JEMS article regarding Medics and intubation

[fiznat]

I don't think paramedics are allowed to do what they do based on a prediction of how many times they might need to perform that procedure. I have a surgical airway kit in my truck, and I've never used it. I may use it once in 10 years or less, who knows. I still need to have that kit in my gear because the value of performing that procedure outweighs the potential negatives of not having it available. I'm not so sure that the same can be said for RSI, and perhaps (gasp!) even intubation. THAT is the reason why docs are hesitant about these procedures, and for no other reason.

[Ridryder 911]

If we were to base our procedures upon the number of times or if needed, then ER physicians would only have to go through a year of school. How many times do you see pericardiocentesis, crich'ss, trach.'s performed in ER by the ER Doc? Yet, we still allow and want them to be able to perform if needed. See the correlation? How proficient do you think that ER Doc is in performing some of those procedures they have not used in 15 years? Not being able goes back to poor education and follow up of proficiency. Yanking the procedures because there was poor rates is foolish. It is not the procedures that is wrong, rather the individuals performing them that is poor.

Sorry, I have worked in rural areas where the nearest trauma center was 2 hours flying time. Does one not think that maybe RSI might be nice in the head injury patients with clenched jaws? Stop at the ER and have a P.A. attempt RSI?... Yeah, they intubated a whopping five times in their life.

Yes, we definitely need to police ourselves. Enforce true education in and on every procedure we perform, ensure safety and the person is qualified and is able to perform correctly. Just wished they made others as responsible too (including physicians).

R/r 911

[fiznat]

I would be interested to know what various services do to promote skill retention.

We don't do much here. Every year we are required to go to "skills review" sessions in order to maintain our medical control, which basically covers airway (intubation, surg, rescue airways), ACLS megacode, peds, IO/IV, and a BLS station (usually KED/backboard/Traction). It is all on dummies and takes about 3 hours total. (We also have CME hour requirements but these arent necessarily skill-specific)

How many of you guys actually get the opportunity to go to cadaver labs, or to the OR to practice your airways? We've asked our medcon about it, but we are a large group of medics competing with Med students/interns/residents for these tubes and it almost never happens.

[p3medic]

The prehospital intubation data showing worse outcomes have come from systems that don't intubate much. San Diego medics average 2 tubes a year, no surprise the data showed worse outcomes in their study. Same patient population (TBI) in Seattle/King County with medics that intubate a lot of patients and guess what? Improved outcome. How can that be? Experience is the difference. Intubation when needed can and does improve outcomes, when it is performed appropriately by a skilled clinician.

[fiznat]

The prehospital intubation data showing worse outcomes have come from systems that don't intubate much.

There is actually quite a bit more than that.

Eckstein et all: Effect of prehospital advanced life support on outcomes of major trauma patients. Los Angeles.

Adjusted survival for patients who had BVM was 5.3 times more likely than for patients who had ETI (95% confidence interval, 2.3-14.2, p = 0.00).

http://cat.inist.fr/?aModele=afficheN&cpsidt=1343863

Murray et all: Prehospital intubation in patients with severe head injury. Los Angeles.

In fact, intubated patients had a significantly higher relative risk (RR) of mortality when compared with nonintubation (RR = 1.74,p < 0.001) and unsuccessful intubation patients (RR = 1.53, p = 0.008)

http://www.ncbi.nlm.nih.gov/pubmed/11130490

Wang et all: Out-of-hospital endotracheal intubation and Outcome after traumatic brain Injury. Pittsburgh.

Out-of-hospital endotracheal intubation was associated with an increased adjusted odds of poor neurologic outcome (OR 1.61; 95% Cl 1.15 to 2.26), moderate or severe functional impairment (Functional Impairment Score 6 to 15; OR 1.92; 95% Cl 1.40 to 2.64), and severe functional impairment (Functional Impairment Score 11 to 15; OR 1.80; 95% Cl 1.29 to 2.52). Conclusion: Out-of-hospital endotracheal intubation was associated with adverse outcomes after severe traumatic brain injury. The implications for current clinical care remain undefined.

http://cat.inist.fr/%3FaModele%3DafficheN&...le=presentation

Bochicchio et all: Endotracheal intubation in the field does not improve outcome in trauma patients who present without an acutely lethal traumatic brain Injury. Baltimore.

Patients who were intubated in the field had a significantly higher morbidity (ventilator days, 14.7 vs. 10.4; hospital days, 20.2 vs. 16.7; and intensive care unit days, 15.2 vs. 11.7) compared with patients intubated on immediate arrival to the hospital and nearly double the mortality (23% vs. 12.4). Field-intubated patients had a 1.5 times greater risk of nosocomial pneumonia compared with hospital-intubated patients.

http://cat.inist.fr/?aModele=afficheN&cpsidt=14580258

Davis et all: The impact of prehospital endotracheal intubation on outcome in moderate to severe traumatic brain injury. San Diego.

Patients intubated in the field versus the emergency department had worse outcomes....Prehospital intubation is associated with a decrease in survival among patients with moderate-to-severe TBI.

http://cat.inist.fr/?aModele=afficheN&cpsidt=16915454

Davis et all: The effect of paramedic rapid sequence intubation on outcome in patients with severe traumatic brain injury. San Diego.

Factors that may have contributed to the increase in mortality include transient hypoxia, inadvertent hyperventilation, and longer scene times associated with the RSI procedure. Conclusion: Paramedic RSI protocols to facilitate intubation of head-injured patients were associated with an increase in mortality and decrease in good outcomes versus matched historical controls.

http://cat.inist.fr/?aModele=afficheN&cpsidt=14686493

Stiell et all: The OPALS Major Trauma Study: impact of advanced life-support on survival and morbidity. Ontario.

