RN intubating in the ED

mommatrauma, RN · Jul 8, 2005

Illinois was the first state to certify PH-RNs and this comes directly from there policies.
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Mike, thanks for that, however judging from the medic's tone, I don't think he was questioning equality based on laws, but rather equality based on how he feels about a nurse coming out of the hospital setting and doing the medics job, without actually going to paramedic school...The experiences are different, hospital vs pre-hospital...and actually as a PH-RN you do really have to prove yourself in comptency, not just for med-command, but also to your fellow ems providers...In PA the number of medics vs the number of PH-RNs in 2004 was like 17,000ish to 1500ish...so its still a new concept for a lot of people...especially since it was almost unheard of for a nurse to work in a 911 setting rather than a inter-facility transport or aero-medical transport type job. Respect is a two way street for sure, and I think as time goes on, it will improve...there are people that are good at what they do, and then there are people who think they are good at what they do....Being a pre-hospital provider definitely has its challenges...like any other job...its about taking those challenges and knowing how to handle them and produce the best outcome possible...I also agree with you, knowing 50% is no better than knowing nothing, because its that 50% that will cause that bad airway situation to go worse, every time....I rather be ventilated for 3 hours with a BVM than let someone that only has a little clue try to jack up my airway before someone that has experience with airway management gets involved...

sgent · Jul 8, 2005

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

There is a lot to answer here....

First off I won't argue that I used an exagerated example. I think that you may be missing much however. You mention the prehospital team, but in the Delta in Mississippi, the prehospital team consists of EMS with no airway training in most (not all cases).

In the mountains of Jamaica, ambulance response varies from 30 minutes to an hour. Physician response maybe half of that as the physician is located at his office or house.

Outside of the mainland of the Bahamas, in Venzeuala, in Nicaraga, South Africa, Kenya rural Alaska, and Zimbabwe, I have seen "field" medicine at its edge.

The OP had witnessed or was concered about a lack of qualified personel causing a delay in airway management for a critical patient, and asked for potential suggestions. There aren't a lot of good answers, but she intimated that often times the physician covering the ER may or may not have much experience (resident), and would be limited if there were multiple critical patients at the same time. In this environment, I think it it is better to have multiple people ready to provide care -- even if its not the ideal solution.

This is nothing new. General Surgeons performing C-sections, Nurse Practitioner's (orginally), etc. We have to try to do what is best for our patient, and sometimes its not what we would prefer to do in a fully staffed, state of the art ER or Hospital.

mwbeah · Jul 8, 2005

I have seen "field" medicine at its edge.

Whatever...........................................................................

Recreational trips do not compare to battlefield injuries, be careful how you define "field".

sgent · Jul 8, 2005

Whatever...........................................................................
Recreational trips do not compare to battlefield injuries, be careful how you define "field".

I just realized how I phrased that, and realize that I didn't do a very good job. My intent was to say as a medical volunteer I have seen and treated multiple conditions, in many countries, away from organized medicine. I am sorry if I left the impression that I did so while serving in the military, or at a field outpost. My quasi-military medicine is limited to the US Public Health Service in the rural south. It in no way compares to those ladies and gentlemen serving in Iraq & Afganistan, nor the people caring for them in true field hospitals.

mwbeah · Jul 8, 2005

I just realized how I phrased that, and realize that I didn't do a very good job. My intent was to say as a medical volunteer I have seen and treated multiple conditions, in many countries, away from organized medicine. I am sorry if I left the impression that I did so while serving in the military, or at a field outpost. My quasi-military medicine is limited to the US Public Health Service in the rural south. It in no way compares to those ladies and gentlemen serving in Iraq & Afganistan, nor the people caring for them in true field hospitals.

Got it.

matt033174 · Jul 8, 2005

First off I am a Guy not a Girl.

Second I wasn't wondering who had the bigest set or who has seen the worst stuff.

I asked for thoughts on the subject. I am glad for everyones thoughts.

