Severe pain + 2mg of Morphine = severe pain.

- Rogue Medic

If We Were Really Serious About Intubation Quality

If We Were Really Serious About Intubation Quality – we would require that each medic be intubated by a different medic at least once a month.

This would get rid of all of the whining about a lack of opportunity to get any live practice.

We would quickly learn who can intubate.

Medics would develop an interest in outcomes that are longer term than just dropping a body off at the ED (Emergency Department).

 

Each month every medic gets at least one tube – or no tubes.

 

Every month.

We get to listen to some Ludwig van while letting our droogies show their stuff.

If you cannot convince any medic to let you attempt to intubate them, then you are prohibited from attempting to intubate any patient for any reason. This will quickly lead to more accurate peer assessment of quality.

You cannot attempt to intubate the same medic in the same year, unless there are fewer than 13 medics in your organization. This means that you can’t just end up with the easiest tube each month.

You cannot have the same medic attempt to intubate you in the same year, unless there are fewer than 13 medics in your organization.

You must also be on the receiving end of an intubation attempt or you are prohibited from attempting to intubate any patient for any reason.

If you cannot convince any of your fellow medics to allow you to attempt to intubate them, do we need to know anything more about how pathetic you are at intubation?

If no medic will allow you to attempt to intubate them, is there any good reason to allow you to harm patients by attempting to intubate the patients?

But . . but . . . but . . . what about infection?

Is there any better way to teach sterile technique?

But . . but . . . but . . . what about irritation?

Is there a better way to get medics to realize that we should lubricate the tube?

But . . but . . . but . . . what about injury?

Is there any better way to teach that intubation is supposed to be gentle?

But . . but . . . but . . . what about . . . ?

What about growing a set and learning to manage an airway?

We also need to make sure that our coworkers know how to manage an airway.

If the complication rate is too high when paramedics attempt to intubate other healthy paramedics in a controlled setting, why should we permit paramedics to attempt to intubate sick people in uncontrolled settings?

Most important may be the last part – you will be hooked up to a vent for 10 minutes after being moved from one stretcher to another.

And you will be heavily sedated, so you will not be assisting the tube into the right place, and you will not be able to let anyone know if your CO2 level is climbing rapidly due to a misplaced/dislodged tube.

Unreasonable?

No.

What is unreasonable is the pathetic way we assess the quality of airway management in EMS.

Do you really trust the intubation skills of your coworkers?

Are you willing to prove it?

Every month.

We would rather whine about how it is unfair to take away intubation.

We do not deserve to intubate.

Our patients do not deserve to be abused by us.

.

Comments

  1. Where is the like button for this?

  2. Holy Pearly Gates Batman! What a concept. I’m surprised it took somebody this long to come up with this. Great plan – sign me up.

    • RevMedic,

      Holy Pearly Gates Batman! What a concept. I’m surprised it took somebody this long to come up with this. Great plan – sign me up.

      Thank you.

      I doubt it is an entirely new idea. I have seen it done in rare circumstances. The occasional medic who has no gag reflex, but likes to teach. Dr. Levitan in his airway lectures. Maybe some others.

      We practice IVs on each other. If we want to practice on other people in the OR, we should at the very least practice on each other, first.

      .

  3. Something that I have noticed during my paramedic clinical time in the Operating Room is that the CRNAs and Anesthesiologists seem to understand the full weight and risks of intubating a patient, and it is almost held “sacred” by them….maybe that’s not the word, but I definitely don’t think EMS folks are imparted or hold that same sense or respect towards the procedure. Maybe some do, but definitely not a lot of folks.

    • DevKrev,

      Something that I have noticed during my paramedic clinical time in the Operating Room is that the CRNAs and Anesthesiologists seem to understand the full weight and risks of intubating a patient, and it is almost held “sacred” by them….maybe that’s not the word, but I definitely don’t think EMS folks are imparted or hold that same sense or respect towards the procedure. Maybe some do, but definitely not a lot of folks.

      Absolutely.

      We take intubation so seriously, that we demand that it not be taken away from us, but we do not improve our skills to the point of actual competence, except in a few places.

      If we had more respect for our patients, we would work much more at our own competence.

      .

