Intubation FAIL

[Dustdevil]

Anesth Analg. 2009 Aug;109(2):489-93.

Prehospital intubations and mortality: a level 1 trauma center perspective.

Cobas MA, De la Peña MA, Manning R, Candiotti K, Varon AJ.

Department of Anesthesiology, Miller School of Medicine, University of

Miami, Miami, Florida 33136, USA. mcobas@med.miami.ed

BACKGROUND: Ryder Trauma Center is a Level 1 trauma center with

approximately 3800 emergency admissions per year. In this study, we sought

to determine the incidence of failed prehospital intubations (PHI), its

correlation with hospital mortality, and possible risk factors associated

with PHI.

METHODS: A prospective observational study was conducted

evaluating trauma patients who had emergency prehospital airway management

and were admitted during the period between August 2003 and June 2006. The

PHI was considered a failure if the initial assessment determined improper

placement of the endotracheal tube or if alternative airway management

devices were used as a rescue measure after intubation was attempted.

RESULTS: One-thousand-three-hundred-twenty patients had emergency airway

interventions performed by an anesthesiologist upon arrival at the trauma

center. Of those, 203 had been initially intubated in the field by emergency

medical services personnel, with 74 of 203 (36%) surviving to discharge.

When evaluating the success of the intubation, 63 of 203 (31%) met the

criteria for failed PHI, all of them requiring intubation, with only 18 of

63 (29%) surviving to discharge. These patients had rescue airway management

provided either via Combitube (n = 28), Laryngeal Mask Airway (n = 6), or a

cricothyroidotomy (n = 4). An additional 25 of 63 patients (12%) had

unrecognized esophageal intubations discovered upon the initial airway

assessment performed on arrival. We found no difference in mortality between

those patients who were properly intubated and those who were not. Several

other variables, including age, gender, weight, mechanism of injury,

presence of facial injuries, and emergency medical services were not

correlated with an increased incidence of failed intubations.

CONCLUSION: This prospective study showed a 31% incidence of failed PHI in a large

metropolitan trauma center.

We found no difference in mortality between

patients who were properly intubated and those who were not, supporting the

use of bag-valve-mask as an adequate method of airway management for

critically ill trauma patients in whom intubation cannot be achieved

promptly in the prehospital setting.

[medic82942003]

So is this good or bad? whats your opinion? I dont think they will cross intubation off the list

of Things to do before reaching the Hospital?

[FL_Medic]

So is this good or bad? whats your opinion? I dont think they will cross intubation off the list

of Things to do before reaching the Hospital?

I wish you were right, unfortunately our peers aren't doing a good enough job giving them a reason to let us keep the skill.

How many paramedics do you know that will say "I am no good at intubation"? Now how many studies have you seen that show a significant percentage of unrecognized failed intubations, or just failed intubations for that matter. If nobody needs improvement with the skill, and we are missing so many....?

The first step to improvement is recognizing that we are the problem.... or a problem amongst many.

I think this study is a good one.

The argument is that BVM alone is not a secure airway. You are putting air into the belly, even with sellicks. I think I would rather have some air in my belly than none in my lungs tho.

[p3medic]

This seems to be an issue with many systems with too many paramedics seeing too few critical patients, or competing with medics on fire trucks for too few skills. LA, San Diego, etc have medics on almost every piece they run, I'm curious how many intubation opportunities medics in these systems get on average each year?

[VentMedic]

Dade County has undergone some changes over the past few years that has seriously hurt its reputation for providing quality EMS. When the many smaller FDs came together to become a mega county FD it grew too fast.

The fact that the FDs do want Paramedic certs to weed through the 1000s of applicants has also presented problems. Medic mills have mass produced Paramedics just before a big department has a hire date announced. Hundreds of hopefuls get the cert but don't get hired during that round and keep their regular jobs flipping burgers or construction until the next year. If they do work on an ambulance, it may be on a BLS truck. Thus, by the time they do get picked up by a FD, a few years have pasted since they have done their 5 tubes on a manikin. Hospitals are also getting more reluctant to allow the poorly prepared students from the medic mills or even the community colleges' "EMS Academies" intubate in their EDs/ORs. Even if the FDs do try to give a refresher, the odds are against them due to time lapsed and the number of Paramedics in these mega departments.

It wasn't always like this and Dade County had at one time been a leader in EMS with many FDs do EMS very well and with pride. The two year degree in EMS was respected and medic mills were thought to be for losers who couldn't get into a college. We even had competitions amongst the departments to prepare for State and National EMS competitions.

[rock_shoes]

Do the services transporting to the facility in question have any kind of quality assurance program? Say for instance any given medic must have X successful intubations per year to continue being allowed to intubate. In my opinion developing a proper quality assurance program would solve the majority of skill retention issues. Failure to ensure skill retention should result in a reduction in allowed scope of practise.

