# Intubations dissapearing?



## MCGLYNN_EMTP (Oct 8, 2009)

I keep reading articles on intubations in the field and how studies are really leaning towards simply using sup. O2 and BVM verses actually intubation the patient. What do you guys think about this???


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## Shishkabob (Oct 8, 2009)

Still alive and strong here from what I see, but



Dallas FD and a few other FD's send their new recruits to the medic school based out of UT SouthWest medical center... and rumor has it that they are going to drop intubation from the curriculum.


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## Lifeguards For Life (Oct 8, 2009)

MCGLYNN_EMTP said:


> I keep reading articles on intubations in the field and how studies are really leaning towards simply using sup. O2 and BVM verses actually intubation the patient. What do you guys think about this???



I had heard this waas being considered while up at a conference in jacksonville. It is still in every local protocol that i know of. i don't know of any local agencies that have stopped doing it.


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## MCGLYNN_EMTP (Oct 8, 2009)

I just became a paramedic and we were still taught intubation for airway management in class....I'd sure hate to see intubations go...but I guess if that's what's best for the patient then that's what we'll have to do....It's still alive in louisiana in the company I work for (Acadian Ambulance)


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## el Murpharino (Oct 8, 2009)

MCGLYNN_EMTP said:


> I keep reading articles on intubations in the field and how studies are really leaning towards simply using sup. O2 and BVM verses actually intubation the patient. What do you guys think about this???



Some literature regarding prehospital intubation...perhaps we're doing more harm than good in spending countless minutes on a tube than rapid transport and a BLS airway.  I personally consider intubation to be the gold standard of airway management, but there is much damage that can be done by a poorly trained and inexperienced provider - which our profession is saturated with.

Out-of-Hospital Endotracheal Intubation: Where Are We? 
Wang HE, Yealy DM
Annals of Emergency Medicine
June 2006 (Vol. 47, Issue 6, Pages 532-541)

Meta analysis of 15 intubation studies (published from 1997 - 2005) that appeared in peer-reviewed medical journals.

Introduction:

Paramedic out-of-hospital endotracheal intubation originated in the 1970s from efforts to improve outcomes from cardiac arrest and major trauma.1, 2, 3, 4, 5 At that time, the best available methods for paramedic out-of-hospital airway management and ventilation were bag-valve-mask ventilation and the esophageal obturator airway.6, 7, 8, 9 Bag-valve-mask performance was perceived to be inadequate, and esophageal obturator airway use resulted in many complications, including inadequate or delayed ventilation, aspiration, pharyngeal and esophageal injury, gastric rupture, tracheal occlusion, and inadvertent tracheal intubation.6, 8, 10, 11, 12, 13, 14, 15 Out-of-hospital endotracheal intubation offered an alternative method to optimize care, promising superior airway protection, efficient ventilation, and a route to deliver endobronchial medications.16 Endotracheal intubation was also the standard for in-hospital resuscitation, classified as a “definitely helpful” intervention by then-current Advanced Cardiac Life Support guidelines.17 Several authors reported groundbreaking efforts to implement out-of-hospital endotracheal intubation in Boston, Columbus, San Diego, and Pittsburgh.1, 2, 3, 4

Despite its accepted role in clinical practice for more than 25 years, a growing body of literature suggests that out-of-hospital endotracheal intubation is not achieving its intended overarching goals. In selected cases, the intervention may cause harm. In this article, we provide an overview of recent data evaluating the effectiveness, safety, and feasibility of paramedic out-of-hospital endotracheal intubation.

Is Out-of-Hospital Endotracheal Intubation Effective?

The fundamental test of a medical intervention is whether it improves the outcome of the targeted patients.18 In this light, the overarching goal of out-of-hospital endotracheal intubation is to reduce mortality and morbidity for those in need of airway support. Several investigators have evaluated survival and neurologic outcome after out-of-hospital endotracheal intubation19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33 (Table). These studies largely involve retrospective analyses of predominantly injured patients. Although 2 studies identified increased survival from out-of-hospital endotracheal intubation, the remaining efforts found either decreased or no effect on survival. No studies have identified improved neurologic outcome from out-of-hospital endotracheal intubation.

Conclusion:

The current literature highlights shortcomings associated with out-of-hospital endotracheal intubation. Few studies affirm current practice. Few studies have demonstrated improved outcome from out-of-hospital endotracheal intubation in any disease group, and several studies describe worsened outcomes. In many studies, adverse events and errors associated with out-of-hospital endotracheal intubation are frequent. Out-of-hospital endotracheal intubation may inadvertently interact with other physiologic processes key to optimizing resuscitation. Significant system-level barriers limit opportunities for endotracheal intubation training and clinical experience. Scientists, medical directors, and clinicians must strive to better understand and ultimately improve this key intervention.


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## el Murpharino (Oct 8, 2009)

Volume 47, Issue 6, Pages 542-544 (June 2006)

Out-of-Hospital Endotracheal Intubation: Half Empty or Half Full?
John H. Burton, MD

published online 27 February 2006.
[Ann Emerg Med. 2006;47:542-544.]


Many researchers, emergency medical service (EMS) providers, and emergency physicians are increasingly viewing ground transport, out-of-hospital endotracheal intubation with skepticism. On one side of the debate are those who continue their support of this practice and read the medical literature with concern that the data are incomplete and not exhaustively studied—the glass is half full. This side of the table expresses confidence in the “A-B-C” mantra, cites the progress in out-of-hospital airway management practice, and advises no change until more conclusive data are brought to the subject.

On the other side of the debate are those who see the glass as half empty, with no credible evidence that out-of-hospital endotracheal intubation contributes meaningfully toward the reduction of morbidity or mortality in ground transport EMS patients. The discourse from this side has a certain crescendo momentum of late because the evidence has increasingly indicated that out-of-hospital endotracheal intubation may cause more harm than benefit.

In this issue of Annals of Emergency Medicine, 2 important contributions appear that add to the discourse: Jacoby et al 1 and Wang and Yealy.2 Jacoby et al 1 describe a clinical trial evaluating midazolam and etomidate for induction agent–facilitated intubation of adult EMS patients. The stance communicated by the investigators in this trial would suggest that they reside on the half-full side of the out-of-hospital endotracheal intubation debate. Wang and Yealy,2 in contrast, weigh in with the half-empty view of the debate as they exhaustively review the medical literature that has attempted to assess the outcomes associated with out-of-hospital endotracheal intubation.

To place the debate about out-of-hospital intubation practice into the proper context, we must first accept the reality of emergency department (ED) endotracheal intubation. Many patients will require a period of mechanically assisted ventilation during hospitalization. The ED is often the point of initial contact, evaluation, or diagnosis for these patients, necessitating the importance of endotracheal intubation skills for the emergency physician. Modern emergency medicine practice incorporates a host of techniques for facilitating endotracheal intubation in the ED. Rapid sequence induction is the primary accepted means of optimizing intubation success rates associated with this procedure.

The practice of out-of-hospital endotracheal intubation, then, would appear to rely on 2 precepts, with the overriding principle of what is good for the patients in the ED must be good for the patients before they get to the ED. The first precept is that the resource expenditure necessary to train and maintain effective out-of-hospital provider intubations skills is a worthwhile investment, given the limited training, oversight, and financial resources inherent in many EMS systems. The second precept is that out-of-hospital endotracheal intubation will improve, and certainly not worsen, patient morbidity or mortality compared to an EMS practice without these interventions.

The first precept, the utility of the resource investment, is one open to debate and may depend on the EMS setting, resources, and the patient population. The emphasis of this precept is on the size of the investment relative to the resources available and the derived patient benefit.

As Wang and Yealy 2 describe, teaching endotracheal intubation takes a great deal of time relative to other EMS skills, requiring didactic and practical skills-based training incorporating mannequins or live models. As one adds medication-assisted or rapid sequence induction strategies to the provider skill set, the investment increases precipitously. The potential for harm induced by the use of neuromuscular blocking and induction agents necessitates a substantial infrastructure investment in training, skill maintenance, oversight, and, in the opinion of most, a live-human, large-volume training environment (usually the operating room).

Few would argue that we should invest limited EMS resources in skills or interventions that will seldom be used or confer no benefit. Two populations in which this principle can be applied are rural EMS patients and cardiac arrest patients. We have previously demonstrated that EMS providers in our rural state uncommonly use intubation skills.3 For any given calendar year, less than one third of the licensed EMS providers in the state of Maine will use their adult intubation skills. Worse, less than 1% of providers in this rural state will annually use their pediatric intubation skills. These findings lead one to the conclusion that out-of-hospital endotracheal intubation training investments in a low-volume or rural EMS setting offer a very poor return for EMS systems, unless it can be demonstrated that these uncommonly used skills translate to a patient survival benefit.

