Author Topic: M.O.V.E.!  (Read 9310 times)

James Yeager

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M.O.V.E.!
« on: November 28, 2008, 07:32:40 PM »
NOTE: This article is the property of SWAT magazine and is posted here with their permission. It is copyrighted and may not be copied or used in any way without the permission of SWAT magazine.

M.O.V.E.!

By: James Yeager

Motionless Operators Ventilate Easily (the acronym M.O.V.E.) is one of the phrases we use during our firearms training courses. It comes from our mantra that if you are not behind cover or concealment when the gunfight starts, you should be moving toward it, or at least, moving off the line of attack as quickly as you are able. Firearms training schools spend the majority of their time concentrating on teaching their students to induce trauma and not relieve it (as they should be) but unfortunately many students walk away with the impression that dealing with gunshot wounds isn’t part of the gunman’s responsibilities. It is.

I often ask my students during classes “Is it more important to shoot the bad guy or for you not to be shot?” A few over eager students blurt out “SHOOT THE BAD GUY!” and as they are just finishing with their answer, their brain fully deciphers the question and they have this look of embarrassment on their faces. It is indeed more important to not be shot than it is to shoot the bad guy. But the reality of gun fighting is sometimes we don’t move fast enough, or our partners don’t move fast enough, and a good guy ends up getting wounded.

The current thinking is you first apply self aide to these injuries. The days of shouting “MEDIC!” and somebody running up to you are a thing of the past. Modern medics are riflemen first and medics second. The next level of care is “buddy aide” and this is where after the fight is quelled somewhat your team mate assists you. The third level of care is “Medic Aide” and this occurs only after the most intense part of the battle has subsided. What does this mean to operators? Regardless if you are “Joe Citizen”, a soldier or a cop you will be on your own for a few minutes and you will need the knowledge and skill to assist yourself and or your team mates. In Vietnam , there were an estimated 2,500 deaths that would be survivable with today’s Combat Life Saver training and tactics that Soldiers receive. This change is long overdue.

Critical blood loss, obstructed airway and tension pneumothorax from a perforating chest wound (yes they all suck) are the “big three” injuries that commonly kill operators. Now don’t get worried about all this medical jargon. If a Neanderthal like me can figure this out so can you. As you begin to dig into what it takes to keep someone alive it isn’t very difficult. Keeping them alive for an extended amount of time has its own more complex series of issues but keeping them alive until the ambulance arrives isn’t too tough.

What is the main difference between the medical training in use during Vietnam and now? The application of tourniquets FIRST is the biggest shift in the modern programs. Previously, medics were told that a tourniquet was a “last resort” and only to be used if there was no other option. By the time they tried several unsuccessful attempts to stop bleeding with substandard bandages, the operator bled out. The medics were great but the protocol was terrible.

Individual medical kits (also called blow out kits) have also greatly improved the last few years as well. A “Blow Out” kit is a kit designed to prevent immediate loss of life from a traumatic injury. A “first aid” or “boo-boo” kit is used for minor cuts and scrapes and is useless for life support. The types of first aid kits at your workplace are little more then a headache relief center. Nothing that will save lives is in that metal cabinet on the wall. The two should NEVER be mixed together. You don’t need to dig through Band-Aids and Chapstick to find your life saving tools. Anything that cannot be used to stop the immediate loss of life goes in a different pouch.

There are several kits on the market and many of them are very good but a few are terrible. I will share my thoughts on what should be in a personal trauma kit. We will use a femoral wound from a gunshot through the thigh as an example. This is a very common wound. I think there are some items that should be in every kit and one is a set of gloves to protect you from blood borne pathogens. Since your hands are your best trauma tools you will use them the most. Most likely you won’t put them on to treat a team mate, but when you stop to help someone in a car wreck, wear them. A tourniquet should be in the kit and should be applied immediately.

In the past, there was much misinformation about the use of tourniquets and it still has a stranglehold on stateside emergency medical services. “But he will lose his limb!” is the biggest fallacy that has managed to live until now. The fact is that every day, tourniquets are used for as many as three or four hours on a regular basis for medical procedures. Applying tourniquets first is saving lives in Iraq and Afghanistan and the harsh reality is that if you had the choice between losing a limb or losing your life you would lose the limb. You won’t lose your limb and neither will your buddy. Put the damn tourniquet on and save his life.

