Too Many Medics? comment from Anonymous

Also posted over at Paramedicine 101. Go check out the rest of what is there.

Sorry for the long post, but . . .

In the comments to Too Many Medics?, Anonymous wrote:

Grrr. Really trying to make an inflammatory post, aren’t we RM ?

Are you kidding? I tone it down to keep it nice and polite.

Couldn’t find a copy of the ACTUAL study, and I’m never a fan of quoting USA Today as a source of anything, other than maybe a horoscope.

I don’t read horoscopes, but here is the abstract.

Academic Emergency Medicine; Volume 13 Issue s5; May 2006; pages S55 – S56; abstract number 121:

Cardiac Arrest Survival Rates Depend on Paramedic Experience

Michael R Sayre, Al Hallstrom, Thomas D Rea, Lois Van Ottingham, Lynn J White, James Christenson, Vince N Mosesso, Andy R Anton, Michele Olsufka, Sarah Pennington, Stephen Yahn, James Husar, Leonard A Cobb.

The Ohio State University Medical Center, Columbus, OH,
University of Washington, Seattle, WA,
British Columbia Ambulance Service, Victoria, British Columbia, Canada,
University of Pittsburgh, Pittsburgh, PA,
Calgary Emergency Ambulance Service, Calgary, Alberta, Canada,
University of Washington, Seattle, WA,
St. Paul’s Hospital, Vancouver, British Columbia, Canada,
Calgary Emergency Medical Services, Calgary, Alberta, Canada

Objective

Out-of-hospital cardiac arrest (OOH-CA) survival varies widely among communities. We compared OOH-CA survival rates among 5 North American cities to identify factors that influenced survival.

Methods

The AutoPulse Assisted Prehospital International Resuscitation (ASPIRE) Trial was amulticenter randomized comparison of the effectiveness of manual chest compression versus AutoPulse during resuscitation of OOH-CA. Adults with OOH-CA were enrolled in five cities. Survival data collected in each city for patients in the manual arm of the trial were compared. Regression using generalized linear models was used to adjust for covariates.

Results

Younger women with witnessed ventricular fibrillation (VF) arrests in public locations who had short first response times had the best chance of survival. Victims receiving bystander cardiopulmonary resuscitation (CPR) had a trend to better survival. Time to advanced life support (ALS) vehicle arrival was not significant. The mean regression residual by site correlated with cases per paramedic per year (Pearson R = 0.97, p = 0.006).

Conclusions

Significant variation exists among the cities even after known predictors of survival are controlled. A positive correlation exists between more cases treated per paramedic and survival to discharge. Whether that relationship is causal or a marker for some other factor(s) cannot be determined.

Did, however find this nugget in ‘Emergency Medicine News’ from the MD that authored that study. Note his last comment in the excerpt.

Excerpt:

The study was presented at the annual meeting for the Society for Academic Emergency Medicine. Almost instantly, it was the darling of the media, hitting the pages of USA Today under the banner, “Cities that Deploy Fewer Paramedics Save More Lives.”

“It touches a nerve,” said Dr. Sayre in explaining why the findings of an academic presentation made such a splash.

For one thing, it’s a sound bite that sounds too odd to be true: The fewer the paramedics in the system, the more likely patients are to survive.

More Skilled?

He cautioned, however, that what remains unexplained is whether the data reflect a direct result, achieved because a relatively low number of paramedics who administer advanced life support are likely to become more skilled at it or whether the correlation is a sign that something else may be occurring, such as more intensive training among systems that have fewer teams or personnel. “It could be a marker; it could be a causal. We don’t know,” said Dr. Sayre, an associate professor of emergency medicine at Ohio State University Medical Center in Columbus.

Nothing odd about it.

There is no evidence that any of the ALS treatments improve outcomes. So, why would it be important to have paramedics arrive at a cardiac arrest quickly?

The focus should be on excellent BLS care. ALS personnel should understand that and help with the BLS. Many probably do not. In stead, they interfere with the quality of the BLS.

BLS, unlike ALS, has been shown to improve outcomes from cardiac arrest. The longer they focus on the BLS, the better for the patient.

