Intubation FAIL

[CBEMT]

I would like to see the numbers for the areas that have EMT-Bs intubating.

Speaking for my area that has this, the chances of an EMT-B having a chance to intubate anyone is so small that I'm starting to believe that the reason ETI is a separate license after EMT-B licensure is to make money off them. I don't know any Basic that's done it, and I'd be floored if any of them know a Basic that's done it.

It's not so much that the numbers are bad- it's that there are, near as I can tell, no numbers.

Edited August 4, 2009 by CBEMT

[DwayneEMTP]

You know, this is where I get confused....

"If numbers don't improve then you're going to lose your right to intubate!"

"If you don't prove that you can do it effectively then they are going to take it away from you!"

"The science says that it makes no difference even if you're competent so you're going to lose it if you're not careful!"

I think I'm genetically damaged as a medic in that intubation doesn't make my nipples hard like it's supposed to. If it became a basic skill tomorrow my basic could do every one if s/he wanted..I've just never found it to be that sexy of a skill.

It took me less than an hour to understand the mechanics, practiced a few hours after that (a gazillion maniquins and 16 live as a student), I've successfully intubated a few dozen times since learning without a failure, there's nothing terribly challenging as to deciding medical need (with the exception of nasal intubations, for me at least). It took me longer to become proficient at starting IVs than it did to successfully intubate, and I certainly do more good with those.

Why is it that we daily preach 'Science Based Medicine' yet when it comes to ETT we suddenly begin to use words like "Have the right", "Going to take it away", "May lose the priveledge."?

If the science shows that our properly placed, maintained, and managed tube is not improving patient outcomes then we should all say good riddence, shouldn't we? Spend that time doing something more productive?

I don't mourn MAST pants,

I don't wish I could still do the Heimlich on drowning patients,

I have no desire to return to uncontrolled fluid delivery on trauma patients,

I don't yearn to hyperventilate head wounds,

and if the SOLID science says I'm wasting my time....I'll never give intubations another thought.

Why does EMS seem to have such a hardon for intubations?

Dwayne

[rock_shoes]

You know, this is where I get confused....

"If numbers don't improve then you're going to lose your right to intubate!"

"If you don't prove that you can do it effectively then they are going to take it away from you!"

"The science says that it makes no difference even if you're competent so you're going to lose it if you're not careful!"

I think I'm genetically damaged as a medic in that intubation doesn't make my nipples hard like it's supposed to. If it became a basic skill tomorrow my basic could do every one if s/he wanted..I've just never found it to be that sexy of a skill.

It took me less than an hour to understand the mechanics, practiced a few hours after that (a gazillion maniquins and 16 live as a student), I've successfully intubated a few dozen times since learning without a failure, there's nothing terribly challenging as to deciding medical need (with the exception of nasal intubations, for me at least). It took me longer to become proficient at starting IVs than it did to successfully intubate, and I certainly do more good with those.

Why is it that we daily preach 'Science Based Medicine' yet when it comes to ETT we suddenly begin to use words like "Have the right", "Going to take it away", "May lose the priveledge."?

If the science shows that our properly placed, maintained, and managed tube is not improving patient outcomes then we should all say good riddence, shouldn't we? Spend that time doing something more productive?

Absolutely. However, from what I've read so far, a quickly and correctly placed tube does not negatively affect outcomes. It's the high (not everywhere of course) rate of pooched intubations that negatively affects patient outcomes.

I don't mourn MAST pants,

I don't wish I could still do the Heimlich on drowning patients,

I have no desire to return to uncontrolled fluid delivery on trauma patients,

I don't yearn to hyperventilate head wounds,

and if the SOLID science says I'm wasting my time....I'll never give intubations another thought.

Why does EMS seem to have such a hardon for intubations?

