The end of intubations?

[Guest guest]

In a message dated 12/14/2006 10:34:02 A.M. Central Standard Time,

ExLngHrn@... writes:

The end result could be that intubation ends up becoming a skill that, while

taught in class, becomes a seldom used intervention.

While I agree with the gist of your post I still feel that we spend far too

much time in teaching the " skills " and too little time teaching the concepts

of ventilation. A patent airway is a patent airway and the " continuum of

airway maintenance skills " should be taught at all levels not just the " gotta

get

a a tube mentality " I've seen over the years.

Louis N. Molino, Sr., CET

FF/NREMT-B/FSI/EMSI

Freelance Consultant/Trainer/Author/Journalist/Fire Protection Consultant

LNMolino@...

(Cell Phone)

(Home Phone)

(IFW/TFW/FSS Office)

(IFW/TFW/FSS Fax)

" A Texan with a Jersey Attitude "

" Great minds discuss ideas; Average minds discuss events; Small minds

discuss people " Eleanor Roosevelt - US diplomat & reformer (1884 - 1962)

The comments contained in this E-mail are the opinions of the author and the

author alone. I in no way ever intend to speak for any person or

organization that I am in any way whatsoever involved or associated with unless

I

specifically state that I am doing so. Further this E-mail is intended only for

its

stated recipient and may contain private and or confidential materials

retransmission is strictly prohibited unless placed in the public domain by the

original author.

[Guest guest]

We've all heard some propose that EMS no longer perform intubations. Perhaps

they're getting their way indirectly when students' ability to practice

intubations no longer exists, except with Fred the Head.

When local ORs are unwilling to open up to EMS students and the local EMS agency

no longer permits EMS students to attempt intubation in the field, what other

options exist? I've even heard some EMS education programs resorting to

sending their students to veterinarian's offices in an attempt to provide some

intubation practice.

If we don't address the inability of students to become comfortable with

intubating a real, live patient before they get their certification, we will

have, in fact, abandoned intubation as a viable option for EMS providers. The

end result could be that intubation ends up becoming a skill that, while taught

in class, becomes a seldom used intervention.

-Wes Ogilvie, MPA, JD, EMT-B

Austin, Texas

________________________________________________________________________

Check out the new AOL. Most comprehensive set of free safety and security

tools, free access to millions of high-quality videos from across the web, free

AOL Mail and more.

[Guest guest]

At the hospital I work at in Tarrant county, EMS students are strictly forbidden

to intubate in the ER. they can do anything else, except intubations. I too,

think it is stupid to let a family practice or sports medicine resident intubate

trauma patients in the ER and make paramedics stand aside. when a patient needs

intubation in most family practice clinics/offices, or on a sports field, who do

the doctors call? PARAMEDICS!!! so why do they get to intubate when they won't

do it?!?!?!

we do allow medic students to intubate in our OR, but they are up there with

medical students as well, and have to " compete " to get tubes.

it IS a silly stupid system, and we must fight it.

ReD

red@...

http://redsanders.com

The end of intubations?

We've all heard some propose that EMS no longer perform intubations. Perhaps

they're getting their way indirectly when students' ability to practice

intubations no longer exists, except with Fred the Head.

When local ORs are unwilling to open up to EMS students and the local EMS

agency no longer permits EMS students to attempt intubation in the field, what

other options exist? I've even heard some EMS education programs resorting to

sending their students to veterinarian's offices in an attempt to provide some

intubation practice.

If we don't address the inability of students to become comfortable with

intubating a real, live patient before they get their certification, we will

have, in fact, abandoned intubation as a viable option for EMS providers. The

end result could be that intubation ends up becoming a skill that, while taught

in class, becomes a seldom used intervention.

-Wes Ogilvie, MPA, JD, EMT-B

Austin, Texas

__________________________________________________________

Check out the new AOL. Most comprehensive set of free safety and security

tools, free access to millions of high-quality videos from across the web, free

AOL Mail and more.

[Guest guest]

Well said, Louis, and it was also the subject of a presentation at the recent

conference by Grayson.

