Intubation and paramedic school

[Paseo Del Norte]

This may rattle some people, but at least just think about what I'm asking and try to be flexible.

With a fair amount of evidence regarding pre-hospital intubation and the role of intubation in cardiac arrest, I'd love to see what people think about teaching intubation in paramedic school to entry level paramedics. Is this something that needs to be taught to every paramedic? Should it remain an integral component of the national curriculum (NSOP), or is it conceivable that we can have safe, competent paramedics coming into the field without experience regarding endotracheal intubation? I'm not asking about basic airway maintenance, adjuncts, non-invasive ventilation, suctioning, safely managing an already intubated patient or using supraglottic devices, but rather asking about the role of the actual pre-hospital intubation. I'm not advocating we drastically change anything now, I just want to have open dialogue regarding this subject.

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[docB]

This is certainly a discussion that needs to be had. I think the data about pre hospital intubation coupled with the training and logistical issues, predominantly getting enough tubes to stay competent in lower volume areas, will force a move to supraglottic airway preference.

Another question would be should we still teach it but then encourage supraglottics as the go to devices?

 

[quechua]

This may rattle some people, but at least just think about what I'm asking and try to be flexible.

With a fair amount of evidence regarding pre-hospital intubation and the role of intubation in cardiac arrest, I'd love to see what people think about teaching intubation in paramedic school to entry level paramedics. Is this something that needs to be taught to every paramedic? Should it remain an integral component of the national curriculum (NSOP), or is it conceivable that we can have safe, competent paramedics coming into the field without experience regarding endotracheal intubation? I'm not asking about basic airway maintenance, adjuncts, non-invasive ventilation, suctioning, safely managing an already intubated patient or using supraglottic devices, but rather asking about the role of the actual pre-hospital intubation. I'm not advocating we drastically change anything now, I just want to have open dialogue regarding this subject.

By "entry level paramedics"... are referring to EMT-Bs?

 

[docB]

By "entry level paramedics"... are referring to EMT-Bs?

I was thinking of freshly minted paramedics. Advanced training such as CCT-P could continue with ET intubation.

 

[Paseo Del Norte]

I appreciate the comments. I am thinking about an entry level paramedic and not an EMT. It appears that several other countries have paramedics who are not required to intubate; however, I understand it is difficult to make direct comparisons between providers due to differences in scope of practice and education, but as an educator I still question the necessity of intubation in many out of hospital circumstances.

docB, I was even thinking about not actually teaching it or simply covering it in a FYI type manner, like what you might receive in an ACLS class. Then, as a paramedic gains experience, allow medical directors to decide what liability they feel that they can take on and develop or have post graduate programmes. However, I'm not sure of the benefit of mandating that every graduating paramedic be "qualified" to intubate. It seems a very high risk procedure that degrades without significant and frequent practice that on the whole has limited benefits when compared to the risks.

 

[jwk]

By "entry level paramedics"... are referring to EMT-Bs?

EMT's are not "entry level paramedics". They're EMT's.

 

[quechua]

I asked for clarity because their licensure is an EMT-P ...vs an EMT-B or an EMT-I. So technically they are all EMTs. When the OP said "entry-level" I wondered if s/he meant EMT-B... Which is considered entry level.

 

[docB]

I asked for clarity because their licensure is an EMT-P ...vs an EMT-B or an EMT-I. So technically they are all EMTs. When the OP said "entry-level" I wondered if s/he meant EMT-B... Which is considered entry level.

I know what you meant. The scope for EMT or EMT-B or whatever we will call it next year has never included endotracheal intubation.

 

[jwk]

I know what you meant. The scope for EMT or EMT-B or whatever we will call it next year has never included endotracheal intubation.

I understood as well - but an EMT-B has never been referred to as an "entry level paramedic". They are not, nor have they ever been, synonymous.

 

[joeDO2]

this discussion is rehashed every few years. i think eventually they will come to their senses and stop the madness with prehospital intubation. leave it for CCT or as a special waiver option for some systems like RSI is. supraglottic will be just fine for the majority of systems.

 

[Paseo Del Norte]

My bad if there is any confusion about provider levels. I am looking at things from a national level, DOT NSC educational model to avoid all the confusion that can occur at the state and local/provincial levels. At the national level, the paramedic is not considered a technician and is simply called a paramedic or nationally registered paramedic while the EMT and Advanced-EMT are considered technicians.

Even considering CCT, is there a huge amount of benefit that outweighs the risk? I do not know and I have not seen much evidence, some limited evidence about well trained flight crews having better advanced airway outcomes than other providers, but nothing systemic that I am aware of.

