Furosemide is good for filling the patient’s bladder, but the patient probably did not call for help filling his/her bladder.

- Rogue Medic

Is it time we give up endotracheal intubation – Part III

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Continuing from Part I and Part II. In response to Kelly Grayson of A Day in the Life of an Ambulance Driver, there is this from The Happy Medic, who seems cranky –

I’m 4/5 on my last few tubes I can recall and felt like a failure. We shouldn’t be “missing a tube” in the field and delivering it to the ER (or the ME in some cases) but using stats like these to take away a tool is insane.

Imagine if a police officer who shot at 5 suspects only hit 4. Would we be considering taking away his weapon or sending him to the range for more training?

What he is describing is missing the first attempt at intubation one time out of five attempts.

Comparing this to the many egregious examples of airway mismanagement is probably not the insanity Happy Medic is describing, but it might be seen as wandering a bit toward paranoia.

The problem medic might be better compared to the police officer who hits 4 suspects and one bystander. Is that the same as the example Happy Medic gave?

I don’t think so, either, but that is the medic who should not be intubating.

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Later, he states –

We need more training. We all know it, but no one is going to come by the station and give it to us.

This is the problem of the administration, the medical director, and the medics.

Maybe people with this attitude should not be trusted with the lives of patients.

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If the industry wants to solve the ETI stats by taking the tubes away I can then guarantee a success rate of ZERO. Instead, let’s apply the same metric to IV starts, medication errors and just disband EMS all together, because if you take one tool because we misuse it and don’t remediate the provider, the problem will spread.

How can we guarantee an airway management success rate of ZERO by removing intubation from those who are bad at it?

We can’t.

We can cut the rate at which incompetent medics kill patients.

As for IVs, how many patients are killed by IV infections and other problems?

Too many patients may be killed by medication errors. We do need to measure this much better. A new blog by a pharmacist working with EMS (EMSMedRx) would be a good place for medics to learn to not make so many medication errors.

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The problem IS NOT the ability to intubate the trachea, it is poorly trained practitioners using a tool they do not completely understand in a manner that may not even be necessary.

Agreed, but that does not mean that we should just allow them to intubate.

We need to demonstrate excellence (which does not mean 100% first pass success) or we need to limit ourselves to less dangerous methods of airway management.

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If an MD needs 200 tubes to be considered proficient, then misses repeatedly in the ER, can I take his tubes away if I can sweep in and get it first try with only 10 under my belt in training?

That would be something for a hospital administrator, or the anesthesia department, or the director of the ED to handle. A medic does not take away hospital privileges from doctors.

His next line is very disturbing -

Of course not, because if they need that tool another time I want them to have it available. Now offer me the same consideration and perhaps we can all move forward.

Who needs incompetent intubation?

Would any patient want to be treated by the doctor, or medic, who can’t intubate to save the patient’s life?

Consider –

This is Dr. Esophagus. We call him that, because every time he tries to intubate, the tube ends up in the esophagus. We allow him to continue to mangle airways, because if they need that tool another time Happy Medic wants them to have it available.

Why?

I don’t know

Why would a patient need a really incompetently managed airway, when the patient could have been safely managed with an LMA (Laryngeal Mask Airway)?

Where is this abuse of patients considered appropriate patient care?

At no time does incompetent intubation become a needed tool.

However, we do have more than enough medics delivering incompetent intubation.

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This is about making sure that we earn the right to take a patient’s airway in our hands.

This is about making sure that we earn the right to take a patient’s life in our hands.

This is about making sure that our medical directors act responsibly and protect patients from dangerous medics.

This is about doing what is best for the patient, not what is best for the ego of the paramedic.

This is not about taking tubes away from medics, but about making medics work for this responsibility.

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Go read Kelly’s article, Is it time we give up endotracheal intubation?

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Comments

  1. 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.

    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. 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.

    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).

  2. 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.

    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.

    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?

    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.

    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.

    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.

    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

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