EMT-Basics intubating

Hence the old adage of .." They are rural, they should be treated differently and be allowed to make compromises, rural folks don't deserve quality care!"....

Excuses, excuses, excuses.... Why does EMS think their so special, to get away with half arse excuses ?

Sorry, does a physician that plans to work in "rural" America get a year off of residency or medical school? Does that RN that plan to work in a rural nursing home get to "test out" or be replaced with a LPN ?

Again, why do we in EMS thnk we can justify lowering standards to rural America? Are we going quit requiring the same standards in the ghetto or maybe in the wealthy prominent area?

Again those in the "power of be" are attempting to compare skills versus knowledge. Within the past decade, research has demonstrated that even Paramedics in large metropolitan areas has skill deterioration and intubation successes were poor. (Wang

Now, why would we think a basic or Intermediate have a higher success rate in a rural area?

With alternative airway devices, such as Combitubes, King Airway, and even the old EOA (main purposes is prevent aspiration) I could understand with a supplemental airway course, and close monitored QI program.

Sorry, ETI is and should be much more than a skill....

R/r 911
 
RALS504 said:
Did you see this article on the JEMS website recently on some studies of rural basics intubating?
http://www.jems.com/news_and_articles/columns/Werfel/An_ETI_Model_for_EMT-Bs.html

So my question is do you think Basics and Intermediates should be allowed to intubate with ETT?
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As stated so many times before..........NO!

There is no sound, evidence based conclusion why there is any remote benefit to an EMT-B intubating a patient. In fact, the opposite exists, several studies have shown that appropriately trained Paramedics even have a hard time with placing an ET tube. Many physicians want pre-hospital intubation removed from the Paramedic scope of practice. Current statistics show as high as a 52% failure rate in intubating pediatric patients. Why on earth would we want to let someone with 3 months of night school and little to no education in the anatomy and physiology of the respiratory system attempt to secure an airway by performing endotracheal intubation? As Rid stated, the whole "rural" excuse is really getting old. These are the patients that truly deserve a well educated and proficient Paramedic. They are the ones who will require true interventions to sustain them for the 30 minute (60 or 90, put what ever time you want in here) transport to what will probably be some back woods, doc in the box ER. It is well known here that I do not believe that an EMT should be tasked with being in charge of a primary 911 unit, much less being allowed to play EMT-I or Paramedic without the proper education. This is just yet another attempt at trying to be cheap and not provide the level of care that all American citizens deserve. As previously stated, it can be done, people are just going to have to be willing to pay for it. If they aren't, then it sucks to be them when the have the "big one"........

At which point, I have no sympathy. You have to lay in the bed you make!
 
Yes, even here with EMT-IV's performing more skills: IV admin, combi/ptl etc;
The state of TN has yet to justify a need for giving these lower level providers the ability to intubate by way of ET.

With responsibility comes liability; with liability comes the need for quality education(well above the current education for both Paramedic and EMT-B)
as well as the need for continuous monitoring and quality improvement.
 
Flight-LP said:
Current statistics show as high as a 52% failure rate in intubating pediatric patients. . . . . .
As Rid stated, the whole "rural" excuse is really getting old. These are the patients that truly deserve a well educated and proficient Paramedic. They are the ones who will require true interventions to sustain them for the 30 minute (60 or 90, put what ever time you want in here) transport . . . . . This is just yet another attempt at trying to be cheap and not provide the level of care that all American citizens deserve. As previously stated, it can be done, people are just going to have to be willing to pay for it. If they aren't, then it sucks to be them when the have the "big one"........
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You are absolutely correct! There is a failure rate over 1/2 of pediatric intubations. That's why our local protocol has gone to the LMA. Now, the argument CAN be made that, 'it's an advanced airway management tool (which I don't disagree with).' But the argument can also be made that if someone has a ZERO percent chance of living without an advanced airway management tool or a XX percent chance of surviving WITH that same advanced management tool, I'll go for the advanced management tool, thank you very much!

As for the rural excuse, well, in some respects you are right. The rural EMS provider really is the one who needs the training and education. How hard is it to throw (not literally, but figuratively) a patient in the back of an ambulance for a 3 minute run to the hospital that most urban EMS providers have? You have about as much time to do your 90 second survey and one set of vitals. A LOT more can happen in a 30 minute run to the hospital that most rural EMS providers have.

As for the 'being cheap' argument, you're close. Being cheap implies that they HAVE the money, but are unwilling to SPEND it. That's not quite the case (at least in my rural area, and I ASSUME others too). The income level for most rural residents is considerably lower that urban dwellers (I took a 25 percent pay cut when I moved from the Washington, DC area to Dayton, OH) but the cost of living isn't that much cheaper when you work it all out. So less money has to go further. IE, most rural EMS providers don't have the money to send their basics to paramedic school. The question is who is going to pay for it? Basics can't generally afford it. A lot of jurisdictions can't afford to send their members. There are a few grants out there for education, but it's not NEARLY enough for everyone that wants it. Once someone DOES find a way to pay for the training and education, why should I stay in this po dunk little hicksburg when I can make more money in the big city? Not to say that ALL of them do it, but a lot of them do. So there's little interest in sending someone to paramedic school when there's no promise they are going to stick around afterwards.
 
