Airway or the highway 🫁

*Just to warn you, this blog post is going to be REALLY ALL OVER THE PLACE but if you can stick with me until the end, hopefully you'll get my point!*

There are 3 things I'd like to address in this post: 

1) We always hear, "BLS before ALS" - what does that actually mean? 

2) We also get A LOT of crap from some senior medics who are stuck in their ways and always know best. You always feel like it's their way or the highway and you walk on egg shells while working with them. 

3) Intubation tips. 

Here is a mnemonic for you to use post-intubation! More at the end! 

When you hear the phrase, "BLS before ALS" don't think... "I always need to do BLS before ALS." Instead just stop and consider BLS before ALS. All it takes is a split second to consider doing something less invasive first and sometimes, it is actually what is best for the patient. This isn't all the time though! Don't get stuck always thinking you need to do BLS first! There have been plenty of times I have rolled up on a respiratory distress and went straight to CPAP. You can't go, "Okay, let's try a nasal (not helping), now a non rebreather (not helping) and now lets try CPAP!" Chances are, if your patient needed PPV when you got there, they are unconscious by the time you take all of those steps.  

Now to address the "My way or the highway" situation. If you are a medic and it is your call, as long as you are within protocol and you have the patient's best interest in mind... DO WHAT YOU THINK YOU SHOULD DO! That is all. It is a tough thing to get over but sometimes you just need to say, "Hey I've got this we can get going" as a nice way to kick them out of the patient compartment :) I wish I had better advice. Still be respectful and don't pick a fight with your coworkers for no reason but this is one of those things you just need to buck up and be an advocate for your patient. ALWAYS be an advocate for your patient. 

Moving on to a more common call for some of us to look at the flip side... How many times have you gotten to an overdose and automatically draw up and give narcan without ever ventilating the patient?? Think about that scenario again... [[Pause to think]] I promise you that everyone in EMS has seen this happen. Honestly, anyone in any emergency type setting of health care has probably seen this happen. Now in theory, the patient probably needs narcan yes... BUT they also need some ventilation support and O2 while they were breathing 6x a minute and turning cyanotic! 

Heck, once and a while, I would just ventilate my patient with a BVM and high flow O2 and as long as they could maintain their own airway and they were stabilizing... I would hold off on the narcan! [[Side note to this side note... I gave narcan 9 out of 10 times but if they borderline didn't need it, I would try ventilating them first... in and out of consciousness etc -- PS I may or may not be traumatized by the fear of causing flash pulmonary edema because it was engraved into my brain when I was an EMT. If you didn't know this was a side effect of narcan, look it up -- and for the love of God please never slam narcan or give absurdly unnecessary amounts. Slow and low!]] I brought and overdose into the hospital once and there was no indications of it being from opioids but he had a hx of substance use and was unconscious. He ALSO had fallen off of his bike without a helmet. Since he was maintaining his own airway and his RR was okay at the time, my concern was his C-Spine... I slapped a collar on him, we loaded him up and off we went to the hospital that was 5 miles away (7-10 min transport). Prior to the transport, I put a non rebreather on him and started an IV.  During transport, his vitals were stable but I ended up using an NPA and BVM because he was OUT and I felt like his respirations were decreasing. It was hard to tell if he was just REALLY relaxed or if he was starting to decomp. I was a little anxious to see if the ER Doc was going to be frustrated that I didn't try narcan but instead he stopped me and thanked me for putting a C-Collar on the guy! (Remember C-Spine is at the top of your assessment worksheets for a reason! This is when you WOULD do BLS before ALS!) His labs came back later and he tested positive for every drug under the sun that narcan WOULDN'T reverse. Would narcan have hurt the guy? No but was it the #1 intervention that was needed? Also, no. You don't respond to an overdose turned cardiac arrest and just give the patient narcan right?... you work the cardiac arrest like any other CPR and THEN give narcan! 

