Guest guest Posted July 31, 2009 Report Share Posted July 31, 2009 PATIENTS SURVIVE BY VENTILATION, NOT INTUBATION. -- M. Rich, RN, CRNA. SLAM; Street Level Airway Management. GG In a message dated 7/31/09 10:22:54 AM, kenneth.navarro@... writes: > > >>> If we aren't impacting mortality levels of those who need it most, > then just what are we doing? This begs the question of should we be worrying > about advanced airway procedures at all if it's not going to change > outcomes, irregardless of how well we do them or how much scene time it takes to > do them. <<< > > It is clear that your last name is Sharp for a reason. > > If suddenly tomorrow, some EMS instructor found a foolproof way to teach > and perform field intubations so that failure or misplacement was > IMPOSSIBLE, we still have no evidence that properly placed tubes in the field are > beneficial to the outcome of patients. > > For the group . . . imagine that you are in the hospital undergoing an > evaluation for an unknown medical problem and the physician walks into the > room with this proposition . . . > > Sir, the medical staff has decided that we need to take you into surgery > to perform a procedure. I am here to explain the procedure and gain consent. > > First, there is absolutely no evidence that the procedure I want to > perform will benefit you in any way. > > Second, if I perform the procedure, there is 25%-35% chance that I will > create a situation from which you cannot possibly recover. > > Finally, I need you to sign this consent form in order for me to perform > the procedure. > > How many of us would sign? > > If it was possible to explain the evidence-based risks and benefits of > endotracheal intubation to our patients, how many would consent to the > procedure. > > If we let our humanity guide our decisions (instead of our hubris), the > fate of endotracheal intubation in the prehospital world seems clear. > > Kenny Navarro > Dallas > > > > ************** A Good Credit Score is 700 or Above. See yours in just 2 easy steps! (http://pr.atwola.com/promoclk/100126575x1222846709x1201493018/aol?redir=http://\ www.freecreditreport.com/pm/default.aspx?sc=668072 & hmpgID=115 & bcd=JulystepsfooterNO115) Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 1, 2009 Report Share Posted August 1, 2009 But Gene it doesn't sound as cool to say I got a good seal with the mask and ventilated. J/K Actually one thing that has stuck with me from back when I was doing Intermediate clinicals was when the CRNA made me make a good seal and bag. With the anesthesiology bag if you do not have a good seal it gets softer and softer, so you can feel that you are doing something wrong. After I got a good seal on each patient then he would let me intubate. But my point in that long winded story was he reminded me of the importance of proper ventilation rather than focusing on the glory of tubing someone. Renny Spencer Paramdic > > PATIENTS SURVIVE BY VENTILATION, NOT INTUBATION. > > -- M. Rich, RN, CRNA. SLAM; Street Level Airway Management. > > GG > In a message dated 7/31/09 10:22:54 AM, kenneth.navarro@... > writes: > > > > > > >>> If we aren't impacting mortality levels of those who need it most, > > then just what are we doing? This begs the question of should we be worrying > > about advanced airway procedures at all if it's not going to change > > outcomes, irregardless of how well we do them or how much scene time it takes to > > do them. <<< > > > > It is clear that your last name is Sharp for a reason. > > > > If suddenly tomorrow, some EMS instructor found a foolproof way to teach > > and perform field intubations so that failure or misplacement was > > IMPOSSIBLE, we still have no evidence that properly placed tubes in the field are > > beneficial to the outcome of patients. > > > > For the group . . . imagine that you are in the hospital undergoing an > > evaluation for an unknown medical problem and the physician walks into the > > room with this proposition . . . > > > > Sir, the medical staff has decided that we need to take you into surgery > > to perform a procedure. I am here to explain the procedure and gain consent. > > > > First, there is absolutely no evidence that the procedure I want to > > perform will benefit you in any way. > > > > Second, if I perform the procedure, there is 25%-35% chance that I will > > create a situation from which you cannot possibly recover. > > > > Finally, I need you to sign this consent form in order for me to perform > > the procedure. > > > > How many of us would sign? > > > > If it was possible to explain the evidence-based risks and benefits of > > endotracheal intubation to our patients, how many would consent to the > > procedure. > > > > If we let our humanity guide our decisions (instead of our hubris), the > > fate of endotracheal intubation in the prehospital world seems clear. > > > > Kenny Navarro > > Dallas > > > > > > > > > > > > > ************** > A Good Credit Score is 700 or Above. See yours in just 2 easy > steps! > (http://pr.atwola.com/promoclk/100126575x1222846709x1201493018/aol?redir=http://\ www.freecreditreport.com/pm/default.aspx?sc=668072 & hmpgID=115 & > bcd=JulystepsfooterNO115) > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 1, 2009 Report Share Posted August 1, 2009 I could save a lot of money on letting my paramedics go, hire good solid basics at no pay, (they have to work anyway, because there are no other jobs in America), cut the supply costs on all advanced life support equipment, drop about 34 drugs, hire a GP as a Medical Director (for about a third of the cost) especially one that is a Med. Director for about 12 services and really doesn't care what we do. I think you people have given me the direction to cut my budget by 1.38 million. Thanks for everyones input. Andy **************A Good Credit Score is 700 or Above. See yours in just 2 easy steps! (http://pr.atwola.com/promoclk/100126575x1222846709x1201493018/aol?redir=http://\ www.freecreditreport.com/pm/default.aspx?sc=668072&hmpgID=115&bcd =JulystepsfooterNO115) Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 1, 2009 Report Share Posted August 1, 2009 Let's just do away with EMS all together, that way those in the ivory towers (i.e. the academic reasearchers) will have nothing to do! This will save a lot of federal research monies that are currently being used to prove what everyone seems to know already. My contribution to the national budget deficit! Lee From: texasems-l [mailto:texasems-l ] On Behalf Of Kenny Navarro