RN intubating in the ED

Specialties Emergency

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Do any of you work at hospitals where RNs intubate patients in the ED under certain situations? We are looking at this at our hospital. What training do you require of these nurses. I've heard some say ACLS, but I teach ACLS and don't feel it rovides enough training to set someone loose even with a doctor or paramedic with them.

Specializes in ER.
See I'm not sure you could really include RSI or induction drugs in. Just seems like there are so many thoughts on what you use. I don't think we would include this as something our RN's could do. What we are really looking at is last resource situation. No one can get patient smith intubated after 13 tries, Sally RN you try. This would never be a Sally patient smith needs a tube get after it.

As a PH-RN I am actually trained to RSI a patient to intubate...If Sally couldn't be intubated after 13 tries..there are other options...having a nurse that doesn't intubate as often just to give it a try is not the best option for that patient...definitely not a last resort type scenario...13 tries seems like a bit of a stretch as well...other options should be attempted way before that...

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13 times was a bit of a exaggeration. The more we look the more we don't really think we want to do it. By the way what is PH-RN.

As a PH-RN I am actually trained to RSI a patient to intubate...If Sally couldn't be intubated after 13 tries..there are other options...having a nurse that doesn't intubate as often just to give it a try is not the best option for that patient...definitely not a last resort type scenario...13 tries seems like a bit of a stretch as well...other options should be attempted way before that...
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This wouldn't be someone who never did it anyway. This would be continued training that included working with a CRNA for several months on intubation. Then they would have to perform X number with that CRNA to show competency. They would then need to be observed in ED situations X number of times. Then they would have to intubate X number of patients a year to retain privileges. You can't tell me this is any different than a Family practice or IM doctor who hasn't touched a blade in several months or years trying to intubate. What I propose is not putting a patient in danger or at risk.

As a PH-RN I am actually trained to RSI a patient to intubate...If Sally couldn't be intubated after 13 tries..there are other options...having a nurse that doesn't intubate as often just to give it a try is not the best option for that patient...definitely not a last resort type scenario...13 tries seems like a bit of a stretch as well...other options should be attempted way before that...
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This wouldn't be someone who never did it anyway. This would be continued training that included working with a CRNA for several months on intubation. Then they would have to perform X number with that CRNA to show competency. They would then need to be observed in ED situations X number of times. Then they would have to intubate X number of patients a year to retain privileges. You can't tell me this is any different than a Family practice or IM doctor who hasn't touched a blade in several months or years trying to intubate. What I propose is not putting a patient in danger or at risk.

I think you could do it. The tough part would be the justification to the administration, you know they will ask "how removing a nurse for extensive training will increase the profit margin for something that might not be necessary".

Mike

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PH-RN is a Pre-Hospital RN.....essentially a RN who goes through a condensed paramedic program.

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A PH-RN is nothing like or even close to a Paramedic.

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Specializes in ER.
A PH-RN is nothing like or even close to a Paramedic.

I sense some bitterness...It's a shame that there are people that are out there that still have closed minds...There are vast differences initially, I agree. However, I actually work in a 911 system...and I'd go head to head with any other medic any day...I can keep up...I've learned alot from the medics I've worked with...and wow..watch this...I've actually taught them a few things...but don't tell anyone..wouldn't want to ruin a reputation...not all are created equal...so don't generalize for a whole field, because that statement could probably swing either way...I've actually read some of your posts..and your "GOD" complex is getting old...By the way, are you are nurse as well or just a medic?

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I think you could do it. The tough part would be the justification to the administration, you know they will ask "how removing a nurse for extensive training will increase the profit margin for something that might not be necessary".

Mike

The original point of the message was that there were many former paramedics, army medics, etc on staff who had already had the training. A refresher course probably wouldn't be bad, be this process would only be open to those who had performed say 100 of these in another job. Depending on how the policy is written, it may allow for parmedics on the ambulance crew to assist as well (assuming they are employees of the hospital). The reality is that if someone doesn't do it, someone very well may die. I'd personally rather have a half trained person intubating me than sufficate.

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The original point of the message was that there were many former paramedics, army medics, etc on staff who had already had the training. A refresher course probably wouldn't be bad, be this process would only be open to those who had performed say 100 of these in another job. Depending on how the policy is written, it may allow for parmedics on the ambulance crew to assist as well (assuming they are employees of the hospital). The reality is that if someone doesn't do it, someone very well may die. I'd personally rather have a half trained person intubating me than sufficate.

First question: Is there an airway specialist in house on-call (ie. CRNA, MDA?)

Second question: How large is your hospital, why wouldn't an airway specialist be available (if your hospital is that small, does it even have an ED?).

Point: Someone who is "half trained" is just that "half trained" so does that mean they are allowed to get "half" of the people intubated and the other half "oh well". (You shouldn't get snippy with your posts, cuz you will get "snippy" in response to your posts). Being an airway expert, I have seen what can happen when people are cavalier with an airway. All of a sudden what started as a controlled situation turns into a mess because someone was "50%" sure they could handle the situation. The person has DL'd the patient 6 times, there is blood in the airway, the front teeth are missing, there is aspirate in the pharynx because cricoid pressure wasn't administered........etc, etc, etc, etc. Someone said earlier that intubating is a "task", I agree that the act itself is a task. But the different situations and equipment/pharmacology necessary for the "task" takes time and experience to learn. If you disagree with what I have said then you may be putting patients in dangerous situations. Handling an airway is not something you can do on occasion.

Just my thoughts,

Mike

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According to the OP, the hospital has 8 physicians total on staff, a number of which are residents who moonlight. The hospital is also over an hour from the nearest hospital. The only airway specialist on staff is a CRNA, who is also the only anesthesology support. The only other person with any airway expertise is a General Surgeon -- the only one on staff.

