Why are we placing ETTs at all?

[usalsfyre]

I can't imagine there is a medical director out there who would allow this to occur.

I think there's probably some that don't know it's occurring.

Sure, asthmatics, COPD'ers, obese pts, burns, etc...anyone where the pressure required to ventilate them is likely to result in more air entering the esophagus than the trachea.

Again, do these outnumber the number of patients harmed from misplaced and inappropriate ETTs? Put another way, "is the juice worth the squeeze" in our current practice? Because changing education and experience requirements is proving to be a glacial process.

 

[systemet]

The honest truth is many EMS providers arguments for or against a particular issue ARE crap. There full of anecdotes, logical fallacies and tradition. If more people are being harmed by endotracheal intubation than helped by it it needs to be pulled.

This is awesome. I could not agree more.

The following commons are general, and not directed at usalsfyre. I will likely perpetuate the tradition of anecdote, logical fallacy, and err.... tradition!

I think there's a few issues that come up when paramedic ETI is discussed.

(1) Intubation success rates are not as meaningful a metric as they first appear. They don't describe how the intubation was performed. If I take five minutes on my first laryngoscopy, I'm much more likely to end up with the tube in the trachea than if I take 30 seconds. This doesn't mean my patient will be better for it.

(2) Unless there's been a large amount of recent research that I'm not aware of, the population of airways seen prehospitally hasn't been adequately characterised. It seems reasonable that EMS patients might be more difficult to intubate. This could mean that there's a greater risk or benefit (or both) to intubating these patients.

(3) Paramedics in the literature are seen as a homogeneous group, despite the fact that training hours, OR time, intubation frequency, QI, agents used, operator experience, etc. vary across the world. It may not be valid to generalise results from one region to another.

(4) As another poster pointed out, many of the studies that show poor performance by paramedics have been performed in systems that lack (vital) equipment such as waveform capnography.

The existing studies that I've seen have been deficient in some manner with regard to (1)-(4). This doesn't mean they're worthless, and it's not going to stop physicians from drawing conclusions from them. One of the things that scares me about evidence-based medicine, is at what point is the evidence that a therapy may be harmful enough to remove it's use? What is the risk of removing a genuinely beneficial intervention?

I should also add, that I don't think placing a tube in the esophagus is a particularly bad crime. It's better not to, but it's forgivable, to a point. It's not recognising that the tube is misplaced (often through hubris and unwillingness to use the available confirmation tools on a routine basis) that's criminal.

 

[Veneficus]

Anecdotaly I have a feeling that assuming a commercial holder and cuffed tube, the device is applied directly and it and the tube are reasonably dry and you disconnect the BVM for moves it would be difficult to displace the tube unless your moving the patient by the ETT.

It has been my experience that gause and shoe strings actually work better than commercial devices.

As for the missed intubations, I think the problem is simply poor skill and poor oversight.

I have written at length on the faults of medical direction so I will not reproduce it here, but in short, any medics not getting at least 12 tubes a year should not be intubating anyway.

Harder in the field and all the other excuses are just that. Excuses. Proficency builds speed, speed does not build accuracy. If you don't have time or the environment to place an airway then an airway should not even be attempted.

There is even a problem going back to training. Most paramedic students spend way too much time intubating Fred the head and no time intubating people. Nobody would think of letting somebody perform surgery who only ever operated on a simulator. Why do we let paramedics intubate who have only done it on a simulator?

 

[boingo]

The problem isn't the ET tube, it is the experience and skill of the provider. Fix the education and experience gap, fix the problem.

The problem of experience is a very real one. If you work in a system that is all ALS, you are likely to see way more non acute patient than acute ones, v.s. the tiered system where paramedics are sent to only high priority calls and see a large number of very sick people.

I've been at work for 7 hours today and have taken 3 patients to hospital, first one was a 74 yo F 2 days s/p stent placement in her esophagus who presented in respiratory failure w/runs of v-tach that ended up on CPAP and an Amio drip, the second was a 60 yo M w/failed AICD in v-tach without a palpable pressure and SOB w/RR of 40, cardioverted into NSR, and the third was a 23 yo obese F status asthma w/EtCO2 of 101 and SpO2 less than 50, RSI'd and transp w/Epi, Mag drip, parayzed, sedated and on a vent.