The kit also needs some wound packing material like gauze. For deep wounds like a femoral wound from a shot through the thigh you need something to pack in the hole so pressure can be applied to the artery from the topside via bandaging. You can use just about anything but something relatively porous with a lot of surface area like gauze works best. After that wound is packed you need to put on a bandage. My personal favorite is the “H-Bandage” which is an absorbent pad sewn onto a elastic bandage. It has a heavy duty “H” shaped anchor in which to wind the elastic around for a super compression. The H-Bandage applies pressure all the way around the leg but now it is pushing on the gauze which is pressing on the artery. Hopefully the combination of the tourniquet and the H-Bandage has stemmed the blood flow.

What is “critical blood loss”? You can take many things to a gunfight like more guns and more ammo but taking more blood with you isn’t feasible. All the blood you have in you right now is all the blood you have. On average we have six quarts of the oxygen carrying fluid in our bodies. We “lose” a pint when we give at the Red Cross and that isn’t a very big deal. As a matter of fact, we can lose an entire quart and still be in pretty good shape. The serious problems begin to occur when we lose more than a quart and when two quarts of the hydraulic fluid leaks out of us, we have most likely lost consciousness. When we lose three quarts of blood or more, we expire.

You cannot swallow your tongue but an obstructed airway can be caused by the muscles at the back of the tongue relaxing and blocking the airway. This is most common with unconscious people lying on their back. The simplest way to solve this is to roll them onto their side and allow gravity to do the work of moving that muscle. A good kit will have an airway. They come in two flavors either nasal or oral. The nasal type are preferred because they are less likely to cause a gag reflex on a semi-conscious patient and since one size will fit the vast majority of people there is no need to carry several different sizes as with the oral type. Safety pins are useful for this as well and even though it is bloody as hell you can pin their tongue to their bottom lip to keep the airway open.

Tension Pneumothorax is the accumulation of air under pressure in the pleural space. The pleural space is the area between your chest wall and your lung. When a bullet enters the chest it makes a “valve” so to speak with the damaged tissues. When you breathe in the valve opens and lets air in but when you breathe out it closes and traps the air. An early warning sign is that your team mate will be telling you he cannot breathe deeply. As the pleural space fills with air, the lung will collapse. No big deal because you can breathe with one lung but the real problem is the pressurized air is now squeezing the heart and if a little more pressure accumulates, the heart won’t be able to pump against it and your buddy will die.

A very late warning sign for Tension Pneumothorax is tracheal deviation. You will see the trachea pushed to the opposite side of the body as the wound. Something must be done immediately and that something is putting a big catheter in the space between the second and third rib known as the “second intercostal space”. Inserting that 14ga needle just above the third rib will most likely provide immediate results and you might even hear air hissing out of it. Be aware some companies won’t put a needle in their kit. Don’t buy that kit.

That brings me to my next point. If you cannot be trusted to carry a needle you need to turn in your gun. We all know they both require training and reading this article won’t meet that requirement. I love it when I am told I shouldn’t talk about catheters and chest decompression because of “liability”. Reality Check: I teach good people to kill bad people and anything else I do carries less liability with it. I have opened up a can of worms with this article and hopefully motivated you to seriously consider some medical training as tactical training if it makes it easier to swallow.

Get some medical training. Even a simple Red Cross first aid class is better than nothing. There are plenty of places doing two day gunshot or immediate action medical classes, so do some research and pick the right one. Take this issue seriously and get yourself into a class. You can get plenty of free info about battlefield medicine at http://www.GetOffTheX.com.

I carry two trauma kits daily. One is for inducing trauma and one is for relieving it. Every soldier, cop, civilian contractor, and armed citizen needs to have to the skill and the tools to save lives along with the ones to take lives. You will find more opportunities to be a hero from saving a life than taking one so put some training and gear for dealing with a medical emergency on your wish list…and don’t forget M.O.V.E.!

