# ET Intubation



## fyrdog (Jan 10, 2007)

We recently had a class on difficult airways and I thought I would share the topic of ET Intubations being under fire.

Apparently there are several medical control directors around the country that do not support the use of ET Intubations by any pre-hospital providers including paramedics.

This past year in the North Central Region of Connecticut, which is Hartford County and a few other surrounding towns, the paramedics were required to participate in a mandatory study of pre-hospital ET intubations (ETTs). It was required that the paramedics provide his/her name and license number on the form. There were 400 documented ETTs. 80% were properly performed on the first attempt. The other 20% required multiple (2) attempts or use of other airway adjuncts (i.e. combi tube, OPA, LMA) 7 of the ETTs were esophageal , one which had a capnography record showing that it was properly placed but dislodged when the patient was moved from the EMS stretcher to the hospital bed.

Number of ET Intubations required to become board certified (national standard) by license type –

Emergency Room Doctor 50
Nurse Anesthetist 100
Anesthesiologist 200
Paramedic 5    (In Connecticut 10)


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## Airwaygoddess (Jan 11, 2007)

Our medical director removed  pedi E.T. from the medics:glare:  such an id**t!!


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## KEVD18 (Jan 11, 2007)

fyrdog said:


> 1....80% were properly performed on the first attempt...
> 2....it was properly placed but dislodged when the patient was moved...



1. sounds like a pretty good ratio to me.

2. hardly seems fair to use that type of thing in consideration of this argument.

pulling tubes from als trucks will kill pts.


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## Ridryder911 (Jan 11, 2007)

This is a national trend.. While many on this forum would love to debate and argue that even basics should intubate, the real reality is many of the EMS Systems are removing or "studying" the efficiently of EMS personal being able to intubate properly. 

Many are describing that "too many " already have intubation certifications, therefore decreasing the ability to intubate and decreasing proficiently. As well nationally intubation clinical sites have decreased and documented "successes" has been on the decline. 

I do believe this a shame, that no esophageal intubations should ever be presented into an ER. With the use of capnography and assessment there is proper documentation of extubation, and correction can immediately occur. 

However; due to the blindness and apathy of most EMS personnel, there is a very rapid discussion among physicians and EMS Medical Directors to have EMS use alternative airways in lieu of intubations. 

I personally see intubation being totally removed from all EMT level curriculum within the next five to ten years. I do believe we are not recognizing the strength of this campaign, and as well do not realize the dangers and risks this place our patients. I am aware of discussion by leading EMS authorities in discussion of this agenda, and it has gained much support recently. 

R/r 911


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## Ridryder911 (Jan 11, 2007)

fyrdog said:


> Number of ET Intubations required to become board certified (national standard) by license type –
> 
> Emergency Room Doctor 50
> Nurse Anesthetist 100
> ...




I would like to know where you obtained the national standards minimal numbers at ? I have not been able to find such documentation describing such. 

This is from the CRNA requirements for obtaining their certification level. 

.."_Clinical Curriculum Requirements
The clinical component of the nurse anesthesia educational program mandates that each student administer a minimum of *450 anesthetics to patients *, representing at least 800 hours of anesthesia time. To meet this requirement, students provide these services under the supervision of qualified clinical instructors, which include CRNAs or anesthesiologists_..

Albeit not all patients requiring anesthesia require intubations, I am sure it is much more 100. As well there is * NO* official requirement for Paramedics to have *any* intubation requirements nationally. There is "recommended intubations", but local and state can mandate. I just attended a meeting two days ago addressing the number of facilities nationwide that now use mannequin training in lieu of O.R. experience. I do agree this is a drastic shame, but they are not able to find O.R. sites.
Hence, part of our problem. 



R/r 911


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## fyrdog (Jan 11, 2007)

I am not sure where the "national Standard" comes from. The instructor who taught the class provided those. He is someone I have known for about 20 years and has always been a reliable source. I'll see where he got the numbers from. It could just be a concensus of many different states. He did say that the numbers come from some certification boards be he didn't go into more detail. It may be a voluntary certification.

I'll also check with OR. I'll be going there in the next month to do some tubes as I have been living under a white cloud for the last two years.


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## yowzer (Jan 11, 2007)

Unfortunately, lots of places are reflexively going "No intubations!" instead of "Make sure our medics get plenty of education and practice, so they can do it right."  Areas that follow the latter philosophy don't have many intubation problems, oddly enough.  It's easier with fewer medics because you get more chances, but even in systems where everyone has to be medic, you can arrange OR rotations or the like.


