When to intubate

[MasterIntubator]

Well... hospitals offer a controlled arena with mega-experience watching, mentoring and giving you the tricks of the trade. Not to mention, you should be able to get as many intubations in hospital in a good clinical setting as one would need to feel comfortable enough in the field. Field medics are in great need of this training, and the field is not adequately providing it. The numbers show it, we see it and it is going to hurt us. Unless you are on a small grouped critical care service, a new medic probably won't get the experience they initially needs.
Tubing the plastic head just does not cut it for experience.
But I do agree that the field is the best area for it, but we need the future medics to graduate having live intubations done and confident/proficient in it.

 

[NomadicMedic]

Luckily, our service has an agreement with the local hospitals and our medics are encouraged to visit the OR often for tubes to maintain proficiency and confidence.


Sent from my iPhone.

 

[MasterIntubator]

n7.... thats awesome!! I wish so many more jurisdictions had it set up like that.

 

[medicsb]

Well... hospitals offer a controlled arena with mega-experience watching, mentoring and giving you the tricks of the trade. Not to mention, you should be able to get as many intubations in hospital in a good clinical setting as one would need to feel comfortable enough in the field. Field medics are in great need of this training, and the field is not adequately providing it. The numbers show it, we see it and it is going to hurt us. Unless you are on a small grouped critical care service, a new medic probably won't get the experience they initially needs.
Tubing the plastic head just does not cut it for experience.
But I do agree that the field is the best area for it, but we need the future medics to graduate having live intubations done and confident/proficient in it.

I didn't say the OR shouldn't be used during initial training, just that for continuing contact, the working paramedic shouldn't expect to get experience in the OR. Further, medics, as a whole, shouldn't expect anesthesiologists to open up to working paramedics. If someone is going to intubate, they need to have frequent experience. The overwhelming majority of EMS systems are set up so that the average medic does NOT get frequent experience. EMS system stake-holders need to find ways to reduce the number "intubators" so that the intubators that do exist can get the number needed to be proficient. Otherwise, the system is set for failure.

 

[NomadicMedic]

I didn't say the OR shouldn't be used during initial training, just that for continuing contact, the working paramedic shouldn't expect to get experience in the OR. Further, medics, as a whole, shouldn't expect anesthesiologists to open up to working paramedics. If someone is going to intubate, they need to have frequent experience. The overwhelming majority of EMS systems are set up so that the average medic does NOT get frequent experience. EMS system stake-holders need to find ways to reduce the number "intubators" so that the intubators that do exist can get the number needed to be proficient. Otherwise, the system is set for failure.

How many tubes did you have to place before you were good at it?

5? 10? How many did you paramedic class require?

Numerous studies have been conducted on students learning how to intubate. One I like to quote used statistical models to show that the average number of intubations to become baseline competent, that is, correctly placing the tube 90% of the time without asking for help, is 47. I don't know about you, but my paramedic class didn't require anything like 47 tubes. It was 10 to graduate. Nowhere near the number I needed to become competent.

So, who cares if it's the field or not? Get to the OR and practice. The opportunity to place tubes in the field is dwindling. It's just common sense, the more tubes you can put into a real head vs. a plastic one can only serve to build your skills.

Laryngoscopic Intubation: Learning and Performance
Anesthesiology:
January 2003 - Volume 98 - Issue 1 - pp 23-27

 

[LondonMedic]

Is this a question about intubating or anaesthetising?

It might take 50 tubes to be really competent to intubate but how many anaesthetics do you reckon you have to give to truly know what you're doing with that?

 

[rhan101277]

I am not aggressive with intubation. I have managed problems like CHF with CPAP. I have yet to intubate someone who was not in cardiac arrest. They have not deteriorated to the point where I thought bagging was in-effective. Once you intubate someone mortality goes up, so its a big decision. If you think death is imminent if an airway is not secure then by all means do it.

 

[medicsb]

How many tubes did you have to place before you were good at it?

5? 10? How many did you paramedic class require?

Numerous studies have been conducted on students learning how to intubate. One I like to quote used statistical models to show that the average number of intubations to become baseline competent, that is, correctly placing the tube 90% of the time without asking for help, is 47. I don't know about you, but my paramedic class didn't require anything like 47 tubes. It was 10 to graduate. Nowhere near the number I needed to become competent.