Out-of-hospital intubation of the cardiac arrest patient assumes dramatic relevance when one observes that approximately one half to two thirds of all out-of-hospital intubation encounters will be in cardiac arrest patients.2, 3 The question of the benefit of out-of-hospital endotracheal intubation to this population has been addressed by Stiell et al,4 who found no survival benefit derived from out-of-hospital endotracheal intubation. Their findings lead one to the conclusion that despite our continued recitation of the “A-B-C” mantra, the data demonstrate that “D” (defibrillation) and “C” (circulation/compressions) have far greater importance than “A” in the out-of-hospital cardiac arrest patient.

We are left with the second precept: that survival outcomes associated with out-of-hospital endotracheal intubation will improve, and certainly not worsen, morbidity and mortality. To address this question, Wang and Yealy 2 consider the multitude of populations and potential approaches to EMS intubation practices. Their review includes investigations devoted to understanding outcomes associated with intubation of the out-of-hospital head-injured trauma patient, with or without rapid sequence induction. Also addressed are focus populations, including cardiac arrest and pediatric patients.

Wang and Yealy 2 conclude that the current scientific evidence “suggests that out-of-hospital endotracheal intubation is not achieving its intended overarching goals” and that out-of-hospital endotracheal intubation as an intervention may cause harm.2 They leave us with the many formidable challenges that lie ahead for those attempting to chart the future course for out-of-hospital endotracheal intubation, including the replacement of out-of-hospital endotracheal intubation with alternate airway management techniques such as the Combitube and laryngeal mask airway.

... detailed analysis of both articles ...

The articles published in this issue of Annals add resounding thunderclaps into what should be a storm of debate surrounding the utility and efficacy of ground transport, out-of-hospital endotracheal intubation. Indeed, the historical arguments laying the foundation for this practice viewed through the lens of these contributions should motivate the half-full and half-empty sides of the out-of-hospital endotracheal intubation debate to craft a unified strategy for the future of EMS practice.


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## MCGLYNN_EMTP (Oct 8, 2009)

It's really hard to study this subject. One can not really prove that the intubation made the outcome better or worse even in a collection of patients who were intubated and who were not...who's to say those patients intubated wouldnt have died anyway regaurdless of simple BVM or intubation? 
I do see a shift toward combi-tube happening in the near future, but we would still have to carry ET tubes due to some patients needing intubation with an active gag-reflex. I'm still curious to see what the future holds for intubations.


My ambulance service is looking into a device called the "S.A.L.T." (click here for link to its website) it is inserted like an OPA and can be used as an OPA....but when it is time to intubate, the ET tube is slipped into a hole in the "S.A.L.T." and the tube is almost always guided into the trachea...The tube would then be confirmed by normal methods and restrained by the usual methods as well...
I deffinately see this being used in the near future as well...


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## zappa26 (Oct 8, 2009)

I'm going to come off as terribly arrogant for this, and I really do apologize, but we're learning ETT and dual lumens as a supplemental skill in our EMT-B class.


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## Smash (Oct 8, 2009)

I am deeply, deeply suspicious of anything authored by Henry Wang as it is very clear that he has an agenda, for whatever reason that seems to be about denying medics the ability to control airways. 

One of the oft cited 'studies' into the alleged deleterious effect of prehospital intubation is Wang's Out-of-hospital endotracheal intubation and outcome after traumatic brain injury, Ann Emerg Med 2004.

I challenge anyone to read this study with anything other than tears, either from laughter, because it is clearly a joke, or from sadness that this tripe is held up as a shining beacon of prehospital research.

Prehospital ETI certainly needs more research into it, however I see the downside of ETI not being whether it is good or bad, but whether medics do it well or poorly.  If we continue to hand out laryngoscopes to people who are only hitting the mark 80% (or less) of the time, then of course we are going to have undesireable outcomes.

All that the research currently shows is that airway management done badly is of no use.

However if we actually give a damn, educate and train medics appropriately, allow them to gain experience and give them the tools (such as RSI) to properly control an airway, then we can start carrying out some decent prospective, randomized trials and get some answers.


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## Dwindlin (Oct 8, 2009)

Smash said:


> I am deeply, deeply suspicious of anything authored by Henry Wang as it is very clear that he has an agenda, for whatever reason that seems to be about denying medics the ability to control airways.
> 
> One of the oft cited 'studies' into the alleged deleterious effect of prehospital intubation is Wang's Out-of-hospital endotracheal intubation and outcome after traumatic brain injury, Ann Emerg Med 2004.
> 
> ...



Personally I don't see the issue as a lack of training/poor training but (for many) a lack to use the skill.  I don't think anyone would argue there is a huge difference between tubing dummies in a class room, versus getting ETT in the OR and then translating that to some of the situations we deal with in the field, then doing enough field intubations to remain completely proficient.  Most of the research (not just Wang as I agree with you about him) shows that as a whole we don't hit tubes as often as we think and more frightening we don't recognize the fact we have misplaced a tube.  For me personally, after getting access to prehospital CPAP about the only time I ever go with an ETT anymore is cardiac arrest.  As with most anything trauma related the best thing you can do for your patient is expediting transport.  Now do I mean skip treatments? No, of course not, but in a trauma situation were the patient may be going downhill quickly I think we are better off placing blind airways, and letting the hospital handle more appropriate airway management (this is also a little simpler for me as we do not have RSI were I work).


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## el Murpharino (Oct 8, 2009)

zappa26 said:


> I'm going to come off as terribly arrogant for this, and I really do apologize, but we're learning ETT and dual lumens as a supplemental skill in our EMT-B class.



The unfortunate part of all of that is they provide minimal education regarding it.  How many live intubations do you have to do before you can be "cleared"?


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## el Murpharino (Oct 8, 2009)

atkinsje said:


> ...I think we are better off placing blind airways, and letting the hospital handle more appropriate airway management



Some systems are adopting this practice, and I wouldn't be surprised to see this as a standard in the near future.


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## triemal04 (Oct 8, 2009)

Smash said:


> Prehospital ETI certainly needs more research into it, however I see the downside of ETI not being whether it is good or bad, but whether medics do it well or poorly.  If we continue to hand out laryngoscopes to people who are only hitting the mark 80% (or less) of the time, then of course we are going to have undesireable outcomes.
> 
> All that the research currently shows is that airway management done badly is of no use.
> 
> However if we actually give a damn, educate and train medics appropriately, allow them to gain experience and give them the tools (such as RSI) to properly control an airway, then we can start carrying out some decent prospective, randomized trials and get some answers.





atkinsje said:


> Personally I don't see the issue as a lack of training/poor training but (for many) a lack to use the skill.  I don't think anyone would argue there is a huge difference between tubing dummies in a class room, versus getting ETT in the OR and then translating that to some of the situations we deal with in the field, then doing enough field intubations to remain completely proficient.  Most of the research (not just Wang as I agree with you about him) shows that as a whole we don't hit tubes as often as we think and more frightening we don't recognize the fact we have misplaced a tube.


'Nuff said really.  But just so everyone get's the point clearly, here goes.

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

Right now the ball is in our court if we want to continue to intubate in the field.  (and yes, it is still in the current national curriculum and the new one that will be in effect soon)  Like so many things in EMS, the initial education and training, and then continuing education are sometimes, often times, not up to the standard it should be at.  Which means there are paramedics out there who are very bad at intubating and recognizing esophageal intubations.  This doesn't mean that everyone should lose the ability, just that, as usual, we need to take a long look at how we teach new medics, and how they maintain their skills

As well, take a look at the vast majority of studies done on intubation (anything really).  You'll notice that many are done in very urban, high call volume areas.  You'll also notice that many of those areas have a very poor reputation as far as EMS in concerned and don't always field good medics.  Think there could be a correlation between the outcomes found in intubation studies and who was doing the intubation?  Both Boston EMS and King County Medic 1 (the Seattle Fire division) have recently done similar studies on intubation to Wang's and others...and both had drastically different results.  From talking with a medic from Idaho, Ada County EMS has done the same.  Apparently if you demand a high level of competency and knowledge, the number of problems you create goes down.  Who'd a thunk it?  Of course, that doesn't matter if 1-nobody knows about it, and 2-the average medic still can't appropriately intubate someone.

So how do we fix this?  If you work for a service that has a great success rate at intubation and have a progressive medical director...get with it!  Start putting the numbers together and publish your own study.  Get the information out there that intubation can, and is done appropriately by paramedics, and get the info on WHY that happens out there.  If people only get one side of an issue, then they can't make the right decision.  Once that's done...get ready for a real fight, and start lobbying the change the initial educational standards for paramedics.  

If we actually want EMS to survive and thrive, it's time to start taking an interest in it; stop letting people outside the field dictate what happens and start thinking for ourselves.