The Tactical Response Gear Ventilated Operator Kit – V.O.K.

Tactical Response Gear is proud to offer the most complete and cost effective personal trauma kit available the “Ventilated Operator Kit”. Each V.O.K. includes a Cinch Tight Compression "H" Bandage, a rugged combat tourniquet, gauze, a nasal airway, Surgilube, a 14ga catheter, two safety pins, 2”x100” roll of duct tape, and a set of exam gloves. It will easily fit in your glove box, BDU pocket, backpack, or range bag so buy a few and place them strategically around your car, home, workplace, and on your person.

Medical kits are avalable at http://www.TacticalResponseGear.com along with books and videos to help you along.

Offline flagtag

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Re: M.O.V.E.!
« Reply #1 on: November 28, 2008, 09:31:48 PM »
Great article! Very informative.  I went to the site via the link and was impressed with the content.  I added it to my favorites for future referance.

Thanks for posting this. 

James Yeager

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Re: M.O.V.E.!
« Reply #2 on: November 28, 2008, 09:35:34 PM »
Thanks for reading!

Offline Taylor3006

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Re: M.O.V.E.!
« Reply #3 on: November 29, 2008, 09:01:48 PM »
"You cannot swallow your tongue but an obstructed airway can be caused by the muscles at the back of the tongue relaxing and blocking the airway. This is most common with unconscious people lying on their back. "

You forgot to mention that this is most common with heavyset people. Rarely seen in people who are thin or trim. I am not so sure about turning a person for most untrained people. Everything of course depends on the situation and the injury. Simply tilting the neck or doing a "jaw thrust" works everytime and for those with spinal or head injuries, could be the difference between being a quad or not. As far as the reducing a pneumothorax, for the love of God leave that to professionals. If professional care is within 30 minutes, by all means just transport. You can not imagine what damage a 14 gauge needle  can do to the blood vessels, heck look at the tip of the needle. They are not just pointed sharp, they are RAZOR sharp to help insertion and wiggling them even just a bit can shred tissue. Any pneumothorax is a true emergency most especially a tension as it puts pressure on the heart. For the average first aid worker or even basic EMT, CPR (if indicated) is the treatment of choice. For ACLS people then by all means, decompress. For all you that think that a collapsed lung is the kiss of death, I had a spontaneous pnemo of my right lung. I "heard/felt" it and knew right away what had happened. I was uncomfortable but not terribly so and finished my shift, took off 12 hours and worked again another 12 hours before my lips started turning blue (an indication my air exchange was poor) and a slight deviated trachea. The lung had collapsed entirely and required a chest tube, a treatment that I received over 48 hours after the initial problem. Again pnemos are all true emergencies and especially a tension pnemo however most traumatic pnemos or spontaneous ones can be left untreated in the field when medical care is fairly closeby.   Personally I would equate this skill equivalent to doing a tracheotomy or intubation. Lots of training required.

Nasal Airways are great if you have the right length ones, personally I keep an old EOA in my kit. Not sure they still used them but easy to place and they prevent getting lots of air into the stomach (when used correctly).

I had to laugh when I saw pinning the tongue to the lip, great idea but I could just imagine the look on the ER's peoples faces when they saw that! In my stint as a corpsman I never saw a single time that a simple jawthrust or proper alignment of airway didn't work, even on the heaviest people. HOWEVER I never had to deal with big time trauma to the soft tissues of the neck either, I imagine that could be probably in a battlefield environment and turning would not only help position the airway, it would allow blood to drain out instead of into the airways. I would try simpler first as a rule.

BTW a really great article with lots of information and insight. I truly enjoyed reading it even when I flinched at the idea of non medical people performing a needle thoracostomy. Your information is spot on and I even learned about a new bandage I wasn't aware of (the H-bandage). In my experience Surgipads with Kerlex or battle dressings usually work out pretty well if you use an inflatable splint, bp cuff, or MAST pants over them for pressure to avoid a tourniquet. We knew as far back as Desert Storm that tourniquets were not really a last resort if transport was readily available but it was something the doctors filled you in about, because of the advances in vascular surgery. Anyways great article, thanks for sharing it James!

