Teaching Airway - Part I - comment from Anonymous

In the comments to Teaching Airway - Part I, Anonymous writes -

We get it,

No. You do not get it. You misrepresent what I wrote. Maybe others get it and maybe not, but all I can tell from your comment is that you do not get it.

This reminds me of debating other anti-science zealots. You attribute things to me that I never stated, then you argue against those statements - statements I did not make. The argument that you are making is called a straw man. You misrepresent my statements. You point out flaws in the statements that I never made. You then claim that my statements are false.

My position is simple. This is the second to last paragraph from the post you disagree with.

We need to prove that intubation works and prove that we have the skill to be trusted intubating patients.

Can you provide any evidence - real evidence, not some stories of one time at band camp - controlled studes, retrospective studies, observational studies, anything? Where is your evidence of improved outcomes due to prehospital intubation?

Science shows us what works. Anecdote can show us areas to examine scientifically, but basing treatment on anecdote is bad patient care. We need to base treatments on science.

you don't want a medic putting in a tube

That has never been my position. I want medics to use the right tool to accomplish the job. The job is patient care.

The specific part of patient care being debated is airway management. Airway management includes intubation as only one of the possible methods. The right method for the patient in the prehospital setting is what matters.

We have presumed that intubation is the right method, because of expert opinion - not because of evidence of benefit.

There are some medics, that I do not want to be allowed to intubate. Those are the medics, who do not intubate competently. According to the studies of prehospital intubation, there are a lot of these medics out there.

I have no problem with competent medics intubating when it is appropriate. We are learning that intubation may not be appropriate for some patients, who used to be routinely intubated. We need to learn more about when intubation is appropriate.

and you're burnt out from the field and want to stop being a medic.

I guess, when you can read minds, you might lose interest in things like science - since there is no science to support mind reading.

Whether I am burnt out is irrelevant. If I am extra crispy, it is irrelevant. If I am just a little toasty around the edges, it is irrelevant. If I am bright and cheery and always eager to have an opportunity to brighten someone's day, it is irrelevant.

So how about for the next 6 months I stop tubing my patients.

A better option would be to do a study with a lot of medics, but only those proficient at intubation. Have the medics intubating only every other day to compare outcomes. Otherwise, we can only speculate about outcomes for many of these patients.

The CHF patient that waited a little to long to call now frothing at the mouth, I'll just have my BLS partner bag while I try to get a line in to start the 4 drugs I need to help them.

CPAP (Continuous Positive Airway Pressure) would be much more appropriate. You should try to get your medical director to write a protocol for it, because research shows that CPAP decreases the need for intubation in CHF (Congestive Heart Failure).

High dose NTG (Nitroglycerine), preferably IV (IntraVenous), but SL (SubLingual) is OK until high dose IV NTG is available. Again, research shows that high dose NTG decreases the need for intubation in CHF.

ACE inhibitors (Angiotensin Converting Enzyme inhibitors, e.g. enalapril or captopril) given SL or IV also has research showing ACE inhibitors decrease the need for intubation.

You may notice that one of the goals of treatment is to reduce the need for intubation, not to intubate. Of course, there are some doctors, who do not keep up with the research. These doctors tend to continue to focus on intubation and furosemide (Lasix). The research shows that these doctors are not encouraging good patient care. I will write a post addressing the treatment of CHF.

Then I'll try to carry them down 3 flights of stairs on a reeves with a king tube shoved in their throat.

One of the most important things to do with respiratory patients is to sit them upright, unless the patient's blood pressure is low. Using a Reeves is a bad idea, unless the patient is hypotensive.

When I finally get to transport I dump them in an ER where the resident pulls the Kingtube and gets to try a few times to put in the ETT before the attending finally steps in. Well that sounds a lot better for my patient.

If you are worried about the resident being able to do something that you might not be permitted to do, then there is an excellent way to frustrate them. Treat the patient with the treatments that decrease the need for intubation. Persuade your medical director to write protocols that permit this. By treating the patient to prevent intubation, and preventing intubation just happens to be good patient care, you get to frustrate that resident.

The resident would probably prefer not to pull the King airway and intubate. The resident would probably prefer to never have a reason to intubate the patient. The resident's lack of understanding of the appropriate use of a King airway is an education problem. The doctors need to realize that they may not need to replace these airways.

