JEMS article regarding Medics and intubation

[txffemtp]

http://www.jems.com/news_and_articles/arti...s_analysis.html

So I know that there are a bunch of doctors out there who don't want EMS to be able to intubate anymore, but is this really needed? When we have our own folks saying we cant intubate or shouldnt have certain drugs, it takes the whole profession down. I mean no MD is going to give there medics the ability to use other drugs except sux. For a medic to say anything else is stupid and just gives the docs an excuse to take the paralytics away alltogether. I dont get it.

[Dustdevil]

I don't quite get what you are saying or asking.

Can you break it down for me?

[flight-lp]

http://www.jems.com/news_and_articles/arti...s_analysis.html

So I know that there are a bunch of doctors out there who don't want EMS to be able to intubate anymore, but is this really needed? When we have our own folks saying we cant intubate or shouldnt have certain drugs, it takes the whole profession down. I mean no MD is going to give there medics the ability to use other drugs except sux. For a medic to say anything else is stupid and just gives the docs an excuse to take the paralytics away alltogether. I dont get it.

Dust - Allow me please, I speak this dialect of Texlish......................

txffemtp.........

Yea, it is really needed......................

This isn't what takes the profession down. What brings us down is the incompetence of Medics who have no clue as to what they are doing. Even in the cited example, the contraindications to Anectine were screaming out in the patient's history. As these occurances are not a rarity, yes closer scrutiny needs to be in place before giving a medic drugs that can effectively end human life.

You are dead wrong in your statement that "no MD is going to give there medics the ability to use other drugs except sux". I don't know where you got your research on that one. Many services carry both a depolarizing and non-depolorizing NMBA, along with a variety of analgesics and sedatives.

In the case where Anectine is all that you have and you know that is is contraindicated you still have several options. You can perform a blind nasotracheal intubation or you can simply bag them. As long as they are ventilating well, a BVM properly used will suffice. It may not be the most optimal situation, but its a lot better than hyperkalemia! Not to mention it allows you to deliver your pt. well oxygenated and ventilated properly which in my experience is usually a great thing!

If you don't grasp this concept or "get it", then your paralytics probably should be taken away. Although, I guess what I say is just stupid, huh????

[emtannie]

http://www.jems.com/news_and_articles/arti...s_analysis.html

So I know that there are a bunch of doctors out there who don't want EMS to be able to intubate anymore, but is this really needed? When we have our own folks saying we cant intubate or shouldnt have certain drugs, it takes the whole profession down. I mean no MD is going to give there medics the ability to use other drugs except sux. For a medic to say anything else is stupid and just gives the docs an excuse to take the paralytics away alltogether. I dont get it.

I read this article, and didn't get the same impression that I think you did.... and please correct me if I misunderstand you... It appears to me that you are taking the stance that MD's don't want medics to intubate anymore, and that is limiting our abilities in the field.

I don't think that is what the article is saying. It is saying that EDUCATION is the key - handing a medic paralytics without the proper education is like handing a 16 year old the keys to a Ferrari.... it has the potential to be disastrous.

For EMS to be considered professional, we have to take the initiative. We have to provide our members with quality education, and those members have to perform to a high standard. We have to be able to explain when and why we would use a medication, the indications and contraindications, and the possible side effects. We have to be able to perform the necessary interventions. In too many cases, medics are given the medication and allowed go to out and use it without being able to prove they have the educational background not to get in over their head. This leads to EMS errors which then make us look unprofessional.

Docs aren't trying to take meds away from us just because they are "higher up the food chain." We have to be able to prove we can handle the responsibility.

[mediccjh]

OK, I need to rant.

I am farking sick and tired of all these doctors saying that Paramedics shouldn't be allowed to intubate. Well, isn't it hard to finesse our work if we aren't taught correctly?!!!

I've been a medic for 7 years, and I've only been unable to intubate 6 patients (1 was last night, because she was clenched). I intubated 26 patients last year, most of them on the first attempt, and I'm up to 12 so far this year.

[/rant]

[p3medic]

You are the exception. Look around the country, most medics don't get that number of tubes, hell, some get none! Look at the fire systems with a medic on every piece, LA and San Diego come to mind. They have so many medics that despite the call volume, the chances of intubating are low. In the infamous SD RSI in TBI trial, the average number of intubations per medic was a whopping 2 a year! How does anyone stay proficient at intubation with those numbers? OR time for tubes would be great, but in a system with 2,000 paramedics its damn near impossible. I think what you will start seeing is fewer systems intubating unless they can prove with hard data that they are proficient and patient outcomes are improved. If not, get used to the King, LMA, combitube or supraglottic airway of choice.