Sent: Friday, July 31, 2009 12:22 PM To: texasems-l Subject: Intubation dogpile >>> If we aren't impacting mortality levels of those who need it most, then just what are we doing? This begs the question of should we be worrying about advanced airway procedures at all if it's not going to change outcomes, irregardless of how well we do them or how much scene time it takes to do them. <<< It is clear that your last name is Sharp for a reason. If suddenly tomorrow, some EMS instructor found a foolproof way to teach and perform field intubations so that failure or misplacement was IMPOSSIBLE, we still have no evidence that properly placed tubes in the field are beneficial to the outcome of patients. For the group . . . imagine that you are in the hospital undergoing an evaluation for an unknown medical problem and the physician walks into the room with this proposition . . . Sir, the medical staff has decided that we need to take you into surgery to perform a procedure. I am here to explain the procedure and gain consent. First, there is absolutely no evidence that the procedure I want to perform will benefit you in any way. Second, if I perform the procedure, there is 25%-35% chance that I will create a situation from which you cannot possibly recover. Finally, I need you to sign this consent form in order for me to perform the procedure. How many of us would sign? If it was possible to explain the evidence-based risks and benefits of endotracheal intubation to our patients, how many would consent to the procedure. If we let our humanity guide our decisions (instead of our hubris), the fate of endotracheal intubation in the prehospital world seems clear. Kenny Navarro Dallas Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 1, 2009 Report Share Posted August 1, 2009 But Gene it doesn't sound as cool to say I got a good seal with the mask and ventilated. J/K I'd argue that it DOES sound pretty cool to say that we saved a life with basic procedures. Phil Reynolds Jr. 115 Harold Dr. Burnet, TX., 78611 HP CP Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 1, 2009 Report Share Posted August 1, 2009 " Lee " wrote: >>> Let's just do away with EMS all together, that way those in the ivory towers (i.e. the academic reasearchers) will have nothing to do! <<< Academic researchers can always find a way to spend federal dollars. However, the fate of tracheal intubation in EMS is not about saving money. It is about not hurting patients. If you (or one the Ivory Tower residents) could find a cost effective way to train paramedics to perform endotracheal intubation flawlessly (which I submit CANNOT be done), then found a cost effective way to maintain competency, there is still no evidence of its efficacy in the field (especially when compared to proper BVM ventilation). Even if we can limit the harm risk to a mere 2% of cases, the risks would still outweigh the benefits (unless paramedic hubris and emotional attachment are considered benefits). The medical literature is ripe with instances where medications and procedures were retired after harming a few patients, even though they helped others. If endotracheal intubation was not already a current skill and, before introduction, was required to meet FDA standards of safety and efficacy, I doubt that it could. Perhaps the researchers could identify the procedures that are making a positive impact and we could focus our attention (and our resources) on those (like CPAP). Then we could give up the things that offer risk without benefit. It is the right thing to do. Sanctimoniously yours, Kenny Navarro Dallas Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 1, 2009 Report Share Posted August 1, 2009 " Lee " wrote: >>> Let's just do away with EMS all together, that way those in the ivory towers (i.e. the academic reasearchers) will have nothing to do! <<< Academic researchers can always find a way to spend federal dollars. However, the fate of tracheal intubation in EMS is not about saving money. It is about not hurting patients. If you (or one the Ivory Tower residents) could find a cost effective way to train paramedics to perform endotracheal intubation flawlessly (which I submit CANNOT be done), then found a cost effective way to maintain competency, there is still no evidence of its efficacy in the field (especially when compared to proper BVM ventilation). Even if we can limit the harm risk to a mere 2% of cases, the risks would still outweigh the benefits (unless paramedic hubris and emotional attachment are considered benefits). The medical literature is ripe with instances where medications and procedures were retired after harming a few patients, even though they helped others. If endotracheal intubation was not already a current skill and, before introduction, was required to meet FDA standards of safety and efficacy, I doubt that it could. Perhaps the researchers could identify the procedures that are making a positive impact and we could focus our attention (and our resources) on those (like CPAP). Then we could give up the things that offer risk without benefit. It is the right thing to do. Sanctimoniously yours, Kenny Navarro Dallas Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 1, 2009 Report Share Posted August 1, 2009 " Lee " wrote: >>> Let's just do away with EMS all together, that way those in the ivory towers (i.e. the academic reasearchers) will have nothing to do! <<< Academic researchers can always find a way to spend federal dollars. However, the fate of tracheal intubation in EMS is not about saving money. It is about not hurting patients. If you (or one the Ivory Tower residents) could find a cost effective way to train paramedics to perform endotracheal intubation flawlessly (which I submit CANNOT be done), then found a cost effective way to maintain competency, there is still no evidence of its efficacy in the field (especially when compared to proper BVM ventilation). Even if we can limit the harm risk to a mere 2% of cases, the risks would still outweigh the benefits (unless paramedic hubris and emotional attachment are considered benefits). The medical literature is ripe with instances where medications and procedures were retired after harming a few patients, even though they helped others. If endotracheal intubation was not already a current skill and, before introduction, was required to meet FDA standards of safety and efficacy, I doubt that it could. Perhaps the researchers could identify the procedures that are making a positive impact and we could focus