Is an ET Tube Really ALS?

[MMiz]

A month or so ago I flew back home to get some pratical CEUs for my EMT-Basic renewal, and the instructor, like almost all EMT classes, finished hours early. Because he couldn't let us out five hours early, he got out the intubation supplies and gave us a quick tutorial on intubating an adult.

I won't say that I was a pro by any means, as dropping a tube down Annie's throat isn't quite like the real world, but it got me thinking as to whether it should be incorporated into the BLS curriculum.

So much of EMS, like many medical jobs, is about performing a skill. EMT-Basics lack so muck of the knowledge, but I wonder if the benefits of adding ET inbutation outweigh the risks, time, and added money of training.

What do you think?

 

[Chiron]

I think they are teaching ET placement to our Basics here in Ohio. I cant see why they wouldn't, no airway no Pt. just seems like common sense.

 

[mikeylikesit]

i think that one must know proper anatomy and physiology before blindly placing tubes. there are many errors that can come from miss placement, knowing not only how and why but what to do if something is to go wrong is extremely important.

 

[daedalus]

It is taught as an optional module, although its a terrible chapter in the Brady book.

 

[Guardian]

No, I don't think it would be a good idea. That’s based on personal experience and the majority of medical directors agree with me. I think the reasons have been made clear.

Speaking broadly, the old risk benefit analysis is always much more complicated than it first appears. For example, if you do a risk benefit analysis and implement changes on the US Military using only military threat as your risk and cost reduction as your benefit, our military could easily be reduced to about 1/8 of the size it is today (No more super power threat from Communists). Of course, common sense tells us we shouldn't do that for various other reasons. My point being: always be cautious of deceptively simple risk benefit analysis. In other words, sometimes you have to use common sense to see past the black and white and interpret the grey.

 

[MMiz]

While it wouldn't make sense for me to have the skill, with ALS only a five minutes away (max), couldn't it be a useful skill in a rural setting?

 

[Chiron]

With respect to others, I absolutely agree that proper training is required, but come on its not really that difficult of a skill to master. we all had to start somewhere, not a single one of us was born into emergency medicine knowing anything without first being trained.

If you look back into our own not to distant past this same topic was being hotly debated among the medical elite as to allowing Paramedics to intubate. It is a foundational skill and if a Basic can be trained to meet the standard then I say good on em'. If I were the one who was down and my only options were an ineffective BLS airway or allowing a Basic to tube me then I'd pick the Basic placing the tube.

Just my 2c. But then again who am I..... Just a street medic with 10yrs experience, a nobody you've never heard of me.

 

[VentMedic]

Where would they get their live intubation skills training? Hospitals are becoming more and more reluctant to allow Paramedics to perform the skill in their ORs and EDs.

What type of patient? Any patient that is not pulseless may need meds to facilitate intubation.

What about competency and proficiency quality control?

How prepared will they be to alleviate the complications caused by direct trachea intubation or attempts?

 

[MSDeltaFlt]

I think they are teaching ET placement to our Basics here in Ohio. I cant see why they wouldn't, no airway no Pt. just seems like common sense.

Define "airway". By definition in my Taber's 17th edition medical dictionary, an "airway" is defined as a natural path from the air to your lungs. That's it. It doesn't say ETT, Combitube, it dosen't even say OPA. A lot of people tend to forget that, I think.

Besides, if you go by the new AHA algorithm, intubation is a bit further down the line, and they don't want you to stop chest compressions.


http://www.acls.net/acls2005/vfpvt.htm

 

[Ridryder911]

Hmm.. let's look at it this way, Paramedics are sucking at intubation. Now would you consider a Basic without any real knowledge of anatomy and definitely no in-depth knowledge of airway control to perform this procedure?

Again, one should not base procedures on the "ease" of a skill, heck removing an appendix is a breeze.. but, would you want just anyone to do it?.. Knowledge of the indications, procedures attaining to why, the etiology of disease process of why your intubating, and well as being able to control or fix things if a mishap during the procedure if it should occur.

R/r 911

 

[JPINFV]

No... just. no. A 110 hour training course with an entire 2 hours of anatomy and physiology should not be enough to go around putting tubes into people's tracheas.

 

[Jeremy89]

I think if one has had proper anatomy classes (such as A&P for Nursing students like myself) then they should be allowed to do so. I agree, the Brady book has a sucky chapter for ALS assist skills...

 

[JPINFV]

I think if one has had proper anatomy classes (such as A&P for Nursing students like myself) then they should be allowed to do so. I agree, the Brady book has a sucky chapter for ALS assist skills...

Is "ALS assist skills" really that complicated? It shouldn't take longer than a few minutes to teach just about anyone how to prime IV tubing or place electrodes.