Given those constraints, I'd take half trained over nothing -- which were the options. Generally the MD at the hospital is not an airway specialist. And if 5 people show up at the same time who need airway management, the option is either allow someone else who has had "half" the training to attempt airway management, or to die. This is a classic triage issue, which is fairly common in rural areas and the 3rd world.

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A PH-RN is nothing like or even close to a Paramedic.

Illinois was the first state to certify PH-RNs and this comes directly from there policies.

"

Prehospital Personnel

1. A currently licensed First Responder, EMT-B, EMT-I, EMT-P or PHRN may perform

emergency and non-emergency medical services as defined in the EMS Act and in

accordance with his or her level of education, training and licensure. Prehospital

personnel must uphold the standards of performance and conduct prescribed by the

Department (IDPH) in rules adopted pursuant to the Act and the requirements of the EMS

System in which he or she practices, as contained in the approved System Program

Plan.

2. A person currently licensed as an EMT-B, EMT-I, or EMT-P may only function as an EMT

or use their EMT license in pre-hospital or inter-hospital emergency care settings or nonemergency

medical transport situations, under the written or verbal direction of the EMS

Medical Director.

3. First Responders: May provide care consistent with the definition of a First Responder

service and within the context of Standing Medical Orders (SMOs) or Standard Operating

Procedures (SOPs). First Responder care should be focused on assessing the situation

and establishing initial care to treat and prevent shock.

4. Emergency Medical Technician - Basic (EMT-B): May provide care consistent with the

definition of a BLS service and within the context of Standing Medical Orders (SMOs) or

Standard Operating Procedures (SOPs). This may include interventions involving airway

access/maintenance, ventilatory support, oxygen delivery, bleeding control, spinal

immobilization and splinting isolated fractures. EMT-B attention should be directed at

conducting a thorough patient assessment, providing care to treat for shock and

preparing or providing patient transportation.

EMT-Bs may perform Basic Life Support Services with the following enhancements:

a. Assist the patient to administer his or her own nitroglycerine, Epi pen, or Proventil

pending an ALS response. If trained and certified, EMT-B providers may carry and

administer various approved medications. Medical Control orders are needed to

assist or provide administration of medications.

b. They will be considered skilled assistants when intubation is necessary, but will not

be expected to perform the procedure.

c. They may use an Automated External Defibrillator (AED) if one is available pending

an ALS response. AED's are only required on BLS vehicles or BLS MedEngines

officially incorporated into the EMS System plan.

5. Emergency Medical Technician - Intermediate (EMT-I): May provide care consistent

with the definition of an ILS service and within the context of Standing Medical Orders

(SMOs) or Standard Operating Procedures (SOPs). This may include all BLS skills and

enhancements along with intravenous fluid therapy, oral intubation, basic EKG

interpretation and defibrillation procedures. EMT-I attention should be directed at

conducting a thorough patient assessment, providing care to treat for shock and

preparing or providing patient transportation.

6. Emergency Medical Technician - Paramedic (EMT-P): May provide care consistent

with the definition of an ALS service and within the context of Standing Medical Orders

(SMOs) or Standard Operating Procedures (SOPs). This may include all BLS and ILS

skills as well as ACLS electrocardiography and resuscitation techniques, administration

of medications, drugs and solutions, use of adjunctive medical devices, chest

decompression and intraosseous access. EMT-P attention should be directed at

conducting a thorough patient assessment, providing care to stabilize the patient by

treating for shock and providing patient transportation. The patient's condition and chief

complaint determine the necessity and extent of ALS care rendered. Consideration

should also be given to the proximity of the receiving hospital. The EMT-P skill level may

be enhanced to include selected critical care medications for inter-facility transfers.

7. Prehospital R.N. (PRHN): The Illinois EMS Act (1995) defines a "Prehospital Registered

Nurse or PHRN as a registered professional nurse licensed under the Illinois Nursing Act

of 1987 who has successfully completed supplemental education in accordance with

rules adopted by the Department (IDPH) pursuant to the Act, and who is approved by an

EMS Medical Director to practice within an EMS System as emergency medical services

personnel for pre-hospital and inter-hospital emergency care and non-emergency

medical transports". All existing Field RNs were grandfathered as PHRNs."

Mike

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According to the OP, the hospital has 8 physicians total on staff, a number of which are residents who moonlight. The hospital is also over an hour from the nearest hospital. The only airway specialist on staff is a CRNA, who is also the only anesthesology support. The only other person with any airway expertise is a General Surgeon -- the only one on staff.

Given those constraints, I'd take half trained over nothing -- which were the options. Generally the MD at the hospital is not an airway specialist. And if 5 people show up at the same time who need airway management, the option is either allow someone else who has had "half" the training to attempt airway management, or to die. This is a classic triage issue, which is fairly common in rural areas and the 3rd world.

My friend, I have cared for wounded soldiers in our combat support hospitals in Iraq, let me assure you that 5 people NEVER showed up to our facility needing immediate airway support. The situation you describe is unrealistic and is far from the "classic" triage scenario. Patients WHO MAKE IT to the ED, don't "just die", but they will if a person who is not trained to standard messes up the airway.

You are speaking beyond your knowledge base. Statistics from WWII, Vietnam, OP Desert Storm, and recently in Iraq point out that less than 1% of all patients arriving at the Echelon II or higher require immediate airway support (not to say they won't require support within the next 2-4 hours, but not immediate). Volume 4 (Anesthesia Care of the Combat Casualty) of the Textbook of Military Medicine does a great job explaining that as well as triage if your interested.

Prehospital personnel do a good job with airways, your examples are just not realistic.

Additionally, You mention the "third world", have you been to the Middle East, Cambodia, Honduras, Guam? If so what part?

Mike

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