Is an ET Tube Really ALS?

[MedicineMan975]

Post du jour

Talking as a newbie medic, I feel that the limited exposure to client's actually requiring advanced airway adjunct's plays a major part in the decreased proficiency. I mean come on, I know of times where there may be a total of 4-5 clients who require intubation in an entire month. That's for the service as a whole! I mean come on, repetition does a good provider make. And considering the fact that most calls are BLS at best, it's easy to see why missed placement's occur. Now, as for the whole letting EMT-Basics perform intubation, I'm going to have to say no for a couple of reasons:

1. By allowing Basics to perform advanced airway procedures, you would have to end up throwing the baby out with the bath water. What I mean to say is, if you're going to teach one advanced life support skill you would eventually have to teach them all. The possible complications associated with endotracheal intubation alone require additional pharmacological, invasive and advanced cardiac skills/knowledge to properly correct them. So in essence, you would require in depth knowledge of A&P, pathophysiology, pharmacology, cardiology, AND pulmonology just to perform a "simple" procedure. Yeah, it's "easy" to slip a tube. But what do you do when it hits the fan as a result? (Here's a link to a PDF on intubation and possible complications http://medind.nic.in/iad/t05/i4/iadt05i4p308.pdf)
2. Like my boy MSDletaFLT said, intubation is down the line in the AHA protocols. Compressions are king right now and all new research in indicate that in the absence of defibrillation, compressions save lives a darn sight quicker than an ETT will.

 

[DBieniek]

I understand what you all are saying, and truth be told I don't disagree with you!

Typically when someone needs intubated they are to the point where a lack of action would do more harm. If someone is pulseless/apneic then they are at a critical low point. If you are unable to establish an airway, they will remain at this critical low point. Attempting to intubate them isn't going to hurt them, but it may help them.

 

[VentMedic]

I understand what you all are saying, and truth be told I don't disagree with you!

Typically when someone needs intubated they are to the point where a lack of action would do more harm. If someone is pulseless/apneic then they are at a critical low point. If you are unable to establish an airway, they will remain at this critical low point. Attempting to intubate them isn't going to hurt them, but it may help them.

Say what?!

There are other devices such as the King that can be also be used that requires less skill maintenance. Although, that is not to say one should not practice the technique with the King many times at many different times.

With ETI, any damage you could do with just the blade insertion can blow your one and only shot at any airway including the BVM in the field by even the ALS team.

Proficiency with the BVM is your best friend. Even in the hospital we may not dive into intubation for a code or any other situation until the right person and the right equipment are at hand for the job. Outside of facial trauma, there have been very few patients that I have not been able to provide some ventilation/oxygenation to with a BVM over the past 30 years.

 

[reaper]

When I came to SC I couldn't believe that they let B's intubate. I told them right away that it would not happen on a truck I was on. Well, what do you know, not 3 weeks later they put out a memo stating the state had revoked intubation for EMT-B's.

Like was said before. Medics don't get enough intubations, to keep proficient. What makes anyone think that an EMT would?

I understand the EMT's wanting to do everything they can to help a pt. If that is you, the best thing you can do to help a pt is go to medic school. This way you are learning everything you need to know, not just bits and pieces.

 

[Epi-do]

Anyone can be taught to do a skill, but having the training to understand the prodcedure is what differentiates ALS from BLS. Can you teach an EMT-B to intubate? Sure, but you could also teach a monkey how to go through the motions of the skill. Understanding the procedure of intubation comes with the increased education and knowledge.

Before doing any invasive procedure, one should know the indications, contraindications, expected outcome, complications (and how to manage them), as well as anatomy & physiology pertaining to the issue at hand. I am sorry, but the majority of EMT-B classes do not contain the information needed to safely and effectively perform any procedure. Heck, I don't think my medic class has provided me with all the information I am going to need to be a good medic. I do feel as if I have been given a good foundation to build from, but it is up to me to continue to learn. That is part of what makes this such a dynamic profession. So many things are constantly changing as new discoveries are being mad in medicine. Every day studies show findings of things we are doing well, things we are doing not so well, and things that could potentially revolutionize how patients are treated. Hence, the title practitioner - the more we learn, the more there is to practice, the more there is to learn.

 

[Ridryder911]

Anyone can be taught to do a skill, but having the training to understand the prodcedure is what differentiates ALS from BLS. Can you teach an EMT-B to intubate? Sure, but you could also teach a monkey how to go through the motions of the skill. Understanding the procedure of intubation comes with the increased education and knowledge.