our attention (and our resources) on those (like CPAP). Then we could give up the things that offer risk without benefit. It is the right thing to do. Sanctimoniously yours, Kenny Navarro Dallas Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 1, 2009 Report Share Posted August 1, 2009 Being the eternal optimist, I believe that medics CAN be trained to intubate correctly and safely, but it takes an integrated program with hospitals. That's where the breakdown currently occurs. When I started we routinely got 25 or 30 intubations, learned to bag patients for an hour, and were helped tremendously by the anesthesiologists and CRNAs. How and why that stopped seemingly depends upon a number of factors, but currently my students here are getting a minimum of 15 tubes and 25 LMAs, which I realize is the exception rather than the rule. I just happen to be in the right place. To my knowledge I have never had a former student misplace a tube and not discover it. With capnography there is no excuse for a misplaced tube remaining in place. With the supraglottic airways, almost anybody's airway can be managed correctly, but all this takes training and practice. I am appalled that we spend more time teaching people to apply spine boards and KEDs than we do to manage airways. While I understand that the studies seem to say that there is no difference in patient outcomes between those who are intubated and those who are not, all of us know empirically that's not so. Until there is a definitive study, one that measures all the variables and dynamics involved (which there has never been that I can identify) we won't know the true story. I believe that there are many services out there whose medics are very good at intubating and whose success rates approximate those of ER physicians. I also believe it's quite obvious that in some places medics cannot intubate well, probably because they were inadequately trained and do not get enough practice, and that must be corrected. System design also plays a role. You can't have 6 medics on every scene and expect all of them to get intubations. Bledsoe and I recently commented about the future of intubation in print. The trend is either to limit those who can do it or discard it entirely. I believe that with new devices such as the Glidescope Ranger and the AirTraq, we can salvage intubation as a paramedic skill, but we will have to do far better than we have done in training. Having been a part of the SLAM course for a number of years, it has astounded me that we have trained board certified anesthesiologists, ER doctors, battlefield surgeons and frontline medics, nurses, paramedics, and basic EMTs, and the only people I have ever had walk out saying " I don't need this course " were fire department paramedics. It is interesting that one of the best classes we ever had involved the entire group of anesthesiologists and CRNAs at a large East Texas hospital. They all loved the course and all said they learned something from it. I believe there is a place for ETI in the field, but I also believe that we must do a much better job of education and training our people to do it, designing systems where they can maintain their skills, and selling the medical community (read anesthesiologists) that training our people is more vital than training first year residents. Gene Gandy In a message dated 8/1/09 5:09:30 PM, L@... writes: > > I say, if it is so bad then take it away from EVERYONE not a select > group. > If you read the insert for Lidocaine it is not FDA approved to give via IV > yet it is given that way every single day. K+ is not supposed to be pushed > IV but it is done every single day, my point is that it is the practice of > medicine and as long as the human factor is in the equation there will > always be a chance for errors. > > Lee > > From: texasems-l@yahoogrotexasem [mailto:texasems-l@yahoogrotexasem] On > Behalf Of Kenny Navarro > Sent: Saturday, August 01, 2009 1:24 PM > To: texasems-l@yahoogrotexasem > Subject: Re: Intubation dogpile > > " Lee " wrote: >>> Let's just do away with EMS > all together, that way those in the ivory towers (i.e. the academic > reasearchers) will have nothing to do! <<< > > Academic researchers can always find a way to spend federal dollars. > > However, the fate of tracheal intubation in EMS is not about saving money. > It is about not hurting patients. > > If you (or one the Ivory Tower residents) could find a cost effective way > to > train paramedics to perform endotracheal intubation flawlessly (which I > submit CANNOT be done), then found a cost effective way to maintain > competency, there is still no evidence of its efficacy in the field > (especially when compared to proper BVM ventilation) > > Even if we can limit the harm risk to a mere 2% of cases, the risks would > still outweigh the benefits (unless paramedic hubris and emotional > attachment are considered benefits). > > The medical literature is ripe with instances where medications and > procedures were retired after harming a few patients, even though they > helped others. If endotracheal intubation was not already a current skill > and, before introduction, was required to meet FDA standards of safety and > efficacy, I doubt that it could. > > Perhaps the researchers could identify the procedures that are making a > positive impact and we could focus our attention (and our resources) on > those (like CPAP). Then we could give up the things that offer risk > without > benefit. > > It is the right thing to do. > > Sanctimoniously yours, > > Kenny Navarro > Dallas > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 1, 2009 Report Share Posted August 1, 2009 I say, if it is so bad then take it away from EVERYONE not a select group. If you read the insert for Lidocaine it is not FDA approved to give via IV yet it is given that way every single day. K+ is not supposed to be pushed IV but it is done every single day, my point is that it is the practice of medicine and as long as the human factor is in the equation there will always be a chance for errors. Lee From: texasems-l [mailto:texasems-l ] On Behalf Of Kenny Navarro Sent: Saturday, August 01, 2009 1:24 PM To: texasems-l Subject: Re: Intubation dogpile " Lee " wrote: >>> Let's just do away with EMS all together, that way those in the ivory towers (i.e. the academic reasearchers) will have nothing to do! <<< Academic researchers can always find a way to spend federal dollars. However, the fate of tracheal intubation in EMS is not about saving