Intubations dissapearing?

[MCGLYNN_EMTP]

Agreed....I got everything I wanted out of this thread and more

 

[firetender]

Prehospital ETI should NOT go away; while there have been some studies that showed no change in morbidity/mortality or pt outcomes (and some that showed a increase in poor outcomes; get to that in a minute) it does not change the fact that ETI still provides the most secure airway, short of a crich, allowing for better ventilation, suctioning, airway protection, and without some of the side-effects of alternate airways (King, LMA, combitube) such as airway trauma, gastric inflation and aspiration (regardless of how you define aspiration, I think most will still agree that an ETT still provides better protection versus other's). When done correctly and appropriately there are more benefits to doing it than there are negatives. Unfortunately, when done incorrectly, which can be done very easily, it can, and often is, disastrous.

I'd like to add to this excellent post. Of all the procedures offered at the beginning of the paramedic program (early 70's) there was no greater controversy than ETI. (I had an ER Doc, rip a securely placed ET tube out of my patient's throat -- cuff inflated of course! -- screaming, "You can't DO that!!")

Then, as now, the primary focus was on "Does the procedure save lives?" Sure it does, and many more lives than any of the studies accounted for, many, MANY more.

Why? Read the above quote. triemal04 nails it.

THE IMPORTANCE OF ETI IS THAT IT FACILITATES THE MANAGEMENT OF AN UNCONSCIOUS, NON-BREATHING PATIENT.

By sticking to the strictly clinical, the studies completely miss how ETI contributes to a favorable outcome by preventing further complications. Yes, for the patient, but more importantly, for the medic.

Once the tube is securely in place, only an occasional check for stability is necessary, you can go about your numerous other therapies without having to always beware of aspiration; whether you're breathing for the patient or not. For example, in traumatic injuries it may be expedient to tube. If the patient stops breathing on you, you're ready to go.

And did any of the studies consider the reduced incidence of aspiration pneumonia in the recovery of the patients?

Will we know for sure how many complications are avoided by the use of ETI in the field? Probably not.

That's why, when it comes to the field of pre-hospital emergency care, any and every of these "scientific" studies should also include ANECDOTAL evidence (subjective assessments by those actually working in the field WITH the procedures in question) in their evaluations.

This all is actually just one more example of the Human Element being neglected in the pursuit of emergency care. Yes, this is a science, but don't forget, it's also an ART!

 

[VentMedic]

This argument has become as ridiculous as the Collier County Fire/medics not understanding why they can't have their ALS drugs when they can not pass a simple med test.

What some of you are failing to see is that it is NOT endotracheal intubation that is in question but those that have failed to maintain their skills and education to have caused the need for this to be examined more closely. The systems that have maintained the quality monitors to assure their Paramedics are capable of doing this skill safely and successfully will probably have no problem with keeping ETI unless they allow their weakest links to drag them down. Those that are discussing this with "fear" of losing a skill may be doubting their own abilities, their own system or believe it is their God given right to do ETI. Many have come to believe ETI is their right rather than a privilege thus some have gotten complacent. Those doing only one intubation per year and feeling that is enough are those that have created this controversy. Then, you have the schools that only require 5 successful tubes on a manikin further complicating the issue.

One can complain all they want about the research done but that fact remains there was an issue to justify the research being done. You can continue to rip apart the studies or you can look at where the issues of weakness are and improve your own skills, education and strive for excellence within your agency.

This one skill is not just an issue for Paramedics but for any other health care profession. If some ED doctors fail at intubation or central lines too many times, their skills' privileges are revoked and the Critical Care or Anesthesia doctors will have to cover for them. If RRTs screw up too many times at A-lines or ETI, the NPs or PAs may have to take over those skills. If your skill level is then only for a BVM or supraglottic, even in a hospital, then that is what you do until someone who is skilled, educated and has the privilege to do ETI. It is not a God given right but a skill that must be seriously maintained through practice and education. It you and your agency can not make the committment to good practice and education, then you and your co-workers have no business doing the skill. There are truly too many that have entered this profession without adequate preparation and without adequate mentoring or oversight provided by their employers. Regardless of the benefits of ETI in the field, if the effort is not put forth by the EMS agencies and the providers, bad performance can do just as much harm and possibly much more.

