# Why are we placing ETTs at all?



## usalsfyre (Mar 10, 2011)

I haven't gotten a hold of the full article yet, but when stuff like this comes out, I really have to ask, why are we even attempting ETTs when we have good, reliable supraglotic airways? 



> A total of 108 intubated patients were studied. On arrival in the ED, *25% (27/108) of patients were found to have improperly placed endotracheal tubes.* Of the misplaced tubes, 67% (18/27) were found to be in the esophagus, whereas in 33% (9/27), the tip of the tube was found to be in the hypopharynx, above the vocal cords.


_Bolding mine_


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## Afflixion (Mar 10, 2011)

This is a good question, one common answer is that the ETT the best way to secure an airway. The rebuttal to that is the airway is not very well secured with the ETT in the esophagus. From what I've been reading here is that a lot of countries who have advanced EMS do not use ETTs rather they use LMAs and King LTs for the mot part. Even a large majority of anesthesiologists are using LMAs for short surgeries, as they place considerably less stress on the body and the vagal response is minimal compared to ETTs.


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## Shishkabob (Mar 10, 2011)

The problem isn't necessarily missed intubations, it's unnoticed missed intubations, which with things such as wave-form capnography, and, I don't know, actually doing a good assessment, it should be a thing of the past.

But, at the same time, I have to question how many were missed, and how many migrated during movement?


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## abckidsmom (Mar 10, 2011)

Should be and IS are so very, very different.  I spent some time reading the Wake County protocols this morning, and even though there were lots of accountability procedures built into the protocol, I have a hard time believing that everyone in the system is on that level of performance.

In my experience, it's the majority of medics out there who just do whatever they want and blame the urgent nature of the job or any random thing for their failure to follow specific patient-safety-inspired guidelines.  

I have NEVER seen an unrecognized misplaced ETT in a hospital.  I have seen many misplaced tubes that were always noticed and corrected immediately.  It's the lack of accountability and freelancing behavior.


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## WTEngel (Mar 10, 2011)

I would be interested in knowing the statistical breakdown by specific service too. If the breakdown of missed intubation by individual EMS service proved to be fairly uniform according to number of intubation attempts, then yes, you could say there is a larger issue. However, if the breakdown indicates that of the missed intubations, 80% were from one particular service, and the other 20% were distributed over the other services, then it isolates the issue a little more.

Intubation is a great tool for field personnel to use. Like all tools, it is one that needs to be used at the appropriate time, with appropriate technique, etc. In my mind the issue of missed intubations can be looked at in the larger context of how many of those patients actually needed intubation? If we are intubating patients who could be treated otherwise, then we are taking a huge risk without much benefit, which is a much worse problem in my opinion.

The bottom line is that it comes down to individual accountability. The individual paramedics are responsible for having the knowledge skills and abilities to be able to get intubations with 100% success rate (not necessarily first attempt.) Showing up with a misplaced tube is absolutely reprehensible. Medical directors need to be individually accountable also. If they are not providing the oversight and education, then the problem is just as much their fault as it is the individual provider. They have essentially created "cowboys" who intubate first, and ask questions later.

Too many providers look at intubation as a procedure without consequences. Even with perfect initial placement, the rate of complications suffered from filed ET tube placement is something that should be taken into consideration when making the decision to intubate. Like all things it should be weighed against the other risks, and factored into the benefit expected to be gained...and all this should happen in a matter of 2-3 seconds for the seasoned provider, right?


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## usalsfyre (Mar 10, 2011)

Linuss said:


> The problem isn't necessarily missed intubations, it's unnoticed missed intubations, which with things such as wave-form capnography, and, I don't know, actually doing a good assessment, it should be a thing of the past.



As abc notes, should be. Apparently by reading the blog post on this at Rogue Medic waveform capnography was available but not consistently used in this system. I've also seen medic argue that the capnography was "wrong" :blink: because they heard "breath sounds" that were actually transmitted from the abdomen.  



Linuss said:


> But, at the same time, I have to question how many were missed, and how many migrated during movement?



It's a legit question as far as identifying where the problem is, but in the end really doesn't matter. If we can't manage ETTs after correctly placing them we still don't need to be placing them. Anecdotaly I have a feeling that assuming a commercial holder and cuffed tube, the device is applied directly and it and the tube are reasonably dry and you disconnect the BVM for moves it would be difficult to displace the tube unless your moving the patient by the ETT.


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## usalsfyre (Mar 10, 2011)

abckidsmom said:


> In my experience, it's the majority of medics out there who just do whatever they want and blame the urgent nature of the job or any random thing for their failure to follow specific patient-safety-inspired guidelines.



I see this more and more (I'm sure it has always gone on, I'm just becoming more aware of it). And it pisses me off more and more each time. EMS has got to stop living in a "public safety not medicine cocoon". If an anesthetists did this we would consider it manslaughter.   



abckidsmom said:


> I have NEVER seen an unrecognized misplaced ETT in a hospital.  I have seen many misplaced tubes that were always noticed and corrected immediately.  It's the lack of accountability and freelancing behavior.



Tubes will be misplaced and displaced. It happens. The recognition and response is the difference.


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## ChorusD (Mar 10, 2011)

usalsfyre said:


> I really have to ask, why are we even attempting ETTs when we have good, reliable supraglotic airways?
> 
> 
> _Bolding mine_



LMAs and King LTs are really nice, especially in patients who have been fasting for 24 hrs. However, how many burn patients or cardiac arrests have you worked with patients that have no gastric contents?

The truth is that the ETT is the gold standard in airway protection for a reason.  Beyond that, it is definitely the paramedic's responsibility to ensure the tube is in place after placement and after pt movement and twice before turning over care to the ER.

my .02


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## usalsfyre (Mar 10, 2011)

WTEngel said:


> I would be interested in knowing the statistical breakdown by specific service too. If the breakdown of missed intubation by individual EMS service proved to be fairly uniform according to number of intubation attempts, then yes, you could say there is a larger issue. However, if the breakdown indicates that of the missed intubations, 80% were from one particular service, and the other 20% were distributed over the other services, then it isolates the issue a little more.


The the study even notes more data is needed to determine how wide spread the issue is. I'm working on getting a copy of the full study now. 



WTEngel said:


> Intubation is a great tool for field personnel to use. Like all tools, it is one that needs to be used at the appropriate time, with appropriate technique, etc.


Based on our discussions on here, I hope you realize we agree 100%



WTEngel said:


> In my mind the issue of missed intubations can be looked at in the larger context of how many of those patients actually needed intubation? If we are intubating patients who could be treated otherwise, then we are taking a huge risk without much benefit, which is a much worse problem in my opinion.


Probably a bigger and more pervasive problem, but it's not out and out killing patients. What's presented above is. 



WTEngel said:


> The bottom line is that it comes down to individual accountability. The individual paramedics are responsible for having the knowledge skills and abilities to be able to get intubations with 100% success rate (not necessarily first attempt.) Showing up with a misplaced tube is absolutely reprehensible. Medical directors need to be individually accountable also. If they are not providing the oversight and education, then the problem is just as much their fault as it is the individual provider. They have essentially created "cowboys" who intubate first, and ask questions later.


Unfortunately, EMS hasn't really shown themselves to be up to the task. What I've seen is vehemently defending intubation without much real reason other that "we've always done it" and ego ("nurses can't do this!"). Anyone who shows up with a dead patient that has misplaced tube and doesn't recognize it, with the modern technology commonly available, is guilty of involuntary manslaughter in my mind. 



WTEngel said:


> Too many providers look at intubation as a procedure without consequences. Even with perfect initial placement, the rate of complications suffered from filed ET tube placement is something that should be taken into consideration when making the decision to intubate. Like all things it should be weighed against the other risks, and factored into the benefit expected to be gained...and all this should happen in a matter of 2-3 seconds for the seasoned provider, right?


The problem is we don't have experienced providers doing it, and a lot of "experienced" providers don't know the complications because their exposure to medicine ends at the ED doors. 

I'm an advocate for paramedic advancement. However, sitting here, looking at this, along with a few things I've personally witnessed in the last year and a half, I can't say I would allow your average paramedic to intubate (no, not just RSI, placing ETTs period) if I was writing protocols. A subset of experienced medics with a good bit of additional education and strong oversight, sure. Joe Blow because he has a pulse and managed to "homeostase"(thanks Brown) his way through a medic program? No way in hell. The LMA and King LTs simply do too good of securing an airway. The fact that I'm starting to think this way scare the crap out of me, because where do we go from here?


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## usalsfyre (Mar 10, 2011)

ChorusD said:


> LMAs and King LTs are really nice, especially in patients who have been fasting for 24 hrs. However, how many burn patients or cardiac arrests have you worked with patients that have no gastric contents?


This is the kinda crap I'm talking about when we defend intubation. As Afflixion noted, how secure is an airway with the tube in the goose? 



ChorusD said:


> The truth is that the ETT is the gold standard in airway protection for a reason.


Who decided an ETT was the "gold standard"? What are the aspiration rates with LMA and King LTs in the non-NPO patient? What about rates with the variants of each that allow you to place gastric tubes? Do we even know? If your not placing OGs the benefit of having the "gold standard" is not nearly what you think. 



