In response to my post Comments on The Endotracheal Tube is Just a Backup Airway Device, there is this response from Too Old To Work, Too Young To Retire –
The problem is EMS education, or actually training which passes for education.
I agree. I have been saying the same thing for years.
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I was shocked to learn that in my neck of the woods most paramedic students get only the minimum mandated 10 intubations in the OR. I don’t know if they are even required to get one intubation in the field before taking the state certification exam.
OR experience is nice to have, but becoming harder to provide.
There is no good reason why medics can’t learn to intubate well with mannequins and the occasional cadaver. We just do not teach airway management well.
It isn’t about the OR. It is about the education.
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Since we aren’t a NR state, I don’t know what the NREMT requires.
As far as I know, NR (National Registry of EMTs) only requires that a student states, I see the tube going through the cords. If squeezing the bag is followed by the mannequin’s lungs expanding, the student wins! Competence assured!
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10 intubations is nothing. During my clinical time I did almost 50 OR intubations and that didn’t really prepare me for attempting intubation in the field.
My first live intubation was working as a medic, bouncing along in an ambulance on a cardiac arrest rendez-vous. I had plenty of practice on mannequins and was comfortable with the tube. Everything went smoothly.
It isn’t the OR that matters. It is the understanding of airway physiology that matters. And lots and lots of practice.
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The CRNA who was my mentor in the OR told me to expect to do about 200 intubations before I felt really comfortable and he was right.
I was comfortable long before then, due to a lot of practice on mannequins.
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If we want to be considered and treated as professionals, then we need to improve paramedic education. It’s ridiculous that after taking the paramedic program and passing the tests to become certified we are then expect to take ACLS, PALS, NALS, AMLS, PHTLS or ITLS, ABLS, and other merit badge courses. All of that material should be included in the paramedic program.
I completely agree. I made a lot of money teaching a lot of those courses, but people were mostly just there taking up space. I tried to make them think, but I could not keep someone from passing just because they were not participating. With a lot of the doctors told they have to complete the course while still satisfying all of their other on call responsibilities, it becomes difficult to get people to pay attention.
The courses are also not set up to accommodate people who work night shift. An 8 AM start time for someone who works 7 PM to 7 AM or 11 PM to 7 AM is not going to catch them at their most alert.
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People talk and blog about taking associates and bachelors programs in “EMS” to improve our professional standard.
The problem is that the current education is often poor. More of the same does not mean better, it only means more of the misinformation.
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How about we concentrate on better educating ALS personnel and stop the trend of a so called paramedic on every ambulance, engine, and rescue truck in the country? More is not better, better is better.
Amen.
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BTW, the reason we intubate burn patients early is because we want to protect their airway against the frequent occurrence of edema at and below the level of the chords. The only two alternatives that do that are intubation or a surgical airway. An LMA will not do that, nor will any of the other “rescue” airways out there.
I understand the pathophysiology.
How is having an unskilled medic poke the trachea, but not properly place the tube, good airway management?
Mauling a burn patient’s airway makes that airway much worse than if no intubation had been attempted.
We assume that an extraglottic device would not work for burned airways (and for epiglottitis), but do we have any good evidence that these patients cannot be successfully ventilated by extraglottic airways?
Even though the problem is edema below the cords, maybe the best solution is not always a tube through the cords.
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No medic I know uses a Mallampati exam before intubating, and I know a lot of medics with 25 or more years of experience.
I’m telling Gene Gandy on you. 😉
It doesn’t matter if we recognize when we are presented with a difficult airway?
We don’t have to use any particular method of assessing for a difficult airway, but if we are not prepared for a difficult airway before we insert the laryngoscope, we are not doing a good assessment.
If we are not prepared for a difficult airway before we insert the laryngoscope, how prepared are we for complications?
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It really doesn’t matter because we are going to attempt (and likely succeed) intubation when necessary.
Of course, that all depends on what your definition of necessary is.
20 years ago, didn’t necessary intubation include every cardiac arrest we treated?
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We do track our intubation success rates and over all it is 90+ % successful. That’s a function of a lower number of paramedics seeing more acute patients every year because we are NOT an all ALS system.
I agree that the low number of paramedics is important. The evidence does seem to support that, but some still disagree and the quantity = quality people may never learn.
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I think you are really missing the mark in understanding what these studies mean. They don’t mean that paramedics shouldn’t be intubating.
Where did I state that this is what they mean?
Did you stop reading before you got to where I wrote –
There is good evidence that paramedics can intubate at very high success rates.
What part of that, and the discussion around it, was not clear?
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They do mean that we need to drastically revamp paramedic education. Unfortunately, I just don’t see that happening.
Not just education, but oversight.
We should not allow medical directors to authorize paramedics to treat patients without some responsibility for endangering patients when they authorize dangerous paramedics.
We also need to pay medical directors enough to make aggressive oversight worthwhile for good medical directors.
If a system does not want to provide aggressive competent oversight, there is no reason that they should provide paramedic services.
