Intubation FAIL

[chbare]

Actually, some of the remote clinics I covered had alternative airways and an AED as part of the resuscitation kit ( No setup for laryngoscopy ) In fact, in some situations, where resources were limited, time was limited, and light discipline was a concern, alternative airways were considered a primary option.

Take care,

chbare.

[DwayneEMTP]

I think many, perhaps all, misunderstood my point, or at least my intended point. Or perhaps it was just ignored.

Why is it that we daily preach 'Science Based Medicine' yet when it comes to ETT we suddenly begin to use words like "Have the right", "Going to take it away", "May lose the privilege."?

Ask anyone that knows me personally or has worked with me and, hopefully, they will disabuse you of the idea that I'm satisfied as a 'taxi driver.'

Do I believe that intubations are critical on a small percentage of my patients? Yes. But I also believe that Bicarb should decrease mortality in my arrest patients, yet the science screams 'bullshit.'

I had only one real point, and that was simply, "If the science, solid science, should show that correctly placed and managed tubes are not decreasing morbidity/mortality (And I have no idea what the studies say about that) then why does EMS begin to use illogical terms when describing it like 'right', 'privilege', etc.?

IF the science is showing that it doesn't help then I have no desire to continue to do it. I know the aspiration arguments, and share them. But I have not tracked my tube/non tube outcomes. For me, tubes are akin to Bicarb. It certainly should make a difference. It seems obvious that it will make a difference, but it's all moot if the science is showing that nationally PH-EMS (prehospital EMS) is doing more harm than good with them, right?

It makes no difference if I have saved 5 patients this year because I'm a wizard at intubations (which, of course I'm not), if my peers have killed 500 nation wide then the fix is in, so to speak.

Call me lazy, or ignorant for not screaming for a fix instead of, in this case only, simply accepting reality, but who here is willing to stand up and say that EMS is so good at coming together, so good at uniting to increase standards, that attempting to fix this issue nation wide while continuing to allow a bunch of idiotic wannabees to continue to drop tubes in the stomach is a really good idea??

We have people on this site that parrot the cry for increased education yet do so with so many typos that thier thoughts are difficult to understand. We have 3 month medic schools. Right?

Isn't our main moral and ethical obligation to patient care? Are we caring for our patients when we allow a bunch of half trained knuckledraggers to continue to kill their patients with intubations so that we can continue to try and save ours with it, if we know that we truly aren't saving as many as we thought?

Wouldn't it be the 'ambulance drivers' that continue to cry for a skill that science (for the sake of argument) is saying does no good for the most part and does harm for the rest?

Again, why does EMS use the words, "Right"(as in I Have a right), "priveledge", when discussing this issue? It's not my right or priveledge to intubate. It's another tool I use to hopefully deliver pts in the best possible condition I'm capable of. If I'm simply bullshitting myself that I'm actually using that tool, to do that thing, then I want to know so I can do better tomorrow than I did today.

Just sayin'...

Dwayne

[tniuqs]

'DwayneEMTP'

I think many, perhaps all, misunderstood my point, or at least my intended point. Or perhaps it was just ignored.

My point is no emotion should really be attached, but to take away something you have become proficient, because of morons in another country and EMS directors spewing non applicable so called EBM studies ... well that does irritate me to no end.

Ask anyone that knows me personally or has worked with me and, hopefully, they will disabuse you of the idea that I'm satisfied as a 'taxi driver.'

Nah Dwayne, just pushing your buttons is all.

Do I believe that intubations are critical on a small percentage of my patients? Yes. But I also believe that Bicarb should decrease mortality in my arrest patients, yet the science screams 'bullshit.'

The withdrawal or removal of BICARB in an arrest situation was based not on outcomes but physiological research that it dissociates and increases acidosis, but now we are being told by physiology researchers say that acidosis is protective at a cellular level.

I had only one real point, and that was simply, "If the science, solid science, should show that correctly placed and managed tubes are not decreasing morbidity/mortality (And I have no idea what the studies say about that) then why does EMS begin to use illogical terms when describing it like 'right', 'privilege', etc.?

There is no true science in medicine thats where everyone is wrong one patient does not equate to another, EBM gives us a pointer but that it ... in FACT most discoveries in modern medicine are through good observational skills ie (ants in a dogs urine = Diabetes and discovery of Insulin) a scientist cut himself on a slide while testing what absorbs infrared light = Pulse Oximetry) a drug being tested to slow premature labour = Salbutamol for Asthma) I could go on.