Offline 19kilo

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Re: M.O.V.E.!
« Reply #4 on: December 02, 2008, 03:01:04 AM »
I've sen tension pneumo's relieved in the E.D.  And we are taught it in school. (respiratory)  Of course we will never use it in a hospital setting.

Tension pneumos are pretty serious and require immediate attention or the Pt. will die.  That whole tracheal deviation is the sign that the heart is getting compressed and Circulation is getting compromised.

While I would still call 911.  Their could be a time when you can't

Mid clavicle 2 inter costal.   I have never just heard air like in my three kings.  But Blood coming out.  Once an IV that had been running for a half hour.

James Yeager

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Re: M.O.V.E.!
« Reply #5 on: December 02, 2008, 09:17:20 AM »
Taylor3006,

I simply wrote the article to raise awareness for "shooters" who think medicine is only a medic's job. We know it isn't! It is just that an article cannot contain all things and that I had to speak in general terms. Not even a book or volume of books could contain all the info we know about trauma care.

 Yes pinning the tongue and lip might get you some stares but it IS effective.  Jaw thrusts do work well...in the ER. This type of medicine, for an austere location, doesn't lend itself well to traditional protocols. This article is also limited in scope only talking about gunshot wounds. High velocity motor vehicle accidents are another kettle of fish.

 Your spontaneous pneumo (I guess you are tall and thin) is a total different animal than Tension Pneumothorax and folks reading your response may feel that Tension is no big deal. It is. I do think people need training and I do not advocate people read and article and begin doing chest decompressions but what if "leaving it for the professionals" means somebody dies?

 I can write article all day long on shooting and killing people and nobody bats an eye but when I write one about saving a life... People with Tension Pneumothorax die NOW. People need to understand the seriousness and get training.  I can show somebody how to do a Tracheotomy is 60 seconds or less. Keeping somebody alive until they get to definitive healthcare in a perfect world is easy. Keeping them alive longer means we have to talk about some formerly taboo issues.

We put size 28 to 30 Nasopharyngeal Airways (NPAs) in our kits and they work with all but some small children. Also included with the NPA is some water based lubricant to ease insertion. Blood or saliva will work as well. Cutting the NPA is not necessary if you tape the trumpet in place (you should anyway) or poke a safety pin through the tube to limit its depth. Both of these options can be performed after the airway is established and the patient is breathing. Cutting, taping and needling were just beyond the scope of the short article.

We have two and five day medical classes that get a lot of good reviews. The loudest of which come from Paramedics and ER docs that are amazed at what we accomplish in such a short time. Let me know if you are ever interested.

Offline 19kilo

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Re: M.O.V.E.!
« Reply #6 on: December 02, 2008, 01:43:25 PM »
Have you ever used the safety pin through tongue?   

Working in an E.D. I seen some crazy things.  But for some reason that just creeps me out.

You could not be more right about the tension pneumothorax though.  People die very quickly with these.  And they recover the same when treated with a relatively easy needle decompression.

What is your training BTW?

James Yeager

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Re: M.O.V.E.!
« Reply #7 on: December 02, 2008, 03:17:52 PM »
19kilo,

I haven't personally done the lip/tongue/safety pin but I have seen it done. Bloody as hell but effective.

When you ask "What is your training?" are you asking what does my company provide or my personal training history?

Offline 19kilo

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Re: M.O.V.E.!
« Reply #8 on: December 02, 2008, 05:50:30 PM »
19kilo,

I haven't personally done the lip/tongue/safety pin but I have seen it done. Bloody as hell but effective.

When you ask "What is your training?" are you asking what does my company provide or my personal training history?

Like EMT b paramedic,  nurse, MD.  That sort of thing.

I am a Respiratory therapist.  So while I don't get to do much of the trauma and "cool" stuff.  We are at the head of the bed and get to watch a lot of it.

James Yeager

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Re: M.O.V.E.!
« Reply #9 on: December 02, 2008, 07:39:46 PM »
 The only nationally recognized "paper" certifications I have is First Responder and Combat Lifesaver. Having said that I have had hundreds and hundreds of hours of training in combat trauma care by the best in the business. I have also been in combat and have had team mates killed and injured and have assisted in thier treatment. I am short on credintials but long on field experince and motivation to learn this craft.

