B eing a firefighter-paramedic is a great job; you get to use both sides of your brain daily. One minute, you’re working a cardiac arrest response using state-of-the-art techniques and equipment to save a life, and the next minute you’re saving lives and property. This transition can be a challenge, especially if you are a new firefighter-paramedic. How do you keep the two jobs separate but equal?
There are many similarities between the two roles, especially in how to attack a fire and how to attack an advanced airway. This article explains how to tackle intubation with the same skill set you would use to attack a fire.
It is common to see and hear the first-arriving officer give an initial radio report and then conduct a 360° size-up. This includes the officer getting out of the truck and walking around the perimeter of the structure. He looks for signs and symptoms of the type of fire, the fire’s severity, and clues as to how it will need to be dealt with before taking any action.
The same can be said of the firefighter-paramedic sizing up a patient’s airway before taking any action. The good firefighter-paramedic should evaluate all the external signs of the airway, each of which follows:
• A LEMON airway assessment (Table 1).
• Trauma or recent surgery to the neck.
• Signs of a rapidly deteriorating airway, such as significant accessory muscle use or an altered level of consciousness.
• Critical vital signs such as a systolic blood pressure under 90 millimeters of mercury (mmHg), respirations more than 30 or under 10 per minute, a heart rate more than 130 or under 50 beats per minute, or oxygen saturation below 90 percent.
The first-arriving officer will choose and announce his strategy for dealing with the fire—offensive or defensive. This strategy can change throughout the fire; the officer can choose to start offensive and then, based on what he sees, switch to defensive. In addition, the officer can start defensive, perform some basic stabilization measures, and then switch to a more advanced offensive strategy.
The good firefighter-paramedic should do the same; he must choose his strategy carefully and quickly. Always ventilate a patient who has been short of breath with critically low saturations with a bag valve mask device. Ventilate the patient, create an oxygen reservoir to work with, and “reset” the patient’s respiratory status the same way you reset a fire: by spraying water from the exterior of the structure. You can accomplish this by applying a high-flow nasal cannula (referred to as passive or apneic oxygenation) at 15 liters per minute during efforts to secure a tube (NO DESAT). Don’t be too quick to go straight to an offensive strategy using an invasive airway; if the patient is hypoxemic, he won’t be able to tolerate the intubation attempt and the lack of ventilation during the attempt.
Choosing the right type and size of hoseline is critical to putting out a fire. You need to be able to flow enough water to control the fire or else things will get worse.
The same is true for the firefighter-paramedic. Choosing the right laryngoscope blade and endotracheal tube is important; the paramedic often overlooks this. A size 3 or 4 laryngoscope blade is used for most adults.
The Macintosh blade is a curved blade inserted into the vallecula and gently pushed forward to put pressure on the hypoglossal ligaments. This lifts the epiglottis out of the way while lifting up the jaw, bringing the vocal cords into view. The Miller blade is a straight blade that directly lifts the epiglottis to expose the vocal cords. Video laryngoscopy can be useful, but it requires confidence and competence, which means considerable practice. A 7.0 mm endotracheal tube is preferable in women, while an 8.0 mm tube will be appropriate for most men. A tube that is too small will leak and affect your ability to ventilate.
Getting access to a building that is on fire is critical for fire crews. The longer it takes to control the fire, the worse the situation gets. However, one of the first things a young firefighter is taught is “try before you pry.” If you can walk in the front door and start spraying water to put out the fire or if you need to use forcible entry, you must do it carefully and efficiently to save time, during which the fire is growing. You also don’t want to do unnecessary damage to the structure.
To the firefighter-paramedic, intubation is the same thing. If the patient is adequately unresponsive and has been properly preoxygenated, then you can do intubation quickly, but be careful. For a patient who is completely unresponsive, “try before you pry”: Assess if the intubation necessitates a full complement of intubation-facilitating medications or if it can be accomplished with minimal meds.
However, if “forcible entry”—medication-facilitated intubation—is needed, do it carefully, efficiently, and safely. The key is to be prepared; this means all drugs are drawn up, alternate airways are ready at the patient’s side, suction is available, and an adequate number of resources (i.e., more trained people) are available.
The first 10 minutes of a fire dictate how the rest of the events will unfold. If things are done correctly the first time, any issues will usually be controlled quickly and the situation will improve quickly. If not, things will not go well.
