Poor Intubations in EMS

[retired_medic61]

Airway management is the most important skill we have. Unfortunately, from what I have seen, has the least amount of training in EMS Education programs and it is given very little time in company sponsored CE's from my last EMS employer who boasts what a great inhouse education program they have.

[EmergencyMedicalTigger]

As much as I hate to admit it, the hosemonkey was correct. He had no duty to stop. And if you already had an assignment, he was more than correct to just keep going. Neither your freedom nor your certification was on the line.

Now, if you did not already have an assignment, and the accident looked serious, then he was probably just being a lazy burnout. But still, he was legally in the right. I suggest you actually study the laws that apply to your profession instead of just making assumptions. You left a job over an incorrect assumption.

We had over an hour until our next pickup and did not have a patient at the time. I have links to TDSHS regulations on my computer. I asked a handful of EMS educators about this situation, and they all stated that they would have stopped. To me, this situation crosses the line from being an EMT to being a human with morals.

I left the job for more than just this situation. Add to it, the owner who would jump on trucks to make up for lack of staffing-he wasn't an EMT, lack of permitting/authorization for half the areas we transported, and the paramedic in question (who could do no wrong in the owner's eyes) constantly dumping in his calls on the other crews, which would make me late to class.

Obviously, he is a lazy burnout, if he quit HFD after only 10 years. Either way, we could go round and round about morals and ethics in EMS. There have probably been many discussions about it. I'll agree to disagree and stay on the topic of poorly trained medics and intubation.

[Dustdevil]

I'll agree to disagree and stay on the topic of poorly trained medics and intubation.

There is really nothing to disagree about. We agree that he's a lazy burnout.

Whether or not stopping would have been the right thing to do would be dependent upon the situation. In the case of a three-car fender bender, I would say no. They don't need you and you'll just complicate the scene. But if you see body parts everywhere, then stopping might be advised.

Regardless, there is no debate on the issue of law. You were not required to stop, and are under no legal or ethical obligation to do so. Whether you do or not is your business, but you should be aware of your legal standing, which says you don't have to.

[John]

Should Paramedic continue prehospital ETI?

“This important paper provides further evidence that prehospital ETI is problematic and the procedure should probably be stopped.” Says Dr. Bryan Bledsoe, “everybody better get used to LMAs, Combi-Tubes and similar rescue airways because routine prehospital ETI is probably a thing of the past.”

Are you ready to give up prehospital ETI? Share your thoughts on EMSLive this Tuesday March 28th as we talk with Dr. Bryan Bledsoe about the future of airway management in the prehospital environment.

Join us at EMSLive.com

http://www.emslive.com/ourshows.php

[Dustdevil]

Share your thoughts on EMSLive this Tuesday March 28th as we talk with Dr. Bryan Bledsoe about the future of airway management in the prehospital environment.

Sweet! Finally somebody on the show who doesn't have a funny accent! :wink:

[JakeEMTP]

Should Paramedic continue prehospital ETI?

“This important paper provides further evidence that prehospital ETI is problematic and the procedure should probably be stopped.” Says Dr. Bryan Bledsoe, “everybody better get used to LMAs, Combi-Tubes and similar rescue airways because routine prehospital ETI is probably a thing of the past.”

Are you ready to give up prehospital ETI? Share your thoughts on EMSLive this Tuesday March 28th as we talk with Dr. Bryan Bledsoe about the future of airway management in the prehospital environment.

Join us at EMSLive.com

http://www.emslive.com/ourshows.php

John was kind enough to inform me of the time for this. 21:00 est.

[Ace844]

Hi All,

It should also be noted that there are very few studies reviewing ETI-RSI in the ED, on either it's efficacy and or success rates. one of the studies in the links below make a valid point that the medicine community is putting pressure on EMS/ER to prove the efficacy of RSI-ETI in our environment, Yet it has even been more inadequately studied "in house". So thus we have little to compare these new studies to. Here are a few articles you should check out.