money. It is about not hurting patients. If you (or one the Ivory Tower residents) could find a cost effective way to train paramedics to perform endotracheal intubation flawlessly (which I submit CANNOT be done), then found a cost effective way to maintain competency, there is still no evidence of its efficacy in the field (especially when compared to proper BVM ventilation). Even if we can limit the harm risk to a mere 2% of cases, the risks would still outweigh the benefits (unless paramedic hubris and emotional attachment are considered benefits). The medical literature is ripe with instances where medications and procedures were retired after harming a few patients, even though they helped others. If endotracheal intubation was not already a current skill and, before introduction, was required to meet FDA standards of safety and efficacy, I doubt that it could. Perhaps the researchers could identify the procedures that are making a positive impact and we could focus our attention (and our resources) on those (like CPAP). Then we could give up the things that offer risk without benefit. It is the right thing to do. Sanctimoniously yours, Kenny Navarro Dallas Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 1, 2009 Report Share Posted August 1, 2009 I say, if it is so bad then take it away from EVERYONE not a select group. If you read the insert for Lidocaine it is not FDA approved to give via IV yet it is given that way every single day. K+ is not supposed to be pushed IV but it is done every single day, my point is that it is the practice of medicine and as long as the human factor is in the equation there will always be a chance for errors. Lee From: texasems-l [mailto:texasems-l ] On Behalf Of Kenny Navarro Sent: Saturday, August 01, 2009 1:24 PM To: texasems-l Subject: Re: Intubation dogpile " Lee " wrote: >>> Let's just do away with EMS all together, that way those in the ivory towers (i.e. the academic reasearchers) will have nothing to do! <<< Academic researchers can always find a way to spend federal dollars. However, the fate of tracheal intubation in EMS is not about saving money. It is about not hurting patients. If you (or one the Ivory Tower residents) could find a cost effective way to train paramedics to perform endotracheal intubation flawlessly (which I submit CANNOT be done), then found a cost effective way to maintain competency, there is still no evidence of its efficacy in the field (especially when compared to proper BVM ventilation). Even if we can limit the harm risk to a mere 2% of cases, the risks would still outweigh the benefits (unless paramedic hubris and emotional attachment are considered benefits). The medical literature is ripe with instances where medications and procedures were retired after harming a few patients, even though they helped others. If endotracheal intubation was not already a current skill and, before introduction, was required to meet FDA standards of safety and efficacy, I doubt that it could. Perhaps the researchers could identify the procedures that are making a positive impact and we could focus our attention (and our resources) on those (like CPAP). Then we could give up the things that offer risk without benefit. It is the right thing to do. Sanctimoniously yours, Kenny Navarro Dallas Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 1, 2009 Report Share Posted August 1, 2009 I say, if it is so bad then take it away from EVERYONE not a select group. If you read the insert for Lidocaine it is not FDA approved to give via IV yet it is given that way every single day. K+ is not supposed to be pushed IV but it is done every single day, my point is that it is the practice of medicine and as long as the human factor is in the equation there will always be a chance for errors. Lee From: texasems-l [mailto:texasems-l ] On Behalf Of Kenny Navarro Sent: Saturday, August 01, 2009 1:24 PM To: texasems-l Subject: Re: Intubation dogpile " Lee " wrote: >>> Let's just do away with EMS all together, that way those in the ivory towers (i.e. the academic reasearchers) will have nothing to do! <<< Academic researchers can always find a way to spend federal dollars. However, the fate of tracheal intubation in EMS is not about saving money. It is about not hurting patients. If you (or one the Ivory Tower residents) could find a cost effective way to train paramedics to perform endotracheal intubation flawlessly (which I submit CANNOT be done), then found a cost effective way to maintain competency, there is still no evidence of its efficacy in the field (especially when compared to proper BVM ventilation). Even if we can limit the harm risk to a mere 2% of cases, the risks would still outweigh the benefits (unless paramedic hubris and emotional attachment are considered benefits). The medical literature is ripe with instances where medications and procedures were retired after harming a few patients, even though they helped others. If endotracheal intubation was not already a current skill and, before introduction, was required to meet FDA standards of safety and efficacy, I doubt that it could. Perhaps the researchers could identify the procedures that are making a positive impact and we could focus our attention (and our resources) on those (like CPAP). Then we could give up the things that offer risk without benefit. It is the right thing to do. Sanctimoniously yours, Kenny Navarro Dallas Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 3, 2009 Report Share Posted August 3, 2009 Lee wrote: >>> I say, if it is so bad then take it away from EVERYONE not a select group. <<< Lee, you are talking about two different issues. It is certainly plausible that some interventions (like endotracheal intubation) may improve outcome if performed in the emergency department (ED) but offer no advantages (or even disadvantages) if performed in the field. This is not a foreign concept. Thiamine is beneficial for some malnourished patients suffering from hypoglycemia, but administration in the field offers no survival advantages over administration in the ED. Steroids offer some morbidity protection for acute asthma patients but IV steroids in the field are no more effective than oral steroid tablets administered in the ED. Endotracheal intubation may improve outcomes in some patients; we just have not identified them yet. It does not appear to be cardiac arrest victims or traumatic brain injury victims or pediatric patients. There are so many other options that offer ventilation opportunities that are