Prehospital intubations - fear and loathing in Rhode Island?

[norski]

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Hey all,

Norwegian nurse anesthetist here, just bored on a rare off-call night. For context, any and all intubations anywhere in my country are performed by anesthesiologists or nurse anesthetists( except for neonates, if there's a paed's doc available,for some reason), tracheal intubations were more or less banned for providers like EMTs or paramedics, who use iGels, and pretty much summon us if that doesn't work. We don't have RTs or non-anesthesia trained intensivists, or even a real specialty of emergency medicine. Just to colour some landscape.

I remember some years ago there was a pretty big thing about EMTs doing prehospital (field) intubations in the state of Rhode Island. From reading the news stories again, RI had a remarkably high unrecognised esophageal intubation rate arriving to the hospital, unsurprisingly resulting in cra*py outcomes. This due to so called EMT-Is being union protected for doing this kind of procedure.

We desperately want our colleagues in the prehospital field to come in regularly to do a few iGels, and at least help them keep some basic proficiency in airway management - mask/bag ventilation - but management and EMTs seem to not really give two sh*ts about that very basic aspect of life support.

How does this work where you practice? I guess some of you might be medical directors for prehospital services, so I believe some of you may know what's up.

Also, do EMTs/paramedics perform field intubations where you practice, and if so, what's the required rate/year to keep skill retention up?

Cheers!

 

[Janders]

Highly variable by region and even town / micro region. The spread of waveform ETCO2 has improved the prehospital game in my opinion. I don’t see many unrecognized prehospital esophageal tubes (I know one major one in our ED in the past few years, from all providers not just my shifts). That said, I see a fair amount of King Airways thrown in to codes and can’t say I love them. Better than an esophageal ETT.

 

[clibby]

It is very rare that I now see paramedics intubating in the urban southern California area. There has been a wide adoption of iGels and use of prehospital CPAP, which has significantly decreased the need for intubation. They are also close enough to the hospitals here that transport times are not prohibitively long. In Florida, I saw a much higher rate of prehospital intubation largely because the transport times were much longer, though, they were moving towards more use of iGel.

 

[norski]

Highly variable by region and even town / micro region. The spread of waveform ETCO2 has improved the prehospital game in my opinion. I don’t see many unrecognized prehospital esophageal tubes (I know one major one in our ED in the past few years, from all providers not just my shifts). That said, I see a fair amount of King Airways thrown in to codes and can’t say I love them. Better than an esophageal ETT.

Kings are laryngeal tubes, right? Much better than an E-ett, possibly safer than an iGel,too.

While I don't exactly love doing field intubations, the very presence of an EMMA capnography makes me feel a lot better about it, even more than in the ICU, where they just don't exist before we ask for them, then found in a dusty cupboard somewhere.

Speaking of iGels, though, I get the distinct feeling that they're just part of an algorithm now. Like "can't get air? - stuff an iGel in, nevermind the vomit going out of the suction port!".

 

[southerndoc]

I mandate all our intubations be video-assisted (we even have a backup video laryngoscope on all units), encourage i-Gels for cardiac arrests, mandate constant end-tidal CO2 monitoring with an uploaded waveform attached to each PCR, and review each and every single intubation/airway management (including i-Gels) that occurs in my agency.

Missed intubations by paramedics are a problem when medical oversight is non-existent. With proper QA and training, there's no reason for it to not be successful.

 

[Rekt]

Unfortunately this isn’t standardized. There’s almost no reason for field intubations. Delays care and increases mortality. I still get an esophageal tube probably every month and unfortunately for some reason it seems like it ends up being on young patients. I bring it up with the crews but they never seem bothered by it. I don’t think a lot of EMS understands the repercussions of a missed intubation. At least with BVM and supratlottics they’re getting ventilation to some degree but as soon as it’s goosed, they’re dead. Essentially a clean kill once they get to the ED. There’s so much variability with no accountability. I have over ten counties doing runs to my ED. I get everything from volunteer EMTs to critical care trained medics.

 

[Ceke2002]

MICA (Mobile Intensive Care Ambulance) will do field intubations here in Melbourne (which includes Cricothyroidotomy, and rapid sequence intubation, as far as I know). The MICA guys aren't just regular ambos though. It's like 3 years undergrad program to become a graduate paramedic, then 12-24 months to become a qualified paramedic, then another 2 years on the job at ALS level, then you can apply for the MICA program which I believe is another 12 months of study plus 18 months total supervised training. They also have standardised/set clinical practice guidelines.

 

[RustedFox]

iGEL airway for the win.
Am I crazy, or are the new models far "skinnier" than what they used to be?
I used to pull what looked like a TV remote out of airways with the old ones.

