Intubation FAIL

[rock_shoes]

Vent, Squint, TIMEOUT .

The fact of the matter is the system studied here has an atrocious intubation success rate. It's pretty hard to try and argue otherwise so I won't bother. This is one of a number of studies showing poor paramedic intubation success rates. I won't try and argue that point either. What I continue to strongly disagree with is the conclusions that have been drawn as a result.

As long as intubation continues to be the "gold standard" in airway management field intubations should "remain on the skill-sheet". The fact that it would be easier to just have everyone using LMA's, King LTD's, Combi-tube's etc. is not an indication that it would be better. This aggressive move towards taking the easy way out instead of fixing the QA/QI, and educational insufficiencies is disturbing. Overall I would say most people here on the city are proponents of education, and evidence based decision making. Why so many pages of discussion when the best solution is education and continuing QA/QI? The better discussion would be what form said education and conitinuing QA/QI should take no?

[joesph]

A few thoughts. The King airway is getting good reviews is this a direction that could improve the track record. Second the study does not give a well defined result for PHI and mortality, if i remember correctly the average survival rate for CPR is 17% should we discontinue that or do we give these minorities a chance. Finaly the opportunities for clinical training training is getting so muddled in politics and liability limiting protocols that we are not getting the hands on time we need.

[spenac]

if i remember correctly the average survival rate for CPR is 17%

Pre hospital is less than 5% survival to release.

[Ridryder 911]

While we are at, since one of the leading variances and dangers in patient care is the stretcher. Then maybe we should remove it as well. Since there is a large number of patients dropped, that fell and workman's comp it would be much easier just to have the patient walk to the unit.

Yeah, instead of educating and reviewing the why's and how to repair we can simply just ignore ways to improve our methods. Sure resort to doing what is the most simplistic... aren't we glad the rest of medicine did not follow that path?

R/r 911

[VentMedic]

Yeah, instead of educating and reviewing the why's and how to repair we can simply just ignore ways to improve our methods. Sure resort to doing what is the most simplistic... aren't we glad the rest of medicine did not follow that path?

R/r 911

The first step is to get providers and management to recognize there is a problem. Some may disagree with the methodology presented in this article but it has presented some data to a situation that needs attention. I do not agree with the direction Dade county has chosen as both a healthcare provider and a tax payer, but it has taken this path. Now the FD must decide whether to continue down this direction as many others have and ignor there exists a problem or deal with it head on.

There are numerous articles that are both good and bad published each month in a wide variety of journals. It is nearly impossible to track all. Those published in specialty journals such as Resuscitation and Air Medical have a more favorable outcome but there are differences in that Resuscitation caters to a worldwide audience and Air Med caters to those that have closer oversight and medication assisted ETI including RSI. We could also look at the studies done on Etomindate which has over 48 articles published just recently. Unfortunately the article with the most negative presentation was reviewed in JEMS and the other studies giving different opinions were not. As well in JEMS, the author forgot to mention the researchers own opinions for limitations of the article. Thus, if you do not read the full original article, you may miss the intentions of the authors. This may be the case in this intubation article as the authors did give background in formation and a summary of limitations for the study which are not mentioned in the abstract.

As far as the stretcher situation, I would agree it is time also for providers to be in better physicial shape for lifting and the training increased as well as monitored to lifting correctness. Providers were in better shape when the stretchers were one position which was the frame resting at 6 inches off the ground. The EMT(P)s actually had to be in decent physical shape to lift and hold a stance while nurses sheeted the patient over.

[joesph]

Pre hospital is less than 5% survival to release.

I stand corrected

[RomeViking09]

<!--quoteo(post=220919:date=Aug 5 2009, 09:07 AM:name=spenac)--><div class='quotetop'>QUOTE (spenac @ Aug 5 2009, 09:07 AM) <a href="index.php?act=findpost&pid=220919"><{POST_SNAPBACK}></a></div><div class='quotemain'><!--quotec-->OK I am know going to speak so everyone sit down shut up and listen. <img src="http://www.emtcity.com/public/style_emoticons/<#EMO_DIR#>/wink.gif" style="vertical-align:middle" emoid="" border="0" alt="wink.gif" />

Now that I have your attention I feel we should still have intubation available. Why? Because I have had multiple patients that would have died prior to reaching the hospital if we had not intubated before the airway closed. So my question is based on most everyones over reacting should we remove the intubation ability and just watch these people die as their airway finishes closing?<!--QuoteEnd--></div><!--QuoteEEnd-->

Spenac, your situation where you have an hour's drive to a hospital is not the norm for everyone in EMS.

Maybe some have not become proficient in alternative airways or the use of the BVM. One of the first things we learn even working in the hospital is how to maintain an airway by various means. If you do flight, you definitely learn alternative means because you prepare for the worst and hope for the best. Look at the Anesthesia docs. Very few ETIs are done now in the OR. This is also one reason why Paramedic students can not get the intubations they need during their OR rotations. Very few will allow ETI just because. Yes ETI is a definitive airway but one should NEVER limit themselves to just one way of establishing an airway. I guess I now know why some Paramedics/students have that deer in headlights look when their assistance is requested for a couple of minutes to bag an apneic patient or one requiring ETI on scene or in the ED. They may have gone straight to performing ETI on a manikin and failed to learn other important things like a BVM or alternatives.

