Taking Away Paramedic and Pre-hospital Intubation

[OzMedic]

I should stress that 20 minimum tubes are required in hospital prior to starting ambulance practicum. If you don't get the 20? You go back. Most anesthetist's generally (for the first few anyway) allow you to tube patients that are evaluated with a grade 1 airway +/- edentulous. I assume that is the same everywhere. Teeth for an elective surgery are an anesthetist's number one priority right?

Just out of interest vs, how many paediatric intubations are you required to do in addition to your 20 intubations in hospital before you are allowed to practice?

[AZCEP]

First, Code 8, know who you are dealing with before you start a fight. :roll:

Second, anyone can talk about airway management, very few can do an adequate job of performing it.

Third, vs-eh?, the literature is against you on your stand that PAI is just as effective as full RSI. I'm somewhat surprised that it didn't get your full attention when published.

http://www.google.com/search?sourceid=navc...only+intubation

Just a few for your perusal.

[FormerEMSLT297]

What the Canuks (no disrespect intended) have to understand is this. In the U.S.A. the anesthesiologist are VERY concerned with law suits, damaged teeth, sore throats, etc. When Intubation was first introduced into my EMS system in 1989 (yes I said 1989) they sent all of the ALS providers to an OR rotation to get live tubes. While I was fortunate to hook up with a relative who was an anesthesiologist and I got a fair number of tubes, a lot of folks reported that the docs just put the blade in and said "see thats the glottic opening" and didn't even allow the student to pass the tube let alone hold the blade.

When I got into a full medic program we spent several weeks in the OR until we got a certain number of tubes. and even in the full paramedic class the docs were so scared of being sued ,,, some didn't let you hold the laryngoscope blade but you could pass the ET tube.

It was only years later when i got to a flight program and went for RSI training that I was allowed and expected to do all the skills from pre-oxygenation to pushing the succs, to direct laryngoscopy , and placing the tube to placing an OG tube...

So you have to understand that the FEAR OF GETTING SUED. is very real in this country and it sometimes stymies EMS training especially when the OR docs don't know you and you rotate through for a few days and then leave.

I still know of several Paramedic basic students who because of liability issues did not go through ANY OR training and was told to get tubes on ambulance rotations, and the only practice they got was on mannequins.

That is the reality of non-socialized medicine where fear of the lawyer outweighs providing paramedics with good realistic training.

My thoughts are my own and don't represent my agency or department.

[Paddy]

I get a kick out of this conversation, every time. The typical urinating match over Canadian vs. US, North vs. South, Air vs. ground etc. My point first. RSI and it's efficacy is not measured by practice or initial education, it is measured by QA. "Does it work or is it necessary in this system" Quotes like "it always works" or it is too dangerous" are simply without merit. Measure it, then tell me it is good or bad, dagerous or not or whether it works in your urban or rural setting.

Funny that our most cherished CCRN's come out of nursing school without any intubations. Some physician's with less than I'm seeing posted here. Wanna know why? I'll let someone else assist me in this but the bottom line is carefully measured skills that benefit the final outcome of the patient, not how long your tube is. ha ha ha

[Code 8 Paramedic]

First, Code 8, know who you are dealing with before you start a fight. :roll:

Second, anyone can talk about airway management, very few can do an adequate job of performing it.

Third, vs-eh?, the literature is against you on your stand that PAI is just as effective as full RSI. I'm somewhat surprised that it didn't get your full attention when published.

http://www.google.com/search?sourceid=navc...only+intubation

Just a few for your perusal.

Well id like to say that I don't feel I started the fight... I mentioned three letters R-S-I and this other guy is having a cow! Like how dare I be in a class where we are discussing things like that. I didn't say we were doing it or anything like that... And this guy gets all high and mighty on me! Second it was very offensive to me to insult our medical control doctors.. and my training, when he doesn't know what my level of training is. I wanted to start a disscusion about recent studies wanting to take ALL INTUBATION away from us, and im getting attacked by this guy. It just wasn't very polite way to start off.

