# Study on Survival vs Intubation during IHCR



## Summit (Jan 25, 2017)

Key Points
Question:  Is tracheal intubation during adult in-hospital cardiac arrest associated with survival?

Findings:  In a study of 86 628 adults with in-hospital cardiac arrest using a propensity-matched cohort, tracheal intubation within the first 15 minutes was associated with a significantly lower likelihood of survival to hospital discharge compared with not being intubated (16.3% vs 19.4%, respectively).

Meaning:  These findings do not support early tracheal intubation for adult in-hospital cardiac arrest.

http://jamanetwork.com/journals/jama/fullarticle/2598717#150045279


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## CWATT (Jan 25, 2017)

From the article:

"Multiple mechanisms could explain a potential causal relationship between tracheal intubation and poor outcomes.
First, tracheal intubation might lead to a prolonged interruption in chest compressions.
Second, tracheal intubation might lead to hyperventilation and hyperoxia, which are associated with poor outcomes.
Third, tracheal intubation could delay other interventions such as defibrillation or epinephrine administration.
Fourth, delays in the time to success of intubation could result in inadequate ventilation or oxygenation by other means. 
Fifth, unrecognized esophageal intubation or dislodgement of the tube during the cardiac arrest could lead to fatal outcomes."


My thoughts:

I do wonder about delaying chest compressions to insert an ET tube.  Has anyone intubated someone while chest compressions are continued (either manually or with a Lucas)?  What was your experience like?

Secondly, hyperventilation and hyperoxia can occur with a King or OPA/BVM, so I think this is a separate issue and not specific to ET.

Third, you should never delay defibrillation.  I'm wondering if the article states this because practitioners were doing that.  Epi on the other hand - well, an ED doc recently told me we give Epi for ourselves and not the patient (because it makes us feel better / like we're doing something)


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## FLdoc2011 (Jan 25, 2017)

Have been involved in a lot of in-hospital arrests and I try not to interrupt compressions.   Can be tricky but certainly possible to intubate during compressions or during a brief pulse check.


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## reaper (Jan 26, 2017)

We do not stop compressions for intubations. We started about 2 years ago and it helped reduce time off chest. It is not difficult. Just have to get providers used to doing it.

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## EpiEMS (Jan 26, 2017)

This is begging for a large-scale RCT...


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## NomadicMedic (Jan 26, 2017)

It should be CPR=SGA. If you get ROSC, then you can eff around with ETI.


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## Uclabruin103 (Jan 26, 2017)

Most of the time you don't need to stop compressions for a tube.  If anything I'll do a brief pause while I actually pass the tube, but otherwise keep compressing.


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## reaper (Jan 26, 2017)

ETI takes no more time then a SGA. Just do not stop compressions.

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## Midazzled (Jan 26, 2017)

Placing a SGA seems reasonable. I certainly wouldn't advocate multiple intubation attempts on a pulseless patient.


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## MackTheKnife (Jan 26, 2017)

CWATT said:


> From the article:
> 
> "Multiple mechanisms could explain a potential causal relationship between tracheal intubation and poor outcomes.
> First, tracheal intubation might lead to a prolonged interruption in chest compressions.
> ...


During CPR in the prehospital setting, I timed my intubation with compressions. Didn't need to stop CPR or delay. During compression, the cords would open allowing passage of the ETT. Easy peasy. As for in hospital, now that I'm an RN, can't say. But ETI is the GOLD STANDARD.

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## MackTheKnife (Jan 26, 2017)

DEmedic said:


> It should be CPR=SGA. If you get ROSC, then you can eff around with ETI.


Disagree.

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## Carlos Danger (Jan 26, 2017)

MackTheKnife said:


> But ETI is the GOLD STANDARD.



Full spinal immobilization is THE GOLD STANDARD, too.

Oh, wait.....


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## LaAranda (Jan 26, 2017)

reaper said:


> ETI takes no more time then a SGA. Just do not stop compressions.
> 
> Sent from my VS985 4G using Tapatalk



I've not found this to be true.


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## reaper (Jan 26, 2017)

Practice! Better you get, easier it will become.

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## Carlos Danger (Jan 26, 2017)

reaper said:


> ETI takes no more time then a SGA. Just do not stop compressions.


I intubate and place SGA's every single day and there is no way I could _consistently_ intubate during CPR with as little interruption to compressions as SGA placement would require.


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## reaper (Jan 26, 2017)

If you did it without stopping each time, you get the hang of it. 

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## Carlos Danger (Jan 26, 2017)

reaper said:


> If you did it without stopping each time, you get the hang of it.
> 
> Sent from my VS985 4G using Tapatalk


Or maybe I'd just overestimate my own abilities.


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## reaper (Jan 26, 2017)

Long time and I never overestimate my abilities.

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## Carlos Danger (Jan 26, 2017)

Why do people in EMS have such a hard time with the idea that intubation shouldn't always be the first thing that we do for patients?

Here we have people essentially rejecting a study with a sample size of almost 90,000 patients across 14 years worth of data - supporting the findings of other smaller studies that found the same thing - just because it says that maybe we should think twice about intubating early in cardiac arrest. You see it with the dozens of studies on intubation in the prehospital setting, too.

It's like people are so emotionally attached to this intervention, that for some reason they just can't admit that maybe we aren't as good at it as we think we are, OR that maybe regardless of how good we are or aren't at it, it just isn't the best thing for these patients.


