Also posted at Star of Life Law.
This post was generated from an email I received from Mark over at Medic999. One of Mark's readers posted the details of a call he ran wherein the patient had a valid DNR order, and he was uncomfortable with the way the the DNR limited the available treatment options. You can visit Mark's blog for a full run down of the opinions there.
For the readers outside of the United States, you should be aware that each State sets its own laws and regulations regarding DNR orders; there is no nationwide standard. Each State's law may be different.
First a bit of a disclaimer: I am educated in United States common law and most specifically educated in the law of South Carolina, the State of my bar admission. I am also registered as a NREMT-P in South Carolina so I am most familiar with South Carolina’s laws on DNR orders.
I will focus first on the law within the jurisdiction I practice law and ride an ALS truck. I will then discuss my thoughts as to the call posted by Matt, and will end with a sampling of DNR regulations from other States for comparison.
Here in South Carolina we have the Emergency Medical Services Do Not Resuscitate Order Act. To establish a DNR order in South Carolina, the patient must: (1) have a terminal condition; and (2) the terminal condition must have been diagnosed by a health care provider and the health care provider's record establishes the time, date, and medical condition which gives rise to the diagnosis of a terminal condition. Thus, it is a pre-requisite to have a physician established terminal condition.
When EMS personnel are presented with a valid DNR order EMS personnel must not use any resuscitative treatment. EMS personnel must provide that degree of palliative care called for under the circumstances which exist at the time treatment is rendered.
Okay, that is some great lawyer-speak, but what constitutes the “resuscitative treatment” we can’t give, and what does “that degree of palliative care called for under the circumstances which exist at the time treatment is rendered” mean for those of us in the street?
For that guidance we must consult South Carolina Department of Health and Environmental Control Regulation 61-7, Sections 1406 and 1407. In the event that the patient has a valid DNR order, the following procedures shall be withheld or withdrawn: (1) CPR; (2) Endotracheal intubation and other advanced airway management; (3) Artificial ventilation; (4) Defibrillation; (5) Cardiac resuscitation medication; and (6) Cardiac diagnostic monitoring. These 6 items are defined as prohibitive resuscitative treatment in the presence of a valid DNR order.
The following treatments may be provided as appropriate to patients who have executed a valid DNR order: (1) Suction; (2) Oxygen; (3) Pain medication; (4) Non-cardiac resuscitation medication; (5) Assistance in the maintenance of an open airway as long as such assistance does not include intubation or advanced airway management; (6) Control of bleeding; and (7) Comfort care. These 7 items are defined as the permissible palliative measures that can be given in the presence of a valid DNR order.
Okay, so that is what I can do and can’t do in the presence of a valid DNR order. But wait, there is more. When presented with a valid DNR order, I must honor it, regardless of the circumstances. If I can’t or won’t honor it, then I must immediately transfer patient care to another EMS provider or other health care provider who will honor it.
That is the law in the State I work.
Let’s restate Matt’s patient presentation: Elderly male, lungs full of fluid, SpO2 mid to high 60s on a nasal cannula, improved to about 69-70% with a non rebreather, respirations about 24, mental status , about a GCS 5. Nursing home staff states aspiration of vomitus, suction attempted with no relief. Valid DNR presented to EMS on arrival.
If I was presented with the above in my jurisdiction, right off the bat there are several things that I cannot do for this patient in the presence of the valid DNR order. I cannot drop an ET tube, King Airway or LMA. I cannot use a BVM to artificially ventilate. I cannot attach my LifePak 12 for cardiac monitoring.
My patient revoked my ability to use these tools, and I will respect their decision, but I won’t just watch them circle the drain. There are things I can do that may really help this patient. First, I will do my own assessment, as I do not trust NH assessments. I can still suction, so I would try to clear the airway as best I can. Here, an OPA is a basic skill, so dropping an OPA to maintain an open airway would be permitted. I can administer oxygen via non-rebreather over the OPA. (A tougher question would be whether CPAP or BiPAP is considered artificial respiration. I’ll punt on that one for now.)
I can also establish an IV and check a BGL. Who knows, maybe his blood glucose is 20 and an amp of D50 perks him up. I can…well, you get the idea. There are things we can do and should do to care for our patients.
I encourage you to become familiar with your State's laws and regulations regarding DNR orders and your local protocols on DNR orders so that when presented with a valid DNR order you know what you can and can't do to care for your patient.
These are tough situations for us because we are used to doing all we can with all we got. But we must remember that our primary purpose is quality patient care, and sometimes that means respecting our patient’s wishes regarding the end of life too.
Other State DNR order regulations for comparison:
State of California
State of North Carolina
State of Texas
Do Not Resuscitate Orders and You
Basic Cardiology - Part I
So lets get started.