We often fail to teach the continuum of airway care. However, I share Wes's

fear that the EBM Gurus have it firmly in their minds to eliminate

endotracheal intubations from street medics' skills except for a few " super

medics " who

would, presumably get all the tubes.

The concerns that some have are that the average medic gets one intubation a

year or less, and therefore cannot maintain skill levels. That is certainly

a problem.

However, the larger problem, at least as I see it, is that there is no

consensus among the medical community that regulates EMS as to what the street

skills and equipment employed by advanced care medics ought to be. There is

even

less consensus about the abilities of first responders to employ the

supraglottic adjuncts that have been proven to be very easy to learn to use.

Too many of the folks who make the final decisions about what EMS providers

can do and what they cannot do never ride with their medics and have few clues

about what actually happens in the field.

Many of them are not up to date on current concepts of airway care

themselves. (That is opinion, not evidence based).

As an instructor/coordinator, why should I bother sending my students to do

field internships with a service that announces up front that students will not

be allowed to do field intubations. I shouldn't, and all such services are

automatically excluded from my company's list of internship providers because

they would not meet our educational requirements.

It is getting harder and harder to find hospitals that will allow students

into the OR to intubate; and even those who do now use the LMA much more often

than ET intubation, so it is really difficult for students to get experience.

Unless students can get experience at endotracheal intubation, it may be the

natural course of events that leads to medics not being able to intubate at

all except with alternative devices. There are even some in the medical

community who would do away with all advanced airway care in the field.

I think NAEMSE and NAEMT ought to begin to look into this problem and see

where we are going. In Texas, I think this issue deserves a look by GETAC and

its education and medical directors' committees. (BTW, why isn't there a

" paramedic committee? " ) This might also be something that EMSAT might take

on.

Those who know me and read my writing should know that I am an advocate of

" ventilation, not necessarily intubation. " However, I would hate to know that

medics could no longer perform ET intubations in those patients in which it is

appropriate. I fear that this is where we are going.

We have not been doing a good job overall in teaching airway care at any

level, but if we are unable to teach and do ETIs, we will eliminate one of the

good tools that we have had.

Much has been made of a few selective studies that purport to have shown that

paramedics have a poor ETI success rate. I don't doubt the accuracy of the

numbers in those studies. What I do doubt is the practical value of them to

the EMS community at large, because, at least to my knowledge, they did not

measure the kind or extent of education and practice the medics who were studied

had had, nor did they talk about the techniques employed, the availability of

airway adjuncts such as the bougie, use of external laryngeal manipulation or

BURP, and other techniques that aid in the difficult intubation. Nor did

they discuss whether or not capnography was available and used, and on and on.

They did show that in the services they measured, things were not the greatest,

but I don't necessarily see a close correlation between the practices in

those services and other services which may have far better stats.

I suggest that some physicians, certainly not all, but some, who are EMS

medical directors, have had a knee jerk reaction to these limited and (in my

judgment) flawed studies, and are seeing lawyers in the shadows where none are

lurking.

Are we forgetting the patient in all of this? After all, patient care is

what we're about, isn't it?

Let's ask the hard question: Regardless of whether you're a first

responder, EMT-B, EMT-I, Paramedic, critical care nurse, or physician, and

you're in a

situation where you are unresponsive and cannot protect your own airway, what

intervention would you want to be done for yourself? What's the best way to

protect the incompetent airway? Hmmmmmm?

Gene G.

>

>

> In a message dated 12/14/2006 10:34:02 A.M. Central Standard Time,

> ExLngHrn@... writes:

>

> The end result could be that intubation ends up becoming a skill that, while

> taught in class, becomes a seldom used intervention.

>

> While I agree with the gist of your post I still feel that we spend far too

> much time in teaching the " skills " and too little time teaching the concepts

> of ventilation. A patent airway is a patent airway and the " continuum of

> airway maintenance skills " should be taught at all levels not just the

> " gotta get

> a a tube mentality " I've seen over the years.

>

> Louis N. Molino, Sr., CET

> FF/NREMT-B/FSI/ FF/

> Freelance Consultant/Trainer/ Freelance Cons Freelance Consultant/Traine

>

> LNMolino@...

