There is also a thoughtful analysis of airway management and intubation in Airways and ET tubes... at 9-Echo-1.

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

Hi, me again...Nothing brings out a good post from you better than BS. Your best posts come from you when you're challenged.

Thank you.

So I get to respond to your post...

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.

Yes, but studies can't be started and performed without anecdotal evidence to steer research. We have to do a few things wrong to figure out what's right.

I agree. Although there may be some research that is begun without some anecdotal evidence to support it, that is probably rare.

We do have to do a few things wrong to figure out what's right. We spend too much time on punishing mistakes, rather than looking for ways to avoid those mistakes. We are taking the wrong approach to figuring out what is right.

I see this as a reflection of insecurity and ignorance by those in charge. Those in charge are insecure because of their ignorance. Maybe they just do not know how to do things well, but they do not seem to be doing the right things to learn how to do things well. One easy way to learn how to do things well. Find somebody doing it well, and ask them for some ideas. In Too Many Medics? comment from Anonymous, I included the abstracts from 2 systems that demonstrate excellence at intubation.

One of our big problems is that we do not look at bad outcomes as opportunities to learn how not to keep making the same mistake. We look at bad outcomes as an excuse to punish somebody. Why learn from our mistakes, when we can deny that we made a mistake, and punish someone else for our mistake? Win - Win? Right?

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

I know and I really don't expect anything less from you. I'm not doing this for the check.

I need the paycheck, but I could probably make more in a different line of work. If I had gone into a different line of work, I would have less debt at the end of the month.

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 agree 100%, but how do you sort them out, in a city wide system, with poor medical command, that sometimes barely has a budget to even staff trucks.

That is probably the thing that is going to have the greatest effect on who should intubate. A system, like the one you describe, will have a lot of horrible medics, but do nothing to get rid of them. Or just a little more than nothing.

A system that gets rid of maybe one bad medic a year, but has a couple dozen bad medics, and has them training new medics, is not likely to stop getting worse. That is a system that is not getting better, but getting much worse. Everybody sees that the bad medics are tolerated. Sure they sacrifice one every year, or maybe every other year, just so they can say that they do something about bad quality. They make it seem as if they are doing something significant, but what they really are doing is telling everyone that they are not serious, or that they really are too stupid to understand.

Who are they?

They are the medical director, the chief, the CEO, the City Manager, the QA/QI/CYA department, the union, and all of their accomplices.

Anyone, who has one of those jobs is responsible for eliminating bad patient care. All of them have that responsibility, but few seem to do anything significant to eliminate bad patient care.

The same medics that keep the CPAP (Continuous Positive Airway Pressure) stuffed under the seat because "we're right down the street from the hospital, we'll just use meds" attitude. I've seen it and it's scary.

I'm NOT supporting these systems, but how do you change it?

That is a good question. There needs to be somebody who just insists that patient care be the priority. That needs to come from the top. When the bosses get on camera and defend horrible care, there is no reason to expect things to change until that boss is gone, and probably some others, too.

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.

Yes, again I agree, in fact I use CPAP, NTG (NiTroGlycerine), and Ace inhibitors on a regular basis and I don't drop a tube, in fact most, are turned around at the hospital. The CHF I described carried down on the Reeves was unresponsive and wasn't going to fit in a stairchair, so yes, my partner bagged, I put in a line, NTG paste w/3 sprays in a foamy mouth (no IV NTG), Lasix (which I rarely give because CPAP works so well), and Captopril 125. Then I suctioned the pt and tubed while waiting for fire to help carry out my pt. The pt waited to long. Indicated for intubation. I saw that pt again, alive, and good for them. You've had that pt before, most medics have.

Was that pt saved by the tube? No idea, yep, no idea. Would CPAP work, no. Would a KingLT which we carry work, maybe, no idea, didn't use it. I saw need for a tube and did it because it was indicated, could I have just bagged that pt, sure, would have been a bitch, but it could be done. I have even used the ramp on the KingLT to place a successful tube, it's was pretty cool actually. The problem is these patients are still presenting while science and training catch up or figure out what's best for the patient and when you FINALLY get people comfortable the rules change. Little and large systems seems to continue to fail, and most likely to "follow the dollar" where other systems seem to always be on top of things.

