Study on Survival vs Intubation during IHCR

[CWATT]

I still firmly believe that prehospital ETI should be reserved for a select few with advanced airway training, not the standard paramedic curriculum alone. Yes, this would include how, and why they should be placed directly on the ventilator.

I couldn't disagree more. And please know I have a lot of respect for you. However, this is clearly a protocol and training/education solution, not scope of practice. To throw the baby out with the bath water because people are jumping to ET too soon will mean that someone in the future who would benefit from the intervention won't have access to it.

I've sent his happen in Canadian jurisdictions where they've taken away Gravol (Dimenhydrinate) and Benedryl (Diphendramine) from EMTs. It's become the joke we'll stop at the drug store on the way to the hospital. Does every patient who gets into poison ivy need Benedryl? No. But that patient of mine who had angio edema - yes, and I didn't have it within my scope.

 

[EpiEMS]

@CWATT, I would agree that there is a component of the issue that is education versus scope of practice. However, we so often define ourselves in EMS by scope of practice and not by education.

Regarding your example, I see a greater cost/benefit discrepancy for ETI - bad use of ETI has much more potential to harm than bad use of diphenhydramine, no (i.e. failed ETI --> lots of money and resources spent --> death anyway, while bad diphenhydramine use generally doesn't kill folks)? While good use of ETI is much more beneficial than good use of diphenhydramine? (i.e. ETI benefit is ventilation vs. no ventilation, while diphenhydramins is itchy vs. not itchy, to grossly oversimplify)

 

[MackTheKnife]

Endotracheal intubation is simply a clinical intervention. In and of itself, it is neither good or bad. It all depends on the scenario.

The problem is that for a long, long time, paramedics had drilled into their heads that any sick patient who had any type of respiratory or airway compromise needed to be intubated ASAP, and that any other manner of airway management was inferior and would only be used by a paramedic of inferior skill. Which of course is false in so many ways, but the idea still became a big part of EMS culture. That's why the ability to intubate is one of the first things that many paramedics bring up in the paramedic vs. RN debates.

It seems that this hard line has been softened quite a bit, but underlying everything is still the idea that ETI is "the gold standard" in every case, and that the more "clinically aggressive" you are (i.e. the more interventions you do) the better paramedic you are. To this day that attitude still very often trumps any research based or well-reasoned recommendation for a more conservative approach.

This study is just the latest in a LONG series of research that fails to support routine early intubation in most scenarios that paramedics do airway management in. Yet still, just look through the responses here. Instead of much discussion even taking place about the study, we get knee-jerk reactions against it. I bet most of the commenters didn't even read it, but are still quick to make nonsensical claims about how quickly they can do an RSI, and how anyone can consistently intubate faster than they can place an SGA, etc. I don't thing many anesthesiologists and CRNA's are as confident in their airway skills as many paramedics are.

On the whole, EMS only respects research that supports them doing what they want to do anyway. Anything that questions a sacred cow is quickly dismissed as flawed

Remi, great words and I fully agree. Everyone does not need intubation. To narrow my point a bit, I'm seeing the comment "this study shows ETI doesn't really make a difference" more and more. it seems like there is an agenda to do away with ETI by some in the EMS community- by no means all.

Sent from my XT1585 using Tapatalk

 

[EpiEMS]

it seems like there is an agenda to do away with ETI by some in the EMS community- by no means all.

That's certainly plausible, but I would suggest the alternative explanation: Practitioners are realizing that poor or misused ETI is worse than no ETI, so they are pushing to reduce ETI use by people who shouldn't be using it (or in circumstances where it is inappropriate).

I see your point, for sure, thinking about it more broadly.

 

[VentMonkey]

I couldn't disagree more. And please know I have a lot of respect for you. However, this is clearly a protocol and training/education solution, not scope of practice. To throw the baby out with the bath water because people are jumping to ET too soon will mean that someone in the future who would benefit from the intervention won't have access to it.

I've sent his happen in Canadian jurisdictions where they've taken away Gravol (Dimenhydrinate) and Benedryl (Diphendramine) from EMTs. It's become the joke we'll stop at the drug store on the way to the hospital. Does every patient who gets into poison ivy need Benedryl? No. But that patient of mine who had angio edema - yes, and I didn't have it within my scope.