ChorusD said:


> Beyond that, it is definitely the paramedic's responsibility to ensure the tube is in place after placement and after pt movement and twice before turning over care to the ER.


What are the consequences in most systems for not doing this? For not using continuous waveform capnography? Like I said, Paramedics and EMS as a whole haven't shown to be up to the task.


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## boingo (Mar 10, 2011)

Is this a recent article?  There was a study published in Annals of Emergency Medicine 10 or 15 yrs ago that had somewhere around a 25% misplaced ETT rate, was out of Orlando, Florida.  

I can't imagine there is a medical director out there who would allow this to occur.


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## 8jimi8 (Mar 10, 2011)

Which device is safer for the pt?   

Can you think of any situations in which ETI is indicated while other devices are not?

At least this is a lesson I will not learn the hard way.


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## boingo (Mar 10, 2011)

8jimi8 said:


> Which device is safer for the pt?
> 
> Can you think of any situations in which ETI is indicated while other devices are not?
> 
> At least this is a lesson I will not learn the hard way.



Sure, asthmatics, COPD'ers, obese pts, burns, etc...anyone where the pressure required to ventilate them is likely to result in more air entering the esophagus than the trachea.


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## ChorusD (Mar 10, 2011)

usalsfyre said:


> This is the kinda crap I'm talking about when we defend intubation. As Afflixion noted, how secure is an airway with the tube in the goose?
> Okay I agree with the fact that the airway is not protected if the tube is in the esophagus.
> 
> Who decided an ETT was the "gold standard"? What are the aspiration rates with LMA and King LTs in the non-NPO patient? What about rates with the variants of each that allow you to place gastric tubes? Do we even know? If your not placing OGs the benefit of having the "gold standard" is not nearly what you think.
> ...





If it's better for our patients then I'm all for it.  But, I don't believe that there will never be a time when a patient needs an ETT. Like a burn pt or any other pt with laryngeal edema refractory to medication.

Sure, put the King LTs and LMAs on the trucks but don't remove the ETT.

Oh and just to be sure, I don't call your point of view crap so I would appreciate it if you would show me and others the same courtesy.  I'm willing to admit if I am wrong, my main purpose for reading this board is to learn not to try to prove you wrong.  The "rebuttals" I post aren't to that point, rather it's to further explore a topic and therefore learn more about it.


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## jrm818 (Mar 10, 2011)

boingo said:


> Is this a recent article?  There was a study published in Annals of Emergency Medicine 10 or 15 yrs ago that had somewhere around a 25% misplaced ETT rate, was out of Orlando, Florida.
> 
> I can't imagine there is a medical director out there who would allow this to occur.



This is that study.

I can't disagree with much of the discussion thus far, but really this study is lacking in a lot of ways.  If you manage to get the full text (PM me if you're can't get it easily) you'll see that really you don't get much more information than the abstract.  

It's unclear  how much colormetric versus waveform capnography was used, though it sounds like mostly colormetric.  The misses aren't really well characterized, except that they seem to have been detected by direct laryngoscopy (and I wonder how good of a "gold standard" this is).  It's not totally clear to me if it was residents or attending performing the laryngoscopy, and given that the authors started with a predisposed suspicion of high miss rates, I wonder about the risk of investigator bias in evaluating placement.

Similarly, and I see that rogue mentions this, tube dislodgement is possible during the final move from stretcher to hospital bed, and its not valid to attribute that to EMS error, when the EMS providers have no chance to re-evaluate placement prior to physician evaluation of the tube.  I also wonder if there is a chance of dislodgment during the manipulation that I"m sure occured to facilitate direct laryngoscopy for verification.

All that aside, I think we're left with a good chance that in this system there is actually pretty poor performance with ETI, but with a study that is far from definitive, and the generalizability of the results are certianly in question.  Actually a recent paper by Dr. Wang suggests that more current missed esophageal intubations occur at a miniscule rate: 1/1000 (the effect of waveform capnogrphy perhaps?  Or maybe a methodological error?).
http://www.ncbi.nlm.nih.gov/pubmed/21288624

Of course this Wang paper is retrospective from a national database, and so there are all sorts of potential errors, biases, etc.

As with much of Dr.Wang's papers, really it seems like the message from the Florida paper is that there are many systems in the US with poor performance with ETI.  That is no the same as saying that ETI should not be used in the prehospital setting, instead its a call to optimize your system's performance.  

What drives me nuts is that there are many authors who are concerned with prehospital ETI and spend much time and effort performing multiple retrospective studies which seem to imply a problem, yet we have to look to the other side of the world to get a prospective study of prehospital intubation.  I don't think that we even have a clear picture of the effectiveness of supraglottic airways versus ETI in a non-NPO field patient, and that seems to be a signifigant deficit in our knowledge.  

It seems to me that what is needed is a prospective randomized trial in a high performing system of ETI versus supraglottic versus BVM prehospitally.  I suppose that may be a pipe dream, but there is so much time and energy going into sub-optimal studies that I wish we could skip a few and combine the focus into a high quality study.


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## usalsfyre (Mar 10, 2011)

ChorusD said:


> I'd say the people who decided it was the "gold standard" are a group of people with a much more considerable amount of training, education, and experience than MOST, not all, of us here.


But WHO were they, and more importantly WHEN was this decided? Is it time to revisit this topic? Because I've heard "gold standard" parroted by every paramedic I've known for 10 years now, with very little understanding of what that means.  



ChorusD said:


> Do you mean the aspiration rates of an LMA when it's placed in patients with no contraindications? Those contraindications, from what I have read, include patients who are not NPO.


Fair, but your talking about contraindications used in the anesthesia setting, not for emergency airway control.  



ChorusD said:


> If it's better for our patients then I'm all for it.  But, I don't believe that there will never be a time when a patient needs an ETT. Like a burn pt or any other pt with laryngeal edema refractory to medication.


Certainly agree with you there. However, is the number of these patients greater than the number of patients who are killed/have a more complicated clinical course by missplaced and inappropriate ETTs? Because we have to focus somewhat on what's better for the patients as a whole. 



ChorusD said:


> Sure, put the King LTs and LMAs on the trucks but don't remove the ETT.


If it can't be done effectively and well by paramedics, why are we putting patients at risk of a half-@ssed provider mucking it up?



ChorusD said:


> Oh and just to be sure, I don't call your point of view crap so I would appreciate it if you would show me and others the same courtesy.  I'm willing to admit if I am wrong, my main purpose for reading this board is to learn not to try to prove you wrong.  The "rebuttals" I post aren't to that point, rather it's to further explore a topic and therefore learn more about it.


I'm sorry if this offended you. I'm not saying your full of crap. Looking at your info, it appears your a student, so I have a feeling you're repeating what's been taught to you so far in your career. The honest truth is many EMS providers arguments for or against a particular issue ARE crap. There full of anecdotes, logical fallacies and tradition. If more people are being harmed by endotracheal intubation than helped by it it needs to be pulled. Keeping it on the truck "just in case" means that skill will likely be so degraded by the time you need to use it it will be worthless anyway. There were probably people helped by blood letting and lobotomies too. However, the harm far outweighed the good.


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## usalsfyre (Mar 10, 2011)

My bad on citing an old study. The new question is, have we improved enough in the ensuing 10 years that this is a non-issue? My personal feeling is no, but I'd like to see what y'all think.


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## abckidsmom (Mar 10, 2011)

usalsfyre said:


> My bad on citing an old study. The new question is, have we improved enough in the ensuing 10 years that this is a non-issue? My personal feeling is no, but I'd like to see what y'all think.



In the systems I see (1 busy urban system 3rd service system, 1 busy suburban fire-based system, and 1 rural, combination career/volunteer fire-based system) there is improvement from 10 years ago, but I think that primarily comes from backup airways.  People are not hesitant to pull the tube and drop a King.

Like you, I would like to see a study about whether the alternative airways really "count" and make any improvement in patient outcomes.


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## 8jimi8 (Mar 10, 2011)

boingo said:


> Sure, asthmatics, COPD'ers, obese pts, burns, etc...anyone where the pressure required to ventilate them is likely to result in more air entering the esophagus than the trachea.




Then we cannot take away ETI.


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## MrBrown (Mar 10, 2011)

Barely homeotasasing looser cookbook medics perhaps?


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## usalsfyre (Mar 10, 2011)

boingo said:


> I can't imagine there is a medical director out there who would allow this to occur.



I think there's probably some that don't know it's occurring. 



boingo said:


> Sure, asthmatics, COPD'ers, obese pts, burns, etc...anyone where the pressure required to ventilate them is likely to result in more air entering the esophagus than the trachea.


Again, do these outnumber the number of patients harmed from misplaced and inappropriate ETTs? Put another way, "is the juice worth the squeeze" in our current practice? Because changing education and experience requirements is proving to be a glacial process.


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## systemet (Mar 10, 2011)

usalsfyre said:


> The honest truth is many EMS providers arguments for or against a particular issue ARE crap. There full of anecdotes, logical fallacies and tradition. If more people are being harmed by endotracheal intubation than helped by it it needs to be pulled.



This is awesome.  I could not agree more.  

The following commons are general, and not directed at usalsfyre.  I will likely perpetuate the tradition of anecdote, logical fallacy, and err.... tradition! 

I think there's a few issues that come up when paramedic ETI is discussed.

