Intubation FAIL

[triemal04]

If you think having a Paramedic getting only one intubation per year is fine then I guess the study is worthless. If you want to continue to make excuses for the esophageal intubations that went unrecognized then I guess the study has little merit to you. If you want to make excuses for the Paramedics that didn't know what damage they could do with any of the airways and made hamburger out of the patient's cords and throat, then I guess there is no need to see if anything needs to be corrected in EMS. It seems most here believe EMS is perfect in every way and will find fault with anyone or any group that dares to say there is room to improve. This study does have data which is useful and hopefully will call for a change. While saying that ETI may no longer be acceptable for prehospital might be a wake up call for some. However, it seems that most will believe ETI will always be around and the same practices will continue.

BTW, check out the list of references at the end of the article.

Funny, I don't think anybody here has said anything that you just complained about. Don't go off on one of your little rants now, ok, for once I think everyone is actually on the same page.

We can point to flaws in the

research and continue bad practices or take the general gist of the research

and correct the wrongs.

Croaker has said it much better than I can so I won't bother trying to repeat it. What needs to be done now (by US if we want any type of credibility in the future) is to look at the systems that fail at intubations and the ones that are successful; figure out what works and what doesn't and what needs to be changed to fix the problem and then publish the results wherever possible. Anecdotaly I think everyone knows the answers allready, but until there has been a comprehensive study that proves that and has the data to back it up...change will be very, very slow if anything changes at all.

[cosgrojo]

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.

Well this is an incredibly salient point Rid... one I agree with completely, and one I have been incredibly ostracized for stating (i.e. Medic's on all trucks, all the time). Granted you have approached it from a different angle than I have in the past, but I think you struck something important.

As far as ETT goes, I have done BLS codes with combitube (available in New Hampshire), and with ETT with medic partners. ETT always takes longer and usually causes more provider consternation. Combitube goes in easy, and is just as secure in my opinion. Already within the last couple of years they have taken away intubation rights from Intermediates in New Hampshire. If they see a trend of diminishing returns with Medics, I believe they will do the same with them.

[Ridryder 911]

It's nice that we are recognizing a potential problem. Potential is the key. Shame that services and personal are not being taught to use the EtCo2 or worse ausculatating for verification for ETI. Although the studies are nice, don't lump the thousands performed daily that are sucessful into the same group.

They hand pick areas that may or may not have adequately trained or educated Paramedics. As well, I see no mention of attempting to resolve the situation of helping or aiding Paramedics in becoming more successful in intubations such as maintaining QI or even providing airway classes by these so called professors of anesthesiology. No, its much easier to cease or cancel a self assumed procedure. I still believe ego's are involved. They failed to mention or recognize that there is less and less clinical availability by guess who? Oh, there is room for CRNA students and anesthesia students as they charge the universities to allow residents and students to allow clinical sites. One group wanted $100 per intubation attempt per patient by EMS students, of course the Paramedic training site could not afford such, they soon filled those spots with an out-of state CRNA program that did. I know of two instutions that the students have to travel > 90 miles for clinicals; because of a such scenario. Yeah, economics has nothing to do with this.... (cough, cough)

Sorry, but I know of two large services and my smaller one that has over 98% success rate and even then secondary airway placements are successful. I would love to compare that with even first attempt intubations per anesthesiologist or even ED physicians without the use of RSI in an ideal environment.

I knew Vent that you would jump on the band wagon. it must be a wonderful world everywhere you work. CRNA's work in a variety of cities and communities, yes mainly smaller ones that cannot afford an additional $250-500K for routine surgeries.

In regards to the EJ comment it was not my service or even within my state. Actually it was a hot topic at the ENA convention few years ago as it was within a state motion in a South Eastern state; not to even to allow any physicians or any other staff members to be able to perform the procedure. Yes, it was strictly money as it was primary mention that they had lost revenue as per not performing special procedures as they had previously. Fortunately, it was killed. Don't be fooled that economics does not have a major role of who and what is performed.

Vent, we realize you don't like EMS and usually rarely have any positive statements in regards to those that provide care. So be it. You are a master of respiratory and airway control and well know the risks of intubation as you stated but as well realize in the real world BVM would be as catastrophic. Studies have shown even the simple technique of CPR is difficult to perform in moving and prehospital arena and we would want to perform BVM?

I would like to see a study of those that work in anesthesia current rates on first try intubations as since the increase usage of LMA, Fastrach and other alternative airways.

As well, most of the flight teams here have went with glide scope and we are considering similar screen laryngoscopes that one can actually visually see and record as one intubates. Oh my... a kink that could prevent unsuccessful intubations and still allow prehospital providers to intubate and yes still provide the same airway as the physicians would charge to provide.

Again, another B.S. cause. Similar to the early 80's acclaiming that IV's should be discontinued in the prehospital environment; because of delay of care and so called documented that Paramedics were taking >20 minutes attempting IV's. Killing patients, even the establishment of IV in ED's were being questioned. Later to be found bogus... and from supposedly from those of high academia ratings.