I don't feel it is pertinent for me to show you a single ECG strip or try and teach you your first rhythm until I give a simple cardiology review.
Basic Cardiology
THE FUNCTION OF THE HEART:
When talking about the function of the heart, it is required for you to think of the two different types of functioning; electrical and mechanical. The electrical functioning of the heart has to do with impulses sent through its electrical pathways. These impulses are regulated by the brain and cellular electrolyte exchange. I will get further into this. The mechanical functioning of the heart is initiated by the electrical functioning and has to do with the actual pumping of blood.
One way I like to explain this is by establishing two separate values with commonly interchanged terminology. When using the term heart rate (HR) you should be referring to the electrical impulses, and when using the term pulse (P) you should be referring to mechanical output. You see a HR and you feel a P. They can be different, and this will be explained in this tutorial. The value the monitor (not pulse oximeter) gives you is a HR. The P is what you feel when conducting vital signs. It will behoove you to look at the HR while taking a P, this can indicate malignant ectopy.
Note: During this tutorial I will provide definitions for certain terms, they will be in italics.
Ectopy - when used in electrocardiography, an unnatural presentation. Possibly a premature beat (ectopic beat).
Pathological - altered or caused by disease.
HEART ANATOMY:
Heart location - The heart sits in the middle of the thoracic (chest) cavity. It is slightly tilted to the left which causes most of the mass to sit just left of the mediastinum. The heart is protected by the sternum and ribs. The apex of the heart is located behind the fifth left intercostal space, slightly medial to the midclavicular line. There are pathological conditions that alter the location of the heart, dextrocardia, COPD (chronic obstructive pulomonary disease/disorder), and CHF (congestive heart failure) are the most common. I may briefly touch on these conditions later on.
Heart chambers - The heart consists of four chambers. Two atria and two ventricles. Blood enters the atria and is pumped into the ventricles, during atrial contraction. The ventricles then pump the blood out of the heart, during ventricular contraction. There are pathological conditions that may effect each chamber, hypertrophy being the most common.
Heart layers - The four chambers are lined by the endocardium which is surrounded by the myocardium (heart muscle). The pericardium then surrounds the entire heart. The pericardium is a protective sac that consists of two layers. The visceral pericardium (epicardium) is the inner layer and lines the heart (visceral tissue always lines the organ). The parietal pericardium which is a fibrous outer layer. In the pericardial cavity is about 25 ml of fluid between the two layers of the pericardium; this reduces the friction caused by the beating and moving of the heart. There are pathological conditions directly involved with each layer of the heart endocarditis, myocardial infarction, pericarditis, and pericardial tamponade. I will explain these conditions as they become pertinent.
Heart valves - In total, there are four heart valves. There are two heart valves which separate the atria from the ventricles, collectively called the AV (atrioventricular) valves. These are named by how many chordae tendineae are attached to them. Between the right atrium and ventricle is the tricuspid valve (three chordae tendineae). Between the left atrium and ventricle is the bicuspid valve (two chordae tenineae) which is sometimes called the mitral valve. An easy way to remember which valve is which is that tri has the letters R and I and right starts with R and I. The chordae tendineae keep the valves from folding back into the atria.
There are two valves that blood must flow through as it leaves the heart. These are collectively referred to as the semilunar valves. These are named due to there shape in relation to the moon. The pulmonary semilunar valve connects the right ventricle to the pulmonary artery, and the aortic semilunar valve connects the left ventricle to the aorta.
The heart sounds that can be auscultated, commonly referred to as "lub-dub" are actually the sounds of the valves flapping closed. The AV valves close first and then the semiunar valves.
Below is a cross section as if you were looking down at the valves.
Heart size - The normal heart is about the size of your fist. The left ventricle predominates in size and has a much thicker wall of myocardium. This is due to the higher pressure needed from the left side to perfuse the entire body. Certain pathologies may alter the size of the heart, and hypertrophy is almost always the result. Hypertrophy - The opposite of atrophy. In cardiology, abnormal growth of heart muscle due to added stress on the heart.
Above is a good example of the blood flow of the heart.
Frank Starling's Mechanism/Law - The more blood that enters the ventricle during diastole, the greater the contraction during systole.
Systole - Cardiac contraction, when the heart contracts
Diastole - Cardiac relaxation, when the heart fills
BLOOD FLOW:
1 - Starting with the superior & inferior vena cavas blood flows into the right atrium. The force put on the atria to allow optimal atrial filling is referred to as preload.
2 - After the right atrium is full of blood the tricuspid valve opens, allowing blood to flow freely into the right ventricle. The right atrium then contracts filling the ventricle even more; this is part of the Frank Starlings mechanism.