(1) Intubation success rates are not as meaningful a metric as they first appear.  They don't describe how the intubation was performed.  If I take five minutes on my first laryngoscopy, I'm much more likely to end up with the tube in the trachea than if I take 30 seconds.  This doesn't mean my patient will be better for it.

(2) Unless there's been a large amount of recent research that I'm not aware of, the population of airways seen prehospitally hasn't been adequately characterised.  It seems reasonable that EMS patients might be more difficult to intubate.  This could mean that there's a greater risk or benefit (or both) to intubating these patients.

(3) Paramedics in the literature are seen as a homogeneous group, despite the fact that training hours, OR time, intubation frequency, QI, agents used, operator experience, etc.  vary across the world.  It may not be valid to generalise results from one region to another. 

(4) As another poster pointed out, many of the studies that show poor performance by paramedics have been performed in systems that lack (vital) equipment such as waveform capnography.  

The existing studies that I've seen have been deficient in some manner with regard to (1)-(4).  This doesn't mean they're worthless, and it's not going to stop physicians from drawing conclusions from them.  One of the things that scares me about evidence-based medicine, is at what point is the evidence that a therapy may be harmful enough to remove it's use?  What is the risk of removing a genuinely beneficial intervention?  

I should also add, that I don't think placing a tube in the esophagus is a particularly bad crime.  It's better not to, but it's forgivable, to a point.  It's not recognising that the tube is misplaced (often through hubris and unwillingness to use the available confirmation tools on a routine basis) that's criminal.


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## Veneficus (Mar 10, 2011)

usalsfyre said:


> Anecdotaly I have a feeling that assuming a commercial holder and cuffed tube, the device is applied directly and it and the tube are reasonably dry and you disconnect the BVM for moves it would be difficult to displace the tube unless your moving the patient by the ETT.



It has been my experience that gause and shoe strings actually work better than commercial devices.

As for the missed intubations, I think the problem is simply poor skill and poor oversight.

I have written at length on the faults of medical direction so I will not reproduce it here,  but in short, any medics not getting at least 12 tubes a year should not be intubating anyway.

Harder in the field and all the other excuses are just that. Excuses. Proficency builds speed, speed does not build accuracy. If you don't have time or the environment to place an airway then an airway should not even be attempted.

There is even a problem going back to training. Most paramedic students spend way too much time intubating Fred the head and no time intubating people. Nobody would think of letting somebody perform surgery who only ever operated on a simulator. Why do we let paramedics intubate who have only done it on a simulator?


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## boingo (Mar 10, 2011)

The problem isn't the ET tube, it is the experience and skill of the provider.  Fix the education and experience gap, fix the problem.  

The problem of experience is a very real one.  If you work in a system that is all ALS, you are likely to see way more non acute patient than acute ones, v.s. the tiered system where paramedics are sent to only high priority calls and see a large number of very sick people.  

I've been at work for 7 hours today and have taken 3 patients to hospital, first one was a 74 yo F 2 days s/p stent placement in her esophagus who presented in respiratory failure w/runs of v-tach that ended up on CPAP and an Amio drip, the second was a 60 yo M w/failed AICD in v-tach without a palpable pressure and SOB w/RR of 40, cardioverted into NSR, and the third was a 23 yo obese F status asthma w/EtCO2 of 101 and SpO2 less than 50, RSI'd and transp w/Epi, Mag drip, parayzed, sedated and on a vent.  

If you are running those kinds of calls on a regular basis you are likely to stay sharp.  If you are running *** aches and psychs all shift, you might get a bit rusty on the when's, how's and if's of advanced airway management.  Just my opinion.


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## boingo (Mar 10, 2011)

Veneficus said:


> It has been my experience that gause and shoe strings actually work better than commercial devices.
> 
> As for the missed intubations, I think the problem is simply poor skill and poor oversight.
> 
> ...



What he said ^^^


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## systemet (Mar 10, 2011)

Here's the citation:

Katz SH, Falk JL.  Misplaced endotracheal tubes by paramedics in an urban emergency medical services system.  Ann Emerg Med. 2001 Jan;37(1):32-7.  PMID: 11145768

Of course, it would be grossly inappropriate to share .pdfs of copyrighted material, but if anyone wants to send me a pm, I might be able to help them find a copy.


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## usalsfyre (Mar 10, 2011)

systemet said:


> I should also add, that I don't think placing a tube in the esophagus is a particularly bad crime.  It's better not to, but it's forgivable, to a point.  It's not recognising that the tube is misplaced (often through hubris and unwillingness to use the available confirmation tools on a routine basis) that's criminal.



I agree with this statement completely. There's nothing wrong with missing. The biggest, baddest MF'er of an anesthesiologist is occasionally going to miss one. The difference is they're not likely to declare the machine wrong, the tube is good "because I said so" and proceed to ventilate the gastric tract right into cardiac arrest.


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## Smash (Mar 10, 2011)

Unrecognised oesophageal intubations are not the problem, they are just a symptom.  Normally I would suggest fixing the underlying problem first, then the symtpoms would resolve.  However it seems that this may not be possible in some places, so symptom control may sadly be required.


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## 18G (Mar 10, 2011)

If your using wave-form capnography I really have no clue why there would be ne misplaced tubes. Its quite clear to see with EtCO2 and the other confirmatory measures when the tube is where it needs to be. 

The new PA 2011 protocols further addressed this by stating "CONTINUOUS" waveform capnogrpahy. 

Providers should be checking lung sounds and tube depth after every move.


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## jjesusfreak01 (Mar 11, 2011)

abckidsmom said:


> Should be and IS are so very, very different.  I spent some time reading the Wake County protocols this morning, and even though there were lots of accountability procedures built into the protocol, I have a hard time believing that everyone in the system is on that level of performance.



We have the airway audit form, but I think the best thing is going to be that ETCO2 is such a useful tool for the code commander that they aren't going to go that long before putting it on, which will give immediate confirmation of placement when that's done, even if initial confirmation wasn't done correctly (or at all).


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## Aidey (Mar 11, 2011)

18G said:


> If your using wave-form capnography I really have no clue why there would be ne misplaced tubes. Its quite clear to see with EtCO2 and the other confirmatory measures when the tube is where it needs to be.






usalsfyre said:


> I've also seen medic argue that the capnography was "wrong" :blink: because they heard "breath sounds" that were actually transmitted from the abdomen.



Been there, seen that. EtCO2 read 7mm/hg for about 2 breaths before erroring for the rest of the transport. The medic who intubated said our machine must have been defective. :wacko:


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## MrBrown (Mar 11, 2011)

Smash said:


> Unrecognised oesophageal intubations are not the problem, they are just a symptom.  Normally I would suggest fixing the underlying problem first, then the symtpoms would resolve.  However it seems that this may not be possible in some places, so symptom control may sadly be required.



Gosh Brown loves Smash to bits, Frank Archer would be so proud B)

Hang on, at the risk of Mrs Brown seeing this, Brown still loves Mrs Brown too.

Its interesting to note that we don't have problems with intubation here, as Brown is sure you do not in fact we have excellent success with RSI.

Brown proclameth loudly the problem is NOT with intubating, its the people who are doing the intubating.


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## M3dicDO (Mar 11, 2011)

I'm probably repeating what some people may have already stated in one way or another. Airway management is one absolute skill that any EMT (Basic, Paramedic or Critical Care) should be good at. Whether it's a simple jaw thrust or a retrograde intubation, they are all life-saving procedures. I have made a condensed list of issues that I seen over and over again, on reasons why airway management fails in the hands of Paramedics in the field, especially ETT placement:

They are scared of performing an invasive procedure
They fail to properly assess initial ETT placement
They fail to continually re-assess ETT placement during transport
If you think about it, intubation is really not a difficult skill. I agree that it takes time and experience to master it, but this is where I think most EMS systems have issues with. Paramedics simply aren't given the proper resources to master intubation. Around the Chicagoland area, Paramedics actually begin their careers on the wrong foot! Intubation is taught by instructors who probably never intubated in the field (i.e. ER nurses) and the anesthesiologists are scared to allow students to perform an intubation all by themselves. I know of a hospital where Anesthesiologists hold the laryngoscope while the student passes the tube. C'mon!

And don't get me started on continuing education. I know of medics that probably intubate once every 5 years, and they are horrible at it. It's not because they do it occasionally, but a real person isn't like the mannequin you practice in the classroom. Most systems do not have any programs that allow practicing Paramedics to go back in to the OR and intubate  *a real human being*.

I could go on and on, but to keep it short, the only thing I can say is that EMS training has lot more room for improvement. Sure you can bring new technologies to help make airway management easier, but you have to realize that airway management has been around for much longer than the end-tidal CO2 monitor on your LifePack! Bottom line is, practice, practice, practice. If your EMS systems is poor in keeping up your skills in airway management, demand it! It is ultimately your responsibility to provide your patients with the best care they deserve. By that I do not mean acquiring ongoing traces of the ETCO2 waveform, but rather doing a simple initial and ongoing BLS airway assessment: look at the patient, auscultate and observe. That's it!


