Intubations for 2009

[HERBIE1]

No foul dwayne: I should have clarified a little better. In a facial trauma or bloody airway I take a quick look see to make the determination of type of classification with the malapatti scale

When I say quick It means in & out in ten seconds or less. Do I need to go with suction at the same time as the tube to clear the airway from secretions? or are there anatomical issues that will make it a harder tube or need an alternative method of securing the airway. You ever had a pt that outwardly looked to be a 7.5 and when you got in the guy has a trachea the size of the holland tunnel ?

Good points

Works both ways, too. Sometimes you have a pt that you would think had an average sized airway and it turns out they are so inflamed and swollen, maybe due to asthma or some other issue, that a coffee stirrer looks too big? LOL

[snakemedic]

I have noticed over the past 8 years that intubations have continued to go down and I think the numbers also go down because we become a little more mature and confident in managing the airway with other adjuncts first, however mine have dwindled to:

3 facilitated 2 of which were accomplished on second attempt

2 RSI accomplished on 1st attempt.

An adjunct I've noticed that made a big difference for me was the Bougie, never had one until I went to the air environment, love it.

and 6 intubations in the OR during CME 1st attempts each but all patients stable and healthy elective surgery.

Snake

[MontvilleFire39]

I actually attempt to keep a running log af all of my intubations...year to date here are my numbers;

26 attempted oral intubations

20 succesfully placed oral endotracheal tubes

5 succesfully placed King Airways following attempted intubation

1 patient unable to secure ett or backup airway due to massive facial trauma

1 attempted nasal intubation

1 successfully placed oral endotracheal tube

Oral ETT Success Rate =81%

Comined ETT / backup airway success rate =97%

Oral Intubation Success Rate=100%

(above numbers are a combination of my full time gig working in the inner city, my part time suburban ems job, and my part time rural ems job w/ RSI capabilities)

While I feel my endotracheal tube success rate is a bit low, I am pleased with my overall success rate of ett/backup device. My reasons for placing the King vary;

1. If I am running without a first responder on a critical call and after one attempt I deem it to be a difficult or lengthy intubation I will place the King as I feel a rapidly secured King Airway frees me up to acomplish other ALS procedures as well.

2. I feel a rapidly placed King Airway is better than multiple lengthy attempts at ETT.

My one call in which I was unable to secure neither an ETT or backup device ended up being carefully bagged to a nearby local facility and recieved a surgical airway prior to air transport to a Level I trauma center with a successful outcome.

In my system we run 33 ALS ambulances with greatly varying call volume. I know some medics who will get 20 plus tubes a year and some who are lucky to get one or two. We don't curently have OR practice sessions avaliable, but have a full time training academy with several different dummys avaliable as well as a decent training staff; additionaly training is avaliable with our very pro ems medical director. It's not a perfect setup but pretty decent IMO.

[vs-eh?]

Probably around 10 or so, with a 60/40 split between dead and alive people (PAI).

I hope medic82942003 is trolling or something, otherwise that is fucking brutal.

[MSDeltaFlt]

So far this year I'm 100% for ETI, however there were 2 pts where it took 2 attempts to get the tube.

[Mateo_1387]

4 Intubations this year, thanks to the cadaver lab.

[kohlerrf]

5-7 this year (in the field) however we are required to have 2 separate days with anesthesia in th OR per year and 4 mandatory CME days for 8 hours each day. Regardless of the topic of the CME we all practice ETI on the manikins on those days as well. Intubation is a critical pre-hospital skill. Our industry operates in a different and unique environment. Although there are some very good adjuncts out there, and we carry many of them, ETI is still the gold standard for airway protection in our environment.

I was concerned to read?.... What is the definition and "unsuccessful intubation"? Discovered at the hospital ER or discovered on the initial attempt on scene and an alternative airway was secured?

ETI is hard and necessary skill to be mastered. To acquiesce and say maybe we should take the tool of ETI out of the carriculum is a shortsighted solution retarding the growth of pre-hopital care. We operate in the world of random, not a predictable hospital environment, in addition by our definition, we cannot step back and bag the pt until the attending arrives to tube the patient. We need more tools than the ER or OR because they only get the patients that we have already cleaned up!

Edited December 18, 2009 by kohlerrf

[VentMedic]

We need more tools than the ER or OR because they only get the patients that we have already cleaned up!

