Should intubation be removed from the paramedic skillset?

[146233]

With various numbers/studies suggesting poor outcomes for patients intubated in the field, should endotracheal intubation be removed from the paramedic's scope of practice in favor of Combitube/King/LMA's?

I'd love to gather some links to hard data for discussion, too. What can we do to improve outcomes?

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[jkelly2]

The key to the phrasing of your question is "With various numbers/studies suggesting poor outcomes for patients intubated in the field." Evidence-based medicine-- surely something EMS lacks. If there is science behind the claim of poor outcomes for patients tubed in the field, then yes get rid of it. We don't do rotating tourniquets for CHF anymore, and Lasix is becoming a less-favored option for emergent CHF. Let the evidence guide us. Better yet, let us participate in research design and execution!

 

[146233]

I love it. Let's get SDN to give us a grant and figure this thing out.

 

[TerraMedicX]

Absolutely not! First, I've yet to see a study showing poor patient outcomes that I feel was actually well designed! Evidence-based medicine requires EVIDENCE, not just isolated studies of varying quality! Frankly, I STILL blame poor outcomes on poor training! Now, I KNOW I'm gonna get a WHOLE bunch of people pissed at me for this next one but...I think the situation could be solved with the following easy steps:

1) Get continuous wave-form capnography on every ALS ambulance.
2) Get the point across that its ok to BLS a patient, but your a total idiot if you don't recognize a misplaced ETT!!
3) Get our companies to do more for us with hands-on training. I know its hard to get into the OR in many places, but the difficult airway manequins out there are getting better every year, and some training is better than nothing!
4) (Here's where people start to get angry!) Tell the freaking IAFF to stop pushing to have everyone become a freaking paramedic!! There is no need!!
5) If fire departments want to run ALS...they need to realize that its just as hard (harder if you ask me) as firefighting and those paramedics NEED to train on EMS, NOT firefighting!!

ok...you can now let me know JUST how you feel about me, my opinions and my mother!

Nate.

 

[MedicFL]

I do see us losing this skill in the next 5 years, I work in my counties medical directors office and there is already talk. Lasix goes away Nov 31st for us. I do agree more training is the key. CO2 reading on every truck has greatly cut down the unnoticed missed tube rate.

 

[leviathan]

I don't see why intubation needs to be removed. It's not too difficult a skill in many cases, as long as you keep your proficiency up. For the difficult airways, combitubes or other adjuncts are always good backups.

How often are you guys getting tubes in your locales? In our targeted system, most people are averaging a tube once every block, or about 4-6/month.

 

[docB]

I don't think we're at the point where we should stop field intubation. Capnography can help with the missed tube problem. Improvements are always popping up too like the recent increase in popularity of the bougie.

I agree with those above who note that often the best fall back for the difficult airway is good BLS airway management and quick transport. I don't like the combitube. It just seems like I see a lot of problems with it.

All of this is impacted by the great EMS paradox (a favorite subject of mine). The rural agencies with long transport times that need the advanced skills and equipment the most are the ones who can't afford it. If you have to transport to a hospital an hour away you need intubation more than the medic who is five minutes away. However, as a rural medic you are less likley to get enough tubes on a regular basis to stay as sharp as your urban counterparts.

 

[TerraMedicX]

All of this is impacted by the great EMS paradox (a favorite subject of mine). The rural agencies with long transport times that need the advanced skills and equipment the most are the ones who can't afford it. If you have to transport to a hospital an hour away you need intubation more than the medic who is five minutes away. However, as a rural medic you are less likley to get enough tubes on a regular basis to stay as sharp as your urban counterparts.

Well said!! How do we fix this? More flight programs? Requiring rural medics to spend time in a more urban setting to keep up their skills? Would training and practice be enough? From my understanding, this was the reason that the EMT-I level was first created, to help rural communities that couldn't support ALS providers to have some higher level of care. Any suggestions people?

Nate.

 

[leviathan]

Well said!! How do we fix this? More flight programs? Requiring rural medics to spend time in a more urban setting to keep up their skills? Would training and practice be enough? From my understanding, this was the reason that the EMT-I level was first created, to help rural communities that couldn't support ALS providers to have some higher level of care. Any suggestions people?