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## Dominion (Oct 8, 2009)

I think it is a combo of a lack of practice and a lack of education.  I mean we hear and see studies about intubation in pre-hospital but I haven't really seen much on the study of intubation in outlying/rural hospitals.  Where I have personally seen a transport from a rural hospital in which the intubation was all jacked up and my medic ended up doing it himself before leaving.  (Of course was a one time situation for me)

You get situations where at my service you might get one intubation every couple months maybe a couple a month in rare situations.  A county over a medic might get one or two tubes a week and maybe one tube every couple weeks nasal.  

ETT is still the gold standard and I think it should be more closely monitored for skill (maybe adding the requirement of clinical hours every year or a specific number of intubation attempts on live patients).  There are always other options for airway management.  We do two attempts at ETT, combitube/LMA, BVM with NPA or OPA.  We get it pounded into our heads that a patient doesn't die from a lack of intubation but from a lack of ventilation.


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## medichopeful (Oct 8, 2009)

zappa26 said:


> I'm going to come off as terribly arrogant for this, and I really do apologize, but we're learning ETT and dual lumens as a supplemental skill in our EMT-B class.



I don't take it as being arrogant.  You can't choose what they teach you.

However, is it a skill you will actually be able to use?  Is it in your protocols?  Or are they just teaching it to you for fun?  If it's just for fun, you may want to bring that up with your instructor, and say that you would like to learn about stuff you can ACTUALLY do.


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## MCGLYNN_EMTP (Oct 8, 2009)

We still intubate with my service and it doesn't seem that intubations are going anywhere anytime soon. We intubate quite often where I work with a very large call volume compared to other services in the area. In a 12 hour shift we run about 10 emergencies so of course the likely hood that we will intubate is higher than other areas because we are exposed to a possibility of more calls that require intubation. 

I was just curious to see what other people thought about the studies out there to see if intubations are actually worth it or not and to see what other services out there are doing right now as far as protocols go.


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## Summit (Oct 8, 2009)

It could go away from a district or two, but it won't go away from schools for a long time.


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## MrBrown (Oct 8, 2009)

Linuss said:


> Dallas FD and a few other FD's send their new recruits to the medic school based out of UT SouthWest medical center... and rumor has it that they are going to drop intubation from the curriculum.



Rumor has it DFR want to bring Paramedic training in-house, I hear too many Firefighters are failing and costing them money to send them there again 

Anyway, intubation is still on the cards for our Intensive Care Paramedics but I don't really know what our success rate is for standard intubation or what the average intubation : officer ratio is (we have had 95-95% success with RSI) 

We do use laryngeal masks at the BLS and ILS level, some ICPs use them first others were ICPs before LMAs came in so have never really "adapted" if you will to having them (we've had them for about 6 years) and still perfer to intubate everybody


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## atropine (Oct 8, 2009)

Who cares let them and I don't even know who "them" is, take it away, does it really matter when your 5-8 min. away from the er?


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## cfd3091 (Oct 8, 2009)

zappa26 said:


> I'm going to come off as terribly arrogant for this, and I really do apologize, but we're learning ETT and dual lumens as a supplemental skill in our EMT-B class.



I don't think your arrogant, learning the skill of ETT does not take much and I'm sure you'll learn it. Intubation is more then the how to. What do you do when the heart rate drops? How do you know? Please don't say pulse ox. A paramedic has the knowledge of Physiology and Pharmocology to handle the situation when the SHTF. I'm sure they are teaching you so you can assist a Paramedic.


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## Summit (Oct 8, 2009)

atropine said:


> Who cares let them and I don't even know who "them" is, take it away, does it really matter when your 5-8 min. away from the er?



I almost missed the


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## MCGLYNN_EMTP (Oct 8, 2009)

I agree, ETT is not a difficult skill to learn. We spent a few days on it in my P class and that was a wrap...The major thing is knowing what to do when something goes wrong...as far as put the tube in the trachea...I think we can all understand that.  I wish I would have had a place to do live intubations like in surgery...I only got 1 live intubation on my clinical...well...it was a complete arrest so maybe not "LIVE" but it was a human none the less...It still doesnt require much training to learn the skill.

Yeah If we are only 5-8 minutes away from the hospital...maybe we should just hold back on ETI...but what about a response where you are 15 to 20 minutes out??

I Dont see the ETT being removed from the trucks anytime soon...but I do see it being used less and less and being replaced with other things maybe...It's still hard to say...I mean ETT has been in pre-hospital since what the 70's?


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## Shishkabob (Oct 8, 2009)

atropine said:


> Who cares let them and I don't even know who "them" is, take it away, does it really matter when your 5-8 min. away from the er?



I don't know if they taught you in your medic school, but oxygen is pretty important.  People can and have died from being deprived of oxygen by an unkempt airway.


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## atropine (Oct 8, 2009)

Linuss said:


> I don't know if they taught you in your medic school, but oxygen is pretty important.  People can and have died from being deprived of oxygen by an unkempt airway.



Who said anything thing about an unkempt airway, an OPA, and BVM is just fine if your 5-8 min away. Let the MD and RT earn their keep


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## Shishkabob (Oct 8, 2009)

Because OPAs and NPAs are so helpful during an allergic reaction with laryngeal edema.


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## atropine (Oct 8, 2009)

Linuss said:


> Because OPAs and NPAs are so helpful during an allergic reaction with laryngeal edema.



Yeah that happens often, if it's anaphylaxis the airway is going to close on you before you even get there and since most of our calls are bls anyways who cares.


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## Summit (Oct 8, 2009)

Hey Linus,

Y so serious?


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## Shishkabob (Oct 8, 2009)

Summit said:


> Hey Linus,
> 
> Y so serious?



I'm and evil evil person with nothing better to do?


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## MCGLYNN_EMTP (Oct 8, 2009)

I had an anaphylactic pt. the other day...Got there within a minute of them calling 911 and he still had a patent airway...had it been 3 minutes later he'd have been closed off...Epi does wonders ...if that didnt work ETT would have been next.. but yeah...MOSTLY BLS calls...you can probly even leave the L out of BLS most of the time..


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## Akulahawk (Oct 8, 2009)

MCGLYNN_EMTP said:


> I had an anaphylactic pt. the other day...Got there within a minute of them calling 911 and he still had a patent airway...had it been 3 minutes later he'd have been closed off...Epi does wonders ...if that didnt work ETT would have been next.. but yeah...MOSTLY BLS calls...you can probly even leave the L out of BLS most of the time..


One of my first ALS patients when I was going through my internship was like that... He didn't progress quite as quickly as your patient was, but he was certainly on his way. At the time, we still had an age requirement to call for an epi order (he was too old to just administer it). He got 50 mg Benadryl... stopped his reaction in it's tracks. The epi turned him around really quickly. (We got an order for that... :wacko These days, the age issue w/ epi in anaphylaxis isn't an issue anymore. He'd have gotten the epi right off the bat... Still, he was headed down that same path. A couple more minutes and his day would have gotten a whole lot worse... I've had a few more since then, but that guy stood out... mostly because he was my first anaphylaxis patient...

That was a few years ago... thanks for bringing him back to mind.


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## MCGLYNN_EMTP (Oct 8, 2009)

No Problem...
I'm still new at this whole being the paramedic now thing...I'm used to being the little EMT-Basic who doesn't completely understand why this drug is given or what the hell those squiggly lines on that monitor mean...
I know what they mean now and I know what to do..its just applying it to the patients I have to work on now..I'm hoping working more and reading this forum will help me out.


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## MasterIntubator (Oct 8, 2009)

Will be one sad day in EMS if they do take it away, maybe restrict it for some... or finally give formalized training/retraining/practice when problems arise with said providers.

Worked beautiful in the 80's, works beautiful now.

in the search archives are many great posts on this subject, very informative.

And just an tidbit of inside info... the hospital statistics are not much better, they just catch it and correct it before bad things happen ( which 3-4 minutes intubation time is common, and OK. )


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## MSDeltaFlt (Oct 8, 2009)

MCGLYNN_EMTP said:


> I keep reading articles on intubations in the field and how studies are really leaning towards simply using sup. O2 and BVM verses actually intubation the patient. What do you guys think about this???


 
Pulling prehospital intubations is a mistake.



el Murpharino said:


> Some literature regarding prehospital intubation...*perhaps we're doing more harm than good in spending countless minutes on a tube than rapid transport and a BLS airway*. I personally consider intubation to be the gold standard of airway management, but *there is much damage that can be done by a poorly trained and inexperienced provider* - which our profession is saturated with.


