Scenario-ish: To intubate or not to intubate?

[SandpitMedic]

Remi, forgive me, what is it that you do exactly? Are you a Medic, RN, etc? And are you in a hospital (floor/ER) or in the field?


Triemal raises a great counter-argument, better than I could raise, and I side with him.

Essentially, given the proper training and tools, Paramedics can effectively perform field intubations that are beneficial to patient outcomes.

There are many who are beyond help, and even though we perform advanced procedures, they truly were never going to make it anyway. Blaming us or intubation or the Epi dose is really just a farce. The studies, one you mentioned from 2002, are outdated.. We're talking 13 years ago; there have been great advancements in field technologies and training that should render "goosing the tube" obsolete... So while there are difficult airways and no one is perfect, I would rather see that phrase along with "missed" tubes go the way of backboards, as you put it, rather than intubation as a whole.

Like I said, EtCO2.....KingVision.....Bougies.....better stethoscopes.... Better understanding.....

Granted they aren't utilized by all agency's... I'd like to see it made into the legislation or CASS or regulatory body standards to have all of those tools mandatory.

There's no reason to miss a tube and not know it in 2015. Period.

And has been established: this patient of the topic requires advanced airway stat.

 

[Carlos Danger]

Well...actually...
What I am suggesting, in fact demanding, is that what any self-respecting individual should do, is look at more than what the conclusion in an abstract says, and look at how the data used was obtained, which includes looking at the services involved.

Not sure what you are getting at here. Are you implying that those who think that prehospital intubation remains unproven are simply ignorant of what the research is really saying, because all we read is the abstracts?

That would be an extremely bold assumption that is insulting to a lot of very smart people who spend plenty of time reading and considering the research.

What national standards do you speak of? Do you mean national registry?

What I mean is that the paramedics working in southern California are trained to the same minimum national standards as they are everywhere else in the US.

If there were a significant difference in training among paramedics in SoCal vs. the rest of the country, then you could argue that studies done there can't be generalized to places where the paramedics are more highly trained, which is why research done in Australia can't be extrapolated to countries where the paramedics have much less training than they do in Aus. This is the same reason we don't expect paramedics to perform as well as ED doctors, or EMT-B's to perform as well as EMT-P's.

But it's not like that..... a run-of-the-mill paramedic from SoCal has essentially the same education as a run-of-the-mill paramedic in Ohio or Utah or Arizona or North Carolina. So you cannot discount research done in SoCal just because think the paramedics there are weak.

If prehospital providers are really taught how to intubate, they can do so safely, effectively, and in a way that is beneficial. And prehospital providers in fact CAN be taught to do so.

This brings us back to my original question: on what basis do you make this claim? What research can you cite that shows it results in positive outcomes, that isn't overwhelmed by other research showing poorer or equal outcomes?

Essentially, given the proper training and tools, Paramedics can effectively perform field intubations that are beneficial to patient outcomes.

Maybe, maybe not. It certainly seems logical. But lots of things in medicine that seem perfectly logical are never proven until eventually, we find that we were actually dead wrong about what seemed perfectly obvious. Consider MAST pants, using IVF to achieve normotension in bleeding trauma patients, and backboards. It wasn't all that long ago that these things were deemed so obviously beneficial that no one even questioned them, and later we found that we were actually harming patients with these interventions.

So again, what is the basis for this position?

There are many who are beyond help, and even though we perform advanced procedures, they truly were never going to make it anyway. Blaming us or intubation or the Epi dose is really just a farce.

Um, no.....those factors are controlled for in any study that is decent enough to make it through the peer-review process.

The studies, one you mentioned from 2002, are outdated.. We're talking 13 years ago; there have been great advancements in field technologies and training that should render "goosing the tube" obsolete...

It's not outdated if studies being published 12 years later are showing very similar results.

Like I said, EtCO2.....KingVision.....Bougies.....better stethoscopes.... Better understanding.....

