Intubation FAIL

[Arctickat]

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.

That's what I am trying to express though. If etCO2 were mandatory on all intubated patients it would go a long way to confirming and more importantly, monitoring tube placement. I suspect that many cases of those esophageal intubations are actually properly placed tubes which became dislodged following movement.

[JakeEMTP]

I agree with Kat. In our little corner of the universe, etCO2 is mandatory on ALL ett intubations. There has been a significant increase in successful intubations as per the Medical Director although I have not seen data to back up that claim, so take it as you will. Only recently we have been given a bougie on the ambulance. I have used it once for a pt. who was extremely anterior. Great little tool. Apparently, the Medical Director is satisfied that we have a handle on the intubation that we recently trained on the Melker surgical cric kit. Just another tool to manage the airway.

[chbare]

More evidence to throw on the already impressive pile of evidence that does not support EMS intubation. While others may have a point regarding ETCO2 use during intubation, this is only one part of the issue. Complications during intubation such as arrhythmia development, desaturation, and hemodynamic changes may go unreported or unrecognized. I will try to find a study where paramedics were asked how they felt the intubation went, and most answered it went fine without any known problems. When in fact, their equipment had continuously monitored and transmitted the date obtained during the said intubation. Unfortunately, the number of unrecognized problems during many of the intubation procedures were numerous. What good is having ETCO2 to verify your tube when you caused your head injury patient to desaturate or drop his/her MAP during the procedure?

IMHO, the take home lesson of all this data is the following: The ball is now in our court. We will have to prove that we can safely intubate patients, and prove that what we do benefits patient outcome. We need to quit looking at this as something personal and we need to quit saying, "In my system..." The data is against us. If your system is different, you need to get off your duff and push for studies that back up what is coming out of your mouth. If we cannot provide large amounts of peer reviewed data to counter the current trend, then I can see the ETT becoming less popular.

This data does not include looking at the ER's and saying , "Oh yeah, well the ER doc messes up, so there." We cannot justify our bad behavior by looking at other peoples bad behavior. This is our problem and we need to prove we have the solutions.

Nothing personal guys, just my thoughts as they relate to the data.

Take care,

chbare.

Edited August 1, 2009 by chbare

[VentMedic]

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.

CRNAs are rare around these parts.

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 can assure you our doctors do not need to troll the ambulances looking for money. If the EJ was removed from your protocols it was probably because someone cannulated something other than the jugular or really mucked it up.

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...

So Rid you believe there is no problem with teaching 2500 Paramedics in one county to intubate? That doesn't even include the many Paramedics working private ambulances or Flight services. This study was done as a wake up call for some to realize that just maybe there might be a problem. I know I've given many examples in my threads of things gone wrong and I haven't scratched the surface.

I can post the whole article when I get back to my own computer next week unless someone with a subscription or university access can paste a copy.

I suspect that many cases of those esophageal intubations are actually properly placed tubes which became dislodged following movement.

We can continue to make excuses or we can also address the problems. I have been in the ED when some of these patients have come in and no, the tube didn't "just" come out of place. I am looking at this as a Paramedic, RRT, Researcher and Educator. There are many factors here. However it seems some in the profession start to get all offended or mushy when a county is asked to answer for the data collected. Since the full article is not readily accessible, many are making a judgement without reading the entire article or knowing the culture of the area. I personally applaud this study since I have followed it and I do hope that Miami can save its reputation. This is just one area that needs to be addressed. Unfortunately, if the other problems were actually presented in another article some here might have a stroke without even knowing where Dade County Florida is.

[Kiwiology]

Here if the New Zealand study on intubation/RSI (although tis is a bit old, I'll talk to our medical director and see if we can get some better numbers) http://adhb.govt.nz/trauma/Forums07/prehos...ehos_intub.html

Questions that come to mind:

1. If we remove intubation, what do we replace it with to deliver definitive (?) airway control? and

2. Do we need more airway control beyond what a King airway or LMA can provide?

[triemal04]

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.

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?

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.

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.

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.

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.R/r 911

Probably the most salient points made so far.