wolfwyndd said:
You are absolutely correct! There is a failure rate over 1/2 of pediatric intubations. That's why our local protocol has gone to the LMA. Now, the argument CAN be made that, 'it's an advanced airway management tool (which I don't disagree with).' But the argument can also be made that if someone has a ZERO percent chance of living without an advanced airway management tool or a XX percent chance of surviving WITH that same advanced management tool, I'll go for the advanced management tool, thank you very much!
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Sorry, but your logic holds no water. What ever happened to utilizing a BVM with proper seal? Guaranteed that your zero percent figure will rise astronomically!


wolfwyndd said:
As for the rural excuse, well, in some respects you are right. The rural EMS provider really is the one who needs the training and education. How hard is it to throw (not literally, but figuratively) a patient in the back of an ambulance for a 3 minute run to the hospital that most urban EMS providers have? You have about as much time to do your 90 second survey and one set of vitals. A LOT more can happen in a 30 minute run to the hospital that most rural EMS providers have.
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This is a little off topic, but why do you only have time to do one assessment and one set of vitals? Could you not do one on scene? There is no law that says you must arrive and throw them into the back of the unit. Why not take the time to assess and treat properly?

wolfwyndd said:
As for the 'being cheap' argument, you're close. Being cheap implies that they HAVE the money, but are unwilling to SPEND it. That's not quite the case (at least in my rural area, and I ASSUME others too). The income level for most rural residents is considerably lower that urban dwellers (I took a 25 percent pay cut when I moved from the Washington, DC area to Dayton, OH) but the cost of living isn't that much cheaper when you work it all out. So less money has to go further. IE, most rural EMS providers don't have the money to send their basics to paramedic school. The question is who is going to pay for it? Basics can't generally afford it. A lot of jurisdictions can't afford to send their members. There are a few grants out there for education, but it's not NEARLY enough for everyone that wants it. Once someone DOES find a way to pay for the training and education, why should I stay in this po dunk little hicksburg when I can make more money in the big city? Not to say that ALL of them do it, but a lot of them do. So there's little interest in sending someone to paramedic school when there's no promise they are going to stick around afterwards.
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Basics CAN afford it. Its called financial aid. Get an education loan, they are easy to qualify for and have some great terms. The community can also afford it. Do you have trash service? You pay them don't you? Are you taxed for emergency services? A nominal taxation of property is not that hard on people. Do you bill your customers or their insurance companies? If not, you are creating your own demise. I think the question comes down to how bad do you want it......................

I want to depart from my personal response to you and evaluate this last paragraph. Please understand this is not directed towards you, but an "attitude" overall that keeps repeating itself (SO PLEASE DO NOT TAKE THIS PERSONALLY!) over and over again from the BLS crowd..................

This hypocritical attitude coming from many is a strong reason as to why EMS remains stagnant. I can't afford it, why would I wan't to stay when I can make more money, why can't I intubate, etc.? You guys and gals sit here and complain that you do not have the tools needed to perform in the rural and specifically volunteer environments, yet when you are offered a solution, excuses come flying out like projectile vomit. But when anyone starts with the view that volunteerism and BLS services are an obselete breed that need to be done away with, we then get the attempted justification of importance to the community and how they rely on our services. We are proud to volunteer! But then you don't wish to do so when you hit the Paramedic level because you can go and make money elsewhere. Its really sad that you have to adjust your attitudes and views based on the current opinion or view that suits you at the time. So it comes down to this...............

You don't want to improve, yet you want all of the tools and benefits that come from it.

Reality check, not going to happen in this lifetime!

This is the exact reason why a national scope of practice does not pass, the reason why there is so many dissimilarities in EMS, and the reason why so many veteran and PROFESSIONAL Paramedics are constantly on your butts about it.

So how bad do you truly want it?

True story.........................

Last year I worked with a Paramedic who moved to Houston after "K" hit New Orleans. She lost EVERYTHING, including a family member. She moved here, sold her only asset, her car, and took out a loan to go to Paramedic school. She had to either walk to work, take the bus, or hitch a ride (which we all were happy to do for her). She never once missed a day, she never once complained. She had pride. She was proud of her accomplishments and she strived to be the best that she could be. She gave up everything she had left to be a Paramedic. She made sacrifices, such as not eating at her favorite restraurants, not being able to go out and drink with her friends, living in a studio apartment with 6 other people. She did what she had to do, so again, how bad do you want it??????

Another example for those of you in the rural environment............

The next time you fly on a commercial airliner out of your small airport to a larger metropolitan airport, talk to your pilots. I'm not referring to the larger Boeing or Airbus aircraft, but your smaller EMB 135's, the twin prop Saabs and Dash 8's, and the small CRJ's. Just chat with them for a moment and ask them what they make per year. You may be surprised to find that the first officer is living off of around $20,000 - $35,000 per year, with some 1st year F.O.'s only making $15,000! Then ask them how much their flight training cost them. The current average is $50,000-$60,000.....................