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## Shishkabob (Mar 11, 2011)

Aidey said:


> Been there, seen that. EtCO2 read 7mm/hg for about 2 breaths before erroring for the rest of the transport. The medic who intubated said our machine must have been defective. :wacko:



To be fair, I've actually had capnography stop working during my last code.  Other medic placed the tube, I confirmed with sounds, and we had EtCO2 return for a fair amount of time... than it just errored out.  

We reconfirmed via visual and sounds, but had no CO2 for the rest of the code despite all of our fiddling except for some random moments where we'd get a decent reading.


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## Aidey (Mar 11, 2011)

Did you also have thick orange goo coming out of the tube along with the guy having a huge belly?


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## Shishkabob (Mar 11, 2011)

Nope.


Luckily the guy was skinny enough that we would be able to see if air actually went gastrically-ish.



Trust me, it wasn't even my tube and I made damn sure it stayed in place the whole time as if it WAS my baby.


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## abckidsmom (Mar 11, 2011)

Aidey said:


> Been there, seen that. EtCO2 read 7mm/hg for about 2 breaths before erroring for the rest of the transport. The medic who intubated said our machine must have been defective. :wacko:



Not to show an over-reliance on technology, but did you consider changing out the probe, suctioning the patient, cleaning out the port where the ETCO2 monitor plugs in, or rebooting the monitor?

Troubleshooting.  I find EMS equipment to be designed to be fairly failsafe.  Usually when troubleshooting "equipment failures" we find user error.

Just saying, in case someone reads this and identifies with the monitor failure.


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## Aidey (Mar 11, 2011)

We suctioned but beyond that no, because all clinical indicators were that the tube was in the wrong spot. It was a bad tube, the EtCO2 just helped confirm it. Even at the hospital after the MD had yanked the tube the medic who intubated was like "Hmmm, why did they pull a good tube?.


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## Melbourne MICA (Mar 11, 2011)

*ETT forever*

Unrecognised oesophogeal intubations usually means dead patients. Failed intubation drills and multiple cross checks with end tidal respiratory waveform on insertion should mean high success percentages for ETT. If all else fails an ETT is pulled and basic airway management is applied.

If the practitioner is well educated and trained, gains experience under guidance from senior staff there should be no reason for airway management techniques to be stuffed up on so many occasions. The issue of audit by senior clinicians also comes into it. Here, if you make a mistake , revision is required. If you stuff up big time - its back to square one. Your accreditation is pulled and you have to do all the training again. This includes theatre time, prac scenarios, theory testing and final sign off. If you stuff up big time again don't bother expecting to ETT anyone. That means no drug assisted intubations or perhaps even no cold tubes as well.

If so many staff are stuffing it up you have to wonder if they were, as a group, actually up to doing the procedures in the first place.

EMS Intensive care Paras don't need bad publicity like that. The neocons of medicine want any excuse to dumb down our skills. 

As for the value of ETT itself - this has been well covered by others.

MM


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## DrParasite (Jan 29, 2018)

bumping an old thread just because I thought it was an interesting topic


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## NPO (Jan 31, 2018)

DrParasite said:


> bumping an old thread just because I thought it was an interesting topic


I'm hoping we have improved equipment and technique enough to engineer out SOME of the failures. As video laryngoscopy and tube inducers become more common-place, I'd hope we would see numbers rise.

I understand the counter argument for a SGA, and I am quick to set down the laryngoscope for an alternative airway when I don't think I'll have quick success with the ETT, but I think we need to have the ETT as an option for definitive airways.


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## VentMonkey (Jan 31, 2018)

Our company’s medical director is getting ready to release a case exemplifying when, in fact, an ETT should still be utilized over, say, a SGA or BLS airway.

Honestly, I think it’s kind of sad that we need to do this kind of handholding. Then again, it’s nothing really new, or groundbreaking that most ALS providers really aren’t all that advanced when it comes to their critical thinking abilities, and that is the real shame.

As @NPO mentioned, many of the equipment and technology that wasn’t available 8 or so years ago as commonly in EMS has hopefully proven their merit.

Sadly, without understanding anythings value I still doubt we’ll appreciate its worth. There’s no value in a skillset without a worthy approach to your thinking abilities in a time-critical situation.


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## MSDeltaFlt (Jan 31, 2018)

Maybe I'm too old school to truly appreciate some clinicians' issue(s) with airway management especially when it regards endotracheal intubation.  Because I have noticed over the years that more and more clinicians (paramedics, nurses, respiratory therapists, etc.), both old and new, that are showing low or decreasing success rates on intubating their patients' trachea are relying more and more on technology to secure the airway and focusing less and less on basic skill and training.

Don't get me wrong. I'm all for technology and equipment that can secure an airway.  But the one thing that will save your patient's life more than technology and equipment is the clinician's brain.  The best paramedics have strong EMT skills, or more accurately, strong basic skills.

This is very prominent with airway management.  The trick to being a paramedic is not in knowing what to do and how to do it.  That's easy.  Any moron can be taught that.  The trick, ladies and gentlemen, is being able to do something and knowing when and when NOT to do it and HOW.  And that requires the one thing that cannot be taught.  That takes experience.

You may have all the nice and neat little toys money can buy.  But if you lack the proper technique then you will fail.  And failing at airway management tends to result in you not delivering to the hospital and viable patient, but instead a cadaver.  That also includes in securing the cotton picking things.  You may be able to insert it into the trachea with no problem:  Grade 1, 2, 3, even a grade 4 airway like it's nobody's business.  But if it is not secure then it can and most likely will come out.  Increasing the likelihood of the aforementioned cadaver delivery.

Mechanical tube holders are not the be all end of airway security.  Not having any weight attached to the ETT on moving the patient from scene to cot and then from cot to ER stretcher also helps but even that might not be all there is to aiding in ensuring their not migrating out of the trachea.  Full C-Spine precautions aid a great deal.  Not only does the spine board aid you in moving patient from point to point.  But the C-collar/head bed/etc. also help.  The less the head and neck move the less the ETT moves.  The less the ETT moves the less it will migrate.

Also, slow your roll.  I tell all my new partners that there are only 4 reasons I can think of where vehicle velocity over the posted speed limits will ever be requested by me are:

1. Patient is running out of time: STEMI/CVA.
2. I am running out of oxygen.
3. I am running out of cardiac monitor battery power.
4. I am running out of medications

Outside of those 4, the speed limit (even lights and sirens) is plenty fast enough.

So in closing.  There are only three things needed for ANY airway management:

1. Technique

2. Situational awareness.

3. Ooh-sah.

Good day


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## VFlutter (Jan 31, 2018)

We have proven that Pre-Hospital ETI can be done well with great first pass success and minimal complications when preformed by the right providers. These groups (CC/HEMS) are composed of experienced and highly motivated individuals with frequent exposure to intubations and extensive continuing education/training requirements. We need to challenge the idea that every paramedic should be intubating. Every medic should be an airway expert sans intubation with access to a select group of highly trained providers capable of RSI if needed. 

I completely agree with mastering the basics and not relying solely on technology however I think the time is quickly approaching for video laryngoscopy to be the standard of care.


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## EpiEMS (Jan 31, 2018)

@VFlutter, it seems to me that most of the western world has adopted the approach you’ve articulated - and I agree with it, FWIW. There’s too much downside risk for ETI to be in Joe EveryMedic’s toolbox.


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## DrParasite (Feb 1, 2018)

VentMonkey said:


> Our company’s medical director is getting ready to release a case exemplifying when, in fact, an ETT should still be utilized over, say, a SGA or BLS airway.


such as, say, burns to the airway?

I know NJ NJ paramedics used to ETT every cardiac arrest.  now in NC, we SGA almost all of them, and often the FD does it before EMS gets there. if we get ROSC back, the medic might intubate.  So I trust almost every NJ medic with being able to intubate on the first attempt.... because they do it regularly (think 2+ times a week) on live patients.


MSDeltaFlt said:


> Full C-Spine precautions aid a great deal.  Not only does the spine board aid you in moving patient from point to point.  But the C-collar/head bed/etc. also help.


True story: I added a C-collar to our EMS bag, for that very reason.  I was taught to always apply a collar for the exact reasons you specify, and our collars aren't accessible from inside the ambulance.The next shift it was taken out because "if we brought a patient to the hospital (which was a trauma center) who was intubated and had a collar applied, the ER would get confused and think it was a trauma, and want to know why we didn't activate a trauma alert."   


MSDeltaFlt said:


> Also, slow your roll.  I tell all my new partners that there are only 4 reasons I can think of where vehicle velocity over the posted speed limits will ever be requested by me are:
> 
> 1. Patient is running out of time: STEMI/CVA.
> 2. I am running out of oxygen.
> ...


you wouldn't include your patient is bleeding out, and you can't replace the blood on the floor of your ambulance in your patient so he needs a trauma surgeon to fix the hole?





VFlutter said:


> Every medic should be an airway expert sans intubation with access to a select group of highly trained providers capable of RSI if needed.


Interesting idea.... do you think it should be removed from the paramedic education curriculum?  After all, if not everyone can or should be able to do it, why force everyone to learn and be evaluated on it?

One thing that frustrates me is being taught something, being evaluated and successfully passing the evaluation, and having it in state "scope of practice" and then being told that I can't do it, even though based on my education, it would be beneficial to the patient.