There are patients like that. Sometimes they do not have time to call, because the onset is so rapid. The train wrecks will not necessarily be any better, regardless of what we do. Positive pressure ventilation (CPAP) is probably the most important treatment for this patient. Next most important is high dose NTG. 10, 20, 50, 100 NTG sprays - whatever it takes. As long as the blood pressure does not dramatically drop. I have given over 50 NTG sprays and still not had the systolic pressure drop to even 200, in some patients. We are unnecessarily afraid of NTG. Hypertensive CHF patients tend to be resistant very resistant to the effects of NTG. The only reason not to be giving 3 to 5 sprays/tabs at a time to hypertensive CHF patients is having a bad protocol.

The NTG paste makes no sense. You are applying it to the skin to be absorbed by the circulation to the skin, but the patients skin signs indicate that the circulation to the skin is just not there.

Pale - due to a lack of hemoglobin reaching the skin.

Cool - due to a lack of the warmth from blood reaching the skin.

Diaphoretic Sweaty - due to the large amounts of adrenaline being released by a body in hypoxic panic. The adrenaline shunts the circulation away from the skin.

The circulation needs to pick up the NTG from the paste on the skin to take it to where it is needed in the pulmonary circulation. It is not needed on the outside of the skin, unless we are looking for ways to accidentally expose our coworkers to NTG.

A great example of this is when someone is suturing a laceration and injects lidocaine with epinephrine (epinephrine is adrenaline). The skin around the injection site becomes more pale, as you are watching. This is what is going on to all of the skin on the pale, cool, sweaty patient. This is one reason that it does not make sense to use NTG paste. The other reason is that the low dose of the NTG paste is like trying to make the tide rise by urinating in the ocean. With precise enough tools, we may be able to measure a minuscule difference, but it does not make any noticeable difference. The epinephrine is shunting the blood away from the skin, not the lidocaine. The lidocaine is for pain relief. The epinephrine is to minimize bleeding during suturing.

As far as educating residents and stopping them from pulling my KingLT, the second you find an answer to that then post it immediately, I'm up for anything with that.

The best way to educate the residents is to educate the attendings. Maybe I have been spoiled, but I have found that the attendings are willing to look at different ways of doing things, if you present it to them in a way that makes sense. You may find that it takes several years to get them to actually change things, but I have found that they are willing to listen. Then it becomes a matter of politics. How do you identify the attending most likely to do something about it? Doctors are more likely to listen to other doctors. Good reasons coming from a medic are less likely to persuade a bunch of doctors, than the same reasons coming from another doctor.

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.

I get that secret smile when I turned the pt prior to arrival also.

You lost me on that one.

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.

I really do know that, and I agree. I have family that I really wouldn't want some of these medics even touching them.

I kind of figured that.

Maybe we should use the term alternative paramedic for those not capable of maintaining adequate intubation skills.

True, but I have seen a few attendings reach for a LMA because they couldn't get an ETT placed. What is their standard for maintaining skills? Are they are judge? I've taken many ACLS classes over the years and every ED doc shows up but shows no initiative and participates. Here's your card doc, oh and did I mention your codes, run like 1998.

The hospital decides what their rules are. Some restrict some skills to only certain doctors, while others may not have any restrictions for any doctor, as long as the doctor maintains a state license and malpractice insurance. Most are probably somewhere in between these extremes. It has been my experience that some ED attendings, board certified in EM, are scary at intubation and airway management in general. Others are great. I have sat in the parking lot to intubate some patients, because they were not responding to medical treatment, I knew that they would be intubated soon, and I knew who was the on duty attending. Why subject the patient to that doctors obligatory 2 or 3 failed intubation attempts, followed by a call to anesthesia and a waltz-by intubation, when they could come in with a tube in place and have less iatrogenic harm?

Some doctors just do not seem to get airway management. We all have our blind spots. I keep trying to minimize mine.

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.

I'm not that old, and would NEVER disagree with that statement.

:-)

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

I've got none, and I'm not going to claim it, they are really new prehospital, around here anyway. LMA's have been around for awhile but as far as I know no squad, at least in my area ever carried them. However I'm sure your reply will have a stat.

I will have to follow up with some posts on prehospital LMAs. There are services using them. There has been research on prehospital LMA use, but it is going to take a while to go through it and come up with something thorough.

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.

Agreed

After all, anesthesia seems to be leading the way in airway management, and they are increasing their use of LMAs. That may be where the rest of in-hospital airway management is headed.

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.