Dwayne

To the best of my knowledge intubation is still considered to be the "Gold Standard" in airway management. As long as that's the case doesn't it make the most sense to QI the living daylights out of everyone to the point that everyone is able to maintain a high success rate on the first try? If an individual is unable to attain that high success rate then intubation should cease to be a part of that individual’s repertoire. For example. In my current service I am allowed up to three attempts to start an IV. I never take more than two and usually only one attempt(s) because I know that my chances of success on the third attempt are extremely low given that I missed the first two. If you miss your first intubation attempt odds are good it would be more prudent to use a different adjunct and move on rather than mess around with repeated attempts. I'm not going to get into failure to confirm placement because frankly failing to confirm (or at least attempt to confirm) placement is just plain negligent. You wouldn't push D50W without making sure the patient’s IV was patent would you?

If there is a better, more easily placed, adjunct available, then I agree whole heartedly that the ETT should be dropped from the pre-hospital environment. Maybe the next round of studies should focus on which adjunct would best replace the ETT? A design competition maybe? If multiple studies show something to be a problem shouldn't the next round of studies focus on what can be done to fix said problem? Why flog a dead horse when "Lazarus" himself is tapping you on the shoulder saying "I think it’s dead".

Edited August 4, 2009 by rock_shoes

[tniuqs]

Dear Dwayne:

Without a definitive airway, aspiration and subsequently acquired pneumonias are the biggest killers in the recovery of stabilized Trauma patients in the ICU setting, (especially the OD patient, that is EBM)

WE KNOW that ETI is the patients best chance at survival, to the best of my knowledge have has any studies done on ANY Rescue Airways in regards to aspiration or VAP, its not a matter of feel good it is a matter of EBM, so if one airway is so called "protected" with LMA or Combi or King ... and is going to go to OR stat ... Anesthesiology usually re intubates, exposing the Airway to further possibilities of aspiration, no mention of that issue at all, and in this study no mention of what patients are then receive a hole in the neck in ICU or during surgery ... weird Eh ?

Head Bledsoe's Words:

We can point to flaws in the research and continue bad practices or take the general gist of the research and correct the wrongs.

As in my previous posts address the issue as a professional group ... the Profession of Paramedicine should take a hard look and improve and constructive criticism is a good thing so look to the future, Do Not extrapolate 30% of us suck at ETI ... Oh well I don't care, seriously we will never advance this profession with that "tude" dude, or are you happy driving that taxi

Besides Outcome studies ie Survival rates with an extended Hospital stay(s) based on ONE field intervention are ALL seriously flawed. The success fail ratio should be the focus, could there be an underlying "wallet issue" in all this cough splutter, no Anesthesiology with money invested in "alternative research items" ok right then.

Dear Rock Shoes:

If there is a better, more easily placed, adjunct available, then I agree whole heartedly that the ETT should be dropped from the pre-hospital environment. Maybe the next round of studies should focus on which adjunct would best replace the ETT? A design competition maybe?

Disagree go for Gold or Go Home attempting to reinvent the wheel when one just has to reevaluate the Tire heck maybe procedure is the real issue ie maybe introduce a bougie FIRST or lighted stylette (no mention of those alternative item's in this study) Seriously not good methodology inventing something to make up for errors in education, practice and procedure if one dares to believe that there is a zero failure rate by ER MDS (hear me laughing in the background) or even have a Gas Passer on immediate call in Williams Lake or Hazelton ??? well WE live in an entirely different word ... WE only have a select few centers that even offer this type of service.

Unfortunately these studies are quoted by EMS medical directors in other countries (like ours) and reflect poorly when there is NO impartial EBM studies on ETI in these areas (and outcomes dare I say) that are no where near a large metropolitan trauma center, this has reflected very poorly on all of we peons in the boonies.

Hell from "Sydney to Victoria" or "North Van to Downtown" in heavy traffic takes 30 minutes VERY unlike having 3 trauma centers in a 10 block radius.