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## reaper (Jan 26, 2017)

Because this study is flawed. It studied an area that stops compressions to gain intubation. A lot of areas have gone to not stopping compressions during CPR and are seeing the results from it. If you stop compressions in your area, then yes, drop a SGA. But not all areas practice the same way. This is how we find the new ideas that work. 

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## E tank (Jan 26, 2017)

Remi said:


> .... regardless of how good we are or aren't at it, it just isn't the best thing for these patients.



Well this is it exactly. Tracheal intubation, as an element by itself, is an objective good for patients that have arrested. "We" are just not so objective in how good we are in intubating the trachea.


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## Carlos Danger (Jan 26, 2017)

reaper said:


> Because this study is flawed. It studied an area that stops compressions to gain intubation. A lot of areas have gone to not stopping compressions during CPR and are seeing the results from it. If you stop compressions in your area, then yes, drop a SGA. But not all areas practice the same way. This is how we find the new ideas that work.


Where in the study does it say that these patients all had compressions stopped to perform the intubation?

And what data is there that indicates that it even makes a difference? Reference, please.


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## VentMonkey (Jan 26, 2017)

Before this turns into the super heated airway debate it probably will, I'd like to chime in.

Honestly I haven't even read the study yet. Why? Well, it's nothing really new or surprising in regards to ETI regardless if it's in the field, or a "controlled" environment. It hardly seems like something new; still worth inciting good discussion though, @Summit.

I still firmly believe that prehospital ETI should be reserved for a select few with advanced airway training, not the standard paramedic curriculum alone. Yes, this would include how, and why they should be placed directly on the ventilator.

FWIW, at least at my service, nowadays more often than not we're looking for ways to _not_ _have_ to intubate someone. Unless of course it poses an absolute risk to the patient, and/ or flight itself.

Clearly, SGA's these days aren't what they were 20 plus years ago, neither is the ACLS algorithm. 

Another point I think worth mentioning is even though I haven't been doing this incredibly long, I've done it long enough to see a positive shift in this particular paradigm with respect to the newer generation of paramedics and properly prioritizing their airway management in a SCA's treatment tree.


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## EpiEMS (Jan 26, 2017)

Remi said:


> It's like people are so emotionally attached to this intervention, that for some reason they just can't admit that maybe we aren't as good at it as we think we are, OR that maybe regardless of how good we are or aren't at it, it just isn't the best thing for these patients.



This is so true. We cannot define a profession by a single skill alone - but so often "I have a laryngoscope and a drug box, therefore I am a paramedic" is the rallying cry.

On the study itself, they specifically stated:



> Potential confounders such as the skills and experience of health care professionals, the underlying cause of the cardiac arrest, the quality of chest compressions, and the indication for intubation were not available in the registry.



Obviously, these are important - recognized - confounders. What would get rid of this is a good ol' RCT. However, to throw out this study *solely* on the basis of this one confounder is overly reductionist.


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## MackTheKnife (Jan 26, 2017)

Remi, seriously? There is a lazyness towards intubation and you know it.

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## reaper (Jan 26, 2017)

EpiEMS said:


> This is so true. We cannot define a profession by a single skill alone - but so often "I have a laryngoscope and a drug box, therefore I am a paramedic" is the rallying cry.
> 
> On the study itself, they specifically stated:
> 
> ...


Where has anyone stated that? The decision to control an airway comes on a as needed basis. We are learning from mistakes of The past and finding out what works and what to change. There is a reason the AHA makes changes and updates. They look at New ways of doing things. What is bringing very good success in resuscitation today, would have never been thought of 10-20 years ago. This is why we evolve and expand.

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## EpiEMS (Jan 26, 2017)

@reaper, FWIW, the AHA is very often behind the state of the science. I'm not sure what you mean with respect to the "as-needed" use of ETI?


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## reaper (Jan 26, 2017)

Have you attended an AHA resuscitation conference? The Drs on this board are some of the best in the industry. They may be behind some areas, because they study the results before publishing changes.

As needed means just that. Each provider must assess the pt in front of them and decide the best course of treatment for that pt. Airway control could be ETI, an SGA or basic adjuncts and maintenance.

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## Carlos Danger (Jan 26, 2017)

reaper said:


> *Where has anyone stated that?* The decision to control an airway comes on a as needed basis. We are learning from mistakes of The past and finding out what works and what to change. There is a reason the AHA makes changes and updates. They look at New ways of doing things. What is bringing very good success in resuscitation today, would have never been thought of 10-20 years ago. This is why we evolve and expand.



It is very much the prevailing attitude among paramedics. Any study that doesn't support intubation is quickly dismissed as "flawed". I've been doing this going on 20 years, and it's always been like that. 

I'm still waiting on a citation to support your claim a few posts back.


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## VentMonkey (Jan 26, 2017)




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## EpiEMS (Jan 26, 2017)

reaper said:


> Have you attended an AHA resuscitation conference? The Drs on this board are some of the best in the industry. They may be behind some areas, because they study the results before publishing changes.
> 
> As needed means just that. Each provider must assess the pt in front of them and decide the best course of treatment for that pt. Airway control could be ETI, an SGA or basic adjuncts and maintenance.



