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Discussion in 'Emergency Medicine' started by Eidee, Jul 9, 2007.
i freakin hate it.
I've found that etomidate and sux seems to clear up any of the patient's anxiety about being intubated.
Or was that not what you meant?
BTW, if its YOUR anxiety, don't worry. That's normal. After your first 10-20 tubes (which, as an EM resident, you'll accumlate very quickly), any trace of anxiety will be gone. Unless it looks like a difficult airway, in which case you should be feeling anxious.
i keep giving myself etomidate and sux and I really feel more and more anxious about it, I mean it does this weird thing to my skin where it all turns blue?? Gives me such a freakin headache dont do it.
Yep ,you may become less anxious after 10-20 tubes but you should never loose respect.
To paraphrase Clint Eastwood: Intubating a man is a hell of a thing. If you succeed, you just might save his life. If you dont, youre going to take away everything he was and everything he every will be.
Nice thing to have going through your head whilst fighting anxiety.
Its a balancing act - Ive seen too many inexperienced residents get too cocky when approaching an airway - yet you cant be effected by fear / anxiety. But the reality is - you are taking away your patients inate ability to breathe and assuming that you will be able to do something about it
After many years in EMS and medicine - that thought always enters my mind during an intubation
Just like the catholic high school baseball player at bat - I find myself making the sign of the cross before intubating. Im not real religious but I will take all the help I can get!
don't stick it in the goose!
As a matter of curiosity: My impression (as an M4 who has never done a tube) is that the average intubation is one of the easier procedures in EM.
While it seems like the bad ones can be hell on wheels it also seems that the average one would be far easier than a complicated lac, a chest tube, etc.
Eh, not quite. You might save his life, but if you fail, he was likely going to die anyway. Maybe not due to neuromuscular blockade, but for whatever reason you felt like intubating him.
However, you can bag for a LONG time if you need to, just have to watch out for gastric distension.
Not quite.. Sure there are the pts ( blunt trauma arrests, cardiac arrests) that are going to die regardless. But, I have seen quite a few folks killed by lack of an adequate airway ie couldnt intubate due to lack of skill, lack of experience or both. Whats really sad is that some never required intubation - lack of judgement. Unrecognised esophegeal tubes are not uncommon in the prehospital arena.
Most recently we had a 10 y/o with a very survivable head injury. The moonlighting FP resident at an small outside ER couldnt intubate him - bagged him for a long time until the CRNA arrived ant tubed the child. He died of an anoxic brain injury from his massive aspiration.
Intubation is not the end all, you need to be experienced with your plan B airways ( combitube, LMA, LT ) . Always have a back up . "Just bagging" wont cut it most of the time
The average intubation is easy because it was well thought out, well prepared for and well executed. The difficult one wasn't.
Fiskus makes a very good point about intubation that, in a rare break from my usual sarcastic unhelpfulness, I'll echo.
Taking control of someone's airway really is a big deal. No matter how many times we do it, we should remember this. Same goes for procedural sedation. These are not things we should approach lightly or without good planning.
yes and no. as others have said it's about preparation, just like anything. always have a plan B( difficult airway kit with eschman catheter, LMA, crich kit, KING airway, etc ) and know when to resort to nonstandard approaches. I have always found intubating a pt in full arrest much easier than someone who needs the intubation but is still "alive" in one way or another. not having to deal with RSI makes life a lot easier, although a bit of versed and some sux usually gets the job done PRN.
I was a medic in the days before RSI and let me tell you nasal intubations can be a big pain in the butt.....
I actually miss a higher % of IV sticks than intubations but obviously I take intubation much more seriously and the IV sticks I do are generally folks the nurses have already tried and missed. Miss on the best extremit vein, go to EJ...no EJ?....it's IO time.....
What really scares me are some ( not all) of the paramedics that perform " RSI" Some of these services average only 1 or 2 tubes per medic per year. Woefully inadequate from the skills and judgement standpoint.
They are then expected to handle some field intubations that would give a seasoned anesthesiologist chest pain.
Its all about proper skill, proper judgement and proper respect
Fools rush in where angels fear to tread
I would say intubation is a skill that looks easy...until you do it.
I personally think a chest tube is a skill anyone could learn easily. I did my first chest tube as an MS1. My brother is a paramedic and they have learned how to do chest tubes (they intubate also... albeit way more than chest tubes). For the most part, as long as you are not too low (i.e. tube the liver) then its really hard to mess up a chest tube.
