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...
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...
Guest guest Posted August 4, 2009 Report Share Posted August 4, 2009 rachfoote@... wrote: >>> I have some comments that can wait until tomorrow. <<< Did you change your mind? I am very interested to read your comments. Kenny Navarro Dallas Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 4, 2009 Report Share Posted August 4, 2009 rachfoote@... wrote: >>> I have some comments that can wait until tomorrow. <<< Did you change your mind? I am very interested to read your comments. Kenny Navarro Dallas Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 4, 2009 Report Share Posted August 4, 2009 rachfoote@... wrote: >>> I have some comments that can wait until tomorrow. <<< Did you change your mind? I am very interested to read your comments. Kenny Navarro Dallas Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 4, 2009 Report Share Posted August 4, 2009 I just have to share! I just returned from a wonderful call where we made EMS history. We nasally intubated , YES FOLKS YOU HEARD IT RIGHT! An actual, for real, long plastic ETT. Imagine my astonishment when it actually went in and I could ventilate and protect the patients airway! Another medical miracle also happened, we kept her ETCO2 at 34 and her SPO2 at 100% on our AutoVent despite the fact that I used that damn old ETT. WHEW!!!!! Sure glad that worked out cuz I sure wouldn't want people writing bad things on this list about my care!!!!!! Lee From: texasems-l [mailto:texasems-l ] On Behalf Of Kenny Navarro Sent: Tuesday, August 04, 2009 5:48 PM To: texasems-l Subject: Re: Intubation dogpile rachfoote@... wrote: >>> I have some comments that can wait until tomorrow. <<< Did you change your mind? I am very interested to read your comments. Kenny Navarro Dallas Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 4, 2009 Report Share Posted August 4, 2009 I just have to share! I just returned from a wonderful call where we made EMS history. We nasally intubated , YES FOLKS YOU HEARD IT RIGHT! An actual, for real, long plastic ETT. Imagine my astonishment when it actually went in and I could ventilate and protect the patients airway! Another medical miracle also happened, we kept her ETCO2 at 34 and her SPO2 at 100% on our AutoVent despite the fact that I used that damn old ETT. WHEW!!!!! Sure glad that worked out cuz I sure wouldn't want people writing bad things on this list about my care!!!!!! Lee From: texasems-l [mailto:texasems-l ] On Behalf Of Kenny Navarro Sent: Tuesday, August 04, 2009 5:48 PM To: texasems-l Subject: Re: Intubation dogpile rachfoote@... wrote: >>> I have some comments that can wait until tomorrow. <<< Did you change your mind? I am very interested to read your comments. Kenny Navarro Dallas Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 4, 2009 Report Share Posted August 4, 2009 I just have to share! I just returned from a wonderful call where we made EMS history. We nasally intubated , YES FOLKS YOU HEARD IT RIGHT! An actual, for real, long plastic ETT. Imagine my astonishment when it actually went in and I could ventilate and protect the patients airway! Another medical miracle also happened, we kept her ETCO2 at 34 and her SPO2 at 100% on our AutoVent despite the fact that I used that damn old ETT. WHEW!!!!! Sure glad that worked out cuz I sure wouldn't want people writing bad things on this list about my care!!!!!! Lee From: texasems-l [mailto:texasems-l ] On Behalf Of Kenny Navarro Sent: Tuesday, August 04, 2009 5:48 PM To: texasems-l Subject: Re: Intubation dogpile rachfoote@... wrote: >>> I have some comments that can wait until tomorrow. <<< Did you change your mind? I am very interested to read your comments. Kenny Navarro Dallas Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 4, 2009 Report Share Posted August 4, 2009 So you mean all that stuff I learned in school will work if I apply it? :0 I hate the knee jerk reactions we see. Instead of removing it from those that follow good practice, causing patients that would benefit from it to suffer, start fining services that allow bad practices, start removing medics certifications for failing to recognize a missed intubation. Just my worthless 2 cents. Renny Spencer Paramedic > > I just have to share! I just returned from a wonderful call where we made > EMS history. We nasally intubated , YES FOLKS YOU HEARD IT RIGHT! An > actual, for real, long plastic ETT. Imagine my astonishment when it > actually went in and I could ventilate and protect the patients airway! > Another medical miracle also happened, we kept her ETCO2 at 34 and her SPO2 > at 100% on our AutoVent despite the fact that I used that damn old ETT. > WHEW!!!!! Sure glad that worked out cuz I sure wouldn't want people writing > bad things on this list about my care!!!!!! > > > > Lee > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 4, 2009 Report Share Posted August 4, 2009 So you mean all that stuff I learned in school will work if I apply it? :0 I hate the knee jerk reactions we see. Instead of removing it from those that follow good practice, causing patients that would benefit from