Guest guest Posted July 19, 2005 Report Share Posted July 19, 2005 Gene, That's an awful lot of trouble. Attend an ACLS or a BTLS class with airway management stations. Observe the participants and score your card at will. (Yes, that was a tongue in cheek comment) Kidding aside, when watching Physicians, Nurses, Paramedics and others going through skills stations during the alphabet courses, it is amazing the higher proficiency of the common medic vs. the run of the mill nurse or MD. I will agree that the ED Physician (not to exclude the Anesthesiologist or CRNA and other healthcare professionals that perform the skill on a regular basis) will or at least should have an extremely high proficiency at the airway skills. We could discuss the other medical professionals failures, but that does nothing to overcome the shortfalls of the field medic and the goal of a high proficiency at arguably the most vital skill the Medics are granted. bkw RE: Paramedic Intubation > > > 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. > > BEB > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 19, 2005 Report Share Posted July 19, 2005 , A good and fair response. I have a friend who is entering his 2nd year of ED residency at the same hospital in LA that ny and Roy worked with. He tells me that he has never had any training in difficult airway techniques. He was never shown a bougie, told about the BURP technique, patient stacking, or any other tricks. He learned about all sorts of things like ViewMax and Grandview blades, bougies, and so forth because he was a paramedic before he went to med school. Now, there's something wrong with that. He gets 12-15 tubes a week, but he has had to learn how to do the difficult ones on his own. In fact, he has taught his attending some tricks that he learned from me. So now the medical community is ready to hang medics for lacking intubation skills when it (1) does everything possible to prevent Paramedic students from getting practice and (2) doesn't even teach its own how to manage the difficult airway. How can the EMS community get the rest of the medical community to " buyin " to getting us the training we need? Does the rest of the medical community as a whole view us as trauma monkeys, ambulance drivers, or worse, simply not a part of the medical team? Gene G. In a message dated 7/19/2005 7:40:09 PM Eastern Daylight Time, " Bledsoe " writes: >See comments in text. > > _____ > >From: Wegandy1938@... >Sent: Tuesday, July 19, 2005 6:01 PM >To: bbledsoe@...; >Subject: Re: Paramedic Intubation > > >, > >Just to engage in a little devil's advocacy with you, if intubation makes no >difference in the prehospital setting, why is it done in the ED? > >A good question. In teaching hospitals, it is done to train residents and >students. In non-teaching hospitals LMAs and other airways are used with >increasing frequency. The biggest reason is that most patients intubated in >the ED will continue on to ICU or surgery where they will be mechanically >ventilated. > >Are there studies that attempt to measure patient outcomes based upon airway >management in the ED? > >This is a mixed bag. Several studies, including one in a recent J of T, >found ED physicians as good at airway management in trauma patients as >anesthesiologists. But, I have a paper that shows trauma outcomes are better >when ETI is performed in the field. The difference is the physicians are >left to police themselves--but with EMS the field personnel are policed by >the physicians. > >What the San Diego and LA studies prove to me is that the medics in the >study couldn't intubate well. > >I agree. They also had few intubations per medic. > >Is it just possible that there's a bias against prehospital intubation in >the way the studies were constructed? > >Some. But the Gauche-Hill study was an RCT and unbiased (pedi intubation in >LA). The Wang study was not really biased as it was a review of existing >data. Bias would have come into play had the data shown that paramedics get >an adequate number of intubations and the researchers failed to publish the >paper (publication bias)/ > >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. The cadavers >should be chosen for a variety of difficulty, and let's see who does the >best job with the difficult airway. > >You have to compare apples and orange. The term " ED doc " is a ubiquitous >term. Many " ED Docs " are internists, surgeons, pediatricians, family >practitioners by training and those bot exposed to ETI in any detail. >Board-certified ED physicians (either through residency training or the old >practice track) have an extensive background in airway management and this >must be documented or they could not be board-certified. But, take all ED >docs and compare to paramedics you might be right. But, take just those >board-certified in EM and compare and you will probably find the docs >better. > >Pull the medics and the docs in randomly and without prior notice. Lay out >the same equipment and see what happens. > >The docs have nothing to prove so why? Certainly liability issues cull out >some of the bad physicians and peer-review gets some more. You can take the >physician with the worst intubation skills and send him away and there is >nothing stopping him from doing airway management in his office or a >freestanding doc in the box. But, a paramedic has to have the MD or DO >oversight and that makes the whole concept a non-sequitur. > >Gene G. > > > > Now, I have been a paramedic and have not seen the skills problems that >Wang and Vilke and Eckstein and Gauche-Hill are seeing. I do feel much of >the problem is a southern California thing (although they had the same >problems in Orange County, Florida). I think the biggest issue here is that >paramedics tend to want to stick a tube when something less invasive will >work. An old internist at and White during my residency said, " , >being a good physician means knowing when not to do a test or procedure >instead of knowing when to. " The problem is poor decision making skills and >thinking like a technician instead of a professional. A good example of such >thinking happened to me at Fort Hood. I wanted to send a women to the OB >clinic for a non-stress test (basically 1/2 -1 hour on a fetal monitor). It >was 11:30 AM. I called the nurses in the clinic and told them of my plan. >They responded, " Well, doctor do what you want, but there will be nobody >here at 12:30 to take her off the monitor cause we go to lunch at 12:00 " > >No, but numerous other stdies (primarily out of San Diego and Los Angeles) >have. > > RE: Paramedic Intubation > > >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. > >BEB > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 19, 2005 Report Share Posted July 19, 2005 And I suggest, Andy, that this is the flaw in the studies that have been done. I still think, no matter who says what, that the