I've suctioned enough of them, I am aware for long term, in my head I was focusing on pt's that should have turned around and are only on a vent for a few days to a week. The patient that I knew would probably turn around if we were all aggressive on in the beginning, the CHF pt who was just to weak, but after being medicated, tubed, and cleared out, would allow the tube to be pulled assuming all the ABG values looked good.

Even that may change. VAP (Ventilator Associated Pneumonia) is a big concern in hospitals. It seems to fall into the never event category. As Ambulance Driver mentioned, hospitals are paying attention to the cost of care. They are going to try to cut down on costs, so I expect that we will see a lot more use of LMAs in the hospital, even if they don't improve outcomes or expenses, but because they might and hospitals are all about saving money.

No waveform, then the tube is pulled, PERIOD.

Yeah, even I slapped myself for that statement, I got out of control. Let me explain what I was thinking. If I place a blind tube and don't see a good waveform then the tube is pulled. This is on a patient that should show an ETCO2 reading. I could expand on it more but I think you get the jist.

Please send video of you slapping yourself. I am not above cheap sensationalist publicity. ;-)

As I understand it, unless there are conflicting assessments, if there is no good wave form, the tube should be pulled. At least, that is the way I approach confirmation, and I get the impression that we agree.

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.

Again, how do we fix it?

I think the first thing is that we need agreement on what should be minimum standards, but that has to come mostly from the medical directors.

We need research to show what the differences are between places that intubate well and those that, even though the service may have some people who are great at intubation, the service overall does a horrible job of intubating patients. To do that we need well done research, which you get into below.

We need very well done research in places that intubate well, that are large enough to show what conditions are likely to benefit from intubation. There will always be good reasons for deviating from the typical treatment, but we do not even have research to clearly show that intubation does not cause harm.

We probably need a separate designation for medics permitted to intubate. I don't know if it should be like the EMT-D add on for defibrillation, or whether it should be something like the critical care paramedic certification, with an broader scope of practice than whatever the regular paramedic would be. There are many ways of handling this.

I think this would be an important part of what Ckemtp is trying to do with EMS 2.0 over at Life Under the lights. My initial impression was that this is just going to be another passing fad, but I think he might be on to something. We need to transform EMS from a trade to a profession. Airway management is one of the areas, where EMS really needs to push the doctors to improve. We do not have the authority to change the rules, but I don't see any reason to let that stop me. EMS 2.0 is also covered in Ckemtp, EMS 2.0 – Momentum Building, Happy Medic, Medic999, Too Old To Work, Too Young To Retire, Ambulance Driver, and even The Fire Critic and Firegeezer.


Waveform capnography?

EMS - Yes, usually. In Pennsylvania, it is mandatory for ALS.

ED - No. Some places have it, but most do not seem to use it.


One-on-one observation of patients for heavy sedation/aggressive pain management?

EMS - Yes, what are we going to do, leave?

ED - No, this requires rearranging staffing and will be done, if necessary, but is certainly not the baseline level of care. Generally, each ED nurse has 3 patients, or more.

These are just a couple of examples of ways EMS should be pushing patient care forward. As I wrote in EMS Needs to Be a Separate Medical Specialty - Now - Part I.

cont still...damn restrictions...

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)

Scary stats, but failed why? Attempted but unable to place or, attempted and misplaced. That's a big difference. If I miss a tube and I can't get it, if I'm still able to oxygenate the pt to keep the stats up then it's still successful, I just may not be able to move on to additional treatments. It sucks but it happens. If I misplace a tube then I'm killing my patient and think I'm helping. If I stick a blade in the patients mouth, it's an attempt if I try to tube or not, even if it's to suction to even clear an airway. If I have to do this on 5 of 10 patients then I'm at a 75% success/failure attempt rate. Data can be manipulated to favor for or against. It all looks bad on a pie chart, something we all learned in statistics at college.

I think there are plenty of problems with the data from Miami, but nobody has come out and provided documentation of these flaws. There is one very interesting rumor that I have heard. I do not like dealing in rumors, but I am hoping that somebody reading this will be able to document this, or get the medical director(s) involved to set the record straight, at least if the rumor is true.

The rumor is that in at least one of the services studied, the medical director strongly encouraged the use of alternative airways as true alternatives to intubation, rather than as back up airways, for airway management. However, the way the success/failure of intubation was determined was based on just two things. Was there any kind of airway intervention - BVM, CombiTube, LMA, crichothyrotomy, endotracheal tube, unrecognized esophageal tube. If any of those methods of airway management were being used, but there was not a properly placed endotracheal tube, this was considered a failed intubation.

