EMT-B intubations

In Minnesota, EMT-Bs are trained in the use of the dual-lumen airway called the Combi-Tube. Local protocols vary, and in some parts of the state, EMT-Bs do intubate.

It really all comes down to proficiency. If you are in a system with few ALS providers and the BLS crews are stuck with LOTS of airway problems then it may be a good idea. As for the dual lumen airways they are a good alternative as they are a blind skill that is designed as a rescue device. In the area I work there are ALS providers on almost every truck or at least within 10 minutes travel time. For us the idea of ALS airway skills for BLS providers is not functional.

On a personal note, there are a few ALS providers I know whom I do not trust and the idea of some of the BLS providers I know placeing an ET tube scares the hell out of me. This does not pertain to all, but just a few screw ups can destrroy a good idea.

part of the emt-b cirriculum in nebraska includes 'advanced airway management' i.e. sticking in et tubes miller and mac blades. now as to whether your medical director will let you do that is another issue.

In CT EMT-I's can use combi-tubes depending of course on the approval of their medical director hospital. Usually, they can only be used if there are airway problems and an oropharyngeal airway won't due or medics are not available or more than 10 mins. out.

I had heard a rumor that EMT-B's could intubate in Virginia, but I have no idea if this is true.

Febrifuge said:

In Minnesota, EMT-Bs are trained in the use of the dual-lumen airway called the Combi-Tube. Local protocols vary, and in some parts of the state, EMT-Bs do intubate.

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OY the combi tube! I haven't used one of those in a long long time!

EMT-I school isn't that long. I took it 2 nights a week for 3 months. Wouldn't that be easier than to trust EMT-B's with tubes? Combitubes are fine for them. Send them to EMT-I school. Then you can have ALS trucks.

you can teach a monkey to intubate..............i say more power to 'em.

i think it is harder doing one handed BVM with good technique and adequate ventilation personally.

later

I assume you're talking about Chicago EMS. Chicago doesn't recognize EMT-I, and it's not an isolated area. Do you want hypothetical feedback, or one more specific for your location?

12R34Y said:

you can teach a monkey to intubate..............i say more power to 'em.

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Apparently you can't teach some paramedics to intubate. I'm specifically referring to the Katz, et al. study from Orlando. 28% undetected esophageal/hypopharyngeal intubation rate.

Quite frankly, I think EMT's have no business intubating. Paramedics have difficulty enough, so why should we expand it to basic and intermediate EMT's? If you want to intubate, become a paramedic.

Robz said:

OY the combi tube! I haven't used one of those in a long long time!

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So I shouldn't even mention the EOA, should I??

While anyone can learn a specific skill, EMT Basics lack training in the respiratory physiology that forms the didactic foundation for the necessity of intubation.
Thus, though "how" could easily be taught in an hour or so, the "why" and "when" cannot. Thus, I say, teach EMT-Basics how to intubate, but reserve the protocol for "on or under order by a physically present EMT-I or EMT-P except for certain situations such as cardiac arrest". This would allow the paramedic to be free doing other interventions during busy calls such as cardiac arrest, trauma, respiratory distress etc., but would prevent the lone EMT-B from performing said skill during questionable calls such as the borderline CHF patient who requires more advanced medical assessment and judgement to arrive at a final treatment plan.
The paramedic would also be responsible for final checking of tube placement, much as a pharmacist is responsible for final checking of all med fills performed by a pharm. tech.

Two studies from the Annals of Emergency Medicine:

Ann Emerg Med. 1998 Jul;32(1):26-32.

Prehospital oral endotracheal intubation by rural basic emergency medical technicians.

Bradley JS, Billows GL, Olinger ML, Boha SP, Cordell WH, Nelson DR.

Emergency Medicine and Trauma Center, Methodist Hospital, Indianapolis, IN, USA.

STUDY OBJECTIVE: To determine whether basic emergency medical technicians (EMT-B) can perform prehospital oral endotracheal intubation with success rates comparable to those of paramedics. METHODS: This was a nonrandomized, controlled trial using historical controls. Seven basic life support emergency medical services systems in six counties and their corresponding emergency departments in rural Indiana participated. Eighty-seven full-time EMTs with no prior or concurrent paramedic training volunteered for intubation training. Apneic prehospital patients aged 16 years or older without an active gag reflex or massive facial trauma were eligible for intubation and study enrollment. The EMTs completed a 9-hour didactic and airway manikin training course in direct laryngoscopic endotracheal intubation. The course was adapted from the national paramedic curriculum. RESULTS: Thirty-four (39%) of the EMT-Bs attempted to intubate 57 eligible patients. In 49.1% of these patients, successful endotracheal tube placement was confirmed by the receiving physician (95% confidence interval, 36.4% to 61.9%); in contrast, the prehospital intubation success rates from three previous studies of manikin-trained paramedics ranged from 76.9% to 90.6% (P < .001). Complications included five (9%) inadvertent extubations, two endotracheal tube cuff ruptures, two prolonged intubation attempts, and one mainstem bronchus intubation. There were no unrecognized esophageal intubations. Two of the seven EMS agencies did not report any intubation data. CONCLUSION: Rural EMTs with didactic and airway manikin training failed to achieve prehospital intubation success rates comparable to those of paramedic controls. Possible explanations include training deficiencies, poor skill transference from manikin to human intubation, infrequent intubation experiences, and inconsistent supervision.




