Dr Blesoe has called us out.....

BLSBoy

makes good girls go bad
733
2
16
I am rather furious about this poorly written article.
To blame a few incidents on egotistical, poorly educated paramedics who obviously have poor supervision and weak interaction with their medical director is absurd.
Dr Bledsoe has written some very fine pieces of literature, and many con-ed pieces, but this is a direct attack on paramedics, based on the events of a few.
 

medic417

The Truth Provider
5,104
3
38
Seems well written record. There is no demands to remove intubation just that we get better education and learn to evaluate airways better and also consider when best to use which airway. This was a round table discussion of many experienced EMS Professionals.

Here are a couple of points from it:

"William E. Gandy, JD, NREMT-P: I wholeheartedly agree with Dr. Wang. Yes, the emphasis should be on ventilation—not intubation. Paramedics should be thoroughly schooled in airway evaluation and should have a variety of airway adjuncts, such as bougies, video laryngoscopy and supraglottic airways, available and be willing to use them."

"Dr. Bledsoe: I think we’re in agreement here that there remains a role for prehospital ETI, but we overemphasize ETI over ventilation. Given this, what are the major issues in EMS in regard to prehospital ETI?"

"Dr. Wang: Supraglottic airways are important parts of the prehospital airway tool kit. No one device is good enough."
 

WolfmanHarris

Forum Asst. Chief
802
101
43
Evidence Based Medicine is not personal.
How many studies have to point out the problems in EMS before the individual provider stops replying with anecdotal rebuttals and "well that's not me" thinking? Regardless of the skill and competence of the individual providers, we cannot ignore systemic problems within this profession (and god knows I hesitate to use that term sometimes). Eventually, the various powers that shape EMS will take the safe route, and folks, that's lowest common denominator.

Don't get mad at the critics. Get mad at the education system that allows incompetents to wear the same patch (or epaulet up here) as you. Get mad at the system that allow services to operate decrepit vehicles, obsolete or missing equipment and pretend that they do the same job as your professional, well run and funded service.

If Bledsoe's article pisses you off, then good. What are you doing to improve EMS in your area?
 

JPINFV

Gadfly
12,681
197
63
I didn't realize a discussion could be "poorly written." It's a discussion, not a commentary piece written from scratch.
 

Veneficus

Forum Chief
7,301
16
0
I am rather furious about this poorly written article.
To blame a few incidents on egotistical, poorly educated paramedics who obviously have poor supervision and weak interaction with their medical director is absurd.
Dr Bledsoe has written some very fine pieces of literature, and many con-ed pieces, but this is a direct attack on paramedics, based on the events of a few.

The trouble is that poor medical oversight and substandard training is the majority, not the minority.

Your serivce maybe exceptional, but I can name most of the exceptional services.

Even in a service (like national privates) one area often operates at a significantlyl different level than the rest.

I can tell you in my area, medical oversight isn't even "lax" it is almost unheard of. More than one medical director has tried to intervene, but the services (type not important as it is the same with all) will replace any medical director who makes waves. There is no shortage of Docs who will take the money to play ball.
 

FF-EMT Diver

Forum Captain
289
12
18
I agree with BLS to some degree, IMO it was in poor taste to start the article with a story of one jackwad medic that screwed the pooch and not also supply one countless where we have given it all to get that one intubation that was badly needed....Although I don't think he was totally bashing Prehospital intubations altogether it could have been better written and that was my thoughts when I read it this morn.
 

WolfmanHarris

Forum Asst. Chief
802
101
43
Intubation doesn't in itself save lives.
Failed intubation or an unnecessary focus on intubation certaintly costs them.
 

bstone

Forum Deputy Chief
2,066
1
0
Not a bad article, well written, looks good to me. Calls for more education, never a bad thing.
 

jjesusfreak01

Forum Deputy Chief
1,344
2
36
That's just annoying...no one gets cleared in my county without a bunch of intubations in hospital and more on cadavers. You get good and then you use it in the field, not the other way around. A few awful medics going to ruin it for everyone. It's totally on the medical director if they are going to let their medics practice without mastering these skills.
 
Last edited by a moderator:

abckidsmom

Dances with Patients
3,380
5
36
Seems well written record. There is no demands to remove intubation just that we get better education and learn to evaluate airways better and also consider when best to use which airway. This was a round table discussion of many experienced EMS Professionals.

Here are a couple of points from it:

"William E. Gandy, JD, NREMT-P: I wholeheartedly agree with Dr. Wang. Yes, the emphasis should be on ventilation—not intubation. Paramedics should be thoroughly schooled in airway evaluation and should have a variety of airway adjuncts, such as bougies, video laryngoscopy and supraglottic airways, available and be willing to use them."