After two ETI attempts, placement of a Combitube is considered as a rescue airway measure.


For this study, members of the Department of Anesthesiology assessed the airways of patients at their admission to the trauma bay. We defined prehospital airway management as paramedics having had an active role in managing the patient’s airway through a variety of approaches, including ETI, laryngeal mask airway (LMA), and Combitube and/or cricothyroidotomy.We defined a failed PHI as the improper localization of an endotracheal tube (ETT) on arrival at the trauma center or the need to use alternative rescue devices for airway management after intubation attempts.


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]

If the CombiTube is used as an initial airway measure, it is definitely not a rescue airway measure. If the doctors assessing the intubations were not familiar the way that airway management was being performed, then their determination of all CombiTubes as failed intubation attempts would be wrong.

From the way I read the study, if a CombiTube, or LMA, salesperson happened to stop at an accident scene and placed an airway, but the patient was transported by a BLS ambulance (no endotracheal tubes anywhere on the ambulance), this might have been classified as a failed endotracheal tube attempt. They might have presumed that paramedics were involved in the management of the airway, since they consider the ConbiTube to be only a rescue airway, rather than an alternative airway. I don't think they would have done the same for a BLS crew transporting with just BVM airway managment if no ALS was available. From the system design, it is possible that all 911 ambulances have a medic on board. Still, there is no good reason why a BLS interfacility transport ambulance could not arrive on scene, deliver excellent care, realize that the closest ALS is at the hospital, and transport. BVM only. No possibility of endotracheal tube. According to the study, it might be classified as a failed intubation attempt.

Well, that is the thing that bothers me the most. Is the rumor true?

If the rumor is true, how many patients classified as having missed endotracheal tube attempts, never had any endotracheal tube attempts?

If the rumor is true, how can the researchers publish this without disclosing that variable? A variable that should have been controlled for, but if the rumor is true, a variable that was not controlled for.

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

Only by experience, discussions with our command doc, and in my training and education I've receive to date that I'm acting in the best interest of my pt.

This is one of the reasons we need to have good research. It is unfortunate, but apparently medical school does not do a good job of preparing doctors to interpret research. If they cannot even interpret the research correctly, what is the research they design going to look like? We need to start doing a much better job of educating people about research and the scientific method.

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

Again, results can be biased.

Yes.

The difference between good research and bad research is that the good research goes to extremes to exclude the influence of bias. Bad research may not recognize bias, or may come up with pathetic excuses for using the biased methodology. Not that there aren't other ways of creating bad research.

Some of the reasons I started this blog are:

To educate people about research.

To get people to discuss research.

To get people to look critically at research, rather than just say, That is too complicated for me.

To get people to seek out research to persuade doctors of better ways to provide patient care.

For your last regarding how medics should be trained and certified I agree, but is it possible and should MD's/Residents be held to the same standards.

I think that doctors should be held to higher standards than medics. This is one of the reasons for having EMS as a separate medical specialty. Sort of a way of saying, If you want to make contributions to EMS, this is the background you need to have. If you do not meet the criteria for board certification as an EMS physician, then go away. We still have too many non-emergency medicine physicians in the EDs, but this would be a start.

We are facing a lot of misunderstanding/obstacles from doctors, who think they understand EMS, even though they do not. That is one thing holding EMS back. Our patients deserve better.

Should we add a new cert level?

EMT-Pi

Forget about EMS 2.0, we're going straight to EMS 3.14159 . . . . Well Vince may enjoy the math humor, even if not many others do. :-)

I think that we need to be continually assessing the appropriateness of the different levels. Just because this is the way things have been done, does not mean that it is the way things should be done. There will be a lot of change in EMS. We should be doing things to try to make the changes good for the patients. Maybe a different certification. Maybe just more widespread use/recognition of the EMP-CC (critical care) level. Maybe much fewer medics and a lot more medical directors growing a set (metaphorically only, since some are women). We need to have an organization with the authority and the understanding to keep us moving in the right direction. I do not see the DOT (Department of Transportation) as that organization. Anything that combines EMS with firefighting, police, homeland security, or any other Wouldn't it be cool if we could be used as an excuse for them to syphon off money for their pet projects? agency.

Love your posts, I've read them all. You too AD.

Thank you. As you have noticed, I enjoy a good debate. I think that we will not change things until we have identified all of the problems. I certainly do not have all of the answers. I don't even have all of the questions. You contribute a lot to the discussion.