So, who cares if it's the field or not? Get to the OR and practice. The opportunity to place tubes in the field is dwindling. It's just common sense, the more tubes you can put into a real head vs. a plastic one can only serve to build your skills.

Laryngoscopic Intubation: Learning and Performance
Anesthesiology:
January 2003 - Volume 98 - Issue 1 - pp 23-27

The opportunity to place ETTs in the field is dwindling because there are too many paramedics allowed to intubate. It is not because the number of patients requiring intubation is dwindling. If one can get to an OR for practice, then great. But that is extremely difficult if not impossible for most EMS systems. You are extremely privileged to have the opportunity to go to the OR. Your system is an exception.

As far as number needed to become proficient - the data varies. One says 17
(Med Educ Online. 2011;16. Endotracheal intubation skill acquisition by medical students.), another indicates between 15-25 (Defining the learning curve for paramedic student endotracheal intubation. Prehosp Emerg Care. 2005;9(2):156–62). There was another study that said >20 prehospital ETIs for a 1st pass success of 90% (Prehosp Emerg Care. 2010 Jan-Mar;14(1):103-8).

I'd like to point our that 1st pass success of 90% in the prehospital setting is unlikely to be obtained by anyone. When one looks at studies involving physicians in the prehospital setting (including anesthesiologists), 90% has never been demonstrated (one example: Resuscitation. 2006 Aug;70(2):179-85. Prehospital airway management: a prospective evaluation of anaesthesia trained emergency physicians.)

Even in the ED, in the US, it has not been demonstrated (Ann Emerg Med. 2005 Oct;46(4):328-36. Airway management by US and Canadian emergency medicine residents: a multicenter analysis of more than 6,000 endotracheal intubation attempts.)

It would probably be best to aim for a 75-80% 1st pass success rate with an overall success of 95%? (I don't know what would be best, hence the question mark.)

Again, reduce the number on intubators/paramedics, you increase the frequency of the procedure bythose who can intubate. It's simple, really.

Now, as London Medic asks, how many anesthetizations (RSIs) does it take to become proficient at using the drugs? Who knows? This is something where simulation and training is probably just as good as hands on experience as it requires more cognitive ability than motor skill. I'd guess that the learning curve, as far as "hands on" experience goes, isn't as big as it is for the actual skill of intubation. I imagine londonmedic will disagree.

 

[jjesusfreak01]

While everything that Medicsb says makes sense, you can't just decrease the number of medics allowed to intubate and expect better outcomes, because you can't choose which medic arrives onscene, and you can't know if a call is going to need intubation before you get there. With the introduction of CPAP and reliable BIADs, the need to intubate has dropped through the floor, so even reducing the number of providers allowed to intubate from 100 in a system to 30 doesn't guarantee that each one of those 30 gets one a year. If we truly believe its a useful skill that belongs in pre-hospital medicine, then we need to focus on continuing education to keep the providers proficient, whether that means practicing on airway dummies or shouldering up next to the anesthesiologist in the local OR.

 

[LondonMedic]

Now, as London Medic asks, how many anesthetizations (RSIs) does it take to become proficient at using the drugs? Who knows? This is something where simulation and training is probably just as good as hands on experience as it requires more cognitive ability than motor skill. I'd guess that the learning curve, as far as "hands on" experience goes, isn't as big as it is for the actual skill of intubation. I imagine londonmedic will disagree.

Of course.

I think you're right, it is a cognative skill. But that doesn't just mean that you can recite the drugs and the doses. I think it means that you've anaesthetised enough people in enough ways that you understand the different drugs that are available to you and can make an informed choice about what the most suitable technique is, you can recognise, identify and respond to the different side effects and complications that occur, you know how deep your patients are when to lighten or deepen and perhaps most importantly you can recognise when there's a need for intubation and when the risk is too high.

Pushing the drugs in and getting the plastic tube between the flaps is the easy bit.

 

[LondonMedic]

While everything that Medicsb says makes sense, you can't just decrease the number of medics allowed to intubate and expect better outcomes, because you can't choose which medic arrives onscene, and you can't know if a call is going to need intubation before you get there.

The way that this has been talked about in the UK, and not just with intubation, is to get various advanced paramedic types to respond to selected calls on a car to back up the techs or paras already assigned. That may not be practicable in large rural areas but should be readily achievable in high-call-density metropolitan areas.