1: Ann Emerg Med. 1998 Feb;31(2):228-33.

Field trial of endotracheal intubation by basic EMTs.

Sayre MR, Sakles JC, Mistler AF, Evans JL, Kramer AT, Pancioli AM.

Department of Emergency Medicine, University of Cincinnati, USA. [email protected]

STUDY OBJECTIVE: The 1994 basic-EMT (EMT-B) curriculum recommended teaching EMT-Bs the skill of endotracheal intubation. In this study we assessed the success and complication rates of endotracheal intubations in the field by EMT-Bs. METHODS: We conducted a prospective clinical trial over a period of 28 months in an urban out-of-hospital EMS system. Four first-responder EMT-B engine companies with paramedic backup received 10 hours; intubation training in three sessions spread over at least 2 weeks. The training module was similar to that of the 1994 EMT-B curriculum and included at least 10 intubations on manikins. The EMTs used manikins with closed chest cavities to learn assessment of endotracheal-tube placement. Patients were eligible for intubation by the EMTs if they were apneic and older than 15 years. We calculated 95% confidence interval (CIs) for intubation success rates. RESULTS: Sixty-six EMT-Bs passed the training examinations and were authorized to perform intubation in the field. Endotracheal intubation was attempted by EMTs in 103 patients; the attempt was successful in 53 (95% CI, 42% to 61%). All patients who were not intubated by EMT-Bs were intubated by paramedics, with the exception of six cases. One attempt at intubation was made in 52 patients, two attempts in 44, and three in 7. Three unrecognized esophageal intubations occurred. CONCLUSION: EMT-Bs trained in a short course successfully intubated about half the patients they encountered in this study. This low intubation success rate calls into question the validity of the endotracheal-intubation training module in the 1994 EMT-B national curriculum.

I agree that there needs to be more training -- the studies indicate that the current national standard EMT / EMT-I curriculum is not sufficient for ET Intubation. Currently in NYS, you can become an EMT-I (who is allowed to intubate and start IV's) without ever intubating or starting an IV on a real patient, only a couple attemps on practice mannikins, as in the studies. I can intubate a manikin in 9 seconds with 100% success rate, but I think a real patient is a different story. This is even scarier since NYS is planning on getting rid of EMT-I, and giving all those skills to EMT-B. (Probably still a few years off though.) Anyone certified to intubate should have done it on real patients, multiple times, as Paramedics do.

Also I do not have access to the articles currently, but so I can not evaluate the phrase "in contrast, the prehospital intubation success rates from three previous studies of manikin-trained paramedics ranged from 76.9% to 90.6% (P < .001)." Does this mean that the paramedics were trained solely on mannikins, and there is some other factor accounting for the EMT's low success rate? Anyone who has access to the article, it would be interesting to see how the control group of paramedics was trained vs. the EMT's....

[EDIT by EMT036]:

Some more information... Arizona looks like they have started to allow EMT-B's to intubate:


R9-25-808. Protocol for an EMT-B to Perform Endotracheal Intubation

A. Endotracheal intubation performed by an EMT-B is an advanced procedure that requires medical direction.

B. An EMT-B is authorized to perform endotracheal intubation only after completing training that:

1. Meets all requirements established in the EMT-B Endotracheal Intubation Training Curriculum, dated January 1, 2004, incorporated by reference and on file with the Department, including no future editions or amendments; and available from the Department's Bureau of Emergency Medical Services; and

2. Is approved by the EMT-B's administrative medical director.

C. An EMT-B shall perform endotracheal intubation as:

1. Prescribed in the EMT-B Endotracheal Intubation Training Curriculum, and

2. Authorized by the EMT-B's administrative medical director.

D. The administrative medical director shall be responsible for quality assurance and skill maintenance, and shall record and maintain a record of the EMT-B's performance of endotracheal intubation.


