Can EMT-B intubate or start IVs?

[MackTheKnife]

If you haven't had a failed intubation attempt, you haven't done enough intubations.
Minimizing intubation as "no big deal" is a dangerous road to head down.

Oh, I've failed a few times. Never said I was batting 1,000. And I'm not minimizing. Some things in life are put on a pedestal, or are made to seem Godlike, as with intubation. It's not complicated or hazardous as say starting a central line or doing a cric to put it into perspective.

 

[MackTheKnife]

That kind of thinking is why there are docs that are very willing and actively trying to pull ETI from prehospital providers in general

It's not that kind of thinking. If it is please cite a study, etc. I have read articles in JEMS for instance, about how medics attempting prehospital intubations are experiencing difficulty and a higher failure rate. And it was being considered to go away from intubation.

 

[Carlos Danger]

Intubation should be a Basic skill. It's an airway, not a drug, or something complicated.

Yeah....read much research on prehospital ETI?

Airway management is easy, alright.....until it's not.

 

[MackTheKnife]

Yeah....read much research on prehospital ETI?

Airway management is easy, alright.....until it's not.

Remi, you, like some of the other commenters, are missing my point. What I am saying is the skill is easily taught, as the skill set is eye-hand coordination and knowing what you're looking at. Didn't say it was easy for everyone. We had a few medics who had a hard time tubing cause they couldn't recognize the cords since it didn't look the same as in the book or in the dummy. Once they figured it out, they became quite good.
What concerns me is the attitude I am inferring from some of you. You probably weren't around when EMS had to constantly fight to stay viable. Doctors and nurses fought us all the time because they didn't think we could do the things we're doing. Medicine advances despite us. We have PAs, NPs, etc., doing things that doctors once did. Not an exact analogy, I know. But no one here has come up with a really good reason we can't have Basics intubating other than it should only be a medic skill because that's how they feel.
And some didn't bother reading that I have a lot of experience motivating and just made snarky comments.

 

[chaz90]

It's not that kind of thinking. If it is please cite a study, etc. I have read articles in JEMS for instance, about how medics attempting prehospital intubations are experiencing difficulty and a higher failure rate. And it was being considered to go away from intubation.

How does this support your point in the slightest?

 

[chaz90]

But no one here has come up with a really good reason we can't have Basics intubating other than it should only be a medic skill because that's how they feel.
And some didn't bother reading that I have a lot of experience motivating and just made snarky comments.

Reason 1: Intubation proficiency requires a significant number of real patient practice to achieve and maintain clinical competency which is likely unachievable and not feasible for a large number of 120 hour BLS providers

Reason 2: It's a low frequency/high risk skill pre-hospitally, particularly if we're talking about rural services with such low call volumes they are using an EMT to intubate since they don't even have any ALS provider or hospital available

Reason 3: Better alternatives exist for EMT airway placement during arrests, IE any number of supraglottic rescue airways

Reason 4: Failing to recognize a misplaced ETT is a fatal error, and most BLS services don't have the equipment, training, or experience to prevent this from occurring frequently

Shall I continue?

 

[NomadicMedic]

A study of EM residents showed it takes upwards of 70 intubation attempts to become baseline competent, which was identified as securing the airway 90% of the time without outside assistance. Not many paramedics, outside of those in high volume areas, will see that many tubes in 10 years.

Emerg Med J doi:10.1136/emermed-2013-202470

Is that a skill basics should be attempting after a weekend add on module?

Hell, I'm of the opinion that regular street medics shouldn't be performing ETI.

 

[Carlos Danger]

Chaz and DE are both right on.

Remi, you, like some of the other commenters, are missing my point.

I'm sorry, but you are the one who is missing the point.

You probably weren't around when EMS had to constantly fight to stay viable.

Not sure how this is relevant, but FWIW, I started paramedic school almost 20 years ago.

Medicine advances despite us. We have PAs, NPs, etc., doing things that doctors once did.