it to suffer, start fining services that allow bad practices, start removing medics certifications for failing to recognize a missed intubation. Just my worthless 2 cents. Renny Spencer Paramedic > > I just have to share! I just returned from a wonderful call where we made > EMS history. We nasally intubated , YES FOLKS YOU HEARD IT RIGHT! An > actual, for real, long plastic ETT. Imagine my astonishment when it > actually went in and I could ventilate and protect the patients airway! > Another medical miracle also happened, we kept her ETCO2 at 34 and her SPO2 > at 100% on our AutoVent despite the fact that I used that damn old ETT. > WHEW!!!!! Sure glad that worked out cuz I sure wouldn't want people writing > bad things on this list about my care!!!!!! > > > > Lee > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 4, 2009 Report Share Posted August 4, 2009 Lee wrote: >>> We nasally intubated . . . . . . Imagine my astonishment when it actually went in and I could ventilate and protect the patients airway! <<< Congratulations. Your department must be very proud. Perhaps her pulse oximetry and capnography values were the result of proper ventilation and not the fact that you used an endotracheal tube. I also do not believe you were astonished that it was a successful placement – you are a much better paramedic than that (although I know you are trying to make a point). Hugs and Kisses, Kenny Navarro Dallas Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 4, 2009 Report Share Posted August 4, 2009 Lee wrote: >>> We nasally intubated . . . . . . Imagine my astonishment when it actually went in and I could ventilate and protect the patients airway! <<< Congratulations. Your department must be very proud. Perhaps her pulse oximetry and capnography values were the result of proper ventilation and not the fact that you used an endotracheal tube. I also do not believe you were astonished that it was a successful placement – you are a much better paramedic than that (although I know you are trying to make a point). Hugs and Kisses, Kenny Navarro Dallas Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 4, 2009 Report Share Posted August 4, 2009 spenair wrote: >>> So you mean all that stuff I learned in school will work if I apply it? <<< It depends on how you define " work " . If you mean successfully accomplish the skill, the answer is yes. By maintaining skill competency and utilizing meticulous performance methodology, you can successfully accomplish the skills. If " work " means to improve patient outcomes, then the jury is still out on that one. >>> I hate the knee jerk reactions we see. <<< You mean like assuming that all EMS practices work because Lee can successfully perform a nasal intubation. Lee is a fine paramedic, If I ever need to be intubated, I would be proud to have him ventilate me with a BVM. Almost every scientific paper I have read for the past twenty years questions the efficacy of ETI in the prehospital environment. After that much time and energy, asking someone to step up and start protecting patients hardly seems like a knee jerk reaction. >>> Instead of removing it from those that follow good practice, causing patients that would benefit from it to suffer . . . . . . <<< I will assume you mean endotracheal intubation. The problem with your statement is that no one has identified (scientifically) the subgroup of patients who may benefit from ETI in the field. We already know the ones who are not benefiting and those being harmed. Kenny Navarro Dallas Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 4, 2009 Report Share Posted August 4, 2009 spenair wrote: >>> So you mean all that stuff I learned in school will work if I apply it? <<< It depends on how you define " work " . If you mean successfully accomplish the skill, the answer is yes. By maintaining skill competency and utilizing meticulous performance methodology, you can successfully accomplish the skills. If " work " means to improve patient outcomes, then the jury is still out on that one. >>> I hate the knee jerk reactions we see. <<< You mean like assuming that all EMS practices work because Lee can successfully perform a nasal intubation. Lee is a fine paramedic, If I ever need to be intubated, I would be proud to have him ventilate me with a BVM. Almost every scientific paper I have read for the past twenty years questions the efficacy of ETI in the prehospital environment. After that much time and energy, asking someone to step up and start protecting patients hardly seems like a knee jerk reaction. >>> Instead of removing it from those that follow good practice, causing patients that would benefit from it to suffer . . . . . . <<< I will assume you mean endotracheal intubation. The problem with your statement is that no one has identified (scientifically) the subgroup of patients who may benefit from ETI in the field. We already know the ones who are not benefiting and those being harmed. Kenny Navarro Dallas Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 4, 2009 Report Share Posted August 4, 2009 Lee, just sit down and try to chill, my friend. Try to relax. Breathe deeply, close your eyes, and think about a beautiful