Among the requirements of the training cirriculum are:

3. Attempted a minimum of 3 endotracheal intubations in the prehospital setting.

4. Performed a minimum of 1 successful endotracheal intubation in the prehospital setting.

Big Papa said:

I think those studies say that the EMTs were not trained enough to perform intubations. I know that paramedics perform intubations on live patients in both the hospital and the ambulance during their schooling. Maybe there would have been better results if the EMTs were trained better?

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How much training do we give the EMT-B? Give them too many hours of training and they can sit for the EMT-Paramedic exam.

Intubation is a skill I learned in paramedic school (and EMT-CC school aka AEMT #3 in NYS) both on the manikin and then in the OR under controlled conditions under an anesthesiologist's guidance. Successful completion of this phase allowed us to attempt intubation in field training under experienced ALS providers during ambulance rotations. All in all we spent a hell of a lot more than 9 hours learning intubation skills. I'd imagine that other medic training programs are just as rigorous. This may account for the great disparity between the EMT-B intubations and the EMT-P intubations. A few years ago, the EMS in my county attempted an EMT-B intubation program (called it EMT-Critical Trauma Care) aside for the relatively infrequent use of the skill, the success rates were also not so good.

Seriously though, I'm sure you guys know of more than one drooling idiot who got through EMT-B training. You know who I'm talking about, the guy who took 3 tries to get through the practical exam or the sort of person who has a snow ball's chance in hell of getting into or through a medic program. Would you really trust this person with a laryngoscope and an ET tube on your family members. I shudder to think that one of these blithering *****s might belly-tube a loved one and never recognize it because he doesn't know lungs sounds from bowel sounds from heart sounds from siren noise. There are some siren and radio enthusiasts out there with very little education, little academic aptitude, and scary skills. Thank Goodness that they can only kill so many using BLS techniques, give them a skill like intubation and many more are doomed. Just my $0.02 Stay safe everyone!

bstone said:

In Illinois, EMT-B are trained and licensed to intubate. Working as a Chicago region EMS we are allowed to use combi-tubes (and my service stocks them in the rigs). As a volunteer with IMERT (Illinois Medical Emergency Response Team) I am equiped and allowed to do intubations (and a bunch of other ALS stuff). I do believe that with the proper training EMT-Bs should be and can successfully do endotracheal intubations. Right now, however, the training is a bit lax.

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Hey bstone,
How much longer was your training beyond the minimum 110 hours of BLS? Do you do just combi-tube, or do you also do regular ETI? Specifically, how long was the intubation training, how many hours did you spend on manikin, Operating room, and field rotations training with ET intubation.

Hey bstone,
Did you feel well prepared with the training you received? How often is the skill utilized by BLS providers? How is the success rate? It just seems that not every EMT should be trusted with this particular skill, you know? IVs, who really cares, but an airway is an airway. I hope there is a weeding out process among emt-b's seeking this additional endorsement. I'd really hate to see a weak EMT trusted with this skill.

No matter what you title is, in order to effectively intubate the trachea you need some hours of class, 15-30 controlled environment successes, some more in the particular field of operation and finally quality assurance from there.

Outside of some class time I doubt the EMT's in the Annals of EM studies were given much else. It strikes me that rather than concluding EMT's can't perform the task well, it illustrates that anyone can do poorly with it when sent to do it without adequate training.

Which leads back to the point of paramedic class.

Take Care!

While, nationally, as with all medicine in the U.S., it comes down to federal, state, and local laws, then the physicians and his delegates set fourth what and EMT-B can and cannot do.

In rural WY, EMT-Bs (with specific training and physician consent),can intubate with a combi-tube, administer basic IV meds and fluids, phlebotomy, and other advanced skills come along per county and per physician.

Would I let an EMT-B... probably not.

6 months of training (112-120) hours is far too few for the basic provider to sufficiently deal with the possible outcomes. Physiology here is minimally important (MINIMALLY, not completely unimportant).. (but not as important as other posts suggest), what is important is medical compentency. Sure you can shove a tube down someones throat as with the combi, or other method.... but what happens when there's and esophageal or tracheal tear? What if the patient had varices that rupture during intubation etc etc etc. How would the basic provider 'provide' for this patient? Drive faster.

There are several studies showing that this, as well as different skills at different levels are not in the patients best interests... but we need to ask ourselves, where do we draw the line in being macho and getting to preform doctor like skills that may not benefit the patient, and foregoeing the ego on the patients behalf?

BB

Exactly. All too often, the new EMT or paramedic, sees a skill being performed by someone of a higher skill level, and assumes that, if taught given the opportunity to learn that skill, then they should be allowed to incorporate it into their current licensure level. The problem is when their knowledge (or lack of thereof) is insufficient in the realm of the "why", "when", and "where" as well as what the prev. poster mentioned about how to deal w/ any potential complications.
I.E. EMT-B's wanting to intubate, or paramedics wanting to do something such as abd. pericentesis.
In both cases, though the skill could be taught to a monkey, the didactic knowledge is insufficient in order to provide the patient the appropriate safety net warranted.

