Taking Away Paramedic and Pre-hospital Intubation

[mediccjh]

OK, so once again, instead of educating providers and letting them practice, let's take the skills away. Not very progressive, is it?

First-time failures....something to consider is the condition we get the patient in while in the field. Case in point tonight, I had a cardiac arrest. Went in the first time, couldn't see crap. Suctioned, pre-oxygenated. Second-time in, I'm in without a problem, ventilating well with good EtCO2 waveform.

These are conditions that all these wonderful studies seem to forget about. Trust me, it's not an excuse. I've only missed 2 ET intubation attempts in the 5 years I've been a medic.

[scratrat]

OK, so once again, instead of educating providers and letting them practice, let's take the skills away. Not very progressive, is it?

First-time failures....something to consider is the condition we get the patient in while in the field. Case in point tonight, I had a cardiac arrest. Went in the first time, couldn't see crap. Suctioned, pre-oxygenated. Second-time in, I'm in without a problem, ventilating well with good EtCO2 waveform.

These are conditions that all these wonderful studies seem to forget about. Trust me, it's not an excuse. I've only missed 2 ET intubation attempts in the 5 years I've been a medic.

THANK YOU!!

[kevkei]

OK, so once again, instead of educating providers and letting them practice, let's take the skills away. Not very progressive, is it?

It's not about the skill and how good we do it, it's about patient outcomes. We can't even educate the providers how to do other things properly with simple things, how do we now expect the majority of students to be able to learn good judgement, good ongoing assessments and good critical/clinical thinking skills? People are always complaining here about how bad XYZ school is, or the overall poor quality of students today. How often do you hear glowing reviews of a bunch of schools or the practicum students? We never hear the positive, it's always the negative.

Trust me, I don't like it for how it applies to me, you and many others, but for the tens of thousands of Paramedics as a whole (plus some EMT-I's, EMTCC and whatever other letter combinations)? They are also saying they want to take ETI out of the hospital setting, so how should we think we are any better. I think we as a profession (as Paramedics) define who we are by the fact that we can intubate and we can do it well, some of the time.

Take for example the airway Kings in Anesthesiology. Even they are moving away from ETI. Current literature suggests that the risk of aspiration from blind insertion devices (LMA, Combitube, King Airway, etc) is remote at best and can probably be suggested the infection risk is even lower than ETI due to the simple fact that the tube is passed through the cords. Simply stated, our arguments of using a 'definitive' airway are lost and don't hold ground any more.

I have had this argument for the last year trying to say we need to keep intubation in our skill set, it is needed for the benefit of the patient, etc. and all the other arguments. If you do what I did and look at the evidenced based recommendations objectively, you would probably see their point.

Try answering this, what are the arguments (benefits) in favor of ETI being preferred or needed prehospitally?

[mediccjh]

It's not about the skill and how good we do it, it's about patient outcomes. We can't even educate the providers how to do other things properly with simple things, how do we now expect the majority of students to be able to learn good judgement, good ongoing assessments and good critical/clinical thinking skills? People are always complaining here about how bad XYZ school is, or the overall poor quality of students today. How often do you hear glowing reviews of a bunch of schools or the practicum students? We never hear the positive, it's always the negative.

Trust me, I don't like it for how it applies to me, you and many others, but for the tens of thousands of Paramedics as a whole (plus some EMT-I's, EMTCC and whatever other letter combinations)? They are also saying they want to take ETI out of the hospital setting, so how should we think we are any better. I think we as a profession (as Paramedics) define who we are by the fact that we can intubate and we can do it well, some of the time.

Take for example the airway Kings in Anesthesiology. Even they are moving away from ETI. Current literature suggests that the risk of aspiration from blind insertion devices (LMA, Combitube, King Airway, etc) is remote at best and can probably be suggested the infection risk is even lower than ETI due to the simple fact that the tube is passed through the cords. Simply stated, our arguments of using a 'definitive' airway are lost and don't hold ground any more.

I have had this argument for the last year trying to say we need to keep intubation in our skill set, it is needed for the benefit of the patient, etc. and all the other arguments. If you do what I did and look at the evidenced based recommendations objectively, you would probably see their point.

Try answering this, what are the arguments (benefits) in favor of ETI being preferred or needed prehospitally?

I believe it is common sense, when you think about it.

The best way to get gas into a space is through a tube. Therefore, the best way to get oxygen into the lungs is by an ET tube, which goes into the trachea, and when properly inserted and sealed, will bring oxygen to the lungs.

[Ridryder 911]

It amazes me how it is suddenly a problem. From a upper 90 percentile to lower levels recently. Is it a result of poor education, poor clinical skills, improved studies, threatened professional attribute, biased studies ? Who knows ?

The studies have been more than biased in reports, even cancelling each other out before heavy analysis occur. Again typical emergency medicine reaction is watered down or substitute instead of correcting the problem. Thank-God, I hope we don't perform patient care techniques and regime this way. Instead of addressing the problem and seeking a way to correct and to make sure that patients obtain the gold standard of airway secured, we much rather study and suggest alternative devices which have proven to be much lower in standards.

