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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