Severe pain + 2mg of Morphine = severe pain.

- Rogue Medic

Comment from Happy Medic on Is it time we give up endotracheal intubation – Part III

In response to Is it time we give up endotracheal intubation – Part III, which was a response to Thoughts on ETI by Happy Medic, there are a couple of comments. This is a response to Justin Schorr, AKA Happy Medic

Excellent points as always Rogue, but I think the underlying message of my post was not conveyed as clearly as I thought. My point was that we need to remove incompetent intubation through realistic training, not just leave the tubes just because we might need them.

Thank you. I think that we all have problems communicating when it comes to intubation. We have so many assumptions about what intubation is, what airway management is, and whether we are improving outcomes with intubation.

I completely agree that we need to eliminate incompetent intubation through excellent training.

As I mentioned in my response to Sean Eddy, the blame is with everyone – not just the medics.

If the arguments for removing tubes are that we don’t need them. Then take my dopamine, Mag Sulfate and the 90% of the kit I never use and could just as easily kill someone with.

How often do medics use/misuse these drugs?

How often do medics use/misuse intubation?

It isn’t that these do not cause problems, they do cause problems, but that they do not seem to cause problems as noticeable as the problems from pumping 100% oxygen into the stomach. And that is just the most blatant example.

We do need to deal with medication mistakes. That is why I think that EMSMedRx is an important new blog for EMS to pay attention to. Medics do not tend to want to learn about medication. People used to feel the same way about 12 leads, but Tom Bouthillet has done a lot to change that with EMS 12 Lead.

We have much to do to improve EMS. We have plenty of people trying to discourage any criticism of the problems we have in this best of all possible EMS worlds.

Training is the key to understanding not when to intubate, but when NOT to intubate. Taking my ETT and replacing it with an LMA is not a solution. Providing both and the training to know when to use each and how is the key, is it not?

Yes, but as we decrease the need for intubation with the use of other methods of airway management, we have to acknowledge that this means a decrease in available experience. Not every system will be willing to do what is necessary to maintain competence. Look at how many systems do not do what is necessary to maintain competence at pain management, on either end of the medical command line.

Anesthesia departments seem to be leading the way in switching to non-intubation airway management. We used to be proud of our similarities with anesthesia.

When anesthesia does something that is good for patients, but bad for encouraging EMS intubation, we no longer see anesthesiologists as doctors to emulate. We are wrong to allow our biases to mislead us on this important issue.

Like an awkward marriage, I think we’re all saying the same thing in this argument, just using different words and not completely explaining ourselves.

This is true.

What do we do to deal with the absentee medical directors? I might be able to find some of the missing posters put up by local EMS agencies.

Have you seen this medical director?

Neither have any of the medics at Sold Out EMS.

We have more resuscitations than sightings of our medical director, but we know that someone is cashing his checks.

I overheard a medic in my service telling a co-worker he wished someone would come by and train him more. I suggested heading to the yard the next morning and I got a look.

If we believe that we have great skills, one way we will find out that we are wrong is by practicing. Of course, if we spend a lot of time at high quality practice, then we might not have to worry about not having great skills.

Too many medics assume their department or service will give them all they need to continue being a competent provider, but we all know this is not true.

It should actually be a bit different.

The department or service should demand that the medics demonstrate excellence.

For example –

If we cannot demonstrate excellence at intubation, we will be removed from the approved to intubate list and our pay will be cut by 25% for failing to maintain competence.

If we really want to improve the quality of intubation in EMS, we can find a way. We can probably find many ways. We should not expect them to be popular.

I would expect unions to oppose this, but if the EMS agency goes to the public and points out that the union is only defending incompetence, there should not be many people supporting union opposition to improved patient care.

It would be better to try to find some ways to get the union to persuade the members that this is a good idea. It would be better to get the union to persuade members that the union does not want to be defending incompetence.

Thanks for the post, it made me realize I had failed to convey my intent completely. Perhaps less angry writing in the future will do me good.

Justin

Thank you for the post.

By working through our different ways of expressing ourselves, maybe we can come up with ways to convince medics to maintain competence in airway management, rather than take away intubation.

Don’t get angry, get a punching bag. I’d recommend Newman’s Gym, but it closed.

.

