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...is one of the most poorly written exams I've seen in EMS yet. 
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Can't say I'm surprised. In addition to it being true that EMS exams are not terribly well written, CC is so new that they're still working out thet bugs! Not something I'll have to deal with, since Colorado totally failed to put together a program! When I graduated P-school 4 years ago now they were talking about how a new CC program was going to be starting in January...well, the latest update to the state "Acts Allowed" completely removed the CCEMT-P level as a recognized level in Colorado. Not that it makes much of a difference...Anyway, good luck on your exam!
Nate.
Nate.
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...is one of the most poorly written exams I've seen in EMS yet.
I didn't think the exam was too bad, but that was like 4 years ago.
The whole CCEMT-P thing never really took off. I thought both the CCEMT-P and the PNCCT were great classes. There was lots of talk about 4-5 years ago but my opinion is that we still lack a good text/curriculum on the subject. I highly recommend any paramedic take the classes.
But, exactly what should a CC-paramedic be allowed to do? At some point, you have to say paramedics just do not have enough education to manage these patients and physicians and/or PA's and/or nurses should do the job. You certainly can't expect to get what you need to know from a 2 week class to manage really sick patients perform chest tubes, retrograde intubation, et cetera.
To me, it comes down to are paramedics going to be the experts in emergency prehospital care or are they going to evolve into experts into any "transport medicine." The current training really does not teach what you need to know for critical care at all. Much of what is needed for critical care transport is CC-nursing. In addition, a large number of paramedic students can't even pass NREMT-P let alone add basic critical care to the test.
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In my system, CC medics do a lot of what the course outlines - tube thoracostomy, retrograde intubation, etc. Depends on where you are. I think it's a great program and also suggest it to any medic regardless of their employer.
It strikes me, however, as a similar offshoot of EMS as EMT-I was. It costs more to staff a CC rig with a doc/PA and nurse/RT/etc. than it does to just train medics some more.
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Dude don't take this the wrong way but if the medics in your system are having to do retrograde intubations then their airway skills aren't up to snuff. Period. Either intubating or ventilating or both. This is the age old problem of medics wanting to do all the fancy stuff when the best care is all about the FUNDAMENTALS.
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No offense taken, boss. Tools in the toolbox, is all. We're ALLOWED to do retrograde; can't think of anyone recently that has. A few bad apples here and there who can't monitor their tubes and now there's all this talk about removing intubation from the EMT-P curriculum altogether. Ridiculous.
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O.k., seriously Zip. Give me one case where retrograde should be performed pre-hospital? You MUST be able to ventilate to properly do a retrograde (no ventilation and no intubation = cric). Retrograde is a means by which to secure a definitive airway prior to OR in the setting of a VERY difficult (read <0.1% of all patients by available data). If such a patient is encountered in the pre-hospital setting, they should be bagged and brought in. Retrograde has little place in the ED (hence it is NOT a RRC required skill). It has NO place in EMS.
Look, I am not against paramedic intubation, or even RSI. And yes, if they do RSI, then cric is needed as a definitive back-up. But retrograde? Really? And you carry the correct kit for this? Wow, who got Mark drunk at the Christmas party to get his approval for that?
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Your beef is with UMBC, not me. It's their curriculum.
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Not a beef. It is in their curriculum. But you seem to be defending it as a viable "tool in the toolbox". My question is when would you, as CCEMT-P, use this tool? And is LUMCEMSS allowing ALS rigs to carry the kits?
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I don't see myself needing to. ALS rigs, no. Critical Care rigs develop their SMO's separately with Dr. C. LifeStar doesn't even do retrograde (the most they do is chest tube insertion); I think ACT has it in their protocols somewhere, but it's certainly not in mine.
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Just to throw my two cents ... I'm all for paramedics doing cool stuff but show me the research that paramedics having critical care skills CHANGE outcome!
Goes back to RSI, mixing paramedics and endotracheal tubes are like mixing handguns and tequila ... nothing good comes out of it.
What annoys me is that people still defend it even though time after time it has been shown to kill people.
I ask them, would you give a drug if your patient was twice as likely to die from taking it and had double or triple the risk of pneumonia? Of course they wouldn't, but because intubation and/or RSI is a cool skill they somehow rationalize using it.