If you are running those kinds of calls on a regular basis you are likely to stay sharp. If you are running *** aches and psychs all shift, you might get a bit rusty on the when's, how's and if's of advanced airway management. Just my opinion.

 

[boingo]

It has been my experience that gause and shoe strings actually work better than commercial devices.

As for the missed intubations, I think the problem is simply poor skill and poor oversight.

I have written at length on the faults of medical direction so I will not reproduce it here, but in short, any medics not getting at least 12 tubes a year should not be intubating anyway.

Harder in the field and all the other excuses are just that. Excuses. Proficency builds speed, speed does not build accuracy. If you don't have time or the environment to place an airway then an airway should not even be attempted.

There is even a problem going back to training. Most paramedic students spend way too much time intubating Fred the head and no time intubating people. Nobody would think of letting somebody perform surgery who only ever operated on a simulator. Why do we let paramedics intubate who have only done it on a simulator?

What he said ^^^

 

[systemet]

Here's the citation:

Katz SH, Falk JL. Misplaced endotracheal tubes by paramedics in an urban emergency medical services system. Ann Emerg Med. 2001 Jan;37(1):32-7. PMID: 11145768

Of course, it would be grossly inappropriate to share .pdfs of copyrighted material, but if anyone wants to send me a pm, I might be able to help them find a copy.

 

[usalsfyre]

I should also add, that I don't think placing a tube in the esophagus is a particularly bad crime. It's better not to, but it's forgivable, to a point. It's not recognising that the tube is misplaced (often through hubris and unwillingness to use the available confirmation tools on a routine basis) that's criminal.

I agree with this statement completely. There's nothing wrong with missing. The biggest, baddest MF'er of an anesthesiologist is occasionally going to miss one. The difference is they're not likely to declare the machine wrong, the tube is good "because I said so" and proceed to ventilate the gastric tract right into cardiac arrest.

 

[Smash]

Unrecognised oesophageal intubations are not the problem, they are just a symptom. Normally I would suggest fixing the underlying problem first, then the symtpoms would resolve. However it seems that this may not be possible in some places, so symptom control may sadly be required.

 

[18G]

If your using wave-form capnography I really have no clue why there would be ne misplaced tubes. Its quite clear to see with EtCO2 and the other confirmatory measures when the tube is where it needs to be.

The new PA 2011 protocols further addressed this by stating "CONTINUOUS" waveform capnogrpahy.

Providers should be checking lung sounds and tube depth after every move.

 

[jjesusfreak01]

Should be and IS are so very, very different. I spent some time reading the Wake County protocols this morning, and even though there were lots of accountability procedures built into the protocol, I have a hard time believing that everyone in the system is on that level of performance.

We have the airway audit form, but I think the best thing is going to be that ETCO2 is such a useful tool for the code commander that they aren't going to go that long before putting it on, which will give immediate confirmation of placement when that's done, even if initial confirmation wasn't done correctly (or at all).

 

[Aidey]

If your using wave-form capnography I really have no clue why there would be ne misplaced tubes. Its quite clear to see with EtCO2 and the other confirmatory measures when the tube is where it needs to be.

I've also seen medic argue that the capnography was "wrong" :blink: because they heard "breath sounds" that were actually transmitted from the abdomen.

Been there, seen that. EtCO2 read 7mm/hg for about 2 breaths before erroring for the rest of the transport. The medic who intubated said our machine must have been defective. :wacko:

 

[MrBrown]

Unrecognised oesophageal intubations are not the problem, they are just a symptom. Normally I would suggest fixing the underlying problem first, then the symtpoms would resolve. However it seems that this may not be possible in some places, so symptom control may sadly be required.

Gosh Brown loves Smash to bits, Frank Archer would be so proud B)

Hang on, at the risk of Mrs Brown seeing this, Brown still loves Mrs Brown too.

Its interesting to note that we don't have problems with intubation here, as Brown is sure you do not in fact we have excellent success with RSI.

Brown proclameth loudly the problem is NOT with intubating, its the people who are doing the intubating.