Before doing any invasive procedure, one should know the indications, contraindications, expected outcome, complications (and how to manage them), as well as anatomy & physiology pertaining to the issue at hand. I am sorry, but the majority of EMT-B classes do not contain the information needed to safely and effectively perform any procedure. Heck, I don't think my medic class has provided me with all the information I am going to need to be a good medic. I do feel as if I have been given a good foundation to build from, but it is up to me to continue to learn. That is part of what makes this such a dynamic profession. So many things are constantly changing as new discoveries are being mad in medicine. Every day studies show findings of things we are doing well, things we are doing not so well, and things that could potentially revolutionize how patients are treated. Hence, the title practitioner - the more we learn, the more there is to practice, the more there is to learn.

Wow! I think I have seen this somewhere before .. Epi over the past years, I have seen you mature more in thoughts and methodologies of true medicine... good going!


R/r 911

 

[Epi-do]

Gee, thanks Rid!

 

[CFRBryan347768]

 

[Ops Paramedic]

Got here a bit late, and not a lot left to say, except for maybe enhancing the the point.

I can take a newspaper vendor off the side of the road and teach him how to intubate in not even 10 minutes. Does this now allow him to do so in future?? The most difficuilt aspect of intubation is not placing the tube itself, but deciding when to do it. At one of our country's largest training hospitals, it is often said that: "see one, do one, teach one", with regards to skills, such as placing chestdrains and urine catheters, but funny enough when it comes to intubating a patient, the skill is reserved soley for the dr...

Yes, there clear indications for intubations, but how many patients fit these criteria 100%. Many times you will have to make an EDUCATED decision as to intubate or not, as it can be benefical or detremental at times. Hence, as mention, you need indepth knowledge of A & P, pharmacology (and the licsense to use the medication), Diagnostic skills, having the ability to perform other procedures should you fail, increased exposure and experience of palcing tubes (supervised and unsupervised), etc.

I firmly believe that this an advanced skill/procedure in totality, and should remain as such.

 

[wolfwyndd]

A month or so ago I flew back home to get some pratical CEUs for my EMT-Basic renewal, and the instructor, like almost all EMT classes, finished hours early. Because he couldn't let us out five hours early, he got out the intubation supplies and gave us a quick tutorial on intubating an adult.

I won't say that I was a pro by any means, as dropping a tube down Annie's throat isn't quite like the real world, but it got me thinking as to whether it should be incorporated into the BLS curriculum.

So much of EMS, like many medical jobs, is about performing a skill. EMT-Basics lack so muck of the knowledge, but I wonder if the benefits of adding ET intubation outweigh the risks, time, and added money of training.

What do you think?

I think this thread goes right up there with the 'lights and siren on POV = whacker' thread.

Intubation is a NREMT-B skill. Personally, despite all the arguments against, I see now reason why a basic shouldn't be allowed to intubate a pt. as long as their local protocol allows it.

 

[tazman7]

If emt's want to learn how to do als procedures then they can spend the time going to medic school instead of going to a bs one semester basic class. Just like others have said, you need to learn the anatomy part before you attempt to shove a laryngoscope in someones mouth.

Thats what the combitube and king airways are for...

As long as you are getting good chest rise with a bvm the only benefit to having an et tube in, is what? To only use 1 hand instead of 2 and to secure the airway from aspiration

 

[wolfie23b]

Combi ok in Ok

Here in Oklahoma I think they just released protocols for Basics to drop Combi tubes, an ET is considered invasive and for some reason the combitube isn't.

 

[wolfie23b]

I am a paramedic student and to be honest if a basic is competent enough then why not let them drop an ET. Its really not that big a deal and paramedics who forget that the basic and medic are a team and the medic cannot do his/her job without a competent basic needs to retrained and remember that its BLS b4 ALS.

 

[mikeylikesit]

I am a paramedic student and to be honest if a basic is competent enough then why not let them drop an ET. Its really not that big a deal and paramedics who forget that the basic and medic are a team and the medic cannot do his/her job without a competent basic needs to retrained and remember that its BLS b4 ALS.

skill competency is one thing but actually knowing where the tube is and where it is going is another. If all intubation's were easy then...yes why not. but in prehospital especially hospital settings this is in fact a rarity. say i am taking care of a patient and them EMT stimulates or create a sudden airway problem...now i have to not only deal with what i was doing but also what i have to fix on their behalf.

