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In the article I was writing about[1] (Experts Debate Paramedic Intubation) in my post Experts Debate Paramedic Intubation - JEMS.com, there is a bit of defense of the status quo in intubation and intubation training.
We get hung up on many of the same problems. We think that there is one right way to do things, rather than accept that we are adapting what we do to the different circumstances we are faced with.
We act as if the OR (Operating Room) is the only place that we can obtain good practice. There is no evidence to support this.
There is nothing to show that OR training is superior to morgue training and mannequin training, but we act as if the decreased availability of OR time is the only reason medics can't intubate competently.
We act as if the only problem with the way we are teaching paramedic school is that the students are not learning. As if this is not a reflection on the teaching.
Teaching means providing information to students in a way that helps the students to understand. If the students do not understand, the teacher did not teach.
Perhaps you do not believe that we do a poor job at intubation education.
Results
Nine hundred twenty-six patients had an attempted intubation. Methods of airway management were determined for 97.5% (825/846) of those transported to a hospital and 33.8% (27/80) of those who died in the field. For transported patients, 74.8% were successfully intubated, 20% had a failed intubation, 5.2% had a malpositioned tube on arrival to the ED, and 0.6% had another method of airway management used. Malpositioned tubes were significantly more common in pediatric patients (13.0%, compared with 4.0% for nonpediatric patients).
Conclusions
Overall intubation success was low, and consistent with previously published series. The frequency of malpositioned ETT was unacceptably high, and also consistent with prior studies. Our data support the need for ongoing monitoring of EMS providers' practices of endotracheal intubation.[2]
Those numbers may be considered good in many areas - batting average, picking winning stocks, votes in an election. When it comes to airway management, we would be more appropriate if we described failure rates.
These failure rates are unacceptably high.
Overall intubation success was low, and consistent with previously published series.
In other words, the authors believe that this is the expected result of the way we train paramedics to intubate.
Can anyone show that this is not true?
The frequency of malpositioned ETT was unacceptably high, and also consistent with prior studies.
This is the expected result of the way we train paramedics to intubate.
Our data support the need for ongoing monitoring of EMS providers' practices of endotracheal intubation.
5.2% had a malpositioned tube on arrival to the ED.
5.2% Unrecognized Esophageal Intubations!
We need to dramatically change the way we handle intubation education.
Footnotes:
[1] Experts Debate Paramedic Intubation - Should paramedics continue to intubate?
JEMS.com
Bryan E. Bledsoe, DO, FACEP, FAAEM | Darren Braude, MD, MPH, FACEP, EMT-P | David K. Tan, MD, FAAEM, EMT-T | Henry Wang, MD, MS | Marc Eckstein, MD, MPH, FACEP | Marvin Wayne, MD, FACEP, FAAEM | William E. Gandy, D, LP, NREMT-P
Thursday, July 1, 2010
Article
[2] A prospective multicenter evaluation of prehospital airway management performance in a large metropolitan region.
Denver Metro Airway Study Group.
Colwell CB, Cusick JM, Hawkes AP, Luyten DR, McVaney KE, Pineda GV, Riccio JC, Severyn FA, Vellman WP, Heller J, Ship J, Gunter J, Battan K, Kozlowski M, Kanowitz A.
Prehosp Emerg Care. 2009 Jul-Sep;13(3):304-10.
PMID: 19499465 [PubMed - in process]
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3 comments:
RM,
I enjoyed the concept of that article quite a bit. I think it is interesting to take on the complaints of 'lack of or time'. There should be no excuse. Also, there should be no excuse for continuing education.
I approached one of my officers with a request to do OR rotations because it had been a while since my last ET-intubation (I am not as cavalier as many of my peers when it comes to ETI). The response I got was that we were not permitted to do any OR rotations because the students take up all the time. I was told to intubate one of our manakins. So I did, but gosh forbid one of my next patients didn't have a perfectly dry and anatomically superb oropharynx.
Cadavers would be great, but withoput a med school nearby, I don't se it happening.
Quality airway mannequins are almost prohibitively expensive. I recently went to go try out a new stylette shaping technique, but damned if the airway head didn't have trismus!
I've been pouring over Airway Cam's educational material, which is far better than anything I remember from paramedic school. Great videos too.
Here's an interesting article that goes against the "status quo" of poor intubation studies that have previously been done.
Airway management success and hypoxemia rates in air and ground critical care transport: a prospective multicenter study. (eng) By Thomas S, Judge T, Lowell MJ, MacDonald RD, Madden J, Pickett K, Werman HA, Shear ML, Patel P, Starr G, Chesney M, Domeier R, Frantz P, Funk D, Greenberg RD, Prehospital Emergency Care: Official Journal Of The National Association Of EMS Physicians And The National Association Of State EMS Directors [Prehosp Emerg Care], ISSN: 1545-0066, 2010 Jul-Sep; Vol. 14 (3), pp. 283; PMID: 20507218; OBJECTIVE: To assess critical care transport (CCT) crews' endotracheal intubation (ETI) attempts, success rates, and peri-ETI oxygenation. METHODS: Participants were adult and pediatric patients undergoing attempted advanced airway management during the period from July 2007 to December 2008 by crews from 11 CCT programs varying in geography, crew configuration, and casemix; all crews had access to neuromuscular-blocking agents. Data collected included airway management variables defined per national consensus criteria. Descriptive analysis focused on ETI success rates (reported with exact binomial 95% confidence intervals [CIs]) and occurrence of new hypoxemia (oxygen saturation [SpO(2)] dropping below 90% during or after ETI); to assess categorical variables, Fisher's exact test, Pearson chi(2), and logistic regression were employed to explore associations between predictor variables and ETI failure or new hypoxemia. For all tests, p < 0.05 defined significance. RESULTS: There were 603 total attempts at airway management, with successful oral or nasal ETI in 582 cases, or 96.5% (95% CI 94.7-97.8%). In 182 cases (30.2%, 95% CI 26.5-34.0%), there were failed ETI attempts prior to CCT crew arrival; CCT crew ETI success on these patients (96.2%, 95% CI 92.2-98.4%) was just as high as in the patients in whom there was no pre-CCT ETI attempt (p = 0.81). New hypoxemia occurred in only six cases (1.6% of the 365 cases with ongoing SpO(2) monitoring; 95% CI 0.6-3.5%); the only predictor of new hypoxemia was pre-ETI hypotension (p < 0.001). A requirement for multiple ETI attempts by CCT crews was not associated with new hypoxemia (Fisher's exact p = 0.13). CONCLUSIONS: CCT crews' ETI success rates were very high, and even when ETI required multiple attempts, airway management was rarely associated with SpO(2) derangement. CCT crews' ETI success rates were equally high in the subset of patients in whom ground emergency medical services (EMS) ETI failed prior to arrival of transport crews.
Persistent link to this record (Permalink):
http://search.ebscohost.com/login.aspx?direct=true&db=mnh&AN=20507218&site=ehost-live
Cut and Paste:
Airway management success and hypoxemia rates in air and ground critical care transport: a prospective multicenter study.
Database:
MEDLINE with Full Text
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