Here is the bio from my website: http://www.tacticalresponse.com/d/node/160

I hope I have answered your questions.

Offline Taylor3006

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Re: M.O.V.E.!
« Reply #10 on: December 02, 2008, 07:42:24 PM »
" Jaw thrusts do work well...in the ER. This type of medicine, for an austere location, doesn't lend itself well to traditional protocols. This article is also limited in scope only talking about gunshot wounds. High velocity motor vehicle accidents are another kettle of fish."

I suppose, never tried it in the ER, I ran meat wagons for 6 years and worked in the field. Never had any problem with it on the sides of roads, decks of ships, or in the field. Had a few weird situations with car accidents (rollovers where the patient is upside down in the restraint) where it only worked while I kept my hands in place while the firemen were cutting the vehicle open and another where the car was partially submerged in water and the patient was slumped sideways in the water. Stuff like that tends to cause a bit of problems, but nothing that figured out. I was only a corpsman though, working in the field was always a bit austere but never where we couldn't get medevacs or a vehicle out to the patient. You must work in some really rugged terrain. I agree that tension pnemos are true emergencies, think I said it a couple of times and require immediate medical care by trained medics (whatever their stripe). As I explained if medical care is fairly close by or at hand, I would not ever suggest that someone who has read an article in a book (or internet) and with no advanced training (this goes way beyond basic first aid) start poking people in the chest with a needle. That was my point. Nothing more, nothing less. And yes am tall and thin, my body type tends towards spontaneous pnemo. Got a VATS done on both the ol airbags so shouldn't ever happen again. Anyways as I said, good and interesting article.

19kilo I agree, was trained and practiced doing needle decompress but never had the opportunity. Got to play with some chest tube insertions many times though in the ER, if ya got blood ya got a hemo pnemo, air ya just got a pnemo.

I still think the safety pin thru the tongue and lip is funny, wouldn't want to do it to a patient unless their tongue and lip were already pierced though. Well maybe if they were annoying I would, ya know the kind that gets all combative in the back of an ambulance so ya give them a few smacks with a bag of NSS.

James Yeager

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Re: M.O.V.E.!
« Reply #11 on: December 02, 2008, 07:47:38 PM »
Guys - I didn't come here to start a turf war. I merely posted that article to motivate people who have never considered trauma care to think about it.  I just wanted to take away some of the mystery and encourage folks to get some training.

Offline flagtag

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Re: M.O.V.E.!
« Reply #12 on: December 02, 2008, 09:17:36 PM »
If it wasn't so expensive, I would love to get into it.  I did check into EMT, but it was too expensive and the classes were too far away. (We don't even have Advanced First Aid classes around here any more.  :( )

James Yeager

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Re: M.O.V.E.!
« Reply #13 on: December 02, 2008, 09:43:21 PM »
I don't know where you live but there are a lot of classes around the country that take all of the stuff you don't need out and compress in what you do need.

Offline 19kilo

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Re: M.O.V.E.!
« Reply #14 on: December 02, 2008, 10:15:05 PM »
If it wasn't so expensive, I would love to get into it.  I did check into EMT, but it was too expensive and the classes were too far away. (We don't even have Advanced First Aid classes around here any more.  :( )

I think that if you have a volunteer fire department in you area, you can learn a lot of stuff.  I could be wrong but I think some pay for EMT training.

I would love to do it, but I'm working two jobs already.

Offline flagtag

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Re: M.O.V.E.!
« Reply #15 on: December 02, 2008, 10:23:09 PM »
Around here, in order to become an EMT, we would have to start with the Advanced First Aid class before we could move on to the higher courses. And as I said, the classes are no longer available at the community college.  I would have to travel approx. 40 mi. , and the cost of the course (EMT) is over $200.oo.
Since I am a single white female with no minor dependants, I couldn't get a grant. (At the CC, the minimum hr. requirement for a grant is 12 credit hours.