 

[Guardian]

While it wouldn't make sense for me to have the skill, with ALS only a five minutes away (max), couldn't it be a useful skill in a rural setting?

I think there are always extreme situations that require unconventional courses of action. So, maybe it could be done in some rare situations. But in general, I think it’s a bad idea and moves the profession backwards.

I would suggest that anyone wanting to promote this as an emt-b skill, should get their paramedic cert. Then, work as a paramedic for a while. Then come on here and promote the idea of emts intubating. I could almost guarantee you would have changed your mind by then. On that note, any paramedics on here in favor of giving emts this skill?

 

[daedalus]

I wouldn't be against it should the EMT curriculum be expanded. The only case I see permissible would be both pulse-less and apenic. But again only when the BLS level becomes more...educated and less arrogant.

 

[DBieniek]

It is BLS in some states/per the national standards...

When I run on the squad in Ohio (as I frequently do), I can intubate using an ET tube as an EMT-basic.

 

[ccfems540]

I agree with Rid. Ekg interpretation and defibriallation are also easy skills to acquire. With a quick pharmacology and intubation class, which aren't that difficult, a basic could perform as a paramedic. Sounds kind of silly doesn't it. It is not just the skill, but all the background knowledge that is needed to make a procedure safe for one to perform. I am not knocking basic EMT's, I was once one. If you want to perform advanced procedures, you need to have a great understanding of anatomy and physiology as well as all the contraindications/complications and resolution of problems that may result from them. This is just not taught in basic EMT school.

 

[firemedic31075]

Hmm.. let's look at it this way, Paramedics are sucking at intubation. Now would you consider a Basic without any real knowledge of anatomy and definitely no in-depth knowledge of airway control to perform this procedure?

Again, one should not base procedures on the "ease" of a skill, heck removing an appendix is a breeze.. but, would you want just anyone to do it?.. Knowledge of the indications, procedures attaining to why, the etiology of disease process of why your intubating, and well as being able to control or fix things if a mishap during the procedure if it should occur.

I agree with you except for saying paramedics suck at intubating. Yes there are medics out there that truely do suck, but intubating in the field most of the time is difficult at best. In the back of a rescue car driving 50 mph down the road and hitting every bump possible or the 350 lb code or OD found in the bathroom naked and lodged between the toilet and the bath tub in a house with barely any light. Intubating in the the hospital is quite a different experience as you know. But seeing how medics have a tough time with intubation even with the schooling and understanding I would not want an EMT-B performing that skill with no real understanding of what their doing or consequences of, and no ability to fix certain complications of intubation...bradycardia, laryngospasm, ICP etc.

 

[VentMedic]

I agree with you except for saying paramedics suck at intubating. Yes there are medics out there that truely do suck, but intubating in the field most of the time is difficult at best. In the back of a rescue car driving 50 mph down the road and hitting every bump possible or the 350 lb code or OD found in the bathroom naked and lodged between the toilet and the bath tub in a house with barely any light. Intubating in the the hospital is quite a different experience as you know. But seeing how medics have a tough time with intubation even with the schooling and understanding I would not want an EMT-B performing that skill with no real understanding of what their doing or consequences of, and no ability to fix certain complications of intubation...bradycardia, laryngospasm, ICP etc.

But, many of the schools that require only 700 hours of training or the career schools have limited intubation training facilities. 5 intubations in the OR does not constitute enough experience and the paramedic is set up to fail in the field. Thus, probably by the standards of other professionals in the hospital who are called to do regular and difficult intubations, the paramedic, by far, lacks in the necessary skills and education for intubation from the very beginning. Do you know how many intubations a CRNA or RRT must do before they are given their competency cert? And that is for a relatively controlled environment. A NICU RRT and/or RN may need 100 intubations to even be eligible for the transport team. There's no margin of error or excuses for them when they are called to pick up a sick baby in need of an airway.

How many Paramedics actually know they are going to have a difficult time or identify the problems prior to inserting the blade?

Now, the EMT-B will have even less of the few advantages of the paramedic. I believe someone posted on another thread the requirements for the EMT-B intubation cert. It read something like "3 attempts".

 

[Jon]

So... those of you saying medics don't often make airway errors:

Have you read any of Dr. Wang's stuff? I don't really agree with all of what he says... but he's got some points. Here are a few articles found with Google:
http://content.healthaffairs.org/cgi/content/abstract/25/2/501
http://lib.bioinfo.pl/pmid:17597255


I think that BLS providers using the Combitube or the King LTD would be a good idea. LA County has had issues with their paramedics not getting enough tubes to be proficient... it would be worse if the EMT's were trying to get tubes too.