 

[norski]

iGEL airway for the win.
Am I crazy, or are the new models far "skinnier" than what they used to be?
I used to pull what looked like a TV remote out of airways with the old ones.

They still look like dildos to me. But yeah, there's some sort of a v2. Larger suction port, maybe slightly skinnier.

 

[norski]

MICA (Mobile Intensive Care Ambulance) will do field intubations here in Melbourne (which includes Cricothyroidotomy, and rapid sequence intubation, as far as I know). The MICA guys aren't just regular ambos though. It's like 3 years undergrad program to become a graduate paramedic, then 12-24 months to become a qualified paramedic, then another 2 years on the job at ALS level, then you can apply for the MICA program which I believe is another 12 months of study plus 18 months total supervised training. They also have standardised/set clinical practice guidelines.

Sounds very solid to me. Do these guys have some sort of yearly requirement for elective intubations? Of course, if they get an intubation or two a week in the field, that's unnecessary.

 

[Ceke2002]

Sounds very solid to me. Do these guys have some sort of yearly requirement for elective intubations? Of course, if they get an intubation or two a week in the field, that's unnecessary.

I'm not sure (don't work in healthcare myself). I know they attend a lot of car accidents, so doing a couple of intubations a week wouldn't be out of the realm of possibility.

 

[TooMuchResearch]

Sounds very solid to me. Do these guys have some sort of yearly requirement for elective intubations? Of course, if they get an intubation or two a week in the field, that's unnecessary.

1-2 per week? I haven't intubated anyone in our community EDs, including a decent sized tertiary care center, in at least two months. I have strongly supported comfort measures on a good number of people who really didn't deserve to be tortured in the ICU before dying though.

I'll probably do 10 in the next month now.

 

[CajunMedic]

I mandate all our intubations be video-assisted (we even have a backup video laryngoscope on all units), encourage i-Gels for cardiac arrests, mandate constant end-tidal CO2 monitoring with an uploaded waveform attached to each PCR, and review each and every single intubation/airway management (including i-Gels) that occurs in my agency.

Missed intubations by paramedics are a problem when medical oversight is non-existent. With proper QA and training, there's no reason for it to not be successful.

This is also my policy at my county service in rural SE Ohio. They have to have so many a quarter, or they are required to meet with me and demonstrate the procedures. I also mandate a yearly airway in-service with me.

 

[ShockIndex]

I have strongly supported comfort measures on a good number of people who really didn't deserve to be tortured in the ICU before dying though.

I'll probably do 10 in the next month now.

You are doing God’s work. Thank you. Seriously, thank you.

 

[alpinism]

This is probably going to be controversial but at this point I really think EMS shouldn't be intubating except in rare circumstances.
Maybe for all flight medics and some ground medics in super rural locations with long transfers. Otherwise the practice is not supported in the current literature and its so rare nowadays that its almost impossible to maintain adequate procedural skills. I'm definitely showing my age but its been 10+ years since I've worked on a rig and even then even the busiest medics were doing maybe 1 in a month at most. This was before we had prehospital CPAP/BIPAP and basically tubed all the severe respiratory distress patients. Nowadays its even more rare and plenty of the medics are literally only doing maybe 1 in 3 months which means even the most experienced medics have essentially done less than 30 tubes in their careers.

 

[norski]

This is probably going to be controversial but at this point I really think EMS shouldn't be intubating except in rare circumstances.
Maybe for all flight medics and some ground medics in super rural locations with long transfers. Otherwise the practice is not supported in the current literature and its so rare nowadays that its almost impossible to maintain adequate procedural skills. I'm definitely showing my age but its been 10+ years since I've worked on a rig and even then even the busiest medics were doing maybe 1 in a month at most. This was before we had prehospital CPAP/BIPAP and basically tubed all the severe respiratory distress patients. Nowadays its even more rare and plenty of the medics are literally only doing maybe 1 in 3 months which means even the most experienced medics have essentially done less than 30 tubes in their careers.

I don't think that's a controversial opinion at all, given the numbers.

As mentioned above, anesthesia docs and nurses do all tubes over here(except for neonates). Igels, bvm, oropharyngeal airways and cpap are all EMTs and paramedics are allowed, except for some higher volume trauma regions, essentially Oslo.

When I graduated as an RN in 2010, we were allowed to do endotracheal intubations on arrests if we had some rudimentary training, just from our ACLS equivalent certification, which was awesome at the time (**** hot dunning kruger) but this was promptly removed from national guidelines the year after, specifying anesthesia personnel. The same for prehospital/EMS.

This due to much the same as the instance of RI; an obscene amount of unrecognised esophageal intubations, portable capnography and VL not yet standard equipment, and so on.