Fair enough, but hardly a comparison. Don't confuse life saving with life-sustaining.

I'd dispute that Benadryl in the face of (non-ACE inhibitor-induced) angioedema would be arguably life saving, while and ETI in the field vs. adequate and effective ventilation and oxygenation by any means that fits the patient at hand is life sustaining.

You do realize the biggest thing harped with RSI, and intubation (and I honestly didn't learn it for a few years) is adequate oxygenation and ventilation, not the procedure itself?

Wouldn't you rather be properly educated on when not to do something, and know when to utilize proper resources, be it higher level (i.e., better trained and educated) providers whether it's prehospital, or in-hospital perform this skill while assisting them if needed in the best possible way(s), ensuring the patient does not go hypoxic?

I, as a patient, would rather you were. To me this shows so much more nobility and heroism.

No one's goal should be to intubate someone blindly, we should now be to the point as prehospital providers where we're aiming to prevent this from happening from the beginning, thus the advent of CPAP in the prehospital arena.

Perhaps more paramedics should spend time in the ICU watching patients have trouble being weaned off their ventilators for some more insightful perspective? Afterall, the goal is ultimately extubation, and this goal can often be hindered by many factors including what we do, or don't do correctly in the field.

I can understand the "laziness" point of view as I have witnessed it firsthand, however I think practicality can also be enforced when having to manage an airway. Critical thinking may trump it, but practicality should not be discounted.

 

[StCEMT]

I think the education for intubation goes both ways. Yea, I've picked up a few little tips and tricks from other medics, but I am by no means skilled at this. It would make me so damn excited to have a place that hooked me up with an OR to not only practice intubation, but all types of airway management. Let me run a bag for a while and stuff. It'd be nice to regularly practice these things (quota essentially) so when it is the better choice, I am not going off of a x month dry spell. That being said, I am all for using other resources first. Realistically I wont need to intubate too many people where I am and when I could, an igel is enough to suit my needs. I've used them, I am familiar and comfortable with them, and so far they have worked well for me. However, part of that stems from my recognition of my limitations in ability intubating. Unless I feel confident I could get it without causing more harm, I just see no need to mess with it unless I absolutely have to.

 

[VFlutter]

I couldn't disagree more. And please know I have a lot of respect for you. However, this is clearly a protocol and training/education solution, not scope of practice. To throw the baby out with the bath water because people are jumping to ET too soon will mean that someone in the future who would benefit from the intervention won't have access to it.

But honestly how many companies are willing to invest in the training and education necessary to produce highly competent airway providers? Would it not be reasonable to limit ETI to a smaller group of practitioners whom can be trained and held to a higher standard?

 

[FLMedic311]

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1182327/

 

[Carlos Danger]

"Published research is mostly false. Unless I published it, then it is true."

 

[mttbdtd]

I personally believe intubation is a skill needed by all medics. Maybe we do need more training in the skill and when to use it. The idea of only letting a small group of more trained EMS providers have that skill is detrimental. What happens when a "regular" medic comes across an overdose and that person needs to be intubated. Anyone that works on the streets or in the ER has seen doctors pull SGAs and putting an ET in pretty fast after arrival. The focus should be more on when to use the skill. I work in a system where pretty much everyone else on scene can get access and push epi. Typically in a run of the mill code I can get a person on compressions, then have someone get access and get the first epi in while I am intubating. I do not let compressions stop. It was very difficult for me at first but after going at it for a while it's not that bad. Without those tubes during codes the two times during the last year when I had to intubate someone alive would have been much more difficult. If you have no tubes during a code skills decline, tubes are gone completely, then what do you do when you need to tube someone alive. Then what about when you have to RSI someone and haven't tubed this year? An SGA isn't always a suitable answer. I had a hanging this year as well and I didn't try a SGA but what if you had that destroyed airway and can't get an SGA to correctly seat? We NEED tubes but with more training.