 
It's not so much the lack of intubation skill as much as it's a lack of situational awareness and lack of proper management of the scene/patient as a proper paramedic.



atkinsje said:


> *Personally I don't see the issue as a lack of training/poor training but (for many) a lack to use the skill*. I don't think anyone would argue there is a huge difference between tubing dummies in a class room, versus getting ETT in the OR and then translating that to some of the situations we deal with in the field, then doing enough field intubations to remain completely proficient. Most of the research (not just Wang as I agree with you about him) shows that as a whole we don't hit tubes as often as we think and more frightening we don't recognize the fact we have misplaced a tube. For me personally, after getting access to prehospital CPAP about the only time I ever go with an ETT anymore is cardiac arrest. As with most anything trauma related the best thing you can do for your patient is expediting transport. Now do I mean skip treatments? No, of course not, but in a trauma situation were the patient may be going downhill quickly I think we are better off placing blind airways, and letting the hospital handle more appropriate airway management (this is also a little simpler for me as we do not have RSI were I work).


 
It's called tunnel vision.



Dominion said:


> *I think it is a combo of a lack of practice and a lack of education*. I mean we hear and see studies about intubation in pre-hospital but I haven't really seen much on the study of intubation in outlying/rural hospitals. Where I have personally seen a transport from a rural hospital in which the intubation was all jacked up and my medic ended up doing it himself before leaving. (Of course was a one time situation for me)
> 
> You get situations where at my service you might get one intubation every couple months maybe a couple a month in rare situations. A county over a medic might get one or two tubes a week and maybe one tube every couple weeks nasal.
> 
> ETT is still the gold standard and I think it should be more closely monitored for skill (maybe adding the requirement of clinical hours every year or a specific number of intubation attempts on live patients). There are always other options for airway management. *We do two attempts at ETT, combitube/LMA, BVM with NPA or OPA. We get it pounded into our heads that a patient doesn't die from a lack of intubation but from a lack of ventilation*.


 
"Airway" does not mean intubation and intubation alone. It means *airway*: an unobstructed path from your oxygen source and the lungs. That's it.



MCGLYNN_EMTP said:


> *I agree, ETT is not a difficult skill to learn. We spent a few days on it in my P class and that was a wrap*...The major thing is knowing what to do when something goes wrong...as far as put the tube in the trachea...I think we can all understand that. *I wish I would have had a place to do live intubations like in surgery*...I only got 1 live intubation on my clinical...well...it was a complete arrest so maybe not "LIVE" but it was a human none the less...It still doesnt require much training to learn the skill.


 
It maybe easy to learn, but it's most definitely hard to master. What I mean by that is mastering the skill of "airway"; not just intubating. I've said this before and I'll say it again. Vent, Rid, and Flight-LP can back me up on this. But knowing what to do and being able to do it is easy. Any moron can be taught that. The "trick" to this job is in being able to do something and knowing when and when NOT to do it. That is the hard part. I've been caring for the critically ill and intubating since the early 90's. And if you can truely master the "trick", then you're a much better provider than I am.


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## MCGLYNN_EMTP (Oct 8, 2009)

MSDELTAFL Great post. Yeah I agree anyone can be taught the skill of intubation.. its the skill of "airway" as you put it that I need practice with..and I guess that will come with time and experience..


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## Dwindlin (Oct 8, 2009)

MSDeltaFlt said:


> It's called tunnel vision.



Can you clarify this?  I don't get what you're trying to say in relation to my post.  I don't get how a lack of opportunity to use this skill enough to be truly proficient is tunnel vision.  Which was my point.  If that was poorly conveyed in my post my apologies.


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## rhan101277 (Oct 9, 2009)

MSDeltaFlt said:


> Pulling prehospital intubations is a mistake.
> 
> 
> 
> ...



Yes our class is really hitting on home on making sure we know why we are doing something and when NOT to do it.  Instead of just acting like a robot.

As far as intubating, I think it is important.  Patients may vomit, if they do then normally you turn them over to clear airway, but that is a very basic concept.  Putting in ETT tube stops aspiration, whether it be vomit blood or what not.  Once that aspiration makes it down the mainstem bronchi and into the smaller and smaller bronchioles, well that leads to less blood getting gas exchange, which leads to poor perfusion.

I think doing it helps, haven't studied it in class yet though.


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## MCGLYNN_EMTP (Oct 9, 2009)

Thats my main thing...It preventrs aspiration in an unreliable pt. be it a bad trauma with a head injury or a complete arrest which are notorious for vomiting everywhere...or atleast 90% of mine do that...and it seems its always chicken nuggets or chicken noodle soup...ughh


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## MSDeltaFlt (Oct 9, 2009)

atkinsje said:


> Can you clarify this? I don't get what you're trying to say in relation to my post. I don't get how a lack of opportunity to use this skill enough to be truly proficient is tunnel vision. Which was my point. If that was poorly conveyed in my post my apologies.


 
Sure.  The reason why medics miss tubes and spend too much time on scene "trying to get the tube" with a resulting poor outcome for the pt (which is the main reason for all of the articals and studies by the way) is because the medics miss a tube and get tunnel vision.  They waste precious time on scene because they have lost their situational awareness and the pt suffers.

You don't go for a tube without your back up airways set up, ready, and within easy arm's reach.

You see the best skill a medic has in his/her arsenal is not intubation, or being a "big gun" with IV's, or figuring out weight-based drug calculations on the fly in our head, or what-have-you.  It's the medic's brain with situational awareness; especially in relation to being on the butt-crack side of the county (we've all been there and done this), with a 500# pt on the 2nd floor in the back bedroom between the bed and dresser, who has just "stroked out", and we have to get that pt to the hospital *alive*, and all we have is limited help (one partner), limited equipment (if it works), and limited protocols.  You have got to be able to think outside of the box.

That, my friends, is what really got me hired on a flight team.  The credentials only helped.  All they did was to make me look pretty on my CV.


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## usafmedic45 (Oct 9, 2009)

> I am deeply, deeply suspicious of anything authored by Henry Wang as it is very clear that he has an agenda, for whatever reason that seems to be about denying medics the ability to control airways.



Most people have "an agenda", especially in those who are publishing research papers.  You have an "agenda".  I have an "agenda" (although I publish my research findings regardless of whichever way the findings come out; the point is to advance knowledge and improve things not to prove that I'm "right").  The difference is that some of us have data to back up a particular "agenda"

You can control an airway without having to do a visualized airway.  Sometimes, it's the best option actually even in cases where intubation under direct laryngoscopy is an option.  Only fools let their egos get in the way of a secured airway.  It doesn't make your penis any bigger to have access to a laryngoscope so if you can still bring the patient in alive and doing better than you found them, what is the big deal?



> the hospital statistics are not much better, they just catch it and correct it before bad things happen



Which is why any viable study looks at the rate of "missed intubations".  That (failure to recognize a misplaced or displaced tube) is the primary issue here along with a lack of appreciable benefit to the patients as a group (or groups rather to be nit picky about it).  Also I would like to know where you are citing the failure rate for hospital intubations from so I can verify that you're not cherry picking your data or bending it to fit your argument. 



> > Because OPAs and NPAs are so helpful during an allergic reaction with laryngeal edema.
> 
> 
> Yeah that happens often, if it's anaphylaxis the airway is going to close on you before you even get there and since most of our calls are bls anyways who cares



Then the argument should be for surgical airways in that handful of cases that do close before our arrival.    In 15 years and with probably 20-30 true anaphylaxis cases (including my former neighbor who was allergic to just about everything from bee stings to paint fumes so I've pumped epi and diphenhydramine into her on probably 10+ occasions) 99% of those never went to full airway closure), rather than for intubation which is at best really difficult and often flat out impossible in anaphylaxis.

A case not amenable to intubation is NOT an argument for intubation.  The fact that you don't see that makes me suspect you may not be quite as well versed in airway management and how to debate something on its merits as you believe yourself to be.



> but we would still have to carry ET tubes due to some patients needing intubation with an active gag-reflex



I assume you're referring to nasotracheal intubation? 



> Pulling prehospital intubations is a mistake.



Agreed, with a few reservations.  However, I think we really should be less hostile to the idea of non-visualized airways with comparable functionality.  



> I keep reading articles on intubations in the field and how studies are really leaning towards simply using sup. O2 and BVM verses actually intubation the patient. What do you guys think about this???



Actually most of the comments I've heard from people who aren't scared out of their freaking minds about losing "the vital skill" of intubation is that we should move towards that with the backup of a non-visualized airway like a Combitube or an LMA.

In fact, I would argue that proper BVM use is one of the few areas that make paramedics look GOOD at intubations by comparison.  It is also a much more technically difficult skill to master and retain than intubation especially if you're doing it for more than a couple of minutes due to the effects of fatigue and attention issues.  The major difference is that you can generally do a half-*** job of bagging someone without killing them whereas with an intubation if you bungle it and don't realize it the margin of error is going to be a lot closer to, if not, zero.


