Supraglotiic Airway Use by EMT's

[DrParasite]

Most medics that I worked with would not attempt intubation and go direct for an SGA, and when asked why the reasoning was normally either a lack of confidence in the procedure or fear of "bringing down the numbers".

Are there clinical reasons to intubate, instead of using a SGA? Outside of airway burns, I can't think of many reasons why an ET tube is better than a SGA (maybe a CHF patient? it's still early, and I haven't had any caffeine). In the county where I live, paramedics (or more accurately, ambulance EMTs) go for a SGA on all cardiac arrests. if they get ROSC, the paramedic has the option of intubating, but why remove a good airway device that is working?

unrecognized esophageal intubation are still far more common than they should be

Not to go down this rabbit hole, but this should results in criminal charges to the provider. Sentinel event, loss of certification, personal lawsuit, criminal charges for dereliction of duty, that's all fair game.

Intubating the esophagus is going to happen. You might even hear lung sounds. and the color metric thing might change color (those things suck anyway). You know what won't be fooled? ETCo2. If you are intubating, 9999/10000 the patient is attached to a cardiac monitor, and if you aren't, then you shouldn't be intubating (I'm looking at you, RI EMT-cardiacs). If the numbers are really low, than either that patient is really really dead, or you aren't in the lungs. In either case, the provider needs to objectively verify the success of their procedure, and if they don't, then severe consequences should occur. And if they aren't willing to do that (the objective verification to show the success of their procedure), than they shouldn't be intubating.

 

[DesertMedic66]

Doc,
Since I've been on this forum, I have repeatedly heard what you said about medics sucking at intubation. What is being used? Glide Scope, Miller, Macintosh, or something else?

In 2021 my county had a 42% first pass rate with ground medics using a mix of DL and VL. For those who used the bougie it was only 52% with the same mix of VL and DL.

The initial training in medic school is usually garbage. There is usually no continuous education regarding intubation or at least no quality education. For example the ground agencies around here are trying to do SALAD however they don’t have a SALAD trainer, don’t have the proper suction caths, the “instructors” who teach it don’t actually know how to do it, and this last go around it was taught by an EMT who has never intubated anyone.

CA needs to make some major changes on how intubations are done. They can fully remove the skill from all paramedics, fully train and make sure all providers are competent with the skill, or only allow certain clinicians to do it.

We removed intubation from our CPR process long ago if BLS is working and we no longer carry any SGAs. So if you pick a random street medic and ask when the last time they intubated was you will probably get an answer of 1 year.

The county wanted to add in the iGels however all the agencies came together and said “we don’t have the budget to train all the paramedic staff on it”.

 

[HardKnocks]

Someone usually points out right about here in the discussion that "more training" is all that's needed to get paramedics better at intubation. Yes, it is true that with enough training, you can teach anyone to be really good at anything. The question is, how much training are we talking about? How much will it cost?

Phoenix AZ Fire has steppted up their Medical In-Service Training for all the points posted., (including PEDS ALS).

I'm trying to find a POC with PhxFD to get more of an outline on their In-Service Training Evoutions.

 

[Carlos Danger]

Intubating the esophagus is going to happen. You might even hear lung sounds. and the color metric thing might change color (those things suck anyway). You know what won't be fooled? ETCo2. If you are intubating, 9999/10000 the patient is attached to a cardiac monitor, and if you aren't, then you shouldn't be intubating (I'm looking at you, RI EMT-cardiacs). If the numbers are really low, than either that patient is really really dead, or you aren't in the lungs. In either case, the provider needs to objectively verify the success of their procedure, and if they don't, then severe consequences should occur. And if they aren't willing to do that (the objective verification to show the success of their procedure), than they shouldn't be intubating.

To be fair, I think what happens in a decent number of these scenarios is that the tube is correctly placed initially and then becomes dislodged and isn't recognized as quickly as it should be. Maybe the ambu-bag starts to feel a little different or maybe you get an alarm on your vent. But the Sp02 doesn't change (because you just gave a handful of breaths of 100% oxygen), and maybe the capnograph doesn't even go away immediately (though it will look different). So you spend a minute troubleshooting, but they are still satting 100% and you know you saw the tube go through the cords and you just don't have much experience with this, so you have a really hard time coming to grips with what is happening. By the time you do, it's either too late or almost too late.

