Medics and Intubation

[nvshelat]

I don't have enough knowledge to critique the article, (ie I don't know how they controlled for comorbidity if thats the right term) but though I'd post the abstract here:

From most recent issue of Health Affairs:

Paramedics provide life-saving emergency medical care to patients in the out-of-hospital setting, but only selected emergency interventions have proved to be safe or effective. Endotracheal intubation (the insertion of an emergency breathing tube into the trachea) is an important and high-profile procedure performed by paramedics. In our study population, we found that errors occurred in 22 percent of intubation attempts, with a frequency of up to 40 percent in selected ambulance systems. These findings indicate frequent errors associated with this life-saving technique. These events might be emblematic of larger issues in the structure and delivery of out-of-hospital emergency care.

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[OSUdoc08]

I don't have enough knowledge to critique the article, (ie I don't know how they controlled for comorbidity if thats the right term) but though I'd post the abstract here:

From most recent issue of Health Affairs:

Paramedics provide life-saving emergency medical care to patients in the out-of-hospital setting, but only selected emergency interventions have proved to be safe or effective. Endotracheal intubation (the insertion of an emergency breathing tube into the trachea) is an important and high-profile procedure performed by paramedics. In our study population, we found that errors occurred in 22 percent of intubation attempts, with a frequency of up to 40 percent in selected ambulance systems. These findings indicate frequent errors associated with this life-saving technique. These events might be emblematic of larger issues in the structure and delivery of out-of-hospital emergency care.

Considering that medics don't tube on a regular basis after training, this is not surprising.

 

[docB]

A lot of the EMS data doesn't even support the existence of EMS. There are reports of trauma patients doing better with less prehospital intervention. Studies show that skills are poorly taught, inappropriately applied and of marginal benefit. From a strict public health standpoint ACLS should be scrapped and those resources redirected into preventive care. Even more so for aeromed. But that's unlikely to happen because of reimbursement structures and the current culture in healthcare. Now don't get me wrong. I used to be EMS and I support EMS but I think it's important to understand all this because it provides a good perspective.

 

[emtcsmith]

Most field intubations are done right to my understanding and what goes wrong is during transport at some point between the tube being placed and the hand off to the Doc and Chest Xray it comes out. There is always room to improve but let me defend my profession and say every Medic I've worked with does his/her job the best they can in situations that demand it.

 

[Wackie]

A lot of the EMS data doesn't even support the existence of EMS. There are reports of trauma patients doing better with less prehospital intervention. Studies show that skills are poorly taught, inappropriately applied and of marginal benefit. From a strict public health standpoint ACLS should be scrapped and those resources redirected into preventive care. Even more so for aeromed. But that's unlikely to happen because of reimbursement structures and the current culture in healthcare. Now don't get me wrong. I used to be EMS and I support EMS but I think it's important to understand all this because it provides a good perspective.

I think "skills poorly taught" depends on the schools. I would assume a school which many cities send their fire fighters to would provide the fastest certification and not necessarily the best so the city can get their employees back into service.
However, in my area there are schools who aren't kidding around at all and produce extremely capable medics.

For trauma, I'm not sure how people would do better with less intervention. I'd be interested in hearing (reading, rather) more on that idea. A severe bleed which is controlled 10 minutes earlier would defiantly help with blood loss. I believe they are testing a solution that is like a "synthetic blood" and can carry oxygen. A patient with severe hemorrhaging would benefit, no? Spinal immobilization is defiantly a big plus vs. a patient being transported via minivan by a soccer mom, etc.

I would venture to say more people benefit from prehospital care than who are hurt by it. But I'm new to EMS. Very, very green in fact so perhaps I’m naïve and gung ho.

 

[docB]

I think "skills poorly taught" depends on the schools. I would assume a school which many cities send their fire fighters to would provide the fastest certification and not necessarily the best so the city can get their employees back into service.
However, in my area there are schools who aren't kidding around at all and produce extremely capable medics.

I'm sure that's true. No one is bashing medics or any particular schools or anything like that.

For trauma, I'm not sure how people would do better with less intervention. I'd be interested in hearing (reading, rather) more on that idea. A severe bleed which is controlled 10 minutes earlier would defiantly help with blood loss. I believe they are testing a solution that is like a "synthetic blood" and can carry oxygen. A patient with severe hemorrhaging would benefit, no? Spinal immobilization is defiantly a big plus vs. a patient being transported via minivan by a soccer mom, etc.