Interruptions in Cardiopulmonary Resuscitation From Paramedic Endotracheal Intubation

Henry E. Wang, MD, MS
Scott J. Simeone, BS, NREMT-P
Matthew D. Weaver, BS, NREMT-P
Clifton W. Callaway, MD, PhD

Presented at the Society for Academic Emergency Medicine annual meeting, May 2008, Washington, DC.
Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA

Study objective

Emergency cardiac care guidelines emphasize treatment of cardiopulmonary arrest with continuous uninterrupted cardiopulmonary resuscitation (CPR) chest compressions. Paramedics in the United States perform endotracheal intubation on nearly all victims of out-of-hospital cardiopulmonary arrest. We quantified the frequency and duration of CPR chest compression interruptions associated with paramedic endotracheal intubation efforts during out-of-hospital cardiopulmonary arrest.

Methods

We studied adult out-of-hospital cardiopulmonary arrest treated by an urban and a rural emergency medical services agency from the Resuscitation Outcomes Consortium during November 2006 to June 2007. Cardiac monitors with compression sensors continuously recorded rescuer CPR chest compressions. A digital audio channel recorded all resuscitation events. We identified CPR interruptions related to endotracheal intubation efforts, including airway suctioning, laryngoscopy, endotracheal tube placement, confirmation and adjustment, securing the tube in place, bag-valve-mask ventilation between intubation attempts, and alternate airway insertion. We identified the number and duration of CPR interruptions associated with endotracheal intubation efforts.

Results

We included 100 of 182 out-of-hospital cardiopulmonary arrests in the analysis. The median number of endotracheal intubation–associated CPR interruption was 2 (interquartile range [IQR] 1 to 3; range 1 to 9). The median duration of the first endotracheal intubation–associated CPR interruption was 46.5 seconds (IQR 23.5 to 73 seconds; range 7 to 221 seconds); almost one third exceeded 1 minute. The median total duration of all endotracheal intubation–associated CPR interruptions was 109.5 seconds (IQR 54 to 198 seconds; range 13 to 446 seconds); one fourth exceeded 3 minutes. Endotracheal intubation–associated CPR pauses composed approximately 22.8% (IQR 12.6-36.5%; range 1.0% to 93.4%) of all CPR interruptions.

Conclusion

In this series, paramedic out-of-hospital endotracheal intubation efforts were associated with multiple and prolonged CPR interruptions.

[Ann Emerg Med. 2009;xx:xxx.]

Benefit to the patient of these interruptions in BLS treatment?

No known benefit.

Cost to the patients of these interruptions in BLS treatment?

Whatever small chance at resuscitation they had is lowered dramatically.

Why?

We have to have more medics, so that they can interfere with BLS care.

Once everybody is a medic, we will probably continue to argue over who has to put up with doing the demeaning BLS stuff, even though that is all that works in cardiac arrest.

From the full text of this journal article:

Assuming the need to reduce endotracheal intubation–associated CPR interruptions, potential strategies include improving paramedic endotracheal intubation skill or altering out-of-hospital airway management techniques. Improving endotracheal intubation skill may prove difficult, given limits in the quantity of paramedic student training and clinical endotracheal intubation experience in the United States.^26-28 Although select paramedics attempt endotracheal intubation without stopping CPR chest compressions, the broader feasibility of this technique remains unclear. To minimize CPR interruptions, many EMS agencies have substituted endotracheal intubation with Combitube or King LT airway insertion.¹³ Select studies suggest the viability of CPR without ventilation, potentially obviating the need for airway management interventions.^29,30 The relative effectiveness of these techniques remains unknown.

Why interrupt compressions to intubate?

Why intubate, in cardiac arrest, if an alternative airway is faster?

Why intubate, in cardiac arrest, if an alternative airway is just as good at airway management?

Why rush a medic to a cardiac arrest if the medic makes things worse?

Also, the more medics you need, the less selective you can be in choosing the ones you end up with. If you are going to scrape the bottom of the barrel, because the supply cannot meet the demand, and you will not pay well, you will get bottom of the barrel quality.

Maintaining quality is also important. This study might suggest that PFD (Philadelphia Fire Department) would have an excellent resuscitation rate. From what I was last told, PFD is 250 medics short of being fully staffed. PFD has political obstacles to consistently providing quality care. PFD has some excellent medics, but not because of oversight. The excellent medics are excellent because they work at it on their own. They are balanced by others, who easily dredge up bottom of the barrel analogies.