While I haven't attended such a conference, I certainly acknowledge that the AHA is regarded as the organization that promulgates what might be considered the standard of care for resuscitation.
As far as airway control and "as needed" choices, I don't buy that - there is evidence for use of certain methods in certain circumstances, and it is incumbent on providers to lean on evidence where possible. In the absolute worst case, biologically/anatomically plausible expert opinions are pertinent. But RCT evidence comes first!


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## reaper (Jan 26, 2017)

10 years ago, I would agree. Times have changed and most systems and Paramedics are advancing the thinking and evidence based medicine. I have been in this 27 years and have seen the changes and evolution of the industry.

The study posted states that a main cause is interuption of compressions and other interventions. 

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## reaper (Jan 26, 2017)

EpiEMS said:


> While I haven't attended such a conference, I certainly acknowledge that the AHA is regarded as the organization that promulgates what might be considered the standard of care for resuscitation.
> As far as airway control and "as needed" choices, I don't buy that - there is evidence for use of certain methods in certain circumstances, and it is incumbent on providers to lean on evidence where possible. In the absolute worst case, biologically/anatomically plausible expert opinions are pertinent. But RCT evidence comes first!


Is this not what I said? Each pt is assessed at that time. The treatment decision is made on what is evidence based best for that pt. That comes on a case by case basis by the findings of your assessment of the pt.

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## E tank (Jan 27, 2017)

reaper said:


> Where has anyone stated that? The decision to control an airway comes on a as needed basis. We are learning from mistakes of The past and finding out what works and what to change. There is a reason the AHA makes changes and updates. They look at New ways of doing things. What is bringing very good success in resuscitation today, would have never been thought of 10-20 years ago. This is why we evolve and expand.
> 
> Sent from my VS985 4G using Tapatalk



Nah...AHA guidelines don't change in order to evolve and expand, ie, "improve". They change to dumb down and simplify for the masses of differently abled providers. Vasopressin is a great drug, but it was taken off in the interests of simplicity, not because it is less useful than epinephrine. The AHA  guidelines are just that and there are levels of providers both prehospital and hospital that are not obligated to adhere to them, simply because they are not by any stretch of the imagination "enough" for what is called for in many settings.


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## StCEMT (Jan 27, 2017)

MackTheKnife said:


> Remi, seriously? There is a lazyness towards intubation and you know it.
> 
> Sent from my XT1585 using Tapatalk


Well 99% of the people I see don't need it. Not as much laziness as lack of necessity. And considering the last 2/3 arrests I know of to go out were heroic OD's, I am gonna guess they weren't in the most ideal locations (one was a bp bathroom I believe). I'm not about to get down on that nasty floor when I can drop an igel, be done in seconds and let the vent do the work from there.


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## MackTheKnife (Jan 27, 2017)

Understand that in some cases other means are more appropo. I just continue to see in a general way intubation being viewed negatively.

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## Carlos Danger (Jan 27, 2017)

MackTheKnife said:


> Understand that in some cases other means are more appropo. I just continue to see in a general way intubation being viewed negatively.


Endotracheal intubation is simply a clinical intervention. In and of itself, it is neither good or bad. It all depends on the scenario.

The problem is that for a long, long time, paramedics had drilled into their heads that any sick patient who had any type of respiratory or airway compromise needed to be intubated ASAP, and that any other manner of airway management was inferior and would only be used by a paramedic of inferior skill. Which of course is false in so many ways, but the idea still became a big part of EMS culture. That's why the ability to intubate is one of the first things that many paramedics bring up in the paramedic vs. RN debates.

It seems that this hard line has been softened quite a bit, but underlying everything is still the idea that ETI is "the gold standard" in every case, and that the more "clinically aggressive" you are (i.e. the more interventions you do) the better paramedic you are. To this day that attitude still very often trumps any research based or well-reasoned recommendation for a more conservative approach.

This study is just the latest in a LONG series of research that fails to support routine early intubation in most scenarios that paramedics do airway management in. Yet still, just look through the responses here. Instead of much discussion even taking place about the study, we get knee-jerk reactions against it. I bet most of the commenters didn't even read it, but are still quick to make nonsensical claims about how quickly they can do an RSI, and how anyone can consistently intubate faster than they can place an SGA, etc. I don't thing many anesthesiologists and CRNA's are as confident in their airway skills as many paramedics are.

On the whole, EMS only respects research that supports them doing what they want to do anyway. Anything that questions a sacred cow is quickly dismissed as flawed


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## EpiEMS (Jan 27, 2017)

Remi said:


> On the whole, EMS only respects research that supports them doing what they want to do anyway. Anything that questions a sacred cow is quickly dismissed as flawed.



You are - sadly - too right!


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## reaper (Jan 27, 2017)

Remi said:


> Endotracheal intubation is simply a clinical intervention. In and of itself, it is neither good or bad. It all depends on the scenario.
> 
> [I believe this was already addressed. That it is a case by case basis of what airway control is needed for the pt in front of you.]
> 
> ...







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## EpiEMS (Jan 27, 2017)

reaper said:


> There are many studies that look at statistics only. There are too many varibles for them to provide evidence based medicine. Most studies like this will state the same, just as this one did. When you look at controlled research studies, they provide the best evidence for any practice. Am I perfect on airways? No, no one is. That is why we practice to stay proficient. Through Sin labs, cadaver labs, and OR time. That is how you stay confident in your abilities. I believe someone stated That they intubate daily. I find this hard to believe, but if that is what they stated, maybe somehow they do. I do not know many medics that value their practice off how many tubes they can get. Those medics never make it too far.



