JEMS article regarding Medics and intubation

[p3medic]

I actually agree with you Rid, the problem is the physicians are not addressing the problem, so unless you can show that it benefits your patient population it is going to dissapear. The systems that believe it is important address training, QA/QI by maintaining records of all intubations, what meds were used, complications, number of attempts, underlying pathology, and outcome.

Look at the fire service in California for example. In the large urban areas fire sends numerous medics to every call on fire engines and sometimes ambulances. The doctors have no control over this. They do have control to some extent as to what they will allow under their license. It would be damn near impossible to get all those medics off their trucks to mandatory rounds, OR time, etc...without resistance from the union and the chiefs. What can the doctor do? Don't allow a skill that can be more harm than good in the hands of a poorly trained medic.

I am all for con-ed, with active involvement from the physicians, this shouldn't be optional but required! Those systems who can't or refuse to participate shouldn't be intubating, with or without drugs.

[Just Plain Ruff]

let's take this example

you are a medical director. Your medics under you have a intubation success rate of 45-55 percent and a 30 % success rate on RSI.

How do you justify allowing them to intubate patients with success rates like that.

I know of a medic out there who has a success rate of 25% for intubations. Do you honestly as amedical director want him tubing someone?

[Ridryder 911]

let's take this example

you are a medical director. Your medics under you have a intubation success rate of 45-55 percent and a 30 % success rate on RSI.

How do you justify allowing them to intubate patients with success rates like that.

I know of a medic out there who has a success rate of 25% for intubations. Do you honestly as amedical director want him tubing someone?

No, neither would I bless or allow them to work under my license. Period. Again, Medical Directors can and should pull a lot of weight. I honor those that are truly involved and do participate as they should.

What many of the Medical Directors do not recognize is, that they can be the screening process. Who is to say whom becomes a functional Paramedic?.. You do! Will it be the EMS service or the one that has the license they will operating under? Many may say ... "the service is too large to control"; is it really? NO!

All one has to do is look at the statistics in the QI program. If there is not one then as a physician demand one! Again, it is your license! Demand better education and more in-depth training and reviewing at the service. Guess what you also control the purse strings! You will get what you want or reduce their provider level.. you will get their attention!

Be pro for better and quality care, but NEVER compromise patient care! This also means removing proven procedures that increases survivability!

If you do not like the care then DEMAND a change! You are the one that really is in charge. Do some house cleaning. They may have the license/certificate/patch but that DOES NOT mean they will get to operate in that capacity.. only you can really determine that!

Most EMS medical directors are poorly educated and trained as such. Majority have never attended a formal EMS Medical Directors Course. Again, whose fault is this?

Fix the problem or be part of the problem, the choice is yours!

R/r 911

[Dustdevil]

I have to disagree that this is the physicians' problem to address. We are the ones that FAIL. It is our problem to address. The physicians are addressing it in the only way they can, which is to "just say no" until we get our act together. And getting our act together is our responsibility, and ours alone. We have to self-regulate. We have to be the ones to decide it is time to stand up and elevate our game educationally. We don't get no respect from doctors? Boo f'ing hoo! I don't respect paramedics either, and I'm no doctor. Yet any attempt to even elevate our basic entry level is opposed fiercely by three-quarters of our ranks. Attempts to elevate our advanced level is opposed by two-thirds or more.

The physicians are not the enemy. I have seen the enemy, and it is us.

[Ridryder 911]

I have to disagree that this is the physicians' problem to address. We are the ones that FAIL. It is our problem to address. The physicians are addressing it in the only way they can, which is to "just say no" until we get our act together. And getting our act together is our responsibility, and ours alone. We have to self-regulate. We have to be the ones to decide it is time to stand up and elevate our game educationally. We don't get no respect from doctors? Boo f'ing hoo! I don't respect paramedics either, and I'm no doctor. Yet any attempt to even elevate our basic entry level is opposed fiercely by three-quarters of our ranks. Attempts to elevate our advanced level is opposed by two-thirds or more.

The physicians are not the enemy. I have seen the enemy, and it is us.