Intubation, on the other hand, has a high failure rate for those untrained people... and by trained, I do not mean a 20 min lecture and practice on a dummy (that suffices for a chest tube), but rather hundreds of times on a live patient.
I agree that if things go just right, its a very simple task.. but unforuntatly it often doesnt, then the high pucker factor kicks in and you better be good at keeping a level head under high stress..
Just .02 from a lowly intern...
Just my 2 cents as a paramedic -- the services that are able to do RSI (mine does not) are required to maintain a specific number of intubations per year. If they don't get those in the field, they have to go into an OR and get the rest. It might be different in other states, but that's how it is here. Most services that do RSI are very busy systems (the medics average around 30-40 tubes a year). In services like mine, we don't do RSI because it would cost our service a lot of time and money to send people to the OR (they would have to send everyone because we each average like 4-5 tubes a year). We are stuck with Versed and Valium...which doesn't really do much. Personally, I'd like everyone to be required to go to the OR yearly anyway to keep up the skills.
I agree that its not adequate training to RSI someone who would make an anesthesiologist have chest pain....a good paramedic should recognize this and not attempt.
As a side note -- this is an issue that is at the forefront of prehospital medicine. There's a group of people that want to take intubation away from paramedics entirely. I think the better answer would be more training and experience required.
As a medic who is allowed to do RSI, I had 11 field tubes last year if someone is someone is only getting 1-2 a year they work in a slow system or they stand back and let the other guy get the tube on scene. WE are required to do an OR rotation every year if we have less than 5 tubes. The avg resident at our local level 1 trauma center will get about 100-120 tubes over there three years there. I have that number of tubes as a medic between field and OR. So to say take intubation away from medics, I disagree, but more training and better upkeep of skills I am all for.....No airway and all the great medicine in the hospital doesn't mean anything..
When you see a service lose a particular skill or access to a certain medication, more often than not what you are witnessing is the least difficult and often most knee-jerk paternalistic action of a medical director. It is far easier simply to pull the equipment or the drugs off the ambulances, than to rehash a skill with a bunch of medics. I witnessed this (and battled against it) several times as a volunteer EMS officer.
The problem is there has been a severe imbalance in EMS regarding the education and standards for so long, it is now becoming apparent how hard it is to change it. One need only look at the two most frequented EMS forums to see the disparity that exists: look at www.emtcity.com and tell me you really think the majority of the providers there should be allowed to even touch a patient....the lack of common sense and the extreme under education there demonstrated is scary to say the least. The opposite end of the spectrum is www.fieldmedics.com/forum where most of the people that frequent it are relatively bright, proactive and interested in improving things in the field bother for the betterment of the provider and the patient. Sadly, the idiots outnumber the professionals by a wide margin in EMS. Until this changes, I fear that we may see our capabilities continue to spiral downward.
Instead of doing our own research and making sure our new colleagues are well versed in the how and why of what we do, we have continued to serve as the bottom rung of the medical hierarchy. Until such time as we can prove our merit, through research and can stand and defend our beliefs as well as anyone who might disparage them, then I must sadly admit that perhaps we are failing not only ourselves but our patients by not demanding these things from one another.
So what you are saying is 40 tubes per provider- say in a small city of 50k - you may have 4 ambulances on the street, 6 medics per ambulance - thats almost a thousand tubes per year - not to mention those who get intubated in the ER / OR / ICU Over 1 out of 5 people in your community get intubated every year!! Is there a nerve gas plant in the area?
Please email me - I have been researching this subject for several years. I have never heard of a flight program, much less a ground paramedic unit that averages over 20 tubes per provider per year.
Obviously not every service that has RSI averages that high, but these services certainly exist. Most services that don't reach the required number have to go to the OR. Flight services definitely have higher than 20 tubes annually because they generally go into the OR bi-annually as well as field intubations. I just got off the phone with a friend of mine who works for Jersey City EMS. He said he has just around 40 tubes for this year and that medics average between 35-40 tubes per year. It depends on the city, the population/demographics, and the number of ambulances in the city.