3 - The right ventricle then contracts while the pulmonary semilunar valve is open and blood enters the pulmonary artery (the only non-oxygenated artery).
4 - Blood flows from the pulmonary artery into the lungs. Blood fills the pulmonary capillaries which surround the alveoli of the lungs. This is where CO2 is exchanged for O2. After the blood becomes oxygenated it leaves the heart through the pulmonary veins (the only oxygenated veins).
5 - The pulmonary vein dumps it's volume into the left atrium using the residual pressure put on it by the right ventricle and pulmonary system (preload).
6 - The left atrium sends blood through an open bicuspid/mitral valve in a manor similar to the right side of the heart.
7 - The oxygenated blood enters the left ventricle, ready to be sent to the rest of the body. The left ventricle then contracts and the blood passes through the aortic semilunar valve into the aorta. The force that the ventricles have to contract against is known as afterload.
8 - After ventricular systole the aortic semilunar valve flaps closed and the blood passes over the aortic arch. Blood that doesn't make it over the arch falls back onto the closed aortic semilunar valve and into the coronary arteries. The right and left coronary arteries are the first exits attached to the ascending aorta. They are used to perfuse the heart.
9 - Most of the blood ejected from the left ventricle passes over the aortic arch and enters into the arteries of the body. From the arteries the blood enters into arterioles and then the systemic capillaries. O2 is exchanged for the bodies waste CO2. The blood then needs to head back towards the lungs. The blood enters into venules and then veins. All the systemic veins eventually lead back to the vena cavas.
In part II I will discuss the electrical conduction system.
Education: Pain Management
I have been procrastinating on approaching this topic. I will start off by reviewing a study that assesses pain management before and after continued education. The results are pretty interesting. I know this a subject of particular interest to Rogue Medic, so don't be surprised if he chimes in with some added opinionated criticism information.
The Abstract:
INTRODUCTION: Pain is a common symptom evaluated by emergency medical services (EMS) providers. Hospital pain management programs began in the early 1990s based on a multidisciplinary approach and principles of total quality improvement. To date, these programs have had limited exposure in the prehospital setting. OBJECTIVES: To evaluate the effects of a pain management educational intervention (EI) for paramedic caregivers. METHODS: All ambulance providers from ten urban and suburban fire departments and two private ambulance companies participated in a three-hour EI during a quality improvement project. A survey was performed prior to the EI and repeated one month after the EI. A two-month collection of EMS runs for pain complaints was performed prior to the EI and repeated one month after the EI. Data analysis was performed using descriptive statistics and chi-square tests. RESULTS: The authors reviewed 397 surveys and 439 EMS runs for pain. Overall, after the EI, paramedics' knowledge of basic pain management principles increased from 57.3% to 74.9% (17.5%; 95% confidence interval (CI): 14.9%-20.2%;) paramedics' utilization of nonpharmacologic pain therapies improved by 32.2% (95% CI: 25.3%-39.2%; p), but there was no significant change in the use of pain medication (20.2% to 24.5%). There were 51.0% (95% CI: 44.1%-57.9%; p) improvement in documentation of pain severity, 24% (95% CI: 21.2%-26.8%;) improvement in documentation of pain characteristics, and 13% (95% CI: 7.4%-18.7%;)improvement in pain reassessment following intervention. CONCLUSION: As a result of a three-hour educational intervention, paramedics had an increased understanding of pain principles, were more likely to provide prehospital nonpharmacologic pain therapy, and were more likely to document the results of their interventions.Well at least they provided pain therapy. Pain is the most common reason people seek healthcare, and prehospital care providers are generally lacking in pain management skills. It is reassuring to see studies like this.
If you read the abstract you will note that there was no significant change in the use of pain medication; 4.3% according to the full study. Documentation improved as well as nonpharmacologic therapy. This was after just 3 hours of training. With appropriate QI/QA follow up, this may improve much more.
It seems the authors of the study were slightly biased. They emphasize the positive results much more than mentioning the slight improvement in medication administration.
I believe the problems we have with pharmacological pain management has to do with a few factors:
- Laziness. Controlled substances usually require more work, during and after the call.
- Fear of administering medications. Some medics just don't like giving drugs.
- A judgmental attitude. Not everyone is a "drug seeker", and we need to use a better assessment.
- Disregarding the complaints. "I'm in pain" generally means "I'm in pain". Some medics have a tendency to completely ignore issues of comfort, searching for a TRUE medical emergency.
- These patients are commonly triaged as BLS.
There are probably many more reasons, but I think these are probably the most prominent. I will touch on this subject in further posts, I just wanted to get the ball rolling.