Nate.

I'm still learning here, but how hard is it really to find out that you've misplaced the tube? I mean, as long as you auscultate the stomach + lungs + get a ETCO2 waveform on your cardiac monitor, you should be able to figure it out right? And if you do fail, you can use a backup device, or just stick to straight BLS procedures. Certainly a rural provider is going to have a higher chance of missing the few tubes s/he gets, but that doesn't mean they can't at least give it a shot, right?

 

[146233]

There is no excuse for not noticing a misplaced tube, even for the [many] agencies without EtCO2 capability. With all of the measures of confirmation we employ (epigastric/lung auscultation, use of EDD's, condensation in the tube, V/S and SpO2, etc.), people not noticing must either be a laziness or training issue (and I hope it's not the former).

I really feel as though hospitals/anesthesiologists/CRNA's should take an active role in training EMS personnel on airway management and intubation. Few medic programs in the country are afforded this opportunity during training, and even fewer places allow this as a form of clinical CE.

 

[docB]

Well said!! How do we fix this? More flight programs? Requiring rural medics to spend time in a more urban setting to keep up their skills? Would training and practice be enough? From my understanding, this was the reason that the EMT-I level was first created, to help rural communities that couldn't support ALS providers to have some higher level of care. Any suggestions people?

Nate.

Not more flight. I personally feel flight medicine is one of the greatest cost/benefit losers in all of medicine.

The real but boring way to fix the problem is with political action and funding. I also think that an increase in the roving medic model where a highly trained ALS provider covers a large area of smaller volly agencies and responds in tendem is the wat to go currently.

 

[docB]

I'm still learning here, but how hard is it really to find out that you've misplaced the tube? I mean, as long as you auscultate the stomach + lungs + get a ETCO2 waveform on your cardiac monitor, you should be able to figure it out right? And if you do fail, you can use a backup device, or just stick to straight BLS procedures. Certainly a rural provider is going to have a higher chance of missing the few tubes s/he gets, but that doesn't mean they can't at least give it a shot, right?

It can be difficult. Dead people don't make CO2 and many agencies can't afford it. I don't have it in my urban EDs due to the cost issue. Sometimes it's hard to tell with auscultation. You're usually in the back of a diesel rig going Code 3 on a patient will lungs full of gunk and a stomach that's been aerated by aggressive BLS airway manuevers. The plunger and bulb methods are good but can get fooled. For exampleif there's chunky vomit in the trachea it will cause the plunger to rebound making you think you're in the goose, if there's a lot of air in the belly it can fool you into thinking the tube's good.

The trickiest unrecognized esophageal tubes I've had brought to me were on patients who were still moving some air on their own. It sounded like they had breath sounds (they did just not from the ETT). Don't underestimate how much more difficult these skill are in the back of a rig or on a scene than in the ED.

 

[leviathan]

It can be difficult. Dead people don't make CO2 and many agencies can't afford it. I don't have it in my urban EDs due to the cost issue. Sometimes it's hard to tell with auscultation. You're usually in the back of a diesel rig going Code 3 on a patient will lungs full of gunk and a stomach that's been aerated by aggressive BLS airway manuevers. The plunger and bulb methods are good but can get fooled. For exampleif there's chunky vomit in the trachea it will cause the plunger to rebound making you think you're in the goose, if there's a lot of air in the belly it can fool you into thinking the tube's good.

The trickiest unrecognized esophageal tubes I've had brought to me were on patients who were still moving some air on their own. It sounded like they had breath sounds (they did just not from the ETT). Don't underestimate how much more difficult these skill are in the back of a rig or on a scene than in the ED.

Very valid points. So how do we get those rural guys trained and keep those skills maintained? It seems like there just aren't enough tubes to go around amongst the paramedics, RTs, medical students, residents, etc...if we wanted these guys to come in for CME in hospital, they'd be fighting to intubate with all of the other staff, and I'm guessing the paramedics come last in that fight.

 

[deleted92121]

Intubation will probably be replaced by King LT/Combitube. But it is up to our medical directors and ALS departments to decide that. I know for a fact though that out of 5000 calls last month in our service area, we had to intubate 15 times and all 15 were successful attempts. To have 100% placement is amazing. But of those 15 Pts that were tubed, only 1 walked out of the hospital.

