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Thank you for the mention.
... ah, hell. Let's just accept it as a given that, on any given day, Rogue Medic is gonna piss someone off about something. That's what he does.
And you generally only see me being suave and debonair as it relates to EMS. Think of all of the people in other fields I get to charm on a daily basis. :-)
Kinda like Henry Rollins with a less-talented barber.
You blame my hair on a barber? Be careful the next time you go to a barber. They might re-enact a scene from The Godfather.
"pain in the ass" might accurately describe him much of the time,
Much of the time?
I don't have to put up with this. You make me feel like a PITA slacker.
Only much of the time?
You CAN negatively impact patient outcome with a correctly placed endotracheal tube.
And that is assuming that the majority of them are correctly placed without the not-so-rare complications of trauma, hypoxia, etc.
If your EMS system is that good at ETI, then browbeat your medical director into publishing a study, so that the rest of EMS can emulate what you're doing.
An extremely important point. Something that can be as much of a problem as the constant studies of systems with blind squirrels. If we do not have much research showing the methods that lead to excellent prehospital intubation success, then people may continue to believe it is impossible, or not worth it, or too expensive, or some other lame excuse. It is far from impossible - if the system is willing to dedicate the resources to not harming patients.
How do I, a person in a fire district who is not a member of the EMT company, work to get the local EMTs up on the latest techniques and get them to drop unnecessary ones? If, as you say, many squads use IVs unnecessarily and are needlessly risking patients via intubating and not using CPAP it would make sense to work towards a better solution.
Short of being a real P.I.T.A., I'm at a loss how to even start the conversation without being blown off as one of the ignorant heathens.
I gotta disagree with that one. I lurves me a good field IV. Saves me a whole step. I may change out the tubing if the pt gets admitted, but I always utilize the medic's IV. Then again, on most days I'd take a medic's anything over a nurse's. *sigh*
I was in Orlando when one of those studies was done. The doctor performing the study would examine patients who got a prehospital tube, and document whether or not the tube was placed properly.
I watched that doctor pull every tube, even ones that were obviously intubated correctly (good capnography, condensation in the tube, SaO2 95%, chest rise, etc) and reintubate them.
The medic joke around here is that every time a Doctor pulls a medic's tube and reintubates, he gets to mail that month's Lexus payment coupon to the patient's insurance company.
I agree with the IV comment. I have a friend whose father died 5 years ago from septicemia, when an IV site got infected. I stopped doing IV's unless there was a good reason for it, and doing one because the nurse at the ER gets grumpy if I don't is not a good reason. Risk versus benefit.
and CPAP is the flippity floppity floop.
I work in an FD with plenty of medics that runs with private EMS transport. We just don't have the quantity of incidents requiring ETI for so many medics. On the flip side, cutting the number of medics would significantly increase the arrival of ALS, and any tubes that would need to be placed might be too late. I believe that the King type airways and CPAP will gradually replace ET tubes in the field.
Funny as hell!
The IV stat, in my area the ER's want an IV and they actually do use them for fluids & meds (kind of surprising since most Nurses & Docs don't think much of paramedics around here).
FACT: I don't intubate many people. I know that my skills are no where near what they need to be to even "think" i am proficient. I also know there I will come across a patient who needs intubation and I will perform that skill as best I can.
I wish we had CPAP (a few medics are pushing for CPAP at my service). We have ventilators (LVT 1000 that have CPAP) but no equipment for the CPAP feature. My state is far behind most of the country in following clinical studies to improve patient outcome. We need a few Happy MEdics, ROuge MEdics and Ambulance drivers help us out. Thanks guys for the good info!
I gotta disagree with that one. I lurves me a good field IV. Saves me a whole step. I may change out the tubing if the pt gets admitted, but I always utilize the medic's IV.
Unfortunately MG, you're a rarity in ED nurses. Depending where I transport to, I will purposely NOT start an IV because I know that it will result in two sticks for the patient (mine and the ER's blood draw) as opposed to one (the ER's IV/blood draw).
The excuse is almost always "I can't use that, it's had saline through it."
So remove the tubing, attach the tube sleeve, and draw off a red top, THEN DISCARD IT. Congratulations, you just removed all the saline from my extension set (which is actually the one you use, because I carry your stuff), and can now draw anything you want.
When finished, simply re-attach the IV tubing (also your brand, cause I pay attention), set the flow, and go do whatever it is you do.
I'm glad you do that, I promise you it makes your EMS crews feel good. I just don't understand what's so hard about it.
Monkeygirl: The nurses around here lurves them a good field IV, too, but they rarely use it for anything. They also like it when I draw blood, so I also draw a rainbow whenever I make an IV stick, time and circumstances permitting.
