Why are we placing ETTs at all?

[DrParasite]

Probably will better trained "BLS" providers. A big part of being a paramedic is recognizing the "subtly sick" and our current EMTs don't really have the ability to recognize this. Sure in urban areas you're probably not that far from a hospital and just taking them to a hospital won't result in a poor outcome most of the time. Except for when it does and the patient needed someone able to deliver an "advanced" assessment and invasive but life sustaining treatments 20 minutes ago but nobody noticed.

please elaborate why EMTs don't have the ability to recognize subtly sick patients. and EMT's assessment and a paramedic assessment should be pretty similar; the exception is a paramedic assessment includes a cardiac monitor. What is this "advanced assessment" you are talking about? I agree that a paramedic can give an advanced intervention, but if the paramedic is going to perform a "advanced assessment" and then do the state of life on the way to the hospital, how beneficial is that advance assessment? And more accurately, why can an EMT not do this advanced intervention?

And if the EMTs missing these subtly sick patients, why have no studies shown this? There have lots of anecdotal stories, and a lot of emotional theories (those EMTs are killing people because they don't know what they don't know), but I haven't seen any EBM, any successful lawsuits, or any actual facts supporting this claim.

My view is certainly clouded by personal experience of working someplace with all P/B or P/P ambulances. But man, we still see it with BLS first responders. We have a pretty good countywide agency education system here but exposure matters. Many of the BLS folks just don't know what a compensating patient looks like. They're very good about ensuring that the sick sick patients get paramedics quickly, but not so good with the middle of the spectrum sick patients. This is career and volunteer places mind you, it seems to transcend all the groups.

If your EMTs are only spending 10 minutes with the patient, and than handing off to EMS, than they aren't really doing EMS (despite what may career firefighters like to think).

In fact, in my experience, it is rare to see a firefighter who is a good EMT, with the exception of those who spent time on the ambulance before they started with the FD. As you said, they just don't get the exposure to EMS, except for the first 10 minutes. Ditto your P/B ambulances; if you always have a paramedic telling you what to do, and always have a paramedic to fall back on, can you see why they might not function as well independently?

My view is, of course, clouded by my personal experience of working on a B/B ambulance in both urban and suburban areas, with a P/P intercept vehicle as needed, as well as working on a B/P truck and an EMT on a first response vehicle.

 

[VFlutter]

I would hope that a paramedic with more, albeit still woefully inadequate, education in anatomy and physiology would have a better understanding and assessment of subtly sick and marginally compensated patients then an EMT with 3 months of education. But maybe I'm just being condescending.

 

[DrParasite]

sure sure sure longer courses = more education = better understanding and better assessment of subtly sick. That's the theory

In theory, a paramedic would have a better understanding of sick vs not sick, at least compared to a nurse. in theory, a nurse would have a better understanding of sick vs not sick, at least compared to a nurse. and in theory, a doctor would have a better understanding of sick vs not suck, at least compared to a nurse. And I agree with the theory.

but is there any evidence that the theory is true? have there been any studies? have there been any successful lawsuits, based on the chronic death and disabilities that resulted from these poor assessments? I would imagine if it was a systemic problem, the court system would be full of them.

I agree, more education is better. But where is the factual support, other than the belief that "more education is better" and "EMTs are grossly unqualified to perform patient assessments; lets ignore the evidence that at least two states, and several major cites use ambulances with 2 EMTs as the people who treat and transport the majority of their EMS patients."

 

[RocketMedic]

We have proven that Pre-Hospital ETI can be done well with great first pass success and minimal complications when preformed by the right providers. These groups (CC/HEMS) are composed of experienced and highly motivated individuals with frequent exposure to intubations and extensive continuing education/training requirements. We need to challenge the idea that every paramedic should be intubating. Every medic should be an airway expert sans intubation with access to a select group of highly trained providers capable of RSI if needed.

I completely agree with mastering the basics and not relying solely on technology however I think the time is quickly approaching for video laryngoscopy to be the standard of care.

The flipside of this argument is that the intubation-capable population of paramedics plummets and now people who need tubes might have to wait for them.

As for the "why" of ETT- I think that it is primarily because we cannot conclusively say that there isn't a good way to replace them.

 

[VFlutter]

The flipside of this argument is that the intubation-capable population of paramedics plummets and now people who need tubes might have to wait for them.