folks who designed the studies did so with the thought in mind to show that paramedics should not intubate. There is a decided movement in this country to use so-called evidence based medicine to further the biases of some in the medical community. There may be many reasons for this, not the least of which is that every time we do an intervention in the field that a physician could have done in the ER, we deprive them of a charge for services. I am not opposed to evidence based medicine. I believe that we need much more research, but it needs to be unbiased. I do not buy into the notion that an intervention that is considered necessary and prudent in the ED is any different in the prehospital setting. When evidence based concepts are applied to prehospital medicine, let's apply the same concepts to practice in the ED. If RSI is irrelevant to the prehospital setting, why is it considered standard of care in the hospital ED? See where I'm going with this? I will be the first to say that Paramedic education sucks for the most part. But it doesn't have to. There are great programs that turn out great medics. Most of them do so in spite of the roadblocks that are set up by the greater medical community, meaning phytsicians and nurses. I greatly admire and thank those few physicians who do support EMS with their hearts and souls. They'll be the first to tell you that the community of physicians is either outright hostile to EMS, apathetic about it, or 99% ignorant about it. If dedicated physicians cannot move their colleagues to recognize EMS as needing their help to do its job, how can we poor unwashed medics hope to do any better? While EMS bears lots of responsibility for our plight, the medical community as a whole is even more guilty of neglect and outright hostility. EMS cannot progress until the greater medical community decides that we're a part of them. So long as we're half firefighter/half medic, that will never happen. Not that some FDs cannot do EMS well, but paramedicine is essentially MEDICINE, not RESCUE. Until we decide what we are and create a place for ourselves within the medical community, we'll remain outside. EMS belongs outside fire services. Period. It is medical, not rescue. Rescue is a peripheral aspect of paramedicine, and it is important, but rescue agencies cannot do a good job of paramedicine simply because there is always the dichotomy of skills and duties that are demanded. There is no reason for a paramedic to become an expert at firefighting as well as being good at medicine. But the chain of command is fire, not medicine. So in order to progress, one must embrace the fire side. Look at the exams for promotion. Are they paramedic based or fire based? Until we end the influence of fire departments in the delivery of EMS, we will never, ever, be a part of the medical community and we will never, ever, improve our status. FDs can and should first respond, defibrillate, secure airways, and stop obvious bleeding if possible, and do extrication, assist with loading, and so forth. But when medics have to also maintain firefighting skills, this does not compute. I have the greatest respect for firefighters. They ought to do what they do best---fight fires, do rescue, and so forth. They should not be trying to do medicine unless the medical duties are split off into a separate division with a separate career pathway. OK, fire away (pun intended). Gene G. In a message dated 7/19/2005 7:47:20 PM Eastern Daylight Time, rachfoote@... writes: >This is just a play on numbers and does not reveal a real picture. I am the >manager of a 3rd City Service that performs intubations daily, at a 99.2% >success rate. I also do QA/QI for other services that have a 10% success rate >and rarely do any intubations, yet make more calls than my City service. >What does that say? Absolutely nothing when you start comparing several >services together. As everyone knows, you can get figures to say just about >anything you want them to say if you know what you are doing and what you are >looking for them to say.. Whew, what a mouthful to say you can't judge the quality >of my service by comparing my numbers to someone else's and then combining >them to get an average. > >Andy Foote >City of Beaumont EMS > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 19, 2005 Report Share Posted July 19, 2005 >>> ...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 Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 19, 2005 Report Share Posted July 19, 2005 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 Re: Paramedic Intubation And I suggest, Andy, that this is the flaw in the studies that have been done. I still think, no matter who says what, that the folks who designed the studies did so with the thought in mind to show that paramedics should not intubate. There is a decided movement in this country to use so-called evidence based medicine to further the biases of some in the medical community. There may be many reasons for this, not the least of which is that every time we do an intervention in the field that a physician could have done in the ER, we deprive them of a charge for services. I am not opposed to evidence based medicine. I believe that we need much more research, but it needs to be unbiased. I do not buy into the notion that an intervention that is considered necessary and prudent in the ED is any different in the prehospital setting. When evidence based concepts are applied to prehospital medicine, let's apply the same concepts to practice in the ED. If RSI is irrelevant to the prehospital setting, why is it considered standard of care in the hospital ED? See where I'm going with this? I will be the first to say that Paramedic education sucks for the most part. But it doesn't have to. There are great programs that turn out great medics. Most of them do so in spite of the roadblocks that are set up by the greater medical community, meaning phytsicians and nurses. I greatly admire and thank those few physicians who do support EMS with their hearts and souls. They'll be the first to tell you that the community of physicians is either outright hostile to EMS, apathetic about it, or 99% ignorant about it. If dedicated physicians cannot move their colleagues to recognize EMS as needing their help to do its job, how can we poor unwashed medics hope to do any better? While EMS bears lots of responsibility for our plight, the medical community as a whole is even more guilty of neglect and outright hostility. EMS cannot progress until the greater medical community decides that we're a part of them. So long as we're half firefighter/half medic, that will never happen. Not that some FDs cannot do EMS well, but paramedicine is essentially MEDICINE, not RESCUE. Until we decide what we are and create a place for ourselves within the medical community, we'll remain outside. EMS belongs outside fire services. Period. It