Back to Basics
In a recent post I asked Paramedicine101 readers what they want more of. One answer was more on the basics of EMS. This is something that we, the authors, might commonly overlook. I am planning on providing some great posts on some of the basics of prehospital care. I am going to keep the more advanced stuff coming, don't worry.
Topics coming soon:
- Basic: ECG Interpretation, starting with basic cardiology.
- Advanced: 12-Lead Differential Diagnosis: Syncope
- To avoid too much cardio stuff, I will probably review some recent prehospital research.
I am posting much less than I once did simply because I have become much busier. I am currently looking to promote to a field trainer position with my agency and I have been preparing for that. I am also teaching EMT lab this semester and taking some classes myself. In addition, I have been working on a few manuscripts to submit to a couple well known EMS publications. So maybe you will actually see something I wright in print, with a fancy glossy cover. I wouldn't hold my breath though.
Fortunately Rogue Medic has stood up to the plate and filled in the gaps with some really great posts. Go read them! I hope to see some stuff from the other authors one day, when they get the time.
Thanks for stopping by,
Adam Thompson, EMT-P
Strip Tease 13: Answer
This was an AVB example provided by my training captain in a class that he taught.
Most people will call this a 3:1 2nd degree type 2, or Mobitz 2.
Lets have a look:
First measure your PP interval, and make sure they "march out"
Okay, seems like the PP is pretty consistent. There are 3 p-waves for every R -wave; this favors third degree AV block. Now lets check the RR-interval.
As expected the RR-interval is consistent. This is also highly favorable of third degree AVB, but isn't conclusive. We have to prove complete atrioventricular(AV) disassociation. We do this by measuring our PR-intervals.
If you measure the first PR-interval against the last PR-interval you will see that they do not match. This leads to a couple conclusions.
Either this is a 3rd degree AVB and the atrial rate just happened to be almost exactly 3 times as much as the ventricular rate. If this is true, further monitoring will show the AV disassociation clearer, since the PR-interval is varying.
Or, this is a high grade transient AVB. Meaning this is the end of a Mobitz 2, as it becomes a 3rd degree AVB. I call these Mobitz 3s.
I personally think this is a simple 3rd degree AVB and coincidence confused the masses. If all else fails, and the pattern continues, call it a 3:1 AVB.
ps. If you don't have a fancy set of calipers, a piece of paper works fine. Just draw lines on the pice of paper to measure out your intervals and see if they match.
Prehospital Intubations and Mortality - comment from 30 ff/pm
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In the comments to Prehospital Intubations and Mortality: A Level 1 Trauma Center Perspective I, 30 ff/pm wrote:
Like most studies done by someone who wants their name in a publication, this one is throws out some numbers as if they mean something.
To compare 4 diff. types of airway management and give the impression that there is a "relation with mortality" without giving at least a head nod to the INJURY is asinine.
I do not know what the motivations of the researchers[1] was, but it is good that they are publishing the results of their study, even though it makes them look really bad.
I would rather have them publicly face their problem, than cover it up and ignore it.
The type of injury should not matter. With a large enough sample size, there should be a wide enough variation in injuries, that the result falls into the category of normal distribution. A few really tough tubes should not make a big difference in this sample size.
The question is, Do they recognize what the problem is?
Sadly, I think we agree that the medical directors probably do not recognize that this is a problem of oversight, not so much a problem of bad medics. The medics were probably just doing what they were trained to do.
If they did 2 successful crics, what did they use for a tube? A Bic pen? If they used an ETT that pt IS TUBED, just not orally. That is NOT a failed intubation.
I will agree that this is successful airway management, if the crichothyrotomy truly was necessary. 1% is on the high side for crichothyrotomy rate, but this is such a small sample size that the numbers are well within the expected normal distribution of crichothyrotomies.
The term should be not a successful orotracheal intubation. You are correct, but it is not an important problem in my opinion. Their lack of understanding of airway management is a much greater problem.
Where we part ways in thought is your hairspltting "control" issues.
We never have control of the airway. Even a properly placed endotracheal tube does not mean control. Control suggests that something does what you want it to do.
We manage airways, i.e., we control them.
The airway may not do exactly what I want it to do - that's why I have a laryngoscope in my hand in the 1st place - but with a tube in place it sure as hell is easier to manage than without it and that is control as far as airways go.
with a tube in place it sure as hell is easier to manage than without it and that is control as far as airways go.
For the 12% of these patients with unrecognized esophageal intubations, the airway was not managed.
How is that control?
Control suggests something that has been accomplished, something that can be considered completed, something that can be checked off. This subconscious, or even conscious, approach to airway management is part of the problem. If you are managing the airway you are constantly reassessing it and looking to maintain oxygenation and, much more importantly, ventilation. Airway management is never a task that has been completed. Airway management is a process that requires perpetual vigilance. Control suggests just the opposite.