[web:9be6ff7313]http://www.foops.org/files/Paramedic%20NMB%20Improve%20ET%20Rate.pdf[/web:9be6ff7313]

[web:9be6ff7313]http://www.bestbets.org/cgi-bin/bets.pl?record=00207[/web:9be6ff7313]

[web:9be6ff7313]http://www.sanfranciscoems.org/index.php?cat=no&name=airway&exten=html[/web:9be6ff7313]

[web:9be6ff7313]http://www.naemsp.org/Position%20Papers/prehospitalintubation.pdf[/web:9be6ff7313]

http://bja.oxfordjournals.org/cgi/content/abstract/96/1/67

[web:9be6ff7313]http://www.rcjournal.com/contents/03.01/03.01.0227.asp[/web:9be6ff7313]

http://www.emsresponder.com/features/artic...;siteSection=16

[web:9be6ff7313]http://www.emtcity.com/phpBB2/viewtopic.php?t=527[/web:9be6ff7313]

http://www.emtcity.com/phpBB2/viewtopic.php?t=687

Hope this helps,

ACE844

On the Importance of getting a good education::“I failed a lot of tests and look at me.”

[Ridryder 911]

Couple of things come in mind after thinking about this. Before we throw the baby out with the bathwater.. let us find out why in the hell this has increased.. especially now we have absolute means of documenting successful intubations. If you are not in.. then don't say so.. there is not embarrassment of not having them intubated and performing BLS, blind intubation device etc.. again, assessing upon arrival to ER should be mandatory and EtCo2 wave form documentation is guarantee you were in, non-disputable.

Second, not trying to share the blame... but, we all know we probably intubate more than ER docs... now about a study on them as well ?.. I would like to see the comparison..before anesthesia was notified. Again it is easy to play arm chair quarterback when you are not judging yourselves.

Yes, let us find out why.. and correct it, not change the standard after 40 years because there has been a decrease recently.

R/R 911

[Ace844]

Couple of things come in mind after thinking about this. Before we throw the baby out with the bathwater.. let us find out why in the hell this has increased.. especially now we have absolute means of documenting successful intubations. If you are not in.. then don't say so.. there is not embarrassment of not having them intubated and performing BLS, blind intubation device etc.. again, assessing upon arrival to ER should be mandatory and EtCo2 wave form documentation is guarantee you were in, non-disputable.

Second, not trying to share the blame... but, we all know we probably intubate more than ER docs... now about a study on them as well ?.. I would like to see the comparison..before anesthesia was notified. Again it is easy to play arm chair quarterback when you are not judging yourselves.

Yes, let us find out why.. and correct it, not change the standard after 40 years because there has been a decrease recently.

R/R 911

"Rid, & others"

It seems to me that there are many potential reasons for these occurances as well. It seems to me that this is co-efficent of factors. Some anecdotal, and others factual.

1.) There has been a rush in EMS to provide 'evidence' for therpies and treatments much like the practice and profession of medicine in general. As a result we are seeing a number of 'knee jerk' reactions to these studies. A prime example of this is the "Amiodarone debate". Seems to me there were a few studies and a significant amount of $$'s pumped into some questionable studies. This drove us to 'immediate change' ECC wise. Now we are finding out as time goes on that the studies and evidence is pointing actually back towards our previous status quo with Lidocaine instead...

Now before all the BOOING and HISSING starts and the screams of ['HEY HE'S OFF TOPIC HERE'] please finish reading my post....

This may be again what we are seeing as far as ETI sucess rates...Furthermore in case you may be unaware here's what the 'Feds' & others have to say about this...

[web:4f005f30b8]http://www.researchagenda.org/Agenda/ExecSumm.htm[/web:4f005f30b8]

[web:4f005f30b8]http://www.nhtsa.dot.gov/PEOPLE/injury/ems/ems-agenda/overcoming.htm[/web:4f005f30b8]

[web:4f005f30b8]http://www.pcrf.mednet.ucla.edu/pcrfarticle4.shtml[/web:4f005f30b8]

2.) Education and experience. We recently had a discussion about this in another thread about ETI minimums, etc...I don't have the link handy at the moment but if someone else does then please post it. It also seems that alot of medic programs have 'downgraded' their educational process and become "Paramedic Factories" As a result their students are just meeting clinical minimums to test and thus aren't becoming 'clinically proficent'. As an example in my state if you are unable to get the minimum # of ETI's in your OR rotation, some programs will let you get them as 'supervised on a mannequin'! Furthermore, if you are unable to get one in your ridde time you may do the same thing in leiu of an 'actual' intubation in the field so that you may test....!!!!!! Does this type of process inspire confidence in either your peers or that of other practitioners?!?!? Not for me it doesn't....There were also alot of opinions rendered here about similar educational scenario::Do your Basics intubate?