[fireflymedic]

Excuse me if I'm wrong, but nowhere in that article did I see them say docs are trying to take intubation away from us. Instead, I think they are addressing the importance of an issue which I discussed in a previous thread (be a kind medic) about the utilization of RSI and proper training and skill associated with it. I'm all in agreement with the author that the majority of services which have RSI protocols really don't need them. It is the new cool toy that everybody wants, but they don't want all the training and responsibility that goes along with it. That is nothing more than a recipe for disaster. I think if you can't do the con ed be it OR time or training on a sim man or als simulator to get the required intubations, plus a reasonable field number, then I think the service seriously needs to consider whether the procedure is warranted. It's just like any other skill - you don't use it, you lose it and I'm sorry but paralyzing and sedating and possibly not having and airway or not sedating someone is a problem I'm seeing frequently with service who don't have the call volume of serious patients to warrant it. The few I'm aware of that do have respectable training requirements in place to prevent this occurence.

As far as what is carried within the drug box, ideally you should have a mixture of both types of paralytics and a myriad of sedation or induction choices. This one drug fits all mentality doesn't cut it with me. Each medic that performs the procedure should have demonstrated proficiency in the skill preferably before the med director before being allowed to practice on patients. It's not a matter of our own sitting there saying we need to take it away, but rather increase the training to maintain the skill. Frankly, if they aren't adequate in the skill, I don't want them doing it on me or my patients and would rather it be taken away and them forced to use an alternative airway or bag rather than causing harm. Just my two cents - keep the change.

[VentMedic]

OK, I need to rant.

I am farking sick and tired of all these doctors saying that Paramedics shouldn't be allowed to intubate. Well, isn't it hard to finesse our work if we aren't taught correctly?!!!

Last time I checked Paramedics still work under a doctor's license.

The doctors may not have any say when the FD chief says all FFs will be a Paramedic (easily done through a contracted medic mill) and all engines will be ALS.

The doctors also have no control over the initial paramedic education which can be a 3 month medic mill with coffee clinicals on an ALS engine. For those, it would take extensive training to get them up to par with a medic who actually got a decent education. Then, the chances of these individuals, who may have looked for an easy Paramedic program over one that might have involved a couple of prerequisites like A&P or Pharmacology, having much desire to advance or maintain skills/knowledge are very slim. That is unless it is handed to them in neat little note cards.

There are also some Paramedics that have gone to CCT and have virtually no chance of getting an intubation or IV since the hospitals may have the patient nicely packaged for transport. In some areas, the Paramedic, due to limitations in scope (state or county), can only look but not touch the IV pumps with the meds already calculated and started for the transport.

I'm up to 12 so far this year.

It is now mid October. That is only about 1 a month. Other professionals who intubate regularly may be pulled from the frontline until they got caught up with a preceptor.

[HellsBells]

This is a very timely article for me to be reading. One of our instructors was just commenting on the fact that we have to be very careful giving "sukks" when there is a possibility for hyperkalemia.

What I find interesting about this article, is the first case study in regards to a doc giving the drug the drug that killed the patient. Giving RSI meds is a very invasive procedure, if a doctor (with much more training and education then a paramedic) can make such a critical error, its absolutely mandatory that we, as prehospital care providers obtain the skill and knowledge to administer paralytics properly. This is not about a cool skill, or feeling good about ourselves for "getting the tube," its about ensuring we do our best to get the patient out of the hospital alive.

[Ridryder 911]

You are the exception. Look around the country, most medics don't get that number of tubes, hell, some get none! Look at the fire systems with a medic on every piece, LA and San Diego come to mind. They have so many medics that despite the call volume, the chances of intubating are low. In the infamous SD RSI in TBI trial, the average number of intubations per medic was a whopping 2 a year! How does anyone stay proficient at intubation with those numbers? OR time for tubes would be great, but in a system with 2,000 paramedics its damn near impossible. I think what you will start seeing is fewer systems intubating unless they can prove with hard data that they are proficient and patient outcomes are improved. If not, get used to the King, LMA, combitube or supraglottic airway of choice.

Again, they are not addressing the problems. Why do away with a proven effective procedure because the system is broke? Would we do away with I.M. injections in clinics because many physicians refuse to hire qualified personal?..no. Paramedics can't intubate, then who's fault is it really?

Instead of throwing the baby out with the bathwater, how about correcting the problem? Naw.. that would make sense.

If the physicians are really and truly worried about the problem become involved! Require a true educational system, don't allow but so many to work under your license. You have the power but don't remove a procedure when performed by qualified personal and proven to prevent deaths because it is much easier to do so.

So I turn this back to them.... don't like the outcome, then change the reason why, but don't change the correct treatment and procedures to do so!

R/r 911