RE: Paramedic Intubation

[Guest guest]

Oh, I am the first to admit I am not without fault, and I do

challenge the status quo all the time. I am not a quiet bystander,

nor am I all talk and no do! I am one HUGE proponent of evidence

based medicine, but I have to question removing a vital skill which

we know saves lives in certain situations. Rural settings being the

most significant. We have yet to see controlled randomized studies

in rural settings, only urban settings. The differences are many,

and the problems are a whole different set. It like the arguement

over RSI. I for one am a proponent of RSI in the right hands and

the right situation. It may not be necessary in an urban setting

with < 10 minute transports, but in a rural setting with > 45 min. +

transports, it is sometimes a necessity. I for one have had

the " dead " CHF patient with fulmonate pulmonary edema, (dead for all

practical purposes but still with a pulse), intubated throught RSI,

managed aggressively with nitrates and diuretics (Bumex or Lasix),

and have the patient ready to be extubated upon arrival at the ER.

There is no question in my mind that the PPV she received via ETT,

saved her live at the point in which she was. She was realy past

the CPAP point, and by the way, I am a huge proponent of pre-

hospital CPAP as it results in lower pre-hospital intubations,

and " fixes " patients rapidly, usually prior to ER arrival.

Restricting it to those few of us (myself included) who are CCEMT-

P's and FP-C's is ludicrous. I think the potential is there for

aggressive medical education regarding proper airway management,

difficult airway management, and proper use of invasive airway

management. The addition of critical thinking and problem solving

skills is of the utmost priority, as I was once told by a professor

of medicine, " Improvisation is the mother of paramedicine. " And he

was correct. FYI, in the last EMS I worked full time, I use to get

2 and 3am calls from the frantic ER doc needing me to come intubate

his patient for him (RSI the patient sometimes because he didn't

know how), just plain intubations other times, intubation with

cetacaine other times, blah blah blah. This is the same physician

who had me do his central lines, chest tubes, and ventilator and bi-

pap settings for him (they had no 24 hour respiratory therapy

support and they were on 3 hour call back, so ye who knew how to do

it, got called to do it). I have my fair share of chest tubes and

centrals under my belt, neither of which I would advocate just

throwing out in an EMS rig, but in some cases they might be useful.

Yet, he as a physician is able to do it, yet he is scared to do it,

and less proficient at it than I am, so he had me come do it. Other

docs would butcher airways before calling us to come save what was

left of the hamburger that they had created for an airway, and

usually after raiding the OR for a bouggie, we could accomplish a

fairly uncomplicated ETT placement. I am also a major advocate for

Waveform Capnography, so much that I bought on for myself when the

service wouldn't, after getting my MD's approval to use it. I will

also fuel the fire by saying that when I worked in a servive where I

did 50 or 60 intubations per 6 months to a year, I had near a 90%

success rate on the first try, and nearly 100% on second try. When

I went to a service where I intubated maybe 3 or 5 times a year, my

success rates dropped to the 60% to 70% range and secondary devices

were used quite a big (with no shame might I add), but there is

something to be said for proficiency based on regular live patient

practice. I am also a major proponent of backup airwawy devices.

You can never have too many tricks up your sleeve, or too many toys

to make your job easier and safer for the patient, whether it be a

bouggie, an LMA, a Combi-tube, and EGTA, an EOA, a plethora of

difficult airway blades for your laryngoscope, and albeit the last

resort airway of a nutrake or quick trach, etc. I personally carry

my own set of Grandview blades, and View Max blades, as well as a

nice set of standard mac and miller blades which I know are properly

maintained by me with fresh bulbs and batteries on a regular basis.

Call it overkill, but anything that makes my job easier, and it

safer for the patient, is money and time well spent. Unfortunately,

what this boils down to is money. For training, for equipment, for

Contiuning training, CE, proficiency verification, labs, difficult

airway manikins, etc. etc. etc....................I am ending my

rant, and going to bed now, so have a good night and stay safe.

Blum (and all of those meaningless alphabet's that go after

my name.....it's the medic, not the number of letters he/she can put

after their name to impress people)

P.S. Most of the patients with a poor outcome in the studies were

probably going to die anyway, so as far as I am concerned, they

can't realistically reflect the true outcome of pre-hospital ETT.

Especially in CPR patients.

> >>>For you to make a statement that you are right 99.9% of the

time

> is just assenine.<<<

>

> The statement was made as a satiric comment on statistics in

> general. Admittedly, my margin of error can be quite high at

times.