This is like the approach to success. Success is a way of doing things, not an easily definable goal. The goal is continually changing as one is presented with different complications.
If we look at intubation as control, once the tube is in, if we saw what we think was the tube going through the cords, how aggressive are we in looking for evidence that we were wrong?
There is one thing that is pretty consistent with unrecognized esophageal intubations. The medic/nurse/doctor thought the tube was in the trachea. They thought the airway was controlled.
They had stopped looking for evidence that the tube was in the wrong place.
They had become complacent with their assumed control.
What I want to know is how the hell did 8 friggin' people live with a tubed gut??
Those had to be tubes that got dislodged at the ED door or bedside moving the pt.
How the hell did 8 friggin' people live with a tubed gut??
They were probably breathing adequately on their own around the misplaced tube. Where is the evidence that all of these patients needed to be intubated? That all of these patients needed to have their airways controlled?
Where is the evidence that the tube suddenly migrated to the esophagus at the ED?
I am under the impression that endotracheal tubes are not any more migratory than coconuts. Besides, good airway management (unlike airway control) involves continual assessment of tube placement. Unrecognized esophageal endotracheal tubes should not happen with good airway management.
These GI medics were only controlling access to the esophagus, and probably not even doing that well. It isn't as if they were aware of what was going on with the airway. Control implies that there is no longer a need to remain aware of what is going on.
They certainly were not demonstrating any awareness of what was going on with the airway.
No. I believe these are the same as other groups of patients, who survived in spite of being esophageally intubated. They were spontaneously breathing. They were breathing around the tube. It isn't as if the tube was blocking the trachea, since it was not in the trachea even a little bit. They were overcoming some of the medics' best efforts to kill them.
With this group of medics, there is no reason to give them the benefit of the doubt about tube placement. They should have had waveform capnography, but even without waveform capnography there should be a much lower unrecognized esophageal intubation rate
Paramedics successfully intubated 95.5% (1,582) of all patients receiving succinylcholine, 94% (1,045) of trauma patients, and 98% (538) of medical patients. They were unable to intubate 4.5% (74) of the patients. All of these were successfully managed by alternative methods. Unrecognized esophageal intubation occurred in six (0.3%) patients. The addition of capnography and a tube aspiration device, in 1990, decreased the incidence of esophageal intubations.[2]
12% vs. 0.3%.
Six (0.36%) unrecognized esophageal intubations were discovered in the emergency department or at autopsy. Only one (0.06%) of these occurred since the addition of capnography and a tube aspiration device in 1990. In this patient, a zero reading on the capnograph was ignored and not verified by a tube aspiration device or by removing the tube and re-intubating the patient.
That is the kind of problem that continues to exist even in places that use waveform capnography - and there is no acceptable excuse for not using waveform capnography.
The problem is that the tube is in the mouth. The medic/nurse/doctor thinks the tube is in the right place, for whatever reason, then the medic/nurse/doctor ignores all evidence to the contrary.
Maybe the tube was in originally, but came out en route. We have no way of knowing because the medics have no way of showing evidence of where the tube was. If we have a series of printouts of a good waveforms, we know that the tube was either in the trachea or above the cords, but resting with the tip of the tube in the top of the trachea. Without waveform capnography, we have the medic's word vs. the word of the unrecognized esophageal tube.
Is the medic telling a lie, or is the tube telling a lie?
We are very good at deceiving ourselves about what we want to believe. That is why we need to continually be looking for evidence that the tube is in the wrong place. That is why we should avoid using words that lead to airway complacency. that is why we should avoid using the word control. We should also avoid this fixation with, I saw the tube go through the cords. that is more self-deception. The only justification for it is to satisfy people who are incompetent at teaching and incompetent at assessment.
Footnotes:
^ 1 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]
PubMed states that the full text article is free at the journal site, but it is not. This seems to have been posted on all of the Anesthesia & Analgesia abstracts at PubMed.
^ 2 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]
.
Prehospital Intubations and Mortality - A Level 1 Trauma Center Perspective II
A new study of EMS intubation appears to show that prehospital intubation is a bad thing.
I do not agree. I wrote about this earlier in Part I.
Let me point out some more of the ways that I think this study demonstrates that the problems, and there are big problems, are with the medical oversight, more than with the paramedics.
During the study period, trauma patients were initially treated in the prehospital setting by fire rescue personnel of various municipalities and with different experience levels; typically, the fire rescue personnel trained as paramedics perform an average of 1–3 tracheal intubations per year and must undergo periodic assessments of their training and ability in airway management and intubation skills.[1]
That's an average of 1 - 3 tubes per year.