As for the "why" of ETT- I think that it is primarily because we cannot conclusively say that there isn't a good way to replace them.

My rebuttal would be that patients that truly need emergent intubation are probably less common than we assume and many can be managed by other means until a RSI medic arrives or you get to the ER.

The way we have it now with all medics intubating we have more access but poentially less competence.

There are a lot of low volume / high risk procedures that are time critical and potentially life saving (I.e pericardiocentesis) that don' have an alternative however I do not think that in and of itself is justification for them.

 

[medicsb]

ETI is associated with harm or equivocal outcomes. The best study showing benefit was the one out of Australia that barely reached statistical significance. There have been a few retrospective studies showing benefit (one out of King Co.), but they have their drawbacks. Generally, most patients can wait to arrival at the hospital. If prehospital ETI is going to be performed it should be by someone who has had good training and relatively frequent experience on live humans, and the only way to do this reliably is to greatly reduce the number of paramedics. Though some services can try and make up for lack of experience with OR time, most places can't do that and those that have that could lose it pretty easily. And those services that have OR experience, they could either eliminate it or greatly reduce it, if the number of paramedics was reduced

As far as other low frequency, high risk procedures, I'd argue that their not actually high risk. Can't intubate, can't ventilate? The patient dies. A cric may save them (great benefit), but if it fails then the outcome is the same as if you didn't perform it. In many instances of prehospital ETI, we know that the overwhelming majority will survive to hospital arrival with a BVM or supraglottic airway. Intubating has the potential in itself to harm the patient and render them worse than that which was the indication for intubation. With cric or pericardialcentesis, death is imminent, and a botched cric or pericardialcentesis does not actually make the original situation worse (unless your assessment was wrong).

 

[RocketMedic]

It is less invasive and less of a cultural barrier to place an ETT than to crike someone, and quite frankly, we might as well keep both.

 

[E tank]

With cric or pericardialcentesis, death is imminent, and a botched cric or pericardialcentesis does not actually make the original situation worse (unless your assessment was wrong).

Might be beginning to mix apples and oranges. Just a point of order with regard to pericardiocentesis. Even with echocardiographic diagnosis of tamponade, at least many non CT surgeon physicians are extremely reticent to attempt putting a needle through the pericardium unless arrest occurs or is "imminent" (whatever that means). Diagnosis in the field is more difficult and making things worse with an attempt is a real possibility.

I wouldn't put cricothyrotomy and pericardiocentesis in the same category.

 

[Carlos Danger]

It is less invasive and less of a cultural barrier to place an ETT than to crike someone, and quite frankly, we might as well keep both.

A field cricothyrotomy is not an elective procedure. It is only done in scenarios where an airway cannot be established any other way, and thus the patient will die without it. It is essentially a risk-free procedure, because even though complications can result, none of those complications are worse than what will happen if an airway is not established.

In contrast, most field intubations are entirely elective, in that the patient will have the same outcome (or even better, statistically, if you believe the research) if another method is used to secure ventilation and oxygenation.

In one case you are making a last-ditch effort and not exposing the patient to any addition risk. In the other, you are deliberately choosing to perform a procedure that caries risk and in most cases isn't even likely to help.

 

[medicsb]

I’m an EM doc and I wouldn’t do a pericardialcentesis except in the most dire situation (cardiac arrest or peri-arrest). I wouldn’t want a paramedic doing it out side of arrest (or at all, actually). I have had patients with large pericardial effusion with echo evidence of tamponade, but stable, and they had a pericardialcentesis performed by interventional cards. I have only done one pericardialcentesis for trauma (an arrest) and it was only done because we couldn’t visualize the pericardial sac due to free air in the chest.

 

[rescue1]

sure sure sure longer courses = more education = better understanding and better assessment of subtly sick. That's the theory

In theory, a paramedic would have a better understanding of sick vs not sick, at least compared to a nurse. in theory, a nurse would have a better understanding of sick vs not sick, at least compared to a nurse. and in theory, a doctor would have a better understanding of sick vs not suck, at least compared to a nurse. And I agree with the theory.

but is there any evidence that the theory is true? have there been any studies? have there been any successful lawsuits, based on the chronic death and disabilities that resulted from these poor assessments? I would imagine if it was a systemic problem, the court system would be full of them.