  4. Great idea! I’m sure you’ve seen this video from the EMCrit blog. This meets the AMA ethical guidelines, so why no ours? I would add bagging with sedation for 10 minutes before intubation. That’s a much more difficult skill to master than intubation, and even more often overlooked.

    • Bob,

      Great idea! I’m sure you’ve seen this video from the EMCrit blog.

      I have. It is excellent, which is something that I expect from EMCrit.

      This meets the AMA ethical guidelines, so why no ours?

      Don’t you know?

      EMS has no ethical guidelines.

      If we had ethical guidelines, we would have to eliminate half of what we do and we could never get away with requirements for medical command permission to treat patients.

      I would add bagging with sedation for 10 minutes before intubation. That’s a much more difficult skill to master than intubation, and even more often overlooked.

      Excellent point. I should have included that. I think that we should never allow a medic student, or medic, to intubate in a controlled setting until after they have demonstrated that skill.

      Medics should have to demonstrate this all over again on a regular basis, such as every month.

      .

  5. Sorry, forgot to add the link.

    http://emcrit.org/misc/awake-intub-video/

  6. The risks of intubation are such that we only perform it when it is likely to prevent someone from dying. When people are so sick that the risk of them dying is greater if we do nothing than if we intubate. Every single procedure carries a risk and intubating people who don’t need it is reckless!

    I agree that something may need to be done but i don’t think this is the answer.

    In Australia we have a tiered system. The paramedics trained to perform intubation (MICA paramedics) are likely to perform it often and as such are well practiced. If non Mica paramedics were trained in intubation they would not need to do it enough to maintain the skill. MICA Paramedics in Australia achieve an almost 100% success rate with intubation, without needing to intubate each other.

    • drastic,

      The risks of intubation are such that we only perform it when it is likely to prevent someone from dying.

      That must explain why patients are intubated for elective procedures.

      I think your point is that paramedics intubate so badly that we should only intubate people actively dying.

      When people are so sick that the risk of them dying is greater if we do nothing than if we intubate.

      Who benefits from EMS intubation?

      Where is the evidence?

      We act as if we are saving lives, but we don’t trust ourselves to intubate each other?

      Every single procedure carries a risk and intubating people who don’t need it is reckless!

      I agree that a lot of paramedics intubate so badly, that they are not safe intubating anyone, but where is your evidence that this is reckless?

      People do intubate each other, such as in the video by Dr. Weingart, during lectures, and at other times.

      This is reckless?

      No. Our current method of skill maintenance is generally reckless.

      Look at the numbers from intubation research. Almost all of the studies demonstrate a level of skill that a chimpanzee could be trained to provide.

      I agree that something may need to be done but i don’t think this is the answer.

      We disagree.

      In Australia we have a tiered system.

      In the US, some systems are tiered and some are not.

      The paramedics trained to perform intubation (MICA paramedics) are likely to perform it often and as such are well practiced.

      What kind of success rates can you show from Australian intubation research?

      If non Mica paramedics were trained in intubation they would not need to do it enough to maintain the skill.

      I don’t understand what you are stating.

      Are you stating that EMS personnel, who do not currently intubate could be allowed to intubate, but that they would intubate less and therefore would need less practice? Please explain, because I doubt that this is what you mean.

      MICA Paramedics in Australia achieve an almost 100% success rate with intubation, without needing to intubate each other.

      Please provide the studies to demonstrate this excellence.

      What do you consider to be almost 100%?

      99.9%

      99%

      97%

      95%

      90%

      80%

      Almost 100% can mean so many things, that it helps to be specific.

      Where do you get the data from?

      .

      • “Are you stating that EMS personnel, who do not currently intubate could be allowed to intubate, but that they would intubate less and therefore would need less practice? Please explain, because I doubt that this is what you mean. ”

        In Australia, Mobile Intensive Care Paramedics are dispatched only to very sick patients, and thus perform more intubations than non intensive care paramedics. I am saying that if non intensive care paramedics were able to intubate they would not perform it enough to maintain the required skill level to intubate safely. This is why only MICA do it.

        Here is one paper giving MICA flight paramedics a 97% success rate.

        http://www.ncbi.nlm.nih.gov/pubmed/12534484

        Here is another giving MICA paramedics a 97% success rate, and also reporting on better patient outcomes after paramedic intubation when compared to in hospital intubation..

        http://www.ncbi.nlm.nih.gov/pubmed/21107105

        The results of another very recent study with a larger sample size were presented at the Student Paramedics Australasia Conference a couple of weeks ago and cited an even higher success rate, but i don’t think it has been published yet.

