More Doubt about Paramedic Endotracheal Intubation

[John]

More Doubt about Paramedic Endotracheal Intubation

Should Paramedic continue prehospital ETI? In a study by, Henry Wang, MD, and his colleagues at the University of Pittsburgh performed a prospective study of 42 prehospital systems. They used a closed response data form that was completed by prehospital personnel and physicians. The form detailed patient demographics, clinical course, complications and outcomes for all patients who received 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 as we talk to Bryan Bledsoe about the future of airway management in the prehospital enviroment

http://www.emslive.com/audio/280306.mp3

[firefighter523]

Just because people arent good at it, doesn't mean we should stop doing it. It means we need to PRACTICE and get BETTER. Since when does the world move ahead and our treatment move in the opposite direction!

[PRPGfirerescuetech]

I have to agree...

A proactive response in medicine isnt to remove skills due to poor utilization and sucess rates...

...You change training to improve the successful skill application.

PRPG

[medic429]

I got the scoop from my boss who attended the debate between Dr. Wang and one of our Command docs....here's the deal, as I understood --

Dr. Wang's study was strictly on trauma patients...no medical ETI's. How about the medical pt's that get intubated?? The debate was very good, and it was packed. NO ONE disagrred that we need more practice...but is the OR really the place to do it?? How often do we get to intubate with a patient paralized, in bright white lights, lying in a perfect position on a nice hard table?? Our command doc. had pictures of where hospital personell get to intubate versus where we get to intubate (ER versus dark street-seeing as the study was on trauma patients) How about the dark narrow hallways, or the cramped bathrooms...and even the back of an ambulance?? A LOT different than a hospital. The debate went on for about an hour and a half with a Q & A session afterward. Dr. Wang himself said he does a "handful" of ETI's a year.....a handful! But he did say he supervises 300......hmmmmmmm........

I have a problem with just yanking the skill......I'd feel better about the entire Dr. Wang issue if he would have a plan in mind to correct the problem, not just say we shouldn't do it.

If I can get the audio CD I'll let you know, if anyone would be interested.

[Ridryder 911]

We need to evaluate the studies in detail. Some of us that can actually interpret studies (have some basic statistics and study interpretation classes) should see what the study entailed.

Again, as the other post have mentioned, we need to correct the problem after we identify it, Second why are we the only ones being looked at and whom are we being compared to ?

We do not allow a "knee jerk" reflex to occur like the horribly flawed MAST/PASG initial study did. Pandemonium set in and no one actually read and understood the poor validity of it.

Yes, let us identify, correct and re-study.. before major changes occur.

R/R 911

[Ace844]

We need to evaluate the studies in detail. Some of us that can actually interpret studies (have some basic statistics and study interpretation classes) should see what the study entailed.

Again, as the other post have mentioned, we need to correct the problem after we identify it, Second why are we the only ones being looked at and whom are we being compared to ?

We do not allow a "knee jerk" reflex to occur like the horribly flawed MAST/PASG initial study did. Pandemonium set in and no one actually read and understood the poor validity of it.

Yes, let us identify, correct and re-study.. before major changes occur.

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:a01deeeecd]http://www.researchagenda.org/Agenda/ExecSumm.htm[/web:a01deeeecd]

[web:a01deeeecd]http://www.nhtsa.dot.gov/PEOPLE/injury/ems/ems-agenda/overcoming.htm[/web:a01deeeecd]

[web:a01deeeecd]http://www.pcrf.mednet.ucla.edu/pcrfarticle4.shtml[/web:a01deeeecd]

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:a01deeeecd]http://www.nhtsa.dot.gov/people/injury/ems/EMSCoreContent/pages/3NatEMSCoreCont.htm[/web:a01deeeecd]

[web:a01deeeecd]http://www.iom.edu/Object.File/Master/20/962/Maio_Prehospital%20EMS%20Research.pdf[/web:a01deeeecd]

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 some 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

[mediccjh]

Not only were the patients only trauma patients, what kind of EMS systems were studied? Big city? Suburban? Rural? The system type can skew the numbers too.

[Dustdevil]

Not only were the patients only trauma patients, what kind of EMS systems were studied? Big city? Suburban? Rural? The system type can skew the numbers too.

Very true. During the discussion, there was a mention of services where medics only do three or four intubations a year. WTF? Where the heck is that happening in a full-time professional EMS system? I don't care if you are urban, suburban, or rural, if you are a full time professional, you are getting several times that number of intubations a year unless you are on the remotest frontier where people are cold and stiff before you ever get to them.

[PRPGfirerescuetech]

Outside of city systems, that isnt the case.

Getting tubes is intrinsic on people dying. If people dont die on your shift, then you dont get tubes.

Simple math really...

We had a medic go a full yearm without a single patient to attempt on...

Just the law of averages.

PRPG

[Dustdevil]

I spent half my career in rural systems where the nearest big city was an hour or more away and there wasn't so much as a WalMart or Dairy Queen in the district. I still got plenty of intubations in. People die in the country just like they do in the big city. Yes, there are more people in the big city, but there are significantly more paramedics too. Being one of 300 medics working the big city doesn't guarantee you many more intubations than being one of three medics working a rural county.

Again, unless we're talking frontier, I just don't see where the law of averages changes significantly between most systems.