Poor Intubations in EMS

[Ridryder 911]

Okay we have been fighting the slander and criticism of missed tubes in the field for sometime. But, now newer studies are showing even more screw- ups ... WTF is going on ! ? ....

Here is a link from our luxurious Dr. Bledsoe on new reports : http://www.merginet.com/index.cfm?pg=airway&fn=ETprobs

Here is a portion :

Of the 1,953 ETIs performed over an 18-month period, ETI errors occurred in 444 patients (22.7 percent). Of these, 61 patients (3.1 percent) had tube misplacement or dislodgement, 62 (3.2 percent) had multiple attempts and 359 (18.5 percent) had failed ET placement. The ETI error rate per service ranged from 0 percent to 40 percent. ETI error rates were more likely in children < 6 years of age, trauma patients and non-cardiac arrest patients. Interestingly, the adjusted odds of ETI were higher for busier services (>5,000 contacts per year) and for slow services (<50 contacts per year). No other system characteristics were associated with ETI errors

22.7 percent !.. How much error should be allowed ?...0 %.. With better intubation equipment, Capnometric indicators, EtCo2 monitoring which shows exactly you are in or not .... WHY IS THIS OCCURRING !?

As a profession we need to evaluate why our treatment modality is dropping down especially in the last 10 years?

Is it poor skill level?

Lack of training?.. yes, you should had O.R. intubation experience, where you intubated several patients prior to EMS intubations

Poor CQI.. and maintenance level.. and continuation skills

Are we getting half arse medics ?.. who don't know what they are doing ?

Your 2 cents worth?

R/R 911

[mediccjh]

It's because we are putting out piss-poor medics these days.

And we're putting out piss-poor medics because EMTs are no longer taught to think. They are taught 15 L NRB, sit on scene and wait for ALS.

If you create piss-poor EMTs, they become piss-poor Paramedics.

[vs-eh?]

I noticed that this is for RSI. I sure as hell hope that if services are allowing RSI that they have a rescue device available (other than cric) in the event of a failed intubation. I assume misplacement or dislodgement is unrecognized. I was going to say that multiple attempts isn't a bad thing per say, but then I noticed the study defined that as 4 or more times. That is a little much if corrective efforts aren't working. You should be going to another a/w device or handing off the tube (if possible).

We have capnography that is of course mandatory on all intubated patients. We also have a policy where the tube is confirmed by auscultation and a strip run of the cap waveform prior to transfer to the hospital bed.

Lack of training?.. yes, you should had O.R. intubation experience, where you intubated several patients prior to EMS intubations

Since you mentioned this I am going to assume it is relatively common. It is absolutely ridiculous that "paramedics" are allowed to pass an ALS program without having OR rotations for intubations. Programs here have a minimum number of OR tubes (usually 20-30) prior to passing the clinical portion. Also the norm is to have either a successful percentage (IV's for example require a minimum of 70% success in 20 or more starts) or being successful in your last 3 tubes or something. Can't get the tube (or line) after 2 attempts? It is considered unsuccessful. Haven't got enough tubes in the OR? You go back for more and you don't pass until they are done.

[Ridryder 911]

This is where I am getting at as well. I would like to see what type of programs have in place for the "intubation phase". I know of very many that do not have a clinical phase requiring intubations, as well of those with CQI in place or not in place. Please, let's not bash those reporting. We as (professionals) need to be aware of what is going on and actually start evaluating what is the etiology, source of the problems. We need to correct the problems for the impact of patient care and for professional purposes. I know many EMS physicians take ACEP studies seriously, and I would hate to think that our scope may change because we did not correct this.

R/R 911

[medic429]

so this is based only on prehospital RSI? are there a lot of medics allowed to RSI patients? we are not, only the flight crews here.....

Dr. Wang will be at our update conference this weekend debating the issue with one of our prehospital docs....of course I have to work, but from what I understand the place is going to be packed!

[mediccjh]

My paramedic program required 5 OR ETTs to pass.

I got 12 in 2 days, and 5 out on the street.

Out of all the tubes I've had in the field (at least 80), I've only been unable to intubate a patient twice, and I used BLS OPA as my backup (before we carried Combi-Tubes).

[nsmedic393]

We were required to shadow a eneasthesiologist for a minimum of 5 shifts and we had to have 20 successfull intubations.

[Ace844]

Hi ALL,

Geez...You guys were only required to do between 12-20 ETT's?!?!?!? Man, you guys got off easy. My medic class required 100, and I actually placed over 180, in the month of 6 days a week I had to spend in my OR rotation... Sheesh, if I only had to do 12 I would be done like a month sooner. Sorry, guess I just got sticker shock at those numbers and figured you guys had to do ALOT more...guess I'm gettin burned out on this whole clinical thing..! :shock: :roll: :?: :!: :arrow: :!:

out here,

ACE844

[vs-eh?]

We were required to shadow a eneasthesiologist for a minimum of 5 shifts and we had to have 20 successfull intubations.

Same, 6 days (48 hours) with a minimum of 20. I believe that is the standard minimum for any CMA ACP program. Most people got over 30, some over 50. It just depended on the hospital.

My medic class required 100, and I actually placed over 180, in the month of 6 days a week I had to spend in my OR rotation...

Ummmm that is a lot. Required a minimum of 100 and you did 24 days in the OR? Do you have a link to this program?

How is it that some programs can require this and others not require any OR rotations...

[mommaparamedic]

You guys are so lucky. Down here there was only 1 hospital that would allow students to have an OR rotation. If you actually were able to do anything you were lucky. Even though it is a teaching hospital for doctors, they really do not like EMS students. The problem is lack of resources in our area. I know that when I went through Intermediate 4 years ago I was only allowed to try 1 intubation. Going through paramedic classes, I actually got some in the field. Where I work now we are allowed to get as much practice as we want on the dummies (I know not the same). We also have capnography, and alternative airways.