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## Smash (Oct 9, 2009)

usafmedic45 said:


> Most people have "an agenda", especially in those who are publishing research papers.  You have an "agenda".  I have an "agenda" (although I publish my research findings regardless of whichever way the findings come out; the point is to advance knowledge and improve things not to prove that I'm "right").  The difference is that some of us have data to back up a particular "agenda"
> 
> You can control an airway without having to do a visualized airway.  Sometimes, it's the best option actually even in cases where intubation under direct laryngoscopy is an option.  Only fools let their egos get in the way of a secured airway.  It doesn't make your penis any bigger to have access to a laryngoscope so if you can still bring the patient in alive and doing better than you found them, what is the big deal?



Hmmmm.....  I may be misreading it, but that seems like an awful lot of hostility.  Are you a personal friend of Dr Wang's?  

Have you read the study I remarked upon?  It tells us next to nothing about the efficacy of pre-hospital intubations.  It does tell us that patients with a head injury and absent airway reflexes tend to do badly, but I'm sure no-one is falling off their seat in surprise over that.  The vast majority of studies into prehospital ETI tell us very little for a number of reasons, not least of which is the fact that so many are retrospective.  This is why I advocate further research before we throw the baby out with the bathwater.

However to carry out the research that we need to do, we must ensure that first we are measuring the same thing.  It is no use comparing, for example RSI in head injured patients with cold ETI.  They are fundamentally different things.

I'm not sure why you think this means I have a large ego, or indeed that I want to make my penis larger (I'm not sure why you think I have a penis at all in fact) but, if that is you see things, so be it.  Feel free to chip in with how long your e-penis is so we can compare notes though.


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## Smash (Oct 9, 2009)

> Putting in ETT tube stops aspiration, whether it be vomit blood or what not



Actually it is a common error to think that ETI prevents aspiration.  It certainly reduces the likelihood of massive aspiration, however as near as makes no difference to 100% of intubated ICU patients have gut flora in their lungs.  This is why it is important to pass an orogastric tube (amongst other reasons) in the intubated patient and to remain vigilant about suctioning not just the tube but also the oropharynx.


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## timmy84 (Oct 9, 2009)

MCGLYNN_EMTP said:


> My ambulance service is looking into a device called the "S.A.L.T." (click here for link to its website) it is inserted like an OPA and can be used as an OPA....but when it is time to intubate, the ET tube is slipped into a hole in the "S.A.L.T." and the tube is almost always guided into the trachea...The tube would then be confirmed by normal methods and restrained by the usual methods as well...
> I deffinately see this being used in the near future as well...



I was just reading about the S.A.L.T (or SALT for anyone searching without the periods) today.  One of my instructors mentioned it about a week ago, and was not able to fully describe it, so I assume it is not all the way out there.  Seems like a pretty good product, I wanted to know if anyone has used it.  What are everyone's thoughts about it?  It certainly looks like it could be cost effective, or will be once it's patent expires (a CombiTube costs our service 50 bucks, versus 3 bucks for an ETT) (wow I am sounding like my boss).


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## usafmedic45 (Oct 9, 2009)

> Hmmmm..... I may be misreading it, but that seems like an awful lot of hostility.



That you are.  I might be a little more bristly than normal (and ask to be forgiven that due to a lot of the crap going on my personal life at the moment), but it's not frank hostility you're encountering.  Just my blunt nature combined with having been up for far too long. 



> Are you a personal friend of Dr Wang's?



Actually no, I've never met the man nor spoken with him in any way so I can't count him as a friend or even an acquaintance, however I do tend to agree with a lot of what he (and nearly every other researcher on the topic) has said.  Not all of it, but I think he's gotten at least the broader gist of things fairly close to correct. 



> The vast majority of studies into prehospital ETI tell us very little for a number of reasons, not least of which is the fact that so many are retrospective.



OK, two things:  

1.  Ever tried to squeeze a prospective airway study past an IRB before?  It's not easy, I should know...I've tried on two different occasions.  You start talking about giving people "differing" (even if the end result of the two devices is effectively the same thing) levels of care and they start to have fits about it, especially when you're talking about doing it under implied consent.  Do a literature review of some of the issues regarding community participation, consent issues, etc in cardiac arrest research and you'll see part of what I'm talking about. 

2.  You can't throw out a study simply because you don't like the fact that it's retrospective.  It's akin to saying you're not willing to be told you messed up a case when your medical director calls you on it at audit and review because it's done retrospectively.  

Actually that particular study does tell us a lot about whether intubation has a potential for benefit in the field.  The fact that a lack of protective airway reflexes in the field (read as: #1 indication for prehospital intubation short of "patient not breathing") correlates with poor outcomes indicates that despite aggressive airway measures, we can't do a lot for them.  That coupled with poor success rates (which are documented elsewhere _ad nauseum_)  for prehospital intubation it would lead a reasonable person to go,  "Hmm...maybe there is a way we can achieve the same ends in patients (proper oxygenation, ventilation, etc) and not have the risks associated with field intubations....".   I agree that there needs to be more research done, but I'm afraid given the increasingly retentive nature of IRBs towards human clinical research under implied consent it'll take a miracle (or some well placed bribes) to see it carried out at least in the US. 



> This is why I advocate further research before we throw the baby out with the bathwater.



I am always game for more research, but I also see the other side of the issue that says why not use an easier option that delivers the same results with fewer risks?  At very least until we settle the issue with more definitive research that would seem to be the more patient safety oriented thing to do.  



> It is no use comparing, for example RSI in head injured patients with cold ETI.



Agreed, at least in part.  It would be interesting to see how the two stack up in comparison, but you're right if we're going to settle the issue those need to at least be separate arms of a study and not lumped together.  



> I'm not sure why you think this means I have a large ego, or indeed that I want to make my penis larger (I'm not sure why you think I have a penis at all in fact) but, if that is you see things, so be it.



It's just the way your previous post came across.  Kind of like how you read my response to be hostile, I read yours as having the same attitude I've encountered numerous times in person from EMTs and paramedics whenever the issue of downplaying intubations comes up.  For that you have my apologies. 

By the way, I like how you handled the aspiration issue.  Well done.


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## Smash (Oct 9, 2009)

usafmedic45 said:


> OK, two things:
> 
> 1.  Ever tried to squeeze a prospective airway study past an IRB before?  It's not easy, I should know...I've tried on two different occasions.  You start talking about giving people "differing" (even if the end result of the two devices is effectively the same thing) levels of care and they start to have fits about it, especially when you're talking about doing it under implied consent.  Do a literature review of some of the issues regarding community participation, consent issues, etc in cardiac arrest research and you'll see part of what I'm talking about.



Try getting permission to run a trial on epi versus placebo in cardiac arrest, despite the lack of hard data that epi is any use and the ever-present and mounting data that it may be detrimental.  It's nearly impossible to get withing 200 feet of the building!  Fortunately though we have our Antipodean cousins to cover for us.  Bernard, who has published a number of papers on pre-hospital stuff is due to publish a real prospective trial on prehospital versus in hospital RSI in traumatic brain injury, and I have been told that the results are very, very promising.  I wait with bated breath and the hope that we are not let down by substandard study design.



> 2.  You can't throw out a study simply because you don't like the fact that it's retrospective.  It's akin to saying you're not willing to be told you messed up a case when your medical director calls you on it at audit and review because it's done retrospectively.
> 
> Actually that particular study does tell us a lot about whether intubation has a potential for benefit in the field.  The fact that a lack of protective airway reflexes in the field (read as: #1 indication for prehospital intubation short of "patient not breathing") correlates with poor outcomes indicates that despite aggressive airway measures, we can't do a lot for them.  That coupled with poor success rates (which are documented elsewhere _ad nauseum_)  for prehospital intubation it would lead a reasonable person to go,  "Hmm...maybe there is a way we can achieve the same ends in patients (proper oxygenation, ventilation, etc) and not have the risks associated with field intubations....".   I agree that there needs to be more research done, but I'm afraid given the increasingly retentive nature of IRBs towards human clinical research under implied consent it'll take a miracle (or some well placed bribes) to see it carried out at least in the US.



I don't dismiss Wang's study purely because it is retrospective.  I dismiss it because it is retrospective; non-randomized; uses an unvalidated registry; relies on a functional impairment score that is not validated anywhere else in the literature; has no adustment made for various factors that could affect prehospital ETI (such as lack of RSI); does not account for failed attempts or why they occured (either in hospital or pre-hospital; does not provide any information on how or when in-hospital intubation was carried out; and does not use matching techniques; has no long term outcomes recorded.

It does nothing to build the case for or against prehospital intubation.  

Oxygenation and ventilation may indeed be provided equally well in that subset of patient by BVM, but the real point is only that the type of massive brain injury that renders a person without airway reflexes also tends to kill them.  I suspect if you ran that trial of ETI vs BVM in head-injured patients with absent airway reflexes you would not find much of a difference in outcomes.  If, however you ran it in a service that has poor success rates and allows proling hypoxia followed by hyperventilation following ETI, then the suspicion would be that the outcomes would be worse still.