is medical, not rescue. Rescue is a peripheral aspect of paramedicine, and it is important, but rescue agencies cannot do a good job of paramedicine simply because there is always the dichotomy of skills and duties that are demanded. There is no reason for a paramedic to become an expert at firefighting as well as being good at medicine. But the chain of command is fire, not medicine. So in order to progress, one must embrace the fire side. Look at the exams for promotion. Are they paramedic based or fire based? Until we end the influence of fire departments in the delivery of EMS, we will never, ever, be a part of the medical community and we will never, ever, improve our status. FDs can and should first respond, defibrillate, secure airways, and stop obvious bleeding if possible, and do extrication, assist with loading, and so forth. But when medics have to also maintain firefighting skills, this does not compute. I have the greatest respect for firefighters. They ought to do what they do best---fight fires, do rescue, and so forth. They should not be trying to do medicine unless the medical duties are split off into a separate division with a separate career pathway. OK, fire away (pun intended). Gene G. In a message dated 7/19/2005 7:47:20 PM Eastern Daylight Time, rachfoote@... writes: >This is just a play on numbers and does not reveal a real picture. I am the >manager of a 3rd City Service that performs intubations daily, at a 99.2% >success rate. I also do QA/QI for other services that have a 10% success rate >and rarely do any intubations, yet make more calls than my City service. >What does that say? Absolutely nothing when you start comparing several >services together. As everyone knows, you can get figures to say just about >anything you want them to say if you know what you are doing and what you are >looking for them to say.. Whew, what a mouthful to say you can't judge the quality >of my service by comparing my numbers to someone else's and then combining >them to get an average. > >Andy Foote >City of Beaumont EMS > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 19, 2005 Report Share Posted July 19, 2005 There is one. The Cochrane Center for Prehospital studies. However, they are talking and not doing much. I plan to give them some grief in Melbourne and Canberra in October over this very issue. Look at the Cochrane Centre for medicine (http://www.cochrane.org/index0.htm). There is a paper and summary for everything from knee arthroplasty to depression treatment. The web site for the prehospital Cochrane center is: http://www.cochranepehf.org/news.php 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 Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 19, 2005 Report Share Posted July 19, 2005 >>> So now the medical community is ready to hang medics for lacking intubation skills... <<< Gene, the medical community is not trying to " hang " anyone. (The medical community has authorized me to speak for it.) EMS researchers are simply asking the questions about endotracheal intubation in the prehospital environment. You seem like a relatively reasonable soul. Do you agree, that even in the best systems, there is some risk associated with endotracheal intubation in the prehospital environment? If, as an example, an aggressive quality control program was instituted with strict medical oversight and the incidence of misplaced tracheal tubes could be lowered to 0.5%, that slight risk still appears to outweigh any potential benefit to be gained. To the group, if your child/mother/father/spouse/life-partner was in the hospital and the physician came to you with the following, how would you answer? We have a procedure we would like to attempt in your loved one. There is absolutely nothing to be gained by performing the procedure and there is an outside chance that we would create a condition, from which your loved one could not recover? Overly simplistic, I know...but I've had a couple of glasses of wine. Kenny Navarro Professional Nemesis Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 19, 2005 Report Share Posted July 19, 2005 >>> I am the manager of a 3rd City Service that performs intubations daily, at a 99.2% success rate. <<< Andy, those are great statistics and you should be proud. It supports my assertion that paramedics can be taught to do it. The questions still remain, however... What percentage of those patients survived-to-discharge neurologically intact? Was the ETT responsible for the survival or could it have been because of other factors? >>> As everyone knows, you can get figures to say just about anything you want them to say if you know what you are doing and what you are looking for them to say. <<< (Not directed at you, but a general statement...) I find it interesting that when statistics seem to support a position contrary to our own, we criticize statistics in general and counter with statistics of our own. I'm right 99.9% of the time! (The other 0.1% is the margin of error.) Kenny Navarro UT Southwestern Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 19, 2005 Report Share Posted July 19, 2005 I have used LMA's and ET's in the field and I personally do not see where LMAs are better when you are working a code. Contrary to popular belief when you are bouncing down a dirt road or rough city street ET’s have a better chance of staying where they belong. I have used ET’s numerously in the field as have several medic without any problem. But, for the one’s that are lacking in the skill there are place where they can get additional training. Also, using LMAs in the operating room is a far cry from using them in the field. " Bledsoe, DO " wrote: Just read up on it for the CCT book and we included it there. Seems like a good airway--Ray Fowler has a nice article this month in JEMS on it. I still feel the LMA is the best secondary prehospital airway. BEB Re: Paramedic Intubation Dr. Bledsoe, What are your thought on the King LT-D Airway? Wood Paramedic/FTO Tulsa, OK 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 Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 19, 2005 Report Share Posted July 19, 2005 I am putting money on the medics smoking em wegandy1938@... wrote: , Just to engage in a little devil's advocacy with you, if intubation makes no difference in the prehospital setting, why is it done in the ED? Are there studies that attempt to measure patient outcomes based upon airway management in the ED? What the San Diego and LA studies prove to me is that the medics in the study couldn't intubate well. Is it just possible that there's a bias against prehospital intubation in the way the studies were constructed? 