Scope of Practice(Combi Tubes)?

[usalsfyre]

Sorry, but I see this trend of moving to airway adjuncts and completely half-a$$ed and a dilution of the medicine that we clearly can provide. If they need intubating, then put an endotracheal tube where it belongs.

As always, just my humble opinion. Take it as you will..........................................

I agree with this statement, but the half-@ssedry and dilution of medicine started long ago, and is only now starting to come full circle.

 

[Flight-LP]

Likewise, on a trauma scene, massive hemorrhage has to be treated first, since inadequate blood volume impedes your ability to restore adequate perfusion regardless of whether you can ventilate the patient or even get their heart restarted. Its a simple, "what is going to kill my patient first?" question. Well, actually, its even simpler than that. Hypoperfusion (shock) is probably what's going to kill a critical patient in the end, 90% of the time. All you have to do is determine the causes that currently (or will lead to) inadequate perfusion, and treat them.

And the majority of these cited cases are not going to be treated or controlled in the field anyways. Thats where the surgeon comes into play.........................

And if you assertation of treating hemorrhage first holds water, please tell us why not one State in the US nor National Registry evaluates a candidates' patient assessment in that manner?

I understand where you are coming from and that is where some multi-taking and delegation comes into play, but you still need to have a systematic approach to ensure consistency.

 

[Bubz628]

I've heard that Louisiana does allow EMT-B's to drop a Combitube, but the local protocol for the EMS company that I'm about to start working for doesn't allow it. Just for that company...

 

[willings]

I'm an EMT-B from MO and we use Kings at my hospital based EMS service. Actually dropped one a couple months ago after a failed ETT attempt. Very useful and effective when you need them.

 

[zmedic]

This says it all! The prime reason some peanut counting researchers make the blanket "Paramedics can't intubate" statement is because they evaluate substandard EMS systems with limited QA and questionable educational oversight. Wong's study and the San Diego study are both prime examples. Both provide on paper some statistical facts, there is no doubt, but what neither study addresses is the underlying deficiencies of the agency as a whole in their lacking oversight and education.

The counter argument is that if I'm setting national policy, I don't care about what the best of the best are capable. I want to know if given the standard paramedic course, how well the average paramedic can intubate. So you look at average departments. I think with research the temptation is whenever a study comes out that people don't like the implications they say "well, they're not us, we're much better, that doesn't apply."

Do I think that a department where medics are getting 40+ tubes a year, have continuous CO2 monitoring, get to go to the OR ever 3 months to get additional tubes, and have good QA can intubate? Sure. But those aren't the guys I worry about. It's the medics who get 4 or 5 tubes a year. And if this is a skill that the average medic can't do well then nobody should be doing it. Or set up an additional certification to be able to intubate that involves additional training and a certain number of tubes per year to maintain.

 

[Flight-LP]

The counter argument is that if I'm setting national policy, I don't care about what the best of the best are capable. I want to know if given the standard paramedic course, how well the average paramedic can intubate. So you look at average departments. I think with research the temptation is whenever a study comes out that people don't like the implications they say "well, they're not us, we're much better, that doesn't apply."

Do I think that a department where medics are getting 40+ tubes a year, have continuous CO2 monitoring, get to go to the OR ever 3 months to get additional tubes, and have good QA can intubate? Sure. But those aren't the guys I worry about. It's the medics who get 4 or 5 tubes a year. And if this is a skill that the average medic can't do well then nobody should be doing it. Or set up an additional certification to be able to intubate that involves additional training and a certain number of tubes per year to maintain.

My argument to you then is that perhaps we should forcus on doing it right instead of just giving up and scraping it altogether. I hate to break it to you, intubation will not in my lifetime depart EMS as a whole. Fortunately, I enjoy being licensed in several states that allow individual Medical Directors determine the scope of practice, rather than have some political State power determine what is best for my clientele. As such, Texas for example, does not put a whole lot of stock into the proposed minimalistic scope of practice.

Instead, why not provide educational, hands on repetitive activites that allow the low volume clinicians get some exposure to maintain proficiency? The lack of exposure to intubation is a FAILURE on the part of the clinician and their agency. Both have a responsibility to maintain proficiency in an applicable skill set. In addition, both need to provide a non-punitive improvement process to ensure continuous advancement of their proficiency. It shouldn't be viewed as "the best of the best", it should be the bar!

