In JEMS, there is an article by almost all of the top people in EMS airway management. There are several omitted, who contribute to the understanding of airway management, such as Richard Levitan, MD[1] and Kelly Grayson, CCEMT-P.[2] This is not that much of a criticism, since the people they included are definitely among the top airway management experts.
The article points out some of the problems we have in teaching paramedics/nurses/doctors to use critical judgment. We do a very poor job of educating people to make good decisions. Then we conclude that our failure means that the alternative is rigid protocols – even for doctors.
That is just another example of bad judgment.
What is wrong with the following paragraphs?
An EMT listens over the chest and abdomen with a stethoscope. He says he hears breath sounds over the chest but doesn’t say anything about the presence or absence of breath sounds over the abdomen. An ECG monitor with capnography is attached to the patient. The EMT operating the monitor is unsure how to set the device to measure waveform capnography.
Approximately a minute later, the EMT states, “There’s something wrong with the monitor.” The paramedic quickly checks the monitor and re-checks placement of the ET tube. He says, “Looks like the monitor’s not working. But the breath sounds are good, so let’s go ahead and get this guy to the hospital.” The patient is then moved to the ambulance and transported to St. Joseph Hospital with mechanical ventilation continued.[3]
When the monitor does not produce a waveform, or confirm what the EMT expected to see, the conclusion is that There’s something wrong with the monitor.
This is bad, because the EMT is already deciding where the problem is. He has made a statement that he will probably feel the need to defend later on. He doesn’t even appear to be considering operator error.
As the patient becomes less stable, the operator error rate increases.
The EMT operating the monitor is unsure how to set the device to measure waveform capnography. Still, he concludes, not that he doesn’t know what he is doing, but that the equipment is wrong.
I’m not the problem! The equipment I don’t understand is the problem!
Not to worry. We still have a paramedic, trained in the use of waveform capnography and drilled in intubation until he talks about it in his sleep. Sorry. Paramedic programs do not seem to drill paramedics on intubation that much, nor do employers, EMS systems, or even medical directors. Intubation is just not taken seriously. Tube placement confirmation and waveform capnography are taken even less seriously
Looks like the monitor’s not working. But the breath sounds are good, so let’s go ahead and get this guy to the hospital.
This is the motto of a serial killer.
It is only a matter of time until someone, who thinks like this, kills and kills again.
Who taught this guy to think like this?
Who hired him to think like this?
What EMS system licensed him to think like this?
What medical director authorized him use this kind of thinking to go out and kill patients?
His paramedic instructor from the local community college is subpoenaed and, during his deposition, reports that it was very difficult for his students to gain access to local hospitals to practice intubation, explaining that students simply learned the procedure on manikins.[3]
So what?
You can learn to intubate competently on mannequins.
You do not need real live dead people to learn to use critical judgment.
The lack of human intubation practice is a pathetic excuse for poor education.
Would this medic have made a better decision about the obvious lack of waveform during his intubation attempt if he had practiced on dozens of live patients?
No.
The education he received does not appear to have included thorough coverage of tube placement confirmation. And that is not even the most important part of intubation.
We spend too much time worrying about intubation, when the real issue is airway management. This medic does not understand airway management – not even a little bit.
This is a systemic problem.
This lack of understanding of airway management begins in EMT/paramedic school, continues with employers, is certified by EMS systems, and is given the Dominus vobiscum of the medical directors.
Then the medic has his license to kill. The question is, Why is anyone surprised when the medic does kill?
We all seem to believe that this series of failures – school to employer to EMS system to medical director – works.
How many people are killed by this misunderstanding?
How many people are killed by this ignorance?
Am I being too harsh on these failures?
No.
Am I going too easy on the medic?
Calling him a serial killer is not exactly killing him with kindness. This is similar to Murder on the Orient Express. There are plenty of fingerprints on the murder weapon. There is plenty of guilt to go around.