 

[M3dicDO]

I'm probably repeating what some people may have already stated in one way or another. Airway management is one absolute skill that any EMT (Basic, Paramedic or Critical Care) should be good at. Whether it's a simple jaw thrust or a retrograde intubation, they are all life-saving procedures. I have made a condensed list of issues that I seen over and over again, on reasons why airway management fails in the hands of Paramedics in the field, especially ETT placement:

1. They are scared of performing an invasive procedure
2. They fail to properly assess initial ETT placement
3. They fail to continually re-assess ETT placement during transport

If you think about it, intubation is really not a difficult skill. I agree that it takes time and experience to master it, but this is where I think most EMS systems have issues with. Paramedics simply aren't given the proper resources to master intubation. Around the Chicagoland area, Paramedics actually begin their careers on the wrong foot! Intubation is taught by instructors who probably never intubated in the field (i.e. ER nurses) and the anesthesiologists are scared to allow students to perform an intubation all by themselves. I know of a hospital where Anesthesiologists hold the laryngoscope while the student passes the tube. C'mon!

And don't get me started on continuing education. I know of medics that probably intubate once every 5 years, and they are horrible at it. It's not because they do it occasionally, but a real person isn't like the mannequin you practice in the classroom. Most systems do not have any programs that allow practicing Paramedics to go back in to the OR and intubate a real human being.

I could go on and on, but to keep it short, the only thing I can say is that EMS training has lot more room for improvement. Sure you can bring new technologies to help make airway management easier, but you have to realize that airway management has been around for much longer than the end-tidal CO2 monitor on your LifePack! Bottom line is, practice, practice, practice. If your EMS systems is poor in keeping up your skills in airway management, demand it! It is ultimately your responsibility to provide your patients with the best care they deserve. By that I do not mean acquiring ongoing traces of the ETCO2 waveform, but rather doing a simple initial and ongoing BLS airway assessment: look at the patient, auscultate and observe. That's it!

 

[Shishkabob]

Been there, seen that. EtCO2 read 7mm/hg for about 2 breaths before erroring for the rest of the transport. The medic who intubated said our machine must have been defective. :wacko:

To be fair, I've actually had capnography stop working during my last code. Other medic placed the tube, I confirmed with sounds, and we had EtCO2 return for a fair amount of time... than it just errored out.

We reconfirmed via visual and sounds, but had no CO2 for the rest of the code despite all of our fiddling except for some random moments where we'd get a decent reading.

 

[Aidey]

Did you also have thick orange goo coming out of the tube along with the guy having a huge belly?

 

[Shishkabob]

Nope.


Luckily the guy was skinny enough that we would be able to see if air actually went gastrically-ish.



Trust me, it wasn't even my tube and I made damn sure it stayed in place the whole time as if it WAS my baby.

 

[abckidsmom]

Been there, seen that. EtCO2 read 7mm/hg for about 2 breaths before erroring for the rest of the transport. The medic who intubated said our machine must have been defective. :wacko:

Not to show an over-reliance on technology, but did you consider changing out the probe, suctioning the patient, cleaning out the port where the ETCO2 monitor plugs in, or rebooting the monitor?

Troubleshooting. I find EMS equipment to be designed to be fairly failsafe. Usually when troubleshooting "equipment failures" we find user error.

Just saying, in case someone reads this and identifies with the monitor failure.

 

[Aidey]

We suctioned but beyond that no, because all clinical indicators were that the tube was in the wrong spot. It was a bad tube, the EtCO2 just helped confirm it. Even at the hospital after the MD had yanked the tube the medic who intubated was like "Hmmm, why did they pull a good tube?.

 

[Melbourne MICA]

ETT forever

Unrecognised oesophogeal intubations usually means dead patients. Failed intubation drills and multiple cross checks with end tidal respiratory waveform on insertion should mean high success percentages for ETT. If all else fails an ETT is pulled and basic airway management is applied.

If the practitioner is well educated and trained, gains experience under guidance from senior staff there should be no reason for airway management techniques to be stuffed up on so many occasions. The issue of audit by senior clinicians also comes into it. Here, if you make a mistake , revision is required. If you stuff up big time - its back to square one. Your accreditation is pulled and you have to do all the training again. This includes theatre time, prac scenarios, theory testing and final sign off. If you stuff up big time again don't bother expecting to ETT anyone. That means no drug assisted intubations or perhaps even no cold tubes as well.

If so many staff are stuffing it up you have to wonder if they were, as a group, actually up to doing the procedures in the first place.

EMS Intensive care Paras don't need bad publicity like that. The neocons of medicine want any excuse to dumb down our skills.

As for the value of ETT itself - this has been well covered by others.

MM

 

[DrParasite]

bumping an old thread just because I thought it was an interesting topic