intubation anxiety

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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.

There is no way that "study" was accurate. Look, where I trained as a resident we had the best door-to-balloon times in the country. We averaged in the 30-40 min range with no case in the previous year >60 minutes. Our residents were well drilled in 12 lead interpretation, with most of us trained by Dr. Hamilton who literally wrote the book. I'm telling you, as a former medic who still rides, I can't make the call accurately in the back of the bus. First off, to be accurate, the 12 lead has to be done in the house, not the bus. The frequency response range is simply too affected by baseline variation (such as a diesel engine) in the diagnostic mode. That delays the transport. But worse, if you rely on your EMS service to "call" 12 leads in the field, you are likely to miss aortic dissections (yeah, I'd love some IIb/IIIa inhibition for my type A that has dissected back to my coronaries), likely to call Brugada or LBBB as MIs, and you are unlikely to recognize new LBBBs (how can you without old ECGs) as MIs. But all of that leaves aside the other problem. If medics "call" MIs in the field, the system is likely to rely on them to do so. Patients transported in by EMS without cath lab activation will likely become seen as "cleared" and that is simply not true. The far better system is close medical control, where EMS calls and says "yeah, I'm really worried about this one". We can then have lab, X-ray, and ECG standing by on arrival. It works great - and it doesn't remove physician level judgement from the equation.

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.

Because that trauma selection system has never been proven in the literature. Look at the published figures on the number of "level 1" or "level 2" trauma patients that go to the OR within two hours of arrival. The number is roughly 10%. (look here as an example, I don't have time for a full lit search: http://www.ncbi.nlm.nih.gov/sites/e...ez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum). The reality is that the availability of a surgeon has been the driving force behind these EMS guidelines. But that isn't even a realistic analogy. What you are advocating is a system whereby the EMS crew makes the decision to proceed directly to the OR with a trauma patient. No way, no how. Remember, cardiac cath is NOT a benign procedure. It requires physician level judgement, period.

- H

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Several of our EMS services activate the cath lab from the field. I think its great. With out transport times it sometimes means the cath team arrives around the same time as the patient. It probably cuts our door to flow time by 20-30 minutes sometimes. They aren't giving thrombolytics or IIB/IIIA's. I think they've been wrong for me maybe twice in the last year. It doesn't mean we don't consider other diagnoses once the patient arrives and it doesn't mean that a chest pain patient who doesn't come in as a "cardiac alert" gets ignored. You want their false positive rate to be low enough that you don't get a boy who cried wolf phenomenon and their true positive rate to be high enough that having the system actually matters. The only down side is that you can't bill critical care time if the patient only spend 5 minutes in the ER.
 
Interesting thread. Back to the original topic, coming from the perspective of an anesthesia resident:

I have probably tubed around 400-500 pts. thus far. The number might seem a little low to some, but pretty soon after we are pretty comfortable tubing someone in the OR most residents move on to things like light wands, fiberscopes, Bullards, etc. In the OR, I really don't have any anxiety about putting the tube in in a normal case. After all it is under controlled circumstances, you should have all your adjuncts at your fingertips, and there is usually plenty of help if things go awry - which happens unfortunately some of the time despite your best intentions. My tone is ratcheted up in certain circumstances like a potential or even know difficult airway, a trauma w/a c-collar on, the morbidley obese, or a very tiny neonate who starts to drop their sats before you even have the blade in the mouth - among others.

I have also carried the airway pager a fair amount during residency, and let me tell you what my tone goes up exponentially. I am by myself, there really isn't any help, the calls can be emergent or critical and so forth. We get called for everything imaginable - morbidley obese pt. where someone has induced anesthesia and can't intubate or ventilate, active gi bleeders, known difficult airways, pts. w/platelets of 3, pts w/known unstable cervical fx who need emergent intubation, pt induced and multiple DL's bloodying up the airway before we are called, etc. You name it, we see it. The vast majority of time, everything goes fine. I have had to call for help a couple of times but fortunately everything turned out alright for these cases in the end. The tube always got where it needed to be. However I do know of several instances where the outcome was not good and one where the patient died. Since I am by myself I always try to line up all my ducks before proceeding - oral airways, suction, multiple blades functioning, bougie w/in my reach, LMA's handy. Usually there are lots of people around but none of the them are really familiar with a lot of stuff in my bag - things like a fast track LMA. Unfortunately our RT's aren't much help either, they give great jaw thrust when bagging, unfortunately it is directed downwards rather than up. Although many other gas guys might disagree w/me (and sometimes I question my own practice) I normally do not administer sux on the floor. There is just too much potential for badness. Instead I use etomidate or propofol. If you can't intubate or ventilate someone after they are paralyzed you are on a bad pathway. I don't like to "burn that bridge". I have given sux a couple of times - each time I have managed to squeak the tube in somehow. It definitely improves conditions but you just have to realize it's downside as well. I guess my point is something that we all know already, no matter how often you do a procedure or how good you are at it, you will pay the piper at some point if you lose your respect for the airway. It can come when you least expect it, I have seen that a few times. Also, intubation is the money shot, but ventilation keeps patients alive.

I know a lot of paramedics want RSI stuff in the field, which I think is a dangerous proposition. Not just in handling the airway once the drugs are given but also knowing when to give them. Just my .02.
 
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One of our new interns had a little anxiety as well. Yesterday He successfully intubated the pt. with the Yankauer.
 
Unfortunately our RT's aren't much help either, they give great jaw thrust when bagging, unfortunately it is directed downwards rather than up.

This is why you write the dumb bastards up and if all else fails have their asses hauled before the state licensing board just like you would do an incompetent doc. Please for the sake of the patients and my current profession, hand them their asses when you see them do this.
 
One of our new interns had a little anxiety as well. Yesterday He successfully intubated the pt. with the Yankauer.

