Continued from Part I.
In the comments to Drug-Assisted Intubation in the Prehospital Setting is this by BackToBasics –
now we are going to lose our Etomidate & Succs. Next we will lose the ET tubes…….
I’d like to sit in court and explain to the lawyers, judges, jury, & parents of the dead child that suffered fatal aspiration pneumonia because we have the inability to control an airway because the BVM causes gastric distention leading to vomiting; unable to get an OPA because of trismus, so therefore unable to intubate. I love how we are going backwards in medicine.
Does the BVM (Bag Valve Mask) cause gastric distention?
Does less than skillful use of the BVM cause gastric distention?
In the Good Old Days, some anesthesiologists insisted that paramedics use just a BVM to ventilate a patient through an entire surgery before the medic would be permitted to intubate any real live OR patient. If the medic produced gastric distention, that medic was not going to be permitted to get any tubes under the supervision of that anesthesiologist.
The anesthesiologist understood that the patients medics will attempt to intubate are real people, who deserve excellent airway management.
Airway management is not the same as intubation.
Real people are not hypothetical victims of a lack of intubation.
The problem is that we have too many real people who are victims of failed airway management by paramedics.
A similar scare story was spread by Dr. Thomas Scalea when Maryland scaled back their flight criteria so that a doctor would have to be called for permission to fly patients for MOI (Mechanism Of Idiocy Injury).
“Whenever someone says they want to ratchet it back,” says Dr. Thomas M. Scalea, physician in chief at Shock Trauma, “I tell them ‘OK, how many people can die next year to make that worthwhile?’”[1]
We were promised dead bodies.
Where are the dead bodies?
You are promising aspiration pneumonia.
I don’t expect you to deliver, either.
How many patients vomit after intubation?
Let me rephrase that – How many patients vomit after intubation of the trachea?
Plenty of patients vomit after intubation of the esophagus. The aspiration pneumonia caused in these patients is caused by the intubation. The aspiration pneumonia is not prevented by the intubation.
These cases of aspiration pneumonia may be better prevented by preventing intubation.
How many of the cases of aspiration pneumonia were caused before the medic placed the tube in the trachea?
If people are not willing to remediate themselves, make their skills better, which would then make them a BETTER provider then why are we willing to let them be paramedics?
On this we agree.
Give them a training remediation for a few weeks; if things don’t change then give them the option of demotion or termination. It’s that simple.
I don’t think that this ends up being as simple as you suggest.
What is an appropriate amount of continuing practice to be permitted to intubate?
I think that we should be required to place a tube in Fred The Head 10 times in a row before the start of each shift. This would be in addition to other intubation/airway training, which should be at least every few months.
If we are serious about airway management.
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Footnotes:
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[1] Advantages of medevac transport challenged
Baltimore Sun
October 5, 2008
Article
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Most of the anaesthetists I’ve come across still do exactly that. My paramedic students moan about it, using the above argument mostly to justify laziness, but I think it’s still very much the right thing to do and try and explain the thinking behind it to them. Hopefully they’ll take that thought process out on the road with them.