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## wolfwyndd (Jan 16, 2007)

Airwaygoddess said:


> Our medical director removed  pedi E.T. from the medics:glare:  such an id**t!!


Our local EMS region is also considering removing intubations for pedi's.  They conducted a study a year or so ago that showed that 80 percent of the intubated pedi's that came into a hospital were incorrectly placed or massive damage was done to the intubated pedi.  Our 2007 local protocols will still allow it, but there's speculation that our 2008 protocols will not allow it.


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## jeepmedic (Jan 16, 2007)

the voices in my head uggggh


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## Strike3 (Jan 18, 2007)

In SC, Basics can intubate across the board, newborn-adult. We use LMA's, Combi's and ET/Endotrol....


We also have fairly strict rules about use of ETC02 detectors with our monitors and whatnot though...  I really don't know how they could justify taking ET intubation out of a states scope. Unless the training is really that bad in said state..


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## captoman (Jan 24, 2007)

This is a very concerning trend. I suppose it is easier to pull the tubes than teach the medics. sheesh. :wacko:


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## Medic2891 (Jan 29, 2007)

The big reason behind this is, in my opinion, is this.  Most hospitals are going to a pay to play type of system for the doctors.  What does this mean?  It means that for everything a doctor does, ie. intubate, chest tube, whatever, they get paid for it.  Since intubations are common and fairly easy, the doctors are not getting paid for it because we are doing it, so creat this "national trend", and get paid more for doing work in the ER.  Pretty screwed up if you ask me as it is witholding patient care, something that kind of goes against the hipocratic oath, I would think.


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## Ridryder911 (Jan 29, 2007)

I believe you are on some valid points. But then why is the rate of "missed intubations" that EMS is making. Why is our intubation rate from 93% nationally to approximately mid to lower 80 percentile ? 

Could it be possibly... uh, we are having less trained and educated people performing them ? Is it we have "too many" people qualified to intubate and the skill attribution rate is high, because "everyone" can intubate and thus no one gets enough clinical exposure ? 

As well, there should never be a patient delivered with an ET tube misplaced and not verified. With the invention of EtCo2 detectors, and good patient assessment (lung/gastric ) sounds, it is not allowable for ER to ever receive  a tube in the esophagus.

I too personally blame a lot of the "intent" of some these studies on professional bias. The same authors are repeating the same studies on a rant to prove something. As well, when Dr. Wang (author of leading anti-paramedic intubation study) how often he intubated, he refused to answer.

If we (EMS) do not take stand with scientific data, and as well be sure only in-depth educated personal with quality assurance (set number of intubations per month, O.R. rotations if not met). Then we will see intubation be removed from pre-hospital care. AHA has already down played airway, and now the paradigm shift is to use alternative airways. This will not happen later, rather within the next two to five years.

R/r 911


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## Guardian (Feb 2, 2007)

Ridryder911 said:


> As well, there should never be a patient delivered with an ET tube misplaced and not verified. With the invention of EtCo2 detectors, and good patient assessment (lung/gastric ) sounds, it is not allowable for ER to ever receive  a tube in the esophagus.



This is the bottom line and missed tubes should be grounds for investigation as to whether or not the provider should be able to continue to intubate.  I think it would be perfectly legitimate to only allow certain paramedics in a system to intubate by themselves, per medical director’s discretion (just like surgical airways in some systems).  It's sad paramedic education has decreased to the point where we are even having this discussion.  I don't think alternative airways are the answer because I've yet to see one that could oxygenate and protect the airway as well as ETT.


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## Guardian (Feb 2, 2007)

Oh yea, and the answer to this problem is better education, but then again, that's the answer to every problem in ems.


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## jeepmedic (Feb 3, 2007)

OK the voices win....


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## jeepmedic (Feb 3, 2007)

fyrdog said:


> We recently had a class on difficult airways and I thought I would share the topic of ET Intubations being under fire.
> 
> Apparently there are several medical control directors around the country that do not support the use of ET Intubations by any pre-hospital providers including paramedics.
> 
> ...



Ok the study says:
"80% were properly performed on the first attempt. The other 20% required multiple (2) attempts or use of other airway adjuncts (i.e. combi tube, OPA, LMA) 7 of the ETTs were esophageal , one which had a capnography record showing that it was properly placed but dislodged when the patient was moved from the EMS stretcher to the hospital bed."

It does not say how many did not receive any airway period. 

I have seen many times in the ED an Anesthesiologist miss on the first attempt.

I had an Anesthesiologist try to pull one of my tubes because he said "I hear air movement all over the place." Said the tube could not be in the right place. The X-ray and ET CO2 confermed the placement. Plus after termination of CPR the ED Dr. (which was my Medical Dir.) checked and guess what IT was in.