Now, they're not going to remove a perfectly good IV placed in the field, but a large number of our IVs are placed by protocol, and the hospital doesn't find much use for them.
A number of studies have been done on this subject, including one by Marianne Gausche-Hill at UCLA Harbor Medical Center. Only a small fraction of the IVs in those studies were actually used for emergency resuscitation meds or fluid boluses in the ER.
Now, maintenance fluids or IV antibiotics a few hours later, that might be a different story. But that negates the reasoning for doing it in the field because it "saves time for the nurses."
Divemedic: The problem of varied physician interpretations of "incorrectly placed" was also a problem the Gausche pediatric intubation study.
Still, there have been a number of other studies, in other major cities, that showed similar results using objective and quantifiable standards for determining tube placement. Orlando alone people may have been able to write off as an aberration, but there are nearly enough studies out there to do a meta analysis on the subject, and the results of many of them do not bode well for paramedic intubation.
John: Call your supply vendor. They make King airways in 2.0 and 2.5 sizes now, small enough to intubate anyone but infants.
I have a hard enough time as an old timer, who knows all of the doctors. I can't imagine trying to do this completely from the outside.
Regarding the current debate, I agree that many/most medics and paramedic programs are inadequately trained to be skilled in advanced airway management. Truthfully, our training and education should exceed pretty much every other clinical provider except anasthesiologists, particularly for rural and critical care providers. We're often expected to intubate patients in conditions that would make any ED resident shudder and we have to secure these already difficult airways without most of the resources (RSI, retrograde intubation, fiberoptic intubation, etc.).
I further agree that many medics are obnoxiously gung-ho about intubation (perhaps even claiming that they could intubate SIX people while falling down a flight of stairs, which is clearly impossible, much like six-minute abs). They refuse to acknowledge the harm that can be done by intubation/refuse to think about the next step in patient care (i.e. is it better to have a secure airway if my 83 year old COPD'er never gets off the vent?).
In the spirit of critical thinking and being a "licensed professional" instead of a certified skill monkey, I look to research to guide my clinical decisions- I will not do anything that has been demonstrated to be bad for my patient. At the same time, however, I defend prehospital intubation. I do so not because I think that the studies are wrong, but rather I think they studied largely defective systems. I would like to see more studies about prehospital systems that have highly competent, experienced medics with rigorous standards for education/clinical competence AND the full range of skills necessary (i.e. RSI, bougies, etc.).
That being said, I am unaware of any such EMS system. My own personal experiences have shaken my faith in my fellow EMS providers and the educational programs they attend. To that end, is anyone aware of such a system in the US? Seriously, I'm looking for a new employer and I need something different.
Unfortunately, my situation is the same as brendan's. The local hospitals will not accept our bloods, even though I have been transporting patients to the hospital for over a decade and even though I used to work as a phlebotomist.
I would like to make the nurse's job easier. We have a lot of great nurses, so it isn't as if there is a lot of animosity, or anything like that. If starting an IV just means that the patient gets stuck twice, then it is not good patient care.
Another problem is that the more times the patient gets stuck, the fewer good veins left for the ED to use.
On the other hand, as I wrote about in EMS Needs to Be a Separate Medical Specialty - Now - Part I, there are a lot of very bad practices in starting prehospital IVs. As much as I would like to say, Just take our bloods and use our IVs, I realize that there are some very good reasons not to, at least in some places.
I was in Orlando when one of those studies was done. The doctor performing the study would examine patients who got a prehospital tube, and document whether or not the tube was placed properly.
I watched that doctor pull every tube, even ones that were obviously intubated correctly (good capnography, condensation in the tube, SaO2 95%, chest rise, etc) and reintubate them.
If you have waveform capnography documenting a correctly placed tube that was pulled by a doctor, you should go to the doctor in charge of the study and bring copies of any other documentation that shows that the tube was in the right place.
As long as the waveform and the numbers document adequate gas exchange, you know that the tube was not in the esophagus. OTOH, if the CO2 is elevated, it might indicate that the tube is above the vocal cords and not properly secured. The sensible thing to do in that case, is not to pull the tube, but to deflate the cuff and advance it to the point where the cuff is beyond the cords. Unless the tube is too big or there is some other situation that requires pulling the tube. Interrupting the delivery of oxygen, just to pull the tube all the way out, is not indicative of good patient care.
You could write to the journal that published the paper. Sending copies of the waveforms might help. It is always a good idea to keep a copy of every waveform capnography, just remove the identifying information except the date and time. It is good to keep a photocopy, too, since the printouts are going to deteriorate with time and with exposure to heat.
and CPAP is the flippity floppity floop.
I could not have expressed it better on my best day. CPAP is a BLS skill in many places. There is no good reason to prevent ALS from using it. There is also no good reason to prevent BLS from using CPAP.