beach with moderate surf, oh, and it's a nude beach, and ........oops. 10-22 that. I hate to tell you this, but as your friend, I have no choice but to be the one to tell you. Lee, there is absolutely NO MEDICAL EVIDENCE to support what you did. That's right, cowboy. I do not know of even ONE study that has looked at morbidity and mortality of patients nasally intubated by paramedics in a suburban fire service based EMS system that shows any difference in patient outcomes between the control group and the others. None. So, you see, your efforts were totally and completely beside the point. According to the published studies, you could just as easily have offered her a Hershey Bar, and her outcome would have been the same statistically. [Note to self. Talk to medical director about putting Hershey Bars on truck.] Nevertheless, with due respect to my friend Kenny, I must say that the research has not been sufficient to prove one way or another that airway interventions do not make a difference in patient survival. Yes, the ones that have been done don't show any advantage, but have those studies been the right kind of studies? It boggles the mind (mine at least) to think that when the same things we do in the field are done in the hospital, they're valid and have an impact on patient survival, but when we do them in the field, they do not. Tell me why, if ER docs intubate the same kinds of patients we do, what they do is valid and what we do is not? Sorry. I can't get my head around that. I respect your devotion to the literature, Kenny. You tell it like it is. I appreciate that. However, what it is, is that the studies have not been structured in the right way, IMHO, to really measure what needs to be measured, and that is patient outcomes based upon a valid analysis of underlying conditions that affect outcomes. It is quite true that patients who are going to die no matter what you do will die whether or not you intubate them successfully or unsuccessfully. What's missing, and Kenny, correct me if I'm wrong, are studies that measure outcomes in patients who are not head injured, multiple trauma, and so forth. I would like to see a summary of the types of patients in the intubation studies broken down by their conditions at the time the medic first encountered them. I have had the privilege of working with some very high powered trauma docs and anesthesiologists with great experience in difficult intubations, and have been involved in writing one manual on emergency airway care, the SLAM: Street Level Airway Management Course, and I can tell you that the authors, who include the inventors of both the LMA and the Combitube, and battle field doctors, do not BUY the studies that show that intubation and other airway care methods make no difference. They will say that the right things have never been studied. I agree. We can talk about EBM, but some folks who are physicians are beginning to question the concept of EBM. More about that later, perhaps. Kenny's right about what the studies say. But the right studies have never been done, in my mind. As long as doctors intubate in the ER or the OR, I think an argument exists for good airway management in the field. Prevention of aspiration, securing an airway in people whose airways are swelling shut, who are bleeding into their airways, and so forth MUST be of some value. How many medics on here who intubate have EVER been a part of a study of intubation success and patient outcomes? Hey, I bash NOBODY! We all bring our knowledge and experience to bear. I respect Kenney's viewpoint, but I also respect Lee's. I've been there myself, but I won't resort to anecdotes. They're all anecdotal. LOL. I'm not ready to consign intubation to the trash heap. I also do not believe that ETI is the only definitive airway. Going back to studies, the Combitube and the LMA have been shown to be very comparable to ETI in airway protection, ventilation pressures, and so forth. As I preach to the choir, it's ventilation, not intubation, that saves patients. But I'm not willing to say that intubation never helps ventilation. It would be nice indeed if there were a study, national in scope, that measured all the dynamics of airway care and survival when all the variables are factored in. I doubt we'll ever have a study like that because it's too difficult to do. In the meantime, I suspect there will be some services that will ditch ETI and opt for SGAs. Others, with an excellent record of ETI, will stay the same. Fortunately, in Texas, the State does not mandate what you do. Here in AZ where I now live, the state can, with a wave of its hand, outlaw paramedic intubations. That might happen. GG. In a message dated 8/4/09 4:02:30 PM, L@... writes: >  > I just have to share! I just returned from a wonderful call where we made > EMS history. We nasally intubated , YES FOLKS YOU HEARD IT RIGHT! An > actual, for real, long plastic ETT. Imagine my astonishment when it > actually went in and I could ventilate and protect the patients airway! > Another medical miracle also happened, we kept her ETCO2 at 34 and her > SPO2 > at 100% on our AutoVent despite the fact that I used that damn old