Which brings me to Davis.

The Davis (2003) study, whilst arguably having flaws in the study design (particularly with matching and scoring) at least added to our knowledge by starkly illuminating the importance of avoiding transient hypoxia and hyperventilation.  This allows us to build on the study and move forward.

I believe the reasonable approach is to look at why we are failing to intubate in the first place and see if that can be corrected.  I believe it can, and the numbers from my service demonstrate that medics can intubate as successfully as ED doctors given appropriate training, education and support.  This then sets up the ideal conditions to be able to compare apples with apples so that we can work out whether or not it is important to be able to intubate in the field, and should also engender confidence in those whom we need to convince to allow us the free reign to carry out studies.



> I am always game for more research, but I also see the other side of the issue that says why not use an easier option that delivers the same results with fewer risks?  At very least until we settle the issue with more definitive research that would seem to be the more patient safety oriented thing to do.



I certainly undertand the point, however without a clear idea of how well the 'gold-standard' (and I use the term advisedly) performs, we are measuring with a flawed ruler.  To compare the success of say LMA insertion with ETT insertion when we are only hitting the mark a handful of times with ETI does no justice to either technique.  Failure to address the systemic issues in prehospital intubation does nothing but cloud the waters for further research.  So far, the literature merely shows that ETI done poorly = poor outcomes.



> It's just the way your previous post came across.  Kind of like how you read my response to be hostile, I read yours as having the same attitude I've encountered numerous times in person from EMTs and paramedics whenever the issue of downplaying intubations comes up.  For that you have my apologies.



Accepted, and you have mine also.


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## Shishkabob (Oct 9, 2009)

Fine usaf, no allergic reaction.  Still plenty if other times where intubation is needed over basic and rescue airways. 


Laryngeal Edema caused by trauma. 

Status asthmaticus refractory to all treatments and has horrible airway complience. 


Or heck, someone with esaphogeal verices.  You try a resue airway on them and you'll kill them.


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## MCGLYNN_EMTP (Oct 9, 2009)

We arn't so much concerned with when is ETI prefered over basic rescue airways. What's the point of that if we can't even perform ETI successfully to being with? I think we need to find the cause of unsuccessful intubations and start from there. It's not that paramedics are just not capable of intubation in the pre-hospital setting, I believe not enough time is spent training on it. If paramedics are just flat out missing the intubation, we need more time training them on how to do it.

Also, who's to say that the reason the tube is not in place when the patient arrives to the ED is soley because the paramedic missed the intubation? Couldn't the paramedic have successfuly intubated the patient and then the tube become dislodged with movement of the patient? I also think if we spend a couple extra seconds after moving the patient to reassess breath sounds or watch your ETCO2 if available (or even both) then we can save alot of tubes from becoming dislodged in transfer of the patient.

When It comes down to it, The most important thing at the end of the day is did ETI really benifit my patient? Would PROPER USE of BVM and airway adjunct with sup O2 have done better? I agree Blind insertion devices such as King and Combitube just don't seem right because they require hardly any training to use, but  in many instances they work just as good as an ETT.
I would really like to see what the future holds as far as airway managment goes.


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## MCGLYNN_EMTP (Oct 9, 2009)

What other Airways do your services carry such as combi-tube?
we carry ETT NTT and Combi


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## Shishkabob (Oct 9, 2009)

Who says anything about "preferred"?

In those 3 I posted,  it's either an ETT or surgical/needle, and there is no reason to do a surgical airway if you can be just fine with an ETT.





I don't think anyone is fighting the "Use a BVM and OPA when it works" idea.





A blind insertion rescue airway can kill someone with esophageal verices.


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## atropine (Oct 9, 2009)

Linuss it's just a stupid skill that not even proven to be effecteive, so who care if they take it away. I mean even in the new ACLS guides intubation is on the bottom of the totem pole and the AHA actually do the real science. Really it's not that big of a deal if the take it away.^_^


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## Shishkabob (Oct 9, 2009)

Do you know WHY it's at the bottom for ACLS?  Because often times a BVM + OPA can do the job, and they'd rather have blood pumping then an attempt at an ETT... but if you need an ETT, you need an ETT.

Now, look at PALS algorhythms.  They want a more definitive airway asap, be it an OPA, King or ETT... whatever gets the job done, because pedi CA's are more airway related.



But you are missing the quite obvious point.  Sure, intubation hasn't been 'proven' in cardiac arrest... but that's not the only emergency we deal with, and is not the only emergency that warrants / requires an ETT.

Cardiac arrest isn't all we do.


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## atropine (Oct 9, 2009)

I get your point, but we don't run enough of those types of calls to do the ETT justice, I would like to see us and I think we are going to King airway which I personally think is way better than the ETT.^_^


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## Shishkabob (Oct 9, 2009)

One saved life a month because of an ETT isn't justice enough?




The problem isn't proven / unproven ETT's.  It's lazy and/or uneducated providers.


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## atropine (Oct 9, 2009)

Wow what kind of sick people are there in texas, I guess everbody in souther Cali is healthy, cause man I haven't tubed in about 9 months.


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## DrParasite (Oct 9, 2009)

here is a question from the uninformed:

why is a ETT considered the gold standard?  meaning, can other procedures (such as an esophogeal tube) be used to prevent vomitting and gastic air (the exact term is eluding me at the moment), and an OPA and BVM can deliver air into the lungs.  this could lead to less oral trauma FROM the ETT placement, as well as still deliver the oxygen to the patient.

I can still see an ETT being needed when dealing with airway burns, where there is a real threat of losing an airway.  

but other than those cases where the airway is closing, why is the ETT considered the "gold standard"?


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## Shishkabob (Oct 9, 2009)

Because OPA's and combi-tubes don't play friendly with ventilators, and if you have a pt with no arms, legs, or a sternum, you can push drugs down it. ^_^


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## atropine (Oct 9, 2009)

Linuss said:


> Because OPA's and combi-tubes don't play friendly with ventilators, and if you have a pt with no arms, legs, or a sternum, you can push drugs down it. ^_^



Who pushes meds down the tube anymore


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## MasterIntubator (Oct 9, 2009)

atropine said:


> King airway which I personally think is way better than the ETT.^_^



Negatory big bird.... but I won't debate that with ya.  The King/EOA/EGTOA/Combitube/LMA/etc are not direct airway devices.  They work, and work well in the time of need.  They get the job done, and as with intubation.... have their own set of problems. ( just uglier ).

The king.... its hard to plug the puke hole side vent.  You get a bleed, or breech in the distal common cuff.... as with all the indirect tubes, and you will ventilate all the stuff into thier lungs.  It happens... one of those ugly probs, you won't know it readily either.

Ya know.... if I am on the scene, and you got it in 2 seconds flat with confirmation... I would be the happiest puppy alive. ( pat on yer back ).  I won't even mess with it.


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## Crepitus (Oct 10, 2009)

> Agreed, with a few reservations. However, I think we really should be less hostile to the idea of non-visualized airways with comparable functionality.


  (quoted for the idea, not necessarily as a response to usafmedic who authored the quote)


usafmedic and smash have a great exchange going and I'm glad there are folks with their depth in the scientific side of the EMS pool.  I'm nowhere near them, though I try every day to educate myself in some way or another.  I do believe that anecdotal evidence derived from common place, practiced experience has value as well in the evaluation process.  Thus I would like to share my experience and views on non visualized airways and get folks feedback as I'm open to the presented idea that ETT's are headed the way of the DoDo.

I started with EOA's and EGTA's as a back up to the ET.  And they were stiff, holding the mask on never seemed as easy as it had been sold, relative to an ET tube the placement of the NG/OG wasn't as easy.  

So those who were able placed an ETT.

But then we got the PTL's and that was going to be our salvation.  So for a year or two we watched patients mouths deform under the pressure of the upper balloon because they never seemed to seal. And the tubes would creep up under the pressure.  Of course the lower balloon sealed as well, so periodically a pt would puke past the lower balloon and the upper balloon held it all in guaranteeing an aspiration.

So those who were able placed an ETT.

Then some constant change/constant new idea guy ran out of the office to the field medics who were watching TV between calls (and BTW even though I find the constant change/constant new idea guy a PITA, we need him because relying on a TV watcher like me is going to get us in worse trouble) and showed us a CombiTube.  The new salvation had arrived!

And I said - yeah so what.  Somebody redesigned the PTL.  No no CC/CNI guy replied this is something completely new!  And so we spent a few years using an improved PTL with less complications while those of us who had learned (in the more complete sense of the word) to intubate just did that.

Recently as I prepared to return to EMS I watched paramedics at fairly busy ALS services tout the new thing, this time a King LT.  I looked at it and said yeah so what.  It's a one tube CombiTube.

No no this is different.  How I ask?  Well it's simpler they say.  