I also find it just as tragic for the patient when the pharynx and cords are so butchered with repeated attempts that a trach will be required, quite possibly permanently, because some didn't know how to assess a difficult airway and consider alternative methods. Or, when they have been told "Paramedics only do ETI" and their ego or pride make them jab away to get that tube. Regardless of how long it takes on scene (or even in the back of an ambulance sitting in the hospital driveway) or the damage they do, they must enter the ED with a tube. Of course, you also have the other end of the scale where some can't be bothered to do ETI.

RNs are much easier to train for maintaining an airway for Flight and Specialty teams because they have no preconceived notions or egos of what must be done because they have seen many different airways used and have had to become proficient in the use of a BVM if they are assisting the intubator. That could also mean bagging for a long time if it is a teaching hospital and the attending decides to lecture first. RNs have had to learn to be versatile when going from one unit to another and learning different procedures or adapt what their know to do it another way. When training Paramedics, they usually have one way set in their brain and that is it.

I am not one for removing ETI totally from prehospital but maybe the training and attitudes need to handled differently. Maybe more emphasis should be placed on airway assessment and determining necessity or difficulty instead of just doing a skill. I also know you have read the intubation threads on the forums by the students who talk about "getting tubes". How many acutally discuss the airway? They might as well be intubating a manikin.

As a current paramedic student who just finished airway and is about to start clinicals I would like to drop my two cents into this "topic". We spent 2 weeks learning about the anatomy, physiology, and pathophysiology of the airway, when to take control of that airway, what methods we have to take control of the airway. Our instructor focused more on management of the airway as a whole and did not focus on just one way to control a patient's airway. Intubation is best used for total airway control in a patient who can not protect their own airway and is going to be given positive pressure ventilation. Just like there are problems with intubation there are also problems with CombiTubes and King Airways. The King Airway does not provide the same back up method as the CombiTube. If you place a King into the trachea you can not ventilate the patient and you must remove the airway device and re insert, this can be a problem with patients with short airways and lots of inflammation of the GI tract. With the CombiTube and King you can not protect a closing airway such as a patient having an allergic reaction and may have to result to in surgical airway methods. If we don't want to be performing more needle and/or surgical cricothyrotomy airways we need something better than blind devices such as king and combitubes. Now what only a few people have pointed out is improve our training in assisting with intubation with devices such as the lighted stylet, retrograde intubation, bougies, and field fiber-optic scopes.

We are lucky to have a hospital that will allow our paramedic students to manage airways on patients undergoing scheduled elective surgery as part of our clinical rotations. We have to get 5 intubations but we also have to perform alternative airways including LMAs, CombiTubes, King Airways, and even good old fashion BVMs with OPA or NPA. It seems to me that more people focus on just intubation as the only form of airway management, intubation is one of many options we should have. From a textbook only point of view a good paramedic should be able to not only intubate but also use blind airways, and perform needle and surgical cricothyrotomy airways. Just because your patient is in cardiac arrest does not mean they need to be intubated, a king is all they need. We also need to remember that we do not have the "right" to do anything as paramedics. We are working under the license of a medical director and he or she gives us permission to perform medical care under his/ her supervision. If the powers that be say no intubation then no intubation and if you want to tube go back to school and become a CRNA or PA or CNP or MD. We should strive to provide the best patient care and give our medical directors reason to let us do more, but we must never get the idea that we have the "right" to do anything we do in EMS.

"Skill authorized to the paramedic in their scope of practice are not a right but a privilege given by the medical director."

Nancy Caroline's Emergency Care in the Street 6th Edition page 1.15

[ERDoc]

A few thoughts. The King airway is getting good reviews is this a direction that could improve the track record. Second the study does not give a well defined result for PHI and mortality, if i remember correctly the average survival rate for CPR is 17% should we discontinue that or do we give these minorities a chance. Finaly the opportunities for clinical training training is getting so muddled in politics and liability limiting protocols that we are not getting the hands on time we need.

The difference is that CPR is the gold standard. We don't have anything better. You also can't make someone who needs CPR any worse. With intubation you are taking a potentially salvageable outcome and subjecting them to a procedure which will kill them if not done correctly. Why subject pts to that risk when acceptable alternatives are available that are just as good and don't guarantee death if not done properly? I hate to beat this dead horse, but the key here is better education (not training) at the college level.

[RomeViking09]

The difference is that CPR is the gold standard. We don't have anything better. You also can't make someone who needs CPR any worse. With intubation you are taking a potentially salvageable outcome and subjecting them to a procedure which will kill them if not done correctly. Why subject pts to that risk when acceptable alternatives are available that are just as good and don't guarantee death if not done properly? I hate to beat this dead horse, but the key here is better education (not training) at the college level.

With the better education do we need to limit those who are not educated to the "new" standard from performing skills they have been doing for some time now?

[ERDoc]

With the better education do we need to limit those who are not educated to the "new" standard from performing skills they have been doing for some time now?

If you are asking me if we should continue to allow people that cannot intubate properly to do so, I'll let you be the judge.

My full answer is too much for this particular thread but I'll try to make a long story short. Minimum of a bachelor's degree for paramedic with a larger scope of practice. Required internship similar to what doctors go through. National standards to be set up by governing bodies similar to what physicians have. Those with previous experience can be grandfathered in assuming they can pass the qualifying exams.