In our area, new Lasix protocol just changed over. Our new protocol states no nitrates are to be given until a 12-lead EKG is done. If 12-lead is neg. for right sided infarct, call med command and provide nitro. If it is right sided, bolus the Pt, call command for authorization to give nitro.

 

[docB]

Very valid points. So how do we get those rural guys trained and keep those skills maintained? It seems like there just aren't enough tubes to go around amongst the paramedics, RTs, medical students, residents, etc...if we wanted these guys to come in for CME in hospital, they'd be fighting to intubate with all of the other staff, and I'm guessing the paramedics come last in that fight.

Funding. I also like the roving medic model.

 

[docB]

Intubation will probably be replaced by King LT/Combitube. But it is up to our medical directors and ALS departments to decide that. I know for a fact though that out of 5000 calls last month in our service area, we had to intubate 15 times and all 15 were successful attempts. To have 100% placement is amazing. But of those 15 Pts that were tubed, only 1 walked out of the hospital.

In our area, new Lasix protocol just changed over. Our new protocol states no nitrates are to be given until a 12-lead EKG is done. If 12-lead is neg. for right sided infarct, call med command and provide nitro. If it is right sided, bolus the Pt, call command for authorization to give nitro.

I hope we don't see a huge push toward the combitube. I have seen too many problems. Anecdotally way more than with intubation. Speaking of data 15 for 15 is good but won't impress anyone in the field because the N is too small.

I also don't like the move to withold NTG. This is delaying a good treatment for the majority of patients because of a sub set. It's like saying we shouldn't give aspirin because some people might have an unknown aspirin allergy.

Interestingly this whole push to curtail existing modalities is based on money, funding and liability. It's attractive to agencies to think they can be up to standard without paying for ALS, which is where this is headed.

The liabiliy issue is pernicious as well. Fact is that any modality has +s and -s. If you have intubation you will kill some patients with unrecognized esophageal tubes. It's just a fact. You implement the modality in hopes that you save more than you kill (need to be way more in fact). If you acheive that from a system level perspective then the loss is justified, given that you will always be fighting to reduce or eliminate it.

 

[deleted6669]

having just taken the difficult airway course I am a much bigger fan of the king Lt than the combitube. easier to use. 1 balloon to inflate instead of 2, harder to misplace in the trachea. costs twice as much but if you are using it rarely it's worth the expense.

 

[MedicFL]

There is no excuse for not noticing a misplaced tube, even for the [many] agencies without EtCO2 capability. With all of the measures of confirmation we employ (epigastric/lung auscultation, use of EDD's, condensation in the tube, V/S and SpO2, etc.), people not noticing must either be a laziness or training issue (and I hope it's not the former).

I really feel as though hospitals/anesthesiologists/CRNA's should take an active role in training EMS personnel on airway management and intubation. Few medic programs in the country are afforded this opportunity during training, and even fewer places allow this as a form of clinical CE.

But the fact of the matter is many many tubes in EMS do go missed and unnoticed. I was just reading a study I will have to dig it up that some areas of the country had a 1/5 chance of a tube go missed and not detected while the national average was 1/8.

 

[146233]

But the fact of the matter is many many tubes in EMS do go missed and unnoticed. I was just reading a study I will have to dig it up that some areas of the country had a 1/5 chance of a tube go missed and not detected while the national average was 1/8.

Right. And this isn't a problem related to technical inability, rather training. Just because they DO go unnoticed doesn't mean all of them SHOULD have been missed. As docB mentioned, of course you'll have some unrecognized esophageal tubes - cost of doing business. But they seem higher than they need to be.

 

[docB]

Right. And this isn't a problem related to technical inability, rather training. Just because they DO go unnoticed doesn't mean all of them SHOULD have been missed. As docB mentioned, of course you'll have some unrecognized esophageal tubes - cost of doing business. But they seem higher than they need to be.