To me that's what it boils down to. Basic = Basic Placing an endotracheal tube is not a basic procedure, period.

Also, when you talk about intubating someone, a Combitube isn't it. Sorry. We used to use the old esophageal airways 25-30 years ago when they were popular. They were a very poor 2nd choice, but pretty much a blind airway technique, easily taught and requiring minimal technical skills. The Combitube is not a great step up from that, IMHO.

If you want to learn how to intubate and use advanced skills, go take the full paramedic course. It's worth it. You'll learn much more of the "why" of things, and not just a knee-jerk, "cookbook" response. I used to have paramedic students in an associate degree program work with me in the OR learning how to intubate. They were great students. It's a much more controlled environment to learn under, much better than a mannequin, and you can learn some tricks and techniques by working with anesthetists and anesthesiologists who do this every day that you simply can't learn from someone who puts in a couple tubes a month.

And don't think you're great when you get in a tube or two and think you're an expert. We can all be humbled. I forgot how difficult it is putting a tube in in the field compared to the OR until a paramedic reminded me if the patient is on the street, you gotta get on your belly to be able to see, as he showed me when I didn't get the tube in and he did.

Though I am no longer a medic, B equaling Basic depends on the state, county, city in which you live, and who is your medical director.

For example, in Wyoming, limitations are few, and basically comes down to the physician. I was both an industrial and emergency EMT, with the same physician advisor. As an industrial EMT-Basic, we could endotracheally intubate, administer medications, IV,IM,Sub-Q, all of the ACLS meds, defibrillate manually and the list goes on... skills somewhere between intermediate an paramedic.

As a emergency (ambulance) EMT, our skills were severely limited to driving, cleaning, chest compressions, basic limitations.

This may seem odd, but it is how the first paramedics were taught, with a physician showing them how.

I don't necessarily agree with this, however, for any level of care. Basic to Paramedic, I think in the United States our EMS personnel are extreemely under/uneducated... and then they complain that they don't get paid enough. Excellent examples of where we SHOULD be but are not are Austailia, Canada, and most of Europe, they require paramedics to complete a Bachelor's degree program in Paramedicine before they can practice. And their pay reflects it too, 40,000 to 70,000.

I, and many, would feel more at ease with personnel who were higher trained, but, of course, this would mean that they'd get paid more, and cost more, and since our healthcare system is a piece of POO right now, its not going to happen.

B

emedpa said:

jwk-
as a former medic I would like to thank you for taking the time to precept medic students in the o.r., many of your colleagues don't.
I have learned some great techniques from mda's and midlevels that I try to pass on in my acls courses. you never know who is going to be working up a friend or family member in a ditch at the side of the road someday so I try to make sure all my students are proficient at standard intubation, bag valve mask use, sellicks maneuver, inverse intubation,intubating while prone, etc
were you a medic and/or PA before becoming an AA? I have talked to some of your colleagues at the aapa conventions and it seems like a great field to go into right now, especially if one is already a pa as you can then work in a variety of settings outside the o.r. such as icu, etc.

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Actually I was a paramedic all through college. It was probably the most fun job I ever had. Unfortunately, the pay is not great for the time involved or I might still be doing it. I enjoyed teaching paramedic students - we had a highly regarded EMS associate degree program in SW Georgia that was run by a good friend of mine. Those medics get a great education and a lot of good clinical exposure during their program.

There have been several PA's go through the AA program. They do very well with their background.

Anesthesia is a good field to get into, regardless of the route taken, and despite all the bickering between MD's, CRNA's, an AA's.

bennyhanna said:

Though I am no longer a medic, B equaling Basic depends on the state, county, city in which you live, and who is your medical director.

For example, in Wyoming, limitations are few, and basically comes down to the physician. I was both an industrial and emergency EMT, with the same physician advisor. As an industrial EMT-Basic, we could endotracheally intubate, administer medications, IV,IM,Sub-Q, all of the ACLS meds, defibrillate manually and the list goes on... skills somewhere between intermediate an paramedic.

As a emergency (ambulance) EMT, our skills were severely limited to driving, cleaning, chest compressions, basic limitations.

This may seem odd, but it is how the first paramedics were taught, with a physician showing them how.

I don't necessarily agree with this, however, for any level of care. Basic to Paramedic, I think in the United States our EMS personnel are extreemely under/uneducated... and then they complain that they don't get paid enough. Excellent examples of where we SHOULD be but are not are Austailia, Canada, and most of Europe, they require paramedics to complete a Bachelor's degree program in Paramedicine before they can practice. And their pay reflects it too, 40,000 to 70,000.