So not an intubating skill problem per se in every case; but one of training and experience. Even with good quality training, some things are just hard to get good - especially under stress - without a lot of experience.

 

[DrParasite]

For example the ground agencies around here are trying to do SALAD however they don’t have a SALAD trainer, don’t have the proper suction caths, the “instructors” who teach it don’t actually know how to do it, and this last go around it was taught by an EMT who has never intubated anyone.

What qualifies someone to be a SALAD trainer? You can't use any hard suction catheter (I'm a fan of the yankauer suction tip personally)? how does an instructor not know how to do it? The fact that you an EMT teaching it is... problematic?

I'm not familiar with the technique, but after a basic google search, it doesn't look too complicated

What You Need to Know About the SALAD Technique

Familiar with the SALAD technique by James DuCanto? Here’s what you need to know.

blog.sscor.com

Introduction to the SALAD Technique

Conceptualized by Jim DuCanto, SALAD comprises a set of techniques to optimize airway management. Airway management is often complicated with the

emcrit.org

Three Airway Management Techniques for Airway Decontamination in Massive Emesis: A Manikin Study

Emesis occurs during airway management and results in pulmonary aspiration at rates of 0.01% – 0.11% in fasted patients undergoing general anesthesia and 0% – 22% in non-fasted emergency department patients. Suction-assisted laryngoscopy ...

www.ncbi.nlm.nih.gov

SALAD

SALAD is an acronym for the technique of Suction-Assisted Laryngoscopy and Airway Decontamination developed by Dr Jim DuCanto, who has created both a training model to give practitioners an opportu…

openairway.org

Suction Assisted Laryngoscopy Airway Decontamination (SALAD)

Suction Assisted Laryngoscopy Airway Decontamination (SALAD) is the term coined by Jim Du Canto and colleagues for a suction technique used to preventing airway soiling during laryngoscopy when there is profuse regurgitation

litfl.com

The county wanted to add in the iGels however all the agencies came together and said “we don’t have the budget to train all the paramedic staff on it”.

Open patient's mouth, aim for a hole, stick it in until it stops.... attach BVM... is it really that expensive to train? That could be an inservice training video, and have the training department evaluate paramedics on shift (swing by HQ, igel fred the head, and go back in service)
*disclaimer: we use king airways, not igels, so it could be more complicated

 

[DesertMedic66]

What qualifies someone to be a SALAD trainer? You can't use any hard suction catheter (I'm a fan of the yankauer suction tip personally)? how does an instructor not know how to do it? The fact that you an EMT teaching it is... problematic?

I'm not familiar with the technique, but after a basic google search, it doesn't look too complicated

What You Need to Know About the SALAD Technique

Familiar with the SALAD technique by James DuCanto? Here’s what you need to know.

blog.sscor.com

Introduction to the SALAD Technique

Conceptualized by Jim DuCanto, SALAD comprises a set of techniques to optimize airway management. Airway management is often complicated with the

emcrit.org

Three Airway Management Techniques for Airway Decontamination in Massive Emesis: A Manikin Study

Emesis occurs during airway management and results in pulmonary aspiration at rates of 0.01% – 0.11% in fasted patients undergoing general anesthesia and 0% – 22% in non-fasted emergency department patients. Suction-assisted laryngoscopy ...

www.ncbi.nlm.nih.gov

SALAD

SALAD is an acronym for the technique of Suction-Assisted Laryngoscopy and Airway Decontamination developed by Dr Jim DuCanto, who has created both a training model to give practitioners an opportu…

openairway.org

Suction Assisted Laryngoscopy Airway Decontamination (SALAD)

Suction Assisted Laryngoscopy Airway Decontamination (SALAD) is the term coined by Jim Du Canto and colleagues for a suction technique used to preventing airway soiling during laryngoscopy when there is profuse regurgitation

litfl.com

Open patient's mouth, aim for a hole, stick it in until it stops.... attach BVM... is it really that expensive to train? That could be an inservice training video, and have the training department evaluate paramedics on shift (swing by HQ, igel fred the head, and go back in service)
*disclaimer: we use king airways, not igels, so it could be more complicated

It’s not a super complicated process but in order to teach it you must know how to do it correctly.