How many of these intubation attempts had a gag reflex? How many of them wound up being "difficult airways?" Where they had to be medicated to be intubated? 

Studys like this only give the people who want to hold EMS back more reasons to with out any real data. Without true data it is hard for anyone to prove anything.


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## Guardian (Feb 3, 2007)

studies also show an increase in hyperventilation of cardiac arrest pts who are intubated.  You know, when the FF ventilates at 80/min, wonder if this has anything to do with it.  Again, lack of education.


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## jeepmedic (Feb 3, 2007)

Guardian said:


> studies also show an increase in hyperventilation of cardiac arrest pts who are intubated.  You know, when the FF ventilates at 80/min, wonder if this has anything to do with it.  Again, lack of education.



This falls back on the AIC. And you are right it does go back to education. If you see the person ventilating to fast then say something to them. Alot of times people will not say anything due to the fact they don't won't to hurt anyone's feelings. But they need to say something. If it is wrong you need to say so.


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## hangit (Feb 4, 2007)

i mentioned this thread to an older medic and had a couple questions on two things he talked about.

1. he said if you see fog on the inside of the tube- you're in.

2. he said if you try on first attempt and miss, leave the first tube in and insert a second and the second will automaticaly go into the trachea.

i'm sure these are probably not accepted practices, but was just wondering.


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## Jon (Feb 4, 2007)

hangit said:


> i mentioned this thread to an older medic and had a couple questions on two things he talked about.
> 
> 1. he said if you see fog on the inside of the tube- you're in.
> 
> ...


Condensation (fogging) of the tube is a secondary indication of propper tube placement, not to be the ONLY method of confirmation, but can be documented in addition to bilateral Lung Sounds, absent gastric sounds, and positive Color Change capnography to make for a VERY good case for propper intubation.


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## fyrdog (Feb 5, 2007)

hangit said:


> i mentioned this thread to an older medic and had a couple questions on two things he talked about.
> 
> 1. he said if you see fog on the inside of the tube- you're in.
> 
> ...



1. Most likely you are in but you really need to check properly. Listen to epigastric and lungs sounds, and use capnography or other detection device.

2. Definitely a NO! The esophagus will stretch enough to allow more than one tube in it. It is easier to intubate the esophagus twice then the trachea. You can leave the first tube in, but it is anything but automatic on the second attempt. You still need to visualize the tube passing the cords and confirm placement.


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## Ridryder911 (Feb 5, 2007)

Fogging the tube is an myth.. Yes, usually condensation will occur, when you are in the trachea... but, will also occur in the esophagus. Remember, condensation is only moisture and heat escaping the body.. 

If you miss, yes it is acceptable to leave the tube in and intubate around it... you only have one hole to hit now. As well you drop a gastric tube and evacuate or decompress the stomach (gastric distention) at the same time.

The only true legal approved verification methods are :
1) EtCo2 - better with capnography wave forms (for documentation) 
2) Auscultation - Bi-lateral lung sounds, and absent epigastric sounds
3) CXR
Other notable ones are Bulb detector, whistle device (breathing patients)

R/r 911


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## jeepmedic (Feb 13, 2007)

I have yet to see anyone state the most obvious way to know that you are in and that is to *WATCH THE TUBE PASS THRU THE CORDS.*


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## Ridryder911 (Feb 13, 2007)

jeepmedic said:


> I have yet to see anyone state the most obvious way to know that you are in and that is to *WATCH THE TUBE PASS THRU THE CORDS.*



Very true ! However, nearly all claim that statement.. 

R/r 911


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## firemedic1563 (Mar 10, 2007)

Interesting topic. Luckily, I do not see our state going that direction. If anything we are becoming less restrictive, now adopting RSI programs (very restrictive to limited personell). Our state and local medical directors are very supportive. I don't know the ratio of misses, but I have yet to see a patient who has presented to our ED's with improperly placed tubes. Sometimes with no tube on a difficult airway. I do know that the state would come down hard on anyone who left an tube in the esophagus.

Personally, i think any attempt to take it out of protocol is BAD, BAD, BAD. Our patients deserve the standard of care.


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## chico.medic (Mar 10, 2007)

The biggest problem lies in the masses paying the price for the few.  In the EMS system I work in we have a lot of 1-2 year medics that are only using the private box as a stepping stone until they can obtain a fire job.  The skill level is just not the same as a system that has retained it's medic's for 10-20 years.  You have EMS crews bringing patients into ED's without tubes, without lines, etc.  In my honest opinion a combi-tube or an LMA shouldn't be a backup for poor intubation skills.