ETT. > WHEW!!!!! Sure glad that worked out cuz I sure wouldn't want people > writing > bad things on this list about my care!!!!!! > > Lee > > From: texasems-l@yahoogrotexasem [mailto:texasems-l@yahoogrotexasem] On > Behalf Of Kenny Navarro > Sent: Tuesday, August 04, 2009 5:48 PM > To: texasems-l@yahoogrotexasem > Subject: Re: Intubation dogpile > > rachfoote@.. rachfoot>>> I have some comments that can wait until > tomorrow. > <<< > > Did you change your mind? I am very interested to read your comments. > > Kenny Navarro > Dallas > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 4, 2009 Report Share Posted August 4, 2009 Every study is skewed by the lowest quality of medics. If a study were done with services with medics that maintained there skills and with properly equipped intubation/ventilation equipment studies would be much different. But because of the lowest quality screwing up patients that need immediate intubation for any chance to live will die because we should not have it as an option. And yes I have been part of several patients that would have died before reaching the hospital with out intubation. Airways would have closed and we would have watched them die had we not intubated. While the chances of survival to release was not good at least we gave them a chance, we gave them to the doctors still alive. But because the studies say we aren't helping lets quit giving anyone with a compromised airway a fighting chance. Again just my worthless $0.02 Renny Spencer Paramedic >>> So you mean all that stuff I learned in school will work if I apply it? <<< > > It depends on how you define " work " . If you mean successfully accomplish the skill, the answer is yes. By maintaining skill competency and utilizing meticulous performance methodology, you can successfully accomplish the skills. > > If " work " means to improve patient outcomes, then the jury is still out on that one. > > > >>> I hate the knee jerk reactions we see. <<< > > You mean like assuming that all EMS practices work because Lee can successfully perform a nasal intubation. Lee is a fine paramedic, If I ever need to be intubated, I would be proud to have him ventilate me with a BVM. > > Almost every scientific paper I have read for the past twenty years questions the efficacy of ETI in the prehospital environment. After that much time and energy, asking someone to step up and start protecting patients hardly seems like a knee jerk reaction. > > > >>> Instead of removing it from those that follow good practice, causing patients that would benefit from it to suffer . . . . . . <<< > > I will assume you mean endotracheal intubation. The problem with your statement is that no one has identified (scientifically) the subgroup of patients who may benefit from ETI in the field. We already know the ones who are not benefiting and those being harmed. > > Kenny Navarro > Dallas > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 4, 2009 Report Share Posted August 4, 2009 Every study is skewed by the lowest quality of medics. If a study were done with services with medics that maintained there skills and with properly equipped intubation/ventilation equipment studies would be much different. But because of the lowest quality screwing up patients that need immediate intubation for any chance to live will die because we should not have it as an option. And yes I have been part of several patients that would have died before reaching the hospital with out intubation. Airways would have closed and we would have watched them die had we not intubated. While the chances of survival to release was not good at least we gave them a chance, we gave them to the doctors still alive. But because the studies say we aren't helping lets quit giving anyone with a compromised airway a fighting chance. Again just my worthless $0.02 Renny Spencer Paramedic >>> So you mean all that stuff I learned in school will work if I apply it? <<< > > It depends on how you define " work " . If you mean successfully accomplish the skill, the answer is yes. By maintaining skill competency and utilizing meticulous performance methodology, you can successfully accomplish the skills. > > If " work " means to improve patient outcomes, then the jury is still out on that one. > > > >>> I hate the knee jerk reactions we see. <<< > > You mean like assuming that all EMS practices work because Lee can successfully perform a nasal intubation. Lee is a fine paramedic, If I ever need to be intubated, I would be proud to have him ventilate me with a BVM. > > Almost every scientific paper I have read for the past twenty years questions the efficacy of ETI in the prehospital environment. After that much time and energy, asking someone to step up and start protecting patients hardly seems like a knee jerk reaction. > > > >>> Instead of removing it from those that follow good practice, causing patients that would benefit from it to suffer . . . . . . <<< > > I will assume you mean endotracheal intubation. The problem with your statement is that no one has identified (scientifically) the subgroup of patients who may benefit from ETI in the field. We already know the ones who are not benefiting and those being