Why are we placing ETTs at all?

NPO

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bumping an old thread just because I thought it was an interesting topic
I'm hoping we have improved equipment and technique enough to engineer out SOME of the failures. As video laryngoscopy and tube inducers become more common-place, I'd hope we would see numbers rise.

I understand the counter argument for a SGA, and I am quick to set down the laryngoscope for an alternative airway when I don't think I'll have quick success with the ETT, but I think we need to have the ETT as an option for definitive airways.
 

VentMonkey

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Our company’s medical director is getting ready to release a case exemplifying when, in fact, an ETT should still be utilized over, say, a SGA or BLS airway.

Honestly, I think it’s kind of sad that we need to do this kind of handholding. Then again, it’s nothing really new, or groundbreaking that most ALS providers really aren’t all that advanced when it comes to their critical thinking abilities, and that is the real shame.

As @NPO mentioned, many of the equipment and technology that wasn’t available 8 or so years ago as commonly in EMS has hopefully proven their merit.

Sadly, without understanding anythings value I still doubt we’ll appreciate its worth. There’s no value in a skillset without a worthy approach to your thinking abilities in a time-critical situation.
 

MSDeltaFlt

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Maybe I'm too old school to truly appreciate some clinicians' issue(s) with airway management especially when it regards endotracheal intubation. Because I have noticed over the years that more and more clinicians (paramedics, nurses, respiratory therapists, etc.), both old and new, that are showing low or decreasing success rates on intubating their patients' trachea are relying more and more on technology to secure the airway and focusing less and less on basic skill and training.

Don't get me wrong. I'm all for technology and equipment that can secure an airway. But the one thing that will save your patient's life more than technology and equipment is the clinician's brain. The best paramedics have strong EMT skills, or more accurately, strong basic skills.

This is very prominent with airway management. The trick to being a paramedic is not in knowing what to do and how to do it. That's easy. Any moron can be taught that. The trick, ladies and gentlemen, is being able to do something and knowing when and when NOT to do it and HOW. And that requires the one thing that cannot be taught. That takes experience.

You may have all the nice and neat little toys money can buy. But if you lack the proper technique then you will fail. And failing at airway management tends to result in you not delivering to the hospital and viable patient, but instead a cadaver. That also includes in securing the cotton picking things. You may be able to insert it into the trachea with no problem: Grade 1, 2, 3, even a grade 4 airway like it's nobody's business. But if it is not secure then it can and most likely will come out. Increasing the likelihood of the aforementioned cadaver delivery.

Mechanical tube holders are not the be all end of airway security. Not having any weight attached to the ETT on moving the patient from scene to cot and then from cot to ER stretcher also helps but even that might not be all there is to aiding in ensuring their not migrating out of the trachea. Full C-Spine precautions aid a great deal. Not only does the spine board aid you in moving patient from point to point. But the C-collar/head bed/etc. also help. The less the head and neck move the less the ETT moves. The less the ETT moves the less it will migrate.

Also, slow your roll. I tell all my new partners that there are only 4 reasons I can think of where vehicle velocity over the posted speed limits will ever be requested by me are:

1. Patient is running out of time: STEMI/CVA.
2. I am running out of oxygen.
3. I am running out of cardiac monitor battery power.
4. I am running out of medications

Outside of those 4, the speed limit (even lights and sirens) is plenty fast enough.

So in closing. There are only three things needed for ANY airway management:

1. Technique

2. Situational awareness.

3. Ooh-sah.

Good day
 

VFlutter

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We have proven that Pre-Hospital ETI can be done well with great first pass success and minimal complications when preformed by the right providers. These groups (CC/HEMS) are composed of experienced and highly motivated individuals with frequent exposure to intubations and extensive continuing education/training requirements. We need to challenge the idea that every paramedic should be intubating. Every medic should be an airway expert sans intubation with access to a select group of highly trained providers capable of RSI if needed.

I completely agree with mastering the basics and not relying solely on technology however I think the time is quickly approaching for video laryngoscopy to be the standard of care.
 

EpiEMS

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@VFlutter, it seems to me that most of the western world has adopted the approach you’ve articulated - and I agree with it, FWIW. There’s too much downside risk for ETI to be in Joe EveryMedic’s toolbox.
 

DrParasite

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Our company’s medical director is getting ready to release a case exemplifying when, in fact, an ETT should still be utilized over, say, a SGA or BLS airway.
such as, say, burns to the airway?

