Taking Away Paramedic and Pre-hospital Intubation

[Spock]

Tough subject that has received a lot of attention in the past few years. AZCEP and Rid have a good handle on this and it is nearly impossible to compare one country against another. I've been a CRNA for ten years and a paramedic for 18 so I've been on both sides of the equation. Just some thoughts.

CCRN's do not intubate but CRNA's do. I did almost 600 intubations during my anesthesia training over 2 years. I work for an anesthesiology group and I guarantee you I do more tubes than the doctors. That's one part of my job. My hospital is one of the few in our region that still lets medic students and flight crews in the OR for tubes. The doctors I work for feel that it is part of their jobs to teach and more than one has said that if they ever need intubated they want a well trained paramedic to do it so they are willing to take the risk.

The research is varied and some is suboptimal but the trend is clearly against paramedics intubating. Where this will all end up is unknown but if medics want to continue intubating they have to do a better job than they are currently. I started a research study with my service where medics are required to intubate the mannequin every shift. I'm trying to show that mannequin practice will improve first time success rate (the average first time success rate across the country seems to be in the 65-70% range.) Unfortunately I'm having a hard time getting people to do the mannequin time because of apathy. They just don't seem to give a damn. They all brag about their tubes but when I look at the trip sheets it is clear that they aren't doing a good job. Yes that is just my service and may not apply to others. A neighboring service had a medical director set up OR time for his medics on a voluntary basis and not one medic ever went into the OR.

Wang reported that almost 40% of Pennsylvania medics had ZERO intubations in one year. The average was 2. The study had some flaws but it is still out there. ETI is a high risk procedure that requires practice plain and simple.

Most medic intubations are in the cardiac arrest population. Compressions and defib are the only interventions that have been proven to make a difference in the cardiac arrest.

Where is this going? I don't know and neither does anybody else. My feeling is that medics will not be allowed to intubate within five years and ETI will be replaced with either the King, LMA or combitube. I feel the King is superior but it hasn't been on the market in the US long enough to gain acceptance. That will come with time because as I have said before I think the King is a better airway than the others. Only time will tell.

Medics are going to have to fight to keep the skills they currently have and research is the only way to succeed.

I'm still looking for the study showing how many intubations ER doctors do in a year. I suspect that MD's in teaching hospitals don't do more tubes than medics because they always have a resident around who wants and needs the tubes. Someone asked Dr. Wang how many tubes he did in a year and he wouldn't answer the question. What does that say?

Live long and prosper.

Spock

[ERDoc]

Tough subject that has received a lot of attention in the past few years. AZCEP and Rid have a good handle on this and it is nearly impossible to compare one country against another. I've been a CRNA for ten years and a paramedic for 18 so I've been on both sides of the equation. Just some thoughts.

CCRN's do not intubate but CRNA's do. I did almost 600 intubations during my anesthesia training over 2 years. I work for an anesthesiology group and I guarantee you I do more tubes than the doctors. That's one part of my job. My hospital is one of the few in our region that still lets medic students and flight crews in the OR for tubes. The doctors I work for feel that it is part of their jobs to teach and more than one has said that if they ever need intubated they want a well trained paramedic to do it so they are willing to take the risk.

The research is varied and some is suboptimal but the trend is clearly against paramedics intubating. Where this will all end up is unknown but if medics want to continue intubating they have to do a better job than they are currently. I started a research study with my service where medics are required to intubate the mannequin every shift. I'm trying to show that mannequin practice will improve first time success rate (the average first time success rate across the country seems to be in the 65-70% range.) Unfortunately I'm having a hard time getting people to do the mannequin time because of apathy. They just don't seem to give a damn. They all brag about their tubes but when I look at the trip sheets it is clear that they aren't doing a good job. Yes that is just my service and may not apply to others. A neighboring service had a medical director set up OR time for his medics on a voluntary basis and not one medic ever went into the OR.

Wang reported that almost 40% of Pennsylvania medics had ZERO intubations in one year. The average was 2. The study had some flaws but it is still out there. ETI is a high risk procedure that requires practice plain and simple.

Most medic intubations are in the cardiac arrest population. Compressions and defib are the only interventions that have been proven to make a difference in the cardiac arrest.

Where is this going? I don't know and neither does anybody else. My feeling is that medics will not be allowed to intubate within five years and ETI will be replaced with either the King, LMA or combitube. I feel the King is superior but it hasn't been on the market in the US long enough to gain acceptance. That will come with time because as I have said before I think the King is a better airway than the others. Only time will tell.

Medics are going to have to fight to keep the skills they currently have and research is the only way to succeed.

I'm still looking for the study showing how many intubations ER doctors do in a year. I suspect that MD's in teaching hospitals don't do more tubes than medics because they always have a resident around who wants and needs the tubes. Someone asked Dr. Wang how many tubes he did in a year and he wouldn't answer the question. What does that say?

Live long and prosper.

Spock

The ER attendings may not get as many tubes in academia, but they get the most difficult. The tube goes up the hierarchy from intern to senior resident to attending. This ends up selecting the most difficult airways for the attending. They may not get quantity, but they get quality.

[Ridryder 911]

ERDoc, would you not agree this is dependent upon the residency program and the setting ? I know, I have been involved in residency programs for over 25 years, and quite aware it is dependent upon the program, on the number of times a physician ever intubates. I know when ACLS required silly things like oxygenation and patient care, many physician had only intubated during their rotations, and then some even admitted they were "walked" through that.

Sure, ER and Anesthesiology, even critical care or I.M. might be able to have more clinical experience in intubation, but I do doubt other residents obtain the same numbers. I know that OB/Gyn's, ortho, etc.. might have not intubated in years or if ever. Understandably so, since most hospitals have code teams with airway teams, usually composing of either ER or anesthesiology. Personally, I intubate at least twice to three times as many times a year as our ER Physicians. Even in larger metro areas... due to >95% cardiac arrest and traumatic patients are intubated prior to arrival.

Again, I do personally feel the reason for the concern is of professional intimidation and threat. If one was "really" concerned upon outcomes, we would never lower our care and stick to the "gold standard", rather develop means to improve education to meet accepted outcomes.

Using alternative airways have not been used long enough as the primary airway to proclaim that it is as effective airway as intubation in my professional opinion. If that is the case, ER should remove intubation process as well and utilize them as the airway of choice. Before long, anesthesia guys will claim ER doc's do not have enough experience and cause delay. Again, this is the same limericks I heard when the EOA/EGTA and so on came out, that Paramedic should be utilizing them because of the ease ... and decreased missed intubations. We seen how that turned out!...

R/r 911

[whit72]

I wouldn't worry about losing ETI anytime soon. PASG was proven in-effective twenty-years ago, but they were still under my bench seat six-months ago. EMS is hardly on the cutting edge, at least in my area. Its like the red headed step child of medicine, everyones hand me downs.

In one state I worked in I was allowed to perform ETI, I haven't worked there in five-years. If I had to perform it now I probably could, would I be proficient at it? Doubt it. Practice makes perfect. If your not performing it regularly, you wont be proficient at it regularly.

[Spock]

Exactly right whit. If you don't do the easy ones you won't be able to do the difficult ones. Quality comes with quantity. You guys are right about the PASG and EOA's but if medics don't stand up for themselves they may lose ETI. Alternative airway devices are not as good as ETI but in the hands of the inexperienced they are more than adequate. Look at the trend from the AHA with ACLS and PALS. Clearly it is away from ETI for all but the most experienced (undefined term) and towards alternative airways. AHA doesn't call the shots with EMS but they do have a powerful message.

Live long and prosper.

Spock