As much as I'm always up for a discussion of how to avoid the unrecognized esophageal tube that's not really the issue at the heart of the debate about taking intubation out of the field. The argument, which is being made based on some data albeit shaky, is that patients don't have better outcomes when they're cared for by agencies that have intubation. We're not just looking at the goosed tubes, we're talking about eh whole shooting match which is more disturbing. If it were just the missed tubes then I would agree that this whole thing boils down to a training issue. It's not. If we are to believe the arguments of those who advocate removing intubation the best trained system in the world is still not getting better outcomes than one with BLS units.

 

[146233]

As much as I'm always up for a discussion of how to avoid the unrecognized esophageal tube that's not really the issue at the heart of the debate about taking intubation out of the field. The argument, which is being made based on some data albeit shaky, is that patients don't have better outcomes when they're cared for by agencies that have intubation. We're not just looking at the goosed tubes, we're talking about eh whole shooting match which is more disturbing. If it were just the missed tubes then I would agree that this whole thing boils down to a training issue. It's not. If we are to believe the arguments of those who advocate removing intubation the best trained system in the world is still not getting better outcomes than one with BLS units.

Your point is well-received. It certainly is more troubling that the total package is what's in question. A big part of the reason I started this thread was to see if we could bring together some of this shaky data that's out there. ...perhaps look at what's been studied, see what needs to be examined, etc. I've asked Bledsoe for some references, but I'd imagine he's busy.

 

[leviathan]

If we are to believe the arguments of those who advocate removing intubation the best trained system in the world is still not getting better outcomes than one with BLS units.

But does the research show that it provides a worse outcome? I think it just has to do with the fact that the ones getting intubated / needing ALS are people who are already very sick. If we had some quality research we might be able to get enough statistical power to show that intubation does help...orrrrr, maybe all those missed tubes offset any benefit from the tubes that are successful when you compile it all together and calculate means?

 

[Dienekes]

Well said!! How do we fix this? More flight programs? Requiring rural medics to spend time in a more urban setting to keep up their skills? Would training and practice be enough? From my understanding, this was the reason that the EMT-I level was first created, to help rural communities that couldn't support ALS providers to have some higher level of care. Any suggestions people?

Nate.

More flight programs are not the answer to anything but an increase in LOD deaths for medics and flight nurses.

 

[docB]

But does the research show that it provides a worse outcome? I think it just has to do with the fact that the ones getting intubated / needing ALS are people who are already very sick. If we had some quality research we might be able to get enough statistical power to show that intubation does help...orrrrr, maybe all those missed tubes offset any benefit from the tubes that are successful when you compile it all together and calculate means?

No, they control for the severity of the patients. The other point to keep in mind is that to make a persuasive argument to eliminate EMS intubations they don't have to show it's worse, just that it's not better than BLS airway manuvers. If it's not better then the expense, liability and complications make it a loser.

I'm trying to review some of the literature. Here's a good start point because they review most of the relevent studies. They are a review article and a review of the review:
Out-of-hospital endotracheal intubation: half empty or half full?
Burton JH.
Ann Emerg Med
01-JUN-2006. Vol.47,Iss.6;p.542-4
Source: MDConsult: Journals - For TUN
2.Out-of-hospital endotracheal intubation: where are we?
Wang HE.
Ann Emerg Med
01-JUN-2006. Vol.47,Iss.6;p.532-41
Source: MDConsult: Journals - For TUN

An important passage from the review article:

"Of these out-of-hospital endotracheal intubation studies, the most notable effort is by Gausche et al.22 In this prospective trial, 830 critically ill pediatric out-of-hospital patients in Los Angeles County received either bag-valve-mask ventilation or bag-valve-mask followed by out-of-hospital endotracheal intubation. The authors found that an airway strategy incorporating out-of-hospital endotracheal intubation offered no survival or neurologic benefit over bag-valve-mask ventilation alone. Although limited by its patient population (primarily pediatric patients in a large urban location), this seminal effort represents the largest prospective, controlled evaluation of out-of-hospital airway management interventions."

 

[Autopulse]

This is a great topic. One that is easily dismissed by prehospital community. Without getting on a soap box...... EMS is like other medical entities, it falls under the house of medicine. That said, if you take a modality used in any other subspecality, ask 2 questions:

1) Does performing this skill help patients?

If the evidence shows a resounding yes than go no furthur...if not?

2) Does it harm patients?