Take the messages provided in the research and do your own assessment honestly within your own department and of your own skills. One just has to look at the other issues of the departments studied to figure out some of the problems. Thus, don't repeat their mistakes and ETI should stay in your toolbox.

 

[MCGLYNN_EMTP]

I think that is also the problem in question...not is it helpfull but should we even be allowed to do ETI anymore. In my service, we intubate quite often and those of us who don't try to keep our skills up on our downtime, at least I make my best effort to do so. I think we need to require more out of the education side of the problem as well as maintaining our skills for those of us who only intubate once a year if even that much. If ETI is removed from our "toolbox" as some say...we have no one to blame but the medic in the mirror because we let ourselves as a profession become less successful at this skill.

I believe that the definitive airway is our direct airway ETT...however I am not at all against indirect airways such as King or combitube I think they are great as a backup but we have to learn that It's ok to have a combitube we do not HAVE to have ETT if the situation comes up that It is just not possible. We don't have to be super medic and never miss a ETI or never have to resort to a combitube.

 

[VentMedic]

those of us who don't try to keep our skills up on our downtime,

Your agency is only as strong as your weakest link.

I believe that the definitive airway is our direct airway ETT...however I am not at all against indirect airways such as King or combitube I think they are great as a backup but we have to learn that It's ok to have a combitube we do not HAVE to have ETT if the situation comes up that It is just not possible. We don't have to be super medic and never miss a ETI or never have to resort to a combitube.

Regardless of where you do patient care be it in ground EMS, HEMS or in the hospital, you should know when to intubate by ETI and when an alternative airway might be the way to go until another skilled person and/or equipment arrives rather than butchering the airway.

If on the helicopter I have a really difficult airway by assessment and score, I may use an alternative airway including BVM/supraglottic until we get to the ED. If the ground EMS has placed a supraglottic airway and it appears to be doing an adequate job, I again may opt to leave it rather than risking no airway at all or the consequences of removing it in a less than ideal setting. However, if there is a problem with the airway, it will be removed and replaced with the ETT or another supraglottic airway.

Those who fail to assess the patient for a difficult airway are usually those that do not understand why they fail at many intubations. Anesthesiologists are extremesly successful not just because of the repetition but because they have taken the time to know if there will be any difficulty with ETI. They also may opt to do a supraglottic device during the procedure. It is not about just doing ETI but the appropriateness of what is best for the patient. If you do not know enough to understand the difference then ETI should not be part of your toolbox. Too many get caught up in the "put the tube through the hole" mentality and don't appropriately assess whether that is even possible with the equipment at hand for that particular patient. It is called tunnel vision and too many fall victim to it in many areas of their assessment.

 

[austinmedic2004]

I agree with Vent...it is important to use the ENTIRE toolbox and your training and experience to determine what is the best course of action for a particular patient. If BVM/OPA works and you are able to manage, then carry on...if that is not adequate...then move to another tool. In addition, make sure to use all of the aides to successful ETI: Mallampati classification, bougie, EtCO2 (wave/numeric), Glidescope (only if available) and possibly drug assisted.

 

[Smash]

However none of that negates the fact that much of the research is absolute garbage. Suggesting that we fix our own problems is indeed admirable and important as I have been at great pains to point out, but it still doesn't answer the question of whether or not we should be intubating, and that is why we need more research. What we don't need is more tripe of the likes of Dr Wang's 'study' being taken as gospel by all and sundry and thus hearing the cry to remove intubation from EMS.