I don't think their the enemy, yet they have not taken the proper actions as well. I definitely agree we are lacking on our part, yet this does not exempt them either just because they are physicians. If you want to assume the role tof medical control then be active and assume the responsibilities seriously. Make sure that your standards are carried out. Again, just you are a Doc does not exempt you not becoming qualified as a medical director and actively participating within the service (controlling whom can function or not). Again, instead of worrying about removing one procedure, I would worry about the total care that may or may not be provided.

I do agree, we should get our act together as well. We should never recommend to physicians idiots that cannot pass tests, perform quality care. Again, alike you described it is as much as of our responsibility. We have became so relaxed in whom, what is produced and still can operate as a Paramedic it is a wonder more procedures are not removed.

Time we start cleaning up our own profession.. anyone got a big broom?

R/r 911

[Just Plain Ruff]

There are several lines of defense

1. your partner - they have a mandate to report your screwups. I have reported enough of my own partners - if it endangered the life or hurt the patient then you have to report it.

2. QI/QA - review every run no matter how simple. I read a report on a cardiac arrest that was 9 sentences long. 9 sentences long. It got flagged and resulted in remediation of the medic.

3. The sup's - they are the next line of defense

4. Medical direction oversite - if a medical director isn't keeping tabs on his people then he should be.

[HellsBells]

Look at the fire service in California for example. In the large urban areas fire sends numerous medics to every call on fire engines and sometimes ambulances. The doctors have no control over this. They do have control to some extent as to what they will allow under their license. It would be damn near impossible to get all those medics off their trucks to mandatory rounds, OR time, etc...without resistance from the union and the chiefs. What can the doctor do? Don't allow a skill that can be more harm than good in the hands of a poorly trained medic.

Hmmm, a good start would be getting paramedics off the firetrucks.

[fiznat]

Couple things:

1. One thing that hasn't been mentioned much here is that the actual clinical value of prehospital intubation is in and of itself questionable. Adding RSI to increase the amount of intubated patients might seem like a valuable endeavor if intubation in fact did our patients some good. There are studies out there that say the opposite, though. It isn't a small percentage of patients in which prehospital intubation does HARM rather than good. I understand (believe me, I'm a paramedic too and I REALLY understand) that intubation is seen as a key ALS skill, but how much of this is based in pride instead of actual patient care? More is not always more.

2. In regards to increasing skill and identifying errors. This may be more specific to my service but here all paramedics work with EMT-B partners. I've been "cut loose" on my own as a medic for just about 2 years now and I have worked alongside another paramedic once. I've met up with other medics on scene before, yeah, but in general I never assess and develop a clinical plan in concert with another ALS provider. It just doesn't happen. I feel like that is a problem. I don't advocate double-medic ambulances because I think that decreases self-reliance of individual medics, but I think we need opportunities to see how other providers do things- to watch and learn, maybe pick up a few things and identify our own errors.

[chbare]

One thing that hasn't been mentioned much here is that the actual clinical value of prehospital intubation is in and of itself questionable.dding RSI to increase the amount of intubated patients might seem like a valuable endeavor if intubation in fact did our patients some good. There are studies out there that say the opposite, though. It isn't a small percentage of patients in which prehospital intubation does HARM rather than good. I understand (believe me, I'm a paramedic too and I REALLY understand) that intubation is seen as a key ALS skill, but how much of this is based in pride instead of actual patient care? More is not always more.

Perhaps the crux of this conversation and a concept that some people simply cannot grasp. How many people do we need to RSI? Do most patients benefit from this procedure? What about intubation without induction and paralysis? Not mush evidence points to definitive benefit for intubating people in cardiac arrest. Funny, I can count the number of RSI's I have performed in the field on one hand. In fact, nearly all of my intubations have been in the hospital. Like Vent stated, most of the patient's I have flown were intubated prior to arrival.

With that, there will always be a small number of patients who really will require invasive airway management modalities.

Take care,

chbare.

[Just Plain Ruff]

[quote="

With that, there will always be a small number of patients who really will require invasive airway management modalities.