Wang has yet had any positive findings in his studies of airway in EMS. Seriously, none? There are plenty of EMS services that perform quality improvement studies, yet he never compares or studies those.. Why not? Decades of studies and still none? C'mon surely one would want a fair and honest study or at the least acknowledge them?

I am all in favor of scientific studies when performed accurately and fairly. Yes, we definitely need to improve and look at ways to change to prevent and decrease errors. Just to cease a procedure because some services are not able to control and modify their programs is an injustice to those that can.

Again, what the studies has demonstrated is : Compared rates to services that do not have an abundance of Paramedics (their skill rates are above those that do). Paramedics that are well educated and have a quality control and the skills are monitored in comparison to cook book medics and services that have a poor monitoring system, have better success rates in care and skills. But wait that would make sense... implementing common sense.

R/r 911

Edited August 2, 2009 by Ridryder 911

[Kiwiology]

the fire rescue personnel trained as paramedics perform an average of 1–3 tracheal intubations per year

WTF!!! What the hell kind of operation are you guys running? In a system that large (Miami-Dade ~ 2.4 million people) a Paramedic is averaging ONE intubation a year? Last I heard we were getting about 1 intubation a week per advanced paramedic in the Auckland metro area (pop. ~ 1 million)

Heck I'm not suprised this data was so bad ...

[VentMedic]

I knew Vent that you would jump on the band wagon. it must be a wonderful world everywhere you work.

Rid, do you not realize why I am commenting about this study? My world was a lot more perfect when the FDs were selective about who rode as Paramedic.

And yes I do know what CRNAs are but in our area there is not much need for them. There are other schools that teach the CRNA program in areas where they use them. You also still have LVNs in your area but we don't have many of them around either.

Vent, we realize you don't like EMS and usually rarely have any positive statements in regards to those that provide care.

I also spent 30 years working as a Paramedic consistently while you were a nurse many of those years. I didn't run off to be an RRT during that time but rather got the education and experience many years ago to improve upon what I do as a Paramedic.

My dislike right now is because I have seen what has happened to systems like Dade, Broward and Palm Beach. If you had actually worked as a Paramedic during all of those 30 years you too might have seen the changes. You also speak as if Oklahoma is the only state that knows anything about EMS.

I do have positive remarks about those in EMS but usually not on these forums which are full of paitent bashing and rants about having to do quality care when shortcuts are so much easier. How many threads have you seen lately asking about the quickest way to be an EMT or Paramedic?

We can point to flaws in the

research and continue bad practices or take the general gist of the research

and correct the wrongs.

triemal04

This was not croaker260's quote. It was Bledsoe's.

WTF!!! What the hell kind of operation are you guys running? In a system that large (Miami-Dade ~ 2.4 million people) a Paramedic is averaging ONE intubation a year? Last I heard we were getting about 1 intubation a week per advanced paramedic in the Auckland metro area (pop. ~ 1 million)

Heck I'm not suprised this data was so bad ...

The was collected as it presented so it was not bad. The way the area has allowed anyone and everyone to do the job of a Paramedic is bad. Fire EMS in this area at one time was excellent and still can be.

Edited August 2, 2009 by VentMedic

[Kiwiology]

Paging Eugene Nagel, paging Dr. Nagel, Dr. Nagel .....

[Ridryder 911]

I also spent 30 years working as a Paramedic consistently while you were a nurse many of those years.

Actually, never left practicing as a Paramedic, as I continued in the field 10 years full time after becoming a nurse. I actually did both full time for a period of time and recently (5 yrs ago) returned back to EMS full time and do part time nursing (although at times work as many hours as a nurse than some of those of full time ). In regards to our local EMS as a being all, I am the first to describe our system is screwed up. The reason I was in meetings at two different educational facilities Friday. We desperately need to change our system, and the reason I continue to attend legislative sessions and lobby to improve on what we have or I should say don't have. The only way real change occurs. No state has the best EMS; but at the same time we have great providers that actually do know about medicine as much as some other health care providers. Something we both always agree upon that the numbers of those should be improved upon.

Fire EMS unfortunately is usually managed by those that do not understand medicine or where or what emphasis should be placed. I admit, as far as providing benefit packages and financial support and PR they usually have better options to offer (for now). Yet, there are more and more third party EMS, that now offers equal or even better benefits and their main and only focus is EMS. Something we in EMS should be supporting, as it would only benefit the profession.