I work only part-time now, so time really isn't a problem. Travel and money are.
Yes, we do have to pay for EMT courses ourselves.  (But, like I said, the first aid has to come first - that's besides the cost of the EMT course.)

Offline Taylor3006

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Re: M.O.V.E.!
« Reply #16 on: December 02, 2008, 10:43:44 PM »
Around here, in order to become an EMT, we would have to start with the Advanced First Aid class before we could move on to the higher courses. And as I said, the classes are no longer available at the community college.  I would have to travel approx. 40 mi. , and the cost of the course (EMT) is over $200.oo.
Since I am a single white female with no minor dependants, I couldn't get a grant. (At the CC, the minimum hr. requirement for a grant is 12 credit hours.

I work only part-time now, so time really isn't a problem. Travel and money are.
Yes, we do have to pay for EMT courses ourselves.  (But, like I said, the first aid has to come first - that's besides the cost of the EMT course.)

You are single, no dependents, and you have free time.. Have you thought about joining up with the reserves or the guard? You get paid during training and when you are done, you give them a weekend a month and then a two week stretch. I know the whole war thing is a bummer for most, but if you go Coast Guard, Air Force, or Navy, you are pretty safe from people shooting at you. You can get all sorts of training even when you are not on duty status. I did over 1400 hours of home study couses and they offer courses on almost everything you can imagine. They are free, you get to keep the course materials and some colleges give credits for the courses. The reserves also help you with your college costs as well and as a vet you have access to lots of programs. Anyways not a recruiter or anything, just read your post and was the first thing I thought of.

Offline 19kilo

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Re: M.O.V.E.!
« Reply #17 on: December 02, 2008, 10:57:19 PM »
Guys - I didn't come here to start a turf war. I merely posted that article to motivate people who have never considered trauma care to think about it.  I just wanted to take away some of the mystery and encourage folks to get some training.

I haven't taken in that kind way at all. These is a place for a free exchange of ideas.

I just think that if a person can't maintain an their airway because of their tongue, then they are more than likely unconscious.  In that case an oral airway would be a good idea. 

Thank you for your service and we welcome you to the forums.

Will

Offline flagtag

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Re: M.O.V.E.!
« Reply #18 on: December 03, 2008, 09:07:14 AM »
Around here, in order to become an EMT, we would have to start with the Advanced First Aid class before we could move on to the higher courses. And as I said, the classes are no longer available at the community college.  I would have to travel approx. 40 mi. , and the cost of the course (EMT) is over $200.oo.
Since I am a single white female with no minor dependants, I couldn't get a grant. (At the CC, the minimum hr. requirement for a grant is 12 credit hours.

I work only part-time now, so time really isn't a problem. Travel and money are.
Yes, we do have to pay for EMT courses ourselves.  (But, like I said, the first aid has to come first - that's besides the cost of the EMT course.)

You are single, no dependents, and you have free time.. Have you thought about joining up with the reserves or the guard? You get paid during training and when you are done, you give them a weekend a month and then a two week stretch. I know the whole war thing is a bummer for most, but if you go Coast Guard, Air Force, or Navy, you are pretty safe from people shooting at you. You can get all sorts of training even when you are not on duty status. I did over 1400 hours of home study couses and they offer courses on almost everything you can imagine. They are free, you get to keep the course materials and some colleges give credits for the courses. The reserves also help you with your college costs as well and as a vet you have access to lots of programs. Anyways not a recruiter or anything, just read your post and was the first thing I thought of.

Might have been able to 30 years ago.  I'm 58 (soon to be 59) and grossly out of shape.   :o I don't think they are that desperate!   ;D

James Yeager

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Re: M.O.V.E.!
« Reply #19 on: December 03, 2008, 01:09:13 PM »

I just think that if a person can't maintain an their airway because of their tongue, then they are more than likely unconscious.  In that case an oral airway would be a good idea. 


You are correct; an oral airway is better. The reason I sugest the nasal type is that is is easier to put in place, there is no need to carry multiple sizes, and it is less likely to cause a gag reflex in patients that are in and out of consciousness.

Thank you for the welcome.