If these things make such a difference, then why are the results of the study done in LA and published earlier this year (the one that I linked to a few posts back) essentially the same as the results of the study from San Diego that was published in 2002? And why did the study done in Australia show such modest differences in outcomes, even in light of the fact that the paramedics there are so much more rigorously trained than the ones in the US?

There's no reason to miss a tube and not know it in 2015. Period.

I agree, but that statement misses the point completely.

The problem in both San Diego and LA studies (as well as others) really isn't tube placement. The problem is that the patients simply don't do as well, after the fact. This points to factors surrounding the intubation that can negatively impact outcomes, such as poor hemodynamic control, hypoxemia, poor ventilation practices, etc.

And has been established: this patient of the topic requires advanced airway stat.

No, this patient requires care that can be counted on to give them the best chance of achieving an optimal outcome.

The bottom line is that no one has yet proven that intubation in the field will provide that chance.

 

[SandpitMedic]

You addressed a lot of things....

However, you did not advise of your role in medicine.

Do tell...

 

[STXmedic]

You addressed a lot of things....

However, you did not advise of your role in medicine.

Do tell...

I'm familiar with what Remi does, but I'm not sure how it matters. He/She is providing relevant information and valid arguments. It shouldn't matter if he's a field provider or an in-hospital provider (a hint: it's both, and he focuses a lot on airway management).

 

[NomadicMedic]

 

[SandpitMedic]

The dynamic in which we work is the focus of this entire debate.

I say it does matter what he does if he is going lambast paramedics and make statements insinuating we: a.) should have advanced airways stripped from our scope, and b.) are too ignorant to learn how/when to do it correctly.

He does offer some valid points, and to that end I'm not taking it personal. However, I think if our environments differ so will our perspectives.

All of us have the common denominator of trying to do what is in our patients best interest, Remi included. It's not personal, I am just of a different mindset.

There is also the possibility that he is exactly right, but then the opposite must be possible as well.

 

[Carlos Danger]

The dynamic in which we work is the focus of this entire debate.

I say it does matter what he does

The dynamic we work in has nothing to do with any of this. The outcomes of our interventions are the topic of debate here.

I'm not sure why my credentials are germane to this discussion; my position is either supportable and valid, or it isn't. I could be a layperson with an interest in clinical research, an EMT-B who has done his homework, or a fellowship trained EM/EMS physician....it really doesn't matter.

What I do is no secret though, and you seem really interested, so I don't mind summarizing my resume: Began my career in the military right out of high school. Been a civilian paramedic since 1997 and an RN since 2004. I spent most of my career working as a flight paramedic and flight nurse. Also did ICU in tertiary hospitals, and ground CCT. I will be done with grad school in about 5 weeks and about a week later, God willing, I'll be a CRNA. I have always had an interest in prehospital airway management, especially in TBI patients, and have stayed on top of the research (for the most part) for about the past 5 years or so.

if he is going lambast paramedics and make statements insinuating we: a.) should have advanced airways stripped from our scope, and b.) are too ignorant to learn how/when to do it correctly.

Please do not put words in my mouth, especially insulting ones. I never "lambasted" paramedics, I never said intubation should be take out of paramedics' scope, and I never ever said anything to the effect that paramedics are too ignorant to learn to intubate. If I thought that I wouldn't still be involved in EMS and I wouldn't bother with this forum.

Unfortunately, there are always people who take this discussion personally. I don't understand why, but I do understand that it's a big part of the reason why we don't see our patient care (as measured by actual outcomes) improving in this area. It's also a big part of the reason why more physicians and other advanced providers don't bother engaging more in these discussions....many of us just don't want to hear what they have to say. Not that they all agree with my position, of course.

It's not at all about "taking skills away" from paramedics. It's all about finding the safest way to effectively manage airways and improve outcomes. Paramedics need to know how to manage airways, including how to intubate. We also need to understand that despite how many of us were trained, intubation is simply not always in the patients best interest, even if we are pretty good at it.

There is plenty of room for intelligent, civil debate in this area. The science is not "settled" by any means....though IMO, it's quite clear that we should be doing certain things differently.

All I did was ask for the folks who say "this patient needs to be intubated now!" to objectively justify their position. Sorry if you find that offensive.

