RE: Paramedic Intubation

July 18, 2005

The only problem I see with this my fair Doctor, is that the

majority are being looked upon because of the " few " and I use this

term loosely because of the studies. I too have read the studies,

and I have a slightly different opinion on the matter. A: I have

always thought intubation has been used inappropriately, for two

reasons a) because we can and because it usually involves getting

to play with all of the neet other drugs that go with it i.e. RSI.

B: Aggressive airway management is necessary in some but not as

many patients as we would like to think, and there are good

alternative adjuncts such as an LMA with deep sedation which will do

the same job, almost if not as well. C: There are plenty of

situations in EMS wher LMA's and other alternative airways are not

apropriate due to transport times, amount of movement of the

patient, etc.; and most aren't recomended for use with NMBA when

NMBA is indicated. I agree poor training, poor skills picked up,

trained into from the begninning, and developed on their own are

part of the cause. I worke in a service where I would perform 2 to

3 a year. Another service where I would perform 2 to 3 a week.

Different areas have different needs, and to blanket the entire USA

based on studies, alot of which if not most of which are based on

urban models, not rural models, would be a bad thing. I think

training, maybe annual qualifications, etc. would be a step in the

right direction, although not a fix for the current problem. It

would be difficult to procure OR time to do these, and most elective

procedures now are using LMA's now in the OR's, so why allow an ETT

to be done with an increased risk to the patient whe it's being done

by a less experienced provider than the anesthesia practicioner?

Second, I see no excuse for the funding not to be spent on necessary

items such as capnography. Capnography is such a useful and vital

tool in conscious / unintubated patients, as well as intubated

patietns, and there are also additional adjucts out there to assist

in making intubation safer and easier. Teams need to practice

skills together, equipment needs to be available and functioning,

proficiency needs to be maintained through alternate means than

regular patient contacts, and probably first and foremost, a mindset

change needs to be made to do away with the do it because we can

attitude. Especiallially in pediatric patients, most can be managed

with BVM alone or LMA. I have done probably 5 pedi ETT procedures

in my time (I am counting pedi to be < teens in age). We know the

education programs as a whole are lacking in many areas, especially

airway management, when that is supposed to be where they are highly

focussed. I think airway maintenance should be built into every

service's ongoing QA / QI program, outside of what they learn in

school. Of course, I am being presumptious in thinking that there

are all that many ongoing QA / QI programs actively in place at

EMS's US wide to begin with. The problem boils down the the fact

that we have many unadressed issues in EMS, education, continuation

of education, re-eduacation, and maintenance of skills are highly

neglected. Just one misplaced and unrecognized tube is too many in

my book. Despite the fact that it happens in clinical settings like

ER's all the time, we are held to a higher level of proficiency

despite our austere working environment, and we must do everything

we must do to show these people that we are not

merely " technicians " ! I with you were wrong Doc Bledsoe, but I

think the trend may follow what you say. Rescue adjuncts may become

primary adjuncts, pushing us backwards to the days of ny and

Roy. I hope you don't support this measure, and want to help to fix

the problem instead of start taking skills away, because I know just

as many bad intubators that are flight medics and nurses, as well as

CCT medics and nurses, as there are general field crews. It just

seems to be that there are more QA / QI programs in these smalller

flight, and ground CCT programs, so there are less overall

problems. They can also afford more of the high tech " toys " (and I

hesitate to call them toys because they are necessary tools), to

make their job safer for their patients. It got so bad a few years

ago, I went and bought my own Capnograph (with MD approval) to use

in my practice with intubated and non-intubated patients because the

ones on the ambulance were frequently damaged, or not enough to go

around. It's late and maybe I am making sense, and maybe I am not,

but this is how I feel. I think it would be a massive wrongdoing to

take this skill away from every paramedic based on the studies which

are limited at best and focus on a select patient set. There are

reasons for intubation in EMS. The skill is overused, and at the

same time underused. Re-training practicioners, MD, DO, Paramedic,

RN, etc, alike is necessary, and can lead to better outcomes.