Good BLS is probably a lot better than bad ALS.
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Overall I agree with most of your points.
A question I have, though, is about your belief that mannequin training can be effective and adequately prepare students for live patient intubation.
With the cost of mannequins, how many different models are your students going to experience? One? Three? There’s a whole lot of changing anatomy that presents itself with humans that is poorly reproduced in plastic. I tend to think that mannequins are like IV arms–do five or ten tubes or IVs on a model, and you pretty much have the ballgame covered.
When I started intubating live patients my first OR day, I kept having trouble because I was trying to lift everything with the laryngoscope. The CRNA finally showed me how to lift the whole head up with my other hand at the beginning of the procedure, and this made all the difference. I had never needed to do that with a mannequin because of how light they are (even the full-sized weighted ones). I know most people do not use the head-lift technique; that’s not my point. My point is that like every other procedure or technique in medicine, it’s often important to adapt to individual variations, and a static model only shows one variation.
Why do you believe mannequin training is adequate (or even important) preparation?
Matt,
It is the repetition of intubation that teaches the technique.
For a variety of intubation experiences, the Airway Cam series provides views of many different airways. We don’t have to experience every airway complication to be prepared to manage that airway successfully.
Instructors can also be creative with the mannequins.
And that can be adequately covered by occasional cadaver models and/or by good instruction. Instructors, who understand intubation, should explain and demonstrate the differences to students as much as possible.
A lot of time on mannequins and one cadaver lab was all I had prior to working as a medic.
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In the main, I don’t think that mannequins have changed all that much in the past 20 years, unless you get one of the high end ones mostly found in sim labs. My experience is much like Matt’s in that I don’t think that mannequin training is sufficient for most paramedics to become proficient..
My experience is also like Matt’s in that the CRNA that drew the short straw and had to mentor me showed me a lot of tricks that I use to this day.
Since the doctors who deal with burn victims tell us that the edema is at or below the level of the chords, it doesn’t take a study to tell us that supraglottic airways aren’t sufficient. If the patient has airway burns, they encourage us to SEDATE, paralyze, and intubate early because edema will develop quickly.
I’lll take a paramedic who has been intubating real patients for 20 or so years over a student that has intubated the same mannequin 100 times in class any day my or a loved one’s life is on the line.
When you state that there is good evidence that paramedics can intubate you are right. The few studies that have been done that show this show that the medics work in high volume systems, but with a lower paramedic to patient ratio than systems with a high number of paramedics. Remember that was the criticism of the Gauche study. In the system studied (LA County) some medics had only attempted one intubation every three years and that was on adult patients.
Yes, we can often tell before we start that someone is going to be a “tough tube” before we start and without putting a score to it. Which I guess was my point, although I probably didn’t make it clear.
Too Old To Work,
OR training does not appear to be sufficient for most paramedics to become proficient, either.
We just use a lack of OR training as an excuse for poor intubation skills.
I am referring to using the 20 year old Fred The Head mannequins.
The new SimMan should be better. I have never had the opportunity to use one.
Why should we assume that those same skills/tricks could not be taught by excellent instructors with mannequins?
Don’t claim that we don’t have excellent instructors. I know that is a big problem, but that is a reason for improving/eliminating EMS education, not for picking and choosing certain parts to be done in the OR, by people outside of EMS.
Gosh, expert doctors have never been wrong about anything they haven’t investigated before, so we should have medics just increase the edema by shoving things randomly into the vicinity of the trachea?
Why do you assume that a burn patient’s airway becomes more patient, when some clown turns it into a trauma airway?
If swelling is a problem, it is even more important to keep unskilled people from attempting intubation.
OK. I can be silly, too.
I’ll take a paramedic who has been intubating for 20 years over a student who has just intubated some OR patients.
More experience is better, but OR experience is not essential. OR experience is traditional.
Would I prefer to have students get some OR experience? Only after they have done at least a thousand successful intubations on a mannequin. There is no good reason to endanger OR patients with unskilled paramedic students.
We need to stop making excuses for bad airway management.
We need to stop making excuses for bad airway education.
I don’t think that any particular method of assessment for a difficult airway is essential. I do think that it is essential to be prepared for a difficult airway before the first attempt at intubation.
Maybe it is better to use an extraglottic device, so that the patient has a patent airway, rather than for the medic to be able to brag that he was able to get the tube that nobody else was able to get. Sometimes we should start with the extraglottic device, rather than wait until the maximum number of attempts have been reached.
What do we do with the patient with the burned airway, when the maximum number of intubation attempts have been reached?
Maybe we should have some alternatives for the burned airway.
Maybe we should find out just what does work and whether an extraglottic airway can be adequate airway management for a burned airway.
If a crichothyrotomy is the alternative and the swelling is below the cords, below where the crichothyrotomy will be, how is that going to produce a patent airway?
Maybe we have assumed too much about burned airways and not looked at the inconsistencies of what we are teaching/being taught.
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