So, it is not just about numbers. However, the more medics you have, the harder it becomes to maintain quality. The harder it becomes to obtain experience. The combination of quality and experience are important.

More medics means a need for more medical oversight.

Do these everyone a medic systems increase the number of medical directors to keep up with the increase in medics?

Do they aggressively work at simulations to make up for their lack of touch with reality?

This topic will eventually be studied and written about more fully. This particular study is not likely to be published in anything other than abstract form.

Here is a study from Boston, where the number of medics is low and the quality is high:

Volume 52, No. 4: October 2008; Annals of Emergency Medicine; page S153; abstract number 364:

Success Rates in Out-of-Hospital Intubation

Temin E, Harrington L, Mitchell P, Rebholz C, Dyer K, Doyle J, Hughes P, Moyer P/Massachusetts General Hospital, Boston, MA; Boston Medical Center, Boston, MA; Boston Emergency Medical Services, Boston, MA

Background

Previous literature has questioned whether out-of-hospital endotracheal intubation (ETI) success rates can be comparable to those performed in the emergency department (ED). Prior studies report ED success rates ranging from 80%–98% with success rates increasing with the experience of the provider. Large studies on ground out-of-hospital intubation report success rates ranging from 33%-100% and a 77% success rate for rapid sequence intubation (RSI), all after multiple attempts. Although Bulger et al 2002 has reported similar out-of-hospital ETI success rates to the ED, some question whether this success can be reproduced in other services. Boston Emergency Medical Services (BEMS) is a 2-tiered system with all advanced life support (ALS) trucks staffed by 2 paramedics. BEMS has a ratio of 0.5 paramedics to 10,000 population making it one of the lowest ratios in the country.

Study Objective

To assess the proportion of successful paramedic out-of-hospital ETI on adult and pediatric patients in a 2-tiered urban EMS system.

Methods

A retrospective chart review from 7/1/06 to 6/30/07 of ETI data from the Boston Airway Registry was conducted. The primary outcome was the success rate of ETI by number of attempts (blade passing through the lips) overall and for the following subgroups: Cardiac arrest prior to ETI, medically assisted intubation (MAI) (any medication), rapid sequence intubation (RSI) (paralytic and sedative), documented head trauma, and pediatric (age ≤ 12 years old) patients. We used descriptive statistics with 95% confidence intervals for analysis.

Results

ETI was attempted on 569 individuals by 61 paramedics. Two were excluded due to incomplete data. 361/567 (64%) of patients were male, mean age was 56 years. 455/567 (80%) had a cardiac arrest prior to ETI. 97/567 (17%) had ETI attempted with MAI. 77/567 (14%) had ETI attempted with RSI. 107/566 (19%) had documented traumatic injury, of those 73/104 (70%) had documented head trauma. Of the 10 pediatric ETI 4/10 were male, mean age was 2.6 years.

Conclusion

In this EMS system, paramedics achieved high success rates in all ETI, comparable to those reported in ED settings. Further research should determine provider and system factors that contribute to this success.

It is only a matter of time until the research is done. Until then we have to wade through a morass of intubation results from the everybody a medic systems.

A prospective multicenter evaluation of prehospital airway management performance in a large metropolitan region.

Denver Metro Airway Study Group.
Colwell CB, Cusick JM, Hawkes AP, Luyten DR, McVaney KE, Pineda GV, Riccio JC, Severyn FA, Vellman WP, Heller J, Ship J, Gunter J, Battan K, Kozlowski M, Kanowitz A.

Prehosp Emerg Care. 2009 Jul-Sep;13(3):304-10.
PMID: 19499465 [PubMed – in process]

Objectives

To determine 1) the success rate of prehospital endotracheal intubation; 2) the unrecognized tube malposition rate; and 3) predictors of tube malposition upon arrival to the emergency department (ED) in the setting of a large metropolitan area that includes 18 hospitals and 34 transporting emergency medical services (EMS) agencies.