"Dr. Bledsoe: I think we’re in agreement here that there remains a role for prehospital ETI, but we overemphasize ETI over ventilation. Given this, what are the major issues in EMS in regard to prehospital ETI?"

"Dr. Wang: Supraglottic airways are important parts of the prehospital airway tool kit. No one device is good enough."

I agree. How hard is it to require solid confirmation of tube placement with continual reassessment of tube placement? I am just now becoming active again in EMS after being out of it for a few years. We were having this same conversation before I left.

The problem, IMO, is laziness. Lazy or time-crunched medical directors fail to required competent performance of instructors and providers, lazy providers fail to follow standards of care, and this problem of misplaced ETTs continues.

In the ICU, tube placement is confirmed and documented after repositioning the patient in the bed. There is no excuse for failure to confirm and document tube placement through at least 2 methods on a fairly continual basis in the the EMS environment.
 

jjesusfreak01

Forum Deputy Chief
1,344
2
36
I agree. How hard is it to require solid confirmation of tube placement with continual reassessment of tube placement? I am just now becoming active again in EMS after being out of it for a few years. We were having this same conversation before I left.

I thought the whole point of a "visualized airway" was that you literally watch the tube pass through the vocal cords. Color cap takes 5 seconds, bulb maybe 10, and if you set up the wave cap then you have a continuous monitor. I just don't get how with a million good and easy ways of confirming tube placement someone could be so stupid not to. Your EMT can even do it for you, fcol (its in our protocols).
 

mycrofft

Still crazy but elsewhere
11,322
48
48
Article OK. Story is probably an illustrative fiction.

Maybe based on some true stories, but I find it entirely believeable.
Yeah, undertrained and poorly managed and screwed up, but it brings home one point (among others) that if you are not ready and you try it anyway, you are outside the envelope. Doesn't matter if you were told to (or assigned to the unit prematurely because they are short-staffed or something), if you don't refuse and you do it wrong, you are at fault.

Nurses have a form to send a copy of to their supervisors and to their union called an "Assignment Despite Objection" form that documents you were assigned to something you are not "comfortable" doing, and whether you accepted it or not. Sort of a must-have for a profession, otherwise you have to be insubordinate every time they screw up or you just don't have it yet.
Rant denied. Next case.
 

Veneficus

Forum Chief
7,301
16
0
Technology, brave men and their proud simulators

You can have every tube confirmation device in the world, with every fiberoptic, tv guided, device on the planet, if a provider sucks to begin with, all the technology in the world will not help.

If you guys didn't know, there are actually lobbists pushing for mandatory simulation technology in healthcare. There is already a major marketing push.

A simulator will never be able to replace actual patient contact. But if you listen to the salesmen and people pushing it, it is going to be the savior of medical training. This week I demonstrated intubating 4 "fred the heads" in under 30 seconds. Never once did the mallampati score change, there was no secretions or vomitus in the airways, they were NPO for years and years, no diseased broken teeth, no selecting of tube or blade size, not one anatomical variance, and in the best conditions available, airconditioned, well lit room.

Even with the $10,000,000 dummies (not nearly as dumb as the people spending that kind of money on it) will always tube the same so you don't actually get practice intubating, you get practice intubating that specific simulator. Does anyone beleive you could become a professional sportsman in any event with your playstation game?

I mentioned about the powerless medical director already, I will not rehash it.

Every Podunk town wants paramedics. Every City wants 1 paramedic for every 10 or so citizens. So you are up against a lack of opportunity to practice in both training and in a more controlled environment with an expert.

Mom and Pop's community hospital simply doesn't do enough procedures to allow a reasonable amount of practice.

Academic hospitals are saturated with residents, CRNAs, respiratory techs, critical care teams, and a host of people with more urgent need of intubation practice than paramedics.

With the cost of insurance and the pityful educational requirements of a paramedic, who in the right mind would expose their agency or practice to that liablity?

The amount of intubations are decreasing. Alternate devices, shorter less invasive or non inasive care of surgical pathology put the numbers on a downward trend. We also figured out that tubing people because we can causes things like increased hospital stays. That is not only bad for patients but the economics.

Many paramedics, including most I see graduate, will never intubate anything other than fred the head prior to being in the field. For most of them, opportunities to intubate are so rare that many will be independantly in charge of a unit with a basic partner before the first tube they attempt on a live person.

I worked at one place that on a truck of 6, 4 crewmen were paramedics. At best a person would get one attempt at every 4th tube.

There are still places that have no FTO or field internship prior to being released to full duty.

How about low volume volunteer agencies or 1 or 2 truck outfits?

How about the IFT unit that catches the occasional 911 call?

There are a few systems (because it is a system wide issue, not just an agency) that actually dedicate the resources needed to maintain proficency with this procedure. Fewer still that dedicate resources to the many procedures performed by paramedics.