There are 650 NYCEMS medics - at 20 tubes a medic - 13000 tubes, again an unbelievable number considering they are only a portion of the NYC ALS response
As per flight services - the average single ship program is doing about 600 flights per year. There are a minimum of 10 providers per ship. 20 tubes per provider . Thats 200 tubes - you are intubating at least 33% of flights? 10 % is extremely high - that averages to about 7 tubes a year.
I know there are busier programs - but they typically have more than one ship and more personell so the %s stay the same
Intubation numbers are like the fish length or penis size - no one will ever admit theirs is small. If it truly is small - they dont talk about it or they exaggerate
when I was a medic our flight guys never got intubations. pts were intubated before critical transports. .....
I think I got 3 last year. Medium-sized town with a disproportionate number of ALS.
Interesting data - median of 1 tube per year with the HIGHEST 23 tubes / year including HEMS. Either Pennsylvania is in the airway stone ages or you folk are talking to supermedics.
INTRODUCTION: Proficiency in prehospital endotracheal intubation (ETI) may be difficult to maintain without regular clinical experience. In this study we calculated ETI frequency rates for prehospital rescuers in Pennsylvania. METHODS: We used statewide prehospital patient care records for calendar year 2003. We included Advanced Life Support rescuers with at least one patient contact. We calculated the number of ETI performed by each rescuer. We calculated univariate relationships between ETI frequency, rescuer age, and per-rescuer clinical and demographic mix. We used multivariate negative binomial regression to identify independent predictors of per-rescuer ETI volume. RESULTS: For 1,322,363 patient care records, 6,112 rescuers performed a total of 13,648 ETI. Per-rescuer ETI volume ranged from 0 to 23 (median 1; IQR 0-3). 2,293 rescuers (37.5%; 95% CI: 36.3-38.7%) did not perform any ETI during the study period. Only 764 rescuers (12.5%; 11.7-13.4%) attained the AHA guideline of 6 or more ETI. The median per-rescuer ETI incidence was 5 ETI/1000 patient contacts-year (IQR 0-16). On multivariate regression, independent demographic predictors of per-rescuer ETI frequency included (all ordinal): rescuer age (Rate Ratio 0.87; 95% CI: 0.84-0.90), mean patient age (1.04; 1.01-1.08), fraction of male patients (1.04; 1.01-1.07), fraction of air medical cases (1.12; 1.10-1.13), mean response time (0.92; 0.88-0.96) and number of patient contacts (1.003; 1.001-1.004). Independent clinical predictors of per-rescuer ETI frequency included mean GCS (0.90; 0.88-0.93), and numbers of cardiac arrests (1.41; 1.37-1.46), major traumas (1.08; 1.06-1.10), respiratory patients (1.15; 1.12-1.17), and patients in life-threatening condition (1.14; 1.12-1.16). Rescuer practice population mix (urban/rural) was not significant. CONCLUSIONS: In this demographically diverse State, prehospital rescuers performed ETI at limited frequencies. Per-rescuer ETI volume is related to patient and rescuer demography, but is associated primarily with severity of patient mix. Prehospital rescuers, particularly those who do not care for large numbers of high acuity patients, may not be able to rely upon clinical experience alone to maintain proficiency in ETI.
I very much agree with this. I've tried to introduce new protocols for my squad, until I realized that they wouldn't just be for me and the others I think are not going to kill someone...they'd be for everyone at that given training level. That thought made me shiver, and I throw away the protocol, because there are too many people in this field that can't accomplish much more than driving the truck and playing fetch. When I evaluated for National Registry exams, I actually failed several paramedic students for failing to properly backboard (head not secured, strap over the shoulders, all other straps on the legs). Some of their responses for medical or trauma scenarios were just plain scary. I knew some of these people from seeing them in the program or in the hospitals, and could have told you they should never have been allowed to test. Part of this blame belongs on the programs, which just want to collect the tuition checks from people who want an "easy" job, so they let anyone in, and pass them constantly.
Ok, I'm willing to admit that my numbers were probably too high. Granted there are services that do over twenty. For example, Saint's Memorial Hospital EMS in Lowell MA requires 20 field intubations per year. Otherwise you must go to the OR. They average about 540 intubations per year for the service, so a little more than an intubation a day for the service as a whole. Most medics get around 20-28 tubes a year. This is not a huge system but its a regional system with fewer medics. That's how these systems get this many tubes. I will admit they are the exception. Flight medics prob don't get this much in the field but they make it up in the OR. The medics where I work probably average around 5 per year and we cover the metro-Boston area (not Boston itself).
