Intubations dissapearing?

[Summit]

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

I almost missed the

 

[MCGLYNN_EMTP]

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

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

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

 

[Shishkabob]

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

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

 

[atropine]

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

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

 

[Shishkabob]

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

 

[atropine]

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

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

 

[Summit]

Hey Linus,

Y so serious?

 

[Shishkabob]

Hey Linus,

Y so serious?

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

 

[MCGLYNN_EMTP]

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

 

[Akulahawk]

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

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

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

 

[MCGLYNN_EMTP]

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

 

[MasterIntubator]

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

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

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

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

 

[MSDeltaFlt]

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

Pulling prehospital intubations is a mistake.

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

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

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

It's called tunnel vision.

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

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

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

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

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

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

 

[MCGLYNN_EMTP]

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

 

[Dwindlin]

It's called tunnel vision.

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

 

[rhan101277]

Pulling prehospital intubations is a mistake.



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



It's called tunnel vision.



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



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

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

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

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

 

[MCGLYNN_EMTP]

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

 

[MSDeltaFlt]

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

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

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

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

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

 

[usafmedic45]

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

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

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

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

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

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

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

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

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

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

I assume you're referring to nasotracheal intubation?

Pulling prehospital intubations is a mistake.

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

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

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

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

 

[Smash]

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

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

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

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

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

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