equal to the endotracheal tube, are easier to train with, much easier to maintain skill competencies even in responders that do not treat many airway emergencies, and are overall safer for our patients. We should stop hurting people with endotracheal intubation. Our humanity and professionalism compels us to do the right thing. Kenny Navarro Dallas Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 3, 2009 Report Share Posted August 3, 2009 Lee wrote: >>> I say, if it is so bad then take it away from EVERYONE not a select group. <<< Lee, you are talking about two different issues. It is certainly plausible that some interventions (like endotracheal intubation) may improve outcome if performed in the emergency department (ED) but offer no advantages (or even disadvantages) if performed in the field. This is not a foreign concept. Thiamine is beneficial for some malnourished patients suffering from hypoglycemia, but administration in the field offers no survival advantages over administration in the ED. Steroids offer some morbidity protection for acute asthma patients but IV steroids in the field are no more effective than oral steroid tablets administered in the ED. Endotracheal intubation may improve outcomes in some patients; we just have not identified them yet. It does not appear to be cardiac arrest victims or traumatic brain injury victims or pediatric patients. There are so many other options that offer ventilation opportunities that are equal to the endotracheal tube, are easier to train with, much easier to maintain skill competencies even in responders that do not treat many airway emergencies, and are overall safer for our patients. We should stop hurting people with endotracheal intubation. Our humanity and professionalism compels us to do the right thing. Kenny Navarro Dallas Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 3, 2009 Report Share Posted August 3, 2009 Lee wrote: >>> I say, if it is so bad then take it away from EVERYONE not a select group. <<< Lee, you are talking about two different issues. It is certainly plausible that some interventions (like endotracheal intubation) may improve outcome if performed in the emergency department (ED) but offer no advantages (or even disadvantages) if performed in the field. This is not a foreign concept. Thiamine is beneficial for some malnourished patients suffering from hypoglycemia, but administration in the field offers no survival advantages over administration in the ED. Steroids offer some morbidity protection for acute asthma patients but IV steroids in the field are no more effective than oral steroid tablets administered in the ED. Endotracheal intubation may improve outcomes in some patients; we just have not identified them yet. It does not appear to be cardiac arrest victims or traumatic brain injury victims or pediatric patients. There are so many other options that offer ventilation opportunities that are equal to the endotracheal tube, are easier to train with, much easier to maintain skill competencies even in responders that do not treat many airway emergencies, and are overall safer for our patients. We should stop hurting people with endotracheal intubation. Our humanity and professionalism compels us to do the right thing. Kenny Navarro Dallas Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 3, 2009 Report Share Posted August 3, 2009 I agree with your premise, Kenny, but the examples you cited are all things which are not terribly time sensitive. Airway management *is* time sensitive. Now, there is nothing to say that the management need be an endotracheal tube in the field, but neither does that apply to the ED, either. Like you, I suspect that EMS will always encounter some patients for whom endotracheal intubation is beneficial. The trick is in identifying which ones. Kenny Navarro wrote: > > > Lee wrote: >>> I say, if it is so bad then take it away > from EVERYONE not a select group. <<< > > Lee, you are talking about two different issues. > > It is certainly plausible that some interventions (like endotracheal > intubation) may improve outcome if performed in the emergency > department (ED) but offer no advantages (or even disadvantages) if > performed in the field. This is not a foreign concept. > > Thiamine is beneficial for some malnourished patients suffering from > hypoglycemia, but administration in the field offers no survival > advantages over administration in the ED. > > Steroids offer some morbidity protection for acute asthma patients but > IV steroids in the field are no more effective than oral steroid > tablets administered in the ED. > > Endotracheal intubation may improve outcomes in some patients; we just > have not identified them yet. It does not appear to be cardiac arrest > victims or traumatic brain injury victims or pediatric patients. > > There are so many other options that offer ventilation opportunities > that are equal to the endotracheal tube, are easier to train with, > much easier to maintain skill competencies even in responders that do > not treat many airway emergencies, and are overall safer for our patients. > > We should stop hurting people with endotracheal intubation. Our > humanity and professionalism compels us to do the right thing. > > Kenny Navarro > Dallas > > -- Grayson www.kellygrayson.com Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 3, 2009 Report Share Posted August 3, 2009 I agree with your premise, Kenny, but the examples you cited are all things which are not terribly time sensitive. Airway management *is* time sensitive. Now, there is nothing to say that the management need be an endotracheal tube in the field, but neither does that apply to the ED, either. Like you, I suspect that EMS will always encounter some patients for whom endotracheal intubation is beneficial. The trick is in identifying which ones. Kenny Navarro wrote: > > > Lee wrote: >>> I say, if it is so bad then take it away > from EVERYONE not a select group. <<< > > Lee, you are talking about two different issues. > > It is certainly plausible that some interventions (like endotracheal > intubation) may improve outcome if performed in the emergency > department (ED) but offer no advantages (or even disadvantages) if > performed in the field. This is not a foreign concept. > > Thiamine is beneficial for some malnourished patients suffering from > hypoglycemia, but administration in the field offers no survival > advantages over administration in the ED. > > Steroids offer some morbidity protection for acute