The Disappearing Endotracheal Tube

[spenac]

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

"What About Patient Outcomes?

Prehospital procedures and methodologies have been more closely scrutinized in the literature during recent years. Some have been found efficacious, some have not. Ultimately, the question medical directors must ask is, "Does this procedure or practice improve patient outcomes?" Prior to recent research, outcome data was unknown or extrapolated from other disciplines. One of the principal areas of study has been prehospital ETI, and the literature is mixed. "

Gene Gandy for those that have not met him is an old Paramedic educactor as well as a lawyer. I had priveledge of meeting him and having him instruct me in skills portions. Plus he is the author of many of the lessons in class.

[rock_shoes]

I would be willing to wager that intubation has a great positive impact on patient outcome. With one caveat of course. Intubation success rates need to be kept very high through a combination of practise and continuing education. Multiple failed attempts are of course to the detriment of patient care and, in the end, outcome. Intubation also needs to be used intelligently. We can't go around putting tubes down peoples airways just because we can.

[FireMedic65]

I have done time in the OR and even then tubes were missed. Perfect environment for the procedures to be done. It's a relatively simple skill, but needs to be routinely practiced.

If a medic misses the tube in the field, people go all stupid about it. They start crying and saying such things as "omg why are you allowed to do these things?!". Yet when an MD misses the tube, it's just "wow, that must be a hard intubation.".

People really should pull their heads out of their butts and realize medics are well trained health care providers. They don't show you the laryngoscope and ETT in school and not teach you how to use them or have extensive practice in using them.

It's the people who think they know everything and say "I've done 1000s of these, I don't need to practice.", that give everyone else a bad rep.

[AnthonyM83]

I have been told that for traumatic brain injury tubes most definitely do save lives, as supported by literature.

I would imagine that with proper equipment (unrecognized) misplaced ET tubes should be pretty much 0%. Enough confirmation devices and and observational signs on pt should make one pretty certain you did or did not get the tube, no?

[fireflymedic]

As others have said, this is not so much an issue of missed tubes, it's an issue of failure of services to maintain the skill at an adequate level. It seems only flight and critical care crews (in general there are some exceptions) are feeling the need to maintain the skills they are lacking in. If you work in a slow service and maybe have one tube a month, then obviously if you have a difficult (or even moderately difficult intubation) you are going to have a higher failure rate than someone who has intubations more frequently. That's just how it is. Either you use it, or you lose it. No arguement there.

With respect to Dr. Bledsoe, as we have discussed many times, his focus is in urban settings, and what works there is fantastic, however, he must not forget those of us who are in rural areas with high transport times where bagging a patient for 30-45 minutes may not be feasible. Is his proposal to take away ETI and be reduced solely to adjunct airways such as King LT or CombiTube? Those are great back ups if ETI fails, but don't completely secure the airways especially in situations such as a devastating gunshot wound etc. Those are your patients that need a definitive airway. However, I am for saying quarterly intubation check offs and yearly clinical time. You may not like it, but it's in the best interest of the patient. Perhaps that is why flight crews have high success rates for intubation. Ever wonder?

I think EMS is on a path to self destruction. There have been strides made to improve patient care, however, we have refused to raise our training standards and continuing education past a few hours every two years. It's just not adequate ! Changes have got to be made or else we will be reduced to nothing more than ambulance drivers with a few bandages. It's time to step up to the plate and get to be professionals, and if you refuse, well then now is the time to get out.

[AlamanceMD]

After reading the replies above, I wanted to make a few comments.

First, please go back and read the "patient outcomes" section of the originally cited JEMS article. Many studies, including the ones noted in the article, do not show benefit to the patient with ETI in the field. You could argue that a study does not apply to your population (urban vs. rural, medical vs. trauma, or some other factor), but I do not agree that the data available is wishy washy or contradictory. The data, overall, has been pointing in the same direction for a while. There are too many studies that show patients, on average, have a worse outcome when they are intubated in the field. This includes patients with TBI.

I would not say that this is a guilty verdict on paramedics skills. Even when the intubation is successfully accomplished on the first attempt, some studies are showing that study populations are having worse outcomes. The big question is... why??

There are various theories on why. I agree with the theory that ETI takes pre-hospital personnel away from other critical tasks. When would you rather be intubated? When you've got two guys kneeling above you trying to do 5 things at once or when you get to the hospital (sooner rather than later) and you have 5 people standing above you, in a controlled environment, with no big break in ongoing care? If there are only a few skilled people on the scene, it only makes sense to instead do the faster thing, take care of the more important stuff first (monitor/pads? IV? fluid or drugs? driving to the hospital?) before placing a definitive airway.