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*sigh* Missed tubes is a training issue. Paramedic airway training focuses almost exclusively on "getting the tube". ConEd focuses on "getting the tube" or "managing difficult airways". Almost nowhere do you see significant emphasis placed on "monitoring and maintaining the tube".
I doubt there is much research on Critical Care medics at all. Show me what you've got.
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With all due respect, you guys who think retrograde has NO place in the field are wrong.
I've done two of them; both were situations involving facial and neck trauma where orotracheal ETI was nearly impossible and a cric was contraindicated due to an inability to locate the landmarks. In one case the patient had had numerous surgeries on his neck to correct congenital abnormalities and had abnormal anatomy even before faceplanting into the guardrail - he was well known by the anesthesia folks at the receiving trauma center for being a hard tube even without the trauma.
I had trained on retrograde many times and the service I was at had it in the protocols just for such unforseeable situations. Sometimes all you can do is the best you can do, even if its not ideal.
I acknowledge the problems with paramedic RSI in general, but if you are transporting really sick patients long distances on a very frequent basis then you will sooner or later come across an indication for pretty much anything you can think of.
If you've never had a really hard time getting a tube and had to resort to something a bit unconventional then....well, you are better at intubating than me, I guess!
I've done two of them; both were situations involving facial and neck trauma where orotracheal ETI was nearly impossible and a cric was contraindicated due to an inability to locate the landmarks. In one case the patient had had numerous surgeries on his neck to correct congenital abnormalities and had abnormal anatomy even before faceplanting into the guardrail - he was well known by the anesthesia folks at the receiving trauma center for being a hard tube even without the trauma.
I had trained on retrograde many times and the service I was at had it in the protocols just for such unforseeable situations. Sometimes all you can do is the best you can do, even if its not ideal.
I acknowledge the problems with paramedic RSI in general, but if you are transporting really sick patients long distances on a very frequent basis then you will sooner or later come across an indication for pretty much anything you can think of.
If you've never had a really hard time getting a tube and had to resort to something a bit unconventional then....well, you are better at intubating than me, I guess!
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For all these extra procedures, how long was the period of education?
Here in Connecticut I dont believe we recgonize any form of Critical Care Paramedic. Flight medicine (closest prehospital gets to critical care I think) is run by dual certified EMT-P/RT or EMT-P/RN personnel. On the ground there is no such thing as critical care except "CCT" where the T stands for "transport" and it is, imo, a complete joke.
Here in Connecticut I dont believe we recgonize any form of Critical Care Paramedic. Flight medicine (closest prehospital gets to critical care I think) is run by dual certified EMT-P/RT or EMT-P/RN personnel. On the ground there is no such thing as critical care except "CCT" where the T stands for "transport" and it is, imo, a complete joke.
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So you could locate the landmarks for a retrograde intubation but could not locate them for a cric? Can you explain how the landmarks are different? Did you blindly stick the wire in the neck?
Also, was orotracheal intubation "nearly" impossible or impossible? There is a big difference in what is subsequently indicated.
As you have presented it, it does not sound as though the patient was a candidate for retrograde intubation.
Failure to locate landmarks for cric should have called for an anesthesiologist or surgeon to manage the airway as it may have required anatomical dissection to place the airway. This doesn't sound like a case for a RN.
I'm with foughtfyr, no place for retrograde in the field. In a hospital, it should be done by anesthesiology as I can't see how anyone gets enough live cases to be proficient.
The point I'm making is retrograde intubation is NOT the bailout procedure for a cric. There are things like combi-tubes and pharygeal airway devices for complex patients like yours if they present in the field. If it is interfacility transfer you should consult anesthesiology or surgery or consider a different device. It is a common theme among flight crews that they think they always need an ETT at all costs.
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I've got to disagree with the blanket statement that retrograde intubation has no place in the field. It's indicated in cervical or severe maxillofacial trauma AND it's a relatively simple procedure. Have you tried inserting an ETT using in-line technique in an aircraft? I'll stipulate that prehospital/CC crews sometimes overlook the Combi/King/whatever airways, but in the face of severe facial trauma, they just may not be feasible.