>

> (Cell Phone)

> (Home Phone)

> (IFW/TFW/FSS Office)

> (IFW/TFW/FSS Fax)

>

> " A Texan with a Jersey Attitude "

>

> " Great minds discuss ideas; Average minds discuss events; Small minds

> discuss people " Eleanor Roosevelt - US diplomat & reformer (1884 - 1962)

>

> The comments contained in this E-mail are the opinions of the author and the

> author alone. I in no way ever intend to speak for any person or

> organization that I am in any way whatsoever involved or associated with u

> nless I

> specifically state that I am doing so. Further this E-mail is intended only

> for its

> stated recipient and may contain private and or confidential materials

> retransmission is strictly prohibited unless placed in the public domain by

> the

> original author.

>

>

[Guest guest]

In a message dated 12/15/2006 1:06:57 PM Central Standard Time,

scapuchino@... writes:

In my 9 years of service I have not

missed a tube. And again to me a miss is getting to

the ER and not being " in " when confirmed by the ERMD.

there are two types of folks who handle firearms...those who have had an

accidental discharge and those who WILL have an accidental discharge...I'm

currently in the latter group...

By the same token, there are two types of folks who intubate...those who

have missed a tube (even by your standards) and those who WILL miss a

tube....the trick is to recognize that the tube is not in or has become DOPE'd

somewhere along the way, before the patient suffers the consequences. Even with

the

practice I've had over the years (which does include a few 'upside down and

backwards in the mud'), I've been known to back off, continue BVM support and

let someone else take a crack at the situation.

The medical maxim that this falls under is: " If you have not yet seen a

particular published complication associated with a particular procedure, that

just means that you have not done enough of those procedures to call yourself

'experienced' yet. "

ck

[Guest guest]

Missing a tube is in my view NOT in and of itself a cardinal sin, in my 25+

years of EMS I've seen Medics, RN's and even Dr's that I know to be GREAT

Providers miss a tube and the like however, FAILING TO VENTIALTE violates a

Commandment! The tube is but a means to an end!

Louis N. Molino, Sr., CET

FF/NREMT-B/FSI/EMSI

Freelance Consultant/Trainer/Author/Journalist/Fire Protection Consultant

LNMolino@...

(Cell Phone)

(Home Phone)

(IFW/TFW/FSS Office)

(IFW/TFW/FSS Fax)

" A Texan with a Jersey Attitude "

" Great minds discuss ideas; Average minds discuss events; Small minds

discuss people " Eleanor Roosevelt - US diplomat & reformer (1884 - 1962)

The comments contained in this E-mail are the opinions of the author and the

author alone. I in no way ever intend to speak for any person or

organization that I am in any way whatsoever involved or associated with unless

I

specifically state that I am doing so. Further this E-mail is intended only for

its

stated recipient and may contain private and or confidential materials

retransmission is strictly prohibited unless placed in the public domain by the

original author.

[Guest guest]

Subject: The end of intubations?

>>>We've all heard some propose that EMS no longer perform

intubations. Perhaps they're getting their way indirectly when

>>>students' ability to practice intubations no longer exists, except

with Fred the Head.

Poor Fred...Thank God he has existed to give students the " basis " of

learning the techniques of ET intubation, combitube, Kings, Cobras,

LMAs, oral and nasal airways (does ANYONE own a Fred that doesn't have

at least on traumatized nare, torn lip and teeth that need derma bond

to stay in?).

I don't think Fred was EVER intended to " be more than he can be " , the

first step in skill technique and practice.

>>> I've even heard some EMS education programs resorting to sending

their students to veterinarian's offices in an attempt to provide

>>>some intubation practice.

This really does have a place in learning in many areas, and it was not

a " resort " in my era of paramedic school, it was an added bonus. The

next step before we started clinicals.

Although I agree with your point, my paramedic class intubated cats. It

was one of the best learning experiences I had. It is amazing how

similar the airway is to humans. Unfortunately, there are many

veterinarian's who have stopped allowing this also, mostly because of a

public sentiment that it is cruel to the animal.

>> If we don't address the inability of students to become comfortable

with intubating a real, live patient before they get their

>>certification, we will have, in fact, abandoned intubation as a

viable option for EMS providers.