Doctors also used to immediately deflate MAST/PASG (Medical Anti-Shock Trousers/Pneumatic Anti-Shock Garment). The ignorance of the resident does not justify bad patient care by EMS.

Oh, how about the anaphylactic patient that's not responding to meds. We'll just wait until we have to cric their neck, because we do that so often and that's so much easier to practice.

Why do you believe that intubation would make that difference?

How about the asthma patient or the old COPD'er that doesn't respond to meds. BLS bagging and alternative airways are so much better for transport.

As I have repeatedly stated, I do not wish to remove intubation from the paramedic scope of practice. However, I definitely do not want dangerous medics intubating. There are too many studies showing horrible rates of intubation. I have written about some of these studies here, here, here, here, here, here, here, here, here, here, and here.

You know why they are called alternative airways? They are used as a last ditch effort to get any air into the body.

Please provide some documentation to support your claim about the origin of the term.

Maybe we should use the term alternative paramedic for those not capable of maintaining adequate intubation skills. The research demonstrates that the lack if intubation skill is widespread.

The name alternative airway is not evidence of anything.

Calling them alternative airways has nothing to do with their ability to provide an adequate airway. It has to do with the preconceptions of those naming the device. If they had been named superlative airways, would you demand to use them because the name says superlative?

As we have learned more about airway management, we have come to realize that the Gold Standard is not intubation. We old timers were taught that intubation is the Gold Standard, but we were taught a lot of other things that are just plain wrong. The Gold Standard is what is best for the patient. The gold Standard is excellent patient care.

Where is the evidence that prehospital intubation is better patient care than prehospital alternative airway use?

The actions of ill-informed emergency physicians and nurses do not determine the value of prehospital treatments. We need to be able to understand what is best for the patient. We need to base what is best for patients on outcomes research, as much as possible.

Maybe research will end up showing that replacing the alternative airway is indicated some of the time, but not indicated other times. We do not currently have research to determine which is better.

We should attempt to have the terminology help us to understand the use of equipment. The research may significantly change the role of alternative airways. The terminology does not determine the outcome of research. The terminology should not limit appropriate care, either.

If they were truly adequate then you could admit the patient to ICU and never move it.

Maybe that is where the research is headed. Maybe some of the ICU patients will be better off with alternative airways, rather than endotracheal tubes.

They are temporary. My ETT can stay in until the patient needs it to be pulled.

You do not appear to be familiar with ICU care. Patients with the need for long term ventilation will have the endotracheal tube replaced by a tracheotomy tube. Apparently, the doctors do not consider your endotracheal tube to be permanent.

Another thing to consider is that the alternative airways may be less likely to result in trauma to the airway, infection of the airway, or other complications.

At least we use capnography to confirm placement though most ED's RN's don't even know what a proper waveform is.

Which is it? Do you base your treatment on what may be done in the ED, or do you congratulate yourself on using better equipment that the ED?

You claim that it is wrong to use an alternative airway, because the ED will not use your airway. I disagree with your conclusion, here.

You claim that it is right to use waveform capnography, in spite of the ED not using your capnography. I agree with your conclusion, here.

No waveform, then the tube is pulled, PERIOD.


Although waveform capnography is probably the single best form of tube confirmation, it is not perfect. Even waveform capnography results in false positives and false negatives. Since it is not perfect, having it overrule all contrary assessment is wrong and dangerous. I wrote about that particular mistake of airway management in Zero Tolerance V - Autopilot Oversight - Sparrowmict comment.

Learning to tube on a dummy or in the OR is fine but the last 4 tubes I had were made on people in real world situations.

The real world is where EMS works. Using dogma to guide treatment, rather than evidence is not good for real patients.

Vomitus, blood from a GSW pooling in the throat, a patient half under a bed, and one apneic in the grass behind an apartment build at midnight. No pretube waveform, no flicking of eyelashes, no controlled situation, no nothing. Just me and a F'd up patient that needed air.

Again, I do not wish to remove intubation from the paramedic scope of practice. More important is that, I definitely do not want dangerous medics intubating. As I have already mentioned, there are plenty of studies showing much less than adequate intubation success rates by paramedics in some systems.

