Our hospital system, after we were "acquired" in 2005, started calling us "emergency care centers," which has confused the population at large into thinking we're an urgent care center. But nope ... full-service ED! :) I love it. My coworkers are great. I've learned so much from them! I spent nearly 4 years as an ED tech in the same facility before becoming an RN.
1) I think a ventilator management course while a great idea, is in fact a topic all by it's self.
2) Many of the various airway courses are great. I went to SLAM a few years ago. However, you pay for what you get. This is especially true of a course with a cadaver lab such as SLAM.
3) My biggest consideration is having a course that specifically emphasizes the "typical" nurse. Since most ER nurses do not perform the actual intubation, the nurses roles and responsibilities are different from the person performing the intubation.
4) Ability to customize based on the environment. For example, an ER nurse is going to have a different role in a level I teaching facility versus a rural 7 bed unit.
But it's worth a try!
GilaRRT
1,905 Posts
Thanks for the replies.
I would not support an airway class based on the EMT NCS with a NREMT like psychomotor station. This is due to the fact that the typical ER RN functions in a different capactity and environment. The ideal course should focus on the following:
1) Airway assessment and anticipating problems/difficulty
2) Review of the pharmacology
3) Preparing for intubation and positioning
4) Assisting with intubation, placement verification, & securing methods
5) What to do when plan A fails
-difficult airway
-failed airway
-emphasis on adjuncts, positioning, suctioning, and mask technique
-supraglottic airway design, function, use, assessment, & management
-preparing for surgical airway
-awake technique and intubation adjunct overview (Bougie, fiberoptics, etc)
6)Airway A&P overview and review of indications/cautions and medical/legal problems associated with airway management.
I envision a two day course with one day dedicated to didactic lecture and case studies. The second day would be a clinical lab exercise.
I agree that the focus should not be on RN's intubating, but rather how to prepare, assess, and respond when things do not go as planned. However, I think the RN should demonstrate proper BLS techniques and be able to properly insert, assess, and manage a supra-glottic airway.
Thus, I see skills labs emphasizing the following:
1) Airway assessment techniques, positioning, and protection
2) Setting up for intubation, monitoring the patient, and medication administration
3) Placement verification and securing
4) BLS techniques to maintain ventilation and oxygenation
5) Recognizing the failed or difficult airway situation
6) Supraglottic airway