More Doubt about Paramedic Endotracheal Intubation

[tinman694]

Lets all panic and run around in circles beating our heads.....

Geez...everyone tends to over react to a half baked 'study'...After looking over many of the materials (The ones you can at least get to) it seems to lack both the reliability and validity to do a positive, realistic job of telling what is really happening. As a former social science researcher, It is easy to make the numbers do what ever you want them to if you try to.

Some people are easy to tube, some are a pain in the behind--Some you just can't get in the field or otherwise. If the doctors determine we (as paramedics) are not capable--then we shouldn't be doing it.

I seriously doubt that will happen.

[PRPGfirerescuetech]

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.

Consider your district unusual at best. I didnt have a code my first three years in EMS.

At an average of 700-900 calls per year.

Now I get them almost weekly.

Its the law of averages.

PRPG

[Ridryder 911]

Lets all panic and run around in circles beating our heads.....

Geez...everyone tends to over react to a half baked 'study'...After looking over many of the materials (The ones you can at least get to) it seems to lack both the reliability and validity to do a positive, realistic job of telling what is really happening. As a former social science researcher, It is easy to make the numbers do what ever you want them to if you try to.

Some people are easy to tube, some are a pain in the behind--Some you just can't get in the field or otherwise. If the doctors determine we (as paramedics) are not capable--then we shouldn't be doing it.

I seriously doubt that will happen.

The problem is that some of these are respected physicians, and anything that is quoted from them get immediate attention. The other problem is you are right panic does set in... Too many times I have seen medial directors yank protocols over 1 study or administrators etc.. change, instead of validity or even a remedy of the problem could occur.

Yes, I believe the studies is very tainted... Just because there are problems with services, the whole system should not be penalized. Again, let us look in ER. On the case of number of intubation daily, I feel that Paramedics do it 3: 1 per day in comparrision to the one the ER physician does... now compare it to the internist.. when was the last time they intubated ?..

Not because I can intubate, but what is right for the patient. Most of the physicians are aware that they too do not intubate on a regular basis... in fact, the few would be ER physicians and anesthesia groups.

Hopefully. we can gather ourselves as a wake up call. NAEMSP & American Ambulance Association ( EMS Administrators) needs to emphasize the need of CQI, and skills retainment. NAEMSE needs the states to mandate clinical surgical rotations for intubation with a a required number of cases. Instructors need to realize that Paramedics ARE NOT coming out prepared!!

The time of shrugging their shoulders and being apathetic is over. Cranking out students that cannot perform at their level of credentials is YOUR responsibility. Administration needs to be sure to put in place a QA/QI program not only for maintaining credible care, but for risk management as well. Supervisor & FTO, are you monitoring your medics, are they rusty or competent and how are you dealing with their skills.. not just ETI, but ALL skills ?

Paramedics need to pull their head out of crevices and wake up that this is really a potential threat and not blow it off! This is a wake up call for our profession... the thoughts of substandard airways, because incompetent care was provided should never be considered. There are already some states that only allow anesthesiologist to establish EJ in hospitals, because of studies shown high infiltration rates.. don't let treatment modalities decrease because of apathy.

Sorry, but I feel better when I know my patient has a patent airway. Yesterday, we had a 3 year old with a TBI and was unresponsive, it was better for that patient she was intubated when she had projectile vomiting. Aspiration did not occur, ventilation's was maintained as well as sedation to decrease ICP. Again, for the best for the patient.

What is next ECG in comparison of cardiologist ?

Let us not revert backwards.. but be progressive and move forwards.

Make other medics aware of the situation...

R/R 911

[vs-eh?]

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.

At least you are getting the experience...Contrary to popular belief with those who use this argument, not all OR intubations are facile and not all OR patients have Grade 1 airways. There are difficult OR intubations. This is why the anesthetist does a consult weeks or months prior to the surgery to (among other things) evaluate the patients airway. I had difficult tubes and grade 3/4 airways during my OR rotations. The doctors have multiple options for intubating these patients - lighted stylet, glide scope, intubating LMA, etc... It is nice to get to see these in use...

People who use the excuse that "well I use the intubating mannequin all the time for practice..." means nothing. At minimum OR rotations allow you to see various grades of airways/patients, ways to correct failed attempts, and ANATOMIC VARIATIONS IN INDIVIDUAL PATIENTS! At least you can get feedback and view and attempt these tubes in a controlled supervised environment before f|_|cking up in the field. Also for OR patients (mainly elective surgery) you have to be more "gentle". The number one concern for docs is chipping teeth and airway trauma, which inherently forces you to take (potentially) even greater care and concentration during laryngealscopy and passing the tube.

There is a severe problem (this forum indicates the US is most prevelent) if you do not have OR rotations, get a MINIMUM of 20 SUCCESSFUL intubations during these rotations, and have a MINIMUM number of field tubes during your preceptorship. Don't get these minimums? Then YOU DON'T PASS UNTIL YOU DO! This is how it is here (and by the sounds of it most Canadian provinces follow suit), those are the brakes.