Anecdotally, I really did not do a significant number of intubations in the real world when I was flying and my total airway experience as a CCT provider would probably not impress anybody on this forum. However, when we look at the spectrum of critical care, do we commonly see critical care RN's intubating patients in the ICU or is the focus more on maintaining and assessing an endotracheal tube that has already been placed? Does the provider's role and scope of practice need to change significantly when making the transition to flight? Granted, the paramedic will probably have more airway experience (on the average), but I am still not sure of the overall efficacy of endo-tracheal intubation.

I may see a necessity when pulling critical patients out of very rural settings where the providers in this situation may not be comfortable or educated in airway management; however, I am still not aware of a great amount of evidence supporting intubation in these situations.

Additionally, let me ask another question. I see another airway management modality being instituted known as rapid sequence airway (RSA). Dr. Braude out of UNM in New Mexico has written a bit of literature and a case study on this novel technique. Basically, it involves administering agents like a traditional RSI but using a supraglottic as the primary method of airway control. The case study was compelling because it focused on a deteriorating trauma patient in the back of a helicopter at night during a turbulent flight. However, I am still not aware of a large base of literature to support this technique.

 

[joeDO2]

the scope does need to change when dealing with aeromedical. they need to be able to paralyze and secure a definitive airway...you can't have these people moving all around during flight. paralyzing with a supraglottic device is an interesting thought but as you point out there is just not enough literature on this. also- the primary concern is aspiration without complete isolation of the trachea which is something you certainly don't want to be dealing with in the air.

 

[jwk]

the scope does need to change when dealing with aeromedical. they need to be able to paralyze and secure a definitive airway...you can't have these people moving all around during flight. paralyzing with a supraglottic device is an interesting thought but as you point out there is just not enough literature on this. also- the primary concern is aspiration without complete isolation of the trachea which is something you certainly don't want to be dealing with in the air.

I think if you do a search you would find a large body of info regarding supraglottic airways (LMA's specifically) and their use in patients with NMB's on board. It's being accepted more and more in OR's in the US as a result of the British/European experience using LMA's for probably 90% of their surgical procedures, including laparoscopic and prone cases. They pretty much consider an LMA equivalent to an ETT, and most assuredly consider it a "definitive airway". I'm not quite that bold to claim that yet, but I am much more liberal with LMA's in surgery now than I was in years past.

Similarly, I think you will find an ever-increasing body of evidence that the risk of aspiration with LMA's and ETT's is essentially the same - although again, I'm not bold enough to make that claim yet, and if I have any question at all, will always prefer an ETT. As with many, I have never regretted placing an ETT, but there are quite a few times I was sorry that I did not.

 

[alpinism]

This may rattle some people, but at least just think about what I'm asking and try to be flexible.

With a fair amount of evidence regarding pre-hospital intubation and the role of intubation in cardiac arrest, I'd love to see what people think about teaching intubation in paramedic school to entry level paramedics. Is this something that needs to be taught to every paramedic? Should it remain an integral component of the national curriculum (NSOP), or is it conceivable that we can have safe, competent paramedics coming into the field without experience regarding endotracheal intubation? I'm not asking about basic airway maintenance, adjuncts, non-invasive ventilation, suctioning, safely managing an already intubated patient or using supraglottic devices, but rather asking about the role of the actual pre-hospital intubation. I'm not advocating we drastically change anything now, I just want to have open dialogue regarding this subject.

I also don't think it needs to be taught for entry level school. Low volume paramedics shouldn't even carry ETTs.
Carry a few LMAs on the rig just in case and be done with it.

 

[docB]

Bear in mind that for EMS use of supraglottic airways we really mean devices like the Combitube (which is on the way out) and the King and similar. LMAs are used much less than those.

 

[Deranged Medic]

Bear in mind that for EMS use of supraglottic airways we really mean devices like the Combitube (which is on the way out) and the King and similar. LMAs are used much less than those.

Interestingly, the LMA is the only supraglottic airway we have at the 2 EMS organizations I work for. My volunteer department uses mainly Kings, but we also have LMAs available. My local protocol, which is used for all departments, has recommended the used of LMA only (no intubation) for pediatrics-are other people seeing this?

docB-I have had this question for a while, and I would love to hear some feedback from you guys. While I have never been in this situation, wouldn't a patient suffering from anaphylaxis or upper airway swelling see more benefit from an ET tube versus a supraglottic airway? If we take away intubation, would this leave a surgical cric as the best intervention? If taking away intubation is better for my patients, I will support it, but I have always wondered if I would be able to effectively care for these patients without intubation?