You may see it as 'ripping apart the studies': I see it as critically appraising the literature that is driving our practice to ensure that we are providing the best care we can. If the literature doesn't stand up to scrutiny then it deserves to be discarded. I suppose however that it is easier to be lead by others rather than taking responsibility for our own practice and the future of EMS.

Just to be clear: I advocate ensuring that paramedics ability to intubate is on par with Drs (yes it can be done). Once this is achieved and we can compare apples with apples, I advocate further research to see if prehospital intubation confers benefit over in-hospital intubation. If methodologically sound research shows that prehospital ETI is of no benefit in whatever population is studied, then so be it. Until then I advocate not calling for the use of potentially substandard techniques as a cop out, or in accepting fatally flawed research as reasons for discarding this tool.

 

[Melclin]

Originally posted by Smash
Fortunately though we have our Antipodean cousins to cover for us. Bernard, who has published a number of papers on pre-hospital stuff is due to publish a real prospective trial on pre-hospital versus in hospital RSI in traumatic brain injury, and I have been told that the results are very, very promising. I wait with bated breath and the hope that we are not let down by substandard study design.

Sigh. As usual

Yeah the RSI trial had been going strong for quite a few years. The trial is solid. It concluded last year and I hear that, pending the results of the follow up studies, it was a resounding success. RSI was expanded to a list of other problems (near drownings, hangings, psychostimulant overdose, strokes etc) during the course of the trial because MICA paramedics were proving themselves to be overwhelmingly competent. RSI was approved for all MICA paramedics as a standard part of their practice guidelines as of last year (or maybe the year before, I forget).


A couple of points on the topic of education and accreditation for this skill. MICA paramedics are our ALS backup, the equivalent of what you'd call a 'paramedic'.

-They are required to have a minimum of 4 years at university (3 years bachelor degree and a year of post grad qualifications) plus at least 3 years practicing at the lower level (Which is on par with your EMT-I).

-Every time an RSI was performed, the case was evaluated and if it was deemed that you 'stuffed up' you had to go through the accreditation process again (education, dummy practice, practice in the OR). A MICA medic may loose their accreditation at any time. The audit took into account many variables including time on scene.

-The outcomes for each RSI were measured and MICA medics consulted with their clinical oversight (DRs, team managers, Clinical support officers [super-medics]) to constantly improve the process.

With this system in place, systems like it, and the high level of educational requirements, our system is and has, achieved fantastic results. (I can't wait for the therapeutic hypothermia in TBI trial). Education and strict oversight guys- this is the key.

I'm going to a conference in late November where Stephen Bernard (name drop, name drop) will be presenting the results of the trial and the implications for national practice. I'll post his thoughts on the matter after wards.

 

[mikethemedic]

intubation

we need intubation, since it is a medicine route for acls

 

[VentMedic]

There is no doubt that ETI is beneficial but if the EMS agencies and providers FAIL to be thoroughly educated about ETI in the schools and maintain their competency, they should not be messing with ETI.

NO ONE, not even Wang, is questioning the value of ETI if done correctly. Paramedics have been intubating for over 40 years but in the areas, such as California and Florida where some of the studies were done, there are other issues such as too many patch Paramedic riding engines doing only one intubation a year. For once, atropine has presented some valid statements even if they should not be taken as the way things should be done.

Pulling out a few articles to say how great intubation is done in EMS does not represent all the agencies that lack the education/training and oversight. One should not use those studies to justify them doing ETI if they do not put in the effort.

The really unfortunate issue comes when the agencies studied that have less than good results FAIL to raise their standards when they are studied again.

Until then I advocate not calling for the use of potentially substandard techniques as a cop out, or in accepting fatally flawed research as reasons for discarding this tool.

Not once did I say alternative airways were substandard especially if attempting ETI was going to do more damage. If you can not understand why assessment of an airway and knowing your own limitations to handle difficult airways in the field either due to lack of the proper meds or equipment is a FAIL on your part which makes your education/training substandard and not the device.