My company is sending myself and another Medic to the SLAM conference in Texas in June.  I'm very excited, as it looks like an excellent course.  A few of our Medics went last year and it sounds like a blast.  

Check it out:  http://www.airwayeducation.com/knowledge_corner.asp

This is the kind of training that should be standardized across the country.


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## Ridryder911 (Mar 10, 2007)

SLAM courses are awesome. I too hate to see potential fire monkeys going through clinicals because "that gives them points to get hired".. They never really truly have an interest in EMS only a side line or potential part time job. 

That is why we have a general unwritten policy once we find out their intention they get "observation clinicals".. if they show an interest, I will teach, if they do not.. they get to sit and ride. I won't waste my time with them. 

R/r 911


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## chico.medic (Mar 11, 2007)

Ridryder911 said:


> I too hate to see potential fire monkeys going through clinicals because "that gives them points to get hired".. They never really truly have an interest in EMS only a side line or potential part time job.
> 
> That is why we have a general unwritten policy once we find out their intention they get "observation clinicals".. if they show an interest, I will teach, if they do not.. they get to sit and ride. I won't waste my time with them.
> 
> R/r 911



I never said that hate potential fire medics.  They are an integral part of many EMS systems.  I work in an area where all ALS is provided by private ambulance.  Some of the fire departments have paramedics working for them, but they do not have ALS equipment.  Fire is a wonderful resource to have at scene, and I am not one to complain when I get help from another agency.  To call them "Fire Monkeys", and not afford them good clinical experience simply because they were smart enough to find a career that offers excellent wages, benefits , and retirement is a little petty.

I was just commenting on the fact that many of our medics only have a few years of experience.  Who could blame them for the wages we get.  If anything, I respect the ones who spend time in private EMS prior to moving on.  Everyone of them that I have met have verbalized the desire to become a good Medic, so that later on, they would not just be a "fire monkey" as it was so elegantly put.

BTW, if my house ever catches fire, I hope those monkeys have wings, because I would want them out of their cages and to my house very quickly.

I am actually working towards a career in law enforcement.  I would love to utilize my skills in a tactical environment.  I suppose that would make me a "handcuff monkey"?


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## Tincanfireman (Mar 11, 2007)

And let's not forget that a medical license does not make you foolproof either. My wife's mom was sent for emergency surgery following complications during a cath. Gross swelling of the thoracic cavity was attributed to a lacerated artery and treated with 4 units of packed cells, LR, etc. She died hours later with no significant or contributory pre-op problems at age 64. Surgical notes made during the thoracotomy to repair said vessels revealed a ruptured stomach, probably due to excessive inter-gastric pressure from an incorrectly placed ET tube that was inserted by the anesthesiologist in the OR. The small amount (<50ml) of blood discovered in the thoracic cavity was attributed to secondary loss from the ruptured stomach. Please hold all the recommendations about contacting 1-800-Lawyer; I bring up the point only to illustrate that those who make the rules that affect us are not always guilt-free themselves.


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## Ridryder911 (Mar 11, 2007)

No one is fool proof, especially me, I admit I have made errors (hopefully learn off them & not repeat them). However many F.D. have prevented the growth of EMS, and there are very few that allow medics to be medics without dual roles. As well, very few actually are into the "medical part" rather it to be more part of the job (no more special than venting a roof). 

I am quite aware of the responsibilities and duties of fire service, before a lashing occurs to me. In fact my first love was firefighting rescue and obtained a degree in Fire Service and Safety Engineering, and served as an line fire officer for ten years. In fact I am still in the IFSTA Rescue manual, and was one of the first Level II F/F to professional level. The problem most F.D. at that time did want to participate in EMS activities and continued to do so, until recently when there is grant money to obtained and to be able to keep FTO for justification. 

There are some exceptional Fire Medics and Fire EMS out there, but the majority of the students we receive that are geared towards F.D have no desire to learn anything about EMS or patient care. It is a more a "chore" they have to do to be able to apply for F.D. 

Personally, I feel it is a shame that F.D. would be considered to be a " step up" for any EMS member. EMS requires more educational level than those of  majority of F.D. require, as well as response volumes are more than those of fire alarms. It is unfortunate that we in EMS do not provide the pay, benefits of those in the Fire Service. Again, the addage and importance of the need of education and promoting of our profession. 

R/r 911


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## chico.medic (Mar 13, 2007)

I'm not trying to lash out, I was merely clarifying that I did not hate to see up-and-coming fire medics.