I know NJ NJ paramedics used to ETT every cardiac arrest. now in NC, we SGA almost all of them, and often the FD does it before EMS gets there. if we get ROSC back, the medic might intubate. So I trust almost every NJ medic with being able to intubate on the first attempt.... because they do it regularly (think 2+ times a week) on live patients.
Full C-Spine precautions aid a great deal. Not only does the spine board aid you in moving patient from point to point. But the C-collar/head bed/etc. also help.
True story: I added a C-collar to our EMS bag, for that very reason. I was taught to always apply a collar for the exact reasons you specify, and our collars aren't accessible from inside the ambulance.The next shift it was taken out because "if we brought a patient to the hospital (which was a trauma center) who was intubated and had a collar applied, the ER would get confused and think it was a trauma, and want to know why we didn't activate a trauma alert." :rolleyes:
Also, slow your roll. I tell all my new partners that there are only 4 reasons I can think of where vehicle velocity over the posted speed limits will ever be requested by me are:

1. Patient is running out of time: STEMI/CVA.
2. I am running out of oxygen.
3. I am running out of cardiac monitor battery power.
4. I am running out of medications

Outside of those 4, the speed limit (even lights and sirens) is plenty fast enough.
you wouldn't include your patient is bleeding out, and you can't replace the blood on the floor of your ambulance in your patient so he needs a trauma surgeon to fix the hole?
Every medic should be an airway expert sans intubation with access to a select group of highly trained providers capable of RSI if needed.
Interesting idea.... do you think it should be removed from the paramedic education curriculum? After all, if not everyone can or should be able to do it, why force everyone to learn and be evaluated on it?

One thing that frustrates me is being taught something, being evaluated and successfully passing the evaluation, and having it in state "scope of practice" and then being told that I can't do it, even though based on my education, it would be beneficial to the patient.
 

Bullets

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I think part of this is a result of the type of system. As @DrParasite alluded, in a tiered system like NJ, medics are only going to the worst calls, so their encounters are usually more acute, and their intubation attempts are more frequent as they are only dealing with really sick people. In a system where a medic is on every truck, what percentage of the patients they encounter are true ALS treats? then what smaller percent need an advanced airway?

@VFlutter says that HEMS and CC have good success rates for this very reason. They only see very sick people, thus their opportunity to intubate against their total call volume is much high.

As long as we are forcing medics to treat BLS and not giving them opportunity to practice outside the field then it will lead to skill degradation.
 

MSDeltaFlt

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you wouldn't include your patient is bleeding out, and you can't replace the blood on the floor of your ambulance in your patient so he needs a trauma surgeon to fix the hole?

That would fall under category number one.
 

Tigger

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I think part of this is a result of the type of system. As @DrParasite alluded, in a tiered system like NJ, medics are only going to the worst calls, so their encounters are usually more acute, and their intubation attempts are more frequent as they are only dealing with really sick people. In a system where a medic is on every truck, what percentage of the patients they encounter are true ALS treats? then what smaller percent need an advanced airway?

@VFlutter says that HEMS and CC have good success rates for this very reason. They only see very sick people, thus their opportunity to intubate against their total call volume is much high.

As long as we are forcing medics to treat BLS and not giving them opportunity to practice outside the field then it will lead to skill degradation.
If we did not send a paramedic on every call in our area paramedics would never make it on scene to make any sort of difference if requested by BLS. If we aren't responding immediately, the geographic limitations make having a tiered system challenging, and I am not sure I am willing to trust EMD when the consequences could be a half hour more. Much of America is too vast to truly benefit from tiered systems.
 

VFlutter

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Frequent opportunities to intubate definitely helps with maintaining competency however it is not the only factor. Our pediatric first pass intubation rate, although worse than our adult, is still much better than the average even though it's a very low frequency. Most providers are lucky to see one a year. However it is heavily trained and simulated. So I do not think low volume is an excuse for poor performance. Just like all other Low Frequency / High Risk procedures (Surgical Cric, Eschartomy, etc) you are expected to perform correctly regardless of how frequently you encounter it.
 

EpiEMS

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If we did not send a paramedic on every call in our area paramedics would never make it on scene to make any sort of difference if requested by BLS. If we aren't responding immediately, the geographic limitations make having a tiered system challenging, and I am not sure I am willing to trust EMD when the consequences could be a half hour more. Much of America is too vast to truly benefit from tiered systems.