asthma patients but > IV steroids in the field are no more effective than oral steroid > tablets administered in the ED. > > Endotracheal intubation may improve outcomes in some patients; we just > have not identified them yet. It does not appear to be cardiac arrest > victims or traumatic brain injury victims or pediatric patients. > > There are so many other options that offer ventilation opportunities > that are equal to the endotracheal tube, are easier to train with, > much easier to maintain skill competencies even in responders that do > not treat many airway emergencies, and are overall safer for our patients. > > We should stop hurting people with endotracheal intubation. Our > humanity and professionalism compels us to do the right thing. > > Kenny Navarro > Dallas > > -- Grayson www.kellygrayson.com Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 3, 2009 Report Share Posted August 3, 2009 I agree with your premise, Kenny, but the examples you cited are all things which are not terribly time sensitive. Airway management *is* time sensitive. Now, there is nothing to say that the management need be an endotracheal tube in the field, but neither does that apply to the ED, either. Like you, I suspect that EMS will always encounter some patients for whom endotracheal intubation is beneficial. The trick is in identifying which ones. Kenny Navarro wrote: > > > Lee wrote: >>> I say, if it is so bad then take it away > from EVERYONE not a select group. <<< > > Lee, you are talking about two different issues. > > It is certainly plausible that some interventions (like endotracheal > intubation) may improve outcome if performed in the emergency > department (ED) but offer no advantages (or even disadvantages) if > performed in the field. This is not a foreign concept. > > Thiamine is beneficial for some malnourished patients suffering from > hypoglycemia, but administration in the field offers no survival > advantages over administration in the ED. > > Steroids offer some morbidity protection for acute asthma patients but > IV steroids in the field are no more effective than oral steroid > tablets administered in the ED. > > Endotracheal intubation may improve outcomes in some patients; we just > have not identified them yet. It does not appear to be cardiac arrest > victims or traumatic brain injury victims or pediatric patients. > > There are so many other options that offer ventilation opportunities > that are equal to the endotracheal tube, are easier to train with, > much easier to maintain skill competencies even in responders that do > not treat many airway emergencies, and are overall safer for our patients. > > We should stop hurting people with endotracheal intubation. Our > humanity and professionalism compels us to do the right thing. > > Kenny Navarro > Dallas > > -- Grayson www.kellygrayson.com Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 3, 2009 Report Share Posted August 3, 2009 Wouldn't this be a simple (ok, relatively simple) question of determining which patients need confirmed access below the glottic opening due to larygnospasm or constriction.?? I'm thinking that airway burns and anaphylactic reactions would fit into this category. -Wes Ogilvie Re: Re: Intubation dogpile I agree with your premise, Kenny, but the examples you cited are all things which are not terribly time sensitive. Airway management *is* time sensitive. Now, there is nothing to say that the management need be an endotracheal tube in the field, but neither does that apply to the ED, either. Like you, I suspect that EMS will always encounter some patients for whom endotracheal intubation is beneficial. The trick is in identifying which ones. Kenny Navarro wrote: > > > Lee wrote: >>> I say, if it is so bad then take it away > from EVERYONE not a select group. <<< > > Lee, you are talking about two different issues. > > It is certainly plausible that some interventions (like endotracheal > intubation) may improve outcome if performed in the emergency > department (ED) but offer no advantages (or even disadvantages) if > performed in the field. This is not a foreign concept. > > Thiamine is beneficial for some malnourished patients suffering from > hypoglycemia, but administration in the field offers no survival > advantages over administration in the ED. > > Steroids offer some morbidity protection for acute asthma patients but > IV steroids in the field are no more effective than oral steroid > tablets administered in the ED. > > Endotracheal intubation may improve outcomes in some patients; we just > have not identified them yet. It does not appear to be cardiac arrest > victims or traumatic brain injury victims or pediatric patients. > > There are so many other options that offer ventilation opportunities > that are equal to the endotracheal tube, are easier to train with, > much easier to maintain skill competencies even in responders that do > not treat many airway emergencies, and are overall safer for our patients. > > We should stop hurting people with endotracheal intubation. Our > humanity and professionalism compels us to do the right thing. > > Kenny Navarro > Dallas > > -- Grayson www.kellygrayson.com Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 3, 2009 Report Share Posted August 3, 2009 Wouldn't this be a simple (ok, relatively simple) question of determining which patients need confirmed access below the glottic opening due to larygnospasm or constriction.?? I'm thinking that airway burns and anaphylactic reactions would fit into this category. -Wes Ogilvie Re: Re: Intubation dogpile I agree with your premise, Kenny, but the examples you cited are all things which are not terribly time sensitive. Airway management *is* time sensitive. Now, there is nothing to say that the management need be an endotracheal tube in the field, but neither does that apply to the ED, either. Like you, I suspect that EMS will always encounter some patients for whom endotracheal intubation is beneficial. The trick is in identifying which ones. Kenny Navarro wrote: > > > Lee wrote: >>> I say, if it is so bad then take it away > from EVERYONE not a select group. <<< > > Lee, you are talking about two different issues. > > It is certainly plausible that some interventions (like endotracheal > intubation) may improve outcome if performed in the emergency > department (ED) but offer no advantages (or even disadvantages) if > performed in the field. This is not a foreign concept. > > Thiamine is beneficial for some malnourished patients