Your first post inferred that "I also" feel that way.  I just did not want my name associated w/ the fire monkey comment.



Ridryder911 said:


> I too hate to see potential fire monkeys going through clinicals because "that gives them points to get hired"
> 
> R/r 911



BTW, very impressive resume.  You seem to have been around the block a few times.  What is it that you do currently?


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## Ridryder911 (Mar 13, 2007)

Currently in grad school for acute nurse practitioner. Been in EMS going on 30 years, at various levels from national and state development to air, ER Manager, Field Supervisor at various types of EMS services. Currently, I work as a Paramedic and in education division for a service, work at a ER as a ER nurse. It is much simpler to work only ten days a month that way.. lol. 

I am involved in several state and national committees for education development and work adjunct for a collegiate Paramedic program. 

R/r 911


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## chico.medic (Mar 13, 2007)

And I thought I was spread thin:wacko:


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## firemedic1563 (Mar 16, 2007)

> I too hate to see potential fire monkeys going through clinicals because "that gives them points to get hired".. They never really truly have an interest in EMS only a side line or potential part time job.



I was hired as part of a move to create a 4th shift for my Department (24/48-24/72). The last few years they have had a requirement in employment contract that ALL new hires must obtain and maintain their ALS certification to the level offered. What that means is when they say to go to "I" school, you report. And when you get sent to the "I" to "P" bridge, you go. Or now they are doing the EMT-B to Paramedic. Regardless, we either pass or we risk getting fired. Nobody that I know of off probation has been fired yet, and it is becoming an issue with the union and lawyers involved.

My point being, don't blame those that don't want to become ALS providers but are made to do so. Yes they knew what they signed up for, but still a tough pill for them. And many of them are jumping ship as soon as the local big city calls,  but even there they require it now.

I personally had no desire to become a Paramedic. But, as I was sent through "I", and then the bridge to Paramedic, I found a few things out. 1. I liked it, 2. I was pretty good at it for a newbie. Now I work in dual roles, assigned to a firefighter position, but detailed mainly to ALS spots due to shortage of providers. The one good that i see in requiring all new hires to become ALS is that when we get enough, our new medic engine program may allow a rotation so those of us who want suppression time can get both.


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## Ridryder911 (Mar 16, 2007)

firemedic1563 said:


> I was hired as part of a move to create a 4th shift for my Department (24/48-24/72). The last few years they have had a requirement in employment contract that ALL new hires must obtain and maintain their ALS certification to the level offered. What that means is when they say to go to "I" school, you report. And when you get sent to the "I" to "P" bridge, you go. Or now they are doing the EMT-B to Paramedic. Regardless, we either pass or we risk getting fired. Nobody that I know of off probation has been fired yet, and it is becoming an issue with the union and lawyers involved.
> 
> My point being, don't blame those that don't want to become ALS providers but are made to do so. Yes they knew what they signed up for, but still a tough pill for them. And many of them are jumping ship as soon as the local big city calls,  but even there they require it now.
> 
> I personally had no desire to become a Paramedic. But, as I was sent through "I", and then the bridge to Paramedic, I found a few things out. 1. I liked it, 2. I was pretty good at it for a newbie. Now I work in dual roles, assigned to a firefighter position, but detailed mainly to ALS spots due to shortage of providers. The one good that i see in requiring all new hires to become ALS is that when we get enough, our new medic engine program may allow a rotation so those of us who want suppression time can get both.



I appreciate your candor and honesty. This is one of the problems I see with Fire Service being responsible for delivery of EMS. As well, many problems have been identified with multiple or "too many ALS" providers and not having those being proficient in skills. 

Many years ago Dallas "drafted" Paramedics requiring every so number to become one, like it or not. This caused many complications and increased number of litigation's. The reason is simple, those that do not want to perform a job, usually does not excel and perform as those that do. The same would be true for those that were required to perform fire suppression and wished not to. I would hate to rely upon an individual that hated going through an academy, that hated and did not ever want to learn fire suppression or rescue. 

By far it is not that I think all fire medics are bad or provide poor care.. by far, I know of very outstanding medics that are in fire service. But mandating personnel to attend courses that are customized is not good as well. 

Hopefully, EMS will mature and develop upon its own. It is difficult enough to perform fire suppression and fire tactics without a being an expert and performing  multiple jobs. 

R/r 911


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## firemedic1563 (Mar 16, 2007)

You raise valid points, and I agree with most of your points. Problem is this is a VERY complicated issue. And what works in one area will not work elsewhere. You have issues like politics, union involvement, call volume, infrastructure, etc.