To play devils advocate here, how many " students " who were given the

opportunities to intubation " real live patients " in a clinical or field

situation, were then proficient at it when they completed their

classes, got their credentials, were hired and THEN actually had their

first opportunity to intubate not as a student? Maintaining levels of

proficiency post classes are where the issue comes into more prominent

play, IMHO.

I believe, like most of us do, we need to find a viable option to

airway management when the " real live patient " situation during

clinicals is taken away by the hospitals and/or services. Is it a

training center issue? I don't know.

I do know the reality is, people have the right to refuse to be

'practiced on' in ORs, everyone has the right to watch out for

liability situations and in the field, preceptors (unless restricted by

service/medical directors) have the responsibility to ensure their

student is being allowed to perform to their training level.

The simulation manikins are providing a fairly good option and the

ability to produce more of the types of situations EMS faces in the

field when intubation is required....now if they could only produce the

smells involved..<G>

>>>>The end result could be that intubation ends up becoming a skill

that, while taught in class, becomes a seldom used intervention.

Wes, I am not disagreeing with you, however, the basic fact is that

intubation IS and should be seldom used when looking at the overall

picture of what we do. It is the BEST airway management tool, but it

isn't the only one. What I have an issue with is " anyone " pulling a

patent Combi-tube, King, etc, simply " because they should have an ET " .

The goal is a patent airway....many times that is accomplished without

the ET tube and it is ego or a misguided belief that compromises that

patent airway. I have seen a patent combitube pulled " because it wasn't

an ET and we have to have one " . The ET was never successfully

placed.....now there is a calamity.

Jules

________________________________________________________________________

Check Out the new free AIM® Mail -- 2 GB of storage and

industry-leading spam and email virus protection.

[Guest guest]

Where are CRNA's getting their intubations during training? What's

their ration of " live " to " mannequin " airways? Obviously they train

on lots of airway adjuncts, but where's that training coming from?

My guess would be the anesthesiologists. Any idea what TMA's stance on this is?

Mike

> We've all heard some propose that EMS no longer perform intubations. Perhaps

they're getting their way indirectly when students' ability to practice

intubations no longer exists, except with Fred the Head.

>

> When local ORs are unwilling to open up to EMS students and the local EMS

agency no longer permits EMS students to attempt intubation in the field, what

other options exist? I've even heard some EMS education programs resorting to

sending their students to veterinarian's offices in an attempt to provide some

intubation practice.

>

> If we don't address the inability of students to become comfortable with

intubating a real, live patient before they get their certification, we will

have, in fact, abandoned intubation as a viable option for EMS providers. The

end result could be that intubation ends up becoming a skill that, while taught

in class, becomes a seldom used intervention.

>

> -Wes Ogilvie, MPA, JD, EMT-B

> Austin, Texas

> ________________________________________________________________________

> Check out the new AOL. Most comprehensive set of free safety and security

tools, free access to millions of high-quality videos from across the web, free

AOL Mail and more.

>

>

>

[Guest guest]

In a message dated 12/15/2006 4:22:47 P.M. Central Standard Time,

scapuchino@... writes:

So like I said, so far I haven't missed one yet.

I bet you also never failed to ventilate any patient needing ventilation

support even absent a tube?

Obviously confidence in all skills is a good thing but this idea of the tube

as the " Gold standard " seems to be ridiculous given the standard is or

rather should " ventilation " .

A simple CE hand maneuver that opens a closed airway creates in many cases a

patent airway and that's what every patient needs period. We place the

emphasis on the " fancy " stuff in EMS.

Louis N. Molino, Sr., CET

FF/NREMT-B/FSI/EMSI

Freelance Consultant/Trainer/Author/Journalist/Fire Protection Consultant

LNMolino@...

(Cell Phone)

(Home Phone)

(IFW/TFW/FSS Office)

(IFW/TFW/FSS Fax)

" A Texan with a Jersey Attitude "

" Great minds discuss ideas; Average minds discuss events; Small minds

discuss people " Eleanor Roosevelt - US diplomat & reformer (1884 - 1962)

The comments contained in this E-mail are the opinions of the author and the

author alone. I in no way ever intend to speak for any person or

organization that I am in any way whatsoever involved or associated with unless

I

specifically state that I am doing so. Further this E-mail is intended only for

its

stated recipient and may contain private and or confidential materials

retransmission is strictly prohibited unless placed in the public domain by the

original author.

