Supraglotiic Airway Use by EMT's

[HardKnocks]

I have seen EMT's successfully use Supraglottic Airways, (i.e. I-Gel) and its been an approved Skill in various States.

Personally I love the I-Gel. Its almost fool-proof compared to Intubation with a Blade-King Airway, (i.e. no over depth insertion issues and no Right Bronchi Entries etc). As we all know Intubation is a very perishable skill.

I don't agree with the discussion; "BVM is Not Taught Well" included in the Aug 2021 National EMS Scope of Practice Model 2019: Including Change Notices 1.0 and 2.

https://nasemso.org/wp-content/uploads/9.16.2021-Corrected-DRAFT-National-Model-EMS-Clinical-Guidelines-1.pdf

How do they qualify that statement? BVM use is a mandatory Pass/Fail EMT Skill.

If certain local training is not adequate or substandard, conduct a review/audit and fix it. Don't make blanket statements that are all encompassing.

The use of supraglottic airways (SGA) and waveform capnography at the EMT level was extensively debated. Several public commenters expressed lack of support on draft language that proposed to add them to the interpretive guidelines for EMTs during the national engagement period. The expert panel was evenly divided on the topic. Several “pros” and “cons” for adding SGA and waveform capnography for EMTs at the national level were considered. It was noted that several jurisdictions are already using SGA as a more definitive airway than the BVM although some panelists added that the BVM is not taught well or used effectively in many cases. Major “cons” point to a critical patient safety concern if an SGA is not placed properly or is not verified using waveform capnography. Many felt the education for SGA and waveform capnography would add significant time and increase expense to the EMT program, a consideration that was worrisome and expressed by the public and members of the expert panel. Others suggested that BVM ventilation may not be done well, but a misplaced advanced airway could lead to no ventilation and patient detriment or demise. Finally, a limited review of the literature highlights the fact there is a general lack of evidence that SGA improves outcomes in cardiac arrest or other etiologies over BVM ventilation. The expert panel concluded that while SGA and waveform capnography could successfully be taught and measured at the EMT level, it is an intervention that should be reserved for an experienced practitioner and therefore, is not a prudent addition as an entry-level skill to the Practice Model for an EMT now. Some States currently allow licensed EMTs to use SGA and/or waveform capnography although this activity is dependent on strict oversight by a physician medical director and is not permitted in all jurisdictions.

How many of you practice in a State that approves and uses them for EMT and/or Paramedics';

If not; Do you support expanding EMT's Scope of Practice to include Supraglottic Airways for EMTs.

As an EMT I've been brought up amd worked most of the time alongside the .Mil Crowd. I've seen 19-25 year old do some incredible saves during Field Trauma work.

Why is there a spectrum of our EMS Community that is so hesitant in advancing new skill sets? Remember when TCCC was first introduced?

Thoughts/Ideas?

HK

 

[Aprz]

I used to work in California. Just after I left, they started letting EMTs use LMAs. I consider California to be one of the most conservative and restrictive states when it comes to EMS. California does thing by county rather than by state so one county may allow LMAs, King Airways, etc., and another might not.

I highly doubt training cost is an issue. At the EMT program I went to about a decade ago, they actually did go over King airways anyways for NREMT and ALS assist. At the paramedic program I went to, we briefly went over it with donated expired King airways and the only time it was used was to have out during intubation practice. You'd have it out to say you had a backup airway ready, but rarely used it. It requires very minimal training.

 

[DesertMedic66]

BVM being a pass/fail skill does not mean if you pass it you are doing it adequately.

Anyone can toss a mask on a manikin, do a C-E grip and bag it. That is all the skills test consists of.

In reality, can the provider maintain an adequate seal? Can they maintain proper head/airway alignment? Are they delivering too much tidal volume? Are they ventilating too fast? Are they applying too much force?

If you take your average EMT and do a blind test on them they will probably: not maintain a good seal, ventilate too quickly, and give too much tidal volume.

The idea of placing PEEP valves on BVMs is a good thought process however in order for the valve to work, you need to have a constant seal to the patients face. As soon as that seal is broken, the PEEP is gone.

 

[E tank]

The idea of placing PEEP valves on BVMs is a good thought process however in order for the valve to work, you need to have a constant seal to the patients face. As soon as that seal is broken, the PEEP is gone.

I think they have intubated patients in mind for using the peep valve. Even if you could get a reasonable mask seal, keeping the actual dialed in peep consistently would be almost impossible in a patient that would actually benefit from it.