Mike I agree that this is not something to take lightly. I have been in a rural ED for 12 years as a RN. I have seen first hand what happens when someone thinks they know what they are doing with an airway and doesn't. I've seen doctors staight out of residency who puke and pee their pants during there first 2 car MVC with 4 dead and 4 critical. And while I respect you statistics and do not dispute them, I have seen situations where our basic EMS crews bring in 2 or 3 critical patients that need airways controled within minutes of each other. If my RN's with years of experence do nothing but hold the doctors hand whil he intubates they will still be more prepared with continued training. And if the need arises they can intubate. I don't think you understand rural america. You asked if the poster had been in the military. Have you ever worked in a rural hospital in the heartland with only one doctor to call and no way to evac a patient other than a helicopter 42 minutes flight time away when its clean skys and the nearest hospital 1 hour drive by groung EMS with basics and intermediates to transfer. I'm not saying RN's should intubate but some time back someone asked the question can RN's work in surgery and administer anesthesia. You have your position today because someone challenged norms. Lets not say all the reasons this will not work and look at how do we make it work. It's easy to say it's the doctors fault he should be better, its admins fault they should find beter doctors, its not my fault I'm the nurse. What I want to do is what nurses have done or years and that is encourage the growth of my carier and provide the tbest care I can. I'm sorry if this sounds like a flame it is not ment to be. I work with army nurses who have been on the ground in Iraq. My father was a lifer and I have all the respect and appreciation for what you do. Just give us guys fighting in the rural settings a little respect back.

I just realized how I phrased that, and realize that I didn't do a very good job. My intent was to say as a medical volunteer I have seen and treated multiple conditions, in many countries, away from organized medicine. I am sorry if I left the impression that I did so while serving in the military, or at a field outpost. My quasi-military medicine is limited to the US Public Health Service in the rural south. It in no way compares to those ladies and gentlemen serving in Iraq & Afganistan, nor the people caring for them in true field hospitals.

mwbeah · Jul 8, 2005

Have you ever worked in a rural hospital in the heartland

Yes, I live in Colorado and have moonlighted at many remote places.

mwbeah · Jul 8, 2005

You have your position today because someone challenged norms.

Nurses were the first professional group to provide anesthesia services in the United States. Established in the late 1800s, nurse anesthesia has since become recognized as the first clinical nursing specialty. The discipline of nurse anesthesia developed in response to requests of surgeons seeking a solution to the high morbidity and mortality attributed to anesthesia at that time. Surgeons saw nurses as a cadre of professionals who could give their undivided attention to patient care during surgical procedures........

Link: www.miana.org/profession/history_of_na_practice.pdf+history+nurse+anesthesia&hl=en

Just for the record,

Mike

matt033174 · Jul 8, 2005

Nurses were the first professional group to provide anesthesia services in the United States. Established in the late 1800s, nurse anesthesia has since become recognized as the first clinical nursing specialty. The discipline of nurse anesthesia developed in response to requests of surgeons seeking a solution to the high morbidity and mortality attributed to anesthesia at that time. Surgeons saw nurses as a cadre of professionals who could give their undivided attention to patient care during surgical procedures........

Link: www.miana.org/profession/history_of_na_practice.pdf+history+nurse+anesthesia&hl=en

Just for the record,
Mike

Now I am confused. Was this quote form the above web site in agreement or disagreement of my quote. Because when I do a little search I see Physicians and even Dentist that used anesthesia before the end of the 19th century. So a nurse did challenge what was being done because they knew they could do a better job. I also see that some of those nurses went on to develop new techniques and even teach inters, residents and even doctors how to preform thos techniques. Just a thought. I appreciate what you say though Mike. I appreciate what you do and thank you for sharing your experence.

pricklypear · Jul 8, 2005

I just don't see why such a big deal is being made out of this. It's well within a RN's scope to intubate if properly trained. There seem to be some people here who seem to think you have to have some sort of EMS gene or an advanced degree to even learn how to do it. Nobody's suggested doing away with EMS or CRNAs once a few nurses in a rural ED become trained to intubate in an emergent situation.

Good luck, Matt.

mwbeah · Jul 8, 2005

Now I am confused. Was this quote form the above web site in agreement or disagreement of my quote. Because when I do a little search I see Physicians and even Dentist that used anesthesia before the end of the 19th century. So a nurse did challenge what was being done because they knew they could do a better job. I also see that some of those nurses went on to develop new techniques and even teach inters, residents and even doctors how to preform thos techniques. Just a thought. I appreciate what you say though Mike. I appreciate what you do and thank you for sharing your experence.

The earliest anesthetics were left to be administered by medical students. Unfortunately, these medical students were more interested in the surgery and did not pay attention to the patient. The result was, in some cases, death for patients. Nurses, being known for there vigilance, were asked to assume that role.

Just thought you should know,

Mike

mwbeah · Jul 8, 2005

If you are at all familiar with google, then finding out about the history of any profession is just a click away. With the ease of obtaining information, one should take a minute and collect data prior to posting something of fact. This helps with posting accuracy.

Mike