We have got to stop resisting needed change. You either need to be a proficient medic and ensure you have the needed tools to produce a consistent level of quality medicine or you need to find another career. Not a personal attack on anyone as I believe most here agree, just something for some to chew on.

 

[Shishkabob]

Put a medic in the OR with an anestheologist and compare the rates to eachother, or put the anestheologist out in the field and compare the rates with eachother. Otherwise it is EXACTLY apples and oranges.

Until all variables are the same except for medic vs doctor, the studies will be pretty darn close to worthless.

 

[usalsfyre]

The counter argument is that if I'm setting national policy, I don't care about what the best of the best are capable. I want to know if given the standard paramedic course, how well the average paramedic can intubate. So you look at average departments. I think with research the temptation is whenever a study comes out that people don't like the implications they say "well, they're not us, we're much better, that doesn't apply."

Do I think that a department where medics are getting 40+ tubes a year, have continuous CO2 monitoring, get to go to the OR ever 3 months to get additional tubes, and have good QA can intubate? Sure. But those aren't the guys I worry about. It's the medics who get 4 or 5 tubes a year. And if this is a skill that the average medic can't do well then nobody should be doing it. Or set up an additional certification to be able to intubate that involves additional training and a certain number of tubes per year to maintain.

I don't think it takes 40+ tubes a year. There's a crapload of ED docs in rural settings who don't see close to 40 a year, yet you don't see a drive to remove intubation from them. Instead of lowering the level of care, how about we raise the level of the "average" paramedic.

However, the states should step in and set up minimum requirements for QA, education and equipment to be able to intubate, since the services and medical directors can't seem to police themselves. Do it right, or give it up.

 

[usalsfyre]

Put a medic in the OR with an anestheologist and compare the rates to eachother, or put the anestheologist out in the field and compare the rates with eachother. Otherwise it is EXACTLY apples and oranges.

Until all variables are the same except for medic vs doctor, the studies will be pretty darn close to worthless.

The anestheologist will win every time, in every setting. Nothing a paramedic does will match three years of residency training.

 

[Shishkabob]

The anestheologist will win every time, in every setting. Nothing a paramedic does will match three years of residency training.

True, and agreed, but one of the main things critics of ems field intubation is how "low" the rates of medics are compared to anesthelogist. Not a fair or logical conclusion.

Field intubations hardly compare to a nice, well lit, well controlled OR. Not an excuse for undiagnosed esophageal intubations, but a miss or two in the field is hardly something to always freak about.

 

[usalsfyre]

but a miss or two in the field is hardly something to always freak about.

Agree completely, as long as hypoxia isn't encountered.

 

[zmedic]

Agree completely, as long as hypoxia isn't encountered.

That's the issue. It's not misses in terms of not getting a tube, it's the rate of unrecognized esophageal intubations. Those are totally unacceptable, especially in this day and age of continuous CO2. And there are plenty of places that have way too many of those unrecognized misplaced tubes.

I'm not sure how I feel about "education" to make up for lack of real tubes. I've intubated airway heads probably about 100-200 times, and it doesn't really compare to how the real tissues react. I'm not sure I'd feel comfortable saying "well, you've only done 1 real intubation this year, but you've done the airway head 20 so you are good to go." I think you need to get those medics with low volume into the hospital and have them do OR intubations.

The other factor is we need less medics out there. If you have 5 FF/Medics on a fire truck well, they are each only getting 1/5 of the trucks tubes. Less medics= more tubes per medic.

It wouldn't surprise me if ET intubation went away prehospitally in the next 20 years, and was just King/Combi for arrests. Because if you don't have RSI, and intubation isn't being prioritized in cardiac arrest when are you going to be intubating?

 

[Icenine]

Never used the SALT, but a similar option does exist with the King LTS-D and the LMA, as long as you have a bougie available. Pass the bougie down the bore of the airway, it should emerge at the larynx. Pass the bougie as normal, remove the LMA/King and pass the tube. Confirm via standard methods, plus direct visualization if needed.