Then read on. And realize that any study can be deconstructed. The point I'm making is that everyone intuitively thinks that the more advanced care the better but that mind set has been very difficult to support in the lit.
http://www.ncbi.nlm.nih.gov/entrez/...uids=15611550&query_hl=15&itool=pubmed_DocSum
Most skills are preformed correctly but have not been shown to improve outcome.
http://www.ncbi.nlm.nih.gov/entrez/...uids=15128123&query_hl=15&itool=pubmed_DocSum
EMS intubation doesn’t improve outcomes vs. BVM.
http://www.ncbi.nlm.nih.gov/entrez/..._uids=9356056&query_hl=15&itool=pubmed_DocSum
Prehospital IVs and fluid boluses don’t improve survival.
http://www.ncbi.nlm.nih.gov/entrez/...uids=15920406&query_hl=15&itool=pubmed_DocSum
Prehospital intubation worsens survival in brain injured patients.

I would venture to say more people benefit from prehospital care than who are hurt by it. But I'm new to EMS. Very, very green in fact so perhaps I’m naïve and gung ho.

I'm not saying that lots of people are hurt buy EMS. I'm noting that the benefits are not borne out as strongly as most people think. Even the lit is conflicted about this:
http://www.ncbi.nlm.nih.gov/entrez/..._uids=6694231&query_hl=15&itool=pubmed_DocSum
ALS benefits the trauma patient.
http://www.ncbi.nlm.nih.gov/entrez/...uids=10780596&query_hl=15&itool=pubmed_DocSum
ALS does not benefit the trauma patient.

 

[docB]

Most field intubations are done right to my understanding and what goes wrong is during transport at some point between the tube being placed and the hand off to the Doc and Chest Xray it comes out. There is always room to improve but let me defend my profession and say every Medic I've worked with does his/her job the best they can in situations that demand it.

Even the best medic (or doc) can tube the goose. Sometimes recognizing that can be tough. The really dangerous ones are not the tubes lost in transfer, those are relatively easy to spot, it's the unrecognized esophageal tube that's a problem. No one is assailing your profession. It's important to understand the reality of what's going on and if it's really helpful and/or cost effective. I'll be the first to say that ERs are not cost effective. If people would plan ahead, comply with their meds and get preventive care we could close half the EDs, save a ton of $ and make everyone happier. Won't happen but it's true. Just like EMS, it's not going anywhere.

 

[EM Junkie]

For trauma, I'm not sure how people would do better with less intervention. I'd be interested in hearing (reading, rather) more on that idea. A severe bleed which is controlled 10 minutes earlier would defiantly help with blood loss. I believe they are testing a solution that is like a "synthetic blood" and can carry oxygen. A patient with severe hemorrhaging would benefit, no? Spinal immobilization is defiantly a big plus vs. a patient being transported via minivan by a soccer mom, etc.

I think the studies docB was referring to don't question the benefit of BLS, or basic life support, interventions (such as spinal immobilization and hemorrhage control). The question is whether ALS (drugs, IV's, intubations) in the field is beneficial to the trauma patient. I think a lot of it boils down to EMT's doing the "scoop and run" of critical trauma patients vs. some medics preferring to "stay and play".

Note I am also an EMT and think EMS is EXTREMELY valuable to society. Trauma is only a portion of what EMS does, but I agree with docB that we should be aware of all sides of the issue.

Now I have a lot of reading to do - thanks docB!

 

[CatsandCradles]

I think a lot of it boils down to EMT's doing the "scoop and run" of critical trauma patients vs. some medics preferring to "stay and play".

In my part of the country we call it "load and go," nevertheless what you say is something important and something I often wonder about.

Now I'm an EMT-B from a rural area....so when sheit hits the fan, I often ponder for a few precious seconds...do we run like hell? or do we wait for the medics to come?

 

[f_w]

And then besides BLS and ALS, there is HBA (home boy ambulance). It is a 'transport only' service, the equipment is typically a 10 year old Lincoln or Caddy. Delivery to the hospital is at the walk-in entrance with two HBs dragging the victim under his arms while the other occupants of the HBA scream at the security guard....

 

[Apollyon]

And then besides BLS and ALS, there is HBA (home boy ambulance). The back seat of typically a 10 year old Lincoln or Caddy. Delivery at the hospital is typically to the walk-in entrance with two HBs dragging the victim under his arms while the other occupants of the HBA scream at the security guard....

Hehehehe...I describe the "HBA" as an Escalade or a Crown Vic (with the vic in the back seat after being capped by 5-0 "oh ****! I shot him, now I gotta save him!").