>

>

> >>> It makes me not want to ever cross your path. <<<

>

> That's too bad. I think I might enjoy the encounter. You've got

to

> admire a man who can write a coherent paragraph using nothing but

> expletives!

>

>

> >>> You too are a paramedic, so why are you not supporting your

> profession? Are you trying to undermine your profession and

forget

> about your roots? <<<

>

> I don't think genuflecting at EMS dogma supports our profession.

I

> think we all should examine everything we do and everything we are

> told. That is the only way to improve.

>

> By the way, at my roots are a couple of very influential

> instructors. The greatest lesson they taught is not to believe

> everything they say just because they say it. In their honor, I

try

> to pass that message on to my students. Challenge the status

quo.

> It frequently will not stand up to scrutiny.

>

>

> >>> YOU ARE NOT WITHOUT FAULT I AM SURE! <<<

>

> On that we agree.

>

> Kenny Navarro

[Guest guest]

>>> There is no " SAFE " or " Zero Risk " environment in performing any

medical procedure, however, we can minimize those risks by being

competent, proficient, and well educated providers. <<<

KN: When I use the term " Zero Risk " in this context, I am advocating

the creation of an environment where paramedics cannot perform an

unrecognized esophageal placement of a tracheal tube. I know that

absolute zero risk can never be achieved, but it is ultimately the

goal.

KN: When I first came to the BioTel system, one of the Medical

Director's asked me to help him create a " Zero Tolerance " atmosphere

for unrecognized esophageal intubations. I told him that I would not,

but I would help to create a " Zero Risk " environment (or get as close

to zero as we could get.) In my analysis of our system, when a medic

arrived at the hospital with a misplaced tracheal tube, he didn't fail

us. We failed him.

>>> I can tell you there are times, especially in the Rural setting in

which ET Intubation is mandatory to protect the patient from further

harm, and better their chances of survivial. <<<

KN: This is the statement I don't know (for sure) to be true.

>>> The studies are not conclusive as to whether or not pre-hospital

intubation is harmful to a patient, and I be they never will. <<<

KN: I would challenge this statement as well. The published studies

are fairly conclusive that tracheal intubation in the hands of

paramedics can be very dangerous. Some EMS systems have reported

unrecognized esophageal intubations of 25%. Those 25% will die. Now

the intubation probably didn't kill them. But, the medics created a

situation from which, the patient could not possibly survive.

KN: Not every system has this problem, but many do. There are ways

to improve this situation to be sure. Beaumont, apparently has found

a way.

>>> What makes it worse to intubate out of hospital as opposed to in

hospital if they need their airway managed. As long as undue delay in

transport doesn't occur, and proper confirmation techniques are used,

and it is not a skill used wrecklessly, I see no way in which harm can

befall a patient. <<<

KN: My argument has not been so much about the harm we are doing, but

about no survival advantages. But to answer your question, for those

who do survive to hospital admission, patients intubated in the

prehospital environment tend to have a greater incidence of airway

related complications (such as pneumonia) than in those intubated in

the emergency department. I will find the references and post them in

a couple of days.

>>> I think LMA's and Combi-tubes, etc. are great backup airways, but

should never be considdered as primary airways in the pre-hospital

setting. <<<

KN: And yet, ILCOR makes the following statement (pg I-87, Guidelines

2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular

Care)... " ALS providers unable to obtain regular field experience (non-

evidence based guideline: 6 to 12 times per year) should use

alternative, non-invasive techniques for airway management. "

Kenny Navarro

[Guest guest]

But again Kenny,

Are these patients who would have developed pneumonia anyway? Would

they have aspirated anyway? We have no way of knowing. We can

hypothesize and make statements of opionion day in and day out, but

we never can really know. Again, we are dealing withe the sickest

of the sick. I know we in most cases aren't doing this procedure in

any less sterile of a situation than in an ER based on what I have

witnessed both working and observing in an ER setting. So, Take the

worst of the worst and that's what we see. The ones that survive to

the ER have usually received quite a bit of stabilizing treatment on

the way to the ER and hence are usually doing better, or are

stabilized upon arrival. A large majority of my patients get

observation, labs, CT's or MRI's, and then sent to the ICU with no

other treatment rendered, because we did it in the pre-hospital

setting. How can we know these patients wouldn't have gotten sick

anyway? We don't, and EMS can't be blamed for an variable which

can't be proven. At least not easily. And we are not talking about

using ET tubes dropped on the floor of the rig, or in the dirt,

etc.........we are talking about maintaining proper " clean "