 

[tssemt2010]

intubating will always be a last resort in my opinion, if the person can tolerate a BVM then so be it, i would much rather insert an OPA (if they tolerate it) or an NPA and bag them on the way to the hospital than insert a laryngoscope into their mouth and cause trauma and damage. airway burns is also a situation where i would always intubate the patient, i would much rather intubate a patient before their airway swells than have to do a surgical crich or needle crich to keep a patient alive, that is one skill we do not use enough and i would not feel very comfortable doing it in any situation

 

[the_negro_puppy]

intubating will always be a last resort in my opinion, if the person can tolerate a BVM then so be it, i would much rather insert an OPA (if they tolerate it) or an NPA and bag them on the way to the hospital than insert a laryngoscope into their mouth and cause trauma and damage. airway burns is also a situation where i would always intubate the patient, i would much rather intubate a patient before their airway swells than have to do a surgical crich or needle crich to keep a patient alive, that is one skill we do not use enough and i would not feel very comfortable doing it in any situation

The problem is, an OPA and BVM provides little airway protection and poor technique risks forcing air into the oesophagus. ETTs are used as a gold standard for airway protection and control due to the protection they provide and more efficient ventilation. There are inherent risks with laryngoscopy and intubation, but these must be weighed up against risks such as the patient aspirating on vomit or passive regurgitation. Not to mention drugs can also be administered via ETTs,

 

[LondonMedic]

There are inherent risks with laryngoscopy and intubation, but these must be weighed up against risks such as the patient aspirating on vomit or passive regurgitation.

What about the risks of anaesthesia which are arguably more serious and more common than both laryngoscopy and intubation combined?

Not to mention drugs can also be administered via ETTs,

I'd hope you'd put a cannula in before anaesthetising someone...

 

[the_negro_puppy]

What about the risks of anaesthesia which are arguably more serious and more common than both laryngoscopy and intubation combined?


I'd hope you'd put a cannula in before anaesthetising someone...

In my post I was talking generally about intubation in an unconscious patient with absent jaw tone/airway reflexes rather than intubation as part of anaesthesia/RSI. Although this thread is more about when to conduct RSI I was answering with respect to intubation in general as an advanced airway.

I am not trained in intubation nor will I be, however I was just correcting tssemt2010's assumption that OPA + BVM will always suffice rather than attempting intubation due to the risks involved. By their post he/she seemed to discount the added benefits of using advanced airways

In regards to administering drugs via ETT I was referring to situations such as cardiac arrest etc where perhaps difficulty in obtaining IV access may exist. Though with rise if IO devices i'm sure this method is probably already outdated.

 

[Katy]

into their mouth and cause trauma and damage

This isn't always the case. Successful intubation techniques and safely placed ETT's will not cause trauma and damage in most cases.

 

[LondonMedic]

This isn't always the case. Successful intubation techniques and safely placed ETT's will not cause trauma and damage in most cases.

Around half of people who are electively intubated for theatre by an anaesthetist will have a sore throat subsequently.

 

[Katy]

Around half of people who are electively intubated for theatre by an anaesthetist will have a sore throat subsequently.

Yes, I know that. I didn't say all would be without trauma or injury, just not all.

 

[LondonMedic]

Yes, I know that. I didn't say all would be without trauma or injury, just not all.

Just not all?

Successful intubation techniques and safely placed ETT's will not cause trauma and damage in most cases.

In an optimal environment intubation done by airway 'experts' with the benefit of proper planning and preparation causes some trauma in around half of all cases, do you think pre-hospital intubation by paramedics in sub-optimal environments done in a hurry is better or worse?

 

[Katy]

Just not all?

Yes, the user I quoted said basically any time intubation is done, that airway trauma and injury happens. I wanted to correct that assumption, considering not every one does cause those injuries.

In an optimal environment intubation done by airway 'experts' with the benefit of proper planning and preparation causes some trauma in around half of all cases, do you think pre-hospital intubation by paramedics in sub-optimal environments done in a hurry is better or worse?

Worse, of course. But, does that mean all of them will have side-effects, no. Is the percentage higher for such injuries? Yes, but still, that doesn't mean every one will have trauma.