 

[SandpitMedic]

Field intubations - yes. So says every EMS medical director in the United States and the Western world as far as I know.

You provide excellent points for debate Remi, and it is correct to question all of the things we do as providers to ensure we provide the highest standard of care through evidence based medicine .

Although, I will continue to intubate patients that present as TBI with a GCS of 3. That is until your research provides explicit concrete proof that by doing so I am essentially signing said patients' death certificate.

We have not proved either way as of yet, despite our own strong opinions. I appreciate your perspective.

I have nothing left to add.

 

[triemal04]

I'm sorry, I think your status as a newly minted CRNA is going to your head a bit. I'd like to say otherwise, but some of your conclsuions and what, what one can only think, you are intentionally ignoring is driving me in that direction. I would hope that's not really the case.

Not sure what you are getting at here. Are you implying that those who think that prehospital intubation remains unproven are simply ignorant of what the research is really saying, because all we read is the abstracts?

That would be an extremely bold assumption that is insulting to a lot of very smart people who spend plenty of time reading and considering the research.

Not at all, it's not in the least bit insulting; anyone who actually takes the time to read a full study and really think about the research will ask questions raised by the data and consider the source of the data. They might even consider all those things I previously mentioned. Someone who does that would understand that results may differ when a similar process is tested by different people/groups with different abilities. My comment does not apply to people like that. People who only read an abstract won't do any of the above though, and they may feel a bit insulted, but someone who actually thinks about it won't, and shouldn't be insulted.

What I mean is that the paramedics working in southern California are trained to the same minimum national standards as they are everywhere else in the US.

Really? Are they? I think many would beg to differ. I think many services that incorporate extra training and education into their new hire process and constant ongoing training and education would differ. Departments that have real standards and track their own success/failure rates might dispute that. While we are judged off our minimums, as it should be, the hubris involved in believing that nobody exceeds those minimums is astounding. But, I suppose if you actually think that there are no differences between any paramedics and any services throughout the country, that's your prerogative...

If there were a significant difference in training among paramedics in SoCal vs. the rest of the country, then you could argue that studies done there can't be generalized to places where the paramedics are more highly trained, which is why research done in Australia can't be extrapolated to countries where the paramedics have much less training than they do in Aus. This is the same reason we don't expect paramedics to perform as well as ED doctors, or EMT-B's to perform as well as EMT-P's.

But it's not like that..... a run-of-the-mill paramedic from SoCal has essentially the same education as a run-of-the-mill paramedic in Ohio or Utah or Arizona or North Carolina. So you cannot discount research done in SoCal just because think the paramedics there are weak.

So you really do believe that a paramedic is a paramedic and LAFD provides the same level of care as...say...Sussex County? Down in Pecos? Or your own previous flight service? I'm sorry, this is an inherently flawed assumption, and if you're willing to admit it, you know it.

What research can you cite that shows it results in positive outcomes, that isn't overwhelmed by other research showing poorer or equal outcomes?

This.
http://www.trauma.org/index.php/community/blog_post/section_research/1169/ (benefit and commentary)
http://www.ncbi.nlm.nih.gov/pubmed/12534484 (beneficial in the short-term, unclear on long-term)
http://www.sciencedirect.com/science/article/pii/S0300957212002705 (benefit)
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4091894/ (read the entire study please)
http://www.researchgate.net/publica..._severe_head_injury_in_children_a_reappraisal (no real benefit...and yet, no real harm)
http://www.ncbi.nlm.nih.gov/pubmed/21841511 (no benefit...and no harm once everything was adjusted)
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4153828/ (this one requires reading the entire thing and some real thinking)
All of the above shows that, yes, when prehospital intubation is performed by competent providers, it can be beneficial, and at the worst, isn't harmful.

http://cjem-online.ca/v8/n2/p116 Now this is a Candian review of a Wang study that points out many of the questions that are raised by these studies, and things that should be considered when reading them. Read the commentary and take it to heart.

I'm sorry, but you are picking and choosing what you want to believe and not thinking beyond what is the stated conclusion of a study. You're even doing the same with some of the responses here.