 

[HardKnocks]

I consider California to be one of the most conservative and restrictive states when it comes to EMS. California does thing by county rather than by state so one county may allow LMAs, King Airways, etc.

Being that California was one of the the so-called "birthplaces" of Paramedics;

What do you attribute the change to extreme restrictions, compared to adjoining States like Arizona, (which is a very proactive with expanding the approved EMT Skills Sets and Meds.

 

[E tank]

Being that California was one of the the so-called "birthplaces" of Paramedics;

What do you attribute the change to extreme restrictions, compared to adjoining States like Arizona, (which is a very proactive with expanding the approved EMT Skills Sets and Meds.

Asking for speculation? California is as territorial as it gets across broad swaths of industry. It seems there is dogma and regulation for nearly every facet of life in that state. Without bleeding into polemics, fact is, it's a very nice (weather, physical setting) place to live and there is a lot of turf protecting that goes on there. It's the culture. You wouldn't believe the antagonism between LE and FD's and FD's and FD's and LE and LE. Just insane. Hierarchy from EMT to brain surgeon is excruciatingly well defined. Improved a little since I was an MICN there in the early 90's but I can't imagine much. Medics couldn't f**t without contacting base then and they were pretty smart guys and gals. Not fly over country, that's for sure.

 

[ghost02]

As dogmatic and regulatory driven as the state is, I wouldn't necessarily say its a bad thing. For the average single service single county medic, most of the counties do a good job of ensuring that the medics working the area are very familiar with it, as well as what the particular county MD expects. There is a strong argument as to it not being necessary and going to a Texas model, but at the same time there isn't a very compelling reason for it.

The vast majority of counties don't have 1+ hour transport times to definitive care, and the ones that do are more open protocol wise. If anything, I would argue that there shouldn't be a state scope, but each county have its own scope. So if a particular county wanted the fancy RSI and blood and such they could.

For places like Texas, Arizona, and Kansas where definitive care is hours away, even by air, having the more open scope makes sense.

What does this have to do with LMAs? Nothing. EMTs should be able to use an LMA.

 

[E tank]

What does this have to do with LMAs? Nothing. EMTs should be able to use an LMA.

Don't ask us...ask the Californian aristocrats....

 

[HardKnocks]

Don't ask us...ask the Californian aristocrats....

LOL

I try to try to stimulate dialog about Cause and Effect Policy Making and how to avoid certain pitfall as a Decision Maker.

My intent is to mentor the group of the future up-and-coming Leaders.

I've been fortunate to have had Mentors that my accented my career development.

Hopefully these discussion will help the next generation of Decision Makers improve our Industry.

 

[HardKnocks]

What does this have to do with LMAs? Nothing. EMTs should be able to use an LMA.

I goes in line with the discussion that I quoted from the Aug 2021 National EMS Scope of Practice Model 2019.

IMHO, You have certain participants that have a certain opinion and/or "Closed Mindedness" that effects the National Scope of Practice, (instead of expanding it).

 

[Aprz]

I brought up the LMA/California thing because the county I used to work in allows EMTs to do it. I am surprised not every EMT can do it considering California won't let EMTs breath air because it is not in title 22. If Californian EMTs can do it, all EMTs should, lol.

 

[Tigger]

Colorado allows first responders to place iGels. If a patient has no gag, they should get an iGel (or other SGA). Every in-service and BLS class I've taught over the years has included what I'd term "extended remedial training" on how to use a BVM properly, and this crosses all different types of agencies. We just are not good at the skill with a single provider. Every time I go to the OR for an RSI refresher I too am reminded that I am not super good at single person mask seals and encourage everyone to have someone dedicated to getting a good seal. SGAs eliminate messing around with getting a seal on many patients, I really encourage our BLS to place to them.

 

[spimx]

I am ok with EMTs using superglotis airway. The patient will not be more dead if they mess it up. Nowadays we use the glidescope and intubation is much easier. I am not ok with putting anything in the patients airway unless it's a crash airway or there is chemical paralysis. It should not be attempted on a patient that is alive without medical direction

 

[Carlos Danger]

I have seen EMT's successfully use Supraglottic Airways, (i.e. I-Gel) and its been an approved Skill in various States.

Personally I love the I-Gel. Its almost fool-proof compared to Intubation with a Blade-King Airway, (i.e. no over depth insertion issues and no Right Bronchi Entries etc). As we all know Intubation is a very perishable skill.