 

[Xclamp]

And then besides BLS and ALS, there is HBA (home boy ambulance). It is a 'transport only' service, the equipment is typically a 10 year old Lincoln or Caddy. Delivery to the hospital is at the walk-in entrance with two HBs dragging the victim under his arms while the other occupants of the HBA scream at the security guard....

Awesome!!!

 

[QuikClot]

Even the best medic (or doc) can tube the goose. Sometimes recognizing that can be tough. The really dangerous ones are not the tubes lost in transfer, those are relatively easy to spot, it's the unrecognized esophageal tube that's a problem.

Indeed, but w/ end tidal, it really should be a thing of the past. In Multnomah County (Portland, Oregon and surroundings) we didn't have a single unrecognised esophageal tube in 2004. As a result, they jacked up our training and set even more strict protocals for tube verification. Their logic for that (and our medical director freely admits the irony) is that by preventing this from happening for a whole year, we have effectively proven that it is negliance to allow this to happen, hence our liablity is huge.

This study needs a link; there are too many "mistakes," variously defined, that could get you a figure of 22 percent or 40 percent; that's not gut tubes per se, I am sure. One also needs to realize that the conditions of prehospital medicine are vastly different than those of hospital practice. Poor light, not enough room to work, etc.

That said, docB is correct that ALS interventions, in general, have not unambigiously demostrated success. Since common sense (and experience) states they are useful in many specific cases, the question is why they do not seem to translate to better patient outcomes. Scene time is a likely culprit.

Tubes are a great prehospital intervention, but sometimes, I think, ego distorts our use of the tool. The tube is a fun and exciting intervention, and as a result, BLS airway tools are under-utilized.

 

[QuikClot]

The point I'm making is that everyone intuitively thinks that the more advanced care the better but that mind set has been very difficult to support in the lit.
http://www.ncbi.nlm.nih.gov/entrez/...uids=15611550&query_hl=15&itool=pubmed_DocSum
Most skills are preformed correctly but have not been shown to improve outcome.
http://www.ncbi.nlm.nih.gov/entrez/...uids=15128123&query_hl=15&itool=pubmed_DocSum
EMS intubation doesn’t improve outcomes vs. BVM.
http://www.ncbi.nlm.nih.gov/entrez/..._uids=9356056&query_hl=15&itool=pubmed_DocSum
Prehospital IVs and fluid boluses don’t improve survival.
http://www.ncbi.nlm.nih.gov/entrez/...uids=15920406&query_hl=15&itool=pubmed_DocSum
Prehospital intubation worsens survival in brain injured patients.

. . .

http://www.ncbi.nlm.nih.gov/entrez/..._uids=6694231&query_hl=15&itool=pubmed_DocSum
ALS benefits the trauma patient.
http://www.ncbi.nlm.nih.gov/entrez/...uids=10780596&query_hl=15&itool=pubmed_DocSum
ALS does not benefit the trauma patient.

Interesting studies, a few comments:

* Most of these studies focus of trauma care, but that is, in my experience, where there is the least difference between ALS and BLS care. Severe exacerbation of COPD, AMI, Hypoglycemia, dysrythmias; these are life-threating emergencies that BLS responders have very few tools to manage.

* The studies which found decreased survival rates for intubated pt.s (in the case of the first study, increased survival for critical pt.s, decreased for moderate to severe pt.s) may not have been able to control for medic intuition; i.e., people who make a medic uneasy, in a general way, are both more likely to be intubated and more likely to die. I doubt the trauma scale is as reliable a predictor of mortality as that intuition.

* Fluid boluses are the evil-spirit-releasing skull holes of our time, and that is not just a prehospital problem. Our agency is testing synthetic plasma and a hypermolar solution, one of which, hopefully, will put an end to the current practice of pumping liters of fluid into pt.s tissues.

 

[docB]

Indeed, but w/ end tidal, it really should be a thing of the past. In Multnomah County (Portland, Oregon and surroundings) we didn't have a single unrecognised esophageal tube in 2004.

End tidal is great. That said I have yet to work in a hospital that has it in the ER or a city where the EMS system uses it. And these weren't tiny towns. I'm talking Philly through '00, Sacramento through '03 and Vegas still doesn't have it.

 

[emtcsmith]

We have etco2 and our county medical director considers it the gold standard for conformation, which it clearly is outside of an xray.

Lets complicate the issue more, what about RSI? My system is on the verdge of getting it and there is alot of debate on both sides of the issue.

 

[emtcsmith]

We have etco2 and our county medical director considers it the gold standard for conformation, which it clearly is outside of an xray.