harmed. > > Kenny Navarro > Dallas > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 4, 2009 Report Share Posted August 4, 2009 Every study is skewed by the lowest quality of medics. If a study were done with services with medics that maintained there skills and with properly equipped intubation/ventilation equipment studies would be much different. But because of the lowest quality screwing up patients that need immediate intubation for any chance to live will die because we should not have it as an option. And yes I have been part of several patients that would have died before reaching the hospital with out intubation. Airways would have closed and we would have watched them die had we not intubated. While the chances of survival to release was not good at least we gave them a chance, we gave them to the doctors still alive. But because the studies say we aren't helping lets quit giving anyone with a compromised airway a fighting chance. Again just my worthless $0.02 Renny Spencer Paramedic >>> So you mean all that stuff I learned in school will work if I apply it? <<< > > It depends on how you define " work " . If you mean successfully accomplish the skill, the answer is yes. By maintaining skill competency and utilizing meticulous performance methodology, you can successfully accomplish the skills. > > If " work " means to improve patient outcomes, then the jury is still out on that one. > > > >>> I hate the knee jerk reactions we see. <<< > > You mean like assuming that all EMS practices work because Lee can successfully perform a nasal intubation. Lee is a fine paramedic, If I ever need to be intubated, I would be proud to have him ventilate me with a BVM. > > Almost every scientific paper I have read for the past twenty years questions the efficacy of ETI in the prehospital environment. After that much time and energy, asking someone to step up and start protecting patients hardly seems like a knee jerk reaction. > > > >>> Instead of removing it from those that follow good practice, causing patients that would benefit from it to suffer . . . . . . <<< > > I will assume you mean endotracheal intubation. The problem with your statement is that no one has identified (scientifically) the subgroup of patients who may benefit from ETI in the field. We already know the ones who are not benefiting and those being harmed. > > Kenny Navarro > Dallas > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 4, 2009 Report Share Posted August 4, 2009 spenair wrote: >>> Every study is skewed by the lowest quality of medics. If a study were done with services with medics that maintained there skills and with properly equipped intubation/ventilation equipment studies would be much different. <<< In many of the studies, a subgroup analysis occurs that compares the outcomes of patients who were successfully intubated to those who had no intubation attempt. None of those show any survival advantages offered by ETI in cardiac arrest, traumatic brain injury, or pediatric populations. In other studies, the medics are successfully placing the ET tubes (at a respectable rate) and there is still no evidence of a survival advantage. Kenny Navarro Dallas Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 4, 2009 Report Share Posted August 4, 2009 spenair wrote: >>> Every study is skewed by the lowest quality of medics. If a study were done with services with medics that maintained there skills and with properly equipped intubation/ventilation equipment studies would be much different. <<< In many of the studies, a subgroup analysis occurs that compares the outcomes of patients who were successfully intubated to those who had no intubation attempt. None of those show any survival advantages offered by ETI in cardiac arrest, traumatic brain injury, or pediatric populations. In other studies, the medics are successfully placing the ET tubes (at a respectable rate) and there is still no evidence of a survival advantage. Kenny Navarro Dallas Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 4, 2009 Report Share Posted August 4, 2009 I submit that if I did not protect my patients airway she would die from aspiration. BVM ventilation could not be accomplished due to the large amount of vomit in her airway despite suction. Lee From: texasems-l [mailto:texasems-l ] On Behalf Of Kenny Navarro Sent: Tuesday, August 04, 2009 8:30 PM To: texasems-l Subject: Re: Intubation dogpile spenair wrote: >>> Every study is skewed by the lowest quality of medics. If a study were done with services with medics that maintained there skills and with properly equipped intubation/ventilation equipment studies would be much different. <<< In many of the studies, a subgroup analysis occurs that compares the outcomes of patients who were successfully intubated to those who had no intubation attempt. None of those show any survival advantages offered by ETI in cardiac arrest, traumatic brain injury, or pediatric populations. In other studies, the medics are successfully placing the ET tubes (at a respectable rate) and there is still no evidence of a survival advantage. Kenny Navarro Dallas Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 4, 2009 Report