I don't agree with the discussion; "BVM is Not Taught Well" included in the Aug 2021 National EMS Scope of Practice Model 2019: Including Change Notices 1.0 and 2.

https://nasemso.org/wp-content/uploads/9.16.2021-Corrected-DRAFT-National-Model-EMS-Clinical-Guidelines-1.pdf

How do they qualify that statement? BVM use is a mandatory Pass/Fail EMT Skill.

If certain local training is not adequate or substandard, conduct a review/audit and fix it. Don't make blanket statements that are all encompassing.



How many of you practice in a State that approves and uses them for EMT and/or Paramedics';

If not; Do you support expanding EMT's Scope of Practice to include Supraglottic Airways for EMTs.

As an EMT I've been brought up amd worked most of the time alongside the .Mil Crowd. I've seen 19-25 year old do some incredible saves during Field Trauma work.

Why is there a spectrum of our EMS Community that is so hesitant in advancing new skill sets? Remember when TCCC was first introduced?

Thoughts/Ideas?

HK

I think it is fair to say that EMS personnel are generally not very good at mask ventilation. Passing a skill station on a manikin in a community college classroom is very different than obtaining actual clinical competence. This is much less of an initial training issue than it is a result of the fact that BVM ventilation is inherently difficult and doesn't get nearly the respect that it deserves as a clinical intervention. It is a skill that takes real practice and significant experience to master. EMS education has always treated mask ventilation the same way it treats chest compressions or backboard application, when in reality it is very different because it takes way more practice to get good at. Anesthesia providers in training spend more hours in the airway lab practicing basic airway skills than most entire initial EMT courses consist of (not to mention the countless hours spent in actual clinical practice), and still struggle with mask ventilation at times.

Modern SGA's are safe and easy to place and should be viewed more as a basic tool to facilitate ventilation than as some "advanced procedure" that only "specially credentialed" providers can use. They aren't without risk and they don't always work, but if you are having a hard time moving air with an Ambu-Bag, the next step should be to place an I-gel, if possible.

 

[MackTheKnife]

I have seen EMT's successfully use Supraglottic Airways, (i.e. I-Gel) and its been an approved Skill in various States.

Personally I love the I-Gel. Its almost fool-proof compared to Intubation with a Blade-King Airway, (i.e. no over depth insertion issues and no Right Bronchi Entries etc). As we all know Intubation is a very perishable skill.

I don't agree with the discussion; "BVM is Not Taught Well" included in the Aug 2021 National EMS Scope of Practice Model 2019: Including Change Notices 1.0 and 2.

https://nasemso.org/wp-content/uploads/9.16.2021-Corrected-DRAFT-National-Model-EMS-Clinical-Guidelines-1.pdf

How do they qualify that statement? BVM use is a mandatory Pass/Fail EMT Skill.

If certain local training is not adequate or substandard, conduct a review/audit and fix it. Don't make blanket statements that are all encompassing.



How many of you practice in a State that approves and uses them for EMT and/or Paramedics';

If not; Do you support expanding EMT's Scope of Practice to include Supraglottic Airways for EMTs.

As an EMT I've been brought up amd worked most of the time alongside the .Mil Crowd. I've seen 19-25 year old do some incredible saves during Field Trauma work.

Why is there a spectrum of our EMS Community that is so hesitant in advancing new skill sets? Remember when TCCC was first introduced?

Thoughts/Ideas?

HK

Way back when, SGAs were unheard of. The Esophageal Obturator Airway ((EOA) was the forerunner of SGAs. Our EMTs could place them. Only problem was there wasn't a peds model. So,yes, EMTs should be allowed to place SGAs. Medics should be intubating. It's still, and will always be, the Gold Standard.

 

[DrParasite]

Medics should be intubating. It's still, and will always be, the Gold Standard.

until it gets taken away, because studies show that many medics suck at intubating.

SGAs are not rocket science; EMTs should be able to do them, and every application should be an automatic QA review to ensure it was done approrpiately.

 

[MackTheKnife]

until it gets taken away, because studies show that many medics suck at intubating.

SGAs are not rocket science; EMTs should be able to do them, and every application should be an automatic QA review to ensure it was done approrpiately.

Doc,
Since I've been on this forum, I have repeatedly heard what you said about medics sucking at intubation. What is being used? Glide Scope, Miller, Macintosh, or something else?