Have you not considered even once that it is possible the medical directors looked at their own data and saw it might even be worse than that in the study and even after trying to improve but the set up of their EMS agency or whole system just makes it difficult? Why have some agencies just gone with fly cars carrying Paramedics who intubate?

Again, read more than JEMS and just a coople of abstracts from the articles. There have been several studies that have recently come out in just the past few months. Go to a college where you have access to a medical search engine. Don't just take the few articles that have been posted on the EMS forums out of JEMS to "critique".

As an EMT-B, how many intubations have you done and what education do you have specific for intubation? How many medications can you push to facilitate ETI?

 

[triemal04]

What some of you are failing to see is that it is NOT endotracheal intubation that is in question but those that have failed to maintain their skills and education to have caused the need for this to be examined more closely. The systems that have maintained the quality monitors to assure their Paramedics are capable of doing this skill safely and successfully will probably have no problem with keeping ETI unless they allow their weakest links to drag them down. Those that are discussing this with "fear" of losing a skill may be doubting their own abilities, their own system or believe it is their God given right to do ETI. Many have come to believe ETI is their right rather than a privilege thus some have gotten complacent. Those doing only one intubation per year and feeling that is enough are those that have created this controversy. Then, you have the schools that only require 5 successful tubes on a manikin further complicating the issue.

Hence why high quality services need to start publishing their own studies on intubation success/failure rates, AND explain how they are able to maintain such standards. Yes, when studies are done in lousy systems they will have lousy results that reflect on all of us; the only ways to fix that are to show proof that the results of a study are not systemic and show ways to fix the problem; something we aren't very good at right now.

Of course, the problem goes a bit deeper than that. Whenever a study is done that casts prehospital ETI in a bad light, the call is never to look at what caused the problem and fix THAT, it's just to remove ETI entirely. Bad idea. What should be happening (and we are failing ourselves by not even trying to fix this) is people should be, at the same time, advocating for change in how people get taught to intubate, maintain their skills, and apply them in the field. The best way to fix a problem isn't simple to ignore the issue by removing something, it's to get to the root cause, in this case poor initial education, continuing education, overuse of medics, etc etc...you know...the same problems everyone (most everyone) already know exist.

Like I said before; the ball is in our court; if people are worried about this, then look at why failed intubations are happening, how services avoid them, and start fixing, or at least trying to fix, the issue.

 

[VentMedic]

Of course, the problem goes a bit deeper than that. Whenever a study is done that casts prehospital ETI in a bad light, the call is never to look at what caused the problem and fix THAT, it's just to remove ETI entirely.

Actually, if you read some of the studies in their entirety, the reasons for failed intubation are discussed and this has been used as arguments for RSI or different intubation equipment by some agencies.

A progressive thinkng agency can take almost any of these prehospital studies and turn it to their favor if there were no medications or inadequate medications used. This can be their agrument especially if they already have ETCO2 capability which can be another stance for equipment.

 

[triemal04]

Actually, if you read some of the studies in their entirety, the reasons for failed intubation are discussed and this has been used as arguments for RSI or different intubation equipment by some agencies.

A progressive thinkng agency can take almost any of these prehospital studies and turn it to their favor if there were no medications or inadequate medications used. This can be their agrument especially if they already have ETCO2 capability which can be another stance for equipment.

Sure, I don't disagree with any of that, and I'm willing to bet some have done just that too.

But, while the cause for failed intubations is sometimes discussed, the end result seems, more often than not, to be not focusing on changing things, but just on removing ETI altogether; that the problem is so big it shouldn't be fixed, just removed. Not true for all studies, but some of the larger ones... The issue won't be what individual services do, but what the national standard becomes; so many states adopt a scope very similar to what's allowed nationally, if ETI is removed from the curriculum it will probably filter down to even those services that are very proficient at it.

Mind boggling that people in EMS will allow other's to dictate the direction our profession goes without even trying change things for ourselves. Wait...no it's not.