Medicine does advance and change. The problem with your comparison though, is that the additional parameters being added to mid-level practice is happening because research has shown it to be effective and efficient....blindly adding advanced skills to the scope of unqualified practitioners is not "advancing" by any definition.

But no one here has come up with a really good reason we can't have Basics intubating other than it should only be a medic skill because that's how they feel.

I'll add two more reasons to the ones that Chaz and DE already listed:

1) Prehospital intubation by American paramedics has never been shown to affect outcomes positively.....so even without a study, you'll never convince anyone that prehospital intubation by EMT's will be good for patients.

2) The success rates of prehospital intubation without RSI are uniformly ABYSMAL and completely unacceptable. So unless you think EMT's should be pushing sux, the whole idea is a non-starter.

These opinions aren't based on my feelings about the issue, they are based on years of experience and reading the related literature.

 

[DesertMedic66]

Sure intubation is just a skill, like needle cric, needle thor, IV, and IO. However providers need to know why they are doing the skill, what can go wrong, and what results they are looking for. All of which can not be taught in a 120 hour class, some would argue it's not even really taught in paramedic school.

Along with these skills the providers should have other tools to verify they skill was done correctly. So for intubation we are talking about ETCO2. Now we have to provide an ETCO2 monitor to the BLS crew, teach them about the different waveforms and different values.

That is asking a lot for a very entry level position.

 

[Shishkabob]

Hell, I'm of the opinion that regular street medics shouldn't be performing ETI.

You can argue on the efficacy and that'd be a valid argument, but proficiency outside of harm should not be the defining issue. Don't delay compressions, don't delay transport, and recognize if it's in the esophagus quickly and correct it and it's really a non-issue, all else being equal.

There aren't many studies on the efficacy of surgical crichs in the field, yet the removal of ETI leaves exactly just that: Surgical crichs on the population who ETI has the potential of being beneficial and/or blind insertion airways are unacceptable, such as esophageal varices, smoke inhalation, etc.


Taking a tool out because it's sometimes missed is not the best way of going about medicine and the issue at hand. Make EtCo2 waveform capnography the norm, make daily airway check-offs the norm, give more access to tubes for Paramedics. THAT'S the correct way of fixing the issue of misses / unrecognized misses.

 

[Carlos Danger]

Taking a tool out because it's sometimes missed is the absolute worst way of going about medicine and the issue at hand. Make EtCo2 waveform capnography the norm, make daily airway check-offs the norm, give more access to tubes for Paramedics. THAT'S the correct way of fixing the issue of misses / unrecognized misses.

What about the fact that it's never been shown to help, and in fact very often causes harm? Somehow we always seem to gloss over that minor detail.

It's not about the fact that it is "sometimes missed", it's about the fact that even when it isn't missed, it doesn't help patients.

Funny how we are so quick to cite the evidence when it comes to spinal immobilization, yet so quick to dismiss the evidence when it comes to prehospital intubation.

At what point do we finally just admit, "you know what, this just isn't working"?

 

[Shishkabob]

What about the fact that it's never been shown to help, and in fact very often causes harm? Somehow we always seem to gloss over that minor detail.

It's not about the fact that it is "sometimes missed", it's about the fact that even when it isn't missed, it doesn't help patients.

Funny how we are so quick to cite the evidence when it comes to spinal immobilization, yet so quick to dismiss the evidence when it comes to prehospital intubation.

At what point do we finally just admit, "you know what, this just isn't working"?

And like I just said: Argue the efficacy, not the proficiency. Proficiency can be increased with minor fixes, thus should not be a bullet-point in the conversation.


Further: Studies say it doesn't always help, however we can't actually say that it actually causes harm with any certainty. Correlation doesn't mean causation, and we don't exactly know why some people fare worse with ETI (outside of delaying compressions or things of that nature). Physiologically speaking, a small plastic tube in someones throat shouldn't cause any difference, so what else is going on? More people who die in the hospital have IVs, however that doesn't mean the IV caused, nor has any correlation, to their death unless it can be attributed to things such as an embolus.