Lets complicate the issue more, what about RSI? My system is on the verdge of getting it and there is alot of debate on both sides of the issue.

 

[OSUdoc08]

We have etco2 and our county medical director considers it the gold standard for conformation, which it clearly is outside of an xray.

Lets complicate the issue more, what about RSI? My system is on the verdge of getting it and there is alot of debate on both sides of the issue.

I worked for a volunteer EMS service, and we had certain paramedics allowed to do RSI and others not. You are given a key to the meds which are locked inside the ambulance if you have been checked off.

 

[QuikClot]

End tidal is great. That said I have yet to work in a hospital that has it in the ER or a city where the EMS system uses it. And these weren't tiny towns. I'm talking Philly through '00, Sacramento through '03 and Vegas still doesn't have it.

That's amazing. Sometimes medicine races forward, and sometime it is seems to be standing still.

Are the EMS systems using Lifepacks? The new 12s come with an end-tidal monitor built in. Single easiest thing on the monitor to use. They are also great for hyperventilating pt.s (diagnosis and biofeedback), hypoventilating pt.s, and, some people think, you can identify PEs with them.

I've always heard good things about Clark County EMS. This baffles me.

 

[QuikClot]

End-tidal is in Clark County's protocols (http://72.14.203.104/search?q=cache...vada+"clark+county"&hl=en&gl=us&ct=clnk&cd=1). Do the hospitals in Vegas not have it? (Or maybe EMS hasn't implemented its new protocols?)That'd be pretty dysfunctional.

 

[docB]

End-tidal is in Clark County's protocols (http://72.14.203.104/search?q=cache...vada+"clark+county"&hl=en&gl=us&ct=clnk&cd=1). Do the hospitals in Vegas not have it? (Or maybe EMS hasn't implemented its new protocols?)That'd be pretty dysfunctional.

Vegas puts the fun in dysfunctional. I asked around. AMR does not have it except on their CCT rigs. Medic West does but lots of the crews have not been trained on it. Fire has it. I haven't seen them use it but that doesn't mean that it never happens. Everyone has the little color change CO2 detectors.

A work about chest xrays. Tehy really aren't the gold standard for tube placement. You use them for checking depth (mainstem or not) and pneumothorax and so on but it is possible to have a tube in the esophagus and a normal looking tube on cxr.

 

[Apollyon]

End tidal is great. That said I have yet to work in a hospital that has it in the ER or a city where the EMS system uses it. And these weren't tiny towns. I'm talking Philly through '00, Sacramento through '03 and Vegas still doesn't have it.

We've had it at Duke since I've been there ('03). There's this unit that is a combined oximeter/capnometer. It can either take a nasal cannula (as for procedural sedation) or there's an inline device that goes between the BVM and tube (like the colorimeter), and it works great!

As far as the cost, I don't know, but think of the savings of no undetected 'gus tubes. I don't think it's prohibitive.

 

[Apollyon]

Just looked it up - between $1500 and $2500 - not unreasonable.

 

[docB]

It's not that it's unreasonable. It's that you're trying to convince a company like an ambulance company or a hospital corporation to make a capital investment in something from which they won't realize a direct return. It's actually easir to get them to buy something like an ultrasound because they can bill for each procedure. I'm not sure if you can bill for ETCO2 monitoring. Remember that they also have to train all the nurses at a significant cost and then train their engineers to do the maint on the units. Across a whole corporation those are big costs. I like ETCO2 and think we should all be using it. I'm just explaining why it will take time for it to be picked up everywhere.

 

[QuikClot]

I would add that people get in their narrow little comfort zones and don't want to learn a new skill. So you've been a medic for fifteen years (fire or transport, doesn't matter). You have a routine. You have assessment tools you like, are good at doing and good at assessing the meaning of. Suddenly something new comes along -- an automated BP cuff or end-tidal or 12-lead capability. This means:

* You have to learn a new skill.

* You are going to be awkward and fumbling with stuff on scene (for a while) -- the permanent condition of newbies but one you're no longer accustomed to.

* You have to learn what the results mean and figure out how they change your treatment plan. (On the plus side, you get new toys. )

So the longer you've been in the field, in general, the less excited you are about new tools. And who has more influence in an organization, newbies or old hands?

The opposition to change is aggravated by the presence of multiple stakeholders in a prehospital juristiction (usually a county). You have multiple fire dept.s, transporting agencies, ER physicians, and the medical director in the middle. Everyone has to agree to the changes, first of all, then schedule the purchase of new equipment and the training of all their people.