Not per month.
Not per quarter.
Per year. An average of 1 - 3 tubes.
Does anybody want to guess what the reason is?
Miami is not a low population are. Miami, Florida is not the location of the Fountain of Youth, although Ponce de León did wander around Florida looking for it. There is no reason to believe that intubation happens at a different rate in Miami, as opposed to Boston, Massachusetts or Bellingham and Whatcom Counties, Washington. Let's compare the number of intubations from the much larger study I cited before.[2] Over 20 years they intubated 94% of 1,045 trauma patients. An excellent record of consistent quality. In Miami, they intubated 68% of 203 trauma patients over about 3 years.
Miami has 203 trauma patients with attempted intubation arriving at this one trauma center over just less than 3 years. 203/3 = 68 trauma intubation attempts per year.
In Washington, they had 1,045 trauma intubation attempts over 20 years. 1,045/20 = 52 trauma intubation attempts per year. In Miami, they are averaging 1 to 3 intubation attempts per medic per year. In Washington, they have requirements for far more intubations per medic.
In Miami, 12% unrecognized esophageal intubations. In Washington, only one unrecognized esophageal intubation from the time they started using waveform capnography to the end of the study. A much longer period than the entire Miami study period.
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.[2]
In Washington, they have fewer intubation attempts. They should have less experience at intubation. However, in Washington, the number of intubation attempts is divided by a much smaller number of medics.
In Miami, they have the EMS equivalent of clown cars full of medics showing up for just one patient.
Why do they need so many medics?
They don't. This is just politics. They do not understand that beyond a certain point, more medics just results in a dilution of skill. This is the More is Better mantra.
In Miami, they seem to have gone way past that point.
And they kept on going. Look at the way they approach airway management, then compare it to what I quoted from the Washington study. The difference is dramatic.
For Miami medics, all they say is: and must undergo periodic assessments of their training and ability in airway management and intubation skills.
Hasn't that been a success beyond their wildest dreams.
Success?
It worked. The blame is falling on the medics, not on the medical directors who designed this abattoir. Not that the medics are blameless, but where is the medical direction?
What do they do to keep the tubes-per-medic-per-year so ridiculously low?
They keep the number of medics unreasonably high.
Emergency medicine residents, for example, are required to perform between 35–200 ETIs prior to graduation.
Research has demonstrated that paramedic students require at least 15–20 intubations to attain basic skills proficiency. The National Standard Curriculum for Emergency Medical Technician—Paramedic requires only five intubations prior to graduation.[3]
The American Heart Association recommends that ALS providers perform a minimum of six–12 intubations a year to remain credentialed in the procedure. EMS systems that have reported a high ETI success rate require a minimum of 15 ETIs per provider per year for credentialing. Only extremely busy EMS systems could ever achieve this level of practice.[3]
Miami is an extremely busy EMS system.
Why do they feel the need to minimize the experience level of the medics?
The medical directors in Miami don't seem to begin to understand what they are doing.
12% unrecognized esophageal intubations pretty much screams incompetence.
Six (0.36%) unrecognized esophageal intubations were discovered in the emergency department or a autopsy. Only one (0.06%) of these occurred since the addition of capnography and a tube aspiration device in 1990. In this patient, a zero reading on the capnograph was ignored and not verified by a tube aspiration device or by removing the tube and re-intubating the patient.[2]
This appears to be beyond their capabilities of Miami. They have been doing an excellent job in Washington, but Miami has been happy to ignore the problem. Maybe the results of this study will cause them to change, but how could they have been this blind until now?
Footnotes:
^ 1 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]
PubMed states that the full text article is free at the journal site, but it is not.
^ 2 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]
Paramedics successfully intubated 95.5% (1,582) of all patients receiving succinylcholine, 94% (1,045) of trauma patients, and 98% (538) of medical patients. They were unable to intubate 4.5% (74) of the patients. All of these were successfully managed by alternative methods. Unrecognized esophageal intubation occurred in six (0.3%) patients. The addition of capnography and a tube aspiration device, in 1990, decreased the incidence of esophageal intubations.
^ 3 The Disappearing Endotracheal Tube - Historic skill threatened by lack of pratice and new devices
by Bryan E. Bledsoe, DO, FACEP, EMT-P and William E. Gandy, JD, LP, NREMT-P
March 2009 JEMS Vol. 34 No. 3
Article
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Prehospital Intubations and Mortality - comment from Herbie
Herbie made these comments in reply to Prehospital Intubations and Mortality: A Level 1 Trauma Center Perspective I.