I'm on your side I promise. You really could take my blade away, I really do only tube as a last resort and I like Mystery Medic's idea. Glidescopes are nice.

You point out one of the problems. The ones in need of having intubation taken away are the ones who will fight to the death (the patient's) to keep intubation, but will resist any refresher/retraining/minimum requirements. They do not get that this is about the patients, not about making medics feel good, briefly, before going back to the routine calls that we do not feel challenged by.

I have not used the Glidescope. I have read good things about it. I think that it has the same potential for leading to bad outcomes as anything else - too much focus on the airway, as if the airway is not connected to a patient. A patient, who might not even have primarilly an airway problem. How many patients suffer anoxic brain damage because of intubation attempts? This is something that we should be able to avoid with excellent oversight, but we do need that oversight.

What do you feel about walking a pt to the bathroom around a corner in the house after getting diltiazem for rapid Afib that reduces and refuses to go with you to the hospital unless she can pee, assuming she is is on O2 and the monitor. Had a partner almost have her own stroke on my decision.

I have probably induced a few TIAs in partners, nurses, doctors, et cetera. If the patient has the capacity to make informed decisions about her own care, she may do pretty much anything that we think is unwise/dangerous.

We can pretend that we know that allowing a patient to do something, that we think is a bad idea, will kill them or make them much worse, but we do not know that. We can present them with all of the information about why we think it is a bad idea, but unless we are abducting the patient, or been given power of attorney, or have involuntarily committed them, . . . we do not have the authority to force the patient not to do what we think is unwise, nor do we have the authority to force patients to do something that we think is essential.

I will write more about this, because it is important and we seem to be very poorly prepared to deal with patients who do not agree with us. I just graduated EMT/medic/nurse/doctor school and I know everything. Usually the person making such an assertion is demonstrating that they actually are the most ignorant person in the room, but they often get their way, because they are the most insistent/intimidating/arrogant person in the room. Except when I am there. ;-)


Then the follow up to Ambulance Driver's comment.

Yeah I gotta fess up. I worked very hard on that first post to A) piss you off a little because I enjoy your follow up to BS and trolls and B) because I think if shows what many medics still really think.

Nothing to apologize for. We need to have good debates about what is best for patients. We currently have to rely mostly on expert opinion, because the research is too often inadequate to answer the question of what is best for the patient or what are the right requirements for intubation.

I still believe current research is biased and I would love to see a wide scale study in direct favor of the patient with all aspects of the pros/cons of intubation.

Research will always have problems, but it is still the best method we have of answering the questions of what is best for the patient. I would like to see that research, too.

I see turmoil in our future. We as medics are expected to learn more every year and that makes it harder to be proficient in the skills we already perform. We do this all without getting a pay raise, my cost of living increase alone was frozen for another year.

That is a problem. We do need to have medics dedicated to EMS. Not cross-trained as anything else. There is too much that we need to do to maintain proficiency to have paramedic be something done in addition to another job that people think is interchangeable, or related, or a way of saving money. These are generally not people you would want providing care for any real patient, yet they make decisions about how that care is delivered. Politicians are the enemies of EMS.

Tom Peters writes about this problem, but not as an EMS topic. He asks the question, Do you suffer from too much talent?

In EMS, we seem to act as if we have such talented medics, that cross-training in another field is not going to interfere with their ability to provide excellent care.

Maybe we just don't care about excellent care - until we are the patients (or our families). Isn't a 52% intubation success rate, even if partially inaccurate (12% esophageal intubations is also ridiculous) worse than bad patient care?

Do we suffer from too much talent?

Hope no hard feelings, RM, great follow-up :)

I do not take criticism personally, so there would be no reason for hard feelings. I like it when you make me think.

Thank you.