If you look at the literature, it is really debateable if prehospital intubation is as "helpful" as we have been lead to believe over the years.
There is strong evidence that prehospital intubation HARMS subsets of the population (head injured patients-Davis et al in Trauma in 2003).

Before becoming a physician, I was a paramedic and I was 100% in favor of prehospital ETI, now however I have my doubts. Paramedic training programs have made RSI/ETI to look like the holy grail for prehospital care, that combined with the "merit badge and toobox" approach to prehospital patient care have created a culture in EMS that shuns those that may advocate reexamining a skill... Go to an EMS conference (JEMS, EMS EXPO) where Henry Wang is speaking about Prehospital Intubation, listen to how long it takes for the crowd to start the muttering, rolling eyes etc, Henry Wang is not an EMS person, rather he gives a good overview of where we are with prehospital intubation and where we need to be. (if you want to know more,PM me). The point being is until the full jury is in on Prehospital Intubation ( we need THE study, a multicenter RCT) I don't think we should be asking should we have intubation in the field...it is still here, rather as it stands, we should be asking how can we make sure we do not hurt people with this practice.

As for ETCO2-look at Katz and Falk-unrecognised misplaced intubations (UMI) you are kidding yourself if you do not think that your agency has similar numbers. Silvestri et al came up with a good solution.. Capnography, if we are allowing prehospital intubation, we should make continuous ETCO2 mandatory with it. In my system, I do not care if you miss an intubation , I care about UMI's. Our Medics are required to use continuous wave form capnography, we do not care about the actual number, rather the waveform. if there is no wavefrom with ventilations and the machine is not initializing etc the medic must pull the tube. I don't care if there are good breathsounds or tube misting etc. Since then we have amazing recognition of UMI's, those few that are not caught, it is always because the Medic (actually all of the medics on a scene-that is scary) ignored or 2nd guessed the machine waveform. As for false readings if you are dead (not like a week out) , I respectfully disagree...if you look at the waveform, it might be low but it is there and I know that that issue is being studied in several centers. Look for some good data soon.

This was put up eariler in the thread and it is a great start (except for #3 regarding simulation as the answer):

TerraMedicX

"1) Get continuous wave-form capnography on every ALS ambulance.
2) Get the point across that its ok to BLS a patient, but your a total idiot if you don't recognize a misplaced ETT!!
3) Get our companies to do more for us with hands-on training. I know its hard to get into the OR in many places, but the difficult airway manequins out there are getting better every year, and some training is better than nothing!
4) (Here's where people start to get angry!) Tell the freaking IAFF to stop pushing to have everyone become a freaking paramedic!! There is no need!!
5) If fire departments want to run ALS...they need to realize that its just as hard (harder if you ask me) as firefighting and those paramedics NEED to train on EMS, NOT firefighting!!"

As for number 4 that is a whole different thread and we can really discuss OPALS in depth to see that issue...

How often are you guys getting tubes in your locales? In our targeted system, most people are averaging a tube once every block, or about 4-6/month.

If you look at Henry Wang's work, paramedics do not get enough attempts at intubation on LIVE patients to be proficient, let alone on kids! Intubating Fred the Head and other devices does not make one good at intubating people, just good at intubating Fred the Head. This may be the downfall of prehospital intubation....the OR time is going away. Where I work we cannot get out paramedic students enough OR intubations and it is the same way around the country.

From all the literature I thing you might be suprised how much lower the national numbers are that that...look at Wang's study......scary

DXU
Intubation will probably be replaced by King LT/Combitube.

You may be hitting the nail on the head....I like the King LT, but there are limited studies...what is the goal, to help, does it matter what type of adjunct does it. I think not. Is it time to get rid of prehospital ETI...no, do we need to have a good hard look on the futility/future of it yes....

Have I become an EMS heretic....

 

[leviathan]

Obviously those who are involved in EMS have biased opinions. However, I will be the first to say 'take it away' if we cannot find get quality research to show that it is not harmful and that it benefits patients.

I'd be curious to know what the rate of undiagnosed esophageal intubations is in my area, because our training is supposedly "superior" here.

 

[docB]

The point being is until the full jury is in on Prehospital Intubation ( we need THE study, a multicenter RCT) I don't think we should be asking should we have intubation in the field...it is still here, rather as it stands, we should be asking how can we make sure we do not hurt people with this practice.