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## Bullets (Feb 1, 2018)

I think part of this is a result of the type of system. As @DrParasite alluded, in a tiered system like NJ, medics are only going to the worst calls, so their encounters are usually more acute, and their intubation attempts are more frequent as they are only dealing with really sick people. In a system where a medic is on every truck, what percentage of the patients they encounter are true ALS treats? then what smaller percent need an advanced airway?

@VFlutter says that HEMS and CC have good success rates for this very reason. They only see very sick people, thus their opportunity to intubate against their total call volume is much high.

As long as we are forcing medics to treat BLS and not giving them opportunity to practice outside the field then it will lead to skill degradation.


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## MSDeltaFlt (Feb 1, 2018)

DrParasite said:


> you wouldn't include your patient is bleeding out, and you can't replace the blood on the floor of your ambulance in your patient so he needs a trauma surgeon to fix the hole?



That would fall under category number one.


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## Tigger (Feb 1, 2018)

Bullets said:


> I think part of this is a result of the type of system. As @DrParasite alluded, in a tiered system like NJ, medics are only going to the worst calls, so their encounters are usually more acute, and their intubation attempts are more frequent as they are only dealing with really sick people. In a system where a medic is on every truck, what percentage of the patients they encounter are true ALS treats? then what smaller percent need an advanced airway?
> 
> @VFlutter says that HEMS and CC have good success rates for this very reason. They only see very sick people, thus their opportunity to intubate against their total call volume is much high.
> 
> As long as we are forcing medics to treat BLS and not giving them opportunity to practice outside the field then it will lead to skill degradation.


If we did not send a paramedic on every call in our area paramedics would never make it on scene to make any sort of difference if requested by BLS. If we aren't responding immediately, the geographic limitations make having a tiered system challenging, and I am not sure I am willing to trust EMD when the consequences could be a half hour more. Much of America is too vast to truly benefit from tiered systems.


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## VFlutter (Feb 1, 2018)

Frequent opportunities to intubate definitely helps with maintaining competency however it is not the only factor. Our pediatric first pass intubation rate,  although worse than our adult, is still much better than the average even though it's a very low frequency. Most providers are lucky to see one a year. However it is heavily trained and simulated. So I do not think low volume is an excuse for poor performance. Just like all other Low Frequency / High Risk procedures (Surgical Cric, Eschartomy, etc) you are expected to perform correctly regardless of how frequently you encounter it.


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## Bullets (Feb 1, 2018)

VFlutter said:


> However it is heavily trained and simulated.


This is they key. I suspect this isnt the case for many providers.


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## EpiEMS (Feb 1, 2018)

Tigger said:


> If we did not send a paramedic on every call in our area paramedics would never make it on scene to make any sort of difference if requested by BLS. If we aren't responding immediately, the geographic limitations make having a tiered system challenging, and I am not sure I am willing to trust EMD when the consequences could be a half hour more. Much of America is too vast to truly benefit from tiered systems.



I would agree, that in your context, all ALS might make sense. But for most of the country's population - i.e. urban & suburban areas - tiered systems are definitely more efficient, no?


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## Tigger (Feb 2, 2018)

EpiEMS said:


> I would agree, that in your context, all ALS might make sense. But for most of the country's population - i.e. urban & suburban areas - tiered systems are definitely more efficient, no?


Probably will better trained "BLS" providers. A big part of being a paramedic is recognizing the "subtly sick" and our current EMTs don't really have the ability to recognize this. Sure in urban areas you're probably not that far from a hospital and just taking them to a hospital won't result in a poor outcome most of the time. Except for when it does and the patient needed someone able to deliver an "advanced" assessment and invasive but life sustaining treatments 20 minutes ago but nobody noticed. Or the wrong patient gets has a refusal done. To me it all comes down to "you don't know what you don't know" and it seems that tiered systems probably don't deliver paramedics to patients that could have benefited more often than we probably know. 

My view is certainly clouded by personal experience of working someplace with all P/B or P/P ambulances. But man, we still see it with BLS first responders. We have a pretty good countywide agency education system here but exposure matters. Many of the BLS folks just don't know what a compensating patient looks like. They're very good about ensuring that the sick sick patients get paramedics quickly, but not so good with the middle of the spectrum sick patients. This is career and volunteer places mind you, it seems to transcend all the groups.


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## VentMonkey (Feb 2, 2018)

@Tigger I agree with you, but would you also agree that many paramedics suffer from this same exact affliction?


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## E tank (Feb 2, 2018)

VFlutter said:


> I completely agree with mastering the basics and not relying solely on technology however I think the time is quickly approaching for video laryngoscopy to be the standard of care.



Maybe not...

http://www.annemergmed.com/article/S0196-0644(17)30878-8/fulltext


This Cochrane analysis finds that first pass success on known difficult airways is improved with VL, but not with non-difficult airways, which are the vast majority.


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## Tigger (Feb 3, 2018)

VentMonkey said:


> @Tigger I agree with you, but would you also agree that many paramedics suffer from this same exact affliction?


No doubt there are many paramedics who don't recognize sick patients that are also slapping them in the face. But paramedics are (should be?) trained to recognized these patients. EMTs are not. So at the very least the argument can be made that the agency/AHJ is failing when paramedics miss the occult sick patient because _they should know better _and not the education itself. Whether that plays out is dependent on where you are, here (the largest combined EMS medical direction system in Colorado), you will be at least taken to task for your inobservance.


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## Carlos Danger (Feb 3, 2018)

E tank said:


> Maybe not...
> 
> http://www.annemergmed.com/article/S0196-0644(17)30878-8/fulltext
> 
> This Cochrane analysis finds that first pass success on known difficult airways is improved with VL, but not with non-difficult airways, which are the vast majority.



But is the fact that VL doesn't help in most airways really an argument for it not being used routinely, at least by "occasional intubators"?

Considering that difficult airways are hard to predict - especially by folks who don't intubate every day - and considering that there's no downside to using a VL when it you probably don't need it, it seems reasonable to me that they would be used routinely.


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## E tank (Feb 3, 2018)

Remi said:


> But is the fact that VL doesn't help in most airways really an argument for it not being used routinely, at least by "occasional intubators"?
> 
> Considering that difficult airways are hard to predict - especially by folks who don't intubate every day - and considering that there's no downside to using a VL when it you probably don't need it, it seems reasonable to me that they would be used routinely.



No argument. But "standard of care"? Especially because, so far at least, VL doesn't seem to be any different when you "don't need it" for first pass success.


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## EpiEMS (Feb 5, 2018)

Tigger said:


> Many of the BLS folks just don't know what a compensating patient looks like. They're very good about ensuring that the sick sick patients get paramedics quickly, but not so good with the middle of the spectrum sick patients. This is career and volunteer places mind you, it seems to transcend all the groups.





Tigger said:


> But paramedics are (should be?) trained to recognized these patients. EMTs are not.


Fair points, for sure.

In my mind, the solution is single medic ALS fly cars. Medic assesses and triages to BLS, goes back to help out the next BLS ambulance. Or rides in, one of the EMTs drives the fly car along to the hospital. Alternatively, you can leave it and have somebody pick it up.


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## medicsb (Feb 5, 2018)

Tigger said:


> Probably will better trained "BLS" providers. A big part of being a paramedic is recognizing the "subtly sick" and our current EMTs don't really have the ability to recognize this. Sure in urban areas you're probably not that far from a hospital and just taking them to a hospital won't result in a poor outcome most of the time. Except for when it does and the patient needed someone able to deliver an "advanced" assessment and invasive but life sustaining treatments 20 minutes ago but nobody noticed. Or the wrong patient gets has a refusal done. To me it all comes down to "you don't know what you don't know" and it seems that tiered systems probably don't deliver paramedics to patients that could have benefited more often than we probably know.



There's another side where a paramedic "over treats" and causes a poor outcome or adverse event when a expedient ride would have been more than enough.  I think one could argue that in an all-ALS system, there are a greater proportion of patients harmed by paramedics than in tiered systems.  And certainly, in tiered systems, there are some patients who are harmed by lack of a paramedic.  The question is which is more - more harmed by medics in all ALS, or more harmed by lack of medics in tiered.  (For sure, one would have to consider the harms by medics in tiered, and the harm by lack of medic treatment in all-ALS.)


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## DrParasite (Feb 6, 2018)

Tigger said:


> Probably will better trained "BLS" providers. A big part of being a paramedic is recognizing the "subtly sick" and our current EMTs don't really have the ability to recognize this. Sure in urban areas you're probably not that far from a hospital and just taking them to a hospital won't result in a poor outcome most of the time. Except for when it does and the patient needed someone able to deliver an "advanced" assessment and invasive but life sustaining treatments 20 minutes ago but nobody noticed.


please elaborate why EMTs don't have the ability to recognize subtly sick patients.  and EMT's assessment and a paramedic assessment should be pretty similar; the exception is a paramedic assessment includes a cardiac monitor. What is this "advanced assessment" you are talking about?  I agree that a paramedic can give an advanced intervention, but if the paramedic is going to perform a "advanced assessment" and then do the state of life on the way to the hospital, how beneficial is that advance assessment?  And more accurately, why can an EMT not do this advanced intervention?  

