Intubation FAIL

[Kiwiology]

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

Well that brings new meaning to the alternate names for the LMA i.e. "fanny gag" or "lesbo lollipop" huh????

[Arctickat]

IMHO the intubation skill is not something that is broken beyond repair. Until something better comes along, endotracheal intubation is still the definitive airway treatment. Perhaps rather than consider abandoning it altogether one should consider adding more opportunities for confirmation of proper placement, etc. For example, all of our LP12s include capnography. It is placed on every one of our intubated patients to continuously monitor respiratory status. As with a suddenly abnormal ECG, first thing you do is check the leads, if a suddenly abnormal etCO2 develops, we check the tube placement.

Additional practice on mannequins may not be ideal and access to operating theaters to conduct intubations on real people may be unrealistic in some instances, but I haven't seen anyone yet suggest cadaver training as an option. Many years ago I even had one doctor approach the family immediately following a code to inform them of his death and request permission from them to allow us to practice intubations on their loved one. I was surprised when they didn't rip off his head, but rather, allowed us to each take turns dropping a couple of tubes. Many people dedicate their bodies to science or education, these are who should be sought out.

In short, practice makes perfect. Higher success rates are a result of experience and tools are available to maintain confidence following tube placement. Use of these tools and opportunities for practice should be considered.

[VentMedic]

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

Not always Rid are the studies skewed. The hospital has nothing to gain by taking ETI away from Paramedics except when problems have developed. Even the expensive/extensive training center at U of Miami/JMH that allows for more training and education of Paramedics is not able to keep up. I have made reference to this study in my other posts and have mentioned examples which have been severe enough that a closer look had to be done. This study was done over a 3-4 year period and the Paramedics knew the study was ongoing. When you and your department know that you are being watched, normally people do try to improve. However, there was also a "let's see if we're really that bad" attitude that is prevalent. Some believe a 20% - 30% failure rate is satisfactory.

Artickat

As with a suddenly abnormal ECG, first thing you do is check the leads, if a suddenly abnormal etCO2 develops, we check the tube placement.

ETCO2 is available in many areas but not all. If one was to look at its use throughout the entire U.S. you might be surprised at the numbers that do not utilze it. Just because the LP12 is capable of ETCO2 that is no guarantee it will be used or that the Paramedics will be trained on it. The same can be said for 12-Lead EKGs. I am still rather surprised at the number of departments even in the larger cities (mostly West Coast) that have no intention of using 12-lead EKGs.

[Spock]

The vast majority of prehospital intubations are in the cardiac arrest patient and this study only looked at trauma patients. The part I find unacceptable is the 12% of esophageal intubations. There is no excuse for this and if a service is going to allow their medics to intubate they should be required to have ETCO2. Pennsylvania mandates all ALS ambulances to have electronic capnography.

I can't speak to the dipolma mills for paramedics because we don't have them here in Western PA but the idea of restricting advanced skills to certain medics with additional training has merit. Not every medic should be allowed to intubate.

I also don't agree with counting "rescue airways" as failed intubations. While true that there is no endotracheal tube in the trachea if the patient is ventilated and saturated upon arrival then the medic has done their job well. I've said before that a better term would be alternative airways instead of rescue airways. I've also said that my experience tells me the King LT-D is the best of the bunch.

The anesthesiologists that criticize paramedics really irritate me because they are the same people that will not allow medics into the operating room. The study identifies a problem but doesn't seem to recommend a solution.

Live long and prosper.

Spock

[VentMedic]

The anesthesiologists that criticize paramedics really irritate me because they are the same people that will not allow medics into the operating room. The study identifies a problem but doesn't seem to recommend a solution.

Live long and prosper.

Spock

U of M/JHM has an elaborate training center. However, there is no way to get 2500 paramedics into the ORs even with a hospital as large as JMH.

The other issue is this is not the whole article. There are several more pages that qualified the reasons they did the study with certain factors involved. This small abstract or summary does not do the whole article justice. However, I'm sure only a summation of this part will be presented in JEMS for sympathy. However, unless the FDs can see where they need to improve, the decline of their once good reputation may continue to slide.

The solution would be to go back to selecting those with an interest in being a Paramedic to work the EMS side and not continue with making all 3500 FFs become Paramedics in that county.

Edited August 1, 2009 by VentMedic

[spenac]

OK here is the most practical and simple solution. Remove the CRNA's and have the Paramedics come in and do all intubation and ventilation in the OR. This saves hospitals money and allows all Paramedics to maintain their skills.

Sorry Vent could not resist.

In reality we do need to remove the fire Paramedics and only have those that have proven to be focused on being medical professionals having advanced procedures .

[Kiwiology]

The solution would be to go back to selecting those with an interest in being a Paramedic to work the EMS side and not continue with making all 3500 FFs become Paramedics in that county.

Now there is a dandy notion that might just have some merit

[HERBIE1]

OK here is the most practical and simple solution. Remove the CRNA's and have the Paramedics come in and do all intubation and ventilation in the OR. This saves hospitals money and allows all Paramedics to maintain their skills.

Sorry Vent could not resist.

In reality we do need to remove the fire Paramedics and only have those that have proven to be focused on being medical professionals having advanced procedures .

The big problem is that where fire based EMS exists, they are the dominant provider in terms of volume, money, and political clout. That means any solution offered could not portray that dominant organization in a bad light.

[akroeze]

On a somewhat related note, the other night I did my first intubation as an independently practicing ACP

Got it on the first try in a cramped room where I was positioned more beside the patient than at the top of their head.

Sorry, just wanted to congratulate myself

[Ridryder 911]

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.

One other piece of factor is the $$$. Many physicians (especially specialty) are feeling the crunch of not performing extra procedures. I know of one state that attempted to remove EJ from the scope of anyone except anesthesiologist and anesthetist. Why? The procedure would generate extra income, short & simple.

I realize it may sound petty but I have seen worse in studies and all in the name of money. Anyone elsde remember the B.S. studies that acclaimed that EMS was taking 15-20 minutes to establish an IV?... Yeah, all from notable researchers. Amazingly, it was debunked and there were no apologies...