It is the CombiTube that is not supposed to be used on short patients. There is a pediatric CombiTube for patients between 3 and 4 feet tall. The pediatric CombiTube may actually work better on some adults (taller than 4 feet) than the adult CombiTube.
The LMA also comes in pediatric and neonatal sizes - down to about the size of a swizzle stick. Guiding this into the neonatal airway with my finger, even my Dr. Evil finger, is not something that produces images of finesse.
I work in the suburb of a major city, a very busy suburb. The city spits out medics like a machine and tosses them to the street while next door to them my system (hospital based) has very rigid preceptor time and we have a very high standard as to our abilty to tube. If you miss a tube more then once your in the OR, we have yearly skill reviews, our ACLS class we are required to tube, and then we have a minimum amount we are required to have which usually isn't a problem. Mostly on unresponsive CHF patients which we get a lot of for some reason. We are tight with command and because of it we have been allowed to carry Amidate. Are other systems able to produce the same results, I have no idea. We still have missed tubes though and I don't think it's because they were a bad, poorly trained medic, just a shitty call in a difficult area and possibly a difficult airway. How do we determine the root cause in a study?
When we put Amidate on the trucks every medic was required to go to the OR and perform 2 tubes before they were allow to adminsiter the drug per our command doc. Everyone passed, all 30. Now are we just great medics or does someone not care in the OR enough to say hey this person got their tubes but they really looked like they were struggling and should come back again. Yeah I'm sure the OR loves a bunch of medics hanging around and couldn't wait to get rid of us.
I don't think anon is a beat your chest "don't take my tubes away" but is probably stuck in a system that has those machine spit medics and probably has shitty command.
Part 1:
I agree with almost everything you write.
We're often expected to intubate patients in conditions that would make any ED resident shudder and we have to secure these already difficult airways without most of the resources (RSI, retrograde intubation, fiberoptic intubation, etc.).
As much as I am critical of intubation, it is because of the lack of oversight. Who tolerates such horrible success rates, if they are aware of them?
However, for the well trained medic with excellent aggressive oversight, I do not see a problem with using RSI. If the medic is skilled enough at airway - most importantly when not to intubate and when not to RSI - then RSI should be safe in the hands of EMS.
We need more research, and as you stated - it should be on high quality systems, not the ones that seem to be playing 3 card monte.
I further agree that many medics are obnoxiously gung-ho about intubation (perhaps even claiming that they could intubate SIX people while falling down a flight of stairs, which is clearly impossible, much like six-minute abs). They refuse to acknowledge the harm that can be done by intubation/refuse to think about the next step in patient care (i.e. is it better to have a secure airway if my 83 year old COPD'er never gets off the vent?).
Well, I do not believe in limiting my obnoxiousness. When you've got it, flaunt it. ;-)
I do agree about the potential for harm being ignored.
In the spirit of critical thinking and being a "licensed professional" instead of a certified skill monkey, I look to research to guide my clinical decisions- I will not do anything that has been demonstrated to be bad for my patient.
I am probably misreading what you write, actually more worried that others may misunderstand, but suggesting that there are things that we do that have not been shown to cause harm is wrong. Everything we do has the potential for harm. An excellent article on this is -
A piece of my mind: the harm of "first, do no harm".
JAMA. 2000 Dec 6;284(21):2687-8.
Shelton JD.
PMID: 11105155 [PubMed - indexed for MEDLINE]
I can send you a copy, if you do not have access to JAMA. roguemedicblog@gmail.com
I completely agree. How do we accurately determine the effect of a treatment, when it is so often abused?
The OPALS cardiac arrest study eliminated EMS systems that did not maintain at least a 90% intubation success rate.
Advanced cardiac life support in out-of-hospital cardiac arrest.
Stiell IG, Wells GA, Field B, Spaite DW, Nesbitt LP, De Maio VJ, Nichol G, Cousineau D, Blackburn J, Munkley D, Luinstra-Toohey L, Campeau T, Dagnone E, Lyver M; Ontario Prehospital Advanced Life Support Study Group.
N Engl J Med. 2004 Aug 12;351(7):647-56.
PMID: 15306666 [PubMed - indexed for MEDLINE]
I would like to see more studies about prehospital systems that have highly competent, experienced medics with rigorous standards for education/clinical competence AND the full range of skills necessary (i.e. RSI, bougies, etc.).
Prehospital use of succinylcholine: a 20-year review.
Wayne MA, Friedland E.
Prehosp Emerg Care. 1999 Apr-Jun;3(2):107-9.