 

[VentMedic]

Every research article is up for interpretation. Thus the debate between lidocaine and amiodorone, albuterol and terbutaline or epi, to board or not to board spines, Etomindate and its effects, which ETT is better, which BVM is better, which ventilator is better etc. We also still have debates for CCT and Flight about doing central lines and chest tubes or who should staff a transport for neonatal, pedi, VADs, adult ECMO and IABP. In the ICU world, there are literally hundreds of thousands of debates. We might review and dispute something Duke or Johns Hopkins has published. They dispute us saying their way is better and so on and so forth. That is the beauty of medicine as it is ever changing. Those seeking answers don't fixate on just one study. For Etomindate alone on another EMS forum over 45 studies were mentioned when discussing its use.

It is up to the EMS medical directors to determine if there is any comparison between those studies and his/her Paramedics. If the medical director looks as a study like the one done in Dade County, FL and sees where it has stated the problem for many is that the FF/Parmedics are only getting one tube per year and that is the tube they messed up on, that may not apply to at all to that MD's agency.

With the large number of studies that are being done, not that many get published in national or international journals. However, that doesn't mean the medical directors don't acknowledge them at a local or state level when there is a review. At the many meetings, these studies may be brought forth regardless of whether they are published and can be used to keep intubation in the protocols. When intubation is removed, it is often after the evidence within that agency is poor and the medical director has analyzed the situation to determine the course.

There are many good studies out there that show prehospital intubation in a favorable light in the U.S and in other countries. Again the agency being studied must be taken into consideration. If I wanted to publish a negative study for just about anything EMS, I do know which agencies I could use to get the results I am seeking. I also would imagine Medic One in Seattle would not think of using the stats from the EMT-I or EMT-intubation certs for their own studies if they want to boast their skills.

 

[MCGLYNN_EMTP]

So what is the BIGGEST concern at hand with ETI in the prehospital setting?

Is it that paramedics don't have a high enough success rate?
Is it that paramedics don't know when and when not to ETI?
Is it that the same job can be done just as effective as with other airway adjuncts?
Is it that Paramedics are just flat out not doing ETI correctly?
Is it all of these? or is it something else entirely different from these??

 

[Smash]

but if the EMS agencies and providers FAIL to be thoroughly educated about ETI in the schools and maintain their competency, they should not be messing with ETI.

Agreed.

NO ONE, not even Wang, is questioning the value of ETI if done correctly.

The trouble is that not many are looking at how correctly it is done in the first place. Again, in the Wang study that I have been referring to, he does not consider at all how prehospital ETI is carried out and does not account for missed attempts or failed attempts. All that we are left with is an unfavourable impression of paramedic intubation based on outcomes that were in all possibility, never going to change anyway. This clearly questions the benefit of paramedic intubation, even if it does show a marked bias to any who are prepared to critique it.

Not once did I say alternative airways were substandard especially if attempting ETI was going to do more damage. If you can not understand why assessment of an airway and knowing your own limitations to handle difficult airways in the field either due to lack of the proper meds or equipment is a FAIL on your part which makes your education/training substandard and not the device.

The issue is not whether I can place and EGD or a tube successfully; the issue is the drift towards using these devices as primary airway management, not becuase we have assessed the patient and decided that that is the best course of action, but instead because it has been decided (rightly or wrongly) that paramedics in general are not able to intubate and so we should use the simpler option. Instead of addressing systemic problems we go for a cop-out of using blind insertion devices in every patient.

Have you not considered even once that it is possible the medical directors looked at their own data and saw it might even be worse than that in the study and even after trying to improve but the set up of their EMS agency or whole system just makes it difficult? Why have some agencies just gone with fly cars carrying Paramedics who intubate?