** My second disclaimer for this post... in case it has gotten lost in translation.. I am A HUGE PROPONENT of ALS interventions. I rarely ran a call without cracking a drug box. N/V? Zofran. Back pain? Toradol (at the very least). SOB? DuoNeb. Chest pain? Let's start the FONA. I think you get the picture.** 

If we are so quick to go ALS on some calls... Why don't we go straight for ALS meds when the dude with a kidney stone is in the fetal position? Why don't we all go straight for ALS meds when the lady with the flu can't hold anything down? Why don't we all go straight for ALS meds when our ROSC patient is so unstable? We shouldn't pick and choose when we feel like using our drug box. Protocols are in place for a reason and that person (in theory) called 911 for a reason. Use the tools you have at your disposal... don't be a lazy medic or lazy provider of any type!!!

Okay back to the airway... One last time, say it with me,"BLS before ALS!" Wow, this may be the most ADD thing I have ever written in my life. 

For real, on to intubation. If you're on a call and it seems like you're going to be intubating...get everything ready! 

How many times have you seen someone trying to intubate a patient and COMPLETELY forget to ventilate the patient in the process? They are having a hard time and all of a sudden a minute goes by and then you hear, "oh shoot can someone bag the patient while I get the king?" - While we are on this topic, ALWAYS HAVE YOUR BACK UP PLAN WITHIN ARMS REACH! 

Use the BVM with an NPA and/or OPA (yes you can use both, maybe just don't tell whoever orders your supplies). DO A JAW THRUST/HEAD TILT CHIN LIFT! Look how big of a difference a basic airway maneuver can be! You put the laryngoscope blade in there and go from "uh oh" to "lets go!" (Thank you to @the.prehospitalist on instagram & NEJM Group on YouTube for this video) 

While your partner/coworker is bagging the patient, get EVERYTHING ready and I mean everything! There are two different mnemonics that can be used for Intubation (see them at the end of this blog, "PREPARE" and "STOP MAID") Prepare for whatever might go wrong. Do they have dentures in? (take them out) Broken teeth? (Document) Can you identify landmarks or could it be a difficult intubation? Make sure the suction is near by, have your capnography ready. Recruit some extra hands when possible to make sure that between intubation attempts, your patient is being adequately ventilated. Shoot... if you have people standing around, get two people on BVM duty for a great seal and more consistent RR. You'd be surprised how often the BVM job is given to the "newbie" and they are too fast, too slow, improper seal etc. If you ever have the opportunity to use a feedback device on your monitors, look at the data after a cardiac arrest! The last thing you want to do, if forget to keep ventilating your patient and now all of a sudden the "impending respiratory arrest" is now a cardiac arrest. 

Other tips → The approach to airway management should be in a stepwise fashion. 

As if I haven't said it enough in the last 5 minutes of you reading this, now is when you REALLY want to think BLS → to ALS 

• Basic maneuvers can sustain life until and advanced airway is placed – without these BLS interventions, the patient may deteriorate much more rapidly. 
• Each patient requires different interventions, intubation is not a cookie cutter process - use your judgment to decide which advanced airway intervention is most appropriate for each patient 
• If patient has a trach/stoma - consider using a pediatric mask to maintain seal or connect bvm directly to tube 
• If using a curved blade (maC = Curved = valleCula), place the tip anterior to the epiglottis into the vallecula 
• If using a straight blade (miLLer = long), directly lift the epiglottis with the tip of the blade 
• ETT should be advanced THROUGH the cords until the proximal portion of the balloon is passed beyond the vocal cords (approx 2-3 cm) 
• It is best if passing through the cords can actually be visualized and not a “shot in the dark” but things happen. 
• If you are having a hard time visualizing the cords → Cricoid pressure (if allowed - aka Sellick maneuver) - debatable on whether we should do this or not. 

Okay I am done rambling but enjoy these intubation notes! 

*As always, follow your medical direction and local protocols*