Other blog posts commenting on this, by others and by me, in order of posting, have been -

The Airway Continuum at EMS1.com by Kelly Grayson, AKA Ambulance Driver. 11/06/07

Teaching Airway: EMS Educast Episode 33 at EMS EduCast. 10/02/09

Teaching Airway - Part I at Rogue Medic. 10/10/09

Teaching Airway - Part I at Paramedicine 101. 10/10/09

Teaching Airway - Part I - comment from Anonymous at Rogue Medic. 10/11/09

Teaching Airway - Part I - comment from Anonymous at Paramedicine 101. 10/11/09

Rogue Medic's Comment Section… at A Day In The Life Of An Ambulance Driver. 10/11/09

Paramedics and intubation at 9-Echo-1. 10/12/09

Attention all Companies at The Happy Medic. 10/12/09

Snapshot from the Paramedic Battlefield at Firegeezer. 10/12/09

Have You Seen This? at The Fire Critic. 10/12/09

Comment On A Comment at Too Old To Work, Too Young To Retire. 10/13/09

Airways and ET tubes... at 9-Echo-1. 10/14/09

EMS as a Profession? at The Fire Critic. 10/20/09

Airway comments by Rachel at Rogue Medic. 10/21/09

Airway comments by Rachel at Paramedicine 101. 10/21/09




.

So there I am sitting at home, still not finished with my response to the most recent comments from Anonymous - 3 parts, due to Blogger's character limit (4,095 characters if I remember correctly - not as limiting as Twitter's 140, but . . . ), when I receive a comment from Rachel of Rachel's Rants. Well, it made me smile like the Grinch on Christmas Day.

Why

This has been a debate among a bunch of crazy old men. I am assuming about Anonymous, but I do not think I am wrong about age or gender. Working in EMS pretty much guarantees the crazy part. As for Ambulance Driver, while he is creeping up on AARPville more slowly than I am, he did just put another candle on the cake.

The comment from Rachel is a bit different. She is a young woman and a relatively new paramedic. 3 years worth of new. Well, here is the comment to Teaching Airway - Part I. I do not need to add much to show you why it puts a spring in my step and whatever other optimistic metaphors might apply.

I have come across your blog from 9-Echo-1's site and I have to say as a 3 year medic, I'm all for more training on intubation or even just taking that skill out of the scope of practice altogether.

Of course, my Y chromosome translates that to A man's got to know his limitations. With the squint and everything. This may be the most important thing to understand in EMS, although it might be better to translate it to - A paramedic's got to know his limitations. Or her limitations.

During my 3 years I've only had 2 chances to intubate. I'm glad to say that I currently have a success rate of 100% as confirmed by ED docs but still only 2 chances in 3 years? If we are going to provide that level of care then we really need more practice.

And it is not just the opportunity to intubate, but the quality of education, the refresher training, and the quality of oversight.

I read some of the other comments here and WOW. What happened to treating each patient the way you would want someone to treat your family. Just because I know how to do a skill does not mean I should or even that my patient needs ME to do that skill.

Exactly.

I would feel much better, if the patient was my family member, having a tube placed at the hospital in a more controlled setting with providers that probably have done it more than twice in the last few years.

Another excellent point.

The next two parts I switched to bold text. They deserve extra attention.

I've said this before sometimes the best intervention is a BASIC one.

Right there, you boiled AD's Airway Continuum down to one sentence.

I know hard concept for some to understand. Too often I see medics treat very aggressively and while sometimes that is indicated it should not be standard operating procedure.

I agree. Although I do not think that aggressive is the right word. I consider myself to be very aggressive in not using treatments that are not indicated. I often receive criticism from some other people in EMS, from some nurses, and from some doctors. Rarely from my medical directors. While I may be forgetting something, I don't think that I ever received much criticism from a medical director for under-treating a patient.

We need to figure out which patients are surviving to the hospital because of us, which are surviving to the hospital in spite of us, and how to tell the difference. This is where assessment combined with good research will make a big difference in what we do - and maybe a big difference in patient outcomes.

Anyway, go read Rachel's blog. She only posts about a once a month, but they are worth reading.


PS. Ambulance Driver has a new address for his blog A Day In The Life Of An Ambulance Driver, with a new banner that has more pictures of KatyBeth, Yay! Maybe there will be a blog from her, something like A Day In The Life Of An Ambulance Daughter.


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Dopamine is one of those drugs that seems to have been designed by a plaintiff's lawyer, at least as far as the dosing is concerned. The dose range is 2 to 20 mcg/kg/min (micrograms per kilogram per minute). Some complicated math to be performing, especially since the main indication for treating a patient with dopamine is that the patient is trying to die before arriving at the hospital. If you do not have this concern about the survival of the patient, perhaps the dopamine is not indicated. It isn't enough that our patient is seeking out the stability of the grave, we seem to find ways to make it as difficult as possible to safely treat these unstable patients.

But on critical care transports dopamine is often used at a renal dose.

That is a whole different post. This is about the packaging of dopamine.

