Petition to Save Intubation

[emt2359]

What is everyone's thoughts on this?

This is a change.org petition to "Allow paramedics to continue to save lives with endotracheal intubation!"

Should the will of the people supersede any data that says the opposite?

 

Edited August 10, 2017 by emt2359

[paramedicmike]

What does the data say?  It doesn't sound like those who wrote the petition haven't reviewed the data.

 

[paramatt_]

Maybe petition for higher (?or minimum) education standards first?

I'm going go out on a limb and say those services that have higher standards and better governance are likely going to have better outcomes no matter what you're measuring.

[paramedicmike]

Wow.  I just realized I wrote my second sentence incredibly poorly.  It should say, "It doesn't sound like those who wrote the petition have reviewed the data."

Damned double negatives.

Anyway, I like Matt's idea of petitioning for higher educational standards.  To the topic in the petition I'll agree there are some circumstances, however rare, where intubation is warranted and the need to be proficient improves success.  However, until we start considering ourselves to be medical professionals and have the educational and training background to support it we'll continue to be treated like the lights and sirens jockeys we are widely seen to be.

[Spock]

OK, I think I am a reasonably intelligent person but when it comes to computers, I am a Neanderthal.  I couldn't read the original petition or any data but since I am not on Face Book the reason should become clear.  One of these days I am going to invent my own anti-social network called "In your Face" and I bet it would be a hit.  But I digress.

I presume this is in response to the proposal to remove endotracheal intubation (ETI) from the paramedic scope to practice.  This has been bounced around for quite some time and the literature I have read is conflicting.  First, the original literature from the late 70's and early 80's was poorly constructed and suspect.  I say that knowing full well the research was conducted in Pittsburgh and I personally knew some of the authors. Second, Dr. Henry Wang published a study in 2005 which found 39% of all paramedics in Pennsylvania had ZERO intubations for the year studied and the average number of intubations per paramedic was TWO.  Now Dr. Wang is a nice guy, he is no friend of EMS or paramedics and he left Pittsburgh a few years ago which was probably in his best interests since the City of Pittsburgh medics were out for blood.  But the point is, how proficient can you be with a procedure done only twice a year?  My EMS agency responds to around 10,000 calls a year and the number of intubations is 50-60.  We have had medics retire after 25 years who have NEVER intubated a patient.  Anecdotal to be sure but you have to scratch your head and wonder about it.

The advent of superglottic airways (SGA) such as the King LT-D, LMA, and i-Gell have revolutionized airway management.  I did not mention the combitube because I think it should go the way of the T-Rex and is an instrument of death.  Now the literature            regarding the SGA versus the ETI in cardiac arrest is conflicting so the answer is yet to be determined as to which is best.  And let's face it, most prehospital intubations are in the cardiac arrest patient and not the patient that is breathing spontaneously.  It is my understanding there is a multi-city and country study under way right now that may answer this question of SGA versus ETI.

As it stands now, I am not in favor of removing ETI from the paramedic scope of practice but we really do need to examine the issue and come to a conclusion based upon good research studies.  As long as the patient arrives at the hospital oxygenated and ventilated, it doesn't matter how that was accomplished.  

Spock

May the tube be with you    

[Just Plain Ruff]

I have nearly 27 years of experience, 18 of it continuous, the rest of it sporadic and I have about 5 times as many total intubations as years experience.  I have approx 5 trauma intubations, I have 3 pediatric and 2 neonatal intubations.  I do not count my intubations in the Operating room with a Anesthetist because those were separate clincal and controlled intubations that were ZERO Pressure and I had all the time in the world to get the intubation right(with plenty of prep time prior to each tube).  

but I have countless cat and dog intubations thank you very much PALS courses. 

 

I would consider myself a seasoned medic who could intubate quite competently except for peds and neonates. 

but honestly, I believe that having a SGA as your backup airway is VERY VERY important and like Spock says, revolutionary.  

Would I trust a medic with only 2 intubations in the past year to intubate my family member? I'm not sure? But if he's the only one who responded then you have to trust him.  But you hope that he has the training throughout the year to make up for the real life experience and doesn't just rest on his laurels and not get that training because a failed intubation means that the person being intubated suffers.  A failed intubation that is not recognized and rectified, DIES.  Simple as that.  We've all seen the video of the lady and the failed airway.  It's awful. 

If medics aren't getting the tubes they need to keep current and competent, then it's up to their services to provide the education that they need on a yearly if not quarterly basis to get that education to keep current and competent.  Be that an OR rotation, a rotation with a busier service or just assorted airway mannikins and Airway education offerings.  

 

For all you EMS service directors/education directors, if you see that your employees haven't had a tube yet this year, what the HELL are you waiting for, get your people into a class and get their skills current.  The life they save might be yours.  Or you may die from a unrecognized Esophageal intubation.  It's your risk that you are willing to take I guess.  

 

[Spock]

The issue is not how many intubations you have, but how many airways did you manage successfully?  The vast majority of EMS calls require no active airway management skills so you could say you were were mostly successful.  I ask is MOSTLY good enough?   Five times the number of years experience equals 135 which is a slow three months for me.  Ruff is good people but we have to be realistic about our capabilities and recognize that practice and every day training is vitally important for good patient care in all areas of medicine including but not limited to airway management.  Ruff was correct in calling out our training colleagues to examine the issue and take proactive steps to prevent problems.  It is easy to apply remediation for a medic that comes into the DEM with an esophageal intubation but a better approach is to have good training protocols in place to prevent  the problem from occurring.

Spock

Let the tube be with you.

Trust but verify.  Capnography and bilateral equal breath sounds.     

[Just Plain Ruff]

On 8/18/2017 at 6:33 PM, Spock said:

The issue is not how many intubations you have, but how many airways did you manage successfully?  The vast majority of EMS calls require no active airway management skills so you could say you were were mostly successful.  I ask is MOSTLY good enough?   Five times the number of years experience equals 135 which is a slow three months for me.  Ruff is good people but we have to be realistic about our capabilities and recognize that practice and every day training is vitally important for good patient care in all areas of medicine including but not limited to airway management.  Ruff was correct in calling out our training colleagues to examine the issue and take proactive steps to prevent problems.  It is easy to apply remediation for a medic that comes into the DEM with an esophageal intubation but a better approach is to have good training protocols in place to prevent  the problem from occurring.

Spock

Let the tube be with you.

Trust but verify.  Capnography and bilateral equal breath sounds.     

That is completely correct.  IT's one thing to get the tube right, but another thing if you really didn't need to originally intubate but failed to manage the airway which led to the need to intubate.  

Spock you rock. 

[Inf]

Hmm.. Having worked with some great and not-so-great medics, I have some ambivalence about this. Personally I've tubed over a 100 patients, from newborns to 90+ year olds. In my humble opinion if you haven't gotten the proper training under supervision of an ER doc or an anesthesiologist, you are more dangerous than beneficial to your patient. That being said, taking away this tool from someone with proper training and experience is not a good idea. The problem is that the wiser/smarter/more educated you are, the less likely you are to stay in this field.

[DwayneERParamedic]

I think the fact that 26,000+ people believed that it made sense to vote on something like this is pretty strong evidence that there's a bunch of providers out there that aren't smart enough to have this skill....