Statistics only? I'm not sure what you mean by that. Do you mean retrospective reviews (case control) as opposed to RCTs? The caveats are clear with a case control or other data review.

(There aren't many large scale high quality RCTs that address prehospital ETI versus SGAs versus BVM that I am aware of.)

Regarding the number of intubations, there is actually very good evidence that practice/quantity matters and ongoing performance matters.


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## CWATT (Jan 27, 2017)

VentMonkey said:


> I still firmly believe that prehospital ETI should be reserved for a select few with advanced airway training, not the standard paramedic curriculum alone. Yes, this would include how, and why they should be placed directly on the ventilator.



I couldn't disagree more.  And please know I have a lot of respect for you.  However, this is clearly a protocol and training/education solution, not scope of practice.  To throw the baby out with the bath water because people are jumping to ET too soon will mean that someone in the future who would benefit from the intervention won't have access to it.  

I've sent his happen in Canadian jurisdictions where they've taken away Gravol (Dimenhydrinate) and Benedryl (Diphendramine) from EMTs.  It's become the joke we'll stop at the drug store on the way to the hospital.  Does every patient who gets into poison ivy need Benedryl?  No.  But that patient of mine who had angio edema - yes, and I didn't have it within my scope.


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## EpiEMS (Jan 27, 2017)

@CWATT, I would agree that there is a component of the issue that is education versus scope of practice. However, we so often define ourselves in EMS by scope of practice and not by education.

Regarding your example, I see a greater cost/benefit discrepancy for ETI - bad use of ETI has much more potential to harm than bad use of diphenhydramine, no (i.e. failed ETI --> lots of money and resources spent --> death anyway, while bad diphenhydramine use generally doesn't kill folks)? While good use of ETI is much more beneficial than good use of diphenhydramine? (i.e. ETI benefit is ventilation vs. no ventilation, while diphenhydramins is itchy vs. not itchy, to grossly oversimplify)


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## MackTheKnife (Jan 27, 2017)

Remi said:


> Endotracheal intubation is simply a clinical intervention. In and of itself, it is neither good or bad. It all depends on the scenario.
> 
> The problem is that for a long, long time, paramedics had drilled into their heads that any sick patient who had any type of respiratory or airway compromise needed to be intubated ASAP, and that any other manner of airway management was inferior and would only be used by a paramedic of inferior skill. Which of course is false in so many ways, but the idea still became a big part of EMS culture. That's why the ability to intubate is one of the first things that many paramedics bring up in the paramedic vs. RN debates.
> 
> ...


Remi, great words and I fully agree. Everyone does not need intubation. To narrow my point a bit, I'm seeing the comment "this study shows ETI doesn't really make a difference" more and more. it seems like there is an agenda to do away with ETI by some in the EMS community- by no means all.

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## EpiEMS (Jan 27, 2017)

MackTheKnife said:


> it seems like there is an agenda to do away with ETI by some in the EMS community- by no means all.


That's certainly plausible, but I would suggest the alternative explanation: Practitioners are realizing that poor or misused ETI is worse than no ETI, so they are pushing to reduce ETI use by people who shouldn't be using it (or in circumstances where it is inappropriate).

I see your point, for sure, thinking about it more broadly.


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## VentMonkey (Jan 27, 2017)

CWATT said:


> I couldn't disagree more.  And please know I have a lot of respect for you.  However, this is clearly a protocol and training/education solution, not scope of practice.  To throw the baby out with the bath water because people are jumping to ET too soon will mean that someone in the future who would benefit from the intervention won't have access to it.
> 
> I've sent his happen in Canadian jurisdictions where they've taken away Gravol (Dimenhydrinate) and Benedryl (Diphendramine) from EMTs.  It's become the joke we'll stop at the drug store on the way to the hospital.  Does every patient who gets into poison ivy need Benedryl?  No.  But that patient of mine who had angio edema - yes, and I didn't have it within my scope.


Fair enough, but hardly a comparison. Don't confuse_ life saving_ with _life-sustaining_.

I'd dispute that Benadryl in the face of (non-ACE inhibitor-induced) angioedema would be arguably life saving, while and ETI in the field vs. adequate and effective ventilation and oxygenation _by any means_ that fits the patient at hand is life sustaining.

You do realize the biggest thing harped with RSI, and intubation (and I honestly didn't learn it for a few years) is adequate oxygenation and ventilation, not the procedure itself?

Wouldn't you rather be properly educated on when not to do something, and know when to utilize proper resources, be it higher level (i.e., better trained and educated) providers whether it's prehospital, or in-hospital perform this skill while assisting them if needed in the best possible way(s), ensuring the patient does not go hypoxic?

I, as a patient, would rather you were. To me this shows so much more nobility and heroism.

No one's goal should be to intubate someone blindly, we should now be to the point as prehospital providers where we're aiming to prevent this from happening from the beginning, thus the advent of CPAP in the prehospital arena.

Perhaps more paramedics should spend time in the ICU watching patients have trouble being weaned off their ventilators for some more insightful perspective? Afterall, the goal is ultimately extubation, and this goal can often be hindered by many factors including what we do, or don't do correctly in the field.

I can understand the "laziness" point of view as I have witnessed it firsthand, however I think practicality can also be enforced when having to manage an airway. Critical thinking may trump it, but practicality should not be discounted.