I agree, however, that retrograde should not be considered the cric backup. That said, there are fewer potential risks to the patient with retrograde vs. surgical cric and retrograde requires, based on my own observational data only, less comfort/skill on the part of the practitioner.
As just one example, Bellingham, WA's ALS protocols contain orders for retrograde intubation whenever an ETT cannot be placed because of an inability to visualize the proper landmarks (and as an alternative to, or precursor for surgical cric). How often is it done? Not sure.
How often does Anesthesia do it?
I agree, however, that retrograde should not be considered the cric backup. That said, there are fewer potential risks to the patient with retrograde vs. surgical cric and retrograde requires, based on my own observational data only, less comfort/skill on the part of the practitioner.
As just one example, Bellingham, WA's ALS protocols contain orders for retrograde intubation whenever an ETT cannot be placed because of an inability to visualize the proper landmarks (and as an alternative to, or precursor for surgical cric). How often is it done? Not sure.
How often does Anesthesia do it?
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Big guy, you are doing what I term the "soft backpedal". You stated that "In my system, CC medics do a lot of what the course outlines - tube thoracostomy, retrograde intubation, etc." Of course what this really means is that you have the capacity to perform these procedures but the reality is that the typical medic in your system rarely if ever performs these procedures. This was easy enough to glean from your post. Medics always want to say they have the ability to perform as much as possible. It's a universal phenomenon. Truth is that although lots of procedures may be in your protocol but it doesn't mean that you run around performing them frequently.
Medics need to give up the notion that they are airway experts and can "handle their tubes" etc. Anybody can drop a tube on someone and think they are pretty good at it. But something is wrong when studies show worse outcomes w/ET tubes in the field. I have performed many RSI's and yet I still am very cautious about administering these drugs because I have seen what happens when things don't go quite as planned. Drugs in inexperienced hands can potentially lead to big problems.
What I find interesting is that there isn't much discussion of pts. clinical status in determining the need for intubation. Even if someone is just barely gimping along who has severe head/neck/maxillofacial trauma or whatever there is no need for an a provider who is inexperienced is advanced airway management techniques trying to perfrom all these airway tricks. Even in the best of hands (ENT, general surgery, anesthesia,etc) securing a airway in a difficult pt. can be extremely hard. There's no need to jump the gun. Stick to the basics, including effective ventilation. Wanting to be a cowboy with procedures shows a cavalier attitude and a lack of respect for the airway. Success in these procedures comes with experience and practice. I mean multiple procedures performed on real live patients, not on some dummy.
I am also very curious as to how one could locate the landmarks for a retrograde tube when the landmarks for a cric are obscured. Sounds pretty dumb to me.
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I can't say I appreciate being talked down to - that is how I am interpreting your comments. If I am mistaken, I apologize in advance.
There are many skills accepted as part of a paramedic's scope of practice that are rarely performed (cricothyrotomy being only one example). I suspect the same trend is observed for the EM physician, the surgeon, the anesthesiologist. To that end, your point is well-received: inexperience at any level can be dangerous.
That said, though, I don't believe that is reason enough to oppose a properly trained (yet green) paramedic from performing a skill that is within their scope.
You refer to the medics who boast their airway acumen and the stats about poor outcomes with field tubes. What no one has done is address my assertion that poor maintenance/monitoring of ETT's is a training/QI issue.
Many providers (especially on the privates here in Chicago) go years at a time without attempting or passing a tube. The majority of them have never performed a cric, either, and I doubt more than a few have performed a needle decompression. Should we remove those skills from the paramedic skillset?
When it comes to advanced airway skills, continued training is sorely lacking. Intubating a plastic head is not adequate. OR time, under the supervision of anesthesiologists (who are notoriously reluctant to allow a medic or medic student to practice intubation), allows real-world application. Participation in cadaver lab workshops is another avenue. The fact remains that many systems do not require the level of training and re-training that skills like crics and retrograde require.
There are many skills accepted as part of a paramedic's scope of practice that are rarely performed (cricothyrotomy being only one example). I suspect the same trend is observed for the EM physician, the surgeon, the anesthesiologist. To that end, your point is well-received: inexperience at any level can be dangerous.