[Guest guest]

To play devils advocate here, how many " students "

> who were given the

> opportunities to intubation " real live patients " in

> a clinical or field

> situation, were then proficient at it when they

> completed their

> classes, got their credentials, were hired and THEN

> actually had their

> first opportunity to intubate not as a student?

> Maintaining levels of

> proficiency post classes are where the issue comes

> into more prominent

> play, IMHO.

Well, I am one of those that is still proficient in

intubations and all this even with lapses in working

between 911 providers and transfer services. Even

after months of no intubations, I was still very

proficient. In my 9 years of service I have not

missed a tube. And again to me a miss is getting to

the ER and not being " in " when confirmed by the ERMD.

I have the EMS program at TSTC-Harlingen to thank for

that. When we took our Intermediate and Paramedic

program we intubated about 20-30 patients in the OR in

the required time. I have had to save many medics who

could not visualize, yet when I went in, the vocal

cords were very much obvious. These medics graduated

from a different program than the one I went to.

> I do know the reality is, people have the right to

> refuse to be

> 'practiced on' in ORs,

The hospital we practiced at states in the small print

of every form the patient signs that it is a teaching

hospital. In one MDs words, they cannot refuse, if

the read the small print they are advised that this is

a teaching facility. So go figure...

I have seen a patent combitube pulled

> " because it wasn't

> an ET and we have to have one " . The ET was never

> successfully

> placed.....now there is a calamity.

I thought we were taught to never extubate a patient

once you tube. If you tube the esophagus then you

simply move the tube over and intubate.

Salvador Capuchino Jr

EMT-Paramedic

--- jkaymdc@... wrote:

>

> Subject: The end of intubations?

>

> >>>We've all heard some propose that EMS no

> longer perform

> intubations. Perhaps they're getting their way

> indirectly when

> >>>students' ability to practice intubations no

> longer exists, except

> with Fred the Head.

>

> Poor Fred...Thank God he has existed to give

> students the " basis " of

> learning the techniques of ET intubation, combitube,

> Kings, Cobras,

> LMAs, oral and nasal airways (does ANYONE own a Fred

> that doesn't have

> at least on traumatized nare, torn lip and teeth

> that need derma bond

> to stay in?).

>

> I don't think Fred was EVER intended to " be more

> than he can be " , the

> first step in skill technique and practice.

>

> >>> I've even heard some EMS education programs

> resorting to sending

> their students to veterinarian's offices in an

> attempt to provide

> >>>some intubation practice.

>

> This really does have a place in learning in many

> areas, and it was not

> a " resort " in my era of paramedic school, it was an

> added bonus. The

> next step before we started clinicals.

>

> Although I agree with your point, my paramedic class

> intubated cats. It

> was one of the best learning experiences I had. It

> is amazing how

> similar the airway is to humans. Unfortunately,

> there are many

> veterinarian's who have stopped allowing this also,

> mostly because of a

> public sentiment that it is cruel to the animal.

>

>

> >> If we don't address the inability of students to

> become comfortable

> with intubating a real, live patient before they get

> their

> >>certification, we will have, in fact, abandoned

> intubation as a

> viable option for EMS providers.

>

> To play devils advocate here, how many " students "

> who were given the

> opportunities to intubation " real live patients " in

> a clinical or field

> situation, were then proficient at it when they

> completed their

> classes, got their credentials, were hired and THEN

> actually had their

> first opportunity to intubate not as a student?

> Maintaining levels of

> proficiency post classes are where the issue comes

> into more prominent

> play, IMHO.

>

> I believe, like most of us do, we need to find a

> viable option to

> airway management when the " real live patient "

> situation during

> clinicals is taken away by the hospitals and/or

> services. Is it a

> training center issue? I don't know.

>

> I do know the reality is, people have the right to

> refuse to be

> 'practiced on' in ORs, everyone has the right to

> watch out for

> liability situations and in the field, preceptors

> (unless restricted by

> service/medical directors) have the responsibility

> to ensure their

> student is being allowed to perform to their

> training level.

