Advanced Airway for QL 5 Med Techs

[Armymedic]

Given technological advances and the need for more advanced skills required by our medics in the field, is it not time for CFHS to allow some advanced procedure to be delegated down to field (QL5) med techs?

Specifically, I am referring to the skills of intubation and cricothyroidotomy. Both should be taught and tested in our QL5 school and skill refreshed prior to each deployment to Afghanistan. Given that the OPA is not effective in either a tactical environment nor ensuring a truly secure airway, that device, whilst a "tool in the toolbox" should not be taught as the medics primary airway tool.

As it stands right now, cric is the "standard" advanced airway for TCCC by operators (NPA being the basic airway) in the US and other countries. It is a relatively safe procedure that with practice can be done safely and effectively in 20-30 secs.

With new technology, such the Airtraq  http://www.airtraq.com/airtraq/portal.portal.action   , and skills like translaryngeal pressure, intubations in the field on difficult patients is quicker and slicker than ever.

Knowing the pros and cons of each procedure, there is no reason why troops can not be trained on mannequins and animal tissue prior to going over to the sandbox.

 

[HItorMiss]

As it stands right now, cric is the "standard" advanced airway for TCCC by operators (NPA being the basic airway) in the US and other countries.

Quick question SMMT what is CRIC???

 

[PMedMoe]

Quick question SMMT what is CRIC???

Cricothyroidotomy.

SMMT, if I am reading your post correctly, you are saying that QL5 Medics shouldn't be doing intubation and cricothyroidotomy but personnel trained on TCCCS can?

 

[HItorMiss]

Thank you Moe

And I think SMMT was saying that intubation should be done by the QL5 medic where as Crics could be done by a TCCC or they are already done by TCCC in other counrties.

Thats just how I read it though.

EDIT: Spelling

 

[COBRA-6]

That optical laryngoscope looks like a good piece of kit! How new is it? Is anyone using it in a military field environment yet?

 

[PMedMoe]

Thank you Moe

And I think SMMT was say that intubation should be done by the QL5 medic where as Crics could be done by a TCCC or they are already done by TCCC in other counrties.

Thats just how I read though.

You're right, HoM.  I reversed the "is it not time" in the first sentence to "it is not time".  Can anyone say dyslexic?  :-[

 

[Armymedic]

"Is it not time...?"

I am advocating QL5 medics and up be able to do cric and ET intubations, and all TC3 advanced trained providers do crics, if not already so in Canada.

That optical laryngoscope looks like a good piece of kit! How new is it? Is anyone using it in a military field environment yet?

It is very new, about a year or so old. And yes, military people are using it.

 

[PMedMoe]

"Is it not time...?"

Hey! I admitted my mistake! (and you know how rare that is!  ) Don't rub it in!

 

[DartmouthDave]

Hello,

I went to the SLAM (Street Level Airway Management) conference in Dallas Texas.  Great course with evey possible bit of airway kit you could think of.  They had the Airtraq there as well.

I used it in the cadaver lab and it worked great.  I also spoke with some paramedics who used it on their tatical team.  From their experiences the major problems were blood and temperature changes.

Blood in the airway would smear over the lens. 

The lens would fog up with temp changes or the warmth of the patients breath.

Cheers

 

[ModlrMike]

Speaking from personal experience, endotracheal intubation is labour intensive, and there is usually no time on the battlefield to perform this advanced airway procedure. The skill is difficult enough to do accurately under controlled conditions as it is. In addition, if you miss and irritate the vocal cords, you hooped.

 

[MedCorps]

When I spent time working with the RAMC, I was pleased to see that Combat Medical Technicians have the endotracheal intubation, nasotracheal intubation, laryngeal mask airway, and combitube airway as part of thier QL5 (equiviant) skillset [D/AMD/113/29].  They were also being trained on needle cricothyroidotomy, jet insufflation, emergency cricothyroidotomy (with the Minitrach and Quicktrach sets), and surgical cricothyroidotomy. 

These skills were also part of the BATLS (Battlefield Advanced Trauma Life Support) course I taught on and were found as part of Casualty Treatment Regime #1&2. 

Yeah... it is about time to start teaching our QL5's some of these skills.

Cheers,

MC

 

[ModlrMike]

When I spent time working with the RAMC, I was pleased to see that Combat Medical Technicians have the endotracheal intubation, nasotracheal intubation, laryngeal mask airway, and combitube airway as part of thier QL5 (equiviant) skillset [D/AMD/113/29].  They were also being trained on needle cricothyroidotomy, jet insufflation, emergency cricothyroidotomy (with the Minitrach and Quicktrach sets), and surgical cricothyroidotomy. 

These skills were also part of the BATLS (Battlefield Advanced Trauma Life Support) course I taught on and were found as part of Casualty Treatment Regime #1&2. 

Yeah... it is about time to start teaching our QL5's some of these skills.

Cheers,

MC

I don't disagree completely, but there's also the issue of skill fade. Those of us with this skill in our scope have very little opportunity to keep ourselves fresh as it is. As the majority of MedTechs who would conceivable use this skill are posted to Fd Ambs, it has the makings of an MCSP nightmare.

 

[MedCorps]

I agree skill fade is a problem for all clinicians who do not practice any psychomotor skill on a regular basis.  Advanced airway management when you are the only clinician around is just one of those things you need to know...