And if the EMTs missing these subtly sick patients, why have no studies shown this?  There have lots of anecdotal stories, and a lot of emotional theories (those EMTs are killing people because they don't know what they don't know), but I haven't seen any EBM, any successful lawsuits, or any actual facts supporting this claim.


Tigger said:


> My view is certainly clouded by personal experience of working someplace with all P/B or P/P ambulances. But man, we still see it with BLS first responders. We have a pretty good countywide agency education system here but exposure matters. Many of the BLS folks just don't know what a compensating patient looks like. They're very good about ensuring that the sick sick patients get paramedics quickly, but not so good with the middle of the spectrum sick patients. This is career and volunteer places mind you, it seems to transcend all the groups.


If your EMTs are only spending 10 minutes with the patient, and than handing off to EMS, than they aren't really doing EMS (despite what may career firefighters like to think).  

In fact, in my experience, it is rare to see a firefighter who is a good EMT, with the exception of those who spent time on the ambulance before they started with the FD.  As you said, they just don't get the exposure to EMS, except for the first 10 minutes.  Ditto your P/B ambulances; if you always have a paramedic telling you what to do, and always have a paramedic to fall back on, can you see why they might not function as well independently?

My view is, of course, clouded by my personal experience of working on a B/B ambulance in both urban and suburban areas, with a P/P intercept vehicle as needed, as well as working on a B/P truck and an EMT on a first response vehicle.


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## VFlutter (Feb 6, 2018)

I would hope that a paramedic with more, albeit still woefully inadequate, education in anatomy and physiology would have a better understanding and assessment of subtly sick and marginally compensated patients then an EMT with 3 months of education. But maybe I'm just being condescending.


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## DrParasite (Feb 6, 2018)

sure sure sure longer courses = more education = better understanding and better assessment of subtly sick. That's the theory

In theory, a paramedic would have a better understanding of sick vs not sick, at least compared to a nurse.  in theory, a nurse would have a better understanding of sick vs not sick, at least compared to a nurse.  and in theory, a doctor would have a better understanding of sick vs not suck, at least compared to a nurse.  And I agree with the theory.

but is there any evidence that the theory is true?  have there been any studies?  have there been any successful lawsuits, based on the chronic death and disabilities that resulted from these poor assessments?   I would imagine if it was a systemic problem, the court system would be full of them.

I agree, more education is better.  But where is the factual support, other than the belief that "more education is better" and "EMTs are grossly unqualified to perform patient assessments; lets ignore the evidence that at least two states, and several major cites use ambulances with 2 EMTs as the people who treat and transport the majority of their EMS patients."


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## RocketMedic (Feb 6, 2018)

VFlutter said:


> We have proven that Pre-Hospital ETI can be done well with great first pass success and minimal complications when preformed by the right providers. These groups (CC/HEMS) are composed of experienced and highly motivated individuals with frequent exposure to intubations and extensive continuing education/training requirements. We need to challenge the idea that every paramedic should be intubating. Every medic should be an airway expert sans intubation with access to a select group of highly trained providers capable of RSI if needed.
> 
> I completely agree with mastering the basics and not relying solely on technology however I think the time is quickly approaching for video laryngoscopy to be the standard of care.



The flipside of this argument is that the intubation-capable population of paramedics plummets and now people who need tubes might have to wait for them.

As for the "why" of ETT- I think that it is primarily because we cannot conclusively say that there isn't a good way to replace them.


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## VFlutter (Feb 7, 2018)

RocketMedic said:


> The flipside of this argument is that the intubation-capable population of paramedics plummets and now people who need tubes might have to wait for them.
> 
> As for the "why" of ETT- I think that it is primarily because we cannot conclusively say that there isn't a good way to replace them.



My rebuttal would be that patients that truly need emergent intubation are probably less common than we assume and many can be managed by other means until a RSI medic arrives or you get to the ER.

The way we have it now with all medics intubating we have more access but poentially less competence. 

There are a lot of low volume / high risk procedures that are time critical and potentially life saving (I.e pericardiocentesis) that don' have an alternative however I do not think that in and of itself is justification for them.


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## medicsb (Feb 7, 2018)

ETI is associated with harm or equivocal outcomes.  The best study showing benefit was the one out of Australia that barely reached statistical significance.  There have been a few retrospective studies showing benefit (one out of King Co.), but they have their drawbacks.  Generally, most patients can wait to arrival at the hospital.  If prehospital ETI is going to be performed it should be by someone who has had good training and relatively frequent experience on live humans, and the only way to do this reliably is to greatly reduce the number of paramedics.  Though some services can try and make up for lack of experience with OR time, most places can't do that and those that have that could lose it pretty easily.  And those services that have OR experience, they could either eliminate it or greatly reduce it, if the number of paramedics was reduced

As far as other low frequency, high risk procedures, I'd argue that their not actually high risk.  Can't intubate, can't ventilate?  The patient dies.  A cric may save them (great benefit), but if it fails then the outcome is the same as if you didn't perform it.  In many instances of prehospital ETI, we know that the overwhelming majority will survive to hospital arrival with a BVM or supraglottic airway.  Intubating has the potential in itself to harm the patient and render them worse than that which was the indication for intubation.  With cric or pericardialcentesis, death is imminent, and a botched cric or pericardialcentesis does not actually make the original situation worse (unless your assessment was wrong).


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## RocketMedic (Feb 7, 2018)

It is less invasive and less of a cultural barrier to place an ETT than to crike someone, and quite frankly, we might as well keep both.


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## E tank (Feb 7, 2018)

medicsb said:


> With cric or pericardialcentesis, death is imminent, and a botched cric or pericardialcentesis does not actually make the original situation worse (unless your assessment was wrong).



Might be beginning to mix apples and oranges. Just a point of order with regard to pericardiocentesis. Even with echocardiographic diagnosis of tamponade, at least many non CT surgeon physicians are extremely reticent to attempt putting a needle through the pericardium unless arrest occurs or is "imminent" (whatever that means). Diagnosis in the field is more difficult and making things worse with an attempt is a real possibility. 

I wouldn't put cricothyrotomy and pericardiocentesis in the same category.


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## Carlos Danger (Feb 7, 2018)

RocketMedic said:


> It is less invasive and less of a cultural barrier to place an ETT than to crike someone, and quite frankly, we might as well keep both.



A field cricothyrotomy is not an elective procedure. It is only done in scenarios where an airway cannot be established any other way, and thus the patient will die without it. It is essentially a risk-free procedure, because even though complications can result, none of those complications are worse than what will happen if an airway is not established.

In contrast, most field intubations are entirely elective, in that the patient will have the same outcome (or even better, statistically, if you believe the research) if another method is used to secure ventilation and oxygenation. 

In one case you are making a last-ditch effort and not exposing the patient to any addition risk. In the other, you are deliberately choosing to perform a procedure that caries risk and in most cases isn't even likely to help.


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## medicsb (Feb 7, 2018)

I’m an EM doc and I wouldn’t do a pericardialcentesis except in the most dire situation (cardiac arrest or peri-arrest).  I wouldn’t want a paramedic doing it out side of arrest (or at all, actually).  I have had patients with large pericardial effusion with echo evidence of tamponade, but stable, and they had a pericardialcentesis performed by interventional cards.  I have only done one pericardialcentesis for trauma (an arrest) and it was only done because we couldn’t visualize the pericardial sac due to free air in the chest.


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## rescue1 (Feb 7, 2018)

DrParasite said:


> sure sure sure longer courses = more education = better understanding and better assessment of subtly sick. That's the theory
> 
> In theory, a paramedic would have a better understanding of sick vs not sick, at least compared to a nurse.  in theory, a nurse would have a better understanding of sick vs not sick, at least compared to a nurse.  and in theory, a doctor would have a better understanding of sick vs not suck, at least compared to a nurse.  And I agree with the theory.
> 
> ...




I can't imagine those studies exist prehospitally, because the vast majority of patients who call 911 will get transported to a hospital (since neither ALS nor BLS can say no to transport in 99% of the US), and the public will almost never know the difference between what ALS or BLS could have done, and so if the patient has a bad outcome the hospital/doctor will likely be blamed. And let's be honest, as long as an ambulance service takes someone to the hospital it's pretty hard to sue them, even if the care provided was subpar.

Probably more importantly, most EMS transports take place in systems with under 20 minute transport times, which means that the difference in outcomes between ALS and BLS transport is probably pretty minimal, if it exists at all (wasn't there a study that said that BLS treated patients do better?).

So I guess I'm mostly agreeing with you haha.


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## Tigger (Feb 7, 2018)

DrParasite said:


> please elaborate why EMTs don't have the ability to recognize subtly sick patients.  and EMT's assessment and a paramedic assessment should be pretty similar; the exception is a paramedic assessment includes a cardiac monitor. What is this "advanced assessment" you are talking about?  I agree that a paramedic can give an advanced intervention, but if the paramedic is going to perform a "advanced assessment" and then do the state of life on the way to the hospital, how beneficial is that advance assessment?  And more accurately, why can an EMT not do this advanced intervention?
> 
> And if the EMTs missing these subtly sick patients, why have no studies shown this?  There have lots of anecdotal stories, and a lot of emotional theories (those EMTs are killing people because they don't know what they don't know), but I haven't seen any EBM, any successful lawsuits, or any actual facts supporting this claim.
> If your EMTs are only spending 10 minutes with the patient, and than handing off to EMS, than they aren't really doing EMS (despite what may career firefighters like to think).
> ...