>

> The simulation manikins are providing a fairly good

> option and the

> ability to produce more of the types of situations

> EMS faces in the

> field when intubation is required....now if they

> could only produce the

> smells involved..<G>

>

> >>>>The end result could be that intubation ends up

> becoming a skill

> that, while taught in class, becomes a seldom used

> intervention.

>

> Wes, I am not disagreeing with you, however, the

> basic fact is that

> intubation IS and should be seldom used when looking

> at the overall

> picture of what we do. It is the BEST airway

> management tool, but it

> isn't the only one. What I have an issue with is

> " anyone " pulling a

> patent Combi-tube, King, etc, simply " because they

> should have an ET " .

>

> The goal is a patent airway....many times that is

> accomplished without

> the ET tube and it is ego or a misguided belief that

> compromises that

> patent airway. I have seen a patent combitube pulled

> " because it wasn't

> an ET and we have to have one " . The ET was never

> successfully

> placed.....now there is a calamity.

>

> Jules

>

>

>

________________________________________________________________________

> Check Out the new free AIM® Mail -- 2 GB of

> storage and

> industry-leading spam and email virus protection.

>

>

>

>

>

[Guest guest]

Very well said doc!

_____

From: texasems-l [mailto:texasems-l ] On

Behalf Of krin135@...

Sent: Friday, December 15, 2006 1:23 PM

To: texasems-l

Subject: Re: Re: The end of intubations?

In a message dated 12/15/2006 1:06:57 PM Central Standard Time,

scapuchino (AT) yahoo (DOT) <mailto:scapuchino%40yahoo.com> com writes:

In my 9 years of service I have not

missed a tube. And again to me a miss is getting to

the ER and not being " in " when confirmed by the ERMD.

there are two types of folks who handle firearms...those who have had an

accidental discharge and those who WILL have an accidental discharge...I'm

currently in the latter group...

By the same token, there are two types of folks who intubate...those who

have missed a tube (even by your standards) and those who WILL miss a

tube....the trick is to recognize that the tube is not in or has become

DOPE'd

somewhere along the way, before the patient suffers the consequences. Even

with the

practice I've had over the years (which does include a few 'upside down and

backwards in the mud'), I've been known to back off, continue BVM support

and

let someone else take a crack at the situation.

The medical maxim that this falls under is: " If you have not yet seen a

particular published complication associated with a particular procedure,

that

just means that you have not done enough of those procedures to call

yourself

'experienced' yet. "

ck

[Guest guest]

Well I am by no means calling myself an expert. I am

merely attributing my success to the intubation

program that the EMS program in TSTC-Harlingen has or

had. And yes I have recognized those instances where

it is better to back off and I have been able to

recognize when a tube was not in and taken the

corrective measures. So like I said, so far I haven't

missed one yet.

Salvador Capuchino Jr

EMT-Paramedic

--- krin135@... wrote:

>

> In a message dated 12/15/2006 1:06:57 PM Central

> Standard Time,

> scapuchino@... writes:

>

> In my 9 years of service I have not

> missed a tube. And again to me a miss is getting to

> the ER and not being " in " when confirmed by the

> ERMD.

>

>

>

>

> there are two types of folks who handle

> firearms...those who have had an

> accidental discharge and those who WILL have an

> accidental discharge...I'm

> currently in the latter group...

>

> By the same token, there are two types of folks who

> intubate...those who

> have missed a tube (even by your standards) and

> those who WILL miss a

> tube....the trick is to recognize that the tube is

> not in or has become DOPE'd

> somewhere along the way, before the patient suffers

> the consequences. Even with the

> practice I've had over the years (which does include

> a few 'upside down and

> backwards in the mud'), I've been known to back off,

> continue BVM support and

> let someone else take a crack at the situation.

>

> The medical maxim that this falls under is: " If you

> have not yet seen a

> particular published complication associated with a

> particular procedure, that

> just means that you have not done enough of those

> procedures to call yourself

> 'experienced' yet. "

>

> ck

>

>

>

>

> [Non-text portions of this message have been

> removed]

>

>

>

>

>