 

[VentMonkey]

I personally believe intubation is a skill needed by all medics. Maybe we do need more training in the skill and when to use it. The idea of only letting a small group of more trained EMS providers have that skill is detrimental. What happens when a "regular" medic comes across an overdose and that person needs to be intubated. Anyone that works on the streets or in the ER has seen doctors pull SGAs and putting an ET in pretty fast after arrival.

I'm sorry, but this statement sounds like a thought process solely based on ego. Perhaps I am reading this wrong.

The focus should be more on when to use the skill.

Agreed, hence the reason for higher-than average trained professionals, if at all; ACP's essentially. Most of the "what if's" you've presented will tolerate proper oxygenation, and ventilation by even basic techniques. Why don't we focus on doing those two things right first? Oh, that's right they're just not as sexy.

If you have no tubes during a code skills decline, tubes are gone completely, then what do you do when you need to tube someone alive. Then what about when you have to RSI someone and haven't tubed this year? An SGA isn't always a suitable answer. I had a hanging this year as well and I didn't try a SGA but what if you had that destroyed airway and can't get an SGA to correctly seat? We NEED tubes but with more training.

Again, ego-driven hogwash. So what if your skills decline because you "can't tube" someone. I'm sorry if you losing out on a skill that seems beneficial for reasons you haven't proven with data (has anyone?) isn't in the best interest of the patient, nor is their adequate data to support such thought process. Where does any of this fall into advancing our thought process of critical thinking abilities to you?

 

[VFlutter]

Just curious, how many companies honestly track their intubation statistics? First pass success, overall success, complications, hypoxic events, etc.

At what point can you objectively state that you are competent and doing more good than harm? Is a 70% first past success rate acceptable? How many peri-intubation arrests are too many?

 

[VentMonkey]

Just curious, how many companies honestly track their intubation statistics? First pass success, overall success, complications, hypoxic events, etc.

At what point can you objectively state that you are competent and doing more good than harm? Is a 70% first past success rate acceptable? How many peri-intubation arrests are too many?

All valid questions, to which I doubt there is a universally adopted position, or answer. Which further goes to show where we as prehospital providers are in regards to training, and education, even after 50 years.

I can say the accrediting body for my service helps us keep tallies on our success rates/ year and things of that nature. I'd rather see paramedic programs include a way more in-depth approach to airway management in regards to education since so many paramedics are so adamant we need to keep this skill; something similar to the time and money we've invested in the other "basic emergencies" covered in the paramedic curriculum. Anyone who thinks that most paramedic programs provide enough initial education on airway management now is only fooling themselves, IMO.

If at the end of such chapters, blocks, lectures or what have you, the student walks away knowing not only a deeper understanding of most respiratory pathologies, but why one would want to pull a tube out of their kit so quickly with such haste, and more importantly why they wouldn't want to would be of value, and its money's worth in actual education.

Again, a failed airway should be viewed as one you cannot adequately oxygenate, and ventilate not one you can't intubate. This is a huge part of the problem with our thought processes as paramedics, and why many of us have to try so desperately to "get the tube" four, five times in.

I think all paramedics regardless of their credentialing could benefit from Ron Walls' book on difficult airway management. As a paramedic, and one who is still a ground paramedic as well, I have no qualms with my viewpoint, nor would I hesitate to say many paramedics are really lacking a broader view with regard to their thought process when it comes to proper airway management techniques; not all, but enough for it to reflect poorly on those who do take it seriously. I still don't understand the "threat" with intubation being taken away? EBM reflects positive trends for the patients, not us, the patients.

Being an above average intubator makes you nothing more than a technician, that doesn't necessarily equate to an above average clinician, or practitioner.

 

[mttbdtd]

If ego driven hogwash was how it came across I'm sorry that was not how it was meant. I was offering my opinion and gave an example. I don't do anything because it is sexy. If an ET tube was nothing but sexy then why do doctors do them? When are you allowed to step it up then? If someone is on scene you have a good airway, patient is being ventilated properly then why not step it up to a better airway? As long you aren't ignoring something else that is more important then why not go as far as you can? As for the tracking of statistics I believe the company I work for does.