Share Posted August 4, 2009 So me getting patients alive to the ER that would not make it there alive w/o intubation means nothing? I agree many if not most that are that bad off will never leave the hospital alive but if they don't reach the hospital alive they have no chance. Being in a rural area it is a long time before definitive care so if they have no airway they will not reach it alive. I see that the studies show no difference in survival rates. But again if the airway closes they will be dead before ever reaching the ER. Can many patients be effectively just ventilated with a BVM? Yes so maybe based on the data we should consider seriously when we choose to intubate, but I see no justification to take intubation completely out of the field and allowing patients to die that could have at least survived to the ER. Not trying to argue, I just have seen benefits of intubation and really have no desire to just sit there and watch a person die that I could have helped. Renny Spencer Paramedic >>> Every study is skewed by the lowest quality of medics. If a study were done with services with medics that maintained there skills and with properly equipped intubation/ventilation equipment studies would be much different. <<< > > In many of the studies, a subgroup analysis occurs that compares the outcomes of patients who were successfully intubated to those who had no intubation attempt. None of those show any survival advantages offered by ETI in cardiac arrest, traumatic brain injury, or pediatric populations. > > In other studies, the medics are successfully placing the ET tubes (at a respectable rate) and there is still no evidence of a survival advantage. > > > Kenny Navarro > Dallas > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 4, 2009 Report Share Posted August 4, 2009 I think you're missing his point, Renny. Which ones of your patients are the ones that will not make it the ER alive without intubation? How do you know that they couldn't have done as well with say, a King airway or an LMA? We've all had patients that we're fairly certain would have done poorly without advanced airway management. But who is to say that advanced airway management necessitates an ET tube? I'm not going to trot out the tired " anecdote does not equal data " argument, but Kenny has a point, one I think everyone is missing: We intubate a lot of people. Thus far, we have a number of studies that show that a few services excel at the skill, and a great many more suck at it, but we have ZERO studies that show even a correctly placed tube improves outcomes. And until we have *data* and not *anecdote* that shows a demonstrable benefit, for however small a subset of patients, we need to be a lot more judicious in who and how often we tube. spenair wrote: > > > So me getting patients alive to the ER that would not make it there > alive w/o intubation means nothing? I agree many if not most that are > that bad off will never leave the hospital alive but if they don't > reach the hospital alive they have no chance. Being in a rural area it > is a long time before definitive care so if they have no airway they > will not reach it alive. > > I see that the studies show no difference in survival rates. But again > if the airway closes they will be dead before ever reaching the ER. > > Can many patients be effectively just ventilated with a BVM? Yes so > maybe based on the data we should consider seriously when we choose to > intubate, but I see no justification to take intubation completely out > of the field and allowing patients to die that could have at least > survived to the ER. > > Not trying to argue, I just have seen benefits of intubation and > really have no desire to just sit there and watch a person die that I > could have helped. > > Renny Spencer > Paramedic > > >>> Every study is skewed by the lowest quality of > medics. If a study were done with services with medics that maintained > there skills and with properly equipped intubation/ventilation > equipment studies would be much different. <<< > > > > In many of the studies, a subgroup analysis occurs that compares the > outcomes of patients who were successfully intubated to those who had > no intubation attempt. None of those show any survival advantages > offered by ETI in cardiac arrest, traumatic brain injury, or pediatric > populations. > > > > In other studies, the medics are successfully placing the ET tubes > (at a respectable rate) and there is still no evidence of a survival > advantage. > > > > > > Kenny Navarro > > Dallas > > > > -- Grayson www.kellygrayson.com Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 5, 2009 Report Share Posted August 5, 2009 Severe burn patients with airway swelling shut. The burns can be thermal or chemical. And there are other times such as anaphalaxis non responsive to the meds. Remember I am in rural areas and at times a long way to a hospital. Airway closes w/o tube you are not going to be able to ventilate. You are just going to watch the person die. And as I mentioned earlier this may not change the ultimate outcome but w/o them getting to the hospital alive they have 0% chance. Maybe my patient will be the +-1% and