It’s really designed to be used with the DuCanto suction as it has a much wider opening, no hole you need to place your finger over to start the suction, and it has a differently angled bend.

How does the instructor not know how to do it? They were never properly trained on how to do it or really what it is for.

The fact that an EMT was teaching it is very problematic.

It is very expensive to train staff. Talking with the education department for the county fire department they say it costs about $100,000 to host a training class for all of their staff. Not every agency can just “swing by HQ”. Sometimes that HQ can be several hours away from that crew or station.

 

[DrParasite]

It is very expensive to train staff. Talking with the education department for the county fire department they say it costs about $100,000 to host a training class for all of their staff. Not every agency can just “swing by HQ”. Sometimes that HQ can be several hours away from that crew or station.

Not to go off on a tangent, but your education department is blowing smoke up your butt. The reason it's costing 100k is that they are accounting for all of the salaries of their personnel, likely off duty/on overtime. There is no reason it can't be done on shift. Assuming there are less than 260 stations in the county, it would take 1 educator an entire year to go to every station and deliver the 8-hour training (assuming 1 class per weekday, no weekends). Assuming you have 3 shifts, that would require 3 educators (or host a train the trainer, have the department's training officers attend, and have them deliver the training). Plenty of county-based fire systems find ways to deliver updates to every provider in a system, and it doesn't cost 100k per class, especially if you deliver it all while the units are on shift and in service (which is how more fire departments conduct in house training).

If you are talking about EMS crews, every EMS crew has a station, where the truck gets parked. sometimes it's a fire station, other times it's a garage where they pick up the truck and go to their street corner. Wherever their EMS administration is, where they pick up supplies, where their white shirts hang out and do desk work, that's HQ. And don't forget, the internet is great for online continuing education, and online learning is more and more common.

Now, if you are looking for an excuse not to do something, making up an incredibly high cost is one way to do it, and get little pushback; after all, California hasn't had a progressive EMS system since the 1970s, so if they don't want to fix it, why bother even trying?

 

[DesertMedic66]

Not to go off on a tangent, but your education department is blowing smoke up your butt. The reason it's costing 100k is that they are accounting for all of the salaries of their personnel, likely off duty/on overtime. There is no reason it can't be done on shift. Assuming there are less than 260 stations in the county, it would take 1 educator an entire year to go to every station and deliver the 8-hour training (assuming 1 class per weekday, no weekends). Assuming you have 3 shifts, that would require 3 educators (or host a train the trainer, have the department's training officers attend, and have them deliver the training). Plenty of county-based fire systems find ways to deliver updates to every provider in a system, and it doesn't cost 100k per class, especially if you deliver it all while the units are on shift and in service (which is how more fire departments conduct in house training).

If you are talking about EMS crews, every EMS crew has a station, where the truck gets parked. sometimes it's a fire station, other times it's a garage where they pick up the truck and go to their street corner. Wherever their EMS administration is, where they pick up supplies, where their white shirts hang out and do desk work, that's HQ. And don't forget, the internet is great for online continuing education, and online learning is more and more common.

Now, if you are looking for an excuse not to do something, making up an incredibly high cost is one way to do it, and get little pushback; after all, California hasn't had a progressive EMS system since the 1970s, so if they don't want to fix it, why bother even trying?

Except that is not how things are actually done.

The county EMS management agency will inform us “hey guys, I know it’s January but here is the training that all your staff needs to take. Everyone must have the training and associating competency forms completed by April 1st because that is our go live date”.

I’m not saying this is a perfect system, as it is no where near it. This is just the reality of how it is. Does it need to change? Yes at every agency.