I agree that the only way to answer this is to study it but it will be difficult. It will be difficult to do it as an RTC unless you can get the IRBs to decide that the utility of intubation is questionable enough to randomize patients away from it. If we can't randomize we'd have to study ALS units vs. BLS units which tend to exist as stand alone in small agencies where numbers will be an issue.

As for false readings if you are dead (not like a week out) , I respectfully disagree...if you look at the waveform, it might be low but it is there and I know that that issue is being studied in several centers. Look for some good data soon.

I was referring to the colorimetric, qualitative CO2 detectors we use here in the third world. They won't indicate on many of the dependently livid nursing home disasters we get.

 

[viostorm]

I was referring to the colorimetric, qualitative CO2 detectors we use here in the third world. They won't indicate on many of the dependently livid nursing home disasters we get.

Has this been validated? Anecdotally I have had very good success with them on anyone who was living within the last 20 minutes prior to use.

Everyone here probably knows my opinion on EMS intubation. Ideally, I'd like to tattoo "I refuse intubation by EMS" on my chest.

 

[MedicFL]

"Everyone here probably knows my opinion on EMS intubation. Ideally, I'd like to tattoo "I refuse intubation by EMS" on my chest."

Co2 detectors can be very off, the longer a person has been down the less accurate they often times are. We only use them as a back up if capnography goes down...


No offense but it seems that many people that have never worked in EMS have this stance, while I will admit there are very bad medics that tube, there are very good ones as well. I am on the flight team we rotate through the OR once or twice a year, I get called down to the ER to aid in difficult tubes quite often. No offense to you, I respect that your a medical student, which is ahead of me but coming in is an Intern with an attitude like that esp in the ER you are going to have a tough time.

 

[docB]

Has this been validated? Anecdotally I have had very good success with them on anyone who was living within the last 20 minutes prior to use.

And the people I'm talking about are the typical "Found down at the nursing home, last seen yesterday" type patients.

 

[viostorm]

No offense but it seems that many people that have never worked in EMS have this stance, while I will admit there are very bad medics that tube, there are very good ones as well.

This is a ridiculous statment, that is like saying its ok to use a medicine although some batches will kill you and some may save you. This would never be tolerated in a pharmaceutical industry.

The main point is here we don't apply the same rigorous evaluation of paramedic intubation that we do to other skills and/or drugs. No way would this be approved if it were held to the same standards pharmaceutical testing was.

I strongly believe more people die when paramedics intubate then if they don't. This is based on my own observation with 11+ years in EMS and review of current evidence.

No offense to you, I respect that your a medical student, which is ahead of me but coming in is an Intern with an attitude like that esp in the ER you are going to have a tough time.

Still working as a paramedic, CCEMT-P, throughout medical school. Paramedics with a cavalier attitude about intubation that don't understand the evidence behind it won't get far with me and will have a tough time.

 

[MedicFL]

I could say the same about Dr's as well, I have seen some that can intubate very well and I have seen some that can't, I would agree with you that there needs to be a higher standard, some systems I have seen have a great standard and some don't. EMS systems vary to much system to system to generalize. Holding those medics to a higher standard would be a good start. And as to your caviler attitude comment I agree but the problem is medic training and continuing education. I know the new research isn't showing great out comes, but a successful tube whether is be in the ED or the rig is still a successful tube. If new devices come out that have the same success rates with fewer complications that is great. Again a word of advice your not yet even a resident, I work at a academic center with a great residency program we see new interns every year that come in with the same attitude as you are displaying here, just chill out. You made you going to be a Doc but your not the only one that knows a thing or two.....If you would like to pm me I will be happy to share all the studies and research I have gathered on the topic. A couple I have co authored, and to agree with you again my system is currently studying alternatives to ET's such as the king LT and others.

 

[leviathan]

A couple I have co authored

Ugh...I hope someone proofread your drafts!

 

[MedicFL]

Ya ya, typing on here from the blackberry I just kind of flew through it, sorry for the lacking grammar and punctuation......

 

[Cooperemtb]

EMT-Bs can practice Intubation in SC, though many services won't allow it. I think we would be better off leaving it as an als skill.