Got my first tube yesterday with little to no anxiety. Grabbed the laryngoscope, dropped the tube, checked for breath sounds. Piece of cake. Just as easy was extubating the gut I had just intubated. :oops: Opps. Got it on 2nd attempt (with assistance).
 
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?

- H
This is why you need a high volume of BLS providers in an area, and only enough ALS to justify their presence.
 
YES.

But then, that was a rhetorical question, wasn't it?

Take care,
Jeff

No, it is an honest question. As more and more cities move to a fire based system, this can become a problem. Unfortunately there are far too many PDs who are far too "hands off" with the medics. So, we get paramedics running around, long on time on the job but short on real experience, operating nearly autonomously, with little real QI/QA.

- H
 
This whole thread is making me want to chuckle and cringe at the same time. I currently work as a field medic in a rural system covering 150 square miles with 25-55 minute transport times to a small community "hospital". I work with an EMT-Basic partner, and we recieve very limited first responder services from the local volunteer VFD. As far as ALS goes, the duty medic is it. We utilize aeromedical when possible, but from December-March they are generally OOS. We see a variety of medical and trauma cases. In this area, when someone calls for CP, they have been sitting on an MI for a week. A car wreck around hear is a truck into a pole at 75+ with ejection.

To make a long story short, our medics get to be medics. We drop alot of tubes. It is quite scary because my paramedic education consisted of a "lets be fireman" type class. A&P was covered in a total of 4 hours. Intubation was a 20 mintue lecture and a plastic dummy. I was thrown to the wolves, and forced to learn on my own.

For me, the key to a good prehospital tube is advanced preperation. It starts with teamwork among the crew. I ensured that my partner is on the same page, and we are both up to snuff. I made sure he was proficient in BVM ventilation. Second, I told him exactly what I want when i say "set me up for a tube". For me that means larygoscope with selected blade, ET tube of my choice tested w/ syringe hooked up and stylet in place, ET tubes +- one size of my choice, penlight, ETco2 adapter, bougie, suction on the ready, stethoscope, and a combitube on the ready. This is all layed out neatly on the counter ( if possible, if not we use a pillowcase or towel). This eliminates the equipment factor. Third, I have developed a standardized approach for assesing an individual airway. This works for me, and allows me to make the right decisions based upon my skills and prefferences. Fourth, I know my protocols inside and out, as well as the # for online med control. This allows me to know the options I have at hand. I know that I have a cric kit and retrograde avaliable to me IF needed. The key is knowing if they are needed and knowing how to use them before you need them. (4 am in a crushed up Chevette is not the time for an irway lesson) Fifth, I know when an attempt is failed. Any airway (LMA, Combitube) is better than no airway (repeated missed ET tubes).

EMS is such a mied bag. Some providers care, some do not give a ****.

Personally, I see many docs looking down on medics. They will belittle their airway skills. I feel they would be better served by taking a proactive approach and giving some education on the issue.

Wow, what a worthless rant. I apologize, just killing time on another 24 hours of paradise....
 
It's fair to say we all have a very wide range of good and bad. There are some doctors out there that I wanted to worship for there ability to intubate the combative motorcycle trauma with a broken jaw and such. Then there are doctors who couldn't intubate the critical medical patient.

Nothing is better then watching your paramedic supervisor of 20+ years experence reminding the doctor the correct way to intubate. I think in the systems that clearly demonstrate an educational base to handle the skill, a high demand for the skill, and strong QA system to give them the drugs. It really comes down to...Would you want a medic intubating your critically ill family memeber with no drugs, only versed or etomidate or having the drugs that would make it the best attempt on the first atttempt.
 
It's fair to say we all have a very wide range of good and bad. There are some doctors out there that I wanted to worship for there ability to intubate the combative motorcycle trauma with a broken jaw and such. Then there are doctors who couldn't intubate the critical medical patient.

Nothing is better then watching your paramedic supervisor of 20+ years experence reminding the doctor the correct way to intubate. I think in the systems that clearly demonstrate an educational base to handle the skill, a high demand for the skill, and strong QA system to give them the drugs. It really comes down to...Would you want a medic intubating your critically ill family memeber with no drugs, only versed or etomidate or having the drugs that would make it the best attempt on the first atttempt.

Isnt this forum for emergency med physicians / students? I guess everyone please submit your much valued opinion - LPNs, phlebotomy, housekeeping
 
It's fair to say we all have a very wide range of good and bad. There are some doctors out there that I wanted to worship for there ability to intubate the combative motorcycle trauma with a broken jaw and such. Then there are doctors who couldn't intubate the critical medical patient.

Umm, you are suggesting that a residency trained, BC/BE EP is somehow less qualified than a paramedic to intubate? Please, please, try and keep your comments to yourself. You will find as you move through your career that many EMS providers who go on to medical school are hampered by a perception that they are "un-teachable" or have too large a sense of superiority. Comments like your demonstrate why.

Nothing is better then watching your paramedic supervisor of 20+ years experence reminding the doctor the correct way to intubate.

Yes there is - watching the PMD hand that supervisor a suspension of privileges for a month

I think in the systems that clearly demonstrate an educational base to handle the skill, a high demand for the skill, and strong QA system to give them the drugs. It really comes down to...Would you want a medic intubating your critically ill family memeber with no drugs, only versed or etomidate or having the drugs that would make it the best attempt on the first atttempt.

Actually, I was a paramedic in a busy system (17+ runs / day) long before prehospital RSI. Truthfully, there were very few patients who "needed" RSI (as opposed to awake nasal intubation or BVM assist). Truthfully, I remain unconvinced either way on pre-hospital RSI but trust me when I tell you that you do not realize that which you do not know. It is far less cut and dry than you make it seem.

- H
 
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