There are also many additional things in the county EMS plan/contract that have further restrictions.

 

[DrParasite]

Except that is not how things are actually done.

The county EMS management agency will inform us “hey guys, I know it’s January but here is the training that all your staff needs to take. Everyone must have the training and associating competency forms completed by April 1st because that is our go live date”.

ok.... so you have 3 months to do everything.... department traing officers complete the train the trainer in January. In Feb and March the training officers go to every station on all shifts and deliver the training, and make sure the paperwork is done. Now, if you are saying the county EMS management needs to directly deliver the training, well, then they need more staff to do it. They chose to operate a certain way, and management needs to be funded accordingly.

I’m not saying this is a perfect system, as it is no where near it. This is just the reality of how it is. Does it need to change? Yes at every agency.
There are also many additional things in the county EMS plan/contract that have further restrictions.

And I will reiterate what I said, there are county-wide systems across the country that do this every day. If your county entered into a contract that prevented these things from happened, well, whose fault is that?

I am in a county-wide system. 857 square miles. 71 fire stations total in the county, all staffed 24/7, on an A/B/C schedule, with volunteers in all but 3 of the county departments. 1 county EMS management system. Almost all of the training for the FDs is done on shift, delivered locally, on a monthly basis. IIRC, ALS training is conducted by the county, either bimonthly or quarterly (I don't remember), and all ALS providers much attend, and all EMS employees are paid to attend (FDs are only BLS here, so ALS providers who are employed by the FDs but not employed by EMS aren't always paid to attend). Is there a cost involved? absolutely, but it's budgeted for, so no one questions it.

Again, your specific contracts are what your county agreed to; so guess what? if you agreed to those restrictions, then you need to deal with all of the financial consequences. I agree it's not perfect, but just because they don't want to change, doesn't mean it can't be done. I'm sorry your county has some issues, but there is no need to reinvent the wheel. But if people don't want to do it, and no one wants to fund it, well, you end up with the system you are currently stuck in.

 

[DesertMedic66]

ok.... so you have 3 months to do everything.... department traing officers complete the train the trainer in January. In Feb and March the training officers go to every station on all shifts and deliver the training, and make sure the paperwork is done. Now, if you are saying the county EMS management needs to directly deliver the training, well, then they need more staff to do it. They chose to operate a certain way, and management needs to be funded accordingly.

And I will reiterate what I said, there are county-wide systems across the country that do this every day. If your county entered into a contract that prevented these things from happened, well, whose fault is that?

I am in a county-wide system. 857 square miles. 71 fire stations total in the county, all staffed 24/7, on an A/B/C schedule, with volunteers in all but 3 of the county departments. 1 county EMS management system. Almost all of the training for the FDs is done on shift, delivered locally, on a monthly basis. IIRC, ALS training is conducted by the county, either bimonthly or quarterly (I don't remember), and all ALS providers much attend, and all EMS employees are paid to attend (FDs are only BLS here, so ALS providers who are employed by the FDs but not employed by EMS aren't always paid to attend). Is there a cost involved? absolutely, but it's budgeted for, so no one questions it.

Again, your specific contracts are what your county agreed to; so guess what? if you agreed to those restrictions, then you need to deal with all of the financial consequences. I agree it's not perfect, but just because they don't want to change, doesn't mean it can't be done. I'm sorry your county has some issues, but there is no need to reinvent the wheel. But if people don't want to do it, and no one wants to fund it, well, you end up with the system you are currently stuck in.

Once again I will say it is not the best system or that I advocate for this system. I am simply saying how it is ran here and because of how it ran it is very expensive. You can keep on going with telling me how it should be all you want but that will have absolutely zero impact on anything except making you feel better. I am not involved with the fire department and have no desire to be involved with them as I absolutely despise fire base EMS systems.

 

[Tigger]

Man it must be nice to have the answer to an enourmous county’s EMS education woes from thousands of miles away.

Also an EMT teaching SALAD? Probably not appropriate given that such a technique is used while intubating. It’s not the most tricky technique but definitely requires some dexterity while intubating which is not exactly an EMT competency.