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## StCEMT (Jan 27, 2017)

I think the education for intubation goes both ways. Yea, I've picked up a few little tips and tricks from other medics, but I am by no means skilled at this. It would make me so damn excited to have a place that hooked me up with an OR to not only practice intubation, but all types of airway management. Let me run a bag for a while and stuff. It'd be nice to regularly practice these things (quota essentially) so when it is the better choice, I am not going off of a x month dry spell. That being said, I am all for using other resources first. Realistically I wont need to intubate too many people where I am and when I could, an igel is enough to suit my needs. I've used them, I am familiar and comfortable with them, and so far they have worked well for me. However, part of that stems from my recognition of my limitations in ability intubating. Unless I feel confident I could get it without causing more harm, I just see no need to mess with it unless I absolutely have to.


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## VFlutter (Jan 27, 2017)

CWATT said:


> I couldn't disagree more.  And please know I have a lot of respect for you.  However, this is clearly a protocol and training/education solution, not scope of practice.  To throw the baby out with the bath water because people are jumping to ET too soon will mean that someone in the future who would benefit from the intervention won't have access to it.



But honestly how many companies are willing to invest in the training and education necessary to produce highly competent airway providers? Would it not be reasonable to limit ETI to a smaller group of practitioners whom can be trained and held to a higher standard?


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## FLMedic311 (Jan 28, 2017)

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1182327/


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## Carlos Danger (Jan 28, 2017)

"Published research is mostly false. Unless I published it, then it is true."


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## mttbdtd (Jan 29, 2017)

I personally believe intubation is a skill needed by all medics. Maybe we do need more training in the skill and when to use it. The idea of only letting a small group of more trained EMS providers have that skill is detrimental. What happens when a "regular" medic comes across an overdose and that person needs to be intubated. Anyone that works on the streets or in the ER has seen doctors pull SGAs and putting an ET in pretty fast after arrival. The focus should be more on when to use the skill. I work in a system where pretty much everyone else on scene can get access and push epi. Typically in a run of the mill code I can get a person on compressions, then have someone get access and get the first epi in while I am intubating. I do not let compressions stop. It was very difficult for me at first but after going at it for a while it's not that bad. Without those tubes during codes the two times during the last year when I had to intubate someone alive would have been much more difficult. If you have no tubes during a code skills decline, tubes are gone completely, then what do you do when you need to tube someone alive. Then what about when you have to RSI someone and haven't tubed this year? An SGA isn't always a suitable answer. I had a hanging this year as well and I didn't try a SGA but what if you had that destroyed airway and can't get an SGA to correctly seat? We NEED tubes but with more training.


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## VentMonkey (Jan 29, 2017)

mttbdtd said:


> I personally believe intubation is a skill needed by all medics. Maybe we do need more training in the skill and when to use it. The idea of only letting a small group of more trained EMS providers have that skill is detrimental. What happens when a "regular" medic comes across an overdose and that person needs to be intubated. Anyone that works on the streets or in the ER has seen doctors pull SGAs and putting an ET in pretty fast after arrival.


I'm sorry, but this statement sounds like a thought process solely based on ego. Perhaps I am reading this wrong.


mttbdtd said:


> The focus should be more on when to use the skill.


Agreed, hence the reason for higher-than average trained professionals, if at all; ACP's essentially. Most of the "what if's" you've presented will tolerate proper *oxygenation, and ventilation* *by even basic techniques.* Why don't we focus on doing those two things right first? Oh, that's right they're just not as sexy.


mttbdtd said:


> If you have no tubes during a code skills decline, tubes are gone completely, then what do you do when you need to tube someone alive. Then what about when you have to RSI someone and haven't tubed this year? An SGA isn't always a suitable answer. I had a hanging this year as well and I didn't try a SGA but what if you had that destroyed airway and can't get an SGA to correctly seat? We NEED tubes but with more training.


Again, ego-driven hogwash. So what if your skills decline because _you_ "can't tube" someone. I'm sorry if you losing out on a skill that seems beneficial for reasons you haven't proven with data (has anyone?) isn't in the best interest of the patient, nor is their adequate data to support such thought process. Where does any of this fall into advancing our thought process of critical thinking abilities to you?


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## VFlutter (Jan 29, 2017)

Just curious, how many companies honestly track their intubation statistics? First pass success, overall success, complications, hypoxic events, etc. 

At what point can you objectively state that you are competent and doing more good than harm? Is a 70% first past success rate acceptable? How many peri-intubation arrests are too many?


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## VentMonkey (Jan 29, 2017)

Chase said:


> Just curious, how many companies honestly track their intubation statistics? First pass success, overall success, complications, hypoxic events, etc.
> 
> At what point can you objectively state that you are competent and doing more good than harm? Is a 70% first past success rate acceptable? How many peri-intubation arrests are too many?


All valid questions, to which I doubt there is a universally adopted position, or answer. Which further goes to show where we as prehospital providers are in regards to training, and education, even after 50 years.

I can say the accrediting body for my service helps us keep tallies on our success rates/ year and things of that nature. I'd rather see paramedic programs include a way more in-depth approach to airway management in regards to education since so many paramedics are so adamant we need to keep this skill; something similar to the time and money we've invested in the other "basic emergencies" covered in the paramedic curriculum. Anyone who thinks that most paramedic programs provide enough initial education on airway management now is only fooling themselves, IMO.