Like this?

http://www.youtube.com/watch?v=LcgaQPfoYRs&feature=related

 

[usafmedic45]

I don't think it takes 40+ tubes a year. There's a crapload of ED docs in rural settings who don't see close to 40 a year, yet you don't see a drive to remove intubation from them. Instead of lowering the level of care, how about we raise the level of the "average" paramedic.

Agreed with the idea of improving the quality of paramedics but that requires a massive amount of effort and it's easier to simply go for a simple engineering fix rather than (or at least while) working your way through the massive political, economic and social battles with those interested in maintaining the status quo.

I disagree with the analogy of rural ER docs. The main difference between them and a paramedic in a low volume service is that while the paramedic has no backup, the doc often has two or three other people in the ER with him who can intubate (RTs and the paramedics who came in with the patient in many cases) and when all else fails they resort to the two best fallback options in an airway: non-visualized airways and a surgical airway. The other major difference between most ER docs and most paramedics in this regards is that most ER docs don't think their penis shrinks when they have to resort to a non-visualized option.

The anestheologist will win every time, in every setting. Nothing a paramedic does will match three years of residency training.

Three years of training doesn't mean crap if they aren't doing a lot of intubations. I know several anesthesiologists who intubate less frequently than I do because of the use of LMAs. What about the ones who do chronic pain management? You still think those docs is going to be better? Recent experience has been shown to be a deciding factor among docs, paramedics, RTs, etc when it comes to most technical skills.

miss or two in the field is hardly something to always freak about.

The only airway issue to be ashamed of is the one where your ego or insecurity get in the way of doing what the patient needs done.

Here are the rules of airway management I teach in the difficult airway courses I provide for both EMS and in-hospital professionals:
#1: Oxygenation and ventilation are the goal, not intubation
#2: Your ego: check it at the door
#3: Call for help; in fact, call for more help than you think you will need
#4: If it is stupid and it works, it isn’t stupid
#5: Newer is not always better
#6: Plan ahead (avoid the “coffin corner”)
#7: Hold your own breath
#8: If it’s not working, let someone else try or try something else
#9: When in doubt, skip to the end of the protocol (surgical airway)
Corrolary: “The hardest part of doing a cricothyrotomy is picking up the knife.” – Peter Rosen, MD
#10: If they are still breathing and you are not sure you can take over, don’t stop them from doing so

I've intubated airway heads probably about 100-200 times, and it doesn't really compare to how the real tissues react.

Talk to a local veterinarian and ask if they mind if you come practice on dogs or cats. Cats are the best way to learn pediatric intubations short of actually tubing kids.

 

[usalsfyre]

That's the issue. It's not misses in terms of not getting a tube, it's the rate of unrecognized esophageal intubations. Those are totally unacceptable, especially in this day and age of continuous CO2. And there are plenty of places that have way too many of those unrecognized misplaced tubes.

Absoloutely, do it right or don't bother doing it.

I'm not sure how I feel about "education" to make up for lack of real tubes. I've intubated airway heads probably about 100-200 times, and it doesn't really compare to how the real tissues react. I'm not sure I'd feel comfortable saying "well, you've only done 1 real intubation this year, but you've done the airway head 20 so you are good to go." I think you need to get those medics with low volume into the hospital and have them do OR intubations.

Ideally, yes, however with the growing list of JACHO/TJC "never events" (anybody else find this as ludicrous as I do?) I see opportunities to learn airway management in the OR being reduced.

Maybe I'm alone in this, but I don't feel like the psychomotor part of DL is all that difficult to learn and master to an acceptable level. the shortcoming I see in most paramedics is not the inability to actually perform the required manipulations, it's a complete misunderstanding of the anatomic landmarks they're looking for/at.

The other factor is we need less medics out there. If you have 5 FF/Medics on a fire truck well, they are each only getting 1/5 of the trucks tubes. Less medics= more tubes per medic.

Maybe the systems that insist on this need to get rid of ET intubation and leave it to those of us who take it seriously.

It wouldn't surprise me if ET intubation went away prehospitally in the next 20 years, and was just King/Combi for arrests. Because if you don't have RSI, and intubation isn't being prioritized in cardiac arrest when are you going to be intubating?

