Intubation & Chest Tube skills

brissie · Feb 17, 2008

Paramedics do not insert chest tubes rather they do needle decompression which of course is usually just a temporary fix. Chest tubes themselves are inserted by physicians. Intubation can be practiced by nurses trained in it, for example critical care transport nurses or certain nurses in NICUs. I do not believe that it is common place for ER nurses or ICU nurses to intubate. I think it's great that you want to expand your knowledge and skill base and I look forward to hearing what other experiences other members have to share.

getoverit, BSN, RN, EMT-P · Feb 17, 2008

Some paramedics are allowed to place a modified chest tube, called a pneumothoraseal. Kind of a trocar hooked to a Foley bag. I've never used one but have seen the video. Some flight nurses can place an actual chest tube, it's up to their medical director and state nursing boards but I have seen that done.

As far as intubation, it's pretty much up to the state nursing board. We have a Category 2 set of nursing skills, which includes ETI, ABG, etc. About certifications, I"m not aware of any that allow you to perform those skills. You can audit an ATLS class (I"ve always taken it with surgical residents) and you will practice intubation, thoracostomy, central line placement, etc. on either cadavers or animals. But those are course completions, just like ACLS, you might be checked off in the classroom but it's up to the nursing board and individual medical director to dictate your skill set.

If you get a chance and you're interested in those, ATLS is a great class to audit (only MD/DO, PA, NP are allowed to actually take the class).

Snuffy · Feb 17, 2008

naz220 you might want to check out the SLAM course (street level airway management) you can google their website. They offer some awesome airway classes, I don't think they offer certifications but it's a pretty intense course, which I highly recommend.

Medic/Nurse, BSN, RN · Feb 17, 2008

I think that it is great that you want to learn new things and even if you CANNOT do the procedure, you may get some benefit from knowing how it is done.

Knowledge is a great thing. Knowing what to do with the knowledge is essential.

I want to caution you that even if you take a "certification" class - you should not plan on actually doing the skill without:

1. Checking with your state BON for RN scope of practice confirmation. Some states are more explicit than others and most have practice restrictions. RN's that do these skills always will operate under MD authorization (generally written protocols) and will have very exacting verifications of competencies.

AND

2. Written confirmation from your employer that you (as an RN, in-house) can actually do these skills even with a physician order. I will bet that the facility in which you work will have restrictions in who can do these procedures and they will be fairly detailed.

Nurses that work in the transport environments are the ONLY RN's (not advanced practice nurses) that I am aware that do these skills. Most paramedics are competent in airway management, but it is a rare paramedic that can actually do chest tubes - I have only encountered a couple in 17 years (one flight and one that practiced in a remote setting). My MD medical director (under whose license I am extended the privilege of being allowed to perform these and other procedures - even as a paramedic my practice is regulated in the same manner) has very comprehensive requirements that I have to meet to in order to be allowed to perform "advanced" skills (initial class, cadaver time, OR insertions under direct MD supervision, monthly/quarterly competencies and his "blessing" after assuring that I am going to be deliberate, prudent and accountable!)

Generally, needle decompression works well as a temporary (and life saving!) procedure in advance of a chest tube (for tension pneumothorax) and is taught in TNCC classes for RN's. Check http://www.ena.org - Choose from the left menu the CATNII/ENPC/TNCC and you can locate courses by state with contact information. The ASTNA (http://www.astna.org) does a course for transport nurses that teaches some advanced skills called TNATC, but none of these classes authorize you to do the procedure.

As for intubation, it used to be taught in ACLS classes though it is not required for course completion - you may still generally get basic instruction in this manner. More advanced classes are offered at some EMS/Trauma seminars in airway management, your local EMS folks may have some info they could share. Intubation is also a critical skill and when it is not done successfully it is going to kill a patient that may otherwise, have had an airway that could be managed in a more basic manner (BVM ventilation). Airway management can be complex for the very experienced provider, so even if you acquire the knowledge/skill -- I will still caution you in actual clinical practice decisions.

"Missed intubations" have disastrous outcomes (for the patient, your liability and the MD that you practice under), so proceed with caution here. Being good at intubation takes a while - I've done a few hundred as a medic, but few as an RN. The reason I am good at it as an RN is my prior paramedic practice - so, I will caution an RN new to the skill that you need extensive preparation and another experienced provider by your side to rescue you (and the patient) if you are unable to intubate. That is just one reason that 2 folks are on the helicopter! There are also many other ways to "manage" a patients airway, so to be good at "airway" you must be good at these too.

Not trying to be a downer, learning new things is worth it, just don't take performing lifesaving skills lightly. There are as many risks as potential benefits and a "certification" class is just a start.

Practice SAFE!

Blee O'Myacin, BSN, RN · Feb 17, 2008

Hello. I am a ER Nurse and I would like to learn Intubation and Inserting Chest tube skills (in cases of Pneumothorax and Hemothorax situations). Is there any certification out there that will allow me to learn those skills? I know some Paramedics are able to perform those skills but I do not wish to go the paramedic route.
Thanks.

In the ER environment, knowing the mechanism of action for the drugs your facility uses for RSI and the dosages are the priority. You are responsible for pushing meds, watching the patient and the monitor and keeping the practioner who is performing the procedures aware of any changes in patient condition. That's plenty without learning the mechanics of the intubation or chest tube insertion!!

If you are still curious about learning how to do those procedures, there are pre-hospital courses that you can take. But I don't know about the availability of practical experience. In my hospital, paramedic students spend a few days in the OR for their intubation practicals. RNs are not allowed to intubate or insert chest tubes under any circumstance in my hospital.

Good luck with finding what you are looking for - keep us updated.

Blee

naz220 · Feb 18, 2008

Thank you to everyone for your input and advice. This information was very helpful.

firecoins · Jul 17, 2008

I understand your not willing to go the paramedic route but don't rule it out. In many states, nurses get advaced standing. You may not need to sit for the whole program.

NY gives advaced standing.

PA has a short bridge class for nurses.