suffering from > hypoglycemia, but administration in the field offers no survival > advantages over administration in the ED. > > Steroids offer some morbidity protection for acute asthma patients but > IV steroids in the field are no more effective than oral steroid > tablets administered in the ED. > > Endotracheal intubation may improve outcomes in some patients; we just > have not identified them yet. It does not appear to be cardiac arrest > victims or traumatic brain injury victims or pediatric patients. > > There are so many other options that offer ventilation opportunities > that are equal to the endotracheal tube, are easier to train with, > much easier to maintain skill competencies even in responders that do > not treat many airway emergencies, and are overall safer for our patients. > > We should stop hurting people with endotracheal intubation. Our > humanity and professionalism compels us to do the right thing. > > Kenny Navarro > Dallas > > -- Grayson www.kellygrayson.com Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 3, 2009 Report Share Posted August 3, 2009 Wouldn't this be a simple (ok, relatively simple) question of determining which patients need confirmed access below the glottic opening due to larygnospasm or constriction.?? I'm thinking that airway burns and anaphylactic reactions would fit into this category. -Wes Ogilvie Re: Re: Intubation dogpile I agree with your premise, Kenny, but the examples you cited are all things which are not terribly time sensitive. Airway management *is* time sensitive. Now, there is nothing to say that the management need be an endotracheal tube in the field, but neither does that apply to the ED, either. Like you, I suspect that EMS will always encounter some patients for whom endotracheal intubation is beneficial. The trick is in identifying which ones. Kenny Navarro wrote: > > > Lee wrote: >>> I say, if it is so bad then take it away > from EVERYONE not a select group. <<< > > Lee, you are talking about two different issues. > > It is certainly plausible that some interventions (like endotracheal > intubation) may improve outcome if performed in the emergency > department (ED) but offer no advantages (or even disadvantages) if > performed in the field. This is not a foreign concept. > > Thiamine is beneficial for some malnourished patients suffering from > hypoglycemia, but administration in the field offers no survival > advantages over administration in the ED. > > Steroids offer some morbidity protection for acute asthma patients but > IV steroids in the field are no more effective than oral steroid > tablets administered in the ED. > > Endotracheal intubation may improve outcomes in some patients; we just > have not identified them yet. It does not appear to be cardiac arrest > victims or traumatic brain injury victims or pediatric patients. > > There are so many other options that offer ventilation opportunities > that are equal to the endotracheal tube, are easier to train with, > much easier to maintain skill competencies even in responders that do > not treat many airway emergencies, and are overall safer for our patients. > > We should stop hurting people with endotracheal intubation. Our > humanity and professionalism compels us to do the right thing. > > Kenny Navarro > Dallas > > -- Grayson www.kellygrayson.com Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 3, 2009 Report Share Posted August 3, 2009 Like you, I suspect that EMS will always encounter some patients for whom endotracheal intubation is beneficial. The trick is in identifying which ones. Trust me, it is not a trick. Andy Foote Re: Re: Intubation dogpile I agree with your premise, Kenny, but the examples you cited are all things which are not terribly time sensitive. Airway management *is* time sensitive. Now, there is nothing to say that the management need be an endotracheal tube in the field, but neither does that apply to the ED, either. Like you, I suspect that EMS will always encounter some patients for whom endotracheal intubation is beneficial. The trick is in identifying which ones. Kenny Navarro wrote: > > > Lee wrote: >>> I say, if it is so bad then take it away > from EVERYONE not a select group. <<< > > Lee, you are talking about two different issues. > > It is certainly plausible that some interventions (like endotracheal > intubation) may improve outcome if performed in the emergency > department (ED) but offer no advantages (or even disadvantages) if > performed in the field. This is not a foreign concept. > > Thiamine is beneficial for some malnourished patients suffering from > hypoglycemia, but administration in the field offers no survival > advantages over administration in the ED. > > Steroids offer some morbidity protection for acute asthma patients but > IV steroids in the field are no more effective than oral steroid > tablets administered in the ED. > > Endotracheal intubation may improve outcomes in some patients; we just > have not identified them yet. It does not appear to be cardiac arrest > victims or traumatic brain injury victims or pediatric patients. > > There are so many other options that offer ventilation opportunities > that are equal to the endotracheal tube, are easier to train with, > much easier to maintain skill competencies even in responders that do > not treat many airway emergencies, and are overall safer for our patients. > > We should stop hurting people with endotracheal intubation. Our > humanity and professionalism compels us to do the right thing. > > Kenny Navarro > Dallas > > -- Grayson www.kellygrayson.com ------------------------------------ Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 3, 2009 Report Share Posted August 3, 2009 Like you, I suspect that EMS will always encounter some patients for whom endotracheal intubation is beneficial. The trick is in identifying which ones. Trust me, it is not a trick. Andy Foote Re: Re: Intubation dogpile I agree with your premise, Kenny, but the examples you cited are all things which are not terribly time sensitive. Airway management *is* time sensitive. Now, there is nothing to say that the management need be an endotracheal tube in the field, but neither does that apply to the ED, either. Like you, I suspect that EMS will always encounter some patients for whom endotracheal intubation is beneficial. The trick is in identifying which ones. Kenny Navarro wrote: > > > Lee wrote: >>> I say, if it is so bad then take it away > from EVERYONE not a select group. <<< > > Lee, you are talking