That being said, this argument about numbers is probably not that important. My main point is that I agree with you. The majority of systems do not do enough intubations to warrant RSI. I don't think anyone in my company would call themselves proficient in intubation by any means, and I think you should be near proficient to be using RSI. These busier systems with higher numbers do well with it, but its not for everyone. Quite frankly, I would be very nervous to see some of the medics at my company attempt this.
I threw this all out there more to see how people felt about field intubations and that some people think they should be taken away altogether (RSI and not RSI). It would be shame. Medical directors should insist upon more training and get the medics into the OR instead of taking away the skill.
This is not necessarily the case. Boston has a population of 600,000 with approximately 2 million daytime population. Boston EMS has 5 ALS units on for the whole city (per the Boston EMS website). This is very disproportionate compared to smaller towns with 1 or 2 ambulances. Jersey City has 3-4 ALS trucks at a time. This is why they are so busy and this is why these types of systems get a lot of intubations per provider. Granted my original numbers were probably wrong.
RSI is a reasonable skill for one area, such as Boston, but is not for another, such as suburban MA.
Thank god this isn't true or our residents would never tube anyone!
I was going on what a guy I worked with told me. I've just begun my second string of 5 12's overnight in a row, so I didn't research what I posted.
ahhhh perhaps this is why some medical directors want to take away prehospital intubation
Loyola University Medical Center EMS System in Maywood, IL has several medics who have averaged 20+ tubes per year (at least they did in the 1990's - I know, I was one of them!).
I would put 33% as low for a trauma heavy flight service. You have to have a "hair trigger" for intubation on a flight team, because you'd vastly prefer RSI on the ground to crashing airway in flight. There are services that intubate every trauma patient that is flown from a scene.
The issue here is "How many paramedics per capita cover an area?". Seattle has just about 100 paramedics. Needless to say, they each get more tubes than does a similar sized city with a full cross trained FF/EMT-P service - say ~ 700 paramedics. The question actually goes beyond intubation, the real question is - as the # of paramedics goes up and therefore the experience of each paramedic goes down (in a given area), is there a point when you have too many paramedics?
Yeah, you would think that they get tons of skills in NYC, but in reality they are pretty saturated with ambulances. The amount of ambulances per square mile significantly decreases the amount of calls they do and the amount of intubation attempts they get. When I did my ride time for paramedic school, some students went to NYC. They were praying for skills by the end of the time. I went to Newark which has only a few ALS trucks for the whole city and I had all my required skills done by the end of two days. Its not always the size of the city - its the number of paramedics covering it.
Boston only having 5 ALS units that is only the FD, there are many hospital and private based ambulances there is no way 5 truck could ever cover a city like that.
For those ER attendings and residents - just out of curiousity, how many intubations would you say that you do in a year? Obviously this varies depending on the type of hospital you work in, but I'm just curious to hear some numbers. I'm assuming attendings do far fewer in teaching hospitals because they go to the residents.
Actually, Boston EMS is not a fire department based service. It is the public health commission, separate from the fire department. There are no hospital based EMS systems in Boston itself and the private services do very very little (they work in the suburbs and surrounding areas and only cover Boston for mutual aid).
Boston EMS has 15 BLS ambulances and 5 ALS.
Back when I was on the old meat wagon I bet that I averaged about 1 a month or so. This was in a very busy system.
Jax Fire averages 2/year according to their director.
I believe it because they have 30 ALS trucks in the city at once. (I might be wrong - this is just want the website said). That's the difference. Its about the number of paramedics versus population.
Like Foughtfyr said, you have to consider whether there are TOO many paramedics so skills slide. I would bet that in a city like this, these paramedics are doing tons and tons and tons of BLS. Is it a waste of resources? Would it be better to have 22 BLS trucks and only 8 ALS so that those intubations and IVs etc get spread out among those paramedics and they actually get practice in their skills? Its difficult because it looks good for the city to say that they have all these paramedics, when in reality, they might not be needed. They are spending their days picking up the local drunk, headache, laceration etc.