Did I miss in the study the optimal time frame to BVM a patient too ?

cheers

[VentMedic]

Without a definitive airway, aspiration and subsequently acquired pneumonias are the biggest killers in the recovery of stabilized Trauma patients in the ICU setting, (especially the OD patient, that is EBM)

WE KNOW that ETI is the patients best chance at survival, to the best of my knowledge have has any studies done on ANY Rescue Airways in regards to aspiration or VAP, its not a matter of feel good it is a matter of EBM, so if one airway is so called "protected" with LMA or Combi or King ... and is going to go to OR stat ... Anesthesiology usually re intubates, exposing the Airway to further possibilities of aspiration, no mention of that issue at all, and in this study no mention of what patients are then receive a hole in the neck in ICU or during surgery ... weird Eh ?

But is ETI always the best course for prehospital? We know what has to be done in the hospital which sometimes also includes changing out field tubes to place one that will help prevent VAP or make a ventilator stay for more than 24 - 48 hours safer and more adaptable to the hosptial technology. The Federal and State insurances have spoken loud and clear. They will not pay for infections and complications caused by medical professionals. EMS has yet to feel that bite but yet many forget healthcare is a system, especially trauma, and what happens or doesn't happen in the field can directly affect outcomes in the hospital.

Edited August 4, 2009 by VentMedic

[chbare]

Vent, absolutely a great point. Pre-hospital intubation because the patients clinical course may include a trip to the OR is simply not a good argument for the said intubation. Unfortunately, from the data I have seen we continue to contribute to morbidity and mortality by intubating people in the pre-hospital environment. All this argument about aspiration and golden standard airway protection really does not seem to pan out when looking at the evidence.

As I have stated in the past, EMS will have to step up and prove that intubation does in fact improve outcomes when utilized by pre-hospital providers. A mountain of evidence now exists that does not support the said concept. We can continue to cry about Wong hating on EMS or actually present our own evidence. Of course, this would mean EMS providers would have to further their education and take an active role in research.

Tniuqs, I can understand your point; however, I have yet to see many EMS providers take any steps to improve this situation. In addition, I am basing my stance on EMS in the United States. I cannot comment about morbidity, mortality, and outcomes in services outside of the United States.

Take care,

chbare.

[tniuqs]

But is ETI always the best course for prehospital? We know what has to be done in the hospital which sometimes also includes changing out field tubes to place one that will help prevent VAP or make a ventilator stay for more than 24 - 48 hours safer and more adaptable to the hosptial technology. The Federal and State insurances have spoken loud and clear. They will not pay for infections and complications caused by medical professionals. EMS has yet to feel that bite but yet many forget healthcare is a system, especially trauma, and what happens or doesn't happen in the field can directly affect outcomes in the hospital.

Ok a different spin on this topic now.

I became a Paramedic to Protect Airways and take away Pain .. just had too many on a BLS level puke and aspirate when one lifts them off the floor of the kitchen or bathroom ... that because Basic FF providers would effectively fill there guts with AIR ... on that note maybe the First responders using the "coup de grau technique" should they be sent the tab for causing an aspiration pneumonia in very the first contact.... how the hell will the private insurance or government decide where to stop, come on they use this as the "funding escape clause ONLY" Always a matter of who's to BLAME in the healthcare system in the US, instead of the drunk rolled his truck .... its never root cause and effect.

ETI with distal suction port is the best Option in my hood from field to rural facility to then definitive care center... period, these BS studied being produced out of the US are affecting my Practice that is what really pisses me off huge and in 27 years I have managed to shoot every tube successful, well except for one (just as well in that case)

Thank God I am not covered by your federal or state regulations on who gets paid what confusing cost and optimal care are fundimentally wrong on every level where I live.

So if someone pukes because they did not get RSI ed is that "not" covered either as IF pre or post VAP can be actually a measured value ? Honestly that is Total CRAPPOLA and I know that you know it too Vent (does it come down to trying to evaluate on who's shift the pneumonia is caused or just a blanket policy ?