Blum, EMT-Paramedic

CCEMT-P / FP-C / EMS-Instructor

P.S. What has happened to the live intubation components of EMS

courses? I remember when I got in, it was a requirement to spend 50

hours in the OR with the anesthesiologist just to gain knowledge

from the anesthesia practicioner, althogh you were only required to

get 5 live tubes.

P.P.S. Another problem I see in this whole situation boils down to

money, money, money..............EMS needs more money worldwide, and

as soon as people decide to fund EMS systems the way they should be,

then we will start on the right path to fixing some of our long

standing problems. Unfortunately, take the skill away, it will save

on money and training costs, sounds like the majority answer. What

is the patient's, much less your life (if you end up being the

patient) worth? I can't put a monetary cost on it, can you? We

need to unite to fight this and many other battles. Why not start

here? Hmmmmmmmmm?

> Mark my words....paramedic endotracheal intubation may soon go

away. There

> is a significant, but quiet, push in academic emergency medicine

to remove

> endotracheal intubation as a general paramedic skill (instead

limit it to

> flight crews, clinical support officers, critical care paramedics

on

> critical care units). This Pitt study, along with numerous studies

from

> Florida, Maine, San Diego, Los Angeles and elsewhere have failed

to show any

> benefit from prehospital endotracheal intubation--in fact many

studies have

> shown a worse outcome. The problems are these: 1) Paramedic

endotracheal

> intubation education in this country is generally inadequate (not

enough OR

> time, chances to intubate, and bad skills from instructors being

transferred

> to students). 2) Poor decision making by paramedics--not every

airway needs

> an ET tube. 3) Paramedics must do at least 5 intubations a year to

maintain

> skill proficiency (per the AHA) and the vast majority do not

achieve this

> number (as shown in the Pitt study and a recent study from Maine).

4)

> Unrecognized esophageal intubation in EMS remains in the 10% range

which is

> totally unacceptable and the liability costs are a driving feature

to

> abandon the practice. It is cheaper to abandon the practice that

to place

> capnography on all ambulances or pay a yearly liability judgement.

5)

> Alternate airways (LMA, ETC, Cobra, Laredal, King) are available

and are

> basically as good as ET (most surgery cases less than an hour in

length are

> ventilated with an LMA). 6) Pediatric intubation by paramedics

only occurs a

> few times in a career--not often enough to justify skills

maintenance (thus

> it has been dropped in LA and other large cities are considering

following

> suit). 7) Minimum hour " get your patch and go to work " paramedic

education

> programs are promoting the problem. I recently ran into a program

(in a

> state to be named later) that required only 15 successful mannikin

> intubations before graduation.

>

> We'll revisit this email in a year and see how correct I am.

>

> BEB

>

July 19, 2005

In a message dated 19-Jul-05 07:30:14 Central Daylight Time,

petsardlj@... writes:

Does this not tell that it is a personal accounting for the Paramedic and not

the skill that is the problem?

I can't see taking this skill away especially from the rural field where it

can make all the difference. Not to mention that there may not be a critical

care paramedic around or an air ambulance.

I can see where there is a problem, but please; would you take a skill from

the medical physician because a certain number are not proficient in it? Has

this been done in other professions in the medical field?

As a matter of fact, yes, there are skills where individual physicians have

demonstrated proficiency, yet cannot perform said skills in the clinical

setting, due to limitations imposed by outside sources.

E.g., I have demonstrated that I can hit a tube, even a difficult tube, 19

times out of 20 first time. Despite this, and despite a demonstrated proficiency

with versed and suxx/vecc for RSI, I am not allowed to use etomidate at all,

nor am I allowed to use propofol prior to intubation.

I had over 500 total deliveries, including 75 c sections in my residency

training. Yet, even when I was fresh out of training, most hospitals would have

insisted that I have at least a dozen more c sections a year to keep full OB

credentials.