I, and many, would feel more at ease with personnel who were higher trained, but, of course, this would mean that they'd get paid more, and cost more, and since our healthcare system is a piece of POO right now, its not going to happen.

B

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I assumed basic meant basic, i.e. an entry-level EMT. Somehow all the ACLS interventions just don't seem to go along with that, although obviously anyone involved with pre-hospital care should learn as much as they can about their field.

Is EMT-B a higher level than what I am assuming? The national registry was in it's infancy 30 years ago when I went through all this, and I know each state has it's own designations - EMT, EMT-P, MEMT, etc., and they don't all mean or imply the same thing. Similarly, each state has it's own allowable scope of practice, and I won't pretend to know about all those.

Well, nationally, there are standards set for each level... Basic, (the lowest) Intermediate, and Paramedic. What one can to at each level depends on state laws, local laws, and physicians.

Some states are very involved in who can do what, and leave the physician no room for expanding/limiting scope of practice.

Some are not. i.e. Wyoming. They basically follow the National DOT curricula for a baseline of what medics of any level can do. Then, it falls upon the medical supervisor to expand or limit scope of practice. So, technically, and legally, Basics in some states, with direct training and supervision by a physician (being under his/her insurance) can practice at a paramedic level, and even do skills not covered in any EMS curricula.

This would mean we could administer some meds that paramedics in other states could not etc... but all responsibility fell on the physician, which is why this is rare, but does occur in more underpopulated states such as WY, where there are only 19 paramedics in the whole state, so scope of practice is expanded to compensate (also, in WY RNs do not practice in EMS as they do in bigger cities).

Still, I do not agree with it, if a Dr. is willing to be liable, then so be it. But, it tempts me to get into why the healthcare system of WY is one of if not the worst in the U.S.... that's another post.

Bb

I am not a big believer in the notion that a medic is all that more trained than an EMT. I learned everything back a$$ward anyway. I was a military medic before I even took my EMT and paramedic courses, but in 13 short weeks of military medic school I was doing everything and more that I could ever do as a paramedic, with few exceptions. The only real "upgrade" so to speak for me was dysrhythmias. But as for tubing, in the service we were taught basic EMT skills along with chest thoracentesis, cric's, IV's, and ET tubes. All of these things can be taught easily and outside the spectrum of paramedic training. The bottom line is that tubes save lives, and bagging a patient with an OP airway is 10 times harder and more dangerous. Tubing is simply one of those skills that medics have held onto and they aren't (we aren't) going to let it go without a fight. That is how things go in all areas of medicine. As docs we are not going to allow PA's to do unassisted general surgery, but that could even change one day. Times usually change things for the better.

niko327 said:

Seriously though, I'm sure you guys know of more than one drooling idiot who got through EMT-B training. You know who I'm talking about, the guy who took 3 tries to get through the practical exam or the sort of person who has a snow ball's chance in hell of getting into or through a medic program. Would you really trust this person with a laryngoscope and an ET tube on your family members. I shudder to think that one of these blithering *****s might belly-tube a loved one and never recognize it because he doesn't know lungs sounds from bowel sounds from heart sounds from siren noise. There are some siren and radio enthusiasts out there with very little education, little academic aptitude, and scary skills. Thank Goodness that they can only kill so many using BLS techniques, give them a skill like intubation and many more are doomed. Just my $0.02 Stay safe everyone!

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I'm sorry but this is kind of rude...i'll take it step further and you see how it feels. Any drooling idiot can get through EMT-P training too. So many "para-gods" out there think they are God's gift to pre-hospital care...or worse, God himself!!! Guys...get over yourselves. I've been through it, I work in EMS and we are not the best thing since sliced bread.

While there are incompetent Basics, there are also incompetent Paramedics. And from my experience, many of them acquire the cocky physician attitude some physicians choose to take.

I feel no more comfortable with an EMT basic tubing than I do with a paramedic. An undergraduate level of anatomy and physiology an EMT P may take, I feel, does not qualify him to perform such skills.

Countless studies show the effectiveness of pre-hospital tubing vs. hospital tubing. to be of no benefit. In some extreme and strictly pre-defined scenerios, it should be allowed, but other than that, paramedics generally over tube.

Not that they can't adequately perform the skills, BoBo the chimp can do an equally adequate job. It's when patient condition, history, medications on board, presentation etc. come into play that an advanced provider would need to think critically at and ABOVE the U.S. standard of EMT-P care and provide treatment. Undergratuate anatomy and physiology cannot equip the medic to accomplish these tasks. Neither can skills oriented training. All of this 'How-To' training leads many medics to think they can diagnose, and often do, though no longer a part of their curricula.