[AZCEP]

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

At the risk of highjacking the thread, perhaps the patients would be doing better if we were to intubate them before they code. The information that I've seen indicates that regardless of what you do after the heart stops, your chances of resuscitation is still pretty poor. My thought is to prevent the cardio-pulmonary arrest from occuring in the first place.

In the last 3 years, I've performed 17 ETI's. Only 2 of them on cardiac arrests. 1 of the sixteen ended up dying in ICU, the remaining 14 were extubated and have returned to functional living. Granted not a lot of skill performance, but the ones that have bought the tube, have recovered, so I'm having a hard time with the argument of needing dead people to practice on.

[kevkei]

Historically, our highest success rates are in pulseless patients. Why is that? Could it be the right amount of anesthesia (sedation and analgesia) as well as flaccid paralysis?????

[streetsweeper]

If prehosp ETI is discontinued. What will happen in the ER's? Most of the physicians depend on patients to have a controlled airway before they arrive at hosp. Most ETI's done in the ER's are done by paramedics here. We do them so often the Doc's would prefer us. It is common practice while in the dept to get asked by a Doc to tube someone.

Going back to using an O/P and a BVM would suck. Filling the stomach with air then getting vomit sprayed everywhere. Not looking forward to that again.

[Ridryder 911]

Most of the physicians depend on patients to have a controlled airway before they arrive at hosp. Most ETI's done in the ER's are done by paramedics here.

This is one thing I would like to addressed and scientifically studied as well. How many ER physicians rely upon EMS for intubated patients ?.. and what is the level of percentages in the emergency department ?

Although, I doubt we see this since we do not have Dr. in front of our names... if you do, it will be allowable to only intubate once or twice every 10 to 15 years. Heck, when I teach ACLS at physician groups some even describe they had NEVER intubated anyone.. not even in internship or residency programs... but, yet again.. they are Dr.'s...

R/R 911

[Spock]

I have mixed emotions about this topic because I have seen very good airway techniques in the field and also very bad techniques in multiple services. Some medics want nothing to do with intubations while others fight over the tube. We do need to concentrate on improving our education and practice for both medic students and practicing medics. Getting OR time is difficult and medical education is increasingly moving toward simulators. I just read an article that demonstrated no difference in intubation success rates for medic students that trained on mannequins versus those trained on live patients in the OR. I'm planning on a research project with my service to improve first time intubation success rates with mannequin training.

I attended the Wang/Roth debate and have also read much of what Dr. Wang has published recently concerning prehospital ETI. There are two questions: Should paramedics intubate and can paramedics intubate? Dr. Wang asserts that the original research (circa 1980) suggesting paramedics can intubate was flawed. Recent research suggested outcomes of patients with TBI intubated by medics had higher mortality and morbidity. Also, he looked at PA medics over one year and found 40% had zero intubations for the year. The average medic had two while the average flight crew had nearly three. He also broke down the intubations by county and showed there were entire counties that had zero intubations for the year. Granted these were rural areas but zero cardiac arrests for the year is hard to believe. As far as I know these areas have ALS services.

I feel Dr. Wang is correct that the original research from 1980 was flawed but I feel he is using equally flawed data to prove his point. Every one of his studies requires extensive statistical analysis to prove his point. As Benjamin Disraeli said, "There are lies, there are damn lies, and then there are statistics." The latest edition of Prehospital Emergency Care has a position statement by the NAEMSP concerning RSI and drug assisted intubations (DAI) and is well worth reading. Dr. Wang has a follow up article on the position statement reviewing the literature. He admits the research is equivocal.

Dr. Roth (a well known and respected local medical director) feels that intubating is like riding a bicycle; once learned you never forget. Dr. Wang (a well known and despised local ER doctor) disagrees with this analogy unless it applies to himself. He readily admits that he does only a "handful" of intubations in a year but he relies on the many tubes he got during his training a few years ago. Sounds like a contradiction to me. I would bet that most ER physicians do fewer intubations in a year than medics but Dr. Wang will not study this because it would create trouble for his peers when it is easier to pick on medics. Crap rolls down hill and medics are standing there with a bucket.

End result is we should not change our practice because of one or two studies by the same investigator who may be biased. We as medics must work to improve and maintain our skills at a high level. We need solid QA/QI procedures in place to identify problems and intervene early to correct deficiencies with our training. PA seldom leads the pack in anything but we may take the lead here by removing ETI from the medic's scope of practice. Most unfortunate.

On a side note, if anybody has the chance to use a King LT-D airway jump at it. We've been using them in the OR in place of an LMA for a few months and I think they are superior to the LMA and combitube. I think they have great utility for prehospital use and could be used by basic EMT's.

Live long and prosper.

Spock

[TechMedic05]

Spock -

Thank you, and that is a rather well written response. I, personally, had no idea of the possible biased opinions of that research. Just proves that EMS needs more research. Just one study isn't enough to go change practices.

It's also interesting to hear more about intubations from someone who, I assume, works primarily in OR's.

Thanks for noticing, and, do you work in the prehospital arena at all?