I consider a lot of things, a lot of times. However to sepculate wildly about why some services use fly cars is no more useful than speculating wildly about what colour underwear President Obama is wearing. I cannot know, cannot post hard data one way or the other and thus am able to add nothing to the conversation by making such speculation. There's more than one reason to use a fly car model of paramedic response and without canvassing some of the services who use it, I do not know their rationale.

 

[VentMedic]

If you do only read JEMS, I will in good faith pull up a few articles for you to read. I am probably wasting my time on you but there might be others who would like to see some of the other research.

An analysis of advanced prehospital airway management
Journal of Emergency Medicine
Volume 23, Issue 2, August 2002, Pages 183-189
Eileen M. Bulger MD, Michael K. Copass MD, Ronald V. Maier MD, Jonathan Larsen, EMT-P, Justin Knowles and Gregory J. Jurkovich MD
Department of Surgery, Harborview Medical Center, Seattle, Washington, USA


Effect of an airway education program on prehospital intubation
Air Medical Journal
Volume 21, Issue 4, Pages 28-31 (July 2002)
Eric R. Swanson, MD, FACEP, David E. Fosnocht, MD, FACEP

A Comparison of Prehospital and Hospital Data in Trauma Patients

Arbabi, Saman MD, MPH; Jurkovich, Gregory J. MD; Wahl, Wendy L. MD; Franklin, Glen A. MD; Hemmila, Mark R. MD; Taheri, Paul A. MD, MBA; Maier, Ronald V. MD

The Journal of Trauma: Injury, Infection, and Critical Care:
May 2004 - Volume 56 - Issue 5 - pp 1029-1032

Prehospital and resuscitative airway care: should the gold standard be reassessed?

Nolan, Jerry D. FRCA

Current Opinion in Critical Care:
December 2001 - Volume 7 - Issue 6 - pp 413-421
Trauma


Prehospital tracheal intubation in severely injured patients: a Danish observational study

Erika Frischknecht Christensen, consultant anaesthesiologist, Claus Christian Schovsbo Høyer, medical student
1 Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Aarhus, Aarhus 8000, Denmark
BMJ 2003;327:533-534 (6 September), doi:10.1136/bmj.327.7414.533

Prehospital determination of tracheal tube placement in severe head injury
Grmec,

Mally
Emergency Medicine Journal 2004;21:518-520

Prehospital Standardization of Medical
Airway Management: Incidence and Risk
Factors of Difficult Airway
Xavier Combes, MD, Patricia Jabre, MD, Chadi Jbeili, MD, Bertrand Leroux, MD, Sylvie Bastuji-Garin, MD, PhD,
Alain Margenet, MD, Fre´ deric Adnet, MD, PhD, Gilles Dhonneur, MD​

ACADEMIC EMERGENCY MEDICINE 2006; 13:828–834

ª 2006 by the Society for Academic Emergency​

Medicine​

Here's are good article from 25 years ago and done when EMS was on its way to being a respected profession with good growth potential.​

Prehospital endotracheal intubation: Rationale for training emergency medical personnel​

Annals of Emergency Medicine
Volume 14, Issue 11, Pages 1085-1092 (November 1985)​

Endotracheal intubation by emergency medical services (EMS) personnel in the prehospital setting decreases morbidity and helps to improve the outcome of critically ill patients, especially those with cardiac or respiratory arrest, multiple injuries, or severe head trauma. The endotracheal tube facilitates better oxygenation and ventilation because it enhances lung inflation and protects the lungs from aspiration. No other alternative modality is as efficacious. Compared to physicians in general, properly instructed, well-supervised paramedics can be trained to perform this procedure safely and more efficiently in the emergency setting. The use of the endotracheal tube in the prehospital setting should be strongly encouraged and the training of EMS personnel in this skill should be given high priority.​

There are hundreds of intubation articles to be found. Wang is just one author but unfortunately someone in JEMS and the internet forums focus just on him. This is why I advise people in EMS to read medical journals and not just JEMS. ​