That said, though, I don't believe that is reason enough to oppose a properly trained (yet green) paramedic from performing a skill that is within their scope.
You refer to the medics who boast their airway acumen and the stats about poor outcomes with field tubes. What no one has done is address my assertion that poor maintenance/monitoring of ETT's is a training/QI issue.
Many providers (especially on the privates here in Chicago) go years at a time without attempting or passing a tube. The majority of them have never performed a cric, either, and I doubt more than a few have performed a needle decompression. Should we remove those skills from the paramedic skillset?
When it comes to advanced airway skills, continued training is sorely lacking. Intubating a plastic head is not adequate. OR time, under the supervision of anesthesiologists (who are notoriously reluctant to allow a medic or medic student to practice intubation), allows real-world application. Participation in cadaver lab workshops is another avenue. The fact remains that many systems do not require the level of training and re-training that skills like crics and retrograde require.
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Well put about the continued training. Our sponsor hospitals here are far too busy training brand new interns and residents how to intubate in the OR, they have no time for the paramedics who may be called upon to slide a tube into grandma's trachea on her living room floor. In my opinion, the priorities are not properly set. I have unlimited access to a used airway mannequin, but virtually NO opportunity to practice on real anatomy. Our system is busy but there are a lot of paramedics, and to be honest I am lucky to get a tube once every few months. I do NOT feel proficient or practiced, and I think I will probably poop my pants when/if I have to do a surgical airway.
That said, I have had plenty of time to think about and plan my use of continuous waveform end-tidal CO2 monitoring, repeat lung sound assessments, etc. In fact the infrequency of intubation makes me REALLY think about it when it comes up: and you bet your ass I will make sure that tube stays in.
That said, I have had plenty of time to think about and plan my use of continuous waveform end-tidal CO2 monitoring, repeat lung sound assessments, etc. In fact the infrequency of intubation makes me REALLY think about it when it comes up: and you bet your ass I will make sure that tube stays in.
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1) I am well aware of the indications and contraindications of these procedures.
2) In both of the cases I've described the membrane could not be palpated; once due to massive SQ air and edema and once due to what I can only describe as a bony plate of some sort where you would expect the membrane to be (this was in the pt with congenital malformations of his pharynx). In both cases the needle was inserted midline in the anatomical location where I would expect the membrane to be. In my estimation this was less risky then using a scalpel.
3) It was impossible to visualize the structures in both cases. In both cases the bougie - which has bailed me out of most of the hard airways I've encountered - resulted in esophageal intubation, but in both cases I was able to find the wire in the pharynx and pass the ETT over it and establish a definitive airway.
4) In both of these cases I would have gladly let an anethesiologist or surgeon manage the airway...if there had been one within 50 miles.
5) In both of these cases the patient would clearly have died enroute to the hospital if I had been unable to establish an airway.
6) Airway skills are just that; skills. The procedures are quite simple and can be mastered by anyone who is provided the appropriate training and experience. It doesn't take an MD.
7) In my career I've done approximately 500 or so intubations, 90% of them outside of the hospital and probably a little less than half of which would be considered "difficult" or "very difficult" by any standard. I'm not bragging or trying to impress; just relating my experience. I can assure you that if I tell you that it was the only option then you can rest assured that it was the only option available at that place and at that time.
8) I'm just curious how many difficult, traumatic airways you've managed, viostorm?
2) In both of the cases I've described the membrane could not be palpated; once due to massive SQ air and edema and once due to what I can only describe as a bony plate of some sort where you would expect the membrane to be (this was in the pt with congenital malformations of his pharynx). In both cases the needle was inserted midline in the anatomical location where I would expect the membrane to be. In my estimation this was less risky then using a scalpel.
3) It was impossible to visualize the structures in both cases. In both cases the bougie - which has bailed me out of most of the hard airways I've encountered - resulted in esophageal intubation, but in both cases I was able to find the wire in the pharynx and pass the ETT over it and establish a definitive airway.
4) In both of these cases I would have gladly let an anethesiologist or surgeon manage the airway...if there had been one within 50 miles.
5) In both of these cases the patient would clearly have died enroute to the hospital if I had been unable to establish an airway.
6) Airway skills are just that; skills. The procedures are quite simple and can be mastered by anyone who is provided the appropriate training and experience. It doesn't take an MD.