Whether you want to admit it or not, there are other providers, both in and out of the hospital who can effectively manage the airway through intubation. Whether you want to admit it or not, there are some paramedic services (not all) that can intubate effectively.

So sorry.

 

[RocketMedic]

Honestly, I am skeptical of many surveys that claim intubated patients do worse than non intubated patients. Generally speaking, patients intubated prehospitally or even on the ed are already far more seriously ill or injured than a control group that isn't intubated despite broadly similar circumstances.

 

[CANMAN]

I'm sorry, I think your status as a newly minted CRNA is going to your head a bit. I'd like to say otherwise, but some of your conclsuions and what, what one can only think, you are intentionally ignoring is driving me in that direction. I would hope that's not really the case.

So you really do believe that a paramedic is a paramedic and LAFD provides the same level of care as...say...Sussex County? Down in Pecos? Or your own previous flight service? I'm sorry, this is an inherently flawed assumption, and if you're willing to admit it, you know it.

Man the borderline poo slinging in this thread is comical! Although Remi I also agree that you bring up some valid points I have to agree with the point above. All services are not created equal in my opinion. We may all be trained to the same National standard, however MANY employer's go above and beyond to provide some awesome initial and recurrent training. I don't know about the rest of the RSI provider's on the forum but at my service we have quarterly skills checkoffs and required number of live tubes. We all have different experience levels, and follow our individual protocols. Again my medical director who is credentialed in Anesthesia and Critical Care Medicine would have an MI if I transported a trauma scene run patient and a GCS of 3 without a more secured airway, so I am held to that by protocol, regardless of my own opinions, if I want to maintain a job. I also believe that an RSI can be easily setup and performed in less then 7 minutes, and if transporting by ground have no problem with intubating enroute.

 

[Carlos Danger]

I'm sorry, I think your status as a newly minted CRNA is going to your head a bit.

Another ad hominem against a person you don't even know, just because you disagree with their point of view on a contentious topic. Very professional.

And so many in EMS wonder why the rest of healthcare views paramedics the way that they do. Dr. Bledsoe had it so right.

we are judged off our minimums, as it should be,

Exactly. Remember that those are your words......and consider how it impacts this debate.

But, I suppose if you actually think that there are no differences between any paramedics and any services throughout the country

Nope, I never said that. In fact, I stated the exact opposite. Maybe re-read my post a little closer.

This.
http://www.trauma.org/index.php/community/blog_post/section_research/1169/ (benefit and commentary)
http://www.ncbi.nlm.nih.gov/pubmed/12534484 (beneficial in the short-term, unclear on long-term)
http://www.sciencedirect.com/science/article/pii/S0300957212002705 (benefit)
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4091894/ (read the entire study please)
http://www.researchgate.net/publica..._severe_head_injury_in_children_a_reappraisal (no real benefit...and yet, no real harm)
http://www.ncbi.nlm.nih.gov/pubmed/21841511 (no benefit...and no harm once everything was adjusted)
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4153828/ (this one requires reading the entire thing and some real thinking)
All of the above shows that, yes, when prehospital intubation is performed by competent providers, it can be beneficial, and at the worst, isn't harmful.

What? Really? Not a convincing list by any means.

Remember, you need to read a lot deeper than the abstract. If you did, you'd know that only ONE of those studies shows improved outcomes in TBI patients who are intubated prehospital. The rest show, at best, no harm. I can probably think of a hundred things that we could do to patients that cause no harm....but bring no benefit, either. Does that mean we should be doing them, especially when they are potentially risky? Using your logic, yes we should.

The study that does show benefit is the Australian study done by Bernard, et al that I already referred to in a previous post. The benefits were minimal and questionable. In fact, the benefits were so far removed from the intubation (GOSe at six months??) that it's difficult to even attribute such an outcome measure to the intubation, given the long period of time and all of the other clinical interventions that occurred between the intubation and when the outcome was measured.

