Poor Intubations in EMS

[Ace844]

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.

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...

"VS,"

It was a program requirement as my director and the program has a philosophy similar to that of a residency, they feel that there should be a broad, thorough, comprhensive (didactic/clinical) medical education before solo practice. In addition, the instruction staff felt that was a bare minimum to become "basically profecient" in this skill and would allow us to be confident in our abilities. Next, we did more than just the ETT's we also were responsible for the sequences, the general anesthesia, airway assessments, H&P, hemodynamic monitoring, etc...; under the supervision of the Anesthesiologists of course. Finally, as you requested here's your URL link to my programMemorial Hospital of Rhode Island Program of Paramedicine Each program can require whatever additional education it wants, as long as it meets and at least slightly exceeds the minimum Natl. Cirricular requirements. The catch is that you can't test until you've "completed" whatever Medic class you started. The school gets to decide whether you've completed the requirements or not. As you will see my program went way beyond them.

hope this helps,

ACE844

[brock8024]

I read a article in JEMS that covered this topic. I will try to get a link to the web page. It was about how some services where making the nurse or doctor make sure tube placement was good before moving the patient. If the hospital staff refused and the doctor then said the tube was bad the medic had to call and 3 people came out. I think it was a supervisor and two other people. They looked at the whole picture, from CO2 monitoring to everything. Alot of tubes where good it was the ER staff that was in a frenzy to get the patient moved that dislodged the tube. I am not for sure if this is a issue or not. I know for my program I have to have I think 12 this semister but 20 or so over the rest of the program. I have done three 8 hour shifts so far. I am planing on asking if I can do more this semister. My instuctor makes us check eachother off every week on the dummy heads. We have to do 2 adult 2 peds and 2 ivs every week. If not we get in trouble. He says it is good pratice which I like. I mean airway is the most important thing there is. We all should be cont. our intubation skills no matter what. If that means we go to a OR after we are out of school once a month or whatever or find a ER. My 2 cents

brock

[Asysin2leads]

I blame it on a lack of fundamentals. The Wal-Mart/McDonald's attitude towards EMS has boiled Anatomy and Physiology down to being able to pick the right letters on a multiple choice test. No matter how chaotic the scene, its pretty obvious if the tube is in the esophagus or the trachea, if you know what you're looking at.

A diagram in Brady's is a far cry from something looked at upside down, in the dark, with loads of secretions.

[TechMedic05]

Rid,

Do you have a link to the original study? Just reading that abstract I found it to be, well, one sided. They come out explaining an incredible number of failed ETI's, but don't explain very well if - were dislodged tubes corrected prehospitally? Or were misplaced tubes immediately recognized? What did they define 'Multiple attempts" as? And what were they defining an attempt?

Also to be considered, as I believe was covered in an article in Jems this month, March 06, was San Diego FD's new intubation protocols, which state the intubating paramedic remains at the airway until the ED Physician evaluates the airway, as they claim ET tubes are being dislodged when patients are transferred.

I'm not saying prehospital providers aways do a great job, but perhaps more education, documentation and full use of etco2 monitoring will bring these numbers where they should be, 0.

[Ridryder 911]

The link is the post. I am not sure all the details. What I am concerned the most is, I have seen more & more medic students that no longer have intubation clinicals. In fact it is now more the unusual to have them than not to. I am wondering is this the cause or other contributing factors, that need to be explored. I have rumors of the concerns of the Paramedic effectiveness in intubations and should this even still be considered for Paramedics. This also comes to mind with the new AHA 2005, recommendations of alternative airway, and airway interventions are now placed down the line of protocols.

I hope we can do some research to correct this and prevent further detrimental discussions. Again, this study & other s are really being observed in the medical community. Something we need to correct and correct it soon. But, we need to find out why it is occurring.

R/R 911

[TechMedic05]

I hope we can do some research to correct this and prevent further detrimental discussions. Again, this study & other s are really being observed in the medical community. Something we need to correct and correct it soon. But, we need to find out why it is occurring.

Rid, I agree with you there, we just need to find a way to correct issues, then re-run studies.

I'm finding with EMS research, which is new to our relatively new field, one study is all it takes for everyone in medicine to whiplash and change what's been done for what, 40-50 years now?

[Ridryder 911]

Very true, the problem is the "knee-jerk" reflex that can occur nationwide over things like this. Obviously there is a problem, and since it is OUR problem, WE need to CORRECT IT. Otherwise someone else will & we may not like their corrections.

Yet again, I can see some of the problem by looking at lack of responses even on this question. Unless it has something to do with lights, gorry details, or sexual humor.. most medics are not interested. I am just curious on clinical education and QI processes, at least a start of an informal dialog.

R/R 911

[flight-lp]

Last year during a conference, myself and several other flight medics had a lengthy conversation with Dr. Bledsoe about this very topic. The big factors that were cited actually had nothing to do with individual medic skill. The biggest causitive agent was the lack of a commercial tube holder and instead using either tape or a shoelace, both of which have been proven ineffective in securing an ETT. The other big problem is a crew resource issue. We use a saying "first attempt, best attempt", meaning have the best provider utilizing all available knowledge and resources. The skill itself is simplistic, but its the evaluation part that is causing a high failure rate. More medics need to use the Cormack-Lehane scale, evaluate the POGO (percent of glottic opening), and remember the acronyms BURP and LEMON. We need to mindful of the various airway algorithms, if its a crash airway, then medics should not be doing a full RSI. If it is a difficult airway, then further evaluation is needed before introducing analgesics, sedatives, and paralytics. And if it is a failed airway, which WILL happen to all of use sometime in our career, we need to remember to stop with the ego of "getting the tube" and drop a failed airway device, 3 attempts and then a Combitube, PTL, or LMA........

So in short, evaluate before you act, drop the medic ego, and do whats best for the patient based on their presentation....

[vs-eh?]

I would wager less than 10% of the paramedics on this forum would know what acronym LEMON stood for in airway evaluation (ooops, I just gave the 'E' away...).

As always I recommend "The manual of emergency airway management" by my friend and yours Dr. Ron Walls. Click on the Amazon thing on the main page and look for it (there ADMIN, now we're even ).

The book is awesome, I have had it for about a year and recommend it to anyone who sees it. It will truly give you a new perspective into the approach of all forms of airway management.

Peace.

[northernmedic]

I think a big factor is not just initial training but also continuous exposure to the skill of intubation. With more and more all ALS systems on the market in North America, there just isn't enough intubations to go around. A simple tenent of any branch of medicine is the more you do the better you get. Nobody in my service does less than 40 tubes a year. Our most recent QI data shows a 97% success rate with no unrecognized esophageal tubes (We also don't have RSI). Our number one area of failure is actually in cardiac arrest in patient's with a grade III or IV airway according to the data.