Can we be assure that all those provide intubation can perform the technique flawless each time ? I can attest even the best will have occasional difficulties, then whom to say the appropriate number should be attempted of times before one is considered non-competent. Hopefully, they will require such standards to apply to all those that provide intubation, not just those in the prehospital arena.

Personally, I believe the concern is not of patient care rather professional worry and the number of decreased intubations, in hospital groups are now being able to intubate.

My state is considering removing intubation clinicals totally. The reason being is anesthesiologist is very willing to work and provide the needed intubation sites as long as there is hard cold cash. The reasoning and explanation was it was time consuming and risky. Albeit, does increase one liability, if proper guidance and monitoring the risks would not be anymore than other health care professionals. No increase in litigation's, insurance was to be found, rather physicians wanting extra cash. It is shameful that they much prefer to place such things over patient care.

This is the same motive that a few years ago, some professional groups wanted and successfully placed that only physicians and anesthesia groups had successfully passed some states to require their services to establish external jugular I.V.'s . Fortunately, and suddenly others were awaken of this absurd requirement and was changed immediately. Again, the main point was to maintain professional status and demonstrate need.

If these so called interest groups was this worried, perform studies on increased intubation rates on different education methodologies, not abandon a technique proven to be essential for secured of airway and decrease aspiration. Again, identifying a fault is easy... finding a solution and answer is not. Any scientific group and research studies can always find faults, but to find solutions is much difficult. Again, there should be no consideration in lowering standards if we in the medical community are truly concerned with patient care. If we based upon outcome and successful procedure on all skills and medical procedures, then CPR should be immediately removed and stopped. With one of the lowest outcome and survival rates...

R/r 911

[emtp269]

Most folks base their arguement on the study published by Wang, et.al. His study was interesting but in my opinion not completely inclusive of all the issues and variables faced as we find our patients in the field environment. I propose we (medics)conduct a scientifc anaylisis of our successes and failures and attempt to discover if these purported statistics are in fact valid. I would be happy to participate with any group or system to form a theory, develop a hypothesis and outline parameters for the conduct of a study that can be published to support or refute the current theory on prehospital intubation.

I find it interesting that we as a group Q/A all of the invasive procedures we do, on all of the reports generated, within our community and have not presented this problem with as much voracity as those who do not function in our capacity and scrutinize us from the outside looking in.

Lastly as a young profession we must ensure we do a better job with our education and monitoring than the healthcare professions we work with have done in the past. We should learn from the mistakes made in other medical fields and do our best at establishing a standard for us all to maintain.

[Ridryder 911]

I agree it appears to me the same authors perform same repetitive studies and unfortunately even begins to one doubt credibility. This is the same mind set that I have seen over the years with supposed scientific data of establishing an IV in the field caused delay in care, even thoughts of establishing them in an ER was questioned. Turns out that the studies (multiple) was full of biased ideas, full of flaws and untruths, and basically was performed to justify the need to fulfill quota of studies and justify their own positions.

I believe when the dust settles, we will see the same. Yes, we aware of the needs of maintaining quality, yet let's be sure the material is of accuracy and validity is true.

Far as nurse anesthetists versus anesthesiologist, I think one would be surprised if one actually compared length of true time of airway management education, would be very similar. Yes, it would be nice to have an anesthesiologist in each case, as well as a cardiologist each chest pain, but it is not economical nor needed.

R/r 911

[kevkei]

I don't disagree with anything you are saying.

The single and simplest question that we should ask is, does it improve patient outcomes? End of story.

Why invest time, energy and money training and properly educating Paramedics in the five W's and how if it does not benefit the patient? As far as I am aware, there is no evidence that suggests it improves patient outcomes.

On the surface, what is suggested is that the blind insertion devices offer the same benefit with lower rates of complications (including aspiration and pneumonia).

[Ridryder 911]

Sorry, I totally disagree with you. Intubation is not any harder than placing an NG tube. Outcome versus what ? Can we technically say out of a few thousand in an metro area in comparison of a few hundred thousand in variable density, that are performed correctly daily, and thus prevents aspiration. I have not yet seen any alternative devices that can assure that. Thus is the best for the patient.

Please let's not water down grade patient care because there is a stumbling block...again, formal education and clinical practice is essential but, when one truly thinks about it lifting the epiglottis and visualization of the glottic opening is really how hard ? I believe sometimes we are making things more difficult than they appear. Intubation is not neurosurgery...

[kevkei]

and thus prevents aspiration. I have not yet seen any alternative devices that can assure that. Thus is the best for the patient....

Rid, the problem is they are arguing that the evidence suggests the ETT is no more beneficial at preventing aspiration than the LMA, Combi, King, etc. hence there is no benefit. Do you or anyone else have anything that says otherwise? Because I haven't seen it. At best, it's anecdotal. Because the ETT is passed through the cords, it is inherently more of a risk for causing nosochmial pneumonia, which none of the others do.

As I said, I'm on your side and agree that ETI is appropriate prehospitally. I'm just arguing the position of the people against it. Of which, our medical director is one.