There are times that specialization is helpful.

and I'm about as staunch a supporter of improved field skills as you will

find, having been an EMT-A and Army medic for a number of years before getting

into medical school.

ck

S. Krin, DO

July 19, 2005

Does this not tell that it is a personal accounting for the Paramedic and not

the skill that is the problem?

I can't see taking this skill away especially from the rural field where it can

make all the difference. Not to mention that there may not be a critical care

paramedic around or an air ambulance.

I can see where there is a problem, but please; would you take a skill from the

medical physician because a certain number are not proficient in it? Has this

been done in other professions in the medical field?

Me thinks cutting off nose to spite face is bad idea!!!!

Danny

Owner/NREMT-P

Panhandle Emergency Training Services And Response

(PETSAR)

Office

Fax

Paramedic Intubation

Mark my words....paramedic endotracheal intubation may soon go away. There

is a significant, but quiet, push in academic emergency medicine to remove

endotracheal intubation as a general paramedic skill (instead limit it to

flight crews, clinical support officers, critical care paramedics on

critical care units). This Pitt study, along with numerous studies from

Florida, Maine, San Diego, Los Angeles and elsewhere have failed to show any

benefit from prehospital endotracheal intubation--in fact many studies have

shown a worse outcome. The problems are these: 1) Paramedic endotracheal

intubation education in this country is generally inadequate (not enough OR

time, chances to intubate, and bad skills from instructors being transferred

to students). 2) Poor decision making by paramedics--not every airway needs

an ET tube. 3) Paramedics must do at least 5 intubations a year to maintain

skill proficiency (per the AHA) and the vast majority do not achieve this

number (as shown in the Pitt study and a recent study from Maine). 4)

Unrecognized esophageal intubation in EMS remains in the 10% range which is

totally unacceptable and the liability costs are a driving feature to

abandon the practice. It is cheaper to abandon the practice that to place

capnography on all ambulances or pay a yearly liability judgement. 5)

Alternate airways (LMA, ETC, Cobra, Laredal, King) are available and are

basically as good as ET (most surgery cases less than an hour in length are

ventilated with an LMA). 6) Pediatric intubation by paramedics only occurs a

few times in a career--not often enough to justify skills maintenance (thus

it has been dropped in LA and other large cities are considering following

suit). 7) Minimum hour " get your patch and go to work " paramedic education

programs are promoting the problem. I recently ran into a program (in a

state to be named later) that required only 15 successful mannikin

intubations before graduation.

We'll revisit this email in a year and see how correct I am.

BEB

July 19, 2005

I have seen residents in the ER who complain that they do not get enough

intubation attempts because most of their patients who need the procedure are

intubated in the field. Some are very vocal about this and some can get out

right rude about it.

The study highlights the number of paramedics who have few or no intubation

attempts on an annual basis. I wonder how many physicians especially those who

are in management, book review and publishing and other non-clinical areas (not

directed at any individual) have few or no attempts on an annual basis. It may

be an apple and orange arguement.

Some of the educators on this list have expressed that they have a difficult

time in getting OR time for their students. Could this be a cause of the

problem?

AJL

PS: Maybe we need to fix these problems before we throw out the baby with the

bath water.

From the original post:

The problems are these: 1) Paramedic endotracheal

intubation education in this country is generally inadequate (not enough OR

time, chances to intubate, and bad skills from instructors being transferred

to students). 2) Poor decision making by paramedics--not every airway needs

an ET tube. 3) Paramedics must do at least 5 intubations a year to maintain

skill proficiency (per the AHA)

Paramedic Intubation

Mark my words....paramedic endotracheal intubation may soon go away. There

is a significant, but quiet, push in academic emergency medicine to remove

endotracheal intubation as a general paramedic skill (instead

July 19, 2005

Your missing the point--the point is research is showing that it does Not

make a difference. Simple airway techniques, mechanical ventilation are all

that are required.