I can't speak for other areas, as I am not well versed on them. I do know while our system has some serious flaws, mainly in the training area where they condense the training, leaving even the best intentioned students ill prepared and forced to rely on protocol for subjects they don't fully understand, it works for us. Mainly it provides rapid ALS care to every patient in need. We have all but phased out BLS units, and most BLS calls are handled by Paramedics.

The biggest problem with change, is that it leaves even more discontent. We have many medics who have spent 20 years on a medic unit, but would have loved to be on an engine. Now we are transitioning to a system that is slowly working toward a rotation, hopefully allowing those that do not wish to be in suppression not to. But we have hired over 200 employees for this. If they came out and said we all had to go into an EMS only role, a large number would quit.

I think the larger issue that breeds the problem of forcing people into EMS is the shortage of ALS providers. We need roughly 350 ALS providers to staff our units. With the mid level pay scale, it is hard to attract people. So they decide to "trap" people into doing EMS. The alternative is hiring the 5 or so they can get for every 50 person academy. And with the rate of retirements that is not an option. Like I said, complicated issue.


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## Medic's Wife (Mar 16, 2007)

This is the medic of medic's wife. My wife pulled me to this board and I have to say, it is interesting conversation. I have heard the trends of removing intubation from a medics list of abilities but that has mostly been from the pediatric age group. Recently I attended a PALS instructor update. What do you know, advanced airway management has been removed from the standard curriculum. 

I feel the problem lies on several fronts. First, our schools are rushing students to quickly. They need more airway training in the clinical arena. They learn the steps and are great with manikins, however, when you place them in a situation in which they are managing more than plastic, remembering those steps are much more difficult. With so many pediatric hospitals being built there is no reason medic students should not be allowed access to those clinical sites. 

Next, look at our own services, How many services have detailed protocols which  address airway assessments, difficult airways, failed airways. What about QA programs, how many require at least 5 documentable confirmation techniques before a tube is considered confirmed? Medical directors should re-evaluate their roles. Instead of banning a valuable skill, why not participate in frequent paramedic refreshers and training. 

These are just some ideas. As far as the physician intubation skills, they face the same problems as ourselves. I have seen too many physician missed airways. I have also secured the airway for some of those same physicians. Lets face it, we all face the same problems. Airway management is a valuable skill for all age populations. We are being forced to abandon some of the key principals that was drilled into our growing paramedical minds. Granted, not everyone is an expert airway clinician but we must help others that are lacking in the skill. Education and controlled experience for the uncontrolled situation is the answer, not a ban.



Remember, it is OK to miss an airway, however, failing to recognize a missed airway is not.


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## Ridryder911 (Mar 17, 2007)

I totally agree with you. EMS is on a slippery slope of going downward, we have allowed excuses to replace the truth. We much rather place a band aid on an arterial bleed and then replace it with another instead of truly to stop and fix the problem. 

The problem now is we are being examined for being incompetent. Although, many do not read it as such, but that is what is being said in diplomatic terms. Whenever studies point out that procedures should be removed and be replaced with "lesser difficult" airways and it would be better for the patient not to do anything, thenwe have a problem. 

It is a shame those in the power to be in EMS are "pushing" training in lieu of formal education and continue to see that it the system is on a downward spiral. Allowing those with less education, credentials & certifications to perform advanced skills only increases problems. Even with a formal education a continuous monitoring of skills and performance has to be established as well as a program to correct eneffectiveness. 

Programs forcing or requiring ones to be perform tasks they were never asked to do will only increase our poor track record. Studies have revealed it is much better to have a quick and good BLS response, followed by competent ALS than have multiple ALS providers. Communities should have ALS, but not all responders should have to be rated at such. It would be more adventitious to have fewer ALS providers that are competent and have the initial rescuers to provide competent BLS, than having poor ALS providers.

We should be at looking providing "quality versus quantity"....

R/r 911


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## VentMedic (Mar 17, 2007)

The paramedics themselves need to become proactive. In one large metropolitain area, a couple of well liked Emergency physicians saw the need for more intubation training/skills. They offered the same course on two different days to give more shifts an opportunity. They borrowed the very expensive intubation manikins from the med school and arranged for a cadaver lab. They kept the cost very reasonable (the physicians were picking up most of the tab) and offered CEUs. There were at least easily 400 - 500 paramedics in the area. 25 total registered for the classes. I attended it and thought it was better than anything offered in many years in that area to the paramedics. 