So we walk a fine line of quality versus quantity (quantity of our money). U.S. healthcare sucks. Until we are willing to fork out the money for higher quality healthcare professionals, we are stuck with what we've got. And when we've rolled our vehicle over in a ditch and are bleeding to death, it is either a paramedic or nothing. (Ahhh it would be nice to be greeted by a physician and trauma nurses like in Britian.) So, since we like our money in our pockets, we gamble on not getting hurt, but insist on keeping mediocre care in place for when we do. Its quite a clusterf#$K.

Bb

The problem Benny is that our country has a few more square miles than Britain and France. You can't make enough EM physicians and then make it cost effective to put them on ambulances.

And since the BVM is soon rumored to be changing to a IIb intervention in ACLS due to the fact that few people can use it correctly, it actually makes more sense to teach basics how to intubate. I can tell you that I plan to be a rural EMS director as well as an FP, and I will teach my basics how to do both IV's and ET tubes. It should be adopted as part of the DOT curriculum.

OSUdoc08 said:

EMT-I school isn't that long. I took it 2 nights a week for 3 months. Wouldn't that be easier than to trust EMT-B's with tubes? Combitubes are fine for them. Send them to EMT-I school. Then you can have ALS trucks.

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This depends on your local protocols. Nebraska is currently in the process of dropping the old '85 curriculum which OSUdoc08 is referring to. Currently in Nebraska, EMT-B's are being trained with intubation and IV fluid therapy. The new EMT-I includes nearly everything the old paramedic program included, but now it takes a year to get through and the paramedic program includes advanced clinical skills such as suturing, chest tubes and other more invasive proceedures. To answer your question, I think it's a great idea for EMT-Bs to be able to intubate. There are patients who don't have access to major ALS squads that need that kind of intervention. Case in point, a patient I did a rural meet on was in anaphylactic shock. Had the EMT's been able to intubate right away, it would have been wonderful. As it was, it was the most difficult tube of my life. But as nebraska is finding out, it takes a very aggressive medical director to be willing to put intubation and IVs into the protocol.

bennyhanna said:

While there are incompetent Basics, there are also incompetent Paramedics. And from my experience, many of them acquire the cocky physician attitude some physicians choose to take.

I feel no more comfortable with an EMT basic tubing than I do with a paramedic. An undergraduate level of anatomy and physiology an EMT P may take, I feel, does not qualify him to perform such skills.

Countless studies show the effectiveness of pre-hospital tubing vs. hospital tubing. to be of no benefit. In some extreme and strictly pre-defined scenerios, it should be allowed, but other than that, paramedics generally over tube.

Not that they can't adequately perform the skills, BoBo the chimp can do an equally adequate job. It's when patient condition, history, medications on board, presentation etc. come into play that an advanced provider would need to think critically at and ABOVE the U.S. standard of EMT-P care and provide treatment. Undergratuate anatomy and physiology cannot equip the medic to accomplish these tasks. Neither can skills oriented training. All of this 'How-To' training leads many medics to think they can diagnose, and often do, though no longer a part of their curricula.

So we walk a fine line of quality versus quantity (quantity of our money). U.S. healthcare sucks. Until we are willing to fork out the money for higher quality healthcare professionals, we are stuck with what we've got. And when we've rolled our vehicle over in a ditch and are bleeding to death, it is either a paramedic or nothing. (Ahhh it would be nice to be greeted by a physician and trauma nurses like in Britian.) So, since we like our money in our pockets, we gamble on not getting hurt, but insist on keeping mediocre care in place for when we do. Its quite a clusterf#$K.

Bb

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I'm not even going to touch on how much I disagree with this statement. Your ignorance towards EMS is grossly misplaced and you have no idea how well paramedics are being trained. Do a little more hands-on research before you post such a strong opinion again.

PACtoDOC said:

I can tell you that I plan to be a rural EMS director as well as an FP, and I will teach my basics how to do both IV's and ET tubes.

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Just make sure they have the LEGAL authority to actually use IV's and intubate. Otherwise, you're leaving yourself liable if you delegate that task to them and something happens.

medicMD said:

the paramedic program includes advanced clinical skills such as suturing, chest tubes and other more invasive proceedures.

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Explain to me why a paramedic would be suturing and placing chest tubes. That borders on absurd.

Suturing is simply NOT something that needs to be done in the field. Chest tubes should not be placed in the field. A needle decompression is one thing - but a chest tube? You've got to be kidding.

Maybe I'm behind the times, but some things simply aren't appropriate in the field. There are some skills that are beyond what a paramedic should be doing given their educational level and technical ability. You're moving into areas that involve a whole lot more knowledge of anatomy and physiology and management of complications than a typical (or even an exceptional) paramedic possesses. Paramedics are not physicians.