 

[DrParasite]

Doc,
Since I've been on this forum, I have repeatedly heard what you said about medics sucking at intubation. What is being used? Glide Scope, Miller, Macintosh, or something else?

To be honest, I don't know, as I have never looked too deep into it. I also think that comparing mac vs miller is a purple squirrel; the Glide Scope is a relatively new game changer, and changes how intubations are performed. Going from a manual laryngoscope to a video laryngoscope is like night and day, but the glidescope isn't standard on every ambulance, or more accurately, every ALS providing vehicle.

As for the studies (since I happen to think most of the medics I've worked with are pretty decent when it comes to intubation, since they do it so frequently), check them out for yourself

The Great Airway Debate

3 EMS physicians highlight the challenges that prevent a consensus on endotracheal intubation across EMS systems and the importance of case review

www.ems1.com

NEJM Journal Watch: Summaries of and commentary on original medical and scientific articles from key medical journals

NEJM Journal Watch reviews over 250 scientific and medical journals to present important clinical research findings and insightful commentary

www.jwatch.org

https://www.hmpgloballearningnetwork.com/site/emsworld/article/206057/evidence-based-ems-endotracheal-intubation

 

[ghost02]

I wish I had actual, hard, service wide numbers but unfortunately I do not, so anecdote will have to do.

When I was working on an ambulance as the only medic on scene, I was 50% first pass DL with a bougie. I did not have very good training or understanding on the preparation or skill of intubating, and every intubation was on an arrest. Most medics that I worked with would not attempt intubation and go direct for an SGA, and when asked why the reasoning was normally either a lack of confidence in the procedure or fear of "bringing down the numbers". I believe when I left that company we were sitting at a 70% first pass success with DL and bougie. I wish I could say I was confident in those numbers but peoples interpretation of what counted as an attempt was fluid.

When I first went into Critical Care I first used a hyperangulated king vision, with an increase in first pass to 100%, but that also required a significant amount of effort and learning about how to "get gud" so to speak, as well as having RSI available. Then went to a company with a C-Mac without recording with 100% success, then to a company with a CMAC with all blade types and recording. I learned the most on my recorded intubations. This leads me to believe that the base Paramedic in CA does not have the training or tools available to safely intubate, nor is it necessary for that which they are intubating. An arrest does not necessarily need an ETT, and the ground providers in this state are not using RSI. If they are to continue to intubate, I believe that at the minimum a VL with a recording function should be necessary with 100% Physician led QA for critique on process and improvements. But that is for CA with no RSI and very infrequent intubations, with poor training and QA processes. Different services with different training, different QA, different continuing education, and different equipment will lead to different results. Basically, gotta pay to play.

Looking at it from a flight perspective, I can see where someone would say that not being able to intubate and then going into an environment where intubation is routine would be difficult, and it would be. The Nurses are able to learn and become proficient, there shouldn't be a difference with the Medics so I feel that's a false argument.

 

[Carlos Danger]

Doc,
Since I've been on this forum, I have repeatedly heard what you said about medics sucking at intubation. What is being used? Glide Scope, Miller, Macintosh, or something else?

The research is pretty clear on the fact that prehospital intubation is generally associated with worse outcomes. You can disagree, but you'd be arguing with a LOT of data collected over several decades and published in dozens of peer-reviewed papers. The physicians and others who argue against intubation are not anti-EMS, and they are not just being mean to paramedics. Keeping in mind the "first, do no harm" concept, they've formed an unpopular opinion based on lots of hard data.

The advent of VL in recent years has definitely helped the situation, but multiple attempts, desaturation, and unrecognized esophageal intubation are still far more common than they should be. Airway management has become more challenging as our population has rapidly gotten fatter and sicker.

Someone usually points out right about here in the discussion that "more training" is all that's needed to get paramedics better at intubation. Yes, it is true that with enough training, you can teach anyone to be really good at anything. The question is, how much training are we talking about? How much will it cost? When and where will it take place? Who will do the teaching? Most paramedics finish their initial paramedic program with a small fraction of the airway management experience that ED docs get during their residency (some without a single live intubation), and a smaller fraction still of what anesthesia providers get. Then they go on to rarely perform the intervention and rarely get any good continuing training on it, yet we're in disbelief when the research shows that they aren't very good at it? How much continuing training is needed to get paramedics to the level of, say, an ED physician? OR time and cadaver labs are expensive and time-consuming.