If you need to do it, and you don't know how the casualty is dead without a chance.
If you need to do it, and you know how to do it, and do it right, the casualty is good.
If you need to do it, and you know how to do it, and screw it up, the casualty is dead with a chance given. 

Even if we teach some of these skills on the QL5 course, and they don't use them, at least they have read and seen them conceptually.  If then, they get a classroom refresher now and then, that is the helpful next step. If we work it into casualty simulation and walk-talk through the procedure with evaluation that is also helpful.  If they get practice on a simulator periodically that is better, and an animal model and/or cadaver lab is best... but expensive and hard’ish to coordinate, so maybe that should be saved for pre-deployment Med Tech's who are going outside the wire.  Hey, maybe even get a few intubations in a controlled situation in the OR or elsewhere for those medics actively requiring the skill set.  This is the British model, although the CF MCSP is conceptually better than theirs, and how the US SOCOM is doing it. 

Only a thought. 

This is the same problem for any of the advanced medical skills we learn.  We often learn it, and then don't do it.  At least we have the academic background (procedure, techniques, risks, anatomy, etc) to give it the college try if we must... when the only other option is watching someone suffocate during the next 6 minutes I will opt for the college try, and expect those around me to give it the college try if it is me laying on the ground.

Again, ideally we would all be pro-stars at every procedure in the book, doing them all weekly on real casualties, but there are all kinds of skills we just cannot do on a frequent basis because the patient population does not support it, the volume of procedure to keep current on, and the other tasks that arise.  It happens from surgeons (e.g. traumatic amputation revisions) to critical care nurses (Swan-Ganz management) to paramedics (advanced airway management skills) to self-aid giving infantrymen (NBCD auto-injector administration). 

Cheers,

MC

 

[kj_gully]

So a ql5 medic is going to do rapid sequence induction (paralytics and sedatives)?  We've been doing intubation for a while, but it takes 2 days in OR to get 6 intubations, with fewer and fewer being done in hospital all the time, as simpler airways and spinal blocks become more widespread.As I've said b4, we don't have paralytics, so only use it during cardiac arrest protocol, discontinue resus protocl, and consider it in post arrest stabilization, though tickling a larynx in a recently resus patient sounds ill advised to me. It is a difficult skill to maintain competancy in. By this I mean finding the training time to get the actual intubations that your competant medical authority deems adequate to allow you to maintain a qualification. Its easy to do a straightforward intubation on a sedated or recently deceased patient, but I don't think its a necessity with all the blind airways coming down the line. Now crics, I think is a different story. They are fast and effective access for your ptential facial trauma. We are ditching intubation for LMA. not as good as intubation, but better than OPA, and simpler than combi tube. my thoughts anyway.

 

[ModlrMike]

You can bet that if PAs can't use paralytics, the QL5 wont. I agree that the LMA is a good option in lieu of ET intubation in the field.

 

[MedCorps]

Whoa... I am not sure that anyone here is saying the QL5 should be using paralytics... and I cannot think of another allied army that has medic's using paralytics. 

LMA... that might be a good place to start with the cric following right behind it (or maybe reversed).  Interesting to see ET intubations are being replaced with LMA in the SAR Tech world, will save the days of sluming in OR waiting for tubes. 

Cheers,

MC

 

[ModlrMike]

So a ql5 medic is going to do rapid sequence induction (paralytics and sedatives)? 

No, he wasn't saying... he was asking. I just responded. Still, there may be some value in teaching the skill we know the troops won't use. They can become very able assistants. The downside is that we'll hear more "Why did they teach that if I'm not allowed to do it?" type questions.

 

[Armymedic]

No paralytics. But there other less invasive ways to neutralize the gag reflex and do a "conscious" intubation. see link:

http://www.pitt.edu/~regional/Airway%20Blocks/airway_blocks.htm

which could be taught (ACP/Sr medic/PA level), but that is a whole different ball of poo.

In training, given the advances of the SIM and Medi man trainers, all students can be trained and tested, given all the tools they need including difficult intubations, before they ever touch a real body.

Re LMA and ET, it is not designed to replace, but to give the SAR Tech a viable option to control the airway better that with a OPA. The LMA that the SARs will be getting has the capability to be able to put an intubation/gastric tube in afterward. The big drawback of LMA vs other blind insertion devices is that it is not internally secured like the King LT or combitube.

In my perfect world world, I as a QL 5 med tech should be taught this sequence of advanced airways:
Blind insertion device,
ET intubation,
surgical Cricoidthyroidomy

 

[Armymedic]

Blood in the airway would smear over the lens. 

The lens would fog up with temp changes or the warmth of the patients breath.

The new model I played with recently has a heating element with the light so that the fogging problem is solved. Blood in the oropharynx is still and issue, but any fluids there need to be suctioned to be able to see the cords properly. They are also working on the next model which will have replaceable batteries so that it can be reused in the field (as long as the light works)

But the Airtraq is just a tool...if you do not have 2 or more tools/options to defeat any obstacles, then perhaps you should not be doing it.

 

[kj_gully]

If QL 5 are reasonably expected to assist an advanced level caregiver place a tube, then this training would be invaluable. Familiarity with the procedure would allow them to anticipate requirements, ie, test ballons and laryngascope, apply lubricant, "BURP" patient, retract stylet etc. It is pretty tough to do the procedure, and talk thru an assistant under stress.