Besides that, many of these skills require constant practice that someone who does a procedure a few times a year simply can't get. I've seen one surgical airway in 25 years of anesthesia because we can't get the tube in. Yet there are far too many surgical airways in the field because a tube can't be placed. Why? Because endotracheal intubation is a difficult skill that requires lots of training and ongoing practice, and those who only intubate on a real patient once every month or two simply cannot maintain that skill level.

We deal with "acceptable risk" every day in surgery. People who live 100 miles from the nearest doctor or 200 miles from the nearest hospital are making a choice about what is an acceptable risk to their own welfare. Having paramedics suture and place chest tubes as an alternative to closer healthcare strikes me as an unacceptable risk.

Like I said, maybe I'm behind the times. I was in EMS in a very aggressive program where the hospital wanted to make a name for itself and it's pre-hospital care. 25 years ago, at the time I moved on to anesthesia, this hospital was training it's paramedics to place trans-thoracic pacemakers in the field (there were no external pacers then). Back then that was on the edge.

It would be nice to have well trained emergency physicians at every ALS call, but it simply isn't possible in this country. Trying to teach paramedics highly invasive techniques that they can't maintain an acceptable level of expertise at, and that in most cases would fall outside their legal scope of practice, is not the answer.

Lets be serious. EMS is actually not a highly litigious environment, and what the EMS director decided is usually the "law". Local protocol can be created to adapt to the environment and its true needs. You can't always wait around for some legislative or department of health to say that its okay for a basic EMT to do something. You'll find yourself waiting around forever in this case. For a litigation to be successful, there has to be action that resulted in harm. Its hard to argue harm was done to someone already basically dead or close to it. If all you have are rural EMT's, it makes no sense to restrict them to bagging someone which is a much more difficult skill, when they probably have to drive miles and miles to get to the hospital. To me it actually makes more sense that you could be held responsible for not teaching basics how to do such a simple skill (relatively simple) and putting a patient at risk with an OP airway that is unsecure. There is a much greater risk of getting sued as an FP for something really stupid in your office than as the EMS director when some bad outcome occurs in the field. Because everyone leaving an FP office is stable but always has the ability to crash later due to something you did. If someone is basically dead when you start working on them, it is so much more difficult to assess whether or not "harm" was done. And in Texas with tort reform now on the books, its even more difficult.

medicMD said:

I'm not even going to touch on how much I disagree with this statement. Your ignorance towards EMS is grossly misplaced and you have no idea how well paramedics are being trained. Do a little more hands-on research before you post such a strong opinion again.

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I stand by my statement. How well paramedics are trained is a matter of opinion, and the effects of the skills they perform can be debated. EMS Magazine, JEMS, JAMA, NEJM, all have conflicting evidence, but mostly do NOT favor these skills in doulble blind tests as life savers.

I have taken the course, and found the amount of knowledge learned is... well, not enough to get a cocky attitude and think you're better than a nurse and a freaking doctor.

However, I make an exception in Military medics. This is a standard that should be strived for. Most truly know WHY they are doing what they are doing, and what to do if **** goes wrong. Whereas a civilian medic knows skills .. .. period.

~Bb

PACtoDOC said:

Lets be serious. EMS is actually not a highly litigious environment, and what the EMS director decided is usually the "law". Local protocol can be created to adapt to the environment and its true needs. You can't always wait around for some legislative or department of health to say that its okay for a basic EMT to do something. You'll find yourself waiting around forever in this case. For a litigation to be successful, there has to be action that resulted in harm. Its hard to argue harm was done to someone already basically dead or close to it. If all you have are rural EMT's, it makes no sense to restrict them to bagging someone which is a much more difficult skill, when they probably have to drive miles and miles to get to the hospital. To me it actually makes more sense that you could be held responsible for not teaching basics how to do such a simple skill (relatively simple) and putting a patient at risk with an OP airway that is unsecure. There is a much greater risk of getting sued as an FP for something really stupid in your office than as the EMS director when some bad outcome occurs in the field. Because everyone leaving an FP office is stable but always has the ability to crash later due to something you did. If someone is basically dead when you start working on them, it is so much more difficult to assess whether or not "harm" was done. And in Texas with tort reform now on the books, its even more difficult.

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Interesting perspective. But how do you feel about suturing and chest tubes as a previous poster indicates is being done in his area? Don't you think that's too far outside a paramedic's acceptable scope of practice? Someone isn't dead to start with if they need suturing, and a complications from a chest tube are a whole lot more significant than a 14 gauge needle in the chest.