 

[VentMonkey]

If ego driven hogwash was how it came across I'm sorry that was not how it was meant. I was offering my opinion and gave an example. I don't do anything because it is sexy. If an ET tube was nothing but sexy then why do doctors do them?
We're probably best not using doctors as a comparison. I would think a bit more articulating with regards to clinical insight, not to mention the ginormous difference in levels of educations between the two career paths goes without saying. How about this: would you rather your physician be a technician or clinician?
When are you allowed to step it up then?
When you see that there is inadequate oxygenation, and/ or ventilation; the potential with both within reason utilizing a strong critical thinking foundation would help make for a smooth transition into decision-making, and reasonable rationale for it.
If someone is on scene you have a good airway, patient is being ventilated properly then why not step it up to a better airway?
If this is how you view intubation, or as a good enough reason why paramedics should continue to intubate, you should at minimum reconsider your position.
As long you aren't ignoring something else that is more important then why not go as far as you can?
Again, I think you and I are of completely different thought processes. If my medical director said tomorrow no more intubations across the board with good rationale to support his theory it would not be a deal-breaking career change event for me.

Is it a skill I think paramedics enjoy? Yes, even I do. Is it one we as whole have proven to be educated and competent at as a whole in doing? Hardly.

Enjoying something and it being potentially harmful to a patient if done improperly are clearly not a combination fit for any astute practitioner.
As for the tracking of statistics I believe the company I work for does.

And there's no need for apologies, we're all entitled to our opinions.

I guess it depends on the type of paramedic one wishes to become. You can be the "I sure hope I get to intubate a lot of people throughout my career" paramedic, or the "I sure hope I can prevent a lot of people from being intubated" paramedic. Personally, I'm glad I grew up and realized I'd rather be the latter.

 

[VFlutter]

If an ET tube was nothing but sexy then why do doctors do them?.

Not all Doctors intubate. Just because your Internal Medicine Doc intubated in residency does not mean they are competent to do it now. Just because a Doctor intubates patients in a controlled setting, with unlimited resources and equipment, with a lot more experience and frequency, does not mean that it is the best option for every medic in the prehospital environment.

A chest tube is definitive treatment of a pneumothorax, should all medics be allowed to do so in the field?

 

[reaper]

And there's no need for apologies, we're all entitled to our opinions.

I guess it depends on the type of paramedic one wishes to become. You can be the "I sure hope I get to intubate a lot of people throughout my career" paramedic, or the "I sure hope I can prevent a lot of people from being intubated" paramedic. Personally, I'm glad I grew up and realized I'd rather be the latter.

You hit that point spot on. You should be the Medic that does not want to intubate your pt. There are times that a pt will need to be intubated. Then there are times we think a pt needs to be intubated. The latter are the ones we should be doing all we can not to have to intubate!

Sent from my VS985 4G using Tapatalk

 

[VentMonkey]

@mttbdtd you seem like a sharp enough person, I think when it comes to this subject matter it often becomes this endless debate of "why vs. why not" with hardly, if any, bold evidence in favor of out of hospital ETI's.

As paramedics it would be nice if we were, as a whole, on the same page with the realistically limited knowledge we possess about the often deleterious outcomes we can, and do inflict on patients requiring an advanced airway that's done in the field in an almost exclusively routine less-than-ideal environment.

 

[Tigger]

My service certainly suffers from the whole "intubation defines the paramedic" mantra. It's embarrassing to me frankly. While a lack of evidence does not necessarily equate to negative outcomes, you'd think if EMS wanted to really hold onto intubating people that we could actually prove why we should. This thread is a prime example of "I think we need it and here are my reasons, however I can't back them up." Throwing around terms like "gold standard" is silly. There is not one airway answer for every environment. Saying "the doc is just going to pull by SGA" does not justify you intubating.

I intubate cardiac arrests solely because that is the expectation during my year of new medicness. We don't stop CPR for it, but it still makes running a code significantly harder. And for what gain?

 

[StCEMT]

And for what gain?

Dat gold standard amigo. In all seriousness, I like that is expected we just go straight to an igel. Cardiac arrest is one of those cases I don't really see a need to intubate for a couple reasons. Just pull that big ******* out and it'll do its job perfectly fine.