But hey, it was a large, well done study, and technically it did show an improvement in outcomes.....so I'll give it to you. We'll ignore the dramatic increase in prehospital cardiac arrests, we'll ignore the fact that all variables (Pa02, PC02, SBP, etc.) measured on ED arrival were no better at all in the patients who were intubated, and we'll ignore that prehospital intubation did not reduce mortality or the need for surgical intervention or the amount of time spent in the ICU or the hospital. We'll just focus on the mild improvement in GOSe six months later and score this one as a win for the folks who think that the more plastic we shove down people's throats, the better care we are providing. No problem.

(guess what: none of that analysis was in the conclusions section of the abstract!)

However.....there is still a huge obstacle you have to overcome if you expect to use this study as evidence that paramedics in the US should be intubating everyone with a TBI: This study was done in Australia, where the paramedics have far more training than American paramedics do.

You can't say that the outcomes achieved by someone whose paramedic training took 5 years is going to be the same as someone whose training took 10 months. If that were the case, we could just get rid of ED docs and replace them with paramedics.

I suggest that you seriously consider taking a course on evaluating research.

All services are not created equal in my opinion

Of course not. That's the whole point.

Again, you cannot take a study done using above-average clinicians and extrapolate it to thousands of run-of-the-mill paramedics who barely have any airway experience.

You guys are so busy being offended and trying to poke holes in my reasoning that you aren't even considering what I'm presenting.

 

[SandpitMedic]

Dr. Bledsoe is my medical director! And I would be fired if I did not intubate that patient.

He wrote the books, lest you forget. (Most of them anyway.)

No one is making passive shots at you, we are pretty much all in agreement that your side of the coin on this is tainted due to your perspective and occupation.

We do hear you though, but disagree.

 

[triemal04]

Another ad hominem against a person you don't even know, just because you disagree with their point of view on a contentious topic. Very professional.

Let's all just take a deep breath for a little bit. That was not, nor have I previously made, any sort of personal attack towards you. What I'm suggesting, and is a valid suggestion, is that your new position is skewing your thinking. It's not an insult, just something you should consider; I only bring it up due to some of your comments here, some of which I pointed out. There's nothing personal about it. Getting upset over nothing is counter-productive, ok?

Nope, I never said that. In fact, I stated the exact opposite. Maybe re-read my post a little closer.

I'm sorry, what you have been implying very clearly, is that you don't see a difference between various paramedic level services within the US. If you did see and understand the difference you'd realize that the results of one study done in one particular area might not be representative of another particular area. It's part of why results of similar studies may differ, and why, when someone is considering implementing changes based on a study, they need to consider if they work in a similar setting and with similar resources.

Remember, you need to read a lot deeper than the abstract. If you did, you'd know that only ONE of those studies shows improved outcomes in TBI patients who are intubated prehospital. The rest show, at best, no harm. I can probably think of a hundred things that we could do to patients that cause no harm....but bring no benefit, either. Does that mean we should be doing them, especially when they are potentially risky? Using your logic, yes we should.

Let's continue to be calm, ok? I very clearly noted that several of the studies I linked showed only no harm, or only a small possible benefit. That's not a revelation, it's just counter to your arguement and other studies that show perhospital intubation is directly harmful.

Now, I'm glad that you are well familiar with Dr. Bernard's study; more people should be. Have you taken the time to read through the rest? If you take the time and think through it as I asked, there is a lot of food for thought in there. If we all remain calm, I'd be happy to discuss it.

However.....there is still a huge obstacle you have to overcome if you expect to use this study as evidence that paramedics in the US should be intubating everyone with a TBI: This study was done in Australia, where the paramedics have far more training than American paramedics do.

This is true; however, it would appear that there are select places within the US that have found a way to overcome that with their own internal training. Again, please read through everything I listed.

Again, you cannot take a study done using above-average clinicians and extrapolate it to thousands of run-of-the-mill paramedics who barely have any airway experience.