The studies I believe are skewed and very biased, as I previously described. Something that a few of us that know how to read not just what is in a journal article but read between the lines as well. Yes, there are poor results in certain areas. Why? Again, look at the systems reviewed and studied. For example let's review Seattle where there is not a Paramedic patch on every firefighter but one that can provide good, quality initial care followed by a seasoned Paramedic. Yes, I do have reservations on their studies and outcomes on cardiac arrest but in comparison of intubations their numbers do not lie. The service I referred to perform thousands of intubations as well at >98 % success. How? By studies of their own, continuous improvement by implementing the usage of flex guide, ensuring EtCo2 and good assessments are performed. It really is not that difficult of a procedure as it has been performed millions of times a day, without an overall non drastic result. I agree, good proper sound education is needed but this is not neurosurgery either. There are new devices that almost totally eleminate poor visualization and even prevent movement while intubating, why has that not been discussed or explored in these so called "scientific studies" as to prevent needless deaths and poor outcomes? Again folks, I am not paranoid but seasoned as I have seen previous hidden agendas with so called studies and opinions.

Let's be very open to studies and methods to improve our care but at the same time, let's not do a knee jerk reflex because of a few bad systems that was studied. It would had made more sense to study why their system had poor intubation rates and how to correct it than to just state one's rates is poor and therefore all systems must be have the same and perform the same as well. If we did this for all hospitals and medical procedures, very few hospitals would perform many procedures and surgeries.

We need to be methodical and enforce proper education on what we have available. For a service not to utilizeand use EtCo2 is negligible. For Paramedics or those not to be able to detect a wave form and be able to interpret the changes in numbers and not perform accurate assessment techniques is non tolerable. Again, we need to improve on what we have not just remove a well needed procedure.

R/r 911

Edited August 2, 2009 by Ridryder 911

[VentMedic]

Let's be very open to studies and methods to improve our care but at the same time, let's not do a knee jerk reflex because of a few bad systems that was studied. It would had made more sense to study why their system had poor intubation rates and how to correct it than to just state one's rates is poor and therefore all systems must be have the same and perform the same as well. If we did this for all hospitals and medical procedures, very few hospitals would perform many procedures and surgeries.

Rid, did you read the full article? They did identify some of the problems as they did describe the system. They also identified alternatives. But this is not new since other systems are also looking at alternatives especially for management of trauma.

Some in EMS don't want to take the initiative to provide their own studies or just use the very few agencies like Seattle to say this is how EMS really is but yet they know it isn't. They would rather criticize those that do actually collect data than do the work themselves. As well, some of the studies done in Seattle have been disputed. If you understand anything about medical literature you would know its purpose it for debate and further research. If all those in EMS do is dismiss an artcle as BS then they have truly not understood the information.

What some also fail to see is this study was done because "trauma" consists of a system and every piece in that system must be up to par to make it work. What happens in one area may affect that patient throughout the system. When weak areas are identified, a better way must be found. There are already other studies to show that the minimalist way might be best for dealing with trauma patients. Again, this article should be thought provoking to reflect on where EMS has been and where it should be going. Medicine is constantly evolving.

The LMA is even big in the ORs now where 10 years ago no one would have thought anything but ETI should be used. Central lines were big in EMS but now that has been reconsidered. Hypothermia for ROSC was a disaster when trialed in the 1980s in prehospital but some still believe it can work with better methods available now. We've had many procedures removed from EMS but it was NOT punitive or because someone thought the providers were not capable. Research is done to see if they are necessary and at what step of the process. No one is out to punish EMS providers and one shouldn't put so must emphasis into one skill where you feel like it is a punishment.

ETI was something EMS has always been proud of especially in Miami but things have changed and possibly methods must be changed to reflect the direction things are going. It doesn't mean the whole system is bad. Fire Based EMS will be around for a long time and regardless of your attitude toward FDs, there are non Fire systems that would probably have the same results if studied. I would like to see the numbers for the areas that have EMT-Bs intubating. I would also like to see why a couple of states discontinued allowing EMT-Bs to intubate. We have a broad mix of education levels and certs in U.S. EMS so where do you want to start addressing the issues?

[p3medic]

There is little doubt that a fire department can run a good EMS system, the problem is, most don't, for a variety of reasons. Using Seattle as the example of a "good" system, you will see that they have very few medics per population, do not run fire suppression ALS companies, and being a medic is seen as a promotion, not a demotion. They staff few, well trained ALS providers that see a lot of sick patients, and pts that don't require ALS intervention are referred to BLS transport units, freeing them up to respond to another call.

Now, system 2, perhaps San Diego, LA, Metro Dade repond medics on trucks, medics on engines, medics on bikes, ambulances, etc....More medics than you can shake a stick at, yet despite putting a medic on scene in 4 minutes there intubation success rates and cardiac arrest survival rates are poor...why is that? My theory is too many medics with not enough critical patients.

This problem of oversaturation isn't unique to the fire service, however it seems to be more a problem there than elsewhere(in my limited experience). Increase the level of education and training, stop cranking out medics at a break neck pace, stop requiring firefighters to be medics, require a minimum number of intubations per medic or mandate OR time. I realize with 2500 medics this would be impossible, however if cities like Miami modeled there ALS system after Seattle, they would cut out about 2,000 of those medics, making it a much easier nut to crack.

[Kiwiology]

I agree!