Besides any Airway Trach even newer ETI with suction ports for below the cuff, Micro aspiration is ALWAYS a possibility its NOT perfect EVER, but sending the bill to insurance or a lawyer is not the motivating factor in delivery of my care, and then extrapulating outcome, from First Responder to End Physio (and ALL that is in between) to discharge or Funeral Home is a cop out by your state bean counters.

Want to compare cost OK ..

ETI about $15 bucks, bougie $10, LT King/ Combi about $80 to $120 for 20 minutes of use.

Come fly with me for 4 hours from High Level or Ft Mac with a Combi tube or LMA on a ventilator or receive a patient in ER and then immediately have to change out an invention from hell ... ALL the ER docs I work with manage the AIRWAY and replace the monstrosities of plastic "STAT"

Point being you can't use Technology to make up for poor education and your medic mills, giving a L scope to every Hose Monkey and believing that will stop the deaths from Poly Trauma..... MYTH BUSTED.

Despite all the advances in modern medicine PEOPLE DIE is just the way it is.

cheers

[HERBIE1]

But is ETI always the best course for prehospital? We know what has to be done in the hospital which sometimes also includes changing out field tubes to place one that will help prevent VAP or make a ventilator stay for more than 24 - 48 hours safer and more adaptable to the hosptial technology. The Federal and State insurances have spoken loud and clear. They will not pay for infections and complications caused by medical professionals. EMS has yet to feel that bite but yet many forget healthcare is a system, especially trauma, and what happens or doesn't happen in the field can directly affect outcomes in the hospital.

Many hospitals as a matter of procedure, routinely disconnect and restart field IV's because they feel the conditions in which they were started were probably less than optimal. It's a CYA thing- regardless of patency or size, they are worried about infection, thus lawsuits.

Same for ET's. If a doc signs off on a tube or procedure, they are agreeing that all procedures done to that point are satisfactory.

[tniuqs]

Tniuqs, I can understand your point; however, I have yet to see many EMS providers take any steps to improve this situation. In addition, I am basing my stance on EMS in the United States. I cannot comment about morbidity, mortality, and outcomes in services outside of the United States

.

chbar:

Enjoyed the motivational post at the onset of this thread .. and I was not going to touch this topic with a 10 foot pole .. but Dwayne poked me in the chest ... again.

So what would you say if your employers took away your L scope in your remote clinic if guys back on a different continent were screwing up royally and have no idea what we deal with in austere/hostile settings and no EBM research to back your position ...

But ok, if I am 10 minutes from an ER and a Polytrauma its BVM and Punch it Chewy ... more that 30 minutes and I am shooting a ETI .

cheers

Many hospitals as a matter of procedure, routinely disconnect and restart field IV's because they feel the conditions in which they were started were probably less than optimal. It's a CYA thing- regardless of patency or size, they are worried about infection, thus lawsuits.

Same for ET's. If a doc signs off on a tube or procedure, they are agreeing that all procedures done to that point are satisfactory.

Ok be realistic are you driven to provide best practice OR worried about Lawsuits ?

Your post speaks for itself.

cheers

[VentMedic]

Many hospitals as a matter of procedure, routinely disconnect and restart field IV's because they feel the conditions in which they were started were probably less than optimal. It's a CYA thing- regardless of patency or size, they are worried about infection, thus lawsuits.

Same for ET's. If a doc signs off on a tube or procedure, they are agreeing that all procedures done to that point are satisfactory.

It is not lawsuits. State and Federal insurances will not pay for the infections. A "simple" course of antibiotics can be quite expensive and extend the hospital stay by several days. One infection can have a catastrophic effect on a patient's hospital stay and recovery. This is a little more than just the CYA or "we don't trust EMS providers" but rather the outcome of patient care must be considered. However, EMS has done it own part where IVs are concerned with "the EMS way" or "do it in the trenches" or "street medicine" and how different EMS is with no time for that hospital technique foolishness.

This has been required reading for almost every healthcare professional in the hospital

The Checklist

http://www.newyorker.com/reporting/2007/12...fa_fact_gawande