The OPALS Major Trauma Study showed that systemwide implementation of full advanced life-support programs did not decrease mortality or morbidity for major trauma patients. We also found that during the advanced life-support phase, mortality was greater among patients with Glasgow Coma Scale scores less than 9. We believe that emergency medical services should carefully re-evaluate the indications for and application of prehospital advanced life-support measures for patients who have experienced major trauma.

http://www.cmaj.ca/cgi/content/full/178/9/1141

Admittedly all of these studies are limited in that they only look at trauma patients, but then again this is probably the population that would most often require RSI. The sheer volume of all of these studies in agreement is staggering. Trust me, these are the articles our docs are looking at when they shake their heads "no."

[Dustdevil]

Out-of-hospital endotracheal intubation was associated with an increased adjusted odds of poor neurologic outcome (OR 1.61; 95% Cl 1.15 to 2.26), moderate or severe functional impairment (Functional Impairment Score 6 to 15; OR 1.92; 95% Cl 1.40 to 2.64), and severe functional impairment (Functional Impairment Score 11 to 15; OR 1.80; 95% Cl 1.29 to 2.52). Conclusion: Out-of-hospital endotracheal intubation was associated with adverse outcomes after severe traumatic brain injury. The implications for current clinical care remain undefined.

That is the most important statement in his entire thesis. And it applies to all of the papers you cited. They have no idea what it all means. Ignorant, empirical speculation leads to all this nonsense about it being harmful or not necessary. But the truth here is as evident as it was with the studies that claimed that patients arriving at the hospital by POV had a greater survival rate than those arriving by ambulance. Well, DUH! No shyte! Those patients requiring an ambulance -- and likewise, those requiring intubation -- are just plain sicker than those who do not! Of course they are going to have worse outcomes. Thank you, Captain Obvious! How friggin' hard is that to figure out?

Shove your statistics up your arse, unless you know how to interpret them, Wank.

[Ridryder 911]

Wang has always had a hard on against EMS. Unfortunately, his studies has always been known to be biased even before publication one can predict which way it will be skewed.

Ironically Wang is getting up in age.. would it not be ironic.. you can guess the rest.

R/r 911

[fiznat]

Ignorant, empirical speculation leads to all this nonsense about it being harmful or not necessary....

Shove your statistics up your arse, unless you know how to interpret them, Wank.

:shock:

Wait just a minute there. Peer reviewed, scientific research is now "ignorant," "speculation," and "nonsense?" You think EMS is somehow special, not to be constrained by mere statistics? You've got to be kidding me.

You wax philosophical here all the time about a lack of education among our ranks, but dude. Scientific literature is the engine that drives medicine. It is the best tool we've got to try and make sense of all that happens with our patients. If you think you can do without it, you are painfully, horrifically wrong. We're not THAT special.

...And don't tell me that ALL of these professional researchers are suffering from some inability to properly interpret the statistics. Statements like those you highlighted are typical within scientific literature, and are reflective of a humbled, scientific approach. They don't claim to have all the answers because they conducted a few studies, rather they intend to contribute to the existing pool of research so that the realities of these situations may be more fully described through aggregate data. I posted seven research articles which all largely say the same thing. Are you going to contribute all of that to some cantankerous old researcher who doesn't understand, or has it out for EMS workers? Really?

It pains me to see you so casually brush off this kind of evidence. It may very well be true that these studies don't fully describe the nuances and texture of you and your particular brand of medicine. ...But believe me, this is as clear as it will ever get, and our medical control doctors are listening. Maybe you should, too.

Oh,

Those patients requiring an ambulance -- and likewise, those requiring intubation -- are just plain sicker than those who do not! Of course they are going to have worse outcomes. Thank you, Captain Obvious!

Actually these studies CONTROL for this kind of thing. If you take a few minutes to click those links, even in the abstracts you will see that the patient populations are of similar ages, demographics, and injury severity. It is a basic tenant of research that the two groups you are comparing must be, well, COMPARABLE. Those egg-head researchers are a little smarter than you think, Dust.

[Ridryder 911]

our medical control doctors are listening. Maybe you should, too.

I do hope that they really read whole the study. Read the type and acuity of what the patients are compared to. Again, skewed and misunderstood studies is of no value. Alike the Houston PASG study that first accused the knee jerk of removing the garments. Many assumed it said that they did not work; when in fact it did NOT say that, it described it did not an increase in survivability. Yet again, the acuity of the type of patients it would be doubtful if a trauma surgeon would had made a difference.

Look at the whole picture.... and then be sure to read in between the lines as well. Again the procedure(s) is not the problem rather the lack of education of the personal.

R/r 911

[p3medic]

Trauma, TBI in particular is a small subset of patients requiring prehospital intubation. San Diego and Los Angeles have medics coming out of their ears, way too many providers and very little skill use. 2 tubes a year doesn't cut it. Don't know much about Baltimore other than it is run by an east coast fire department, and the Wang study in Pennsylvania looked at the entire state, no just a city like Pittsburgh (3rd service) and I don't believe it addressed RSI. The data out of the Pacific Northwest goes contrary to the data from the California fire services, and our data, although not yet published would suggest and improved outcome in the TBI population, as well as other, non trauma patients as well. I agree that as it stands today, not every medic should be performing intubation, but the answer lies in education and experience, not on removing a potentially life saving skill, in my opinion.