This is why studies relating to EMS should not automatically be done in areas with the largest number of incidences; yes, it will take longer to get enough data to reach a conclusion, but all to often the areas with a high volume also have pathetic EMS services. p3medic can correct me if I'm wrong, but I believe there was an internal study done in Boston awhile back that had a much different outcome as far as successful intubationspractice and undetected esophageal intubations were concerned. Appropriate oversight, QA/QI, internal/external continuing education/training, and good initial education can make a huge difference in the results of a study (depending on the subject matter anyway). The kneejerk reaction would be to limit what we can do, but if that reaction is based of the lowest common denominators...perhaps a better way would be to look at what good systems are doing and focus on bringing people up to THAT standard.

And, without knowing why the authors choose to count LMA's/combitubes as a failed intubation (beyond the obvious that an ET tube wasn't placed...anyone know please share) gotta call it a BS move to include them in the total number of failed intubations; knee jerkwhile an ET tube was not placed, the airway was successfully secured beyond only using a BVM and OPA/NPA. Not ideal no, but a distinction should be made between being unable to place a tube and unknowingly placing one in the esophageus. That (12% esophageal intubations) is unacesophagusceptable any way you look at it, and should be the more important part to look at. I will note though that 10-12 years ago a similar study was published (also based out of Florida) that showed somewhere between 20-30% unrecognized esophageal intubations before the widespread use of capnography. It's still unacceptable, but things do seem to be improving (though much to slowly), and as capnography becomes more and more used hopefully that number will continue to fall...though it may be to late.

[VentMedic]

And, without knowing why the authors choose to count LMA's/combitubes as a failed intubation (beyond the obvious that an ET tube wasn't placed...anyone know please share) gotta call it a BS move to include them in the total number of failed intubations; knee jerkwhile an ET tube was not placed, the airway was successfully secured beyond only using a BVM and OPA/NPA.

If you note the term "rescue" is used with LMAs/Combitubes which also means this device was used after attempts at ETI was used and not necessary as a frontline because they deemed the tube difficult by assessment.

The other study was in central Florida near Orlando and yes that did not have good numbers either. Both studies were done after major changes to the departments. Again, one would have to know Dade county a few years ago and their successes to where no one would ever have questioned ETI to what it has become now.

Edited August 2, 2009 by VentMedic

[triemal04]

If you note the term "rescue" is used with LMAs/Combitubes which also means this device was used after attempts at ETI was used and not necessary as a frontline because they deemed the tube difficult by assessment.

The other study was in central Florida near Orlando and yes that did not have good numbers either. Both studies were done after major changes to the departments. Again, one would have to know Dade county a few years ago and their successes to where no one would ever have questioned ETI to what it has become now.

I understand that part, and yes, if a backup airway had to be used then the intubation did fail. But, this could have happened for multiple reasons, from poor prep/inexperience on the medics part to a anatomical problem that was not found during the intubation assessment. What I'm getting at is that it may have been used through no fault of the paramedic. This is not the case with esophageal intubations though; all the blame rests on whoever passed that tube. It's a bit disingenous to use both types of situations (back up airways and esophageal intubations) for the total number of failed intubations without breaking down why each backup was used; makes the numbers look worse than they allready are.

[croaker260]

There is an awesome discussion on this topic on the NEMSMA google group...here are some highlights...I post them here because in many cases they say thoughts better than I could.....

Another detail not mentioned is that the study only looked at trauma

patients requiring PHI. Is it fair to extrapolate the success/failure

of trauma tubes to all prehospital tubes?

Saw this one too and was going to review it for JEMS but was totally

confused by their methods. Poor definitions and tracking. Then when I

got to their conclusion I almost crapped my pants. Even if you

misplaced the tube it did not have any impact on mortality? I find

that hard to believe. This raises questions as to their definition of

"failed" PHI.

Bad study but unfortunately its going to get some press.

In this study, securing the patient's airway was sometimes a failure to secure the patient's airway :-/

"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."

WTF? How is it supported, if it wasn't included in the study data? It is a complete non sequitur that to me is sufficient to call the entire study into question. I can make a clearer case (I know the numbers are not really there, but bear with me, its still a better case) that since 79% died with Combitube, 68% with esophageal intubation, 67% with LMA, 60% with successful PHI, and only 50% with cricothyroidotomy that we should cric all compromised trauma patients and discard the other methods as too dangerous. At least some cric's were included in the observational data.