If you want people to have 10 tubes before graduation and 2 a year in the field then fine but YOU are on a mission to stop a skill that has been used to save more people then will ever have showed up on any research report.

I am trying to limit intubation to people who might actually not be dangerous with a tube.

I am trying to limit intubation to patients for whom there is likely to actually be a benefit in their medical outcome.

The seatbelt of a car has saved many more then it's harmed and it has harmed but do you think we should stop wearing them because of the 3% of the cases where someone couldn't get out of the vehicle to safety.

I never made any such claim.

You are suggesting that the harm of prehospital intubation is less than the benefit. Not just a little less, but a lot less.

Before you start making claims about Mom, Apple Pie, and how wonderful prehospital intubation is, maybe you should show that the benefit is real. Please, just provide some evidence that there is as much benefit from prehospital intubation as there is harm.

When you can show me data that say medics are missing 25% I might start to agree that something might need to be done but every medic knows this skill.

Of the 88 patients who were transported by ground, 46 (52%) were successfully intubated in the prehospital setting and 42 (48%) had a failed PHI (PreHospital Intubation)

Prehospital intubations and mortality: a level 1 trauma center perspective.
Cobas MA, De la Peña MA, Manning R, Candiotti K, Varon AJ.
Anesth Analg. 2009 Aug;109(2):489-93.
PMID: 19608824 [PubMed - indexed for MEDLINE]

You claim that there are no studies that show worse than 3/4 prehospital intubation success rate. That is an unacceptable success rate, but the reality is that I have written a bit about this study that only shows 1/2 success. It appears that you like to make dramatic, but completely wrong statements.

I do everything I can to avoid a tube and when I do it, it's necessary.

I generally agree with this approach, but it seems to contradict your claim that intubation is so good for patients.

You claim that you know that it is necessary. How do you know?

You also claimed that there is no research showing worse than a 75% prehospital intubation success rate.

If I haven't done one in 6 months so what, as a proficient medic I recognized the need, and I have been trained to perform, if I failed then most likely no alternative airway would substitute.

Maybe you would be good after 6 months of not intubating. Would you have had any practice with a mannequin, or with a cadaver, or anything else?

Even if you were still good at intubation after 6 months of not intubating, what about others? The research definitely does not support the belief that going 6 months without intubating is tolerable.

if I failed then most likely no alternative airway would substitute.

Another bold statement. Based on what?

The intubation research, that documents success rates of prehospital intubation, shows a pretty good success rate for alternative airways after the failure of intubation. This is exactly the opposite of what you claim about alternative airways not being able to substitute.

After all my rant answer me one yes or no question. Assuming the way medics are currently trained, do you think medics should intubate? Yes or No?

Which way that medics are currently trained?

If you mean the way that medics are trained as described in this study demonstrating intubation excellence?

This training includes didactic education in endotracheal intubation, alternative airway techniques, and skill simulation. Extensive education is provided in the pharmacology, indications, contraindications, and complications of the paralytic agent used, succinylcholine. Following didactic training, each student must successfully complete a minimum of 20 intubations, in the operating room, under the supervision of a board-certified anesthesiologist. Additionally, paramedics are required to successfully intubate at least one patient monthly for three years, post certification, and one per quarter thereafter. At least one intubation, annually, must be performed under an anesthesiologist’s supervision.

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]

Is that the way medics are currently trained? Yes, but only in some very limited places. Maybe prehospital intubation needs to be limited to places that maintain these standards.

Maybe we just need to stop making excuses for having such low standards.

Maybe we need to stop making excuses for harming patients.



akroeze said...
This comment has been removed by the author.
akroeze said...

I would request that whoever this anonymous is, in the future have the courtesy to include your identity in some form (be it a web board known name or your real name). If you feel this strongly about things you should have no issue putting your name to it.

RM, you have defended your position and given this 'anonymous' person more time than was deserved for such vitriol. My hat is off to you.

Alex Kroeze
Advanced Care Paramedic

Anonymous said...

Hey, just for the record - this is a different 'anonymous', not me :-) I like to think of myself as the 'kinder, gentler' kind of anonymous.