A whole other can of worms... Intubating people that shouldnt be intubated. It happens too often in the prehospital arena. I cant count the number of "bad traumas" that I have extubated in the ER. There are programs out there that discharge up to 40 % of there scene flights from the ER or from the hospital within 24 hrs with no procedures. Good judgement is far better than a hair trigger
Part of this could have to do with the length of time with a patient. Where I work as an EMT-I we're 35 minutes from the hospital, and the bird can be to us in 10 and to the hospital in another 4. I've had plenty of MVCs with serious entrapment where we've called the bird only to find out by the time the patient was fine (vital signs were stable and WNL, pt didn't have serious complaints). Every time we've done this (7 times since Jan) I've spoken the an MD on the service who is an attending in the ED we fly to, and he's said from the info we had our decision was right. Yes, there are people who have hair triggers, but in my view, with trauma/bad medical, its better to over activate then stand down the trauma team/cath lab then to drive there code 1 only to find out the patient is severely messed up.
How many of those "bad traumas" you've extubated in the ED had a bad outcome from the process? Look, I'm not a fan of the current over-triage that goes into the aeromedical process. I agree that too many folks are flown that don't have to be. But I also think that the prospect of maintaining an airway in flight (if only from air sickness vomiting) on a patient in spinal precautions (again, a whole other can of worms ) is daunting to say the least. I've dropped and tubed lots of folks in the trauma bay in order to facilitate CT scans or other tests. Once cleared they were extubated in the ED. Was it wrong to intubate them too? The problem is not intubating patients who are flown from the scene. The problem is in selecting the right patients to fly from the scene.
Wasn't it you who said:
Doesn't that mantra argue for controlling the airway on the ground and as quickly as possible?
I'd also disagree that "Good judgement is far better than a hair trigger." Good judgement comes at the cost of many, many years of both education and experience. As this debate has pointed out, many EMS providers are short on both (education and experience). I'm not sure that I trust their judgement in every case. I'd far rather EMS personnel have "hair triggers" and emergency physicians have "good judgement". The system seems to work better that way.
This is a good point and it touches on the biggest conundrum we face as EMS educators (those of us who are). The systems with the most resources (read as $$$) are the ones who can afford to train, equip and maintain their people to do all the high end stuff and have the volume for training and experience are the ones who don't need it. The money is all in the big, dense, urban areas with short response times. Where is RSI (or central venous access, or 12 lead telemetry, on rig MRI, whatever) needed more? In the back of the rig 3 minutes from the hospital of 30 minutes from the hospital? Well, it's a moot opint because the rural agency can't even afford to hire medics instead of EMT-Is or maybe FRs.
I would say, however, that the 12 lead is pretty important everywhere. In more urban areas, generally there are several hospitals to choose from and a 12 lead helps make the choice as to where to go. Instead of going to hospital A which is 2 minutes away, you might choose hospital B which is 6 minutes away but has a cath lab - eliminate the interfacility transfer and decrease the time to balloon. A rural system might not have a choice as to their hospital, but again it still helps with early activation.
But now I'm getting off topic...
But you aren't getting off-topic. A paramedic with a 12-lead and the "right" to change his/her destination hospital is a problem. Without previous ECGs, some reasonable assessment for aortic dissection, and a system to know if that cath lab is open and available at that moment, I would much rather the paramedic go to the absolute closest facility. Data show that cath is not significantly enough superior to thrombolysis to allow that decision to be made with EMS blinders on.
When did we collectively lose sight of the fact that the job of EMS is to get an injured or ill person to definitive care without causing further harm? When did it become their mission to provide, or direct the provision of, that definitive care?
One of the paramedic services near my house recently (two years ago) got permission to activate the cath lab from the back of the bus. Background on this service: They run 8 medic ambulances for a population of ~100,000 and do medic intercept for a much much larger area. There are only two hospitals in town, and the one with the cath lab is the hospital of choice for anyone who is "sick" anyway. The decision to give them the "power" to activate the cath lab was made because the MDs in charge of the cath lab did a big study and looked at their interperation of the clinical data at hand (12 leads et al) and found that the medics were "right" as often as the MDs in the ED.
My basic point is this, EMS for a while (where I'm from) has been allowed to choose hospital destination based on how critical a trauma patient is. Why not let EMS (when trained well) choose hospital destination for critical medical patients. There is very little difference in my mind between activating a trauma team (done without complaints by EMS) and activating a cath lab.
Hennepin County EMS (MN) does this already.