They had a passion to fly and they pursued their dreams without excuse. They are now spending over 50% of their paycheck to payback student loans..........

HOW BAD DO YOU WANT IT?????????????
 
If you're going to intubate -- which is an invasive procedure -- then you need to practice on live patients. Period.

On the lower-than paramedic level (and I really don't follow all the EMT B's and I's and all that stuff) you are focusing on what you can do non-invasively, primarily because you are not apportioned the time to really learn and experience delivery of services at that level.

Intubation also is part of a connected whole that involves thinking and acting on a much more sophisticated level. It is not a simple skill you can just pick up and use like fancy card-shuffling in Texas Hold'em. It is something that is part of an overall plan of action that requires integration into a much more technical -- and demanding -- realm.
 
Flight-LP,

while i have mixed it up out here with the ALS crowd on some issues, on others i totally agree with you...

as a basic in a rural area, i would want no part of advanced airway management... the farther away from a hospital also means longer time to fix something that a basic has screwed up... there is plenty for basics to work on, namely assessment skills, and basic life support, without getting all the "tools"... frankly, the more i learn and the more i read, the less i want to do at the basic level...

not that i don't want the skills, i do... i will be entering an ALS class (we have EMT CC where i am) in the fall, so i can have the training necessary to perform some of these skills... certainly, not as a basic.

i have a new family, it is a major commitment.. but i won't stay out here and complain without doing something about it...

also, i agree that too many basics, even out here, are complaining about not being able to do meds and advanced skills, but i don't see too many questions about improving assessment techniques, and learning more theory. think the energy is misplaced... the more i learn, the more i start to realize just how much i don't know...
 
[Endo-]Tracheal intubation is a potentially dangerous invasive procedure that requires a lot of clinical experience to master. When performed improperly (e.g., unrecognized esophageal intubation), the associated complications will rapidly lead to the patient's death. Subsequently, tracheal intubation's role as the "gold standard" of advanced airway maintenance was downplayed (in favor of more basic techniques like bag-valve-mask ventilation) by the American Heart Association's Guidelines for Cardiopulminary Resuscitation in 2000, and again in 2005.
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http://en.wikipedia.org/wiki/Intubating
 
Until they develop a manikin that pukes, gags, has saliva, a slippery tongue, has a dark, mysterious airway, lips you can cut, teeth that chip (and are non-replaceable so the student has to pay for it) and actual material that feels like skin...EMT-Bs should not be intubating on the basis of manikin-only training.

Airway Manikins are NOT like real people.

I'm surprised the studies even passed the Institutional Review board.
 
Gotta chime in on this one, as it is a passionate subject. ( I'm still bitter since they took the beloved EOA/puke blocker/ET bite stick away ). I am definitely for intubation, and even across the board as a basic skill. BUT, there is a severe lack of training and supervision for these skills, especially for the first 20-30 intubations one may get.
Intubation is an easy skill to learn, and is the gold standard... and will always be the gold standard. Where we go wrong, is the recognition of placement. Folks, it is not that hard!! Why the heck do the stats tell us different?

I'll tell ya, training.

Having intubated since the 80's pre-hospital and in-hospital, I think any provider who has been around watching a tad bit will relate to this....
You reach your pt who is in cardiac arrest, you have not had one since a month ago... the family is screaming, your crew is worked up... you are a bit worked up, the senior medic may have 10 years of service in, but yet folks rush, get to yelling... grabbing equipment... nervous hands sometimes fumble the equipment, the trach tube is nervously and forcefully shoved in, blade catching the teeth and lip together ( ouch ), the soft tissue abrasions in the posterior oropharynx, the tube cuff drags across the teeth creating a tear... and the list goes on.

Instead of calmly humming and effectively intubating, most folks rush and do haphazard work. Now this, this right here... is where our stats kill us in the field.
Don't get me wrong, I am not claiming to be the all mighty, I have missed some and tried some. No biggie, pull out and start bagging or use another tool.
It is an art, and most of it is in your attitude, demeanor and requires you to be calm and effective. There is no way around it.
In the surgical suite, the anesthesiologists are about as calm as anything, drives many medics nuts! 45 seconds went by since the last ventilation, and they are talking about breakfast while slowly grabbing their tools. They know 2 minutes will not harm a patient with a non-complicated airway ( as most are non-complicated ), and they can have the tube in right after do the direct laryngoscopy. ( 5-10 seconds )... without a drop in SaO2. ( thats another subject ). --- Point is... you have time!

Our standard is what.... within 20 seconds? On a bad day.

Intubation is a beautiful thing, and I hate to see it go because of some over-zealous anxious hoseheads make the stats look terrible. For those incidents that went sour, the action should be one-on-one retraining, not slap everyone's hands. It's not for everyone, and if you don't like it, bag them. It works just as good. ( I just like my fringe benefits )

Let you in on a secret, think our stats are bad by the 2005 AHA standards, you should see the unpublished in-hospital rates, they are many times worse than ours. ( I'm talking time to intubate, they just recognize it faster )

But anyhoot... that is just my .01 .
Be safe...
 
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