This scenario also applies to the firefighter-paramedic. Your first attempt at intubation needs to be your best attempt; this means proper preoxygenation, proper equipment, and proper technique. This can also mean that a more experienced operator should do the intubation if complications are anticipated. Take the ego out of the situation and do what is best for the patient. This also means being willing to use adjuncts such as video laryngoscopy, bougies, and other devices that improve your chances of intubation.
Continuous waveform capnography is also essential for every intubation performed in the prehospital environment. Just as a fire can rekindle, a patient can easily be extubated, often without warning. Capnography ensures the tube stays in the right place. A commercial endotracheal tube holder also helps prevent accidental tube dislodgement.
On the fireground, the incident commander (IC) will ask for a Conditions, Actions, and Needs (CAN) report after actions are taken to control the scene. The IC needs to know the Condition of the fire environment, what Actions have been taken or are currently being taken, and what else is Needed to continue to manage the fire.
The same goes for the firefighter-paramedic in managing the patient. Use a CAN report to evaluate if your actions are improving the patient’s Condition now that he is intubated. Does the carbon dioxide (CO2) [End Tidal CO2 (ETCO2)] demonstrate that the tube is in a good position? Are you seeing good ETCO2 values (35 mmHg or higher) and good waveforms?
Next, check for continued Airway signs of a successful intubation such as misting in the tube, good lung sounds, easy bagging, equal chest wall expansion, and so on.
Next, what else do you Need? Bronchodilators? Suction? Fluids? Pressors? What other interventions do you need to make?
When the chief officer arrives on the scene, there is a transfer of information to confirm and document what had been done prior to his arrival. The initial commander lets the chief know what decisions have been made and what actions have been taken.
The same is true for the firefighter-paramedic. Keeping track of key information regarding the intubation will ensure not only that the correct actions have been taken but also that these actions are accurately documented, including the reasons they were taken.
To ensure the quality of patient care, pass on to the next caregiver the following information:
• Preintubation condition and vital signs.
• Preintubation size-up information (LEMON assessment, critical vital signs, signs of accessory muscle use, trauma, or recent surgery).
• How the airway was managed.
• Postintubation vital signs and intubation confirmation values.
• Any other information you feel is important. Just as a fire report is uploaded into the department electronic records system, these data should be captured from the patient care monitor and uploaded into the patient care reporting system.
An intubation in the field can be similar to a fire. There is much information to process in a short time to make a critical decision and to use a skill set that is rarely used. As it is with firefighting, the only way to prepare is to train, formally and through personal initiative.
Airway Management: Performing Difficult Intubations
The Officer’s Role in EMS
Prehospital Management of Bariatric Patients
1. Alberta Health Services Medical Control Protocols 3.0 (Alberta, Canada).
2. Walls R and M Murphy. Manual of Emergency Airway Management (4th edition). Lippincott Williams and Wilkins, 2012.
3. https://www.youtube.com/watch?v=2M71X-dspU4 .
DAVID BAIN is a 22-year fire/emergency medical services veteran, a firefighter/advanced care paramedic, and the full-time training officer for Red Deer Emergency Services in Alberta, Canada. Bain is also a rescue specialist for Canada Task Force 2, a federal heavy urban search and rescue and provincial disaster response team.
The LEMON airway assessment (Table 1) mnemonic is a helpful tool to identify risks and possible complications involved with establishing the advanced airway.
• Look externally. Are there any physical features that might suggest a difficult airway (small mandible, large tongue, short neck, and so on)?
• Evaluate the 3-3-2. This relates geometric considerations of mouth opening, mandible size, and thyromental distance. The premise of the 3-3-2 evaluation is as follows:
◊ The “First 3.” The patient should be able to insert three of his own fingers between the upper and lower incisors.
◊ The “Second 3.” The patient should be able to accommodate three fingers between the mentum and the tip of the chin.
◊ The “2.” The space between the patient’s chin-neck junction (hyoid bone). Also, the thyroid notch should accommodate two fingers.
• Mallampati score (Figure 1). This scores the degree of visual structures within the oropharynx.
• Obstructions/Obesity. Check for upper airway obstructions and indicators such as stridor, a muffled voice, and difficulty swallowing. Fluids like blood and saliva, tumors, and foreign bodies can cause obstructions. Obesity is also associated with more difficult airways and comorbid decisions.
• Neck mobility. This is any reduction in the flexion/extension of the neck. Examples are cervical spinal immobilization, medical spinal deformities, past neck trauma, and so on.
Any of the findings can complicate the establishment of the advanced airway; therefore, the skilled practitioner should weigh benefits and risk.