My thoughts on that are well 'simpler that is faster' is indeed a good thing.  If it's simpler because a paramedic found the CombiTube confusing . . . well I guess I don't want them intubating anyway.

But in the end, I don't personally find placing an ET complicated.  I don't find that placing an ET tube takes me that long.  About the same as CombiTube, probably longer than a King.

I agree that there is much more to airway management than tube placement.  And I believe that I can say that while I have missed a tube, I have never missed an airway.  I believe that while ventilation is our goal, good airway management resulting in a patent airway is the path to that goal.

-ETT is a more direct path to the goal.  Because the blind airways take away my ability to see with my own eyes the patentcy of the airway it feels like a compromise.  Because I give up the ability to place the air directly where I want it (trachea) and rely on a mechanical device (a balloon) to redirect the air it would seem that a diminished level of control of where that air is going is inevitable eventually.

-Relying on the same balloon to seal the gastric contents in (which typically are under pressure right  ) rather than relying on a balloon in the trachea to seal against non pressurized secretions is counterintuitive.  Particulary when you forfeit the NG/OG tube option.  (though I understand the King LTS-D addresses this issue.)

-I am open to the idea of reprioritizing the pt care.  If OPA/BVM needs to be done for a while while we redirect our emphasis, that seems reasonable.  Maybe we'll scrap the whole ABC concept in CPR someday and do it CAB instead.  

-While I have yet to become convinced that blind insertion airways have comprable functionality I believe that the blind inserts have a place.  I've used them when I was unable to achieve a patent airway using an ET.  I have seen other medics peform airway care with an ET that I would not accepted from myself and wish they had used a blind insert.

-Because I think that there will always be times when effective ETT intubation is inhibited by skill levels, environment, or the patient's condition I do believe that forcing all paramedics everywhere to always turn to the ET first is a compromise in pt care.

-But I think that forcing all paramedics everywhere 'down' to the use of a blind insertion airway first in every situation is a much more aggriegous compromise, because it seems to say 'okay, we give up, we won't ever be able to get these paramedics up to an acceptable level, so let's go ahead and lower the bar.'

Thanks to those of you read this long of a ramble and to the forum for the opportunity to exchange thoughts with all you.

Crepitus


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## MasterIntubator (Oct 10, 2009)

Nice post, crep.

Nice.


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## cfd3091 (Oct 10, 2009)

Yes Crep, Very good.


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## MCGLYNN_EMTP (Oct 10, 2009)

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


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## firetender (Oct 10, 2009)

triemal04 said:


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



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

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

Why? Read the above quote. triemal04 nails it.

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

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

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

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

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

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

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


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## VentMedic (Oct 10, 2009)

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

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

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

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

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


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## MCGLYNN_EMTP (Oct 10, 2009)

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

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


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## VentMedic (Oct 10, 2009)

MCGLYNN_EMTP said:


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


 
Your agency is only as strong as your weakest link.



MCGLYNN_EMTP said:


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


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

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

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


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## austinmedic2004 (Oct 10, 2009)

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


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## Smash (Oct 11, 2009)

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

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

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


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## Melclin (Oct 11, 2009)

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



Sigh. As usual  

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


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

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

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

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

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

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


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## mikethemedic (Oct 11, 2009)

*intubation*

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


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## VentMedic (Oct 11, 2009)

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

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

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

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



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


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

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

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

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


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## triemal04 (Oct 11, 2009)

VentMedic said:


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


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

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

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


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## VentMedic (Oct 11, 2009)

triemal04 said:


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


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

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


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## triemal04 (Oct 11, 2009)

VentMedic said:


> Actually, if you read some of the studies in their entirety, the reasons for failed intubation are discussed and this has been used as arguments for RSI or different intubation equipment by some agencies.
> 
> A progressive thinkng agency can take almost any of these prehospital studies and turn it to their favor if there were no medications or inadequate medications used.  This can be their agrument especially if they already have ETCO2 capability which can be another stance for equipment.


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

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

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


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## VentMedic (Oct 11, 2009)

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

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

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

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


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## MCGLYNN_EMTP (Oct 11, 2009)

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

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


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## Smash (Oct 11, 2009)

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


 Agreed.



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


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




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


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



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


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


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## VentMedic (Oct 12, 2009)

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

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


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

*A Comparison of Prehospital and Hospital Data in Trauma Patients*

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

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

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

*Nolan, Jerry D. FRCA*

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


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

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

_*Prehospital determination of tracheal tube placement in severe head injury *_
_Grmec, 
	

	
	
		
		

		
			





 Mally _
_Emergency Medicine Journal_ 2004;*21*:518-520 

*Prehospital Standardization of Medical*
*Airway Management: Incidence and Risk*
*Factors of Difficult Airway*
Xavier Combes, MD, Patricia Jabre, MD, Chadi Jbeili, MD, Bertrand Leroux, MD, Sylvie Bastuji-Garin, MD, PhD,
Alain Margenet, MD, Fre´ deric Adnet, MD, PhD, Gilles Dhonneur, MD​
ACADEMIC EMERGENCY MEDICINE 2006; 13:828–834 
_ª _2006 by the Society for Academic Emergency​ 
Medicine​ 



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


*Prehospital endotracheal intubation: Rationale for training emergency medical personnel*​ 
Annals of Emergency Medicine
Volume 14, Issue 11, Pages 1085-1092 (November 1985)​ 


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


 




There are hundreds of intubation articles to be found. Wang is just one author but unfortunately someone in JEMS and the internet forums focus just on him. This is why I advise people in EMS to read medical journals and not just JEMS. ​ 
Here's a little more help in case you are not familar with search engines:
http://scholar.google.com/scholar?start=20&q=prehospital+intubation&hl=en​ 
There are many pages of articles there and many more can be found with different word combinations.​ 
example:
http://scholar.google.com/scholar?q=air+medical+journal+intubation&hl=en​ 
Google Scholar is easily accessible to medical information without signing in to a medical search site.
http://scholar.google.com/​ 
I also hope you and atkinsje take not of the real letters behind the names of the researchers. They do mean something.​


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## ffemt8978 (Oct 12, 2009)

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

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

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


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## Melbourne MICA (Oct 15, 2009)

*Late as usual*

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

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

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

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

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

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

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

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

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

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

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

So along came the RSI trial. 

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

The rest is history.

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

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

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

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

MM


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## gicts (Oct 21, 2009)

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


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## karaya (Oct 21, 2009)

gicts said:


> Where would we be without items that required tubes? RSI? Drug administration via the tube? Not going to happen IMO.


 
Now that the preferred alternate to drug administration lacking an IV in cardiac arrest patients is intraosseous infusion; the argument of the ET tube as a drug delivery method appears to be waning.


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## MSDeltaFlt (Oct 22, 2009)

MCGLYNN_EMTP said:


> So what is the BIGGEST concern at hand with ETI in the prehospital setting?
> 
> Is it that paramedics don't have a high enough success rate?
> Is it that paramedics don't know when and when not to ETI?
> ...


 
Sorry for the dalay, MCGLYNN.  This has been one hell of a month at work.  But to answer your questions.  I believe it's going to more along the lines of your last question...kind of.

What I mean is that the biggest problem with ETI in the prehospital setting is a lack of situational awareness and experience when it comes to prehospital ETI.  ETI is like any skill.  It's easy to learn, but hard to master.  And skills are like muscles.  If you don't use them, you lose them.

What does that mean?  It means you can't teach experience.  Getting proficient is one thing.  *Maintaining proficiency* is all together different.  That, my friend, is where the problem(s) arise(s).

There are many medics who get pretty good at ETI in the controlled setting of the OR during paramedic school under the guidance of the Certified Registered Nurse Anesthetist or the Anesthesiologist.  The only thing is it may be 6 months to a year after they've passed NREMT before they get their first tube during a code at a nursing home, and even longer, a year or more, before they're faced with a bad trauma pt needing a definitive airway.

And people wonder why some medics miss their tubes.  It ain't rocket science.  I know a helicopter mechanic who used to build missiles for Lockhead-Martin.  Them's rockets.  He knows what rocket science is, and he can tell you this ain't it.

As said earlier.  You can't teach experience.  Skills are like muscles.  You don't use them, you lose them.  Period.


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## resq330 (Oct 22, 2009)

I just wanted to throw this out there...our squad has recently been introduced to and trained to use the King Airway, all the way down to the EMT-B level.  We now carry them on our trucks.  This is taking the place of the CombiTube and rumor has it could possibly take the place of ETT.   Just sayin....