And, while we are at it, since 60% died with successful PHI and aeromedical providers are more adept at providing this dangerous procedure, we should deny them landing rights at our scenes less they interfere with our surgical airways! Again, it at least includes data that was observed!

People on both sides of this issue (as with most studies) will find that for which they are looking. I wonder if they considered classifying all patients who did not require airway intervention as PHI "failures" to juice the numbers? Just think of it, another 2,500 "failures," who are likely to have better survival stats, because they are less injured. They missed that opportunity. Of course they also missed the opportunity to include the 1,117 patients who were intubated in hospital but were not afforded PHI. I wonder what the comparison would be? Better? Worse? We can't know, because it was left out of the analysis.

..I am perplexed that the study references the use of EtCO2 ("All procedures need to be confirmed by physical examination and end-tidal CO2 assessment."), but does not provide any of that data. If it were used, wouldn't it have diagnosed the esophageal tubes in the field? If that were the case then 12% of the patients (with a 68% mortality) could have had the failure corrected in the field, possibly with improved results. (Assuming that they avoided the deadly Combitube, of course). If EtCO2 was not used, then its hard to compare the field practices of this system and its medics with those that have been using the tool for a decade or more. Using data from systems that are not up to speed with current practice and then extending the results to those that are is flawed. Also, I did not see any reference to the number or length of attempts to intubate. If a medic tried 3 or 4 times and took 3 minutes to do each attempt, would that be a failure or a success? Those kind of things might skew the survival data a little.

Anyhow, I see this as yet another study that just muddies the water. I'm truly not for or against PHI. I just don't see anything here to convince me one way or the other.

ANd here was my contribution to the discussion.... It was in reply to a comment that ETT as a gold standard and successful airway doest translate to a good airway for EMS...and the comment evolved from there...

I would (and do) agree with you on most of your points Tim...But for one thing... If the ETT didn't translate well to the pre-hospital environment, then we would see universally poor success rates across the board, in GOOD systems and BAD. But that’s not the case. SO we must ask ourselves WHY. Perhaps the cause isn’t the ETT, but something behind the ETT. Remember , patients don’t clinically change when they wheel through the door of the ED…And They certainly don't change in when lying on the street in Miami as opposed to Seattle. The fault isn’t the ETT, but the medic behind that laryngoscope blade, and the system behind the medic.

I have said this before......I think that there are some (few) systems that do it well, why arent we taking what they do well and publish a "best practices" for services that want to continue to use ETT? I think we don’t because we don’t have the balls to do so. Perhaps because that would cause us to ask uncomfortable questions on system design, training methods, and lack of support from our "allies" in hospital.

I truely think we are oversimplifying the issue because the ETT is easy to blame. The simple truth is we train medics to intubate poorly in school, we reinforce that poor training with more poor training, we support this training poorly, and then we blame the medics and the device. WE (administrators, Physicians, Educators, senior role model medics) are to blame.

Ironically, We are at a cusp of turning that around with high fidelity simulators (as one example), more funding at the organizational level in training, More emphasis for real FTEP programs, and better EBM.

Now I am going to sound like one of those medics who refuses to let go of the past, ....I'm not. BUT, Im not one to get caught up in HYPE either.

For example, I think the services that have gone to a 1 or 2 ETT attempt rule based on statistics of first time success vs second attempt success are right on. But I also think that we are COMPLETELY ignoring improving that first time success rate in favor of simply pushing the King, LMA, or other device. The manufacturers are having a field day with this of course, because it means more $$$ in their pocket.

Can we all agree that if most services had a first time success rate >90% (or like the KCM1 system, >95% IIRC) this would be an absurd discussion? Why, because clinically, the ETT is superior.

OK, BEAR WITH ME On this one…..Clinically, I remain unconvinced that the King, Combi tube, PTL, or LMA are "as good" as the ETT. Yes, we can oxygenate as well as an ETT with these devices, and yes these are the ultimate issues, but not the only issues...... Issues such as tissue necrosis, cuff pressures, airway swelling, {{big issue anecdotally}}difficulty by ED docs replacing the alternative airways with an ETT, risk of aspiration, ability to use PEEP, and related issues have all be conveniently ignored in the hype and rush to replace ETT and seem "cutting edge". THESE ARE REAL CLINICAL ISSUES, just because these are not discussed in training, in chart review, and in school doesn't mean they don't exist. Ask any RT that manages vents in an ICU if I'm lying.