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. The cadavers should be chosen for a variety of difficulty, and let's see who does the best job with the difficult airway. Pull the medics and the docs in randomly and without prior notice. Lay out the same equipment and see what happens. Gene G. > No, but numerous other stdies (primarily out of San Diego and Los Angeles) > have. > > RE: Paramedic Intubation > > > 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. > > BEB > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 19, 2005 Report Share Posted July 19, 2005 I don't know about the rest of medics in the state but as far as the hospitals around here are concerned, if any ambulance shows up without the patient being intubated (as long as they need it) they will get a severe butt chewing. wegandy1938@... wrote: And I suggest, Andy, that this is the flaw in the studies that have been done. I still think, no matter who says what, that the folks who designed the studies did so with the thought in mind to show that paramedics should not intubate. There is a decided movement in this country to use so-called evidence based medicine to further the biases of some in the medical community. There may be many reasons for this, not the least of which is that every time we do an intervention in the field that a physician could have done in the ER, we deprive them of a charge for services. I am not opposed to evidence based medicine. I believe that we need much more research, but it needs to be unbiased. I do not buy into the notion that an intervention that is considered necessary and prudent in the ED is any different in the prehospital setting. When evidence based concepts are applied to prehospital medicine, let's apply the same concepts to practice in the ED. If RSI is irrelevant to the prehospital setting, why is it considered standard of care in the hospital ED? See where I'm going with this? I will be the first to say that Paramedic education sucks for the most part. But it doesn't have to. There are great programs that turn out great medics. Most of them do so in spite of the roadblocks that are set up by the greater medical community, meaning phytsicians and nurses. I greatly admire and thank those few physicians who do support EMS with their hearts and souls. They'll be the first to tell you that the community of physicians is either outright hostile to EMS, apathetic about it, or 99% ignorant about it. If dedicated physicians cannot move their colleagues to recognize EMS as needing their help to do its job, how can we poor unwashed medics hope to do any better? While EMS bears lots of responsibility for our plight, the medical community as a whole is even more guilty of neglect and outright hostility. EMS cannot progress until the greater medical community decides that we're a part of them. So long as we're half firefighter/half medic, that will never happen. Not that some FDs cannot do EMS well, but paramedicine is essentially MEDICINE, not RESCUE. Until we decide what we are and create a place for ourselves within the medical community, we'll remain outside. EMS belongs outside fire services. Period. It is medical, not rescue. Rescue is a peripheral aspect of paramedicine, and it is important, but rescue agencies cannot do a good job of paramedicine simply because there is always the dichotomy of skills and duties that are demanded. There is no reason for a paramedic to become an expert at firefighting as well as being good at medicine. But the chain of command is fire, not medicine. So in order to progress, one must embrace the fire side. Look at the exams for promotion. Are they paramedic based or fire based? Until we end the influence of fire departments in the delivery of EMS, we will never, ever, be a part of the medical community and we will never, ever, improve our status. FDs can and should first respond, defibrillate, secure airways, and stop obvious bleeding if possible, and do extrication, assist with loading, and so forth. But when medics have to also maintain firefighting skills, this does not compute. I have the greatest respect for firefighters. They ought to do what they do best---fight fires, do rescue, and so forth. They should not be trying to do medicine unless the medical duties are split off into a separate division with a separate career pathway. OK, fire away (pun intended). Gene G. In a message dated 7/19/2005 7:47:20 PM Eastern Daylight Time, rachfoote@... writes: >This is just a play on numbers and does not reveal a real picture. I am the >manager of a 3rd City Service that performs intubations daily, at a 99.2% >success rate. I also do QA/QI for other services that have a 10% success rate >and rarely do any intubations, yet make more calls than my City service. >What does that say? Absolutely nothing when you start comparing several >services together. As everyone knows, you can get figures to say just about >anything you want them to say if you know what you are doing and what you are >looking for them to say.. Whew, what a mouthful to say you can't judge the quality >of my service by comparing my numbers to someone else's and then combining >them to get an average. > >Andy Foote >City of Beaumont EMS > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 19, 2005 Report Share Posted July 19, 2005 I have just started training my guys on the LMA even the basics. I believe it is a great secondary airway and a great airway for my basics to use. stephen > Just read up on it for the CCT book and we included it there. Seems like a > good airway--Ray Fowler has a nice article this month in JEMS on it. I still > feel the LMA is the best secondary prehospital airway. > > BEB > > Re: Paramedic Intubation > > Dr. Bledsoe, > What are your thought on the King LT-D Airway? > > Wood > Paramedic/FTO > Tulsa, OK > 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 > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 19, 2005 Report Share Posted July 19, 2005 That is exactly where the LMA should stay, a secondary. Granted they they are better than a lot of other airways out there and they are probaly the best option for basics but they will not replace the security of an endotracheal tube. sstephensmedic wrote: I have just started training my guys on the LMA even the basics. I believe it is a great secondary airway and a great airway for my basics to use. stephen > Just read up on it for the CCT book and we included it there. Seems like a > good airway--Ray Fowler has a nice article this month in JEMS on it. I still > feel the LMA is the best secondary prehospital airway. > > BEB > > Re: Paramedic Intubation > > Dr. Bledsoe, > What are your thought on the King LT-D Airway? > > Wood > Paramedic/FTO > Tulsa, OK > 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 > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 20, 2005 Report Share Posted July 20, 2005 Kenny, The problem is that all of these studies are Urban, not Rural, and hence we can't base all EMS practice on Urban studies. And I being an EMS educator have never heard of any push, quiet or otherwise that we remove ET Intubation from the paramedic skill