Methods

Prospective data were collected on patients for whom prehospital intubation was attempted between September 1, 2004, and January 31, 2005. Endotracheal tube (ETT) position upon arrival to the ED was verified by emergency medicine attending physicians. Missing cases were identified by matching prospective data with lists of attempted intubations submitted by EMS agencies, and data were obtained for these cases by retrospective chart review. Successful intubation was defined as an “endotracheal tube balloon below the cords” on arrival to the ED. Patients were the unit of analysis; proportions with 95% confidence intervals were calculated.

Results

Nine hundred twenty-six patients had an attempted intubation. Methods of airway management were determined for 97.5% (825/846) of those transported to a hospital and 33.8% (27/80) of those who died in the field. For transported patients, 74.8% were successfully intubated, 20% had a failed intubation, 5.2% had a malpositioned tube on arrival to the ED, and 0.6% had another method of airway management used. Malpositioned tubes were significantly more common in pediatric patients (13.0%, compared with 4.0% for nonpediatric patients).

Conclusions

Overall intubation success was low, and consistent with previously published series. The frequency of malpositioned ETT was unacceptably high, and also consistent with prior studies. Our data support the need for ongoing monitoring of EMS providers’ practices of endotracheal intubation.

This is not a system with every person on every apparatus a medic, but their success rates are not good. Less than 80% success? 5% unrecognized esophageal tubes? We need to start improving quality or restricting skills to those who can actually demonstrate skill. Adding more medics only makes this quality problem worse. A system that is just doing more of the same is not one you want taking care of those you love.

Here is one from one of the happy everybody a medic Pollyanna places:

Prehospital intubations and mortality: a level 1 trauma center perspective.

Cobas MA, De la Peña MA, Manning R, Candiotti K, Varon AJ.

Department of Anesthesiology, Miller School of Medicine, University of Miami, Miami, Florida 33136, USA. mcobas@med.miami.ed

Background

Ryder Trauma Center is a Level 1 trauma center with approximately 3800 emergency admissions per year. In this study, we sought to determine the incidence of failed prehospital intubations (PHI), its correlation with hospital mortality, and possible risk factors associated with PHI.

Methods

A prospective observational study was conducted evaluating trauma patients who had emergency prehospital airway management and were admitted during the period between August 2003 and June 2006. The PHI was considered a failure if the initial assessment determined improper placement of the endotracheal tube or if alternative airway management devices were used as a rescue measure after intubation was attempted.

Results

One-thousand-three-hundred-twenty patients had emergency airway interventions performed by an anesthesiologist upon arrival at the trauma center. Of those, 203 had been initially intubated in the field by emergency medical services personnel, with 74 of 203 (36%) surviving to discharge. When evaluating the success of the intubation, 63 of 203 (31%) met the criteria for failed PHI, all of them requiring intubation, with only 18 of 63 (29%) surviving to discharge. These patients had rescue airway management provided either via Combitube (n = 28), Laryngeal Mask Airway (n = 6), or a cricothyroidotomy (n = 4). An additional 25 of 63 patients (12%) had unrecognized esophageal intubations discovered upon the initial airway assessment performed on arrival. We found no difference in mortality between those patients who were properly intubated and those who were not. Several other variables, including age, gender, weight, mechanism of injury, presence of facial injuries, and emergency medical services were not correlated with an increased incidence of failed intubations.

Conclusions

This prospective study showed a 31% incidence of failed PHI in a large metropolitan trauma center. We found no difference in mortality between patients who were properly intubated and those who were not, supporting the use of bag-valve-mask as an adequate method of airway management for critically ill trauma patients in whom intubation cannot be achieved promptly in the prehospital setting.

From the full text of this journal article (PHI = Pre-Hospital Intubation):

The significant difference we found in the success of PHI performed in connection with air (67%) and ground transport (33%; P < 0.001) may reflect the deployment to aerial units of paramedics with more experience and skills, including intubation, because it is usually a promotion from the ground units. Although this study did not correlate intubation skills of individual paramedics, data from Germany, where air rescue crews perform ETI three times as frequently as ground crews,¹ support this. Therefore, clinical experience of those performing the intubation is invaluable and perhaps the most important piece of the PHI puzzle.

The 67% and 33% are a bit misleading. They are the percentages of the overall successful intubations, not the percentage of intubation attempts.