This also completely ignores the fact that the cost of an ETT compared to any of these other devices is much different as well. There are far cheaper, and IMHO BETTER ways clinically ways to address this issue.

Just my ideas that would dramatically change the landscape of this discussion....

1- Start at the beginning.....Since too many medic schools out there teach to the NREMT, completely DITCH the old ETT skill sheet station for NREMT and any state agency that uses something similar. Trying to ETT in 30 seconds or less is not an indicator of skill nor even of proficiency. Replace it with a "mega Airway" (think Mega-code) clinical thinking station using difficult airway simulators iin the NREMT...then all schools would change their teaching methodology.

2- Now this is a fix that EVERY service can do.....Anecdotally, both personally and in my contacts locally, providers that have begun ALWAYS (whether anticipating a difficult airway or not) using CHEAP devices like the BOUGIE have seen their first time success rates approach 100%. Think about it, if these large, overburdened, under trained services with hordes of medics; mandated first time intubation with a cheap device like the bougie, besides the cost savings, think of the clinical impact on patients. They would have an airway that didnt need to be replaced If it did need to be replaced, it didn’t make replacement more difficult when it did happen or require an anesthesiologist to make it happen, They would get an airway that there is a long Hx of PEEP and ventilator management with, And they would get an airway that was FDA approved most of the reasons we would use the ETT. (Ever look at the package inserts for the King or other airways, the list of relative contraindications includes CHF, COPD, and many other uses) I bet ETT success 1st time would improve 20% AT LEAST. (then follow that with ETCO2)

3- A position paper by SOME group on best practices on what to do to be fully successful with ETT, instead of simply stating get rid of it. The changes made by most services to meet these best practices would pay dividends way outside of the discussion of airway management.

4- And I know this is a PIPE DREAM, but tying the ORs accessibility to EMS to accreditation as a trauma center, burn center, pediatric center, XYZ center, what ever......and provide legislative immunity to hospitals that do open their ORs up, since this is a public health issue. (SIDE THOUGHT: What if reimbursement improved for EDs if they were accredited “Emergency Centers” like “STEMI Centers”, “STROKE CENTERS”, etc…..Hmmmm)

5- Readdressing the Advanced Practice/Expanded scope/what ever you want to call it…degreed paramedic. Move these high risk skills (ett, RSI, many medications, etc) firmly over there to the new level, and tie it to increased training and other benchmarks. Leave the King and ETT of dead floppy patients who arnt going to survive anyway to those paramedics (they are still called paramedics) and systems who cant or wont invest the extra effort.

In closing:

I hope you can see I'm not trying to be a cheese hording mouse (that’s for Troy), but realizing that if we all want to keep the best cheese possible, we need to change the way we store, make, and even eat our cheese, or else we will be “making do” with cheese that someone else is giving us…no matter how we tell people is just as good… really isn’t. It will keep us from starving, but it isn’t as healthy as the cheese we had. Its up to us to determine the type of cheese we get.

And I readily admit that If we cant make those changes, then we deserve what we , and our patients, get. And I know that many services cant…or wont..until made too.

Edited August 2, 2009 by croaker260

[VentMedic]

At least they were able to put the whole article on that site on Google.

From the article:

During the study period, trauma patients were

initially treated in the prehospital setting by fire rescue

personnel of various municipalities and with different

experience levels; typically, the fire rescue personnel

trained as paramedics perform an average of 1–3

tracheal intubations per year and must undergo periodic

assessments of their training and ability in airway

management and intubation skills.

Bryan Bledsoe's comment:

There are methodological flaws in many of the airway studies. Henry Wang's

studies have been pretty methodologically robust. The nature of EMS is

difficult to measure and there always will be issues related to quality of

the studies. Regardless, there are now 20 or so studies from 10 or so

separate data sources showing a problem with prehospital ETI and there are

few studies showing an outcome advantage. We can point to flaws in the

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

and correct the wrongs. We're starting to sound like the CISM people now

(e.g., the studies are flawed, they did not do it like we taught them, the

researchers are biased [a priori], or the constant referral to anecdote [i

remember a patient...]).

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.