set. >>> There is a significant, but quiet, push in academic > emergency medicine to remove endotracheal intubation as a general > paramedic skill... <<< > > Good for you, Dr. Bledsoe. I love it when people attack the sacred > cows, especially when the position can be supported by facts, > evidence, and common sense. > > Kenny Navarro > Blinded by Science > UT Southwestern Medical Center Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 20, 2005 Report Share Posted July 20, 2005 Kenny, There is always a risk, pre-hospital or otherwise. This is a risky business we are in, and the procedure is inherrently risky PERIOD! P.S. And from your earlier post....Who gave you the authority to speak on behalf of the EMS community? > >>> So now the medical community is ready to hang medics for lacking > intubation skills... <<< > > Gene, the medical community is not trying to " hang " anyone. (The > medical community has authorized me to speak for it.) EMS > researchers are simply asking the questions about endotracheal > intubation in the prehospital environment. > > You seem like a relatively reasonable soul. Do you agree, that even > in the best systems, there is some risk associated with endotracheal > intubation in the prehospital environment? If, as an example, an > aggressive quality control program was instituted with strict medical > oversight and the incidence of misplaced tracheal tubes could be > lowered to 0.5%, that slight risk still appears to outweigh any > potential benefit to be gained. > > To the group, if your child/mother/father/spouse/life-partner was in > the hospital and the physician came to you with the following, how > would you answer? > > We have a procedure we would like to attempt in your loved one. > There is absolutely nothing to be gained by performing the procedure > and there is an outside chance that we would create a condition, from > which your loved one could not recover? > > Overly simplistic, I know...but I've had a couple of glasses of wine. > > Kenny Navarro > Professional Nemesis Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 20, 2005 Report Share Posted July 20, 2005 Kenny, For you to make a statement that you are right 99.9% of the time is just assenine. It makes me not want to ever cross your path. 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? YOU ARE NOT WITHOUT FAULT I AM SURE! > >>> I am the manager of a 3rd City Service that performs intubations > daily, at a 99.2% success rate. <<< > > Andy, those are great statistics and you should be proud. It > supports my assertion that paramedics can be taught to do it. The > questions still remain, however... What percentage of those patients > survived-to-discharge neurologically intact? Was the ETT responsible > for the survival or could it have been because of other factors? > > > >>> As everyone knows, you can get figures to say just about anything > you want them to say if you know what you are doing and what you are > looking for them to say. <<< > > (Not directed at you, but a general statement...) I find it > interesting that when statistics seem to support a position contrary > to our own, we criticize statistics in general and counter with > statistics of our own. > > I'm right 99.9% of the time! (The other 0.1% is the margin of error.) > > Kenny Navarro > UT Southwestern Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 20, 2005 Report Share Posted July 20, 2005 Andy, I too don't understand this. Again, however I feel one of our problems aren't too few paramedics or too few intubations....it is too few good paramedics who don't have an ego over airway control and ventilation. It is the medic that will go to a LMA or Combi- when the tube can't be achieved. It is the medic who pulls the tube anytime its location in the trachea is not certain. It is the medic who sees intubation as another tool for airway control and ventilation...not the only one. It is the paramedic who sees pharmacological assisted intubation as something they can do...not something they have to do. Sit back and think...how many paramedics do you know that, if told there we no breath sounds, wouldn't argue about the location of the tube? Even against ETCO2? I do have one question however for the list. How many agencies protocol having the ED physician confirm tube placement BEFORE moving the patient to the ED bed? How many of these 8 or 10% of " misplaced " tubes were only misplaced after the patient was aggressively moved to the ED stretcher with RT holding onto the bag and no coordination of the patient moving? I now work for my second service where tube placement is confirmed on the EMS stretcher in the ED prior to the patient being moved to the ED bed. Like Andy, we have not had any misplaced tubes in either service following this protocol. If in doubt....pull it out! Dudley Re: Re: Paramedic Intubation I must have missed something when we in the Pre-hospital setting decided (or it was decided for us) that pre-hospital intubation was an unnecessary evil. I have never and I mean NEVER seen a bad result from any patient being intubated when needed by my service. I have scoured the history of my patients back to 1989 and have never seen nor has there ever been a tube in the goose arrive at an ER from my service. These occurrences get reported by every ER Doc we see and we see a lot of ER Docs. I do see them brought in by supposedly far more educated (fly medics) members of our profession. In fact, there have been 2 cases this year of Flight Medics bringing in esophageal intubations. In Beaumont, we take these accusations by supposedly good members of our profession very strongly. It is a disgrace to accuse without proof. I could not imagine working some of these patients while attempting to use a BVM for proper oxygenation. I wish that the ER Docs could do the work my paramedics do. There are patients that we have improved greatly in the field (saved their ass) only to hand them off to a Professional ER physician and watch them slowly go down the drain because they would not take the differential we arrived at through pertinent negatives, history, medications, etc. I must stop now and take a deep breath because I do not want to lose my focus. In the summation, why take away privileges of excellent, hard working, professionally driven, educated (monthly) paramedics because some can't perform as well as others. As my brother-in-law the Orthopedic Surgeon once said as he graduated from medical school, " I would not let anyone out of the top 5 in my graduating class ever touch my family " . Andy In a message dated 7/19/2005 10:04:40 P.M. Central Standard Time, kenneth.navarro@... writes: You seem like a relatively reasonable soul. Do you agree, that even in the best systems, there is some risk associated with endotracheal intubation in the prehospital environment? If, as an example, an aggressive quality control program was instituted with strict medical oversight and the incidence of misplaced tracheal tubes could be lowered to 0.5%, that slight risk still appears to outweigh any potential benefit to be gained. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 20, 2005 Report Share Posted July 20, 2005 , I knew what you were referring to and never let me be the guinea pig on any of those studies. I doubt very seriously that you would volunteer either. While teaching, we are very serious about never taking the groceries away from the brain. New movement in CPR suggests that there is a large enough quantity on witnessed arrest that mouth to mouth is no longer a necessary evil. When you are working with good first responders and an excellent partner, ETT does not cut short the process. I state that while it may not have been the main ingredient for a successful outcome, it played a roll. Especially in lengthy transports. It should remain an active part in the process. Andy In a message dated 7/20/2005 7:44:58 P.M. Central Standard Time, kenneth.navarro@... writes: What I'm suggesting is that we in EMS cannot say for sure that endotracheal intubation is the skill that makes the difference in cardiac arrest. Published studies to date (some of which are very well designed) seem to suggest that correct placement of tracheal tubes offers no survival advantages over BVM or alternative airway devices. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 20, 2005 Report Share Posted July 20, 2005 Dudley, I have to agree with you 100% on this entire post. Exactly how I would have put it. > Andy, > > I too don't understand this. Again, however I feel one of our problems aren't too few paramedics or too few intubations....it is too few good paramedics who don't have an ego over airway control and ventilation. It is the medic that will go to a LMA or Combi- when the tube can't be achieved. It is the medic who pulls the tube anytime its location in the trachea is not certain. It is the medic who sees intubation as another tool for airway control and ventilation...not the only one. It is the paramedic who sees pharmacological assisted intubation as something they can do...not something they have to do. > > Sit back and think...how many paramedics do you know that, if told there we no breath sounds, wouldn't argue about the location of the tube? Even against ETCO2? > > I do have one question however for the list. How many agencies protocol having the ED physician confirm tube placement BEFORE moving the patient to the ED bed? How many of these 8 or 10% of " misplaced " tubes were only misplaced after the patient was aggressively moved to the ED stretcher with RT holding onto the bag and no coordination of the patient moving? > > I now work for my second service where tube placement is confirmed on the EMS stretcher in the ED prior to the patient being moved to the ED bed. Like Andy, we have not had any misplaced tubes in either service following this protocol. > > If in doubt....pull it out! > > Dudley > > > > Re: Re: Paramedic Intubation > > > > I must have missed something when we in the Pre-hospital setting decided (or > it was decided for us) that pre-hospital intubation was an unnecessary evil. > I have never and I mean NEVER seen a bad result from any patient being > intubated when needed by my service. I have scoured the history of my patients > > back to 1989 and have never seen nor has there ever been a tube in the goose > arrive at an ER from my service. These occurrences get reported by every ER > Doc we see and we see a lot of ER Docs. I do see them brought in by > supposedly far more educated (fly medics) members of our profession. In fact, > there > have been 2 cases this year of Flight Medics bringing in esophageal > intubations. In Beaumont, we take these accusations by supposedly good members > of our > profession very strongly. It is a disgrace to accuse without proof. I could > not imagine working some of these patients while attempting to use a BVM for > proper oxygenation. I wish that the ER Docs could do the work my paramedics > do. There are patients that we have improved greatly in the field (saved > their ass) only to hand them off to a Professional ER physician and watch them > slowly go down the drain because they would not take the differential we > arrived at through pertinent negatives, history, medications, etc. I must stop > > now and take a deep breath because I do not want to lose my focus. In the > summation, why take away privileges of excellent, hard working, professionally > driven, educated (monthly) paramedics because some can't perform as well as > others. As my brother-in-law the Orthopedic Surgeon once said as he graduated > from medical school, " I would not let anyone out of the top 5 in my > graduating class ever touch my family " . > > Andy > > > > In a message dated 7/19/2005 10:04:40 P.M. Central Standard Time, > kenneth.navarro@u... writes: > > You seem like a relatively reasonable soul. Do you agree, that even > in the best systems, there is some risk associated with endotracheal > intubation in the prehospital environment? If, as an example, an > aggressive quality control program was instituted with strict medical > oversight and the incidence of misplaced tracheal tubes could be > lowered to 0.5%, that slight risk still appears to outweigh any > potential benefit to be gained. > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 20, 2005 Report Share Posted July 20, 2005 >>> How many of those (cardiac arrests) would have had the same or better result if we had not intubated, I do not know, nor do I wish to find out. I feel sorry for anyone that would refuse to intubate a patient just to find out those stats. <<< Andy, I'm not suggesting that you stop intubating people to attempt to answer this important question. There are already many courageous researchers performing these studies for us. What I'm suggesting is that we in EMS cannot say for sure that endotracheal intubation is the skill that makes the difference in cardiac arrest. Published studies to date (some of which are very well designed) seem to suggest that correct placement of tracheal tubes offers no survival advantages over BVM or alternative airway devices. You seem to have created a zero risk environment for endotracheal intubation in your city and I applaud you for that. I would actually like to spend some time with you learning how you have accomplished this. We have created a very safe intubating environment within the BioTel system through a very aggressive CE and QI program. While I can say with certainty that paramedics can be taught to intubate with the same level of accuracy as a physician, I can't be certain that it influences the outcome of cardiac arrest (my gut tells me it does not.) I'm not your enemy (I'm Gene's) (kidding, for those of you without a sense of humor.) Kenny Navarro Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 20, 2005 Report Share Posted July 20, 2005 Kenny, I would differ in the wording you are using. 