I guess you haven't seen all the damage that can be done to the throat and cords by botched intubations or repeated attempts when ego takes over where commonsense should have stepped up. They don't come to us in the ED "all cleaned up" but rather their oral cavities are sometimes full of blood and vomit. Suctioning is even a lot art partly due to lack of training for the skill or too lazy to get out the equipment. It is sad when a patient who should have spent only a few hours on the ventilator ends up on it for over a week and possibly a trach to get them off of it while the throat heals. For some, vocal cord paralysis may be permanent. Unfortunately I have seen this happen too many times to young people who have taken GHB or OD'd on alcohol. Some Paramedics have even gone as far to say the patient got what they deserved to justify their lack of ability to intubate or the commonsense to back off and try something different.

If some were given the better equipment, would that automatically make them better intubators? Some don't get a solid foundation for the procedure in the (U.S) Paramedic programs to where 5 successful passes on a manikin is considered adequate. Then when companies do not even offer refreshers on a manikin head for those who do get only one or two or none for the number of intubations, we have a problem much larger than just getting some new equipment. How many of our ALS IFT or CCT services even require a minimum number of intubations for their Paramedics. Some may have worked for years on these trucks without even starting an IV. You can also work for years on an ALS engine without the need to intubate if you can stall until the Fire Rescue truck or county EMS arrives.

Edited December 18, 2009 by VentMedic

[Spock]

Two for two in the field this year. I work at a level 1 trauma center as a nurse anesthetist and I don't know how many tubes I have in the hospital but I would guess about 400. Those are split between the OR, the floor, the ICU's and the ED.

I just finished looking at our service and we had 53 intubations for the year with 5 being the most for any one medic.

The data for Pennsylvania was reported in 2005 with the average of two per medic. Almost 40% of the medics in the state had zero intubations.

As someone already pointed out the goal is to arrive at the hospital with a patient that is saturated and ventilated. How that occurs in not all that important. We do not automatically pull an alternative airway in the ED (I dislike the term rescue airway.) If the airway in place is working we use it. Most of the alternate airways are the King which is my favorite. The only time we change the King is if the patient is going to the OR or will be admitted to the ICU.

I wish I knew how many intubations are needed to maintain proficiency but I don't. I'm not in favor of pulling ETI from the paramedic skill set but we need to get away from the idea that if we don't place an endo tube we have failed. Again, ventilation and saturation are the key.

Live long and prosper.

Spock

Forgot one thing. I think the importance of regular mannequin practice cannot be underestimated. It gives you practice going through the many steps of intubation. It is no different than the checklists airline pilots go through for every step of a flight no matter how many times they have done it. A few years ago we started that in my service and though there was very poor compliance the medics that practiced every shift improved their success rates by 100%.

May the tube be with you.

Spock

[kohlerrf]

I guess you haven't seen all the damage that can be done to the throat and cords by botched intubations or repeated attempts when ego takes over where commonsense should have stepped up. They don't come to us in the ED "all cleaned up" but rather their oral cavities are sometimes full of blood and vomit. Suctioning is even a lot art partly due to lack of training for the skill or too lazy to get out the equipment. It is sad when a patient who should have spent only a few hours on the ventilator ends up on it for over a week and possibly a trach to get them off of it while the throat heals. For some, vocal cord paralysis may be permanent. Unfortunately I have seen this happen too many times to young people who have taken GHB or OD'd on alcohol. Some Paramedics have even gone as far to say the patient got what they deserved to justify their lack of ability to intubate or the commonsense to back off and try something different.

If some were given the better equipment, would that automatically make them better intubators? Some don't get a solid foundation for the procedure in the (U.S) Paramedic programs to where 5 successful passes on a manikin is considered adequate. Then when companies do not even offer refreshers on a manikin head for those who do get only one or two or none for the number of intubations, we have a problem much larger than just getting some new equipment. How many of our ALS IFT or CCT services even require a minimum number of intubations for their Paramedics. Some may have worked for years on these trucks without even starting an IV. You can also work for years on an ALS engine without the need to intubate if you can stall until the Fire Rescue truck or county EMS arrives.

Your absolutely right, the fault here it the dam plastic ET tube, no matter what we do it just wont go in the right hole! Come to think of it I have seen CPR done poorly causing a flail chest. We have to stop doing CPR its killing people! By the way I have heard of ambulances on their own running red lights and killing people, the better thing here is to ride bicycles.

Its a poor clinition that blames the equipment! If you cant tube don't do it, we carry 6 other airway adjuncts on the truck because there are times you just cant tube. If you have some ego issues your in the wrong profession. if you have another adjunct that provides better airway protection than a properly placed ET tube I'm all ears. Otherwise don't deprive the patients, take your ego outside and let a competent medic manage the airway!