canjosh said:
As for places that don't let the medics intubate because they're no good at it...that is absolutely 110% the fault of their medical direction. Laryngoscopy is a technical skill that can be taught to a child. Get their butts in the OR with an anesthesiologist or CRNA and let 'em have at it. Most medics simply don't get enough 'practice' doing intubations, I think that we should have to do a certain # per year on real patients with an airway expert (anesthesia) to stay up to speed.
There is evidence that you need about 10-15 intubations to get accustomed to the anatomy, and then at least 100 to become decently proficient at inbuation. Perhaps our anesthesiology colleague can comment on this, but this is what I've been told by one of our anesthesiology attendings.
The problem is (1) most paramedic programs do poor jobs of getting enough intubations in real patients during training, (2) there aren't enough pre-hospital intubations to keep skills proficient, and (3) there are too many paramedics in most systems that further dilute the available procedures.
Even in busy systems, the average paramedic probably intubates less than 5 times per year. In systems where there is an overabundance of paramedics (i.e., ALS first response, double paramedic transport units, all ALS units and no BLS transport units, etc.), then the procedures available per paramedic is even lower.
There are several ways to address this: (1) lower the number of paramedics in a system (i.e., limit ALS first response procedures; eliminate all ALS units), (2) substitute field intubations with OR intubations, or (3) limit intubations done by paramedics.
Nobody will probably limit intubations on adult cardiac and respiratory arrest patients unless there is a high incidence of unrecognized esophageal intubations (see the Orlando data). However, pediatric intubations are few and far between, and the study by Gausche, et al., demonstrates no change in survival with pre-hospital intubation of pediatric patients. Therefore, this skill should probably be limited to systems that maintain high pediatric intubation rates (i.e., pediatric transport units) and not be routinely performed in all paramedic systems.
RSI seems to be associated with increased mortality rates, which has mainly been studied in the head injury population. Is it the fact that patients desaturate during "easy" intubation attempts? Or is it related to the procedure itself, even without desaturations and bradycardia? Nobody knows. For all we know, RSI in head injured patients might worsen outcome even if performed in the ED! This needs to be studied, but because it's so routinely practiced and pretty much a standard of care to intubate patients with a GCS <9, it's doubtful that an institution review board would approve such a study.
In summary, I support pre-hospital intubation of adult cardiac and respiratory arrest patients. I do not support pre-hospital intubation of pediatric patients or rapid sequence induction of trauma or medical patients. Yes, both can be performed safely in some systems, but it is not associated with improvements in survival.
There should be an active QA process whereby paramedics should obtain at least 5 intubations every six months. This can be supplemented by OR experience, but might be limited in certain areas due to students competing with practicing paramedics for practice/learning. Systems with high unrecognized esophageal intubation rates should NOT perform endotracheal intubation as this is a legal nightmare.
As always, this is just my two cents.