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. Beaumont has done that and has a reputation for having done so. Other systems have as well. Not all are set up to track the patient through discharge as they have, but 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. In the urban setting, I am sure there are plenty of the same situations. The key is to do what is right for the patient, when it is right for the patient. The studies are not conclusive as to whether or not pre-hospital intubation is harmful to a patient, and I be they never will. However, isn't the move to bring definitive care from the hospital to the streets, and hence reduce the patient's time to definitive care? Improving patient outcomes? 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. 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. > >>> How many of those (cardiac arrests) would have had the same or > better result if we had not intubated, I do not know, nor do I wish to > find out. I feel sorry for anyone that would refuse to intubate a > patient just to find out those stats. <<< > > Andy, > > I'm not suggesting that you stop intubating people to attempt to answer > this important question. There are already many courageous researchers > performing these studies for us. > > What I'm suggesting is that we in EMS cannot say for sure that > endotracheal intubation is the skill that makes the difference in > cardiac arrest. Published studies to date (some of which are very well > designed) seem to suggest that correct placement of tracheal tubes > offers no survival advantages over BVM or alternative airway devices. > > You seem to have created a zero risk environment for endotracheal > intubation in your city and I applaud you for that. I would actually > like to spend some time with you learning how you have accomplished > this. We have created a very safe intubating environment within the > BioTel system through a very aggressive CE and QI program. While I can > say with certainty that paramedics can be taught to intubate with the > same level of accuracy as a physician, I can't be certain that it > influences the outcome of cardiac arrest (my gut tells me it does not.) > > I'm not your enemy (I'm Gene's) > (kidding, for those of you without a sense of humor.) > > Kenny Navarro Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 20, 2005 Report Share Posted July 20, 2005 I don't know Kenny, I usually need someone to shake the bed while I am starting an IV in the ER, because I've adapted to aiming for the moving target! Just figured a little humor was due here. > >>> Now you're the silly one, because you're saying that intubation > in the ER is a different thing from intubation in the field. Well, > let me tell you that it's not. <<< > > KN: Just because you say it with conviction, doesn't make it so. OF > COURSE intubation is a different animal in the emergency department > compared to the prehospital environment. (I thought I was the one > who was drunk when I posted last night!) I could go on and on > listing the differences between the two environments, but you already > know them. > > > > >>> If it's a procedure that helps patients in the ER, then it ought > to help patients in the field. <<< > > KN: There are two things wrong with that statement. 1) I never > suggested that endotracheal intubation (of the cardiac arrest > patient) in the emergency department improves outcome compared to BVM > ventilation or the use of an alternative airway. (My guess - and I > don't have literature to back this statement right now - is that > correct ETT placement does NOT improve outcomes in that population > over BVM or alternative airways even in the ED. 2) What OUGHT to > work and what ACTUALLY works may not always be the same. Helicopter > evacuation of trauma patients from the jungles of Vietnam improved > outcomes, but has not been shown to reduce trauma mortality in the > urban or suburban areas. > > > > >>> Tube placement verification is the background issue here, and > it's no different in the field than it is in the ER. <<< > > KN: I agree. (That leaves a bad taste in my mouth.) > > > > >>> If it benefits the patient in the ER, then it should benefit the > patient in the field. Don't get off on the differences in > environment, because there are no studies that compare the two. <<< > > KN: Do you need a study to tell you that an emergency room and the > street are two different places? BTW, later in the same e-mail you > make this statement, " The only differences are in the environment, > which may or may not be more difficult. " That confirms my statement > above that you know there are different environments. > > > > >>> Next you'll be saying that the efficacy of IV placement is > different in the field than in the ER. <<< > > KN: I don't have that information available at this computer, but I > do know that complications from pre-hospital IV initiation are higher > than ED access. I also suspect if you asked paramedics if they > thought it was easier to start an IV in the ED or in the field, they > would choose the former rather than the latter. > > I do make room for the possibility that I could be mistaken. > > The Riddler to your Batman, > Kenny Navarro Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 20, 2005 Report Share Posted July 20, 2005 As much as I hate to interfere in such a well thought out argument between two very well educated and meaning people, I have to interject a thought here. The lack of improvement in cardiac arrest victims who are intubated vs. adequately ventialted I have to agree with, that said the imperative thing to see is that the ventialtion is " adequate " . If ventilation with a BVM does not maintain proper acceptable ETCO2 levels, then agressive airway measures must be used, in a upgrading fashion, i.e. ETT, LMA or combi-tube if unsuccessful. Proper BVM ventilation is difficult at best with only one person in the back of a bumping, swerving, braking, non-air ride suspension rig (and that's on the GOOD streets). The study, we have to remember, pits ETT against ADEQUATE VENTILATION in the field, and in that case, I have to agree with Kenny, if in fact you have good ventilatory success, and you feel confident that you can maintain that throughout transport, I can see where the study would prove to be correct. Now, that said, we go back to the bumping, grinding yada yada ambulance, trying to keep a seal with the great 'C' under the chin with one hand while squeezing the bag with the other, chances are, that the word 'adequate' will not be in play here, and hence, intubation will be important, if not imperative. BVM usage in the ER is much easier, more people, more hands stable environment, etc. Just my opinions, Mike > Re: Paramedic Intubation > > > > >>> Now you're the silly one, because you're saying that intubation > in the ER is a different thing from intubation in the field. Well, > let me tell you that it's not. <<< > > KN: Just because you say it with conviction, doesn't make it so. OF > COURSE intubation is a different animal in the emergency department > compared to the prehospital environment. (I thought I was the one > who was drunk when I posted last night!) I could go on and on > listing the differences between the two environments, but you already > know them. > > > > >>> If it's a procedure that helps patients in the ER, then it ought > to help patients in the field. <<< > > KN: There are two things wrong with that statement. 