PACtoDOC said:

I can tell you that I plan to be a rural EMS director as well as an FP, and I will teach my basics how to do both IV's and ET tubes. It should be adopted as part of the DOT curriculum.

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Right on. You would probably do well to do that, especially if you are directly involved in their education... not to many EMS physicians are, and are many times physicians in another field with the tite EMS physician, or medical director so the town/city can have an ambulance... In smaller towns where "any physician will do" as long as he/she has, MD after their names, it seems they are there just for the extra paycheck.

You, as a former medic, would know best what should be taught.

I also think it is absurd to think that paramedics need to be suturing anything in the field. And chest tubes are never a necessary thing in the field. Needle decompression is an asset but chest tubes??? nuts!! Paramedic organizations, like all other allied health organizations, always find it necessary to try and take a little more scope of practice away from the physician. PA's and NP's can get away with this, but a paramedic? Lets not kid ourselves into thinking that a paramedic has any real pathophysiology training or any true anatomy background.

As a current paramedic and medical student, in a month, I have to agree that the whole chest tube/suturing thing is WAY outside of the clinical scope of practice for an EMT-P. I have been doing this for almost a decade, and have never seen the need for either of these skills. They belong in the hospital with those who have the knolege base to manage the side effects/complications of these and other skills that do not have an immidiate bearing on life and limb. In essance it is that the job of a medic to protect life and limb, if it does not fall under this then there is no need in the bus. Just my humble opinion.

Keberson said:

I'm sorry but this is kind of rude...i'll take it step further and you see how it feels. Any drooling idiot can get through EMT-P training too. So many "para-gods" out there think they are God's gift to pre-hospital care...or worse, God himself!!! Guys...get over yourselves. I've been through it, I work in EMS and we are not the best thing since sliced bread.

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Keberson,
First off let me tell you that the majority of EMTs I've worked with are great providers and competent, so please don't think I meant that drooling idiots abound amongst the ranks of BLS providers. But I also feel that the emt certification is an the entry level (aside from CFR etc) certification. Entry level providers being authorized to perform endotracheal intubation is a little scary. If you do it wrong and don't recognize it you done harm. Who the heck gets out of EMT school and feels like they can do it all, I know I didn't. It takes many first time EMTs a year or two to get comfortable in their role as BLS provider. It's my opinion that a green EMT just out of training should concentrate on becoming proficient at basic airway and ventilation techniques. Imagine a nervous new EMT on their first cardiac arrest trying to remember how to properly suction, correctly maintain a mask seal, properly hyperventilate, gauge the effectiveness of ventliations and properly intubate a patient. It can be a little overwhelming when you're new don't you think? If you're an EMT who is comfortable with BLS, by all means move up and become a paramedic. If your state feels it's appropriate and logistically feasible then they should even create an upgrade module for experienced BLS providers. But this skill should not be in the hands of all providers.
I can also assure you that it is most certainly easier to get through the EMT program than the medic program. You have a much greater possibility of being weeded out of a medic program if you're a drooling idiot than an EMT program. But I am well aware that some people slip through the cracks in medic school and actually get certified but med school and nursing school are no exceptions either. It sucks, but that's life.
All that Para-God stuff is alot of nonsense. I never liked it myself. It's enough to try and do our own job well and leave definitive care to the doctors and the nursing to the nurses. As for those who engage in it I say read a book and learn enough to realize what you don't know.

The facts are, in some EMS systems the successful intubation percentages are staggering! 5-15% intubations performed in the field are esophageal tubes.

With this in mind how could anyone suggest intubations could be preformed by an EMT-B?

There is just not enough tubes to go round, for a Medic to maintain any type of competency,

Also, shame on the medic who chooses to jump on the “King Tube” band wagon, without an ET attempt.

I wouldn’t be surprised if you start to see Intubations in the field disappear.

It’s all about education and practicing the skill to maintain a medic’s comfort with the placement of an ET tube.

It’s virtually impossible for a medic, (post completion of a paramedic program) to schedule an intubation clinical in with an OR or a cadaver lab.

Legal liabilities and competition with medical schools prevent any further intubation training.

Tracheal intubation is a potentially very dangerous invasive procedure that requires a great deal of clinical experience to master.

Why yes you can teach a monkey to tube.
You can also teach a monkey to make love to a football

No offence intended, As a health care provider you have to respect the fact, If you don’t have an airway you don’t have a patient.

Holy hell "Ditch Doc!" You do realize that this thread is 5 years old don't you? ...Or are we to suppose since you put your comments in bold that they are important enough to justify dredging this topic up from the depths?

In my country they say to let an EMT-B intubate is like to let monkey fly a plane!

niko327 said:

cardiac arrest trying to remember how to...properly hyperventilate

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LOL it's funny how much our practice changes in only 5 years!