A couple of things:
1. These studies always seem to forget the fact that we, as Paramedics, receive these patients in atrocious conditions: pinned in cars, crap in the airway, etc, etc, etc. Of course there are going to be misses; however, that is NOT an excuse.
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]
Paramedics successfully intubated 95.5% (1,582) of all patients receiving succinylcholine, 94% (1,045) of trauma patients, and 98% (538) of medical patients. They were unable to intubate 4.5% (74) of the patients. All of these were successfully managed by alternative methods. Unrecognized esophageal intubation occurred in six (0.3%) patients. The addition of capnography and a tube aspiration device, in 1990, decreased the incidence of esophageal intubations.
94% of over a thousand trauma patients successfully intubated. That seems to make it clear that EMS can intubate trauma patients well.
That system did have succinylcholine, while the Miami medics did not, but outside of EMS, does anybody intubate trauma patients without succinylcholine?
This is similar to the way we approach pain management, sedation, and nitrates for hypertensive CHF. If we allow any treatment at all, it is probably going to be limited to inadequate treatment. There are some places that allow EMS to deliver appropriate patient care, but they do not seem to be the ones in the big studies that get all of the press.
Calmly providing appropriate care is just not glamorous or newsworthy.
2. The other major problem is Paramedic Oversaturation. Everyone thinks they're entitled to a Paramedic; they're not. It's simple math. If you have 1 MICU covering an area that intubates 100 patients a year, that's about 25 per provider (4 full-timers). Add another MICU, cut all the numbers in half. You see the point.
On this, we completely agree.
Another problem is that with a limited number of paramedics, we are able to pick and choose the best available. When everybody is a paramedic, we take what we can get. We scrape the bottom of the barrel, then we scrape some more.
A patch and a pulse? That's asking too much! Can't I choose one or the other for my job requirement? How else will I con the population into believing that more medics means more marvelous medicky mojo.
3. It doesn't help that ORs and the like are turning to LMAs.
I don't really see this as a problem. Yes, we should try to get more live intubation practice for paramedics, but there is no good reason to believe that we cannot make up for a lot of the decreased live intubation opportunities with simulations provided by good, creative instructors.
Part of the intubation problem is the emphasis on live intubation practice. Simulations are not taken seriously in many medic programs. We do ourselves and our students a disservice, when we encourage them to believe that live intubation practice is essential, that anything else is not good enough. Simulation is the future of EMS airway management, especially in the rural setting, where patients requiring actual airway management may not be common. Agencies need to cooperate and pool resources to be able to regularly get their medics to practice on simulators. Or they need to admit that intubation is something that is beyond their means.
The rural EMS experience is the opposite in the cities, where the administrators and politicians have decided that, when skills have been diluted down to the point where they no longer exist, they are best. Homeopathic EMS airway management.
Both are methods of inflicting medics, with a lack of airway skill and a lack of airway experience, on a helpless population. Both demonstrate a criminal disregard for the well being of the patients abused by these medics.
3a. It doesn't help that ORs are skittish about letting medic students hone their skill.
Hone implies that there are some skills to begin with. If the thing keeping medics from being good at intubation is a lack of live intubation practice, then I don't think there is a skill being honed. It is merely a turd being polished.
Intubation skill does not depend on live intubation experience.
I would much rather see medics using a BVM during their OR time, than intubating. Good BVM use is far more important than intubation skill. Good BVM use is much more about assessment skills. Excellence with a BVM needs to be a prerequisite for beginning intubation training. Intubation encourages more of a set it and forget it attitude. If you doubt that, how do you explain all of these esophageal tubes?
12%? One out of every eight intubations was left in the wrong place.
Not only did they miss the trachea, but they did not recognize their mistakes. The whole time the tube was in the wrong place, the medics did not realize it.
The one unforgivable sin of airway management is an unrecognized esophageal tube.
It is OK to use a BVM, as long as the patient is being ventilated.
It is OK to use a CombiTube, as long as the patient is being ventilated.
It is OK to use an LMA, as long as the patient is being ventilated.
It is OK to use a crichothyrotomy, as long as the patient is being ventilated.
It is even OK to use a properly placed endotracheal tube, as long as the patient is being ventilated. I will not be critical of that.
But, It is not OK to use an endotracheal tube placed in the esophagus, not recognize that the tube is in the esophagus, and mindlessly keep oxygenating the stomach.
The gold standard is not intubation. The gold standard is ventilation by whatever means of airway management happens to be appropriate. BVM, LMA, CombiTube, crichothyrotomy, the patient protecting his own airway, et cetera. The method does not matter. The result is what matters.
4. Common sense and physics still take over: the best way to get oxygen to the lungs is a direct route; that direct route is the ET tube.