1) I never > suggested that endotracheal intubation (of the cardiac arrest > patient) in the emergency department improves outcome compared to BVM > ventilation or the use of an alternative airway. (My guess - and I > don't have literature to back this statement right now - is that > correct ETT placement does NOT improve outcomes in that population > over BVM or alternative airways even in the ED. 2) What OUGHT to > work and what ACTUALLY works may not always be the same. Helicopter > evacuation of trauma patients from the jungles of Vietnam improved > outcomes, but has not been shown to reduce trauma mortality in the > urban or suburban areas. > > > > >>> Tube placement verification is the background issue here, and > it's no different in the field than it is in the ER. <<< > > KN: I agree. (That leaves a bad taste in my mouth.) > > > > >>> If it benefits the patient in the ER, then it should benefit the > patient in the field. Don't get off on the differences in > environment, because there are no studies that compare the two. <<< > > KN: Do you need a study to tell you that an emergency room and the > street are two different places? BTW, later in the same e-mail you > make this statement, " The only differences are in the environment, > which may or may not be more difficult. " That confirms my statement > above that you know there are different environments. > > > > >>> Next you'll be saying that the efficacy of IV placement is > different in the field than in the ER. <<< > > KN: I don't have that information available at this computer, but I > do know that complications from pre-hospital IV initiation are higher > than ED access. I also suspect if you asked paramedics if they > thought it was easier to start an IV in the ED or in the field, they > would choose the former rather than the latter. > > I do make room for the possibility that I could be mistaken. > > The Riddler to your Batman, > Kenny Navarro > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 20, 2005 Report Share Posted July 20, 2005 And a side note to Mike Hatfield's post.......to get adequate ventillation with a BVM you really need 3 people just to operate the BVM. How frequently do we have that? One to hold the mask properly sealed to the patient, one to apply cricoid pressure to diminish gastric insuflation (which has been proven to hinder resuscitation attempts, increase emesis and aspiration, as well as reduce cardiac output), and one to actually ventillate the patient with the BVM. If you can manage a patient with just a BVM.....hey, I am all for it. The most bang for the buck with the least invasive and risky procedure is my motto, but in this case, BVM ventillation is not a practcical option by itself due to staffing issues, properly trained individuals (I am sure there are those on here that don't know that it really takes 3 people to use a BVM correctly), and transportation conditions, i.e. rough roads, lack of air ride, partners that can't drive worth a damn, etc. etc. etc............there are just too many variables. > > >>> Now you're the silly one, because you're saying that intubation > > in the ER is a different thing from intubation in the field. Well, > > let me tell you that it's not. <<< > > > > KN: Just because you say it with conviction, doesn't make it so. OF > > COURSE intubation is a different animal in the emergency department > > compared to the prehospital environment. (I thought I was the one > > who was drunk when I posted last night!) I could go on and on > > listing the differences between the two environments, but you already > > know them. > > > > > > > > >>> If it's a procedure that helps patients in the ER, then it ought > > to help patients in the field. <<< > > > > KN: There are two things wrong with that statement. 1) I never > > suggested that endotracheal intubation (of the cardiac arrest > > patient) in the emergency department improves outcome compared to BVM > > ventilation or the use of an alternative airway. (My guess - and I > > don't have literature to back this statement right now - is that > > correct ETT placement does NOT improve outcomes in that population > > over BVM or alternative airways even in the ED. 2) What OUGHT to > > work and what ACTUALLY works may not always be the same. Helicopter > > evacuation of trauma patients from the jungles of Vietnam improved > > outcomes, but has not been shown to reduce trauma mortality in the > > urban or suburban areas. > > > > > > > > >>> Tube placement verification is the background issue here, and > > it's no different in the field than it is in the ER. <<< > > > > KN: I agree. (That leaves a bad taste in my mouth.) > > > > > > > > >>> If it benefits the patient in the ER, then it should benefit the > > patient in the field. Don't get off on the differences in > > environment, because there are no studies that compare the two. <<< > > > > KN: Do you need a study to tell you that an emergency room and the > > street are two different places? BTW, later in the same e-mail you > > make this statement, " The only differences are in the environment, > > which may or may not be more difficult. " That confirms my statement > > above that you know there are different environments. > > > > > > > > >>> Next you'll be saying that the efficacy of IV placement is > > different in the field than in the ER. <<< > > > > KN: I don't have that information available at this computer, but I > > do know that complications from pre-hospital IV initiation are higher > > than ED access. I also suspect if you asked paramedics if they > > thought it was easier to start an IV in the ED or in the field, they > > would choose the former rather than the latter. > > > > I do make room for the possibility that I could be mistaken. > > > > The Riddler to your Batman, > > Kenny Navarro > > > > > > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 20, 2005 Report Share Posted July 20, 2005 >>>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 Quote Link to comment Share on other sites More sharing options...
Recommended Posts
Join the conversation
You are posting as a guest. If you have an account, sign in now to post with your account.
Note: Your post will require moderator approval before it will be visible.