During one mandated refresher class (40 Paramedics-active on City or county rescue), I asked how many intubations each performed during the past 2 years. A couple had 10, majority had 6 or less and about 5 medics had 0.  There was not time allowed in the refresher to cover intubation as it should be. I suggested they take part in one of the local Medical University's intubation ... labs. Everybody said they didn't have time for more "CEU" stuff. 24 hours were too much already. The City/County should offer it to them but none of them had even asked their agencies about it.  They said it would "sound like they *needed* training".  Most big agencies are oblivious to any extra training needs until it is brought to their attention by the paramedics themselves. If nobody speaks, then they assume all is well. After talking with other instructors, the responses have been the same. Even when our college offered to make the arrangements for them...very few expressed a desire to go for more training. This is just like when a couple of ERs offered paramedics the chance to start IVs to keep their skills...another lacking area for some. No paramedic took them up on the offer. Most said something about being used as cheap slave labor...  In 4 hours they could have done easily 5 - 10 IVs and shown competency. 

Can't help those who don't want to be helped. Even when there are alternatives to keeping their skills updated and they don't go for it.  Even more unfortunate, there were probably those in that group that might actually want the additional training but felt they must go along with their louder peers. 

As I have said in previous posts, over the past 30 years, paramedics in the U.S. have not increased their education minimums. All the other professions have passed them up at the national level. In the hospital setting, skill level/proficiencies are closely monitored by inhouse and outside agencies. Until the entry level eduacation levels are increased and there is some national unity with standards among paramedics, the 1970s will remain. Actually, I think I did more in the 70s as a paramedic - just didn't have a lot of fancy gadgets to do my assessments. The fancy gadgets shouldn't take the place of good assessment and intubation skills.


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## Ridryder911 (Mar 17, 2007)

I agree with you vent. In the 70's most medics were starving for any education and would had jumped at the chance to improve themselves. I remember medics working twice as many hours as most of the ones now, but would had gladly took any courses all in the name of improvement. 

As you identified, a lot of the problem may be in the bias attitude of not thinking one has to continuously improve and prove one self. Many believe because they received a year of training or less they are automatically knowledgeable in emergency medicine and the skill that lies within. 

I do believe that is where many of the differences in between those that are trained and educated is separated. Education demonstrates the need of continuous improvement and monitoring of proficiency. Unfortunately, many EMS is now being placed into areas that much rather have numbers of employees that are "certified" to be able to deliver care, rather than to able to deliver competent care. We could blame it upon economics and politics, but again EMS and EMT's much rather take the easy way out, only to pay for it later. 

Intubation is only the beginning of examining of our competencies. Yes, technology is wonderful and has definitely improved patient outcomes when used appropriately. Unfortunately, many providers are placing money and interest of using such equipment to make diagnosis and treatment regimes, instead of requiring medics to have a thorough knowledge and proficiency in assessment and diagnostics. EMT's and medics relying upon equipment to determine what treatment and how in-depth should occur. A good example is the use of pulse oximetry. Most EMS personal are very lacking in understanding of the use, the restrictions, and inaccuracies of such. 

I do personally believe we have came to a fork in the road of prehospital care philosophies. One side is to produce mass numbers, with just the minimum number of hours to follow lengthy and detailed protocols, thus providing systems from litigation and at the same time provide "patient care".. and the other fork is having more educated medics with a in-depth and knowledge, with liberal protocols adapting care, what is best for the patient to stabilize and treat. The problem is the latter is more costly and takes more time, which many services do not want to invest in. 

Again, as you have pointed out apathy is one of EMS biggest enemies. 

R/r 911


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## Medic's Wife (Mar 17, 2007)

Ridryder911 said:


> Until the entry level education levels are increased and there is some national unity with standards among paramedics, the 1970s will remain



I agree wholeheartedly, but wouldn't an increase in pay scale have to go hand in hand with this?  Where my husband works is one of the highest paid counties in the state, but they are still hurting badly for medics.  They're having trouble filling the slots with warm bodies, much less highly competent bodies.  I can only imagine that with higher educational standards and continuing education standards' minimums being raised, there would be an even greater shortage than there is right now.  Is everyone experiencing this problem, or is it just regional?  I'm definitely for more intensified training and education, but I'm afraid I see pay being one of the things getting in the way of that happening.


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## Ridryder911 (Mar 17, 2007)

It is a hand in hand situation. You pay more, more would be attracted upon entering the profession that is serious about it. Shortages, are there for a reason.. Filling the slots with warm bodies and a pulse, will not correct the problem only aggravate it. 

Far as those that complain they cannot afford to go to school, that is a lame excuse. Just like any other profession one could get a student loan, work extra, etc.. If one wants to enter a profession bad enough, one will find a way to afford it. 