Funny actually that we "stumble" across the biggest developments in medicine, heck many amputation procedures are based on Napoleons Surgeon.

IF the science is showing that it doesn't help then I have no desire to continue to do it. I know the aspiration arguments, and share them. But I have not tracked my tube/non tube outcomes. For me, tubes are akin to Bicarb. It certainly should make a difference. It seems obvious that it will make a difference, but it's all moot if the science is showing that nationally PH-EMS (prehospital EMS) is doing more harm than good with them, right?

Ok let talk using CPAP ... very dependent on the expertise of the Provider this cannot be quantified ... nothing is black and white in medicine.

It makes no difference if I have saved 5 patients this year because I'm a wizard at intubations (which, of course I'm not), if my peers have killed 500 nation wide then the fix is in, so to speak.

Following the sheep logic ... so those 5 that you did provide competent and definitive care in protecting airway with ETI now (if your peers are killing others) we go on a massive search for the Golden Goose er LT King experiment ?

Call me lazy, or ignorant for not screaming for a fix instead of, in this case only, simply accepting reality, but who here is willing to stand up and say that EMS is so good at coming together, so good at uniting to increase standards, that attempting to fix this issue nation wide while continuing to allow a bunch of idiotic wannabees to continue to drop tubes in the stomach is a really good idea??

Controls need to be in place so success ratios will improve ... simple really, wherever they did the study requires a re evaluation ... see my first rant.

We have people on this site that parrot the cry for increased education yet do so with so many typos that thier thoughts are difficult to understand. We have 3 month medic schools. Right?

Sorry English is not my major, 3 years for we very northern Texans er Albertans.

Isn't our main moral and ethical obligation to patient care? Are we caring for our patients when we allow a bunch of half trained knuckledraggers to continue to kill their patients with intubations so that we can continue to try and save ours with it, if we know that we truly aren't saving as many as we thought? Wouldn't it be the 'ambulance drivers' that continue to cry for a skill that science (for the sake of argument) is saying does no good for the most part and does harm for the rest?

Save or give the best chance at a positive outcome ?

Ok is there any harm in allowing EMTs in areas of long response to shoot Combi-Tubes in arrest situations ... hey can't kill a cadaver, maybe just one in a thousand may have a positive outcome.

Again, why does EMS use the words, "Right"(as in I Have a right), "priveledge", when discussing this issue? It's not my right or priveledge to intubate. It's another tool I use to hopefully deliver pts in the best possible condition I'm capable of. If I'm simply bullshitting myself that I'm actually using that tool, to do that thing, then I want to know so I can do better tomorrow than I did today.

I earned the right to perform that procedure safely for my patients .... didn't you ?

cheers

[CBEMT]

Many hospitals as a matter of procedure, routinely disconnect and restart field IV's because they feel the conditions in which they were started were probably less than optimal. It's a CYA thing- regardless of patency or size, they are worried about infection, thus lawsuits.

Too bad they didn't read the study I saw that had the infection rates as statistically identical, with a slight numerical edge to EMS. I haven't had to post it in a couple of years, I'll try to remember where I found it.

[VentMedic]

Too bad they didn't read the study I saw that had the infection rates as statistically identical, with a slight numerical edge to EMS. I haven't had to post it in a couple of years, I'll try to remember where I found it.

One study and a "slight" numerical edge is not going to convince the State and Federal Insurances especially since EMS has not been able to convince them of much even pertaining to EMS with the fragmented levels of various hours of training. Of course there might be services that do have better stats then others but the environment may still against them. As I mentioned before, EMS has been its own worst enemy with "the EMS way" or "do it in the trenches" or "street medicine" and how different EMS is with no time for that hospital technique foolishness. IVs can also be in the same predicament that ETI is in. Too few numbers to demonstrate proficiency for each Paramedic can go against them.

Again you have to look at this from the view of a health care system and do what is best for the patient so that they make it from prehospital to discharge without additional complications. Egos need to be set aside so one can look at the bigger picture clearly. If doctors have had to come to terms with this a Paramedic should be able to. Doctors in the units are now scrutinized for handwashing, stethoscope cleaning, procedures and even the clothes they wear in the patient care areas. EMS is still not that diligent. We still have to tell EMT(P)s to remove the gloves they brought the patient in with before they reach for the coffee pot at the nurses' station or do their charting at the front desk.

