ET Intubation

[fyrdog]

We recently had a class on difficult airways and I thought I would share the topic of ET Intubations being under fire.

Apparently there are several medical control directors around the country that do not support the use of ET Intubations by any pre-hospital providers including paramedics.

This past year in the North Central Region of Connecticut, which is Hartford County and a few other surrounding towns, the paramedics were required to participate in a mandatory study of pre-hospital ET intubations (ETTs). It was required that the paramedics provide his/her name and license number on the form. There were 400 documented ETTs. 80% were properly performed on the first attempt. The other 20% required multiple (2) attempts or use of other airway adjuncts (i.e. combi tube, OPA, LMA) 7 of the ETTs were esophageal , one which had a capnography record showing that it was properly placed but dislodged when the patient was moved from the EMS stretcher to the hospital bed.

Number of ET Intubations required to become board certified (national standard) by license type –

Emergency Room Doctor 50
Nurse Anesthetist 100
Anesthesiologist 200
Paramedic 5 (In Connecticut 10)

 

[Airwaygoddess]

Our medical director removed pedi E.T. from the medics:glare: such an id**t!!

 

[KEVD18]

1....80% were properly performed on the first attempt...
2....it was properly placed but dislodged when the patient was moved...

1. sounds like a pretty good ratio to me.

2. hardly seems fair to use that type of thing in consideration of this argument.

pulling tubes from als trucks will kill pts.

 

[Ridryder911]

This is a national trend.. While many on this forum would love to debate and argue that even basics should intubate, the real reality is many of the EMS Systems are removing or "studying" the efficiently of EMS personal being able to intubate properly.

Many are describing that "too many " already have intubation certifications, therefore decreasing the ability to intubate and decreasing proficiently. As well nationally intubation clinical sites have decreased and documented "successes" has been on the decline.

I do believe this a shame, that no esophageal intubations should ever be presented into an ER. With the use of capnography and assessment there is proper documentation of extubation, and correction can immediately occur.

However; due to the blindness and apathy of most EMS personnel, there is a very rapid discussion among physicians and EMS Medical Directors to have EMS use alternative airways in lieu of intubations.

I personally see intubation being totally removed from all EMT level curriculum within the next five to ten years. I do believe we are not recognizing the strength of this campaign, and as well do not realize the dangers and risks this place our patients. I am aware of discussion by leading EMS authorities in discussion of this agenda, and it has gained much support recently.

R/r 911

 

[Ridryder911]

Number of ET Intubations required to become board certified (national standard) by license type –

Emergency Room Doctor 50
Nurse Anesthetist 100
Anesthesiologist 200
Paramedic 5 (In Connecticut 10)

I would like to know where you obtained the national standards minimal numbers at ? I have not been able to find such documentation describing such.

This is from the CRNA requirements for obtaining their certification level.

.."Clinical Curriculum Requirements
The clinical component of the nurse anesthesia educational program mandates that each student administer a minimum of 450 anesthetics to patients , representing at least 800 hours of anesthesia time. To meet this requirement, students provide these services under the supervision of qualified clinical instructors, which include CRNAs or anesthesiologists..

Albeit not all patients requiring anesthesia require intubations, I am sure it is much more 100. As well there is NO official requirement for Paramedics to have any intubation requirements nationally. There is "recommended intubations", but local and state can mandate. I just attended a meeting two days ago addressing the number of facilities nationwide that now use mannequin training in lieu of O.R. experience. I do agree this is a drastic shame, but they are not able to find O.R. sites.
Hence, part of our problem.



R/r 911

 

[fyrdog]

I am not sure where the "national Standard" comes from. The instructor who taught the class provided those. He is someone I have known for about 20 years and has always been a reliable source. I'll see where he got the numbers from. It could just be a concensus of many different states. He did say that the numbers come from some certification boards be he didn't go into more detail. It may be a voluntary certification.

I'll also check with OR. I'll be going there in the next month to do some tubes as I have been living under a white cloud for the last two years.

 

[yowzer]

Unfortunately, lots of places are reflexively going "No intubations!" instead of "Make sure our medics get plenty of education and practice, so they can do it right." Areas that follow the latter philosophy don't have many intubation problems, oddly enough. It's easier with fewer medics because you get more chances, but even in systems where everyone has to be medic, you can arrange OR rotations or the like.

 

[wolfwyndd]

Our medical director removed pedi E.T. from the medics:glare: such an id**t!!

Our local EMS region is also considering removing intubations for pedi's. They conducted a study a year or so ago that showed that 80 percent of the intubated pedi's that came into a hospital were incorrectly placed or massive damage was done to the intubated pedi. Our 2007 local protocols will still allow it, but there's speculation that our 2008 protocols will not allow it.

 

[jeepmedic]

the voices in my head uggggh

 

[Strike3]

In SC, Basics can intubate across the board, newborn-adult. We use LMA's, Combi's and ET/Endotrol....


We also have fairly strict rules about use of ETC02 detectors with our monitors and whatnot though... I really don't know how they could justify taking ET intubation out of a states scope. Unless the training is really that bad in said state..