Far as shortages, I believe it is a myth. There are plenty of medics out there, but the problem is multicomplex. The pay sucks so bad, generally most civilized persons prefer not to work > 40 hrs a week, and have 2-3 jobs to pay for rent. I know we have plenty of NREMT/P that work at Wal-Mart, K-Mart and used car dealers, yet most are not the type most of the administrators prefer to have representing them, even if their standards are poor. 

Every 16 weeks we crank out about 100 Paramedics for a demand of about 20 so we are overloaded with the numbers, but still a shortage in supply. So, again it is the type of individual that we produce as well. 

I see many that exit medic programs that never enter the workforce, or even challenge the registry test. This is even in all levels of EMS. If medic school was that hard, costly, and really challenging, then one would make sure that they took advantage of doing what they were educated and trained to do. You do not see many professionals not entering a profession after spending years of study and thousands of dollars on studies, not to go into that profession. 

Again, I still contend it is too easy to become a medic. No entry requirements, very reasonable costs of medic schools (<$2000 -10,000), < 5 months to 2 years. So it is really not that difficult to "waste" the time, to see if it is for them. Some will say the pay off is poor, that is the reason why Compare this with even beautician school (>1 yr, $9,000) or even truck driving school in costs and return investment. 

There are no easy answers, but we need to compare our profession with other health careers and see how they were able to meet the needs and as well succeed. Physical therapists, nursing, even physicians maintain a supply and demand, only allowing a selected number into programs and thus allowing quality and serious students and for those students to have a position and competing salaries. Compare this where we have a over abundance of EMT's and have flooded the market. 

There are many out there, that would never want us to perform such due to increased costs for salaries, (which would dip into administration budgets) as well as professionals will demand such things such as benefits and career ladder movements. Many much rather for us to be a "trade" and keep status quo with description of shortages as an excuse to "get what they can".. 

The whole system need to be revised. It is poor designed from the top to the poor EMT in the street, working at poverty level. With increasing call volumes, poor financial reimbursements, and many EMS closings, it is time for EMT and medics to become very concerned with their profession. 

R/r 911


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## VentMedic (Mar 17, 2007)

I'm with Rid totally on the education issue. AND, where there's a desire to learn, there's a way. 

Many have wondered why the paramedic is not fully utilized in hospitals and clinics. They are not recognized in Washington, D.C. as a profession. Since there are no standards or consistency in education, Medicare and other re-imbursement  agencies will only pay for a "service" and not the professional. Insurance will reimburse for the "ambulance service" and not for the service provided individually for that health care professional. When working in the ER, paramedics will go under nursing services and be counted in cost as aides. Thus the ability to use a paramedic in the ER will be determined by the budget for extra staff that provides no reimbursement quality. Intubation will be provided by the health care professionals that can be reimbursed for it; MD, NP, RT.  

Each profession must think of itself as a business that must market itself to exist. The other healthcare professions have increased their value and through their powerful national organizations, have lobbied on Capitol Hill for a piece of the pie. There is money to be had. 

Even Massage Therapists are now recognized healthcare professionals. In many states, their initial training hours has surpassed that of a paramedic.  They are also now established in state community colleges with a 2 year degree of their own in the School of Health Sciences. Once they pass their national exam they now have a state LICENSE to practice in many states. They have a strong national lobbying organization to get more benefits and reimbursement. MTs are now widely accepted in hospitals due to their professional status and reimbursement potential. This has all occurred over the last 20 years.


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## chico.medic (Mar 18, 2007)

VentMedic said:


> During one mandated refresher class (40 Paramedics-active on City or county rescue), I asked how many intubations each performed during the past 2 years. A couple had 10, majority had 6 or less and about 5 medics had 0.



What are the demographics of your area?  I work in a county of 210,500 people, and my company provides services to approximately 3/4 of them.  I've had 7 tubes since January 1st.:excl:  (It might just be the fact that I'm averaging 80 hours a week.)


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## Guardian (Mar 19, 2007)

there's some great stuff on here, thanks, couldn't agree more with rid and vent.


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## jeepmedic (Mar 31, 2007)

Here at the BOP we Paramedics are a cross of what you on the street think of a paramedic, ER nurse, and a MLP. I have done a lot of other things that I never thought I would be allowed to do on the street.

As far a the education part. I have seen in my 20+ years how the people have changed. It used to be " lets see how many classes we can get to this year" to " lets see how many classes we can skip this year" this has been on the Fire and EMS side. People want the certs. but don't want to put the work in.

As far as Firemen in EMT-B classes I have taught classes and ask "Why are you taking this class?" and always get the "because I have to have it to get a job with X Fire Dept.


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