Just like the arguments about Epi in SCA. Studies show that it increases ROSC... we also know that discharge-intact is not statistically different with Epi. Instead of pinning it on Epi, why not take a more holistic approach and ask why someone may get ROSC but not maintain it? Perhaps there's something being missed, something that can be changes, and discarding that viewpoint can prevent further studies in to such and possibly changing medicine in the future. (The first person to invent a medication that causes systemic vasoconstriction without causing cerebral edema / etc, will be a trillionare).



With the restrictions placed on studies in emergency medicine, it makes it much harder to do random double-blinded studies, thus we generally have to go off of reviews, conjecture, etc. Obviously not the best way to do studies, let alone medicine; we have studies contradicting each other all the time. Luckily we have studies such as ALPS in the pipeline right now which will hopefully help narrow things down in the future.

 

[Carlos Danger]

And like I just said: Argue the efficacy, not the proficiency. Proficiency can be increased with minor fixes, thus should not be a bullet-point in the conversation.


Further: Studies say it doesn't always help, however we can't actually say that it actually causes harm with any certainty. Correlation doesn't mean causation, and we don't exactly know why some people fare worse with ETI (outside of delaying compressions or things of that nature). Physiologically speaking, a small plastic tube in someones throat shouldn't cause any difference, so what else is going on? More people who die in the hospital have IVs, however that doesn't mean the IV caused, nor has any correlation, to their death unless it can be attributed to things such as an embolus.

Just like the arguments about Epi in SCA. Studies show that it increases ROSC... we also know that discharge-intact is not statistically different with Epi. Instead of pinning it on Epi, why not take a more holistic approach and ask why someone may get ROSC but not maintain it? Perhaps there's something being missed, something that can be changes, and discarding that viewpoint can prevent further studies in to such and possibly changing medicine in the future.



With the restrictions placed on studies in emergency medicine, it makes it much harder to do random double-blinded studies, thus we generally have to go off of reviews, conjecture, etc. Obviously not the best way to do studies, let alone medicine; we have studies contradicting each other all the time. Luckily we have studies such as ALPS in the pipeline right now which will hopefully help narrow things down in the future.

True that the studies are almost all retrospective, but there are many of them and they are almost unanimous in their findings: prehospital ETI fails to improve or worsens outcomes. The one large prospective study (the Bernard TBI study done in Aus) showed small statistical benefits but they were arguably clinically insignificant - certainly not overwhelmingly positive - and that was even in a system where the paramedics are much better trained than in the US.

Such evidence against a non-sexy intervention would result in widespread calls among paramedics to have it removed from the protocols.

Personally, I think these findings are a result of several subtle but very important factors, of which proficiency with passing the tube through the cords is only one (though obviously a critical and foundational one).

We do need more prospective trials before we know for sure, and they shouldn't be so hard to approve given the current lack of evidence of benefit.

However, the fact is, at the present time, the best evidence we have simply does not support routine prehospital ETI by paramedics, nevermind by EMT's.

What is the ALPS trial?

 

[Shishkabob]

What is the ALPS trial?

ALPS is the Amiodarone, Lidocaine, Placebo Study that the ROC is doing in a few locations (one of which is at my location). Basically a double-blinded, placebo controlled study for cardiac arrests, determining Amio vs Lido vs nothing.


Believe they are aiming for 1500 enrollments before expanding it, which last I heard will be reached pretty soon. I have 2-3 myself.

 

[triemal04]

Intubation should be a Basic skill. It's an airway, not a drug, or something complicated.

You know, I was going to ask you to answer this question:

Don't hedge on these answers.

Do you think that made you competent to intubate properly? Yes or no.

Do you agree with people who have that same amount of training being allowed to intubate? Yes or no.

Just checking.

