The Disappearing Endotracheal Tube

[FireMedic65]

What needs to be done is have ALL EMS on the same page. Instead of each state doing their own thing, and even down to each state having regions doing their own thing. National Standard my butt!

If we all work together, and get on the same page. Get everyone trained, properly, do the right documentation, and all follow the same standards... this kind of stuff probably wouldn't happen.

[VentMedic]

What needs to be done is have ALL EMS on the same page. Instead of each state doing their own thing, and even down to each state having regions doing their own thing. National Standard my butt!

The minimum education requirements should be standard but different regions of the country may still require advanced techniques while other EMS agencies run into a hospital every couple of blocks.

Some very rural EMS agencies still can do pericardiocentesis, central lines and chest tubes. They know these procedures may be necessary and do keep up their skills. The same goes for some HEMS, Flight and Specialty teams.

[FireMedic65]

The minimum education requirements should be standard but different regions of the country may still require advanced techniques while other EMS agencies run into a hospital every couple of blocks.

Some very rural EMS agencies still can do pericardiocentesis, central lines and chest tubes. They know these procedures may be necessary and do keep up their skills. The same goes for some HEMS, Flight and Specialty teams.

I suppose I am in one of those regions where we don't get to do much of anything. We don't even have needle crich!

I am all for the advancement of skills for EMS. Not taking them away.

[VentMedic]

I suppose I am in one of those regions where we don't get to do much of anything. We don't even have needle crich!

I am all for the advancement of skills for EMS. Not taking them away.

Over 30 years ago when I first started in EMS, pericardiocentesis, central lines, chest tubes and intra cardiac epi were taught as part of the Paramedic curriculum and were in the protocols throughout the country. Research and urban growth has changed alot of protocols in many areas of medicine, not just EMS. Look at how many times ACLS and CPR have changed the guidelines.

While I prefer ETI, I also understand the need for solid initial education, continued competency and alternative airway. I also know Paramedic schools are having a difficult time getting intubation time for their students in the hospital. Some schools just use the mannequin if the student can not get live intubations. I heard one school substitutes 5 successful mannequin intubations for 1 "live" intubation until they get the equivalent of 5 live intubations. Others may not practice again on a mannekin after school even if they are not getting may live intubations. I do 5 mannekin intubations each morning while I'm making my coffee in the office as a warm up for intubating during my shift. This is even with many years of experience and the chance to do a lot of intubations. I do get to see a lot of new equipment and one should be very familiar with it before using on a live patient

Now, because I am a very good at one skill of intubation, it is the whole basis of my worth in either EMS or as an RRT. I can use a BVM or alternative airway device just as well. But, I also have the knowledge to know the functions and limitations for each device along with the ability to be flexible as the situation or patient anatomy dictates. Some fail when it comes to seeing the need for Plans B and C.

Edited March 12, 2009 by VentMedic

[FireMedic65]

That's what I am saying. We learn a skill, and some people just say ok, I learned it, and that's it. We need to keep up with these skills and practice them. Those who do not practice their skills, are usually the ones who lower the success rates on such skills.

[p3medic]

Yes, but without continuous practice "skills" deteriorate. If your department can't or won't provide the opportunities to stay profficient you can't be expected to perform as well as those that have frequent experience. I don't care if you work in an area with one tube every five years, if you can get regular OR time or intubation experience in the ED more power to you. On the other hand, if all you have for experience is the few attempts in the field, you might want to rethink things.

[spenac]

We don't even have needle crich!

Now that sucks. No airway equal death. Your system fails.

[FireMedic65]

Now that sucks. No airway equal death. Your system fails.

Tell that to my medical director.

[paramedicmike]

It's interesting that shortcomings are identified and problems noted with even possible solutions discussed but no one is willing to start advocating or implementing those solutions.

Prehospital intubations have been routinely identified as being problematic. Education and limited practice have been pointed to repeatedly as issues contributing to these problems. Yet no one, not the people identifying the problems, not those point out and lamenting the problems, not those saying, "This is a problem so we'll just remove the problem", not those who directly control our ability to practice on a day to day basis have taken any steps to address the issues directly and work to correct them.

There will always be patients who will need to be intubated in the field (but not every EMS provider should be able to intubate). They may be few and far between but that only reinforces the idea that there are many major changes that need to be affected within the EMS segment of health care. And those changes need to be affected yesterday!

The evidence is damning. There's no getting around that. But let's work to change the evidence instead of working to remove the evidence. This isn't ego. This isn't crying over taking away a "toy from the toy box". This is a genuine desire to see a major overhaul of the system from the ground up.

-be safe

[MontvilleFire39]

I suppose I am in one of those regions where we don't get to do much of anything. We don't even have needle crich!

I am all for the advancement of skills for EMS. Not taking them away.

I am also for advancement of skills if found to be of a positive result as backed by legitimate research.

Intubation is a skill that is poorly addressed in most paramedic programs. There seems to a preumption that you will get the tube without enough emphasis on backup airways. One should approach intubation expecting to suceed but prepared to fail.

Education should include standardized techniques for assesing the ease or difficulty of seuring an ET tube. Skills such as Mallampati scoring should be standard. On top of this, nasotracheal intubation IMO should be emphasised as an option as well. I have utilized this on several occasions with positive outcomes. Use of bougie assisted intubation should be standard IMO as well. Deployment of King Airways, Combitubes, and emergency surgically invasive airways needs to be ingrained as a readily avaliable back up to safe, expeditious placement of an ETT. Mechanics have many different tools for performing the same repair with different surounding circumstances (different makes, models, and years of vehicles IE). Intubation is nothing more than a standardized procedure with different surrounding circumstances (body weight, airway anatomy, precipitating medical conditions). Increase the tools in your toolbox to ensure success.