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i freakin hate 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.
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.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.
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.
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.
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.
Wrong?
FISKUS;5360702 Always have a back up . "Just bagging" wont cut it most of the time[/QUOTE said:Well, not exactly. You can save your ass and your patient's by bagging properly. A lot of people don't do it well. Thankfully, I had nazi-like anesthesiology attendings that made me bag people through entire cases.
mike
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.
Wrong?
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
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.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..
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.
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
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
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.
I know there are busier programs - but they typically have more than one ship and more personell so the %s stay the same
NYC*EMS
Thank god this isn't true or our residents would never tube anyone!
Thank god this isn't true or our residents would never tube anyone!
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.
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 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.
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.
Jax Fire averages 2/year according to their director.
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.
- H
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
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
Its been almost 15 years and 65,000 pts ago that I finished my EM residency. In my opinion- procedures you should know in order of importance/frequency
AIRWAY
AIRWAY
AIRWAY
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 $$$) are the ones who can afford to train, equip and maintain their people to do all the high end stuff and have the volume for training and experience are the ones who don't need it. The money is all in the big, dense, urban areas with short response times. Where is RSI (or central venous access, or 12 lead telemetry, on rig MRI, whatever) needed more? In the back of the rig 3 minutes from the hospital of 30 minutes from the hospital? Well, it's a moot opint because the rural agency can't even afford to hire medics instead of EMT-Is or maybe FRs.I'd also disagree that "Good judgement is far better than a hair trigger." Good judgement comes at the cost of many, many years of both education and experience. As this debate has pointed out, many EMS providers are short on both (education and experience). I'm not sure that I trust their judgement in every case. I'd far rather EMS personnel have "hair triggers" and emergency physicians have "good judgement". The system seems to work better that way.
- H
This is a good point and it touches on the biggest conundrum we face as EMS educators (those of us who are). The systems with the most resources (read as $$$) 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.
important point.
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...
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?
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.