I don't believe anyone, least of all myself, has suggested that all paramedics are capable of performing select skills at the same level as various high-performing systems. In fact, everything that I've said has been the opposite. The vast majority of departments in the US should not be intubating anyone. Yet, there are some services that have the abilities to do so in a safe, and competent manner. Should departments like that change what they do because under-performing systems don't operate as efficiently? I say no. Just as under-performing systems shouldn't immedietly change what they do because a better service is...well...better. (of course this isn't to say that they shouldn't try and effect wholesale change on their system to improve by emulating a better service; just that they shouldn't increase their skillset because someone else does it better)

You guys are so busy being offended and trying to poke holes in my reasoning that you aren't even considering what I'm presenting.

I don't know that anyone is getting offended; I'm not. By the tone of this post, you seem to be, and I have to ask why? You posted a study from LA to bolster your claim that all prehospital intubation is detrimental. There are flaws within that arguement that have been pointed out. We can either continue on this road, or not, it's up to you.

 

[Carlos Danger]

That was not, nor have I previously made, any sort of personal attack towards you. What I'm suggesting, and is a valid suggestion, is that your new position is skewing your thinking.

If you had simply suggested that my anesthetic experience may negatively impact my ability to objectively consider all of the variables in play here, that would have been one thing. It would have been false - considering that I have spent far more of my career intubating people in ambulances and helicopters than in the OR, and also considering that many of the greatest contributors to EMS research have been physicians and others who never even worked prehospital - but it would have been a fair question.

Instead, what you actually wrote was "I'm sorry, I think your status as a newly minted CRNA is going to your head a bit." That means something very different than saying my position is "skewing my thinking", and it is insulting. I've also been accused of not actually having read the research that I refer to, of wanting to take intubation out of the paramedic scope, and of saying that paramedics are ignorant. None of which even approaches the truth.

I don't get personally offended by anything that some anonymous, random stranger who knows nothing about me says on some random internet forum. But the reality is, this kind of personal reaction to questioning or criticism of certain practices is very common among the EMS community, and fair or not, it does contribute to the perception that others in healthcare have of the professionalism of the EMS community, not unlike the way that the "Race the Reaper" t-shirts and the FB posts that say, in all seriousness, "I'm a hire levil of car then nerses r becuz I kin intibate" do. I'm just sayin'.

I'm sorry, what you have been implying very clearly, is that you don't see a difference between various paramedic level services within the US. If you did see and understand the difference you'd realize that the results of one study done in one particular area might not be representative of another particular area.

No, I am very well aware of the fact that there are big differences in EMS systems and the level/quality of care that they provide. I'm the one who keeps pointing out that you can't extrapolate the results of studies done in Australian EMS systems to EMS systems in the US. Also, in my reply to your first reply to my first post on this topic (if you can follow that), I wrote "There are some studies that show mildly improved outcomes with intubation (I would not say "the polar opposite"), but those tend to be in select systems with much higher standards than normal, and therefore can't really be extrapolated to the majority of EMS agencies." I then referred to a study done in Seattle that showed improved outcomes. So clearly I recognize that there are differences from place to place, and I also recognize that the research is not homogenous.

The EMS systems in LA and SD are not nearly as different from the rest of the American EMS systems as the Australian EMS systems are. They are large, busy systems whose paramedics meet the same minimum national training standards as every other paramedic everywhere in the US, whereas the Australian paramedics have far higher educational standards. So it's not a double standard to say that you can't extrapolate from Australian EMS to American EMS, but you can extrapolate from SoCal to the rest of the US.

As you wrote yourself in your last post, "we are judged by our minimums". What that means that as a whole EMS profession, we have to answer to the results of large studies, even if we feel those studies are not representative of the quality of care provided by other agencies. So even if you think paramedics in SoCAl suck, you have to answer for their performance, because that is where most of the studies are done.

How do you answer for it? By countering with other studies that show different outcomes. But unfortunately, there just isn't much of that. There are a few. But they tend to be in "elite" systems that are just as different from mainstream as the weaker systems are.

I have read A LOT of research on EMS airway management (not just in TBI) over the years. What I can tell you is that the majority of it is negative. I'm not happy about that; it just is what it is.