We've also had this same discussion about central lines as now they are falling out of favor for flight teams.

I also remember the same reactions from EMS providers when subclavian central lines, intracardiac epi, chest tubes, pericardiocentesis, Bronkisol, Alupent and Bretylium were removed from everyday use for ground EMS. It was hard to imagine life without any of these interventions.

[spenac]

OK I am know going to speak so everyone sit down shut up and listen.

Now that I have your attention I feel we should still have intubation available. Why? Because I have had multiple patients that would have died prior to reaching the hospital if we had not intubated before the airway closed. So my question is based on most everyones over reacting should we remove the intubation ability and just watch these people die as their airway finishes closing?

Perhaps we should start taking certifications away from Paramedics that fail to catch failed intubation's. Perhaps we should start closing services that fail to stay up to date with items that make it where there is no excuse not to catch a misplaced tube.

[VentMedic]

OK I am know going to speak so everyone sit down shut up and listen.

Now that I have your attention I feel we should still have intubation available. Why? Because I have had multiple patients that would have died prior to reaching the hospital if we had not intubated before the airway closed. So my question is based on most everyones over reacting should we remove the intubation ability and just watch these people die as their airway finishes closing?

Spenac, your situation where you have an hour's drive to a hospital is not the norm for everyone in EMS.

Maybe some have not become proficient in alternative airways or the use of the BVM. One of the first things we learn even working in the hospital is how to maintain an airway by various means. If you do flight, you definitely learn alternative means because you prepare for the worst and hope for the best. Look at the Anesthesia docs. Very few ETIs are done now in the OR. This is also one reason why Paramedic students can not get the intubations they need during their OR rotations. Very few will allow ETI just because. Yes ETI is a definitive airway but one should NEVER limit themselves to just one way of establishing an airway. I guess I now know why some Paramedics/students have that deer in headlights look when their assistance is requested for a couple of minutes to bag an apneic patient or one requiring ETI on scene or in the ED. They may have gone straight to performing ETI on a manikin and failed to learn other important things like a BVM or alternatives.

I also find it just as tragic for the patient when the pharynx and cords are so butchered with repeated attempts that a trach will be required, quite possibly permanently, because some didn't know how to assess a difficult airway and consider alternative methods. Or, when they have been told "Paramedics only do ETI" and their ego or pride make them jab away to get that tube. Regardless of how long it takes on scene (or even in the back of an ambulance sitting in the hospital driveway) or the damage they do, they must enter the ED with a tube. Of course, you also have the other end of the scale where some can't be bothered to do ETI.

RNs are much easier to train for maintaining an airway for Flight and Specialty teams because they have no preconceived notions or egos of what must be done because they have seen many different airways used and have had to become proficient in the use of a BVM if they are assisting the intubator. That could also mean bagging for a long time if it is a teaching hospital and the attending decides to lecture first. RNs have had to learn to be versatile when going from one unit to another and learning different procedures or adapt what their know to do it another way. When training Paramedics, they usually have one way set in their brain and that is it.

I am not one for removing ETI totally from prehospital but maybe the training and attitudes need to handled differently. Maybe more emphasis should be placed on airway assessment and determining necessity or difficulty instead of just doing a skill. I also know you have read the intubation threads on the forums by the students who talk about "getting tubes". How many acutally discuss the airway? They might as well be intubating a manikin.

Edited August 5, 2009 by VentMedic

[HERBIE1]

Too bad they didn't read the study I saw that had the infection rates as statistically identical, with a slight numerical edge to EMS. I haven't had to post it in a couple of years, I'll try to remember where I found it.

Well, the oversight in hospitals is clearly better. They have infection control nurses who patrol and do QA's. With the advent of things like MRSA, it's simply not something they can play around with. Prehospital, we have no such watchful eyes- just our own integrity to do it right. If you say the stats show not much difference between the 2, then like many things in our business, it's incumbent on us to prove our critics wrong.

