Severe pain + 2mg of Morphine = severe pain.

- Rogue Medic

Comment from Sean Eddy on Is it time we give up endotracheal intubation – Part III

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In response to Is it time we give up endotracheal intubation – Part III are a couple of comments. This is a response to Sean Eddy, AKA Droid Medic, AKA Medic Madness

You make some very good points here. The whole “nobody wants to come train us” argument is weak. It is up to us as providers to stay on top of our game and refresh on skills that we don’t use very often.

Yes and No.

Yes, it is a weak argument. Although Happy Medic is more interested in acting as the devil’s advocate, there are plenty of medics who will make this argument and insist that they have no responsibility for maintaining their skills.

No, it is also the responsibility of the medical director, the testing organizations (such as the National Registry of EMTs), the paramedic schools, employers, and the receiving hospital staff (doctors and nurses) to do something about bad airway management. Those are not in a particular order, since all contribute to allowing dangerous medics to continue to be dangerous to their patients.

Yes. These are the patients of the paramedic schools.

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I probably intubate on average once a month. When I have an intern, I don’t intubate (unless he/she is unable to) at all.

I recently heard of a medic who supposedly carries his own laryngoscope on his belt and will fight anyone for the tube. He has paramedic students ride with him, but will not allow his students to intubate.

If this is true, he is dangerous.

We do not learn from what we do ourselves. We learn from teaching others.

I will allow anyone else to take the first shot at the tube (as long as it is, or will be, in that person’s scope of practice).

If that person is not able to get the tube, maybe I will use an alternative means of ventilation (LMA, King, CombiTube, BVM) or maybe I will attempt intubation. It will depend on what I think is appropriate after seeing the other person attempt intubation.

If I state that I am not going to attempt intubation and that the person should use a ______ airway, that may help others to see that airway management is more than just intubation.

EMS seems to be starting to move toward this approach to airway management.

Some places have an absolute limit on intubation attempts of two. If one medic tries twice, that’s it. No more prehospital intubation attempts at intubation for that patient by anyone.

But what if the patient has airway swelling secondary to burns?

It is not the right thing to do for the patient. Further stimulating airway swelling is not good for the patient.

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Now I realize that this, along with other infrequently used skills, are critical and I need to stay sharp. Unfortunately with intubation, it’s hard to get the real-life practice when you don’t get the calls. However, like Kelly mentioned, cops don’t practice shooting at people that are shooting back. They practice shooting pieces of paper.

Exactly.

Practice is about much more than fidelity of representation of the airway.

Practice is about learning how to hold the laryngoscope, so that I don’t have to think about it.

Practice is about learning how to position the patient’s head, so that I don’t have to think about it.

Practice is about learning how to use the laryngoscope to lift up, rather than as the arm of a slot machine applying leverage to the patient’s teeth, so that I don’t have to think about the right way to do it.

Practice is about learning how to deal with all sorts of odd things that do happen, just not that often. If I learn to deal with things in practice, then when I encounter similar presentations/complications I don’t have to spend much time thinking about what to do. I have already considered ways to deal with this from working on it in a practice scenario.

Will there be things not anticipated?

Of course, but having to learn to deal with a lot of complications will improve our ability to deal with real complications.

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To address this issue, I recently organized a group of fellow medics that meet once a month. We reserve the training room at our station and pull out the ped and adult manikins. We practice intubations, needle decompression, needle cricothyrotomy, BLS skills and anything else that we don’t do all that often. We critique each other, run through scenarios and learn from the more experienced medics. Then when it’s over, we head out for lunch and beers (hey, gotta have some incentive to get people to show up).

This is an excellent way to acknowledge our responsibility for maintaining our skills.

This is an excellent way to maintain, and even develop, skills.

Anyone who claims tyhat there is nothing to learn from practice with mannequins does not understand airway management well enough.

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