I am working on an a lit review and evidence table for my blog that aggregates and compares all of the studies done on American EMS systems and their outcomes with intubating TBI's, but it is slow going since I don't have a lot of free time, and what little I do have tends to get gobbled up on EMTLife.

I very clearly noted that several of the studies I linked showed only no harm, or only a small possible benefit. That's not a revelation, it's just counter to your arguement and other studies that show perhospital intubation is directly harmful. Now, I'm glad that you are well familiar with Dr. Bernard's study; more people should be. Have you taken the time to read through the rest? If you take the time and think through it as I asked, there is a lot of food for thought in there.

First, everyone needs to understand that the point of doing or evaluating research should be to try to find out the truth, not to try to find evidence that supports what you already think is true. We should go into reading each article with an open mind, having no idea what we'll learn, and analyze it objectively.

With that in mind, I do not have a vendetta against prehospital intubation. I am not out to find proof to support my preconceived ideas. I am perfectly, 100% open to any research that shows that intubating TBI patients (or any other patients) actually helps make them better. In fact I would welcome it. I love managing airways, and I like doing things for patients that help them in the long run. The research I have read, as well as my personal clinical experience, is the source of my opinion, not something that I use as a club to try to beat others into seeing things my way.

I agree, there is plenty of food for thought in those papers. But the Bernard study is the only one that actually shows an improvement in clinical outcomes in TBI patients. I do not see where the others show a benefit. If I am missing something, please point out specifically which study and specifically what outcome was improved.

My overall point in challenging ya'll to provide evidence of your position was not to argue that paramedics should not be intubating TBI patients.....it was to make the point that for something so many people feel so strongly about, it's actually quite difficult to justify objectively. You can make good arguments for it, but the objective data is either not there or in most cases is not strong.

 

[SandpitMedic]

On an aside... From the aside...

My job is emergency medicine.

While I take note of the probable continuation of care and treatment, my job is to consider the best approach or combination of approaches to mitigate life threatening circumstances as they arise or become imminent. Not to worry about what the CRNA in the OR or the ICU doctor thinks, notwithstanding this person is getting intubated the moment we walk into the ER if I choose not to. I have to worry about the here and now within my scope of practice to prolong the patient's life.

With Robb's patient:

Do I BLS this trauma patient with a TBI, GCS3, and no gag... Increasing the probability of aspiration after trying to one man BVM this guy and pumping loads of air into his stomach for 10 minutes? Does this person have a high likelyhood of survival with a normal quality of life as it is? Are there other factors to consider such as internal hemmorage or pneumothorax? How about the likelyhood of vomiting even without a BVM to the face?

Or do I go for the secure airway via ETT as trained....and be able to move on from the airway?

It's common sense. It's basic ALS emergency medicine for this patient, so long as you are competent and capable. It's also an objective logical reason.

Sorry I'm not sorry. You paramedic the way you want to if you disagree. I get this went off on a wild debate about the topic. But I'm sticking to intubation en route.

 

[triemal04]

Instead, what you actually wrote was "I'm sorry, I think your status as a newly minted CRNA is going to your head a bit." That means something very different than saying my position is "skewing my thinking", and it is insulting.

Not really. I wrote both those things because, based on your comments in this thread, what you choose to ignore, and how those comments are coming across to me, that is how it appears. I have no doubt that you don't want to consider that and I don't say it to be insulting and in all honesty I don't care, it's just as a simple statement of what my perception is; if you choose to see it another way, that would be on you.

But the reality is, this kind of personal reaction to questioning or criticism of certain practices is very common among the EMS community, and fair or not, it does contribute to the perception that others in healthcare have of the professionalism of the EMS community, not unlike the way that the "Race the Reaper" t-shirts and the FB posts that say, in all seriousness, "I'm a hire levil of car then nerses r becuz I kin intibate" do. I'm just sayin'.

Nor does the content of your previous post. You can't really talk professionalism and keeping things impersonal with that type of response. Want this to be professional? Let's move on then.