Here's a little more help in case you are not familar with search engines:
http://scholar.google.com/scholar?start=20&q=prehospital+intubation&hl=en​

There are many pages of articles there and many more can be found with different word combinations.​

example:
http://scholar.google.com/scholar?q=air+medical+journal+intubation&hl=en​

Google Scholar is easily accessible to medical information without signing in to a medical search site.
http://scholar.google.com/​

I also hope you and atkinsje take not of the real letters behind the names of the researchers. They do mean something.​

 

[ffemt8978]

Okay, now that I've spent the past half hour cleaning up the mess that was this thread by editing 5 posts and removing 22 off topic posts, this thread is reopened.

If you got a PM stating that your thread had been edited/moved/removed, I did it in an effort to retain the actual informative material while removing the off topic garbage.

If I have to go through this again with this thread, it will be closed permanently and some people will getting a short vacation from the forum.

 

[Melbourne MICA]

Late as usual

As usual I have come in late in the post with a comment. ETI in Melbourne is a hugely valuable component of our MICA practice and always has been. The principle reason for the ongoing success of this practice in our skill-set is not just our success rates (98%+ across all clinical spectrum's) but rather maintaining the competency to standard in all respects.

This has been accomplished through rigorous external and internal audit. If you muck up the procedure in either a practical sense or in terms of clinical decision making expect to go back to "school" for a refresher. If you keep mucking it up expect to lose your accreditation for the skill - and you may never get it back.

On top of this the MICA officers themselves are constantly self-evaluating through debrief, discussion with peers and seniors and of course had the educational foundation to rest upon to begin with.

MICA officers have also pressed for an evidence base for this skill-set particular to specific clinical pathologies, airway and ventilation scenarios and in practical management terms unique to each patient event.

Our medical standards committee is constantly evaluating ongoing ETI practice relative to published evidence and practice around the world. It is also evaluated in terms of the overall ambulance dynamic and scope of practice.

The best example for all of this is our RSI protocol.

It may surprise some to learn we used no paralytics up until this protocol was introduced in 2003. We only had SFI for drug mediated ET placements.

While this was okay in some clinical scenarios, in trauma it was problematic to say the least. This was due in no small part to the fact that the only agents we were allowed to use were Diazepam and Morphine despite many alternatives being widely available.

Why this was so was nothing to do with the ETI skill itself - MICA guys could place tubes consistently well on the back of good clinical decisions. The docs, is seemed, just didn't trust lowly Paramedics using powerful induction agents and sedatives. It was like they were going to give us explosives with short fuses to use if they did. (There is a lot of validity to the Docs position it must be said).

In the meantime guys were using big doses of Diaz and Morph because more often than not a tube was clearly needed but the drugs were less than ideal to accomplish the ET placement. It was a clinical and ethical dilemma for the guys having to do it. Cover your arse and let the pt suffer of even die or give the pt a chance even though the process was rsiky and far from having any guarantees of success.

Matters got to the point where we were going to lose SFI and most likely the whole ETI skill-set mainly, you guessed it, because of hypotension issues particularly in trauma pts and especially those with closed head injuries - go figure!!!

So along came the RSI trial.

Well run, well practiced, thoroughly researched and closely scrutinised.

The rest is history.

We are now directing ETI management even more specifically with more trials coming up including an RSI/ Cold fluid for trauma HI pts.

I don't know whether there is a chicken and egg argument in all this - you can't give them the drugs/procedure unless they can do it safely but how can you know that if you don't give it to them in the first place?

In the end it 's about trust, competence, evidence, ongoing evaluation and always looking both inward and beyond to the future.

Great skill to have but as I have said many times before - definately one for the grown ups - Heroes, cowboys and kids looking to play ambulance need not apply.

MM

 

[gicts]

An argument against removing ET tubes: (perhaps it has been discussed, I haven't paid 100% attention to the last 8 pages) Where would we be without items that required tubes? RSI? Drug administration via the tube? Not going to happen IMO.