If at the end of such chapters, blocks, lectures or what have you, the student walks away knowing not only a deeper understanding of most respiratory pathologies, but why one would want to pull a tube out of their kit so quickly with such haste, and more importantly why they wouldn't want to would be of value, and its money's worth in actual education. 

Again, a failed airway should be viewed as one you cannot adequately oxygenate, and ventilate not one you can't intubate. This is a huge part of the problem with our thought processes as paramedics, and why many of us have to try so desperately to "get the tube" four, five times in.

I think all paramedics regardless of their credentialing could benefit from Ron Walls' book on difficult airway management. As a paramedic, and one who is still a ground paramedic as well, I have no qualms with my viewpoint, nor would I hesitate to say many paramedics are really lacking a broader view with regard to their thought process when it comes to proper airway management techniques; not all, but enough for it to reflect poorly on those who do take it seriously. I still don't understand the "threat" with intubation being taken away? EBM reflects positive trends for the patients, not us, the patients.

Being an above average intubator makes you nothing more than a technician, that doesn't necessarily equate to an above average clinician, or practitioner.


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## mttbdtd (Jan 29, 2017)

If ego driven hogwash was how it came across I'm sorry that was not how it was meant. I was offering my opinion and gave an example. I don't do anything because it is sexy. If an ET tube was nothing but sexy then why do doctors do them? When are you allowed to step it up then? If someone is on scene you have a good airway, patient is being ventilated properly then why not step it up to a better airway? As long you aren't ignoring something else that is more important then why not go as far as you can? As for the tracking of statistics I believe the company I work for does.


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## VentMonkey (Jan 29, 2017)

mttbdtd said:


> If ego driven hogwash was how it came across I'm sorry that was not how it was meant. I was offering my opinion and gave an example. I don't do anything because it is sexy. If an ET tube was nothing but sexy then why do doctors do them?
> *We're probably best not using doctors as a comparison. I would think a bit more articulating with regards to clinical insight, not to mention the ginormous difference in levels of educations between the two career paths goes without saying. How about this: would you rather your physician be a technician or clinician?*
> When are you allowed to step it up then?
> *When you see that there is inadequate oxygenation, and/ or ventilation; the potential with both within reason utilizing a strong critical thinking foundation would help make for a smooth transition into decision-making, and reasonable rationale for it.*
> ...


And there's no need for apologies, we're all entitled to our opinions.

I guess it depends on the type of paramedic one wishes to become. You can be the "I sure hope I get to intubate a lot of people throughout my career" paramedic, or the "I sure hope I can prevent a lot of people from being intubated" paramedic. Personally, I'm glad I grew up and realized I'd rather be the latter.


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## VFlutter (Jan 29, 2017)

mttbdtd said:


> If an ET tube was nothing but sexy then why do doctors do them?.



Not all Doctors intubate. Just because your Internal Medicine Doc intubated in residency does not mean they are competent to do it now. Just because a Doctor intubates patients in a controlled setting, with unlimited resources and equipment, with a lot more experience and frequency, does not mean that it is the best option for every medic in the prehospital environment. 

A chest tube is definitive treatment of a pneumothorax, should all medics be allowed to do so in the field?


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## reaper (Jan 29, 2017)

VentMonkey said:


> And there's no need for apologies, we're all entitled to our opinions.
> 
> I guess it depends on the type of paramedic one wishes to become. You can be the "I sure hope I get to intubate a lot of people throughout my career" paramedic, or the "I sure hope I can prevent a lot of people from being intubated" paramedic. Personally, I'm glad I grew up and realized I'd rather be the latter.


You hit that point spot on. You should be the Medic that does not want to intubate your pt. There are times that a pt will need to be intubated. Then there are times we think a pt needs to be intubated. The latter are the ones we should be doing all we can not to have to intubate! 

Sent from my VS985 4G using Tapatalk


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## VentMonkey (Jan 30, 2017)

@mttbdtd you seem like a sharp enough person, I think when it comes to this subject matter it often becomes this endless debate of "why vs. why not" with hardly, if any, bold evidence in favor of out of hospital ETI's.

As paramedics it would be nice if we were, as a whole, on the same page with the realistically limited knowledge we possess about the often deleterious outcomes we can, and do inflict on patients requiring an advanced airway that's done in the field in an almost exclusively routine less-than-ideal environment.


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## Tigger (Jan 30, 2017)

My service certainly suffers from the whole "intubation defines the paramedic" mantra. It's embarrassing to me frankly. While a lack of evidence does not necessarily equate to negative outcomes, you'd think if EMS wanted to really hold onto intubating people that we could actually prove why we should. This thread is a prime example of "I think we need it and here are my reasons, however I can't back them up." Throwing around terms like "gold standard" is silly. There is not one airway answer for every environment. Saying "the doc is just going to pull by SGA" does not justify you intubating. 

I intubate cardiac arrests solely because that is the expectation during my year of new medicness. We don't stop CPR for it, but it still makes running a code significantly harder. And for what gain?


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## StCEMT (Jan 30, 2017)

Tigger said:


> And for what gain?


Dat gold standard amigo. In all seriousness, I like that is expected we just go straight to an igel. Cardiac arrest is one of those cases I don't really see a need to intubate for a couple reasons. Just pull that big ******* out and it'll do its job perfectly fine.


