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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