[web:4f005f30b8]http://www.nhtsa.dot.gov/people/injury/ems/EMSCoreContent/pages/3NatEMSCoreCont.htm[/web:4f005f30b8]

[web:4f005f30b8]http://www.iom.edu/Object.File/Master/20/962/Maio_Prehospital%20EMS%20Research.pdf[/web:4f005f30b8]

3.) In my experience it seems that there have in the past been cases where 'shtuff has happened' in the ED and the tube became compromised at the point of 'rendering of care' or transfer of the pt. There has been a silent precedent set in some areas where the ER would 'just blame EMS' to protect themselves and because as I have heard soem say ' nothing will happen to them'...Sad but true!! Pulled Tube , Intubation article , Medical Control for RSI

4.) As previously stated here (which ties nloosely into point #1)

It should also be noted that there are very few studies reviewing ETI-RSI in the ED, on either it's efficacy and or success rates. one of the studies in the links below make a valid point that the medicine community is putting pressure on EMS/ER to prove the efficacy of RSI-ETI in our environment, Yet it has even been more inadequately studied "in house". So thus we have little to compare these new studies to. Here are a few articles you should check out.

and

Second, not trying to share the blame... but, we all know we probably intubate more than ER docs... now about a study on them as well ?.. I would like to see the comparison..before anesthesia was notified. Again it is easy to play arm chair quarterback when you are not judging yourselves.

Yes we need accountability, and yes we should be striving to excel and for higher sucess rates in this critical skill. But as mentioned previously this seems like a text book case of the 'Pot {medical pracitioners in general}calling the Kettle {EMS}...."

Anecdotally it seems to me that there may be more than a few of us who have in our opinions seen 'IN HOUSE CARE' to be lacking and even below what we may expect in the field. An example of this can be found here::How is a resuscitation ran in the ED?

Lastly, in part it may just be that soem of these studies are skewed and inaccurate or using averages which don't adequately refelct all of the clinical variables much like those in the L&S debate we have been having in another thread here! We can always improve, but before we all run about crying about how the sky is falling we should each evaluate what that substance actually is that we may be getting hit with......

Out here,

ACE844

[Ridryder 911]

Good points ACE,

Unfortunately, since we do not have Doctoral programs in EMS, we are at the mercy of having outside sources providing our research. We need to find out the agenda to "why" the study was performed. Was it a "national notice" or a local one in particular. Yes, MD/DO is our masters in providing "direction" however; again in what comparison in ratio was the "success" based at ? I really would like a comparative study to see if we are "below par" or maybe even "above the norm".

Agreeable, <100% is not acceptable (theoretically).. What I am angered about, we continue to allow ETI to be brought in in the wrong place. If it is during transit or movement.... this is simple to correct. Stop !.. run a EtCo2 with verification and clinically assess the patient. The reason for the strip... it written, absolute. Others can not change the words afterwords.. AFTER verification them move patient onto stretcher.

We have just started this policy due to staff not attaching pacemaker to patient during transit... etc.. So we have now made policy that the before transit.. an ECG strip with Sp02, EtC02.. etc.. will be performed, then and only then the Paramedic WILL disconnect wiring. pacer, etc.. Usually a verbal acknowledgment of confirmation of ETI .. the patient then will be reassessed after movement for proper placement etc.. There will be NO debate that the patient was intubated upon arrival... word

We need to monitor and inform other paramedics of the seriousness of this study... most are "blowing it off" .. but, I have seen things change that had no reason or enough data to cause radical changes. Our patients deserve "gold standards" of care... not secondary devices, because of sloppy care, education, or laziness.

Be safe,

R/R 911