As someone who has gone through paramedic school, I should hope you understand the difference between an EMT and paramedic level assessment. If you didn't get that out of paramedic school, I don't really know what to do. Even the assessment "module" is longer than most EMT classes. A solid program also integrates better assessment skills the more your progress through it. The cardiology portion of medic school is a lot more than putting a monitor on. What do the findings mean in context? What will you do with them? There is no way to learn these things in 120-150 hour class. 

Did you ever work as a medic and integrate your assessment skills?


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## rescue1 (Feb 7, 2018)

I think the question should not be are paramedics better at assessing patients than EMTs, since I think everyone would agree that they are. I think a better question is, practically, does it make a difference in outcomes, and on which patients does it make a difference.

However, it's also pretty off topic from intubation.


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## VFlutter (Feb 7, 2018)

I know I have mentioned this before but how many providers know the intubation statics for their company? How they compare to other EMS, HEMS, or ER/ICU. 

What is an acceptable first pass rate and overall intubation rate?

If there is a large variation between a certain department and ER/HEMS/CC how can you justify continuing to perform intubations?


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## EpiEMS (Feb 8, 2018)

VFlutter said:


> If there is a large variation between a certain department and ER/HEMS/CC how can you justify continuing to perform intubations?



To add on to this, consider that in many Anglosphere systems (Canada, Australia), paramedics who perform many ALS skills aren't performing ETI...and they've often got 2+ year degrees in paramedicine.


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## DrParasite (Feb 8, 2018)

Tigger said:


> As someone who has gone through paramedic school, I should hope you understand the difference between an EMT and paramedic level assessment. If you didn't get that out of paramedic school, I don't really know what to do. Even the assessment "module" is longer than most EMT classes. A solid program also integrates better assessment skills the more your progress through it. The cardiology portion of medic school is a lot more than putting a monitor on. What do the findings mean in context? What will you do with them? There is no way to learn these things in 120-150 hour class.?


when I was in medic school, I had completed the requirements for many medical and PA programs, and had already been working in EMS for almost 15 years.  I will say that I learned a lot about diseases and interventions, and felt very frustrated that all too often, I could know a lot about something, and still be unable to do anything in the field, other than tell the doc "hey, i think this is what is going on based on A/B/C."

Your example of how "cardiology portion of medic school is a lot more than putting a monitor on" is 100% accurate: but the vast majority of cardiology involved information gathered from the monitor, treatments based on that information, both electrical and medical.  and a whole lot of conditions and issues, and how to fix them (sometimes). 

Can a paramedic do more interventions than an EMT?  absolutely.  Are they typically more experienced, so they have seen more than an EMT?  sometimes because they have seen more, so they might be looking for different things that they can fix.

So if you can't explain what the difference is, than I'm guessing you are too ashamed to admit that the assessment (how you are searching for the problem) is pretty much the same.  Or feel free to list exactly what makes a paramedic exam, that every paramedic does on a regular basis (ie, it's the paramedic standard) different than that of an EMT, in terms of patient assessment.  I'll be here waiting patiently.

hypothetically, lets take you off your ambulance, and put you on my engine.  you have a standard BLS bag, no cardiac monitor, no ALS medications.  How will your assessment differ?  how will your report differ to the paramedic ambulance who arrives 10 minutes after you do?

Oh, and I use my assessment skills every shift.  I just don't use my intervention skills.


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## Carlos Danger (Feb 8, 2018)

DrParasite said:


> *So if you can't explain what the difference is, than I'm guessing you are too ashamed to admit that the assessment (how you are searching for the problem) is pretty much the same.*  Or feel free to list exactly what makes a paramedic exam, that every paramedic does on a regular basis (ie, it's the paramedic standard) different than that of an EMT, in terms of patient assessment.  I'll be here waiting patiently.
> 
> hypothetically, lets take you off your ambulance, and put you on my engine.  you have a standard BLS bag, no cardiac monitor, no ALS medications.  How will your assessment differ?  how will your report differ to the paramedic ambulance who arrives 10 minutes after you do?
> 
> Oh, and I use my assessment skills every shift.  I just don't use my intervention skills.



I'll explain what the difference is: emphasis, mentoring, and time spent in training, and the resulting experience. Those things matter.

Even if EMT's and paramedics do learn the same exact assessment skills - and I'm not sure thats's even true - a paramedic on his first day after passing finals will have dramatically more experience, overall awareness, and confidence in performing a given assessment than an EMT will on his first day passing finals. Quite often, that experience gap only widens with time spent in the field.


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## Tigger (Feb 8, 2018)

DrParasite said:


> when I was in medic school, I had completed the requirements for many medical and PA programs, and had already been working in EMS for almost 15 years.  I will say that I learned a lot about diseases and interventions, and felt very frustrated that all too often, I could know a lot about something, and still be unable to do anything in the field, other than tell the doc "hey, i think this is what is going on based on A/B/C."
> 
> Your example of how "cardiology portion of medic school is a lot more than putting a monitor on" is 100% accurate: but the vast majority of cardiology involved information gathered from the monitor, treatments based on that information, both electrical and medical.  and a whole lot of conditions and issues, and how to fix them (sometimes).
> 
> ...


Ashamed? That must be it. 

Remi pretty much covered it. The sky is up too, but I'm sure you're anecdotal experiences will have something to say about that too. 


VFlutter said:


> I know I have mentioned this before but how many providers know the intubation statics for their company? How they compare to other EMS, HEMS, or ER/ICU.
> 
> What is an acceptable first pass rate and overall intubation rate?
> 
> If there is a large variation between a certain department and ER/HEMS/CC how can you justify continuing to perform intubations?


We had 69 intubations as a service in the past two years. An additional maybe 10 intubations were done at hospitals with a doctor for our patients but were the "doctor's tubes." In that time we had a 72% first pass success rate and all but one patient with an intubation attempt was intubated in three or less attempts. The one failed RSI was managed with a king airway. We have 15 full-time paramedics on staff. Last year we began using McGraths. Most but not all of our paramedics have RSI privileges.


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## DrParasite (Feb 9, 2018)

Remi said:


> Even if EMT's and paramedics do learn the same exact assessment skills - and I'm not sure thats's even true - a paramedic on his first day after passing finals will have dramatically more experience, overall awareness, and confidence in performing a given assessment than an EMT will on his first day passing finals.


I agree with you there, 100%. a paramedic has more experience (in most cases), as their clinical time is longer, when they are fresh out of school.  Plus, many programs require a paramedic to be an EMT for a year before they even start the paramedic program, so, of course, the paramedic is more experienced, especially immediately after graduation, when the EMT, literally, has 0 real world experience as an EMT (maybe 3 clinical shifts if they were lucky).  It would be nearly impossible for an EMT to have more experience than a paramedic immediately following graduation.

But the claim was that a paramedic assessment is better than an EMT assessment.  There has been nothing to back up that claim.  But if you say an experienced provider is better than a newbie provider, than wouldn't an EMT with 10 years of experience be able to perform a better assessment than a newbie paramedic?



Remi said:


> Quite often, that experience gap only widens with time spent in the field.


So my former coworkers, who see 15 patients in 12 hours, aren't as experienced as a paramedic who sees 2 patients in 24 hours?  They saw sick and not sick patients (probably more not sick than sick, it was an urban city).

Lease common denominator, sure, the industrial EMT, volunteer who does it once or twice a month, or the firefighter who only does first response, heck, even the law enforcement officer who is a paramedic and has never been full time on the ambulance; all these people couldn't compare to a busy ambulance paramedic when it comes to patient assessment, because they don't have the experience level.  

But that's experience in the field, not medical training.  and experience matters.


Tigger said:


> Ashamed? That must be it.
> 
> Remi pretty much covered it. The sky is up too, but I'm sure you're anecdotal experiences will have something to say about that too


No need to be snarky.  You made a claim, and I asked you to back it up.  I'm betting you still can't, because your claim is baseless.

Oh, and I pulled my old syllabus out of my email archive.  We spent a week on "patient assessment", two whole days.  everything else we covered patient conditions and interventions (and a ton on cardiology).  And then we did a lot of patient assessments based on the conditions we covered.  but the "patient assessment" lecture was about the same as in my EMT class.


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## Carlos Danger (Feb 9, 2018)

DrParasite said:


> I agree with you there, 100%. a paramedic has more experience (in most cases), as their clinical time is longer, when they are fresh out of school.  Plus, many programs require a paramedic to be an EMT for a year before they even start the paramedic program, so, of course, the paramedic is more experienced, especially immediately after graduation, when the EMT, literally, has 0 real world experience as an EMT (maybe 3 clinical shifts if they were lucky).  It would be nearly impossible for an EMT to have more experience than a paramedic immediately following graduation.
> 
> But the claim was that a paramedic assessment is better than an EMT assessment.  There has been nothing to back up that claim.  But if you say an experienced provider is better than a newbie provider, than wouldn't an EMT with 10 years of experience be able to perform a better assessment than a newbie paramedic?