I've also been accused of not actually having read the research that I refer to

Yes, by me. Because based on your comments it appears to me that, with many, you are not considering anything else other than the abstract. If that isn't so, and you are considering all, or as many as possible, aspects of the data, as I said before, then you shouldn't be bothered by that as it doesn't apply to you. But, that isn't what I see from your posts, sorry.

f wanting to take intubation out of the paramedic scope, and of saying that paramedics are ignorant.

Not by me. So let's move on.

Also, in my reply to your first reply to my first post on this topic (if you can follow that), I wrote "There are some studies that show mildly improved outcomes with intubation (I would not say "the polar opposite"), but those tend to be in select systems with much higher standards than normal, and therefore can't really be extrapolated to the majority of EMS agencies." I then referred to a study done in Seattle that showed improved outcomes. So clearly I recognize that there are differences from place to place, and I also recognize that the research is not homogenous.

And yet you also have said this:
Are you saying that studies done in LA are impertinent because standards there are significantly different than the rest of the country? Are paramedics in SoCal not trained to the same national standards as other places in the US?

What I mean is that the paramedics working in southern California are trained to the same minimum national standards as they are everywhere else in the US.

If there were a significant difference in training among paramedics in SoCal vs. the rest of the country, then you could argue that studies done there can't be generalized to places where the paramedics are more highly trained,

a run-of-the-mill paramedic from SoCal has essentially the same education as a run-of-the-mill paramedic in Ohio or Utah or Arizona or North Carolina. So you cannot discount research done in SoCal just because think the paramedics there are weak.

There's a bit of a discrepancy here, and again, the hubris involved in thinking that no place ever exceeds the minimum is astounding. If you can explain that, great.

As you wrote yourself in your last post, "we are judged by our minimums". What that means that as a whole EMS profession, we have to answer to the results of large studies, even if we feel those studies are not representative of the quality of care provided by other agencies. So even if you think paramedics in SoCAl suck, you have to answer for their performance, because that is where most of the studies are done.

How do you answer for it? By countering with other studies that show different outcomes. But unfortunately, there just isn't much of that. There are a few. But they tend to be in "elite" systems that are just as different from mainstream as the weaker systems are.

Of course we do; I brought that up because it's true. Just as I said previously about your study from LA: I'm absolutely not going to discount the results of that retrospective analysis; nobody should.

And now we apparently come to the crux of the problem. Do me this favor: stop, go back and re-read everything I posted in this thread. Seriously, do that for me. Now, based on all that, what part of what I have previously said is not in line with this statement: I don't believe anyone, least of all myself, has suggested that all paramedics are capable of performing select skills at the same level as various high-performing systems. In fact, everything that I've said has been the opposite. The vast majority of departments in the US should not be intubating anyone. Yet, there are some services that have the abilities to do so in a safe, and competent manner. Should departments like that change what they do because under-performing systems don't operate as efficiently? I say no. And: The problem is that not every system is set up to really perform intubation properly.

What part of that do you have a problem with and disagree with?

In all honesty, you can say that you're just trying to challenge people, but when you're argueing out of both sides of your mouth...c'mon...

 

[RocketMedic]

Acadian as a whole practices in a manner very, very, sickeningly similar to California.
Most places work basically the same.

For what it's worth, many places emphasize all the wrong things....very short scene times, universal protocols, c-spine, etc- and don't do much about the important stuff.

 

[WiserOne]

Just adding my two cents...... The patients condition upon your arrival was not such for his lack of intubation. You managed the patient well and if time permitted very well COULD have intubated. Given the time circumstances, I would have not intubated.

Add ten minutes to transport time and I would have tried dropping a superglotic or intubated sans sedation.

 

[SeeNoMore]

Honestly I am less concerned with whether or not someone would choose to intubate this patient, and more concerned with whether the provider (generally speaking not the OP) had a clear confident approach to airway management. It's fine to evaluate a patient and choose BLS airway management, especially with short transport times. It's also fine to move to intubation with a clear organized plan including what you are going to do if you are not successful in placing an ETT. I have seen providers get rushed and move to intubation before they had covered their BLS airway bases and had a plan B, C etc. I think part of this is the culture of "get the toooobe".