I agree, more education is better. But where is the factual support, other than the belief that "more education is better" and "EMTs are grossly unqualified to perform patient assessments; lets ignore the evidence that at least two states, and several major cites use ambulances with 2 EMTs as the people who treat and transport the majority of their EMS patients."

I can't imagine those studies exist prehospitally, because the vast majority of patients who call 911 will get transported to a hospital (since neither ALS nor BLS can say no to transport in 99% of the US), and the public will almost never know the difference between what ALS or BLS could have done, and so if the patient has a bad outcome the hospital/doctor will likely be blamed. And let's be honest, as long as an ambulance service takes someone to the hospital it's pretty hard to sue them, even if the care provided was subpar.

Probably more importantly, most EMS transports take place in systems with under 20 minute transport times, which means that the difference in outcomes between ALS and BLS transport is probably pretty minimal, if it exists at all (wasn't there a study that said that BLS treated patients do better?).

So I guess I'm mostly agreeing with you haha.

 

[Tigger]

please elaborate why EMTs don't have the ability to recognize subtly sick patients. and EMT's assessment and a paramedic assessment should be pretty similar; the exception is a paramedic assessment includes a cardiac monitor. What is this "advanced assessment" you are talking about? I agree that a paramedic can give an advanced intervention, but if the paramedic is going to perform a "advanced assessment" and then do the state of life on the way to the hospital, how beneficial is that advance assessment? And more accurately, why can an EMT not do this advanced intervention?

And if the EMTs missing these subtly sick patients, why have no studies shown this? There have lots of anecdotal stories, and a lot of emotional theories (those EMTs are killing people because they don't know what they don't know), but I haven't seen any EBM, any successful lawsuits, or any actual facts supporting this claim.
If your EMTs are only spending 10 minutes with the patient, and than handing off to EMS, than they aren't really doing EMS (despite what may career firefighters like to think).

In fact, in my experience, it is rare to see a firefighter who is a good EMT, with the exception of those who spent time on the ambulance before they started with the FD. As you said, they just don't get the exposure to EMS, except for the first 10 minutes. Ditto your P/B ambulances; if you always have a paramedic telling you what to do, and always have a paramedic to fall back on, can you see why they might not function as well independently?

My view is, of course, clouded by my personal experience of working on a B/B ambulance in both urban and suburban areas, with a P/P intercept vehicle as needed, as well as working on a B/P truck and an EMT on a first response vehicle.

As someone who has gone through paramedic school, I should hope you understand the difference between an EMT and paramedic level assessment. If you didn't get that out of paramedic school, I don't really know what to do. Even the assessment "module" is longer than most EMT classes. A solid program also integrates better assessment skills the more your progress through it. The cardiology portion of medic school is a lot more than putting a monitor on. What do the findings mean in context? What will you do with them? There is no way to learn these things in 120-150 hour class.

Did you ever work as a medic and integrate your assessment skills?

 

[rescue1]

I think the question should not be are paramedics better at assessing patients than EMTs, since I think everyone would agree that they are. I think a better question is, practically, does it make a difference in outcomes, and on which patients does it make a difference.

However, it's also pretty off topic from intubation.

 

[VFlutter]

I know I have mentioned this before but how many providers know the intubation statics for their company? How they compare to other EMS, HEMS, or ER/ICU.

What is an acceptable first pass rate and overall intubation rate?

If there is a large variation between a certain department and ER/HEMS/CC how can you justify continuing to perform intubations?

 

[EpiEMS]

If there is a large variation between a certain department and ER/HEMS/CC how can you justify continuing to perform intubations?

To add on to this, consider that in many Anglosphere systems (Canada, Australia), paramedics who perform many ALS skills aren't performing ETI...and they've often got 2+ year degrees in paramedicine.

 

[DrParasite]

As someone who has gone through paramedic school, I should hope you understand the difference between an EMT and paramedic level assessment. If you didn't get that out of paramedic school, I don't really know what to do. Even the assessment "module" is longer than most EMT classes. A solid program also integrates better assessment skills the more your progress through it. The cardiology portion of medic school is a lot more than putting a monitor on. What do the findings mean in context? What will you do with them? There is no way to learn these things in 120-150 hour class.?

when I was in medic school, I had completed the requirements for many medical and PA programs, and had already been working in EMS for almost 15 years. I will say that I learned a lot about diseases and interventions, and felt very frustrated that all too often, I could know a lot about something, and still be unable to do anything in the field, other than tell the doc "hey, i think this is what is going on based on A/B/C."