[Kiwiology]

I think Vent is right ... oh if Eugene Nagel could see Miam-Dade Fire now.

Look at the skills that EMS has thrown out over the past decade as the evidence has not supported them (big fluid volumes, MAST pants, etc) and I think perhaps endotracheal intubation will go this way. In saying that I am not totally convinced even though some of what I've seen presented in the journals is either negative or neutral (I did see one positive study a while ago). For RSI (which is a very controversial topic here, the studies have been abismally negative from what I have seen)

Here in New Zealand endotracheal intubation is still a skill taught to and practiced by our Advanced Paramedics (ALS) although I don't know at what frequency or with what success rate; perhaps could be something we could look at studying. Beyond the OPA and NPA we use the laryngeal mask airway (LMA) and although I don't have any hard data to back it up I personally believe it's a cheap piece of shit because the mask only partially seals the laryngeal opening of the pharynx and gaining a seal can be difficult in a patient with high airway pressure.

Perhaps we should be looking in-hospital at practices around airway control there. I know of some systems where only RTs and anaesthesologists are allowed to intubate (i.e. it's been taken away from emergency physicians and nurses) because presumably they are doing it at a high enough rate with enough success to be of some benefit. Some EMS systems seem to follow this logic around ALS (such as Tulsa, Boston and Phoenix; restrict the number of Paramedics to ensure high skill utilization and relative success; there was a big writeup in USA Today about it a while back). I know that in the OR the LMA is quite popular (BUT in saying that, they have better monitoring and patient control).

So the question remains do we take away intubation or say, give everybody bougie's and video laryngascopy or something heck if I know but that also begs the question ..... do we need to be intubating people in the first place? I believe we need some form of definitive airway control but as to what that is, I'm not sure.

[CBEMT]

It kills me that these studies which will eventually completely destroy intubation as a prehospital intervention are being based off of the worst our industry has to offer.

I'm not blaming them for doing it or disputing the results, I'm just saying that if a similar study were run by Harborview, Mass General, Brackenridge, or Duke, you would very likely NOT be getting these kinds of results.

Edited August 1, 2009 by CBEMT

[tniuqs]

CONCLUSION: This prospective study showed a 31% incidence of failed PHI in a large

metropolitan trauma center.

Could this be just the base line study that opens up some eyes as to a problem REAL problem that is occurring, honestly I too snap when this service is used as the "standard".

Don't throw the L scope out with the bathwater just yet.

Just my twisted look at this but there could be possibly 3 nails to be pounded upon first and foremost ... the Coffins (as coin by)

1- the educational system.

2- the Con Ed system i.e. the delivery of care.

3- the comparison of airway capture and end outcome. (huge folly in poly trauma equating outcome when so many other factors influencing end point/outcome)

This study actually suggests that: We found no difference in mortality between patients who were properly intubated and those who were not.

I dare suspect that TRAUMA is killing those patients ... so should we stop even transporting Trauma patients ... just call them on scene ?

We do know that without a definitive airway you WILL die and in the field vs a controlled setting is unfair as well, I have yet to see anesthesia intubate anyone on a bathroom floor, perhaps we should put all anesthesia residents "On Car" and see if this changes their success ratios ?

Supporting the use of bag-valve-mask as an adequate method of airway management for critically ill trauma patients in whom intubation cannot be achieved promptly in the prehospital setting.

Define "PROMPTLY"

As for the 12% of unrecognized esophageal intubation .... wtf where's ETCO2 ?

cheers

ps Agreed Kiwi the LMA is a useless piece of plastic in a field setting not even good as as sex toy either.

Edited August 1, 2009 by tniuqs

[Ridryder 911]

We have to look at some myths in EMS. Such as every fire truck and every person has to be a Paramedic. Those with having a higher save rate actually has fewer Paramedics than those that a having multiple Paramedics.

Would you want a surgeon to describe that he has performed a surgery once every 6 months or one that is able to perform it every week? Again, over saturation of a good thing = skills deterioration.

Second, why is such a simplistic procedure became so hard? With the invention of EtCo2 and good assessment there should NEVER be any patients delivered to the hospital with esophageal intubations. Seriously, poor and gross incompetence behavior.

This does not mean we should eliminate the procedure however. How many central lines or intubations do I see missed by physicians all because they too have became relaxed or poor skills? Yet, no discussion is ever made to remove their ability to perform such procedures.

Such studies are slanted. Never is discussed the reason or a working solution of resolving the problem other than a knee jerk response. I do wonder how many of those anesthesia areas allows or would allow Paramedics to intubate to maintain their skill level? Yeah, I thought so.

R/r 911

Edited August 1, 2009 by Ridryder 911