actually survive because they had airway secured. I do not want to say well studies say you will die anyway so we are just going to sit here and attempt to force air past you closed off airway, please quit struggling the studies say it doesn't matter anyway. And hey studies never make mistakes so so long. I don't know about you but if I get to them alive I want to be able to keep them alive to the hospital. I have had some die in the ambulance and I understand that is part of what we do. In fact I hate when people say no one dies in my ambulance, what a load of poop. I understand the studies say ultimately it seems not to change outcomes, well if we get them to the hospital alive we have changed outcome at least for a little while. I do agree maybe we should use a simple adjunct and if effective save the intubation for the controlled environment of the hospital. But not all patients can wait. Again no disrespect meant to you more experienced Paramedics than I am. No disrespect meant to anyone and I am not trying to argue, I just can not see the benefit of completely removing something that can benefit some patients even if in a very low percentile. Thanks for putting up with my worthless thoughts. Renny Spencer Paramedic > > I think you're missing his point, Renny. > > Which ones of your patients are the ones that will not make it the ER > alive without intubation? How do you know that they couldn't have done > as well with say, a King airway or an LMA? We've all had patients that > we're fairly certain would have done poorly without advanced airway > management. But who is to say that advanced airway management > necessitates an ET tube? > > I'm not going to trot out the tired " anecdote does not equal data " > argument, but Kenny has a point, one I think everyone is missing: > > We intubate a lot of people. Thus far, we have a number of studies that > show that a few services excel at the skill, and a great many more suck > at it, but we have ZERO studies that show even a correctly placed tube > improves outcomes. And until we have *data* and not *anecdote* that > shows a demonstrable benefit, for however small a subset of patients, we > need to be a lot more judicious in who and how often we tube. > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 5, 2009 Report Share Posted August 5, 2009 Severe burn patients with airway swelling shut. The burns can be thermal or chemical. And there are other times such as anaphalaxis non responsive to the meds. Remember I am in rural areas and at times a long way to a hospital. Airway closes w/o tube you are not going to be able to ventilate. You are just going to watch the person die. And as I mentioned earlier this may not change the ultimate outcome but w/o them getting to the hospital alive they have 0% chance. Maybe my patient will be the +-1% and actually survive because they had airway secured. I do not want to say well studies say you will die anyway so we are just going to sit here and attempt to force air past you closed off airway, please quit struggling the studies say it doesn't matter anyway. And hey studies never make mistakes so so long. I don't know about you but if I get to them alive I want to be able to keep them alive to the hospital. I have had some die in the ambulance and I understand that is part of what we do. In fact I hate when people say no one dies in my ambulance, what a load of poop. I understand the studies say ultimately it seems not to change outcomes, well if we get them to the hospital alive we have changed outcome at least for a little while. I do agree maybe we should use a simple adjunct and if effective save the intubation for the controlled environment of the hospital. But not all patients can wait. Again no disrespect meant to you more experienced Paramedics than I am. No disrespect meant to anyone and I am not trying to argue, I just can not see the benefit of completely removing something that can benefit some patients even if in a very low percentile. Thanks for putting up with my worthless thoughts. Renny Spencer Paramedic > > I think you're missing his point, Renny. > > Which ones of your patients are the ones that will not make it the ER > alive without intubation? How do you know that they couldn't have done > as well with say, a King airway or an LMA? We've all had patients that > we're fairly certain would have done poorly without advanced airway > management. But who is to say that advanced airway management > necessitates an ET tube? > > I'm not going to trot out the tired " anecdote does not equal data " > argument, but Kenny has a point, one I think everyone is missing: > > We intubate a lot of people. Thus far, we have a number of studies that > show that a few services excel at the skill, and a great many more suck > at it, but we have ZERO studies that show even a correctly placed tube > improves outcomes. And until we have *data* and not *anecdote* that > shows a demonstrable benefit, for however small a subset of patients, we > need to be a lot more judicious in who and how often we tube. > Quote Link to comment Share on other sites More sharing options...
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