 

[triemal04]

I am a paramedic student and to be honest if a basic is competent enough then why not let them drop an ET. Its really not that big a deal and paramedics who forget that the basic and medic are a team and the medic cannot do his/her job without a competent basic needs to retrained and remember that its BLS b4 ALS.

Have you performed any intubations on live people yet?
Have you performed any intubations on live people in the field yet?
Have you been fully educated on when to intubate, why to intubate, this risks associated with it, the complications that may arise, how to fix the complications, how to avoid them, when not to intubate, how to judge the difficulty of an intubation before attempting it, and what you will do if intubation is impossible yet?
When you are able to answer yes to all those questions I'll be curious to hear if your answer changes.

And I actually function just fine without a basic, competant or otherwise.

 

[VentMedic]

I am a paramedic student and to be honest if a basic is competent enough then why not let them drop an ET.

How many intubations and on who or what will you need to maintain that competency?

http://www.jems.com/news_and_articles/columns/Rodenberg/How_Much_Training_Is_Enough.html

Are you talking about EMT-Bs intubating only the pulseless "dead" patients as a few states do or are you wanting to intubate everybody?

Its really not that big a deal and paramedics who forget that the basic and medic are a team and the medic cannot do his/her job without a competent basic needs to retrained and remember that its BLS b4 ALS.

Not that big of a deal? It is considered a big deal every time someone gets intubated in the field because that is a very serious situation. Even for those that get intubated for minor procedures in the hospital under controlled settings are fully informed of all the things that can happen with intubation.

Can you start an IV started?
Can you give any type of sedation?
Can you give cardiac meds to fix any arrhythmias you cause?
Can you do a cric?

Have you ever talked to a patient that has had an awake intubation? They will tell you that is one of the most uncomfortably painful and suffocating experiences of their life. To put a patient through that needlessly because you are not trained, educated or certifed to do anything to prevent that much physical and emotional trauma on a patient in addition to whatever else is going on medically is just inhuman.

 

[JPINFV]

I am a paramedic student and to be honest if a basic is competent enough then why not let them drop an ET. Its really not that big a deal and paramedics who forget that the basic and medic are a team and the medic cannot do his/her job without a competent basic needs to retrained and remember that its BLS b4 ALS.

"BLS before ALS" is just about as self serving cliche as any cliche is. What exactly does an basic bring to the table that a paramedic doesn't? Besides that, who gets to decide which basics are smart enough to start placing ET tubes? A 110 hour course is not going to make anyone competent to start placing ET tubes.

 

[MSDeltaFlt]

"BLS before ALS" is just about as self serving cliche as any cliche is. What exactly does an basic bring to the table that a paramedic doesn't? Besides that, who gets to decide which basics are smart enough to start placing ET tubes? A 110 hour course is not going to make anyone competent to start placing ET tubes.

It takes 2 minds to do one task or one skill. Your partner, at whatever level, needs to have common sense. That being said, medics are the lowest level of provider that should be able to intubate.

 

[VentMedic]

There are also the questions that will arise from a failed intubation, a poor outcome or the damage that is done during intubation.

Our ED (teaching hospital) is fortunate to have RRTs in the ED who have fairly immediate access to a video-bronchoscopy cart if a particularly bad intubation attempt arrives. We literally have dozens of videos of every imaginable complication. After the Paramedics present their information, the physicians (ED and another specialist) will review the information and videotape. Many times it will be agreed that everything within the scope of the Paramedic was done correctly and the doctors will stick by that if a lawsuit occurs. There have been a few botched intubations where that may not always be the case.

What defense can the doctors present on the EMT-B's behalf?
Did they have enough proven competencies and live intubations prior to the intubation in question?
Did they assess a difficulty score prior to intubation and adjust accordingly?
Did they adequately sedate?
Was RSI available to them?
Did they perform preventive measures for aspiration?
Did they do corrective measures after the failed intubation?
Did they utilize capnography?

The above is not even scratching the surface of questions one will encounter in a room of attorneys.

 

[DBieniek]

Okay, and that's perfectly fine. I respect your opinion as a paramedic. However, I follow the protocols set by my squad medical director who just so happens to be an MD that doesn't have any issues with it.^_^