[AZCEP]

Unfortunately, the evidence may well indicate that prehospital endotracheal intubation is not benefitting any patients, it is increasing time prior to definitive care, and the first attempt success rate is dismal.

Taking the emotion out of the equation, and looking at the published reports, why should medical control physicians continue to allow us to do this incredibly invasive procedure? Particularly when considering there are alternatives that CAN provide just as adequate ventilation volumes and pressures.

[p3medic]

The "evidence" is questionable, and certainly doesn't apply to every system. It seems obvious that systems need to establish their own airway registries, collect and analyze the data, and come up with the facts for themselves...

[ERDoc]

Don't get too upset about not getting many tubes in the OR. Even as an ER resident, it was difficult to get tubes in the OR. You hear the same things, this is a diffuclt tube, blah blah blah. I can understand where this is coming from. As someone mentioned, at least here in the US, lawsuits are a very big reality. Anyone can bring a lawsuit for anything, even if there wasn't any injury (they won't necessarily win though). Put yourself in the anesthesiologists position, you are being asked to trust a total stranger that you know nothing about with intubating a fully stable and healthy person. This just reeks of a high risk procedure waiting for a problem to happen. As a resident, I was an MD and they were still hesitant about letting me try of a tube. Now imagine them placing their career in the hands of some nonMD that they know nothing about and you can see why they are so protective. As for the CCRNs, they are protective because they fear for their jobs. They are trying to justify their existance so if someone with theoreticaly less training comes along and can do the job, how do they justify their existence? An anesthesiologist told me the patients that they feared the most were the healthy ones that were going in for elective surgery because if something happened there was going to be a lawsuit. If they too a sick, unstable pt who needed an emergent surgery to the OR, it was going to be a tough case, but no one would think anything if they died because they were so sick. Let's face it, you can teach a monkey to do the simple, straightforward intubations. See one, do one, teach one. It is the difficult airways, where you need to think through the problem that would be more beneficial to manage. These are the ones where the more you do, the better you get.

[Doczilla]

Kind of Off-topic but I've seen the concept of two nasals and an oral mentioned many times on here. I get the feeling that if I were to bring a pt in like that they would look at me strange due to excessive airways. Isn't one or the other sufficient if you're getting good air flow?

Putting in all 3 is a very good idea, and is what is taught to the ER residents here for BLS management while preparing to intubate. I don't think it's excessive, and bringing a patient like that in signals to me that you are paying close attention to the airway and maximizing ventilation. The airways will not interfere with each other, and improves the available airway through which you can ventilate. The more you can get that airway wide open, the better you can ventilate with lower pressures on the bag, and reduce insufflation of the stomach.

Scratrat's suggestion of "why don't you just intubate them" is fine, except that you have to ventilate them while getting ready to tube and to maximize your intubation attempt. The better you can ventilate them before the attempt, the more time you have for placing the tube. And then if you can't get them tubed on the first or second try, good BLS management will save you from having to perform a cricothyroidotomy. I see the mistake made fairly frequently by ALS providers: they concentrate so much on ALS skills like intubation, that they just don't pay that much attention to good solid BLS skills.

'zilla

[Paddy]

Don't be discouraged. Like many other pre-hospital issues, one must look (including me, you, and the person who jumped ya) at patient outcome as well as many other things. RSI is done all over Texas, sometimes with appropriate QA, sometime not. Texas was firmly against the original, National Scope of Practice due to its global approach to procedure. (one size fits all) RSI is appropriate in some settings. It is dangerous but then again, so are central lines, thrombolytics (yuck), morphine, TTJI, and manual defib. for that matter. The question is; Does it work and improve patient outcome. Keep on challenging yourself and others because if the question does not get asked the answer will never come.

Intubation itself is being measured and debated. It is not a matter of someone wanting to steal away our tools. The outcome, I predict will be a "urinate or get off the pot" conclusion. Do it, do it well or you will be killing your patient and held accountable. (Medical Directors, mostly)