But that last line in the paragraph above is the big problem: "It only makes sense...". We all use this mentality to justify what we think makes sense and thus must be right. "It only makes sense to do ETI and secure an airway in the field". No.... it only makes sense if the studies involving thousands of patients show they have a better outcome is we do this.

Please don't get defensive and also don't think this is all about whether you got the tube or not. There's a lot more going on, both at the scene and physiologically for the patient.

Last, but important: this is not the end of EMS as we know it. Being a paramedic is not being an intubator (that doesn't sound right, but you know what I mean). The medics that I'm most worried about are the ones fresh out of school who have good skills from there training. They can get that tube in, but they don't have the experience and the judgement yet. They don't know when to do a more thorough patient assessment or when to cut and run. They're unsure when to shock or when to use drugs. They can't anticipate the patients condition, so they're always playing catch up. The point is... pre-hospital care involves judgement, not just a set of skills from your tool box.

"It just makes sense" ;-)

[mobey]

Last, but important: this is not the end of EMS as we know it. Being a paramedic is not being an intubator (that doesn't sound right, but you know what I mean). The medics that I'm most worried about are the ones fresh out of school who have good skills from there training. They can get that tube in, but they don't have the experience and the judgement yet. They don't know when to do a more thorough patient assessment or when to cut and run. They're unsure when to shock or when to use drugs. They can't anticipate the patients condition, so they're always playing catch up. The point is... pre-hospital care involves judgement, not just a set of skills from your tool box.

Sounds like another advocate for increasing education, practicum time, and setting up 2 medic cars ensuring one is experienced.

Thanx for your prospective Doc.

[chbare]

A few thoughts to consider:

1) As stated, we need to check our ego at the door. This is not a war against taking skills away from paramedics. Obviously, a fair amount of research exists that points to the possibility that the status quo is not helping patients as much as we like to think, and in fact may be causing harm. Nothing personal, at least consider the evidence, and deal with it.

2) I am so tired of the typical kindergartner argument. When you moan and say, "oh yeah, well what about the physicians, what are their actual intubation rates," you sound like a child making a childish argument. I did this to justify my behavior as a kindergartner; however, we are all grown up now. Do not justify bad behavior by looking at somebody else's bad behavior. At least consider the evidence without pointing the finger at somebody else. It's a hard pill to swallow sometimes.

3) Consider the data as a whole. It is easy to focus on special situations such as prolonged transport times. Yes, looking at solutions for some of these problems is important; however, look at the bigger picture before focusing on every detail.

4) In line with number three, it is easy to become overwhelmed in the details. For example, I could potentially justify every little possible scenario. What about tamponade, pneumothorax, and epidural bleeds. Obviously, we many not be able to perform the interventions to correct some of these problems in the field. Again, we need to look at the big picture. What really should be our emphasis as pre-hospital professionals? Having the ability to perform every skill for every conceivable situation, or having a clear understanding of our role and how it fits in with the big picture? We need to identify key modalities that are crucial to good patient outcomes, and have strong evidence to support our decisions.

5) While I am not saying pulling ETI completely out of the pre-hospital arena, we must at least realize there may be less emphasis on this procedure, and in fact many of our patients may not really need a tube in their trachea.

Take care,

chbare.

[p3medic]

Systems should start their own airway registries, much like the National Emergency Airway Registry. Collect data on all your intubations. What drugs were used to facilitate intubation? How many attempts? What difficulties if any were encountered? SpO2, EtCo2, etc... If you as a system can't prove that you are helping, then perhaps you shouldn't be doing it. I don't think supraglottic airways are sufficient for all patients, however if you only intubate a few times a year, it is probably the safest choice. However, if you intubate frequently, and collect data showing a high success rate, low instance of desat or difficulty then perhaps intubation should remain in those systems. Just my opinion.

[VentMedic]

Systems should start their own airway registries, much like the National Emergency Airway Registry. Collect data on all your intubations.

This is why some in EMS have gotten to the point where ETI is in question. Too many agencies have failed to monitor their providers' competencies. If problems and deficiencies were recognized earlier and ongoing, this might not be an issue. For the agencies that have carefully monitored their employees, ETI is not an issue.