The best way to get the oxygen to the lungs and the CO2 out of the lungs, is the method that is the most effective and the least harmful. The removal of CO2 is actually more important than the delivery of O2
How easy is it going to be to place the tube properly? How much of an interruption in ventilation? How much hyperventilation afterward? How much of a vagal stimulus? How much of an increase in intracranial pressure?
We have research that shows that during intubation attempts, medics induce hypoxia, hypercarbia, increased intracranial pressure, and other things that may be more harmful than any possible intubation benefit.
We need outcomes research. Something to show when intubation actually is good for the patient. In order to do that, we need to limit the research to systems with medics competent at intubation and medical directors competent at the oversight of paramedics.
I'm not holding my breath waiting for that to happen.
These systems exist, but the medical directors seem to be pretty busy doing the other things that competent medical directors do.
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Prehospital Intubations and Mortality: A Level 1 Trauma Center Perspective I
A new study looking at EMS intubation appears to show that prehospital intubation is a bad thing.
I do not agree.
Let me point out the ways that I think this study demonstrates where the problems are. And there are big problems. The problems are with the medical oversight, more than with the paramedics. This does not absolve the paramedics of responsibility for their lack of skill.
Control of the airway is the first priority for the management of critically ill patients and is prioritized in established patient-management algorithms, such as Advanced Cardiac Life Support and Advanced Trauma Life Support.[1]
From the first sentence, we disagree. Control of the airway is the wrong way to think about airway management. We never have control of the airway. Even a properly placed endotracheal tube does not mean control. Control suggests that something does what you want it to do.
Having a properly placed endotracheal tube does not mean that you can get the airway to do what you want it to do.
Having a properly placed endotracheal tube does not even mean that you can get the endotracheal tube to do what you want it to do.
What do we want it to do?
Little things, like remaining properly placed, not kinking, not becoming obstructed with mucus, not separating at the adapter, not separating from the BVM (Bag Valve Mask), not having the cuff deflate, having the cuff be properly inflated, et cetera.
As you can see, control is a foolishly optimistic description of what an endotracheal tube provides.
But that is just an unimportant semantic distinction.
Our choice of words is important. We should use words that mean what we intend them to mean. The meaning of the words we use should match what we mean. Otherwise how do the speaker and the listener understand each other?
They don't?
Exactly.
Tell people that an endotracheal tube provides control. Plenty of them will ignore the many possible ways that a properly placed endotracheal tube does not mean control.
Maybe, but you keep asking for evidence. Where is your evidence?
Look at all the research on prehospital intubation. Thousands of intubations and attempted intubations have been studied. Some research demonstrates that intubation can be performed excellently in the prehospital setting.[2]
Then we have this new study, and plenty of others with similarly pathetic results, that show that if you do not take intubation seriously,
I believe, but cannot prove, that a part of the reason for the bad intubation results is from not using terminology correctly. For example, if I state that the tube is in the airway, I do not mean that the tube passes through the airway on the way to the esophagus. This is technically accurate, but not what one wants to know when asking if the tube is in the airway, is it?
No, but control is a different term.
Yes, but it appears to be similarly misunderstood. Elsewhere in this study . . .
Oh good, we're going to move beyond the first sentence.
Elsewhere in this study, there is a breakdown of the method of airway management. This gives you more of an idea of the way that they misunderstand airway management. PHI = PreHospital Intubation.
The esophageal tubes are not really viewed differently from the use of the LMA[3] or the CombiTube[4] or crichothyrotomy.[5]
This approach demonstrates a complete misunderstanding of airway management.
The use of an alternative airway should not be seen as a failure. While it is true that it is not a successful intubation, that does not mean that it is not successful airway management. Airway management should be viewed as a continuum.[6] Airway management is not a choice between intubation is good vs. any other form of airway management is bad.
Also, teaching that airway takes priority over everything else is finally being recognized as a mistake.
Footnotes:
^ 1 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]
PubMed states that the full text article is free at the journal site, but it is not. This seems to have been posted on all of the Anesthesia & Analgesia abstracts at PubMed.
^ 2 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]
Paramedics successfully intubated 95.5% (1,582) of all patients receiving succinylcholine, 94% (1,045) of trauma patients, and 98% (538) of medical patients. They were unable to intubate 4.5% (74) of the patients. All of these were successfully managed by alternative methods. Unrecognized esophageal intubation occurred in six (0.3%) patients. The addition of capnography and a tube aspiration device, in 1990, decreased the incidence of esophageal intubations.
^ 3 Laryngeal Mask Airway
Wikipedia
Article
^ 4 Combitube
Wikipedia
Article
^ 5 Cricothyrotomy
Wikipedia
Article
^ 6 The Airway Continuum
by Kelly Grayson
EMS1.com
Article
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