How about instead of $10,000 on a simulator, we start sending paramedics to the local animal pound to intubate euthanized animals? It is a lot cheaper, and while not a substitute for a human in an OR under the supervision and direction of anesthesia, it is what was used historically.

Would you let a surgeon who only operated on a simulator operate on you?

Why not?

Then what on earth would cause you to not demand intubation be removed from EMS providers who cannot obtain and maintain proficency in a procedure that could actually cause death when it fails?

When did being good a a procedure become less important than knowing when you failed at it?

Stands to reason if you are good at something you fail less often and probably recognize quickly when you do.

EMS has become the excellence of half assed mediocrity.
 

EMS49393

Forum Captain
258
1
0
I have personally elected to use a King LTD airway the last two times I was faced with an intubation before I even attempted an intubation. In both cases, the patients looked like they were going to be difficult to intubate because of size and structure of the neck. Rather then play around with an ETT, I spent less than 5 seconds placing a King and was able to oxygenate and ventilate the patients with no difficulty.

We don't get enough practice here with ETI, and it's becoming a skill that I'm almost not comfortable preforming unless it's a little, tiny patient with a beautiful neck.

It seems the point of this discussion is not to "bash" paramedics or try to take away any ALS toys, but to point out that there are several paramedics that can go as long as years without intubating a patient, and that is a skill that simply requires some practice to keep from being rusty. I think it also points out the need for paramedics to be educated enough to recognize an esophageal intubation immediately so it can be corrected.

Honestly, and I don't really care who bashes me, I'm not sure we need ETI any more. We have some really good airway devices on the market that are as effective, and honestly, much easier than ETI. This is not about cool paramedic vanity, it's about doing the right thing for our patients.
 

EMTinNEPA

Guess who's back...
894
2
16
Finally, when ready, the paramedic positions the patient and inserts the laryngoscope. The patient starts to gag and reaches for the paramedic’s hand.

If the paramedic had been allowed to administer 0.5 to 2mg/kg of Ketamine and 1 to 1.5mg/kg of Succinylcholine, the above wouldn't have been a problem.

But in addition, the lack of proper education and medical oversight is a problem as well. Tools such a video laryngoscopy would be great, but unfortunately most EMS systems are too cheap to purchase such a device. However, with so many tools that ARE at our disposal (bougies, the BURP technique, suction, waveform capnography, etc.), there should be no reason that you can't obtain a patent airway. And if you absolutely can't obtain an airway, that's what surgical crics are for. Unfortunately that brings us back to proper education and medical oversight.

So we go back to the same problems we always have... paramedics lacking education, lack of continuous quality assurance, paramedics lacking tools to properly manage the airway of a critical respiratory patient with a gag reflex, and EMS systems putting money before patient care. So what are we going to do to solve these problems?
 

reaper

Working Bum
2,817
75
48
Sorry, but a lot of the success rates fall on Lazy Dr's and RTT's that are not truly confirming the placement, before pulling it.

We have proved this in our system. According to the Dr's our system had an ETI success rate of 25%. We as a system called BS on this. Our medical director implemented an airway form that had to be signed by the receiving Dr. They were signing off on confirmation of the ETI.

After three months in use, it is surprising that the ETI success numbers were 92%. Every pt brought in to the ED intubated, is confirmed by the MD on the call. These papers were taken by the medical director to a meeting with the heads of the ED's. Their jaws dropped at the difference and realized that the Dr's before this, were not doing the job of confirming the airway. Let's just say that heads rolled and now the system has proved what they were saying all along. We have very tight QA on ETI and very strict training and education standards.

This actually made some of the Dr's very happy. They always knew that the others were BSing their airway checks. and the select group of Dr's respect EMS and have faith in us.

So if you are having that many problems in a system. Implement strict training and education standards. Then implement a check and balance system, to keep everyone honest!
 

Smash

Forum Asst. Chief
997
3
18
I say let them take it away, one less thing to worry about.

I agree. They should probably take away all of drugs you carry too, even less for you to worry about. Maybe the keys to the rig too.

However, on a non-trolling note:

The points raised in this article (and here) are valid. However the vignette at the start of the article does no credit to the authors by reinforcing a biased view of the lowest common denominator paramedic with inadequate education and oversight as being the norm. Some of you may have seen this scenario played out (or even played a part in it yourself) and we all know that in certain areas this may be the norm. However, constant reinforcement of such negative stereotypes is unhelpful when the root causes and solutions aren't part of the discussion.

I was surprised that Dr Wang was as unbiased as he seemed in this article given some of the 'studies' he has been responsible for in the past.

I suspect we all know that with education, training, oversight and the will to institute these things, paramedics are capable of intubating even in difficult situations or with drug assistance. The real question is why do we continue to accept the lowest standard as being acceptable, then get up in arms when some people want to take our "toys" away instead of addressing the root causes of the problem?
 
Top