200 mg (milligrams) in 250 ml (milliliters) of D5W (A solution of 5% Dextrose in Water) -

Or -

400 mg (milligrams) in 250 ml (milliliters) of D5W (A solution of 5% Dextrose in Water) -

Or -

800 mg (milligrams) in 250 ml (milliliters) of D5W (A solution of 5% Dextrose in Water) -

Or -

Maybe even some other concentration. Those are the only concentrations I have seen, but that does not mean that others do not exist. Some places carry the dopamine that needs to be mixed by the medic prior to use. That means that there are practically endless possibilities for concentrations, based on the actions of the medic.


Here are some charts for calculating the drip rates for different concentrations. The different concentrations are in different colors near the top. You can open these in their own tab, or window, and print them out. I used to do this and tape them to the dopamine bags, so that every bag had a copy of the correct chart taped to it. When you need, or think you need, dopamine is not the time to be messing around with math. Your attention should be on patient assessment. It isn't as if we do not already have enough distractions from patient assessment.


200 mg in 250 ml (which also works for 400 mg in 500 ml and 800 mg in 1 liter):





400 mg in 250 ml (which also works for 800 mg in 500 ml and 1,600 mg in 1 liter):





And then there is the highly concentrated 3.2 mg/ml dopamine. At one place, where I used to work, this was the concentration they carried, but the punchline was that they only used 10 drop/ml tubing (trauma tubing). Look at this chart of drip rates and divide everything by 6 to get the right drip rate. Most patients were in the 1 or 2 drops per minute range. The pot holes had more of an effect on the drip rate than I did. A 100 kg patient (220 pounds - no lightweight) at 10mcg/kg/min would be getting all of 3 drops per minute. Of course, when you have a basic EMT as the ALS coordinator and he is more concerned about keeping the costs down by ordering only one type of tubing, or whatever brainstorm might have been going on in his head, well then patient care is definitely not the priority.





Of course, it does not help that we are still in the dark ages, using ounces and pounds, and miles, and all sorts of other bizarre measurements. The metric system is much easier to work with, but when we are using entirely different measurements outside of patient care, we need to be able to convert from that Imperial System to the metric system.

We in the US almost switched, back in the 1970s. If we had, most of you reading this would have grown up with the metric system. You would not have to do all of these conversions. You can thank your parents for that piece of stupidity. They were not thinking of you.

Of all of the iatrogenic deaths in the US, how many are due to conversion errors? Thousands each year? Tens of thousands each year? Nobody knows. If we admit that this is a problem, then we might feel obligated to do something about it. Better to ignore the problem. Just be glad that we switched to a decimal monetary system long ago.

We package dopamine in 200/400/800/1,600/3,200 concentrations. Why? Do we need to make it complicated for people to calculate? We could use nice simple numbers, as we do with dobutamine, which comes in 250 mcg/ml, 500 mcg/ml, 1 mg/ml, 2 mg/ml, and 4 mg/ml concentrations. Nice simple math. Not dopamine with 800 mcg/ml, 1.6 mg/ml, and 3.2 mg/ml concentrations. It is as if ATLA (the American Trial Lawyers Association) designed the packaging to assure a steady supply of cases.

We can change the labels to DOPamine and DOBUTamine, so that the drugs are not confused, because reading is not one of our strong points, but how many people are better at math than they are at reading?

Risk management is not among our strong points.

Maybe it is all a part of a fiendishly clever plan to free up beds, so that hospitals are not on divert all of the time? Yeah! That's the ticket. It's a conspiracy.


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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.

No!

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.


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Photo credit: The Canadian Press

That Drunk May Be More Than Just Drunk

by Adam Thompson, EMT-P

Studies suggest that up to 80% of patients with Wernicke encephalopathy may not be diagnosed, which makes estimates of mortality rates unreliable. Wernicke encephalopathy is a significantly disabling and potentially lethal condition that can be prevented or reversed if treated early. Established Wernicke encephalopathy can have major long-term consequences among patients requiring permanent institutional care.

Treatment = Thiamine and fluid replenishment

Wernicke encephalopathy is caused by thiamine deficiency in the central nervous system, and is defined by the triad of confusional symptoms, ocular alterations and ataxia. Some other factors may also predispose alcoholic patients to this deficiency. We report two patients with hyperglicaemia and ketoacidosis due to diabetes mellitus decompensation and chronic alcoholism who developed Wernicke encephalopathy before their hospital admission. The outcome was successful after intravenous thiamine administration and insulinotherapy. The presence of Wernicke encephalopathy in alcoholics with diabetic ketoacidosis, suggests that metabolic decompensation is essential in the onset of the disease.