I think perhaps we define "assessment" differently. If you are just talking about the NREMT skill sheet stuff - the ability to take a set of vitals and compare them to normal ranges and remember which questions to ask about chief complaint and onset and medications and allergies and which order to do your physical exam in, then yes perhaps there is little or no difference between an EMT and a paramedic. When I think about "assessment", I think more broadly. To me it is the overall ability to accurately gather objective and subjective information and use that information to identify and sort through differentials. The overall ability to figure out what is going on with a patient. EMT's can't do that like paramedics can because they don't know even half of what paramedics know about the potential differentials for any given complaint.

It's been a few minutes since I endured any formal EMS book learnin', so perhaps things have just changed. But I know when I finished paramedic school, I had way better assessment skills than I ever did as an EMT. You were much better off being taken care of by Remi the paramedic than by Remi the EMT, and not because of the expanded treatment options. It was the overall increase in clinical knowledge and the confidence that came with my additional training. I just knew more. And because I knew more, I was better able to figure out what was going on with my patients.

Plus, I don't think you can discount assessment tools that EMT's don't have, like cardiac monitors. Things like that are a big part of what makes a paramedic different from an EMT. If nothing else, a paramedic is better at assessing because they have paramedic assessment tools.


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## VentMonkey (Feb 9, 2018)

Forget the EMT/ paramedic assessment debate for a minute, but how many fresh out of school paramedics even look for, take into account, or are prepared for that difficult airway the second their eyes hit the patient?

Sure Mallampati scores may be brushed up on, perhaps Cormack scores too. They may touch on ramping a morbidly obese patient, but even with this how many will readily *honestly* say you know what the best I can do is effectively BVM, or let me just direct to SGA vs. knowing the proper patient for their skill abilities? 

Hopefully schools are beginning to emphasize this methodology. Yes, ETT still has its place in the prehospital setting IMO, but the split second decisions most likely need to be much more accurate. And yes, without VL I don’t think any paramedic has any business attempting to intubate a predictably difficult airway.


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## Tigger (Feb 9, 2018)

VentMonkey said:


> Forget the EMT/ paramedic assessment debate for a minute, but how many fresh out of school paramedics even look for, take into account, or are prepared for that difficult airway the second their eyes hit the patient?
> 
> Sure Mallampati scores may be brushed up on, perhaps Cormack scores too. They may touch on ramping a morbidly obese patient, but even with this how many will readily *honestly* say you know what the best I can do is effectively BVM, or let me just direct to SGA vs. knowing the proper patient for their skill abilities?
> 
> Hopefully schools are beginning to emphasize this methodology. Yes, ETT still has its place in the prehospital setting IMO, but the split second decisions most likely need to be much more accurate. And yes, without VL I don’t think any paramedic has any business attempting to intubate a predictably difficult airway.


We did have a condensed "difficult airway" day, but that was all about techniques once you had identified one. Additionally, we were required to assess 30 strangers airways, which consisted of a more targeted history, mouth opening, neck mobility, teeth presence, jaw protrusion, neck size, and Mallampati. Talk about some weird looks at the community college. Pretty useful exercise though. I think where things lacked the most though was sort of implying that everyone could be intubated. That's just not so for most paramedics, and knowing when difficult meant do not attempt was not something really touched on.


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## Carlos Danger (Feb 9, 2018)

I'm not sure that assessing for the difficulty of an intubation should really be stressed to paramedics. This is largely because no assessments have ever been shown that reliable, but also because, as you often hear from the advocates of using rocuronium (vs. sux) for RSI, if a person really _needs_ an airway established they need it, and the fact that it looks difficult doesn't take away that need. Between VL, SGA's, and cricothyrotomy, failed airways should be practically non-existent these days.

I'm not saying don't do an airway assessment, I'm saying don't focus a lot of effort on trying to predict the difficulty of intubation.

Just like we use universal precautions even on people who appear to be at low risk of having HIV or hepatitis, we should approach every intubation in the field as though we know it is going to be difficult. Make your first attempt your best attempt every time, and plan to move down your algorithm to cricothyrotomy. Having that deliberate mental preparation for moving down the algorithm is a useful cognitive "trick". Once you've gotten it in your head that you are likely going to have to do something like that, you've given yourself permission to take that step and it's a little easier to do, should it actually come to that.

I think the most important element of airway assessment in the field before doing an RSI is answering two questions:

1. Do I really need to take this airway? Right now? Is the benefit really worth the risk?
2. Can I easily identify the landmarks for cricothyrotomy? Not being able to should make you seriously consider the necessity of giving a paralytic.


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## MackTheKnife (Feb 10, 2018)

It is interesting to note that the OP posted back in 2011 and the debate goes on still. The article cited by the OP came from PUBMED, a highly reliable source for EBP. However, in the article cited, it did not specify which locale, if any, or if it was a nationwide study. With the low sample population, I would think it would be relegated to a specific urban/suburban area vice nationwide.
I have engaged in debates on different forums about ET intubation, and some of the replies went to the lack of people surviving cardiac arrest neurologically intact who were intubated. I question the validity of this argument in that an ETT is not the sole arbiter of patient survival. Length of down time (anoxia), length of delay in ROSC, comorbidities, etc., all lead into whether or not the patient survives, neurologically intact or not.
Misplaced tubes should be a rarity, not commonplace. Yes, there the "no-neckers", people with anterior anatomy (my wife), etc. But if you can see the cords, you should be able to properly place the tube. I think some people rush their intubation and hope it's in the right place, IMHO.
I have also seen intensivists in the hospital pick too large a tube all too frequently. They are not a good judge of which size tube to use. They usually take at least two attempts to place the tube. And all use Macs. I prefer a Miller #3; I've always loved the straight blade.


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## E tank (Feb 10, 2018)

MackTheKnife said:


> I have also seen intensivists in the hospital pick too large a tube all too frequently. They are not a good judge of which size tube to use.



It isn't a question of poor judgement. Intensivists appreciate larger tubes in the event the patient requires ICU bronchoscopy and or lavage and by and large, respiratory therapists appreciate them for ease of routine pulmonary toilet, less likelihood of plugging etc.


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## Carlos Danger (Feb 10, 2018)

MackTheKnife said:


> It is interesting to note that the OP posted back in 2011 and the debate goes on still.



The debate started WAY before 2011, and it shows no signs of slowing down. After quite a few years of staying on top of the research related to EMS airway management and debating it ad nasueam, I have come to a few conclusions as to why the debate continues.

Suffice it to say that there is no other intervention that offers as much risk to the patient with as little demonstrated benefit - yet somehow continues to be considered "standard of care" - as prehospital endotracheal intubation.



MackTheKnife said:


> The article cited by the OP came from PUBMED, a highly reliable source for EBP. However, in the article cited, it did not specify which locale, if any, or if it was a nationwide study. With the low sample population, I would think it would be relegated to a specific urban/suburban area vice nationwide.



PubMed indexes practically every article related to medicine that is published in journals written in English. So the quality and strength of the evidence presented in each article varies dramatically by study design and execution.

This study was done in Orlando over an eight month period in 1997. It is one of the rare prospective studies done in the US on prehospital intubation. With a sample size of 108, it's pretty legit in size, though you are correct in pointing out that it is limited to a single geographic location.

The reason for the high rates of unrecognized esophageal intubation in the study appears to be largely related to lack of use of Etc02 monitoring.



MackTheKnife said:


> I have engaged in debates on different forums about ET intubation, and some of the replies went to the lack of people surviving cardiac arrest neurologically intact who were intubated. *I question the validity of this argument in that an ETT is not the sole arbiter of patient survival. Length of down time (anoxia), length of delay in ROSC, comorbidities, etc., *all lead into whether or not the patient survives, neurologically intact or not.



Well of course it isn't the sole arbiter but age, downtime, and co-morbidities are pretty easily controlled for in these studies. The investigators generally group the patients by those traits and run stats separately on each group. So that isn't really a problem. The evidence on how ETI affects survival from cardiac arrest is inconclusive. Some analyses show a benefit, some show that it doesn't help or even negatively correlates with survival. Personally I think we put too much emphasis on trying to bring back the dead so I tend not to pay a heck of a lot of attention to studies looking at different airway management techniques in cardiac arrest.

Where the rubber really meets the road is in looking at field RSI. There are a handful of retrospective studies on field RSI over the past 20 years and none of them have shown a clear benefit, while many have actually shown harm.

There has only been one large, well-done prospective study and that was the Bernard study done in Australia and was also very unconvincing.



MackTheKnife said:


> Misplaced tubes should be a rarity, not commonplace.



Since Etc02 has become common in the field, misplaced tubes really don't happen that often. Most studies on field RSI show pretty high rates of success with tube placement. The problem as it relates to benefit appears not to be getting the tube, but all the other details.


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## MackTheKnife (Feb 10, 2018)

E tank said:


> It isn't a question of poor judgement. Intensivists appreciate larger tubes in the event the patient requires ICU bronchoscopy and or lavage and by and large, respiratory therapists appreciate them for ease of routine pulmonary toilet, less likelihood of plugging etc.


Yeah, but my point is they usually wind up downsizing!


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## E tank (Feb 10, 2018)

[QUOTE"MackTheKnife, post: 663303, member: 10500"]Yeah, but my point is they usually wind up downsizing![/QUOTE]



MackTheKnife said:


> I have also seen intensivists in the hospital pick too large a tube all too frequently.




Huh?


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