 

[alpinism]

Bear in mind that for EMS use of supraglottic airways we really mean devices like the Combitube (which is on the way out) and the King and similar. LMAs are used much less than those.

For the US, absolutely. I've been spending too much time w/ anesthesia and my international EMS buddies (europe/australia) who use prehospital LMAs all the time instead of ETTs. We also used them from time to time when I was in doing CCT in the Air Force.

Unfortunately, I've never had the chance to use a King LT on a real patient, but it seems like a great device and I've heard mostly good things about it (hence why its replacing the combitube).

I like LMAs b/c w/ minimal training and experience, almost anyone can quickly insert it during an arrest w/o stopping compressions. I'm assuming a king would be similar, maybe even better. Its a great option esp if the primary goal is to maintain adequate ventilation w/ minimal interruptions.

 

[Paseo Del Norte]

Pure anecdote, but my experience with LMA's has been interesting. They work and work well but during my limited time in the OR placing them, I've found that I think the LMA probably requires more training and experience than you may initially assume. They seem easy to dislodge and tend to curl up during insertion. I'm not sure how that translates to a less educated provider using it in a highly suboptimal experience? I cannot say, because I've never used them outside of the hospital. Anecdotally, I've had very good experiences with the Combitube and the King airways. However, LMA has introduced some newer generation devices such as the LMA supreme with many positive features such as a gastric port. One of the EMS services in my area has transitioned to this device, so I'm interested to see how it goes.

With that said, I believe the only widely available supraglottic option in paediatric patients pretty much remains the LMA.

 

[24IdaFire]

This is certainly a discussion that needs to be had. I think the data about pre hospital intubation coupled with the training and logistical issues, predominantly getting enough tubes to stay competent in lower volume areas, will force a move to supraglottic airway preference.

Another question would be should we still teach it but then encourage supraglottics as the go to devices?

I recently secured funding for my residency research project. I'm going to equip my local EMS crews with video laryngoscope scopes and see how first pass intubation rates fair as compared to direct.

If I can prove that video scopes improve airway management with everyday EMS crews, intubation may still have a role in EMS.

 

[docB]

I recently secured funding for my residency research project. I'm going to equip my local EMS crews with video laryngoscope scopes and see how first pass intubation rates fair as compared to direct.

If I can prove that video scopes improve airway management with everyday EMS crews, intubation may still have a role in EMS.

Your problem here is that the poorer outcomes associated with prehospital intubation don't seem to be due to missed tubes. We don't really know why the outcomes are worse yet but theories include oxygen based free radical damage, dropped BP with associated tissue hypo perfusion due to positive pressure ventilation, accidental hyperventilation and so on. Consequently decreasing the rate of misses would obviously be good but it wouldn't save prehospital intubation from the outcome data. In fact I think the real sequela from all this will be a reexamination of when and why we intubate people in the ED.

 

[isquared]

Paramedic here. (NRP).
I started out as an EMT-B in 2008, and then transitioned to EMT-I in 2010. I have been licensed as a P for a year.

I have performed many prehospital intubations, both orotracheal and nasotracheal.

Currently, our system allows EMT-B providers to use airway adjuncts only, while EMT-I providers can use Combi-tube type devices and perform orotracheal intubation, but are not allowed to perform nasotracheal intubation.

Our system requires tube placement confirmation with auscultation and waveform capnography.

Personally, I have never missed when I have had to place a tube. (Confirmed by x-ray in the ED).

I much prefer to manage a patient's airway with an adjunct or CPAP if at all possible, and then I usually opt for the Combitube. I rarely go straight for the endotracheal tube, unless I anticipate difficulty with the device. (I have found that the Combitube doesn't work as well for extremely anterior airways, or for smaller elderly patients.)

I would prefer to have the option to use a supraglottic device, but for some reason our medical director thinks that they aren't as reliable as the other options we have at our disposal.

I definitely see why this is a controversy. I have seen medics fumble with multiple attempts before giving up and trying to use a Combitube, or resorting back to an adjunct.

The training we get for advanced airway management includes 6 hours in the cadaver lab, and two days in a local OR supervised by anesthesiologists. There are optional extra training classes available for difficult and neonate airway management. (They RSI ferrets.)

I think we should have much more access to training on a continuing basis. Ideally, three times a year. If they expect us to be able to perform this skill effectively, we should be practicing it regularly. Otherwise, we are probably doing more harm than good.