Pubmed [Link 2]

BACKGROUND AND PURPOSE: Wernicke encephalopathy is a severe neurologic disorder that results from a dietary vitamin B1 deficiency. It is characterized by changes in consciousness, ocular abnormalities, and ataxia. This study was undertaken to analyze and compare findings on MR imaging and neurologic symptoms at clinical presentations of patients with Wernicke encephalopathy with and without a history of alcohol abuse. MATERIALS AND METHODS: A multicenter study group retrospectively reviewed MR brain imaging findings, clinical histories, and presentations of 26 patients (14 female, 12 male) diagnosed between 1999 and 2006 with Wernicke encephalopathy. The age range was 6-81 years (mean age, 46 .6+/-19 years). RESULTS: Fifty percent of the patients had a history of alcohol abuse, and 50% had no history of alcohol abuse. Eighty percent showed changes in consciousness, 77% had ocular symptoms, and 54% had ataxia. Only 38% of the patients showed the classic triad of the disease at clinical presentation. At MR examination, 85% of the patients showed symmetric lesions in the medial thalami and the periventricular region of the third ventricle, 65% in the periaqueductal area, 58% in the mamillary bodies, 38% in the tectal plate, and 8% in the dorsal medulla. Contrast enhancement of the mamillary bodies was statistically positively correlated with the alcohol abuse group. CONCLUSIONS: Our study confirms the usefulness of MR in reaching a prompt diagnosis of Wernicke encephalopathy to avoid irreversible damage to brain tissue. Contrast enhancement in the mamillary bodies is a typical finding of the disease in the alcoholic population.

Also posted over at Paramedicine 101. Go check out the rest of what is there.


On Teaching Airway: EMS Educast Episode 33, they have Kelly Grayson as their guest. The first of many times they will have Kelly Grayson as a guest. Hint! Hint!

Kelly says (50 minutes into the 1 hour show, so I am starting at the beginning) -

If you are going to allow paramedics to intubate, and I happen to agree with Bryan Bledsoe on this, . . . unless things change in the way we educate and regulate our EMS providers, within 10 years you are going to see intubation disappear from the paramedic skill set, except for a relatively few very well trained providers.

Since I have made similar comments, I want to point out the way that a lot of paramedics seem to interpret this sentence.

They are going to take our tubes away!

That ignores the really important part of the sentence. The part of the sentence that comes before and after the part I highlighted. That important part is this - unless things change in the way we educate and regulate our EMS providers, . . . except for a relatively few very well trained providers.

The way to prevent having the tubes taken away? If we really want to have intubation in our scope of practice, we need to continually prove that we can intubate well. We need to continually practice and work on learning more, if we expect to be able to prove that we can intubate well.

Many paramedics do not want to be told that. They want to be able to intubate, just because they think wanting to is enough. They want their Nobel Intubation Prize. Well, this isn't politics, you actually need to do something.

What do we need to do?

Kelly's immediately follows that with -

If we would pull the trigger and do what is necessary to make every paramedic like those well trained providers we envision intubating in the future. That's what needs to be done. We need to have far more stringent requirements for intubation in the initial clinical experience. It needs to be far more than 6, or 8, or 10 tubes. If it takes an extra 6 months to get those tubes, then so be it. That's the price we're going to have to pay to be taken seriously. And once on the street, if you are not getting say X number of tubes - a tube a month, call it 12 a year - if you don't get 12 successful intubations, or at least 12 attempts, in a 12 month period, there should be a clinical re-education requirement.

This was followed by Buck Feris saying, Agreed.

Can any of us disagree? Unfortunately, for many a medic/medic wanna be, that is asking too much.

Why should we have to be competent? Isn't sitting through the classes, getting food for the preceptors as a bribe, and following all of the rules that I agree with - isn't that enough?

Sure. That is good enough, but only if you work in a really unimportant job, not one where incompetence can kill patients.

We cannot demonstrate that prehospital intubation improves outcomes, but we insist on intubating.

Except for a few, we cannot demonstrate competence (pick almost any EMS intubation study), but we insist on intubating.

Why do we insist on harming our patients?

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

We do have to want it. We have to want to work at competence - not whine about being victims and whine about not being given what we want.


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