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## Tigger (Jan 30, 2017)

StCEMT said:


> Dat gold standard amigo. In all seriousness, I like that is expected we just go straight to an igel. Cardiac arrest is one of those cases I don't really see a need to intubate for a couple reasons. Just pull that big ******* out and it'll do its job perfectly fine.


And if you discover that the patient must be intubated at a later point, you can still do that. 

For a while we were doing passive oxygenation on cardiac arrests of non-respiratory etiology. If we got pulses back, then they got intubated. Arrests were way easier that way. Realistically it takes two people to intubate someone undergoing compressions. That's two less people to monitor the code...


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## mttbdtd (Jan 30, 2017)

I agree that this debate will never be over. I think some of the things I said were taken the wrong way and I'm not going to write out more clarification. I think it's a skill that's needed. I agree there are some out there that are not behaving as clinicians and are also terrible at the skill of intubation. Both of which are detrimental. More training at the foundational levels of paramedicine is necessary for more than just intubation.


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## VentMonkey (Jan 30, 2017)

My issue isn't with the skill itself. In and of itself it's just that, a skill. How rudimentary did or does the procedure seem when you learned on "Fred the Head"?

Maybe read what others have said. It's only a fraction of airway management. If you're a fairly new paramedic, it would be hoove you to realize sooner rather than later you're best bet would be to re-educate yourself on the "Alphas and Omegas" of airway management; _NOT_ intubation_, airway management_.

Saying it's "just needed" does nothing for you, me, or any other paramedic as clinicians plain and simple. If you felt that firmly about your position with adequate reasoning to support such you would have no hesitation writing out what or why it is you think what you do. Again, this is all in the sake of dialogue; hardly an argument, how else can we (all of us) learn from one another?

Also, you're hardly the only paramedic who feels this way, but at least you had the stones to post your opinion, so kudos for that.


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## mttbdtd (Jan 30, 2017)

Bustin my balls here vent. The skill in itself is no more difficult than any others we perform. My medic instructor apparently used to bring in his grade school daughter and show that she could intubate. He hounded us on WHEN to intubate not how to. 
Speaking on certain situations and barring unforeseen complications. First, CPR in progress. Walk in, patients dead. Everything handled appropriately. You intubate. You now have a definitive airway. No need to change if rosc, or things like gastric distention come to get you. At least in my experience as soon as I walk in with rosc RT and the doc "is that an ET or a king?". I'm not comparing paramedic to doctors but in this situation doctors are intubating for the same reasons we are and are apparently making the same mistakes. By chance I run an assload of codes and I intubate every one of them when I get a chance. It's not intubation itself it is the "wake effects" of a medic intubating. As long as it's in my scope and I can mitigate those effects then I will intubate.

Phone dying more coming in a bit


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## mttbdtd (Jan 30, 2017)

The second is your alive but dying patient. Pill overdoses with unresponsive patients you've got a good chance of vomiting. It's not easy to manage a large patient in the back of an ambulance that is vomiting all over, aspirating and compounding their already significant problems. It is easy to manage a properly timed and performed ETT. Not in the sense that you've nothing left to do but in the interest of the patient there are times where taking absolute control of that patients airway is very nessasary. I do not work in a system that allows RSI and I have only once come across a patient that had me wishing I could. He was immediately RSId in the ER. And again no, just because a doc will do it anyways is not the reasoning.
 I'm not of the crowd that is saying I want to intubate more people!!!
If I contnue to come across as a [unneeded expletives] new paramedic swingin my [unneeded reference to anatomy] around that is not me. I am new to this game but I'm not running in to calls laryngoscope in hand like [unneeded expletive] yes my patient is dying. I posted before regarding narcan use routinely. I'm not for a big blanket, black and white practice but medicine. I don't have study's I can pull out of my *** at the moment I can only speak from my limited experience. And as I said before all of us could benefit from more foundational knowledge and experience.

EDIT for language.


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## VFlutter (Jan 30, 2017)

mttbdtd said:


> The second is your alive but dying patient. Pill overdoses with unresponsive patients you've got a good chance of vomiting. It's not easy to manage a large patient in the back of an ambulance that is vomiting all over, aspirating and compounding their already significant problems. It is easy to manage a properly timed and performed ETT. Not in the sense that you've nothing left to do but in the interest of the patient there are times where taking absolute control of that patients airway is very nessasary. I do not work in a system that allows RSI and I have only once come across a patient that had me wishing I could. He was immediately RSId in the ER. .



Wait, so you are using risk of vomiting as justification for intubation yet you do not have the ability to RSI? Something seems a little off with that rationale. If you have only seen one patient in your career that would benefit from RSI over sedative only intubation then that is another discussion in and of itself.


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## mttbdtd (Jan 30, 2017)

Not so much that I've only seen one patient that would benefit. I can think of one particular case that sticks out in my mind in which a patient was on the verge of being unresponsive but never quite there and I knew I would not be able to go any farther without RSI. He needed it right at that second. 
No, it's not solely vomiting. Your patient starts semi responsive most likely with a gag reflex and then becomes suddenly unresponsive despite your interventions. Patient is not dead, not in a ventricular rhythm, secure that airway.


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## mttbdtd (Jan 30, 2017)

Let's make this about nitpicking me. Not the issue at hand. I have a particular stance, presented it and you would rather hit my lack of experience and obviously less education in EMS. Calling me young and dumb is not a discussion.

I'm out.