7) In my career I've done approximately 500 or so intubations, 90% of them outside of the hospital and probably a little less than half of which would be considered "difficult" or "very difficult" by any standard. I'm not bragging or trying to impress; just relating my experience. I can assure you that if I tell you that it was the only option then you can rest assured that it was the only option available at that place and at that time.
8) I'm just curious how many difficult, traumatic airways you've managed, viostorm?
D
deleted6669
I just took " the difficult airway course". it definitely increased my comfort level with difficult airway situations, surgical airways, etc
check it out: www.theairwaysite.com
ems version of the 2 day course is 350 dollars.
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I'm signed up for the December course in Columbus. Looks great.
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8) I'm just curious how many difficult, traumatic airways you've managed, viostorm?
Everyone whip 'em out and and lets measure!
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Curious as to why you think it's a joke?
There are some things (in AZ) that a medic either can't, or isn't allowed (medical diresction) to transport...How would you propose getting them from A to B, especially when B is <10 miles from A? Flying? Too cost prohibitive; especially when you can have a CCRN and a medic sharing the call?
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8) I'm just curious how many difficult, traumatic airways you've managed, viostorm?
It is classic you THINK I've never managed a prehospital difficult airway or you THINK you have more tubes because my title says "medical student" on SDN.
You make my point exactly why non-physicians should not have retrograde intubation. They get a few intubations under their belt then they go stick wires in necks when they can't even identify the landmarks.
As a new member realize your now having conversations with physicians and students, most of these people with pretty incredible backgrounds ... even some flight people
. I wouldn't make it a habit of calling people out on their experience. If however, you want to have someone stroke your ego and tell you how cool it is you did something totally stupid save it for flightweb.
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Listen, folks, we CAN have intelligent discussion without making it personal. ...right?
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I'm sure he said it that way because it's commonly understood that when someone says medics in some place do a skill, it means their protocols allow them to do the skill, not that they necessarily do. It's reaching to tarnish his rep, just a little bit.blotto geltaco said:
I think it's also assumed that in the examples of retrograde intubation, the medics had decided that it WAS actually needed. One can't assume irresponsibility (as was later said, one example was a 50mi transport).
Basically, it seems that like the other poster said, you guys are arguing each other and not the topic.
As far as the topic itself, I would just keep in mind that in EMS, it's not unreasonable to prepare for the extreme scenarios, since they actually do happen...maybe it doesn't happen to be in your system, but somewhere some medic is going to get that situation.
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I hope so, because my popcorn is getting cold now!Listen, folks, we CAN have intelligent discussion without making it personal. ...right?
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Dude if half your intubations are difficult then maybe you need some more practice. That number is way too high.
D
deleted6669
don't know about that....aside from trauma airways most of the intubations I have done were folks who were significantly obese with malampatti and lehane(?sp) scores of 3 or 4...enough to call them potentially difficult.....50% might be a bit high as most little old ladies in nursing homes almost intubate themselves but 40% difficult airways probably isn't a stretch. the last several I have done have been 300 lb hep c + ivda folks way past their prime.....
I've only had 1 outright failure( as in no tube in 3 attempts ) but that was in the days before field rsi. with rsi I am fairly confident I could have intubated that pt as well.he was a suicidal tricyclic o.d. with a very clenched jaw despite resp arrest. was able to bag him though with nasal airways in place and the ed doc paralyzed him with pavulon and was successful on attempt #2. guy coded in icu but was resuscitated and walked out of the hospital with no deficits a week later.
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Yeah, I'm with emedpa on this one. If you're only doing elective in-hospital intubations, you could reasonably expect a lower # of unanticipated difficult airways. The field is different.
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My two cents on the intubation issue. If there is a skill that requires so much training/ CE to do well that many (not all) departments are unable to keep up, then it may be worth a hard look. I'm in no way advocating medics not tubing, but the average provider/deparment has a limit on how much training time they can devote to any one skill. You could justify field providers doing just about any procedure if "they had enough time to practice it."
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This is where the concept of a layered response system comes in to maintain proficiency.
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True true...but at least you cut down on the number of procedures which are deemed 'rare'.