technique while intubating. Intubated patients are at an

inherrently increased risk for pulmonary infection anyway, yet, by

intubating patients and placing them in sedated states, we also

reduce their metabolic rate by up to 70% ALLOWING THEM TO CONSERVE

ENERGY FOR FIGHTING INJURY OR DISEASE. We can bennefit these

patients in many ways by " resting them " . Conserving energy, body

heat, reducing caloric demands, etc. This has been proven and is

taught in ATLS, or at least it was 2 years ago my last Audit. I

stay up on Anesthesia quite well with many " gas men and women " as

friends, as well as reading the current literature, and they all

agree EMS does a wonderful job managing these patients, getting

airways they would have problems getting, and that we use great

judgement for the most part in when to implement aggressive airway

measures. I have fortunately gotten the change to spend alot of OR

time on my own on the side with them as an " observer " to learn and

discuss these issues. I have yet to hear one of them say EMS

shouldn't intubate, and i have heard them say that we are better

intubators than most other physicians they know, as well as some

anesthesiologists. I am not blowing anyones whistles here, just

stating fact. I think this is an area which needs much more

research and discussion before we go off with some knee-jerk

reaction to pull it off the trucks, such as we did with some of the

ACLS changes over the last few years which were supported by only

one study. Granted they are being confirmed in more studies now,

but originally they were implemented based on limited evidence

thought to be crucial at the time.

> >>> There is no " SAFE " or " Zero Risk " environment in performing

any

> medical procedure, however, we can minimize those risks by being

> competent, proficient, and well educated providers. <<<

>

> KN: When I use the term " Zero Risk " in this context, I am

advocating

> the creation of an environment where paramedics cannot perform an

> unrecognized esophageal placement of a tracheal tube. I know that

> absolute zero risk can never be achieved, but it is ultimately the

> goal.

>

> KN: When I first came to the BioTel system, one of the Medical

> Director's asked me to help him create a " Zero Tolerance "

atmosphere

> for unrecognized esophageal intubations. I told him that I would

not,

> but I would help to create a " Zero Risk " environment (or get as

close

> to zero as we could get.) In my analysis of our system, when a

medic

> arrived at the hospital with a misplaced tracheal tube, he didn't

fail

> us. We failed him.

>

>

> >>> I can tell you there are times, especially in the Rural

setting in

> which ET Intubation is mandatory to protect the patient from

further

> harm, and better their chances of survivial. <<<

>

> KN: This is the statement I don't know (for sure) to be true.

>

>

> >>> The studies are not conclusive as to whether or not pre-

hospital

> intubation is harmful to a patient, and I be they never will. <<<

>

> KN: I would challenge this statement as well. The published

studies

> are fairly conclusive that tracheal intubation in the hands of

> paramedics can be very dangerous. Some EMS systems have reported

> unrecognized esophageal intubations of 25%. Those 25% will die.

Now

> the intubation probably didn't kill them. But, the medics created

a

> situation from which, the patient could not possibly survive.

>

> KN: Not every system has this problem, but many do. There are

ways

> to improve this situation to be sure. Beaumont, apparently has

found

> a way.

>

>

>

> >>> What makes it worse to intubate out of hospital as opposed to

in

> hospital if they need their airway managed. As long as undue

delay in

> transport doesn't occur, and proper confirmation techniques are

used,

> and it is not a skill used wrecklessly, I see no way in which harm

can

> befall a patient. <<<

>

> KN: My argument has not been so much about the harm we are doing,

but

> about no survival advantages. But to answer your question, for

those

> who do survive to hospital admission, patients intubated in the

> prehospital environment tend to have a greater incidence of airway

> related complications (such as pneumonia) than in those intubated

in

> the emergency department. I will find the references and post

them in

> a couple of days.

>

>

> >>> I think LMA's and Combi-tubes, etc. are great backup airways,

but

> should never be considdered as primary airways in the pre-hospital

> setting. <<<

>

> KN: And yet, ILCOR makes the following statement (pg I-87,

Guidelines

> 2000 for Cardiopulmonary Resuscitation and Emergency

Cardiovascular

> Care)... " ALS providers unable to obtain regular field experience

(non-

> evidence based guideline: 6 to 12 times per year) should use

> alternative, non-invasive techniques for airway management. "

>

> Kenny Navarro

[Guest guest]

I would not rely on the San Diego study. As i mentioned in an earlier post it

used data over a 16 year period. Dont you believe that alot of changes occured

over that time frame?

Maybe with a shorter and more recent time frame (2-3 years, 2000-2003) with the

same results but not 16 years.