 

[captoman]

This is a very concerning trend. I suppose it is easier to pull the tubes than teach the medics. sheesh. :wacko:

 

[Medic2891]

The big reason behind this is, in my opinion, is this. Most hospitals are going to a pay to play type of system for the doctors. What does this mean? It means that for everything a doctor does, ie. intubate, chest tube, whatever, they get paid for it. Since intubations are common and fairly easy, the doctors are not getting paid for it because we are doing it, so creat this "national trend", and get paid more for doing work in the ER. Pretty screwed up if you ask me as it is witholding patient care, something that kind of goes against the hipocratic oath, I would think.

 

[Ridryder911]

I believe you are on some valid points. But then why is the rate of "missed intubations" that EMS is making. Why is our intubation rate from 93% nationally to approximately mid to lower 80 percentile ?

Could it be possibly... uh, we are having less trained and educated people performing them ? Is it we have "too many" people qualified to intubate and the skill attribution rate is high, because "everyone" can intubate and thus no one gets enough clinical exposure ?

As well, there should never be a patient delivered with an ET tube misplaced and not verified. With the invention of EtCo2 detectors, and good patient assessment (lung/gastric ) sounds, it is not allowable for ER to ever receive a tube in the esophagus.

I too personally blame a lot of the "intent" of some these studies on professional bias. The same authors are repeating the same studies on a rant to prove something. As well, when Dr. Wang (author of leading anti-paramedic intubation study) how often he intubated, he refused to answer.

If we (EMS) do not take stand with scientific data, and as well be sure only in-depth educated personal with quality assurance (set number of intubations per month, O.R. rotations if not met). Then we will see intubation be removed from pre-hospital care. AHA has already down played airway, and now the paradigm shift is to use alternative airways. This will not happen later, rather within the next two to five years.

R/r 911

 

[Guardian]

As well, there should never be a patient delivered with an ET tube misplaced and not verified. With the invention of EtCo2 detectors, and good patient assessment (lung/gastric ) sounds, it is not allowable for ER to ever receive a tube in the esophagus.

This is the bottom line and missed tubes should be grounds for investigation as to whether or not the provider should be able to continue to intubate. I think it would be perfectly legitimate to only allow certain paramedics in a system to intubate by themselves, per medical director’s discretion (just like surgical airways in some systems). It's sad paramedic education has decreased to the point where we are even having this discussion. I don't think alternative airways are the answer because I've yet to see one that could oxygenate and protect the airway as well as ETT.

 

[Guardian]

Oh yea, and the answer to this problem is better education, but then again, that's the answer to every problem in ems.

 

[jeepmedic]

OK the voices win....

 

[jeepmedic]

We recently had a class on difficult airways and I thought I would share the topic of ET Intubations being under fire.

Apparently there are several medical control directors around the country that do not support the use of ET Intubations by any pre-hospital providers including paramedics.

This past year in the North Central Region of Connecticut, which is Hartford County and a few other surrounding towns, the paramedics were required to participate in a mandatory study of pre-hospital ET intubations (ETTs). It was required that the paramedics provide his/her name and license number on the form. There were 400 documented ETTs. 80% were properly performed on the first attempt. The other 20% required multiple (2) attempts or use of other airway adjuncts (i.e. combi tube, OPA, LMA) 7 of the ETTs were esophageal , one which had a capnography record showing that it was properly placed but dislodged when the patient was moved from the EMS stretcher to the hospital bed.

Number of ET Intubations required to become board certified (national standard) by license type –

Emergency Room Doctor 50
Nurse Anesthetist 100
Anesthesiologist 200
Paramedic 5 (In Connecticut 10)

Ok the study says:
"80% were properly performed on the first attempt. The other 20% required multiple (2) attempts or use of other airway adjuncts (i.e. combi tube, OPA, LMA) 7 of the ETTs were esophageal , one which had a capnography record showing that it was properly placed but dislodged when the patient was moved from the EMS stretcher to the hospital bed."

It does not say how many did not receive any airway period.

I have seen many times in the ED an Anesthesiologist miss on the first attempt.

I had an Anesthesiologist try to pull one of my tubes because he said "I hear air movement all over the place." Said the tube could not be in the right place. The X-ray and ET CO2 confermed the placement. Plus after termination of CPR the ED Dr. (which was my Medical Dir.) checked and guess what IT was in.

How many of these intubation attempts had a gag reflex? How many of them wound up being "difficult airways?" Where they had to be medicated to be intubated?

Studys like this only give the people who want to hold EMS back more reasons to with out any real data. Without true data it is hard for anyone to prove anything.

 

[Guardian]

studies also show an increase in hyperventilation of cardiac arrest pts who are intubated. You know, when the FF ventilates at 80/min, wonder if this has anything to do with it. Again, lack of education.

 

[jeepmedic]

studies also show an increase in hyperventilation of cardiac arrest pts who are intubated. You know, when the FF ventilates at 80/min, wonder if this has anything to do with it. Again, lack of education.

This falls back on the AIC. And you are right it does go back to education. If you see the person ventilating to fast then say something to them. Alot of times people will not say anything due to the fact they don't won't to hurt anyone's feelings. But they need to say something. If it is wrong you need to say so.

 

[hangit]

i mentioned this thread to an older medic and had a couple questions on two things he talked about.

1. he said if you see fog on the inside of the tube- you're in.

2. he said if you try on first attempt and miss, leave the first tube in and insert a second and the second will automaticaly go into the trachea.

i'm sure these are probably not accepted practices, but was just wondering.