Your example of how "cardiology portion of medic school is a lot more than putting a monitor on" is 100% accurate: but the vast majority of cardiology involved information gathered from the monitor, treatments based on that information, both electrical and medical. and a whole lot of conditions and issues, and how to fix them (sometimes).

Can a paramedic do more interventions than an EMT? absolutely. Are they typically more experienced, so they have seen more than an EMT? sometimes because they have seen more, so they might be looking for different things that they can fix.

So if you can't explain what the difference is, than I'm guessing you are too ashamed to admit that the assessment (how you are searching for the problem) is pretty much the same. Or feel free to list exactly what makes a paramedic exam, that every paramedic does on a regular basis (ie, it's the paramedic standard) different than that of an EMT, in terms of patient assessment. I'll be here waiting patiently.

hypothetically, lets take you off your ambulance, and put you on my engine. you have a standard BLS bag, no cardiac monitor, no ALS medications. How will your assessment differ? how will your report differ to the paramedic ambulance who arrives 10 minutes after you do?

Oh, and I use my assessment skills every shift. I just don't use my intervention skills.

 

[Carlos Danger]

So if you can't explain what the difference is, than I'm guessing you are too ashamed to admit that the assessment (how you are searching for the problem) is pretty much the same. Or feel free to list exactly what makes a paramedic exam, that every paramedic does on a regular basis (ie, it's the paramedic standard) different than that of an EMT, in terms of patient assessment. I'll be here waiting patiently.

hypothetically, lets take you off your ambulance, and put you on my engine. you have a standard BLS bag, no cardiac monitor, no ALS medications. How will your assessment differ? how will your report differ to the paramedic ambulance who arrives 10 minutes after you do?

Oh, and I use my assessment skills every shift. I just don't use my intervention skills.

I'll explain what the difference is: emphasis, mentoring, and time spent in training, and the resulting experience. Those things matter.

Even if EMT's and paramedics do learn the same exact assessment skills - and I'm not sure thats's even true - a paramedic on his first day after passing finals will have dramatically more experience, overall awareness, and confidence in performing a given assessment than an EMT will on his first day passing finals. Quite often, that experience gap only widens with time spent in the field.

 

[Tigger]

when I was in medic school, I had completed the requirements for many medical and PA programs, and had already been working in EMS for almost 15 years. I will say that I learned a lot about diseases and interventions, and felt very frustrated that all too often, I could know a lot about something, and still be unable to do anything in the field, other than tell the doc "hey, i think this is what is going on based on A/B/C."

Your example of how "cardiology portion of medic school is a lot more than putting a monitor on" is 100% accurate: but the vast majority of cardiology involved information gathered from the monitor, treatments based on that information, both electrical and medical. and a whole lot of conditions and issues, and how to fix them (sometimes).

Can a paramedic do more interventions than an EMT? absolutely. Are they typically more experienced, so they have seen more than an EMT? sometimes because they have seen more, so they might be looking for different things that they can fix.

So if you can't explain what the difference is, than I'm guessing you are too ashamed to admit that the assessment (how you are searching for the problem) is pretty much the same. Or feel free to list exactly what makes a paramedic exam, that every paramedic does on a regular basis (ie, it's the paramedic standard) different than that of an EMT, in terms of patient assessment. I'll be here waiting patiently.

hypothetically, lets take you off your ambulance, and put you on my engine. you have a standard BLS bag, no cardiac monitor, no ALS medications. How will your assessment differ? how will your report differ to the paramedic ambulance who arrives 10 minutes after you do?

Oh, and I use my assessment skills every shift. I just don't use my intervention skills.

Ashamed? That must be it.

Remi pretty much covered it. The sky is up too, but I'm sure you're anecdotal experiences will have something to say about that too.

I know I have mentioned this before but how many providers know the intubation statics for their company? How they compare to other EMS, HEMS, or ER/ICU.

What is an acceptable first pass rate and overall intubation rate?

If there is a large variation between a certain department and ER/HEMS/CC how can you justify continuing to perform intubations?