PMID: 10225641 [PubMed - indexed for MEDLINE]
Also -
Success Rates in Out-of-Hospital Intubation
Annals of Emergency Medicine;
Volume 52, No. 4: October 2008; page S153; abstract number 364
I posted the abstract here, because it is not available from PubMed.
That being said, I am unaware of any such EMS system. My own personal experiences have shaken my faith in my fellow EMS providers and the educational programs they attend. To that end, is anyone aware of such a system in the US? Seriously, I'm looking for a new employer and I need something different.
Above, I listed studies of two systems that are rather well known for their excellence at airway management. There are others out there, but many of them do not publish their results for a variety of reasons.
Mr. EMT came into the room, shined a light through my baby's hand/wrist, and found the vein in a matter of minutes. I was, and am, very grateful. It's hard for me to understand why, with that kind of expertise, a nurse would remove a working IV placed by an EMT.
I listed the wrong post. The one on IV techniques and myths is The Harm of Rituals in EMS.
Now where did I leave that Aricept?
Sick pts are money losers for the hospital - intubation is just one of the symptoms.
The "stormy clinical course" is in store for any pt that is sick enough to be intubated sans RSI, IMHO.
Huge adrenaline rush?? Ummm, no.
In my area there are so many hospitals, (we have 5 Level 1 trauma centers - God only knows how many level 2s & 3s) - that trying to keep up with who does what with our IV's is impossible. I do know that *most* use field IV's like they use their own and change them out only if there is a problem with them.
Starting a line to "help the nurses" is not something to avoid. We are an EMS team. Helping team members, esp. if they are busy as hell is a good thing!
I agree with you 100% that RM isn't trying to advocate removing ETI from the medic skill set. Anymouse hasn't read enough of his blog apparently. He just wants medics to be competent.
Don't you just love a dreamer? ;)
Maybe I'll chime in when I get the bug back.
My FD doesn't have the smaller Kings, this thread is the first I knew they came in a ped size. I will be calling our EMS guru to suggest we get them.
I'm surprised that no one commented on our preference for the king vs ETI. Does anyone think that is the "lazy" way out, or were the reasons I listed sufficient for agreement?
I am in agreement on the ET tube issue. The King airway has become our first choice-no delays to break out the ET kit, no worries about visualization, less chance of getting bodily fluids in the face, and most importantly, it minimizes the time needed to secure the airway.
I read this and interpreted it as the way you approach cardiac arrests, not all airways.
I agree with this approach. Skip Kirkwood was discussing using this approach on EMS Garage Episode 29: Traction Control.
I do not see a need for intubation in cardiac arrest. I think that intubation only interferes with compressions in cardiac arrest. There was a good study of this in -
Interruptions in Cardiopulmonary Resuscitation From Paramedic Endotracheal Intubation.
Wang HE, Simeone SJ, Weaver MD, Callaway CW.
Ann Emerg Med. 2009 Jul 1. [Epub ahead of print]
PMID: 19573949 [PubMed - as supplied by publisher]
Editor’s Capsule Summary
What is already known on this topic
Decreased interruption of chest compressions in out-of-hospital cardiac arrest is strongly associated with increased survival in animal models and clinical trials. Little is known, however, about the specific issues that lead to interruptions.
What question this study addressed
What are the frequency and duration of cardiopulmonary resuscitation chest compression interruptions associated with paramedic endotracheal intubation during out-of-hospital cardiac arrest?
What this study adds to our knowledge
In 100 out-of-hospital cardiac arrests, patients' chest compressions were interrupted twice, on average, because of efforts to intubate, with a mean total interruption time of nearly 2 minutes.
How this might change clinical practice
This adds support for the current movement to de-emphasize intubation and delay it until later in resuscitation attempts for out-of-hospital cardiac arrest.
Using the King airway as the first method of airway management in cardiac arrest, seems like a reasonable thing to do and consistent with the above study.
Anything that interferes with chest compressions, except for defibrillation, should be avoided.
We may even be able to avoid interruptions in compressions for defibrillation, but I am not encouraging that until I know more about that research.
I always stress that intubation is a SKILL that needs to be used and a couple of tubes in the field, an occasional go around with Fred the Airway Head is not enough!! I also teach the use of King Airways. The medics often whine about them!! A blind insertion that you do quickly and usually it goes right where you want it!!
If you cannot place a King you have no business trying to intubate!!
I see another Motivational Poster out of that one!
Thanks for a great quote, AD.
After completing MICA training, drug assisted intubation sign off is after another year of road consolidation.
Crucial to the outcome of this study was the following
1.Small cohort of staff trained for this skill ~250 out of 3500
2.Intensive training with inservice, training materials and equipment, and theatre time.
3.An effective failed intubation drill
4.Waveform capnography to be used on all intubations
5.Clinical review of every case