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## VFlutter (Jan 30, 2017)

mttbdtd said:


> Let's make this about nitpicking me. Not the issue at hand. I have a particular stance, presented it and you would rather hit my lack of experience and obviously less education in EMS. Calling me young and dumb is not a discussion.
> 
> I'm out.



I never questioned your experience or your education, and I never called you young and dumb. But if you feel so strongly about your position then you should be able to defend it, this is meant to be a discussion. I am guessing this is the first time people have challenged your practice, don't get defensive. I am playing the devils advocate a little. I won't harp on the RSI vs drug assisted intubation too much but I think you have a much harder time justifying taking someone's airway when you lack the proper tools. My last comment wasnt meant as a jab at your experience but rather that having not used RSI you may not be familiar with it's advantages, the evidence behind it, the effects on outcomes, etc.


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## VentMonkey (Jan 30, 2017)

mttbdtd said:


> The second is your alive but dying patient. Pill overdoses with unresponsive patients you've got a good chance of vomiting. It's not easy to manage a large patient in the back of an ambulance that is vomiting all over, aspirating and compounding their already significant problems. It is easy to manage a properly timed and performed ETT. Not in the sense that you've nothing left to do but in the interest of the patient there are times where taking absolute control of that patients airway is very nessasary. I do not work in a system that allows RSI and I have only once come across a patient that had me wishing I could. He was immediately RSId in the ER. And again no, just because a doc will do it anyways is not the reasoning.
> I'm not of the crowd that is saying I want to intubate more people!!!
> If I contnue to come across as a badass motherfuckin new paramedic swingin my **** around that is not me. I am new to this game but I'm not running in to calls laryngoscope in hand like **** yes my patient is dying. I posted before regarding narcan use routinely. I'm not for a big blanket, black and white practice but medicine. I don't have study's I can pull out of my *** at the moment I can only speak from my limited experience. And as I said before all of us could benefit from more foundational knowledge and experience.


Yeah, I have to agree with Chase, no one called you young, or dumb; inexperienced, perhaps? But it seems like you've taken it the wrong way. If anything, maybe you should be flattered the guy is trying to enlighten you. He's a well educated, and experienced nurse with significant ICU time. 

Something also worth mentioning is that this thread was created and shown to question the importance of early _in-hospital _intubation. If it's postulating it's ineffectiveness in early in-hospital arrests in a much more controlled, and presumably sterile environment with a vast array of experienced airway experts why should we be allowed the same privileges without any profound documentation, EBM, literature, etc. other than it being the "gold standard"?

Again, I can respect your opinion, and know I too was once there, but I chose to take it upon myself to become better acquainted with airway management, not just the intubation; I seem to be echoing this a lot. I had a  instructor who was adamant about gastric tubes being placed, and that an ET tube without one is just about useless, where does this fit into your aspiration patient? If you intubate said patient should you be placing them on the ventilator immediately even with very basic settings, and parameters? Is hand-bagging with a BVM the same as the ventilator, why or why not? If you arrive to find fire or whoever has placed a SGA that is showing adequate oxygenation, and ventilation why do _WE_ need to pull it? What about the morbidly obese patient with a grade 4 mallampati? How would you protect their airway? are we going to need to change our choice of airway devices from the start, is a SGA sufficient in this case? What about DL vs. VL, where do they fit into one's plans for first time success? That is the goal, and not because any of us should be ego-driven, but because the patient doesn't deserve anything less. What techniques can you use to improve their likelihood of not desaturating? When you first walk in and find a patient that needs to be intubated should you have a back up airway in mind already, and if so, what would it be, and can it provide adequate oxygenation, and ventilation in the face of the unforeseen failed intubation?

I'm not asking you to answer any of these questions, nor do I care how much experience you do, or don't have. This is merely the "tip of the iceberg" that should be going through a prudent airway clinicians mind pre-intubation, at least in my opinion; they go through my mind.


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## StCEMT (Jan 30, 2017)

Tigger said:


> And if you discover that the patient must be intubated at a later point, you can still do that.
> 
> For a while we were doing passive oxygenation on cardiac arrests of non-respiratory etiology. If we got pulses back, then they got intubated. Arrests were way easier that way. Realistically it takes two people to intubate someone undergoing compressions. That's two less people to monitor the code...


Do you have (or have plans?) VL for intubating? I would probably feel better about intubating an arrest after oxygenating them for a bit if I had that. Then again, I don't know that I would actually stray away from an igel in this case even if it was available.


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## Tigger (Jan 30, 2017)

StCEMT said:


> Do you have (or have plans?) VL for intubating? I would probably feel better about intubating an arrest after oxygenating them for a bit if I had that. Then again, I don't know that I would actually stray away from an igel in this case even if it was available.


We will have McGraths on the truck soon. I plan to use it for every tube, especially since that particularly device can be used as a regular DL handle/blade as well.


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## StCEMT (Jan 30, 2017)

Tigger said:


> We will have McGraths on the truck soon. I plan to use it for every tube, especially since that particularly device can be used as a regular DL handle/blade as well.


I never got to try one on a messy airway, but I am a fan of them. They are comfortable and in my limited experience, work well. Should be a good addition for you.


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## mttbdtd (Jan 31, 2017)

Sorry guys. This is typically why I don't participate in online forums. I get misconstrued or someone misconstrues me. Then someone gets butt hurt and this time it was me.


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