But after reading that it's pretty clear what your answer is. And for those just checking in, attitudes like this is why EMS in the US, as a whole, is a failure.

That kind of thinking is why there are docs that are very willing and actively trying to pull ETI from prehospital providers in general

And truly, it's appropriate for doctors to do things like that with that kind of ignorant, flip attitude.

Taking a tool out because it's sometimes missed is not the best way of going about medicine and the issue at hand. Make EtCo2 waveform capnography the norm, make daily airway check-offs the norm, give more access to tubes for Paramedics. THAT'S the correct way of fixing the issue of misses / unrecognized misses.

It's not that "it's sometimes missed" that is pushing the drive to remove endotracheal intubation from the paramedic skillset (which, for the record I agree with, outside individual systems that can actually prove that it is appropriate for them to do), it's the fact that the average paramedic is incompetant from the get go when it comes to intubation.

The initial education on it, the physical hands on training, continued performance to maintain competancy, education on real post-intubation management...all of that is sorely lacking. And without that, it becomes a skillset that will cause more problems than any potential benefit it could bring.

The other part is that paramedics ARE missing tubes or STILL, in this day and age, placing a tube in the esophageaus and not recognizing it. With exceptions, when paramedic intubation gets looked at the success rate is dismal; I honestly don't remember the last study that mentioned what the first pass success rate was, but I'd bet it also would be horrifying. (obviously there are exceptions to this, but for the average paramedic, pretty accurate)

 

[Carlos Danger]

It's not that "it's sometimes missed" that is pushing the drive to remove endotracheal intubation from the paramedic skillset (which, for the record I agree with, outside individual systems that can actually prove that it is appropriate for them to do), it's the fact that the average paramedic is incompetant from the get go when it comes to intubation.

The initial education on it, the physical hands on training, continued performance to maintain competancy, education on real post-intubation management...all of that is sorely lacking. And without that, it becomes a skillset that will cause more problems than any potential benefit it could bring.

The other part is that paramedics ARE missing tubes or STILL, in this day and age, placing a tube in the esophageaus and not recognizing it. With exceptions, when paramedic intubation gets looked at the success rate is dismal; I honestly don't remember the last study that mentioned what the first pass success rate was, but I'd bet it also would be horrifying. (obviously there are exceptions to this, but for the average paramedic, pretty accurate)

Success rates with RSI are really generally not that bad (providing you take self-reported data about the attempts at face value); it's really the outcomes that are troublesome. And that's a result of the factors you mentioned in the second paragraph, as well as the unique difficulties inherent to prehospital ETI.

 

[MackTheKnife]

How does this support your point in the slightest?

Didn't say that it did.

 

[gotbeerz001]

Didn't say that it did.

Interesting tactic.

 

[RefriedEMT]

Either way I think supraglottic and blind insertion devices should still be used not only by medics but emts because they IMO are fairly basic.

 

[hogwiley]

Not only should EMT Basics never be allowed to intubate, they shouldn't be allowed to do IVs outside of a hospital setting.

Starting an IV is relatively easy to learn, difficult to master, and comes with the potential for many complications, some of them life or limb threatening.

Catheter shear, air embolisms, infection, phlebitis, disease transmission and needle sticks, infiltration, tissue necrosis, forgetting to remove the tourniquet, hitting nerves, tendons or arteries. Its a pretty long list. Not to mention causing the patient unnecessary pain, leaving them with bruises and hematomas, and using up good veins in failed attempts and leaving Paramedics or the ER with nothing.

Then you have to worry about EMT Basics wasting time on scene trying to get an IV and getting tunnel vision. And finally what are they going to do with that IV? EMTs cant give IV meds, and giving fluids can open up the possibility of even more complications, and if given inappropriately can do more harm than good. Do you really want some 19 year old ricky rescues with 2 months of training doing that in an uncontrolled pre hospital environment? LPNs cant even start an IV in most settings and their education far surpasses EMTs.