Comments

  1. Thanks again Rogue. “Don’t get angry, get a punching bag. I’d recommend Newman’s Gym, but it closed.”
    I’ve found the sword game on my wii not only helps with aggression but is a good shoulder work out!

    • Justin,

      Thanks again Rogue. “Don’t get angry, get a punching bag. I’d recommend Newman’s Gym, but it closed.”
      I’ve found the sword game on my wii not only helps with aggression but is a good shoulder work out!

      Of course, uttering the official incantation would be a part of that game?

      You have the ring, and I see your Schwartz is as big as mine. Now let’s see how well you handle it. :-)

      I just received a hand-me-down Wii. I’ll have to look into that game. Treating the keyboard like Whack-a-Mole probably voids the warranty.

      I was hoping to make a post out of my response to your response and call it Comment from Happy Medic Cubed or start off with 500 words just explaining where the discussion had been – and it was going to be the definitive piece on intubation. ;-)

      .

  2. We have more resuscitations than sightings of our medical director, but we know that someone is cashing his checks.

    Paid medical directors who are supposed to be more than signatures on paperwork?

    NOW I’ve heard everything.

    • CBEMt,

      “We have more resuscitations than sightings of our medical director, but we know that someone is cashing his checks.”

      Paid medical directors who are supposed to be more than signatures on paperwork?

      NOW I’ve heard everything.

      I wish I were making this up.

      A lot of non-medical management will just see the need for a medical director as a requirement to be satisfied, like wearing a parachute when jumping out of a plane in flight, without considering that there can be good reasons for wearing a parachute. These tend to be the employers that attract the kind of employees who do not survive with real medical oversight.

      .

      • How about those that have “paid” medical directors whose job being medical director is a part time(or less) paid job behind their full time job of being a doctor in a hospital. And to boot, can’t do anything because of the service(s) paying them and not allowing the doctor to do anything too progressive because they don’t want to spend any money they’re not required to do so by the law that oversees them? How is that better than not having a medical director at all?

        • Can’t say, clowns will eat me,

          How about those that have “paid” medical directors whose job being medical director is a part time(or less) paid job behind their full time job of being a doctor in a hospital.

          Part of the problem is that we do not act as if we value medical direction.

          Is there any good reason that we should pay medical directors less per hour, to provide medical oversight to an entire company of people providing ALS care, than to work as a doctor treating patients in the ED?

          We make it quite clear that medical direction is not a job that is worth much.

          And to boot, can’t do anything because of the service(s) paying them and not allowing the doctor to do anything too progressive because they don’t want to spend any money they’re not required to do so by the law that oversees them?

          That is another huge problem.

          Maybe we need to ridicule the medical directors who allow the CEOs, fire chiefs, city councils, and other non-medical personnel to tell them what is good medicine.

          How is that better than not having a medical director at all?

          At least with no medical oversight, there should not be any ALS. :-)

          Do agencies that provide bad ALS kill more patients than they help?

          Should we study this to see just how dangerous incompetent medical oversight is?

          .

          • Oh, and don’t forget the states/systems that allow a paramedic or less to be the ‘medical director’ and simply have some random ‘doctor’ sign off for prescription necessary items. That’s gotta be better, right?

            • Can’t say, clowns will eat me,

              Oh, and don’t forget the states/systems that allow a paramedic or less to be the ‘medical director’ and simply have some random ‘doctor’ sign off for prescription necessary items. That’s gotta be better, right?

              Considering some of the doctors I have had as medical director, things would only become more entertaining with non-physician medical directors.

      • I wish I were making it up that some agencies in my state don’t even have one. “Doesn’t matter anyway, the MD can’t change the protocols and we all have one at the state level.” Uh huh.

        I wish I were making it up that we’ve got one ER doc who’s the “Medical Director” for about 10 different services. Great guy, great doc, very interested and involved in pre-hospital care and education. He just allows himself to be used by the services who need a guy to order their stuff. So contradictory it gives me a headache.

        I know of a company that had a medic lose his cert for a few weeks because the boss was on vacation at NR renewal time and nobody knew how to get in touch with the medical director to get the renewal app signed off. If they’d even known his name they probably could have figured it out, but they didn’t even have that.

        And yet you ask enough people and you’ll be able to find some who think we aught to get RSI capability statewide, just like we got Ipratropium statewide.

Speak Your Mind