about two different issues. > > It is certainly plausible that some interventions (like endotracheal > intubation) may improve outcome if performed in the emergency > department (ED) but offer no advantages (or even disadvantages) if > performed in the field. This is not a foreign concept. > > Thiamine is beneficial for some malnourished patients suffering from > hypoglycemia, but administration in the field offers no survival > advantages over administration in the ED. > > Steroids offer some morbidity protection for acute asthma patients but > IV steroids in the field are no more effective than oral steroid > tablets administered in the ED. > > Endotracheal intubation may improve outcomes in some patients; we just > have not identified them yet. It does not appear to be cardiac arrest > victims or traumatic brain injury victims or pediatric patients. > > There are so many other options that offer ventilation opportunities > that are equal to the endotracheal tube, are easier to train with, > much easier to maintain skill competencies even in responders that do > not treat many airway emergencies, and are overall safer for our patients. > > We should stop hurting people with endotracheal intubation. Our > humanity and professionalism compels us to do the right thing. > > Kenny Navarro > Dallas > > -- Grayson www.kellygrayson.com ------------------------------------ Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 3, 2009 Report Share Posted August 3, 2009 Like you, I suspect that EMS will always encounter some patients for whom endotracheal intubation is beneficial. The trick is in identifying which ones. Trust me, it is not a trick. Andy Foote Re: Re: Intubation dogpile I agree with your premise, Kenny, but the examples you cited are all things which are not terribly time sensitive. Airway management *is* time sensitive. Now, there is nothing to say that the management need be an endotracheal tube in the field, but neither does that apply to the ED, either. Like you, I suspect that EMS will always encounter some patients for whom endotracheal intubation is beneficial. The trick is in identifying which ones. Kenny Navarro wrote: > > > Lee wrote: >>> I say, if it is so bad then take it away > from EVERYONE not a select group. <<< > > Lee, you are talking about two different issues. > > It is certainly plausible that some interventions (like endotracheal > intubation) may improve outcome if performed in the emergency > department (ED) but offer no advantages (or even disadvantages) if > performed in the field. This is not a foreign concept. > > Thiamine is beneficial for some malnourished patients suffering from > hypoglycemia, but administration in the field offers no survival > advantages over administration in the ED. > > Steroids offer some morbidity protection for acute asthma patients but > IV steroids in the field are no more effective than oral steroid > tablets administered in the ED. > > Endotracheal intubation may improve outcomes in some patients; we just > have not identified them yet. It does not appear to be cardiac arrest > victims or traumatic brain injury victims or pediatric patients. > > There are so many other options that offer ventilation opportunities > that are equal to the endotracheal tube, are easier to train with, > much easier to maintain skill competencies even in responders that do > not treat many airway emergencies, and are overall safer for our patients. > > We should stop hurting people with endotracheal intubation. Our > humanity and professionalism compels us to do the right thing. > > Kenny Navarro > Dallas > > -- Grayson www.kellygrayson.com ------------------------------------ Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 3, 2009 Report Share Posted August 3, 2009 I'll bite, Andy. Which ones benefit from prehospital endotracheal intubation, as opposed to, say, supraglottic airways? Aside from rapidly deteriorating airway status due to irreversible swelling, or inability to manage secretions with positioning and suction, I can't think of any. rachfoote@... wrote: > > > > Like you, I suspect that EMS will always encounter some patients for > whom endotracheal intubation is beneficial. The trick is in identifying > which ones. > > Trust me, it is not a trick. > > Andy Foote > > Re: Re: Intubation dogpile > > I agree with your premise, Kenny, but the examples you cited are all > things which are not terribly time sensitive. > > Airway management *is* time sensitive. Now, there is nothing to say > that > the management need be an endotracheal tube in the field, but neither > does that apply to the ED, either. > > Like you, I suspect that EMS will always encounter some patients for > whom endotracheal intubation is beneficial. The trick is in identifying > which ones. > > Kenny Navarro wrote: > > > > > > Lee wrote: >>> I say, if it is so bad then take it away > > from EVERYONE not a select group. <<< > > > > Lee, you are talking about two different issues. > > > > It is certainly plausible that some interventions (like endotracheal > > intubation) may improve outcome if performed in the emergency > > department (ED) but offer no advantages (or even disadvantages) if > > performed in the field. This is not a foreign concept. > > > > Thiamine is beneficial for some malnourished patients suffering from > > hypoglycemia, but administration in the field offers no survival > > advantages over administration in the ED. > > > > Steroids offer some morbidity protection for acute asthma patients > but > > IV steroids in the field are no more effective than oral steroid > > tablets administered in the ED. > > > > Endotracheal intubation may improve outcomes in some patients; we > just > > have not identified them yet. It does not appear to be cardiac arrest > > victims or traumatic brain injury victims or pediatric patients. > > > > There are so many other options that offer ventilation opportunities > > that are equal to the endotracheal tube, are easier to train with, > > much easier to maintain skill competencies even in responders that do > > not treat many airway emergencies, and are overall safer for our > patients. > > > > We should stop hurting people with endotracheal intubation. Our > > humanity and professionalism compels us to do the right thing. > > > > Kenny Navarro > > Dallas > > > > > > -- > Grayson > www.kellygrayson.com > > ------------------------------------ > > Quote Link to comment Share on other sites More sharing options...
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