Marc Eckstein, MD, MPH, FACEP, EMT-P: The take-home point here is that we need prehospital research that involves prospective randomized controlled trials (RCTs) with meaningful outcome variables, which are decreased morbidity and mortality.[3]
Essential to the study of intubation and airway management is that the researchers control for the quality of the paramedics.
We need to stop looking at intubation as something that is not affected by the quality of the people attempting intubation.
Dr. Eckstein: These alternative airway devices, particularly the King airway, can be placed quickly, and they provide good oxygenation and ventilation. However, they don’t protect against aspiration, which of course is a major concern with emergency airway management, especially in the field.[3]
I disagree about the major concern of aspiration.
Where is the research to support this?
In the studies comparing intubation with basic BVM use, where is the flood of emesis worsening outcomes?
I think that intubation protecting against aspiration is mostly just another EMS myth.
William E. Gandy, JD, NREMT-P: I wholeheartedly agree with Dr. Wang. Yes, the emphasis should be on ventilation—not intubation. Paramedics should be thoroughly schooled in airway evaluation and should have a variety of airway adjuncts, such as bougies, video laryngoscopy and supraglottic airways, available and be willing to use them.[3]
If you have heard Gene (William E. Gandy) talk about airway management, you have heard this over and over.
You may get tired of hearing that airway management is about ventilation, not intubation or oxygenation. If that is the case, then you really do not understand airway management.
If you do not understand airway management, then you do not understand intubation.
Footnotes:
[1] Laryngeal view during laryngoscopy: a randomized trial comparing cricoid pressure, backward-upward-rightward pressure, and bimanual laryngoscopy.
Levitan RM, Kinkle WC, Levin WJ, Everett WW.
Ann Emerg Med. 2006 Jun;47(6):548-55. Epub 2006 Mar 14.
PMID: 16713784 [PubMed – indexed for MEDLINE]
[2] The Airway Continuum
The Ambulance Driver’s Perspective
by Kelly Grayson
ems1.com
Article
[3] Experts Debate Paramedic Intubation – Should paramedics continue to intubate?
JEMS.com
Bryan E. Bledsoe, DO, FACEP, FAAEM | Darren Braude, MD, MPH, FACEP, EMT-P | David K. Tan, MD, FAAEM, EMT-T | Henry Wang, MD, MS | Marc Eckstein, MD, MPH, FACEP | Marvin Wayne, MD, FACEP, FAAEM | William E. Gandy, D, LP, NREMT-P
Thursday, July 1, 2010
Article
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I work in a busy system that runs about 85,000 calls per year. We don’t have RSI. So if you plan on intubating someone, you have either nasal intubation for the conscious or oral intubation for the obtunded. But even in our system my opportunity to intubate is so infrequent that I know my ability to perform it has wilted to the point where I’m worried that I might cause more harm than good.
And what’s the first rule of medicine: first do no harm.
No matter the system, there’s the issue of practice. On real people. In the OR. AND HARDLY ANYONE GETS THIS OPPORTUNITY ONCE OUT OF SCHOOL. Until EMS systems understand that intubation is a perishable skill, and an overrated way to manage the airway given the tremendous risks associated with it, EMS needs to really think about how safe it is.
I agree with you 100% that the aspiration myth is overhyped, overrated, and WAY overblown. I can’t remember the last cardiac arrest patient I saw who didn’t aspirate BEFORE I GOT ON SCENE. What’s the point in intubating then? What’s done is done. I am so tired of hearing that “airway X doesn’t protect against aspiration as effective as intubation.” Please. Look at the structure and design of the LMA supreme, the Combitube, the King. These are actual mechanical barriers that occlude the esophageus. If they did not, the device would not function. There are studies talking about aspiration and alternative airway devices. And as I recall, the risk was nonexistent. They did in fact work to prevent aspiration.
EMS has far too long held hold of this dream of intubation without ever doing anything to keep the skills sharp. I don’t know if it some “this is what makes us special” thing or what. But if prehospital intubation is to be preserved, so too do the skills necessary to perform it properly. That means regular, structured, and appropriate training to work with real patients.