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## MCGLYNN_EMTP (Oct 22, 2009)

Great skill to have but as I have said many times before - definately one for the grown ups -  Heroes said:
			
		

> We need to learn when to tube and when not to tube....I worked a call with another paramedic the other night and we had an overdose patient....he decided to intubate the patient...he couldnt get the tube no to mention while he was fighting to get the tube in..i happened to look at the  monitor and he dropped that guy from ST at 140 to SB at 35..amazing.....so he put in a combi tube....then for some unknown reason gave 2mg of narcan...well you can immagine what happened from there..needless to say when he dropped his patient off at the hospital...the patient had a combi tube in his hand and not in his esophagus.
> 
> that patient should have never been tube..and shoud nver have been given the whole 2mg of narcan either...   0.5mg would have been enough to bring his resp. up enough to hold for his own.
> 
> ...


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## Jeremy89 (Oct 27, 2009)

MCGLYNN_EMTP said:


> We need to learn when to tube and when not to tube....I worked a call with another paramedic the other night and we had an overdose patient....he decided to intubate the patient...he couldnt get the tube no to mention while he was fighting to get the tube in..i happened to look at the  monitor and he dropped that guy from ST at 140 to SB at 35..amazing.....so he put in a combi tube....then for some unknown reason gave 2mg of narcan...well you can immagine what happened from there..needless to say when he dropped his patient off at the hospital...the patient had a combi tube in his hand and not in his esophagus.
> 
> that patient should have never been tube..and shoud nver have been given the whole 2mg of narcan either...   0.5mg would have been enough to bring his resp. up enough to hold for his own.
> 
> ...



Perfect example, Mcglynn.  Speaking from a hospital standpoint, I find medics are hesitant to intubate if they need to paralyze and sedate (I'm sure the documentation for that is horrendous).

The one pre-hospital tube I saw was very poorly done (It was a trauma code- I bet an MD couldn't do any better).  The airway was barely in place- I held as RT bagged.

Once you decide to drop that tube, you're cutting all communication off with that pt- so you better be damned sure you have all the hx, meds, etc.

We had a pt that PHX fire brought in once- asthma exacerbation.  She was literally begging for the tube.  And our MD listened...
Come to find out she was admitted to the ICU on a vent and was extubated 3 hours later.  The medics made the right call by holding back the tube.

Just my 2 cents


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## VentMedic (Oct 27, 2009)

Jeremy89 said:


> We had a pt that PHX fire brought in once- asthma exacerbation. She was literally begging for the tube. And our MD listened...
> Come to find out she was admitted to the ICU on a vent and was extubated 3 hours later. The medics made the right call by holding back the tube.
> 
> Just my 2 cents


 
Are you saying the doctor was wrong for intubating?  Why?

What were her numbers on the ventilator at intubation as far as compliance, resistance, PIP and Pplat?    What alternative methods of ventilation did the ED have?  Heliox? 

We do have a few short term intubations and if a patient has been intubated before to where he/she knows the procedure we may listen rather than wait for total failure.   Few patients beg for the tube if they have had it before unless they feel they really need it.  We may also need to mechanically ventilate the patient for a few hours with heliox until the effects of the steroids kick in.   

Each situation is considered individually and on one's ability to maintain their airway on heliox and/or other alternatives.  If no alternative gases such as heliox are available in that ED, I would definitely not criticize the doctor for intubation.    Establishing an airway on a crash and burn asthmatic is never good.  Putting the tube in the throat is the easy part but once the airways have tightened up, no about of paralytics, sedation, bronchodilators and heliox may be effective.   Again, good assessment skills and knowledge are needed to avoid that situation as well as the necessary devices and meds/gases.


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## Jeremy89 (Oct 27, 2009)

VentMedic said:


> Are you saying the doctor was wrong for intubating?  Why?
> 
> What were her numbers on the ventilator at intubation as far as compliance, resistance, PIP and Pplat?    What alternative methods of ventilation did the ED have?  Heliox?
> 
> ...



Usually its something we can control using various Neb's, steroids and even bipap.  The MD didn't try anything- just went straight for RSI because thats what the pt wanted.


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## VentMedic (Oct 27, 2009)

Jeremy89 said:


> Usually its something we can control using various Neb's, steroids and even bipap. The MD didn't try anything- just went straight for RSI because thats what the pt wanted.


 
Usually but not always...

Do you happen to  remember the initial numbers?


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## Jeremy89 (Oct 27, 2009)

I was working triage that day so all I saw was EMS go by saying "She's ready for the tube", then heard "Dr Murphey to 15 stat" as one of the techs cracked the code/ intubation cart.  Later I saw her on a vent...


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## Tal (Oct 27, 2009)

MCGLYNN_EMTP said:


> I keep reading articles on intubations in the field and how studies are really leaning towards simply using sup. O2 and BVM verses actually intubation the patient. What do you guys think about this???



I just had my ACLS-AHA course, they said that intubation should come after eprox. 600 compressions, or after ROSC.
I think its nice and all in class but in the field BVM sometimes, even for a good paramedic, is not that easy.

Also, I dont think intubation ig going to dissapear cause you will allways have the 4:00 am CHF old lady with the 260 sys.B)


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## Pyromedic (Oct 27, 2009)

We had a conversation in class about this today. They are thinking of getting rid of intubating just because the many fail attempts and pt. injuries thanks to Medic pride. Now I heard this might be happening in florida, I'm not sure about the rest of the us. :/


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## MCGLYNN_EMTP (Oct 27, 2009)

I had a talk with some other medics while making crew change today... One of them was telling me how there are 2 states that allow EMT-Basics to do ETI! We kind of discussed everything that this post has discussed and one of the medics said that before they pull ETI from paramedics nationally they will have to pull ETI from those states that they allow basics to do ETI.....see how that effects the stats of ETI then determine from there what needs to be done. 

In the end, I dont think this will be leaving our scope of practice any time soon. Some people just really need to be intubated and there's just no way around it.


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## Dwindlin (Oct 28, 2009)

MCGLYNN_EMTP said:


> I had a talk with some other medics while making crew change today... One of them was telling me how there are 2 states that allow EMT-Basics to do ETI! We kind of discussed everything that this post has discussed and one of the medics said that before they pull ETI from paramedics nationally they will have to pull ETI from those states that they allow basics to do ETI.....see how that effects the stats of ETI then determine from there what needs to be done.
> 
> In the end, I dont think this will be leaving our scope of practice any time soon. Some people just really need to be intubated and there's just no way around it.



Ohio is one, however its only in a cardiac arrest situation.


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## MCGLYNN_EMTP (Oct 28, 2009)

I don't see anything wrong with the actual skill of intubation being performed by a basic...especially when its in a defined situation..(cardiac arrest) something you can't mistake..(unless you're a nursing home nurse)...but The main thing with intubations is I think we are doing it too often...more than we should be doing it. We should focus more on learning when to tube and when not to tube rather than how to do the skill.


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## Tal (Oct 29, 2009)

MCGLYNN_EMTP said:


> . We should focus more on learning when to tube and when not to tube rather than how to do the skill.



spoken like a real genius!
any monkey with two hands could do ETI, the knowledge is when!


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## Melclin (Nov 21, 2009)

I'll probably post about this and a few other things a bit later on in a new thread, but I thought I'd mention it here.

I've just got back from the conference I spoke about earlier where, amongst other things, Stephen Bernard presented his findings.

The study is not quite as perfect as I keep hearing from people but its still good. There is a clear reduction in mortality for the RSI group, but a worrying trend of cardiac arrest also. A couple of outcome measures were suggested during question time that seem quite obvious but that were never considered at the time, which is unfortunate (such as whether or not there was an equal number of cardiac arrests when the non-RSI arm was later RSI'd in the ED). 

A/Prof Mark Fitzgerald pointed out that they often RSI haemodynamically unstable pts in the trauma centre without sedation (suxamethonium only) because it was safer. It seems possible that the mandatory pre sux sedation with midazolam and fentanyl could be responsible for the few cardiac arrests. 

In any case it was clear that it was leading to better outcomes measured at 6 months. Apparently there is also a cost benefit analysis kicking around (it was very expensive to train, equip and oversee the process) that apparently was very positive, and the whole concept seemed to be very well received by the intensivists and EM physicians in attendance.

I asked Stephen later, if he felt the considerable education gap between Australian and US paramedics had anything to do with the difference in results between our study and some of yours. He felt that the more important factor was the continuing education components. I'll expand more on what he said in a new thread a bit later.


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## guardian528 (Nov 21, 2009)

MCGLYNN_EMTP said:


> I keep reading articles on intubations in the field and how studies are really leaning towards simply using sup. O2 and BVM verses actually intubation the patient. What do you guys think about this???



intubations are alive and well here, but the king tube is making itself more known. the standard for our company is that you go to the king tube after 2 failed attempts at intubating, or you can go directly to the king tube if you can tell it would be an extremely difficult/time consuming intubation.

however, i think ventura county has lost their's completely to the king tube for a 1 year trial or something like that.... pardon me if someone has already posted that, i didn't actually read these 10 pages


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