[VentMedic]

Well, the oversight in hospitals is clearly better. They have infection control nurses who patrol and do QA's. With the advent of things like MRSA, it's simply not something they can play around with. Prehospital, we have no such watchful eyes- just our own integrity to do it right. If you say the stats show not much difference between the 2, then like many things in our business, it's incumbent on us to prove our critics wrong.

Critics? Everyone is picking on EMS..boo hoo. Did one happen to think about the environment you work in?

Hospitals may also change out lines from other hospitals or those done in an emergency situation or under less than idea conditions even if it is in their hospital and done by one of their doctors. If a line is set up with an open port, the whole line is changed. Meds from another hospital are changed out. Florida is even changing the wording in one of it statutes to have the rec'g physician determining what needs to be done for interfacility transport rather then the referring. Enough with this "oh woe is me the poor picked on Paramedic". There is a patient involved and whatever can be done to prevent an infection will be done.

Edited August 5, 2009 by VentMedic

[tniuqs]

RNs are much easier to train for maintaining an airway for Flight and Specialty teams because they have no preconceived notions or egos of what must be done because they have seen many different airways used and have had to become proficient in the use of a BVM if they are assisting the intubator. That could also mean bagging for a long time if it is a teaching hospital and the attending decides to lecture first. RNs have had to learn to be versatile when going from one unit to another and learning different procedures or adapt what their know to do it another way. When training Paramedics, they usually have one way set in their brain and that is it.

I think thats a bit over the top with gross generalization there Vent, I know of many RNs with a deer in the headlights look myself .. Thats not MY job .... anyway.

I do agree more time should be spent with all levels of providers in the use of BVM .. as for butered airways I have seen way more as an RRT from MD residents than Paras, to that end I present a paper by a good friend Dr. Peter Brindley an Assosiate Professor in Intensive Care Medicine. The issue of "in house" for failed intubations by resident Mds on code teams, no real records keep on failure rates oddly enough, as I have said in past I would LOVE to see a good study on ER MDs and GPs in rural areas ... nuff said.

‘‘Win with your chin’’

An alternative to the ‘‘sniffing position’’ analogy for teaching optimal head-positioning with intubation

Sir,

Airway patency and airway protection are essential parts of resuscitation. Acute care practitioners understand the importance of optimal head position in order to align the three airway axes prior to intubation attempts. As such, we are commonly expected to teach airway positioning, and have traditionally used the analogy of the ‘‘sniffing position’’.

In contrast, I have had far more success using the analogy of ‘‘winning a running race with your chin’’. This letter is offered to outline an alternative teaching method that others may find applicable. The ‘‘sniffing position’’ analogy is intended to convey three elements: flexing the lower cervical-spine; extending the upper C-spine (atlanto-occipital joint), and positioning the ears level with, or anterior to, the sternum.

However,

experience has shown that while most trainees can recall the term ‘‘sniffing position’’, far fewer demonstrate the correct flexion and extension of the lower and upper cervical-spine.

Furthermore, fewer-still demonstrate that the head should not be posterior to the sternum.

In contrast, I tell trainees to ‘‘mimic the optimal head position when running across the finish line of a closely contested race’’.

To avoid any misunderstanding — such as mistakenly placing the forehead anterior to the chin — I emphasize that the chin should lead. This has led to a rhyming, and while admittedly corny, nonetheless easy to remember: ‘‘win with your chin’’.

Experience has also shown that many trainees are reluctant to leave a pillow beneath the head, to use towels to raise the occiput, or to use a ramp to minimally elevate the shoulders and significantly raise the occiput. My experience is that the ‘‘win with your chin’’ analogy has mitigated this reluctance, while the using the traditional ‘‘sniffing position’’ analogy has not.

With an increasing number of obese patients, emphasizing that the ears should not be posterior to the sternum is particularly important. I would also argue that modern healthcare workers are more familiar with the experience of running races compared to sniffing for smoke. Regardless, we should embrace anything that increases the likelihood of

successful endotracheal intubation, and decreases potential airway complications.Therefore, this simple, familiar, and memorable analogy provides a simple, but nonetheless useful, teaching point.

Conflicts of interest statement

None.

P.G. Brindley∗

Division of Critical Care Medicine, Unit 3C4, 4H1.22

University of Alberta Hospital, 8840-112th Street,

Edmonton Alberta, Canada

Reproduced with permission

oi: 10.1016/j.resuscitation.2008.03.006