Unfortunately I agree. Look at what Australia and New Zeland have done with prehospital RSI and it's clear it CAN improve outcomes. Unfortunately most US EMS systems refuse to put the engineering and quality control measures in place to ensure this.

 

[usalsfyre]

Agreed with the idea of improving the quality of paramedics but that requires a massive amount of effort and it's easier to simply go for a simple engineering fix rather than (or at least while) working your way through the massive political, economic and social battles with those interested in maintaining the status quo.

Dead horses, dead horses :glare:

I disagree with the analogy of rural ER docs. The main difference between them and a paramedic in a low volume service is that while the paramedic has no backup, the doc often has two or three other people in the ER with him who can intubate (RTs and the paramedics who came in with the patient in many cases)

Depends, RTs at the local doc in the box are not credentialed in that facility to provide airway management and if I touched a laryngoscope in there they'd likely try to pull my card at the state level due to politics.

and when all else fails they resort to the two best fallback options in an airway: non-visualized airways and a surgical airway. The other major difference between most ER docs and most paramedics in this regards is that most ER docs don't think their penis shrinks when they have to resort to a non-visualized option.

Paramedics thinking ET intubation is related to penis size? Say it isn't so....

Three years of training doesn't mean crap if they aren't doing a lot of intubations. I know several anesthesiologists who intubate less frequently than I do because of the use of LMAs. What about the ones who do chronic pain management? You still think those docs is going to be better? Recent experience has been shown to be a deciding factor among docs, paramedics, RTs, etc when it comes to most technical skills.

See above, I would still take a residency trained anesthesia doc over a six month fire medic even if the fire medics doing 50 tubes a year and the docs been doing pain management.

The only airway issue to be ashamed of is the one where your ego or insecurity get in the way of doing what the patient needs done.

Here are the rules of airway management I teach in the difficult airway courses I provide for both EMS and in-hospital professionals:
#1: Oxygenation and ventilation are the goal, not intubation
#2: Your ego: check it at the door
#3: Call for help; in fact, call for more help than you think you will need
#4: If it is stupid and it works, it isn’t stupid
#5: Newer is not always better
#6: Plan ahead (avoid the “coffin corner”)
#7: Hold your own breath
#8: If it’s not working, let someone else try or try something else
#9: When in doubt, skip to the end of the protocol (surgical airway)
Corrolary: “The hardest part of doing a cricothyrotomy is picking up the knife.” – Peter Rosen, MD
#10: If they are still breathing and you are not sure you can take over, don’t stop them from doing so

The only one I sort disagree with is #7, I've seen lots of missed tubes by people getting in a hurry and am a fan of using physiologic signs for termination of attempts .

I'm gonna steal this if you don't mind. Great way to distill airway mangement down for interns and students.

Talk to a local veterinarian and ask if they mind if you come practice on dogs or cats. Cats are the best way to learn pediatric intubations short of actually tubing kids.

Never thought of that, although I have heard of PALS classes using ferrets.

 

[usafmedic45]

The only one I sort disagree with is #7, I've seen lots of missed tubes by people getting in a hurry and am a fan of using physiologic signs for termination of attempts .

It's a good way to judge when you're taking too long to tube. It's actually a much better option than waiting for the patient to desaturate to abort the attempt. Also, in a large chunk of the population, controlling your breathing actually is a fairly good to calm down and focus.

If you're in such a panic or in such bad shape that you have to "rush" while holding your breath, you probably should find other work (in the former) or be checked out by a doc (in the latter).

I'm gonna steal this if you don't mind. Great way to distill airway mangement down for interns and students.

If you want me to come do the full presentation, let me know. I don't mind you using the rules I outlined, so long as I am given credit for it. Just call them "Steve's Rules" or something. LOL

 

[usafmedic45]

Depends, RTs at the local doc in the box are not credentialed in that facility to provide airway management and if I touched a laryngoscope in there they'd likely try to pull my card at the state level due to politics.

Wow....every hospital I have worked at from a 25-bed critical access hospital to a 900-bed trauma center has let the RTs intubate. Those are some screwed up politics right there.

 

[lr2148]

Ignore Post

 

[lr2148]

In Wisconsin(well, some parts), First Responders can drop a King or Combi!!!!