AJL

Re: Paramedic Intubation

>>> ...if intubation makes no difference in the prehospital setting,

why is it done in the ED? <<<

Gene, now you're just being silly. Two separate environments. If

you want to know if something works in the field, you have to study

it in the field. If you want to know if something works in the ER,

study it in the ER. It is a leap of faith, however, to suggest that

something that might work in the ER will work in the field.

>>> What the San Diego and LA studies prove to me is that the medics

in the study couldn't intubate well. <<<

Perhaps. Maybe medics in Southern California are endotracheally

challenged in some way...that is always a possibility. However, it

doesn't seem plausible that most of the endotracheally challenged

medics in the United States are concentrated in that area. Those

studies do not suggest that the medics can't intubate, but that

endotracheal intubation ACCOMPLISHED in the field does not improve

outcome.

I don't understand why folks have difficulty with that concept. In

the few years I have been a paramedic, the overwhelming majority of

patients I have intubated have been victims of cardiac arrest. The

overwhelming majority of those patients DIED. Overall, then,

endotracheal intubation did not improve the survival rates in my

cardiac arrest patients.

In Orlando, it was demonstrated that as many as 27% (or so) of the

field-placed ET tubes will be unrecognized esophageal placements by

the time the patient arrives in the ER (This study was before the

introduction of waveform capnography.) Now, when I was intubating in

the old days, I had been similarly trained and worked in a system

comparable to Orlando. It is reasonable, then to think that 27% of

my tubes could have been unrecognized esophageal placements.

Even if a system can institute a zero-risk environment for

endotracheal intubation, the question still is, " Does endotracheal

intubation performed in the prehospital environment improve

outcome? " The answer appears to be, " No. "

>>> I'd like to see a study done using cadavers where paramedics and

ED docs from the same system were compared under the same conditions.

<<<

Again, the question is NOT whether paramedics can be trained to

perform endotracheal intubation correctly but whether it improves

outcomes. It is said you can teach a monkey to intubate, although I

have never personally put that to the test. (I have taught

intubation to a few medics who, I swear, have only been upright for a

couple of generations.)

Love,

Kenny Navarro

UT Southwestern Medical Center

[Guest guest]

In a message dated 7/21/2005 11:34:54 AM Central Daylight Time,

alambert@... writes:

AJL

BTW, this is not from the IAFF dog and pony show propaganda. I am not an IAFF

member nor am I a firefighter - I work for a 3rd service municipal agency

As you put it, " BTW " do you have a name?

[Guest guest]

Kenny,

Here is my question about intubation. Is there a

better way to secure your airway?

Tom

Not a very bright paramedic but still learning to this

day.

PS - " If the patient can't take the laryngscope out

of your hand and beat you over the head, they need a

tube. " Guess who said that. <giggle>

[Guest guest]

Yes, it's listed properly in his email header as Alan Lambert.

Those of you on AOL can't properly see correctly-formatted email

headers, as AOL assumes you are morons and hides such things from you

in their interface. No, I didn't say AOL users were morons - AOL just

thrives on providing a fisher-price interface to the internet for the

mass of people who are AFRAID of technology - and became a ubiquitous

method of internet access for millions more.

Alan, and others who are asked for their name, often have it correctly

listed in their email headers, as dictated by email standards for 15

years. AOL simply doesn't apply those standards, thinking that its

users are somehow unable to cope. Pity, it is.

Mike

> In a message dated 7/21/2005 11:34:54 AM Central Daylight Time,

> alambert@... writes:

> AJL

> BTW, this is not from the IAFF dog and pony show propaganda. I am not an IAFF

> member nor am I a firefighter - I work for a 3rd service municipal agency

> As you put it, " BTW " do you have a name?

>

>

>

>

>

[Guest guest]

The Prehospital & Transport Medicine Research Program which is supported by the

University of Toronto and Sunnybrook & Womans Research Institute.

See their web page at www.prehospitalresearch.com

They have not published anything yet but according to their newsletter they have

submitted for approval a study to be published in Resuscitation. They were

recently notified that the study will be published this year. The study compares

survival rates of monophasic defibrillation vs biphasic defibrillation.

AJL

RE: Paramedic Intubation

I think I have a solution. Let's develop a stand alone organization

dedicated to unbiased, non-political EMS Research. Any organization that

has a vested interest in EMS Research can pay into the big pot, the $$ will

be used to support ALL research and know one will have any say in how their

money is utilized except that it is used for the betterment of EMS and

ultimately patient care.

Lee