The Disappearing ET

[karaya]

Here's a new article titled The Disappearing Endotracheal Tube by Dr. Bledsoe and William Gandy that appears on JEMS.com:

http://www.jems.com/news_and_articles/articles/jems/3403/the_disappearing_endotracheal_tube.html

 

[Aidey]

Interesting information, but I have a huge issue with studies that imply causation when there may not be any.

In this article the authors talk about how trauma patients intubated in the field had lower survival rates vs. trauma patients intubated in the ED. They use this information to back up the idea that the intubation is causing more harm than good.

I used to work in an area that had a very large number of high speed MVAs. The only trauma patients I ever intubated in the field were basically dead already. Their outcome had nothing to do with the intubation, and everything to do with the massive injuries they had. The really bad but not quite dying patients didn't get intubated in the field, they got intubated in the ED where they had RSI.

The patients intubated pre-hospital were "sicker" than the patients not intubated pre-hospital. So strictly comparing if they were intubated pre hospital or not vs. their survival rates could be totally skewed if the study did not take into account the patients chances of surviveability.

 

[daedalus]

I think Bledsoe likes to be controversial sometimes. I am just as willing as anyone to embrace evidence based practice, but I think more information and research will be required before we start making articles called "The disappearing Endotracheal Tube".

More recently, scrutiny has moved beyond analysis of simple skills performance and is now focused on patient outcomes.

-from above article.

This point is actually moot, because we have just recently introduced end tidal CO2 and EDDs in many systems, so it was way premature to preform studies on patient outcomes. These studies should be preformed after Paramedics have had a chance to learn to utilize detection devices and review both skills and indications of the procedure. I am against removing ETI from the paramedic scope of practice.

Further, I suggest that the percent of successful field intubation in high enough (86%) that it should not be removed from the scope of practice even if it has not been shown to improve patient outcomes. Some patients need ETI, and paramedics are clinicians who can be taught who will benefit from ETI. Instaed of removing a vital tool from our tool box, we can refine its indications for use in the field.

 

[daedalus]

For road-based paramedics, rapid transport to hospital without intubation should be regarded as the standard of care

From same article.

Are you kidding? Back to throw em in and code 3 em to the hospital? Really?

 

[karaya]

From same article.

Are you kidding? Back to throw em in and code 3 em to the hospital? Really?

Com' on D! I know you have it in you! You're not reading the article carefully. What you are referring to is the second sentence in the quote from the 2006 Australian study about Australian EMS using ETIs and is not Dr. Bledsoe's assessment. Watch for the end quotes and you'll see what I mean.

 

[boingo]

I know that when I intubate I have pulse oximetry and capnography being monitored and recorded on every case. I know (and so does the medical director) when I have a desat or a misplaced tube. All that data is recorded and merged into the electronic chart.

When a patient is intubated in the ED, sometimes I see pulse oximetry, never capnography. None of the data is recorded.

I can (and have) argued that patients are better monitored in my truck than in the ED when it comes to ventilation, blood gasses aside.

If the ED can't prove that they are doing the procedure without causing harm, perhaps they should remove it from the ED doc skill set and just call anesthesia. After all, a supraglottic airway is "good enough" for the short time it would take for an anesthesiologist to arrive and they are the expert at airway management. <_<

 

[daedalus]

If the ED can't prove that they are doing the procedure without causing harm, perhaps they should remove it from the ED doc skill set and just call anesthesia. After all, a supraglottic airway is "good enough" for the short time it would take for an anesthesiologist to arrive and they are the expert at airway management.

Agree. If they go into the ER needed a tube, than they needed one in the field even more.