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A study of prehospital intubation[1] was just published. The surprising result is that in the system studied they are able to intubate 3 out of 4 patients they try to intubate.
I will write another post with more detail on this. From that study, there are some quotes worth reading.
Compliance with documentation of ETCO2 was poor.
This suggests that the medics do not understand the connection between exhaled CO2 and intubation.
Let me rephrase that. This suggests that the medical directors have been unaware of the lack of documentation of ETCO2.
and
The medical directors appear not to have done a good job of explaining the importance of assessing CO2 in tube placement confirmation.
There you go blaming the medical directors, again.
Yes. How do you provide oversight of paramedics and not notice that there is no documentation of, or that there is less than adequate documentation of, exhaled CO2?
I give up.
I don't know the answer to that one either, but there is good news.
Since the completion of the study, training and education on the use of capnography interpretation and documentation have been emphasized by the group of supervising EMS medical directors, and continuous-waveform capnography is now incorporated into the airway management protocol.
That is reason to celebrate!
Maybe.
Maybe they learned from the study, but why did it take a study to get them to notice that The Gang That Couldn't Shoot Straight needs remediation?
Why do the medics not understand the importance of capnography?
Why do the medical directors not understand the importance of capnography?
Here is one partial answer:
Our finding that EMS providers reported only 70% of attempted intubations suggests that self-reported rates of intubation may underestimate the number of intubation attempts and therefore overestimate success rates.
Footnotes:
^ 1 A prospective multicenter evaluation of prehospital airway management performance in a large metropolitan region.
Denver Metro Airway Study Group.
Prehosp Emerg Care. 2009 Jul-Sep;13(3):304-10.
PMID: 19499465 [PubMed - in process]
All quotes are from this study.
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9 comments:
1. Nobody should be intubating without waveform capnography. This is 2009. Then again, people still smoke cigarettes.
2. I once worked in a system where the QA process counted, "I tried to insert the laryngoscope, but the patient started chewing on it, so I stopped," as equivalent to "I placed a tube in the esophagus and cheerfully ventilated the stomach for 15 minutes." This MAY have influenced how certain providers documented their care.
The number one problem with intubation is always the last thing to be fixed... training.
Until paramedics are treated like other practitioners that utilize intubation, our proficiency will be lacking.
ETCO2 monitoring has become the gold standard for confirmation of tracheal placement, but as stated, it hasn't been accepted by many paramedics. Might egos be the problem once again...?
FG,
1. Nobody should be intubating without waveform capnography. This is 2009. Then again, people still smoke cigarettes.
I agree. Waveform capnography is an excellent resource. Unfortunately, there are some who even take that too far. I wrote about this in Zero Tolerance V - Autopilot Oversight - Sparrowmict comment. Sparrowmict works in a system that requires that the tube be pulled if not confirmed by capnography.
2. I once worked in a system where the QA process counted, "I tried to insert the laryngoscope, but the patient started chewing on it, so I stopped," as equivalent to "I placed a tube in the esophagus and cheerfully ventilated the stomach for 15 minutes." This MAY have influenced how certain providers documented their care.
This actually brings up a couple of the positives about the way this study was done. I will get to those in a follow up post.
All of these studies also make an implied comparison between prehospital success rates and in hospital ones. Training and poor performance aside, it stands to reason that there is going to be a higher failure rate just due to environmental (dark, confined, poor positioning, entrapment etc) and equipment (we have a laryngoscope, not a glidescope or endoscopic camera and a nice lit resus room table).
The question at hand really is what the patient outcomes may have been had intubation of some sort not been done in the field ? If this was no longer a Medic skill (as some would propose) how many patients would suffer as a result ? Would it have been more than 5% of the study group ?
The environment issue is used as an argument to take intubation away from the prehospital practitioner. I think there would be a good number of patients that would suffer if intubation was taken away from us, how many currently suffer from esophageal intubations though? Would more patients survive with lesser morbidity if intubation was taken away?
I'm not an advocate of removing the skill. I am an advocate of reducing it. I am also an advocate of much much more training. By reducing it, I mean the attempts, and the number of patients that RSI is used on. In my system it has been a judgement call for quite a while. We have too many medics that have become complacent with the skill.
The problem is that by reducing the skill's use, we will be reducing the experience. Less intubations equals less experience and that experience is the extent of the continuing education of intubation that my agency provides.
There's also the issue of hospital based medical practitioners being critical of Paramedics ability to intubate in the field (with studies such as these), but being very reluctant to open their doors to us when it comes to clinical (or refresher) training. As a medic student currently doing my clinicals, getting my ten tubes has required FORTY hours of time in the OR, waiting for an anesthesiologist who will work with Paramedic students (despite the fact that 30-40 patients went through the OR each day). It's very frustrating. If doctors wanted us to get better at skills, then welcoming us for training opportunities IN THE HOSPITAL would be a good way to do it.
I'm all for a requirement that we should all have to do at least a certain number of intubations a year, if not in the field then in a hospital setting under the scrutiny of a doctor.
Adam,
Until paramedics are treated like other practitioners that utilize intubation, our proficiency will be lacking.
I think that is a big part of the problem.
I would add this - Until paramedics act like other practitioners that utilize intubation, our proficiency will be lacking.
To whip out the old Pogo title. We Have Met the Enemy and He Is Us.
Well said. We should right a book. Of coarse, I'd have to first practice what I preach...and learn how to write.
Haha, that typo was an accident. Write a book. It's too late for me on a long shift.
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