We had 69 intubations as a service in the past two years. An additional maybe 10 intubations were done at hospitals with a doctor for our patients but were the "doctor's tubes." In that time we had a 72% first pass success rate and all but one patient with an intubation attempt was intubated in three or less attempts. The one failed RSI was managed with a king airway. We have 15 full-time paramedics on staff. Last year we began using McGraths. Most but not all of our paramedics have RSI privileges.

 

[DrParasite]

Even if EMT's and paramedics do learn the same exact assessment skills - and I'm not sure thats's even true - a paramedic on his first day after passing finals will have dramatically more experience, overall awareness, and confidence in performing a given assessment than an EMT will on his first day passing finals.

I agree with you there, 100%. a paramedic has more experience (in most cases), as their clinical time is longer, when they are fresh out of school. Plus, many programs require a paramedic to be an EMT for a year before they even start the paramedic program, so, of course, the paramedic is more experienced, especially immediately after graduation, when the EMT, literally, has 0 real world experience as an EMT (maybe 3 clinical shifts if they were lucky). It would be nearly impossible for an EMT to have more experience than a paramedic immediately following graduation.

But the claim was that a paramedic assessment is better than an EMT assessment. There has been nothing to back up that claim. But if you say an experienced provider is better than a newbie provider, than wouldn't an EMT with 10 years of experience be able to perform a better assessment than a newbie paramedic?

Quite often, that experience gap only widens with time spent in the field.

So my former coworkers, who see 15 patients in 12 hours, aren't as experienced as a paramedic who sees 2 patients in 24 hours? They saw sick and not sick patients (probably more not sick than sick, it was an urban city).

Lease common denominator, sure, the industrial EMT, volunteer who does it once or twice a month, or the firefighter who only does first response, heck, even the law enforcement officer who is a paramedic and has never been full time on the ambulance; all these people couldn't compare to a busy ambulance paramedic when it comes to patient assessment, because they don't have the experience level.

But that's experience in the field, not medical training. and experience matters.

Ashamed? That must be it.

Remi pretty much covered it. The sky is up too, but I'm sure you're anecdotal experiences will have something to say about that too

No need to be snarky. You made a claim, and I asked you to back it up. I'm betting you still can't, because your claim is baseless.

Oh, and I pulled my old syllabus out of my email archive. We spent a week on "patient assessment", two whole days. everything else we covered patient conditions and interventions (and a ton on cardiology). And then we did a lot of patient assessments based on the conditions we covered. but the "patient assessment" lecture was about the same as in my EMT class.

 

[Carlos Danger]

I agree with you there, 100%. a paramedic has more experience (in most cases), as their clinical time is longer, when they are fresh out of school. Plus, many programs require a paramedic to be an EMT for a year before they even start the paramedic program, so, of course, the paramedic is more experienced, especially immediately after graduation, when the EMT, literally, has 0 real world experience as an EMT (maybe 3 clinical shifts if they were lucky). It would be nearly impossible for an EMT to have more experience than a paramedic immediately following graduation.

But the claim was that a paramedic assessment is better than an EMT assessment. There has been nothing to back up that claim. But if you say an experienced provider is better than a newbie provider, than wouldn't an EMT with 10 years of experience be able to perform a better assessment than a newbie paramedic?

I think perhaps we define "assessment" differently. If you are just talking about the NREMT skill sheet stuff - the ability to take a set of vitals and compare them to normal ranges and remember which questions to ask about chief complaint and onset and medications and allergies and which order to do your physical exam in, then yes perhaps there is little or no difference between an EMT and a paramedic. When I think about "assessment", I think more broadly. To me it is the overall ability to accurately gather objective and subjective information and use that information to identify and sort through differentials. The overall ability to figure out what is going on with a patient. EMT's can't do that like paramedics can because they don't know even half of what paramedics know about the potential differentials for any given complaint.

It's been a few minutes since I endured any formal EMS book learnin', so perhaps things have just changed. But I know when I finished paramedic school, I had way better assessment skills than I ever did as an EMT. You were much better off being taken care of by Remi the paramedic than by Remi the EMT, and not because of the expanded treatment options. It was the overall increase in clinical knowledge and the confidence that came with my additional training. I just knew more. And because I knew more, I was better able to figure out what was going on with my patients.

Plus, I don't think you can discount assessment tools that EMT's don't have, like cardiac monitors. Things like that are a big part of what makes a paramedic different from an EMT. If nothing else, a paramedic is better at assessing because they have paramedic assessment tools.