Most of us don't intubate that often. My area is a little busier than others in the county because of a large elderly population, and higher rates of traumatic injuries from accidents and violence. I probably average one or two tubes a month, but that isn't enough to keep the skill fresh.

Anyway, that's just my two cents...from the bottom of the emergency medicine totem pole.

 

[jwk]

Paramedic here. (NRP).
I started out as an EMT-B in 2008, and then transitioned to EMT-I in 2010. I have been licensed as a P for a year.

I have performed many prehospital intubations, both orotracheal and nasotracheal.

Personally, I have never missed when I have had to place a tube. (Confirmed by x-ray in the ED).

Most of us don't intubate that often. My area is a little busier than others in the county because of a large elderly population, and higher rates of traumatic injuries from accidents and violence. I probably average one or two tubes a month, but that isn't enough to keep the skill fresh.

If you've "never missed" then you haven't done very many intubations. Nobody is 100% - NOBODY - even those of us like me in anesthesia. 1-2 a month may be a lot for EMS providers, but that doesn't strike me as "many" intubations over a three year period. That would be an n=36 to 72.

Difficult airways are not terribly common, but as with many things, experience is the master. Airways that are "difficult" early in one's experience are not so difficult later on. But trust me on this - don't let your "I've never missed" attitude make you think you "can't miss".

 

[joeDO2]

I have never missed when I have had to place a tube.

Watch out my friend, it is coming. The most dangerous thing of all is being overconfident.

 

[isquared]

I didn't mean that to sound overconfident. Just that in my service, one or two each month is considered to be more frequent than most, and I have been very lucky. I am due for a very difficult airway, and I am pretty nervous about it.

What I was trying to convey, is that my one or two tubes a month is more than most medics get, and we don't have access to regular training to keep the skill fresh. So the medics who get 2 or 3 a year are more likely to miss than those of us who get more practice.


I think if they are going to continue o allow us to intubate in the field, we should have access to regular training. (But that costs money.)

 

[Dwindlin]

I didn't mean that to sound overconfident. Just that in my service, one or two each month is considered to be more frequent than most, and I have been very lucky. I am due for a very difficult airway, and I am pretty nervous about it.

What I was trying to convey, is that my one or two tubes a month is more than most medics get, and we don't have access to regular training to keep the skill fresh. So the medics who get 2 or 3 a year are more likely to miss than those of us who get more practice.


I think if they are going to continue o allow us to intubate in the field, we should have access to regular training. (But that costs money.)

The bold portion is exactly the problem. 2 - 3 intubations a month is considered "a lot" by EMS standards. Personally in the camp of moving to either supraglotic/blind insertion type airways for all EMS providers.

 

[joeDO2]

The bold portion is exactly the problem. 2 - 3 intubations a month is considered "a lot" by EMS standards. Personally in the camp of moving to either supraglotic/blind insertion type airways for all EMS providers.

Generally agree with that but I think we need to retain it in aeromedical / CC. I know some services where the medics are getting 100 tubes / yr either field or OR. I think that is probably entering the level that is enough for proficiency.

 

[docB]

Generally agree with that but I think we need to retain it in aeromedical / CC. I know some services where the medics are getting 100 tubes / yr either field or OR. I think that is probably entering the level that is enough for proficiency.

I agree. My CCT-P teams routinely intubate in sending facilities prior to transport and I think that's superior to running the whole transport with a supraglottic airway or waiting and dealing on the road in many cases.

Just to be clear, I don't advocate or anticipate the removal of endotracheal intubation from the out of hospital or prehospital arenas. I think we need to be more judicious in the patients who get this modality and who we train and keep current to practice it.

The situation we find our field in now is one where the evidence and the alternatives have coincided to demand we have this discussion and make changes. But I don't see the out of hospital endotracheal tube going the way of MASTs or sky hooks.

 

[Dwindlin]

Generally agree with that but I think we need to retain it in aeromedical / CC. I know some services where the medics are getting 100 tubes / yr either field or OR. I think that is probably entering the level that is enough for proficiency.

Thanks, I should have specified I was talking about standard ALS 9-1-1 services.

 

[isquared]

The bold portion is exactly the problem. 2 - 3 intubations a month is considered "a lot" by EMS standards. Personally in the camp of moving to either supraglotic/blind insertion type airways for all EMS providers.

Exactly. We are a fire based system, so we don't see patients in hospitals except for when we drop them off.

There should be a requirement of continuing practical skill maintenance, which allows us to sign up for a couple shifts a month at the OR.

We should also be able to use supraglottic airways. I have no idea why our system doesn't use them.