        I agree with you that training and skills maintenance is required, however i feel that a change to the system – ie introducing an intensive care ambulance tier – would be more effective and safer for employees than intubating each other (as demonstrated by the success of MICA). Personally i don’t care how amazing my colleagues are at intubation. There is no way i would have it done to me for no reason. I would be risking infection, trauma, hypoxia, and more. It seems like a bit of a pointless debate though, as i can’t see it passing ethics.

        ps.

        “Look at the numbers from intubation research. Almost all of the studies demonstrate a level of skill that a chimpanzee could be trained to provide.”

        Which intubation research is this?

  7. My nursing school forced all students to preform all skills on each other (after learning on a manikin), even the not-so-nice/pleasant ones. I will tell you it works. I am a better nurse for it and I actively preach this method of teaching for students and also for continuing ed classes. If they are unable to show compentency or proficiency, then it’s back to the manikin. The skill cannot be preformed on a live human until they can show proficiency. Great post.

  8. I’m getting really bored of your anti-intubation posts. Other then a misplaced tube which should be recognized immediately by auscultation and waveform, a standard in PA, show me the statistics that are for or against placing an airway in an acute CHF or respiratory arrest patient who can no longer support their own airway using a BVM vs an ETT. Show me data that says a BVM keeps vomit out of the lungs with a decreased LOC. Several patients are difficult to maintain a proper seal due to facial features combined with movement and transport. In a cardiac arrest I agree the first thought shouldn’t be intubation and that has been statistically proven. If a medic misplaces a tube and they can’t recognize it then maybe that is not the person we should have performing the skill or doing the job. There are a lot of procedures medics can perform that aren’t done on a regular basis and that goes for ER doctors/residents and Anesthesiologists. How many emergency tracheotomies are performed by them and have they recertified to someone every year to prove they still can do it and can they perform the same skill if they were called out to perform the same skill laying on a floor of a bathroom with no immediate access outside while the family is yelling over their head to save their baby? Can I perform an emergency tracheotomy, needle decompression, EJ, intubation, KingLT, or pacer capture on you once a month to make sure I’m up to your standards of proficiency? We are trained to use skills that we may seldom use or never at all but if we do we are trained to recognize if it was done wrong to correct it if possible. After years of working in the ER and EMS I have seen many ER attendings and residents miss tubes. I’ve seen them call anesthesia stat and watched them come down and fail as well watching the patient die in the room due to a difficult airway. No one can be 100% proficient in medicine, EVER!!! Ever missed an IV on a diabetic? How about twice on the same patient? BGL is 15!!! What do I do??? Try again, transport, should I give Glucagon? Whatever you did may or may not have saved the patient. Guess we have to send you with the IV team in the hospital to make sure you know how start a line because you must be out of practice because you failed. Try for once instead of regurgitating statistics from studies post something you have done as a medic that worked. Show me studies you have been involved in to discount what what you preach against. You discount paramediine in every post. Sure I can bag a overdose due to respiratory depression for an hour and take them to the ER or I can give them a small dose of naloxone to reverse the effects and increase respiratory effort. Tell us your latest 911 story where the patient benefited from ALS care and promoted paramedicine. I know I have several. I’ve seen 3 patients this year walk out the door of the hospital post cardiac arrest that I personally coded. Can you say the same? If you want to be anti EMS, be a personal injury lawyer, or use your research knowledge as a medic to help move our profession forward instead of dragging it back by showing the short comings of a system that the public barely understands. Your just an ambulance driver. Maybe I should just be a transport medic and report what the nurse told me to tell the other nurse while taking a set of vitals enroute. Do you think we even need 911? Maybe the hearse can swing by and pick up the patient and bring them to the ER because the care there is better and a medic may not hurt them. I think that’s called a taxi to triage.

  9. Regarding the idea that we intubate each other, yes VIRGINIA that is INSANE (and no there is no Sanity-clause),

    You keep referring to “Trust” as if that is a data point that needs to be considered.

    May I remind you here that this is not a breakout session in a conference where we try to fall into each