Of the 203 patients, 115 (57%) were transported by air, and within that group, 94 (82%) were properly intubated in the field, and 21(18%) were not. Of the 88 patients who were transported by ground, 46 (52%) were successfully intubated in the prehospital setting and 42 (48%) had a failed PHI (P < 0.001 compared with patients transported by air).

52% is still a number that should not be tolerated in intubation. There are 2 considerations not made clear.

How many of the failed intubations actually had intubation attempts?

How many intubation attempts did they have?

Maybe we need to include another data point? Total intubation attempts.

If almost all of the patients actually had intubation attempts and there were 2 attempts before moving to an alternative/rescue airway and some of the successful intubations were on the second attempt, then the success rate per attempt is possibly much lower than 1 in 3.

How many holes are we dealing with in the airway?

Hush. Let’s not be inflammatory. If we throw more medics at it maybe one of them will find the trachea.

In these everybody a medic systems a piñata might live for ever. The patients on the receiving end of the intubation attempts might be jealous of the piñata.

Even the flight crews only intubated 82% successfully. That is about the same as the ground medics in the Denver study above it. It is true that this is trauma, while the others are not limited to trauma.

At least to me, the most important conclusion from that study seems to be (PHI = Pre-Hospital Intubation):

Therefore, clinical experience of those performing the intubation is invaluable and perhaps the most important piece of the PHI puzzle.

What about intubation in the system that had the highest resuscitation rate in the original study – Cardiac Arrest Survival Rates Depend on Paramedic Experience?

Here is an abstract from their 20 year study of intubations. These medics do use succinylcholine. So do the flight crews in Miami. They did break down their results into trauma intubations and medical intubations. How did this system do? They focus on keeping the number of medics low and the quality high. Let’s see:

Prehospital use of succinylcholine: a 20-year review.

Wayne MA, Friedland E.

Prehosp Emerg Care. 1999 Apr-Jun;3(2):107-9.
PMID: 10225641 [PubMed – indexed for MEDLINE]

Emergency Medical Services, Bellingham/Whatcom County Washington, WA 98225, USA. mwayne@cob.org

Objective

To determine the safety and efficacy of succinylcholine, as an adjunct to endotracheal intubation, administered by paramedics trained in its use.

Methods

Retrospective review of 1,657 consecutive patients, aged 16 years or older, receiving prehospital succinylcholine administered by paramedics. In this community of 175,000 people, trained paramedics intubated both medical and trauma patients with the assistance of succinylcholine. Main outcomes measured were success of intubations, complications of the procedure and/or the drug, and use of alternative methods of airway management.

Results

Paramedics successfully intubated 95.5% (1,582) of all patients receiving succinylcholine, 94% (1,045) of trauma patients, and 98% (538) of medical patients. They were unable to intubate 4.5% (74) of the patients. All of these were successfully managed by alternative methods. Unrecognized esophageal intubation occurred in six (0.3%) patients. The addition of capnography and a tube aspiration device, in 1990, decreased the incidence of esophageal intubations.

Conclusion

Paramedics trained to use succinylcholine, to assist the process of endotracheal intubation, can safely intubate a high percentage of patients.

They intubated 94% of trauma patients successfully over a 20 year period.

From the full text of this journal article is the most likely explanation for the high success rate.

Following didactic training, each student must successfully complete a minimum of 20 intubations, in the operating room, under the supervision of a board-certified anesthesiologist. Additionally, paramedics are required to successfully intubate at least one patient monthly for three years, post certification, and one per quarter thereafter. At least one intubation, annually, must be performed under an anesthesiologist’s supervision.

I will repeat that Paramedic ≠ Intubation. It may be that intubation is the easiest way to measure paramedic quality. On the other hand, it may be that a lack of intubation skills is a good indicator of a lack of overall paramedic quality, rather than the other way around. It seems that many systems have a significant problem with quality. In some of these low quality systems, the attitude does not appear to be to fix the quality problems, but to make everyone a medic. How is more of the same an improvement?

EMS in Boston and Bellingham/Whatcom County take airway management seriously, while the everybody a medic people in Miami average 1 – 3 intubation per medic per year. After however many attempts at intubation, they still only get it half right.

What do the everyone a medic systems do about quality?

Miss.

A lot.

.