I would agree, that in your context, all ALS might make sense. But for most of the country's population - i.e. urban & suburban areas - tiered systems are definitely more efficient, no?

popdensity2011.jpg
 

Tigger

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I would agree, that in your context, all ALS might make sense. But for most of the country's population - i.e. urban & suburban areas - tiered systems are definitely more efficient, no?
Probably will better trained "BLS" providers. A big part of being a paramedic is recognizing the "subtly sick" and our current EMTs don't really have the ability to recognize this. Sure in urban areas you're probably not that far from a hospital and just taking them to a hospital won't result in a poor outcome most of the time. Except for when it does and the patient needed someone able to deliver an "advanced" assessment and invasive but life sustaining treatments 20 minutes ago but nobody noticed. Or the wrong patient gets has a refusal done. To me it all comes down to "you don't know what you don't know" and it seems that tiered systems probably don't deliver paramedics to patients that could have benefited more often than we probably know.

My view is certainly clouded by personal experience of working someplace with all P/B or P/P ambulances. But man, we still see it with BLS first responders. We have a pretty good countywide agency education system here but exposure matters. Many of the BLS folks just don't know what a compensating patient looks like. They're very good about ensuring that the sick sick patients get paramedics quickly, but not so good with the middle of the spectrum sick patients. This is career and volunteer places mind you, it seems to transcend all the groups.
 

VentMonkey

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@Tigger I agree with you, but would you also agree that many paramedics suffer from this same exact affliction?
 

E tank

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Tigger

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@Tigger I agree with you, but would you also agree that many paramedics suffer from this same exact affliction?
No doubt there are many paramedics who don't recognize sick patients that are also slapping them in the face. But paramedics are (should be?) trained to recognized these patients. EMTs are not. So at the very least the argument can be made that the agency/AHJ is failing when paramedics miss the occult sick patient because they should know better and not the education itself. Whether that plays out is dependent on where you are, here (the largest combined EMS medical direction system in Colorado), you will be at least taken to task for your inobservance.
 

Carlos Danger

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Maybe not...

http://www.annemergmed.com/article/S0196-0644(17)30878-8/fulltext

This Cochrane analysis finds that first pass success on known difficult airways is improved with VL, but not with non-difficult airways, which are the vast majority.

But is the fact that VL doesn't help in most airways really an argument for it not being used routinely, at least by "occasional intubators"?

Considering that difficult airways are hard to predict - especially by folks who don't intubate every day - and considering that there's no downside to using a VL when it you probably don't need it, it seems reasonable to me that they would be used routinely.
 

E tank

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But is the fact that VL doesn't help in most airways really an argument for it not being used routinely, at least by "occasional intubators"?

Considering that difficult airways are hard to predict - especially by folks who don't intubate every day - and considering that there's no downside to using a VL when it you probably don't need it, it seems reasonable to me that they would be used routinely.

No argument. But "standard of care"? Especially because, so far at least, VL doesn't seem to be any different when you "don't need it" for first pass success.
 

EpiEMS

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Many of the BLS folks just don't know what a compensating patient looks like. They're very good about ensuring that the sick sick patients get paramedics quickly, but not so good with the middle of the spectrum sick patients. This is career and volunteer places mind you, it seems to transcend all the groups.

But paramedics are (should be?) trained to recognized these patients. EMTs are not.
Fair points, for sure.

In my mind, the solution is single medic ALS fly cars. Medic assesses and triages to BLS, goes back to help out the next BLS ambulance. Or rides in, one of the EMTs drives the fly car along to the hospital. Alternatively, you can leave it and have somebody pick it up.
 

medicsb

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Probably will better trained "BLS" providers. A big part of being a paramedic is recognizing the "subtly sick" and our current EMTs don't really have the ability to recognize this. Sure in urban areas you're probably not that far from a hospital and just taking them to a hospital won't result in a poor outcome most of the time. Except for when it does and the patient needed someone able to deliver an "advanced" assessment and invasive but life sustaining treatments 20 minutes ago but nobody noticed. Or the wrong patient gets has a refusal done. To me it all comes down to "you don't know what you don't know" and it seems that tiered systems probably don't deliver paramedics to patients that could have benefited more often than we probably know.

There's another side where a paramedic "over treats" and causes a poor outcome or adverse event when a expedient ride would have been more than enough. I think one could argue that in an all-ALS system, there are a greater proportion of patients harmed by paramedics than in tiered systems. And certainly, in tiered systems, there are some patients who are harmed by lack of a paramedic. The question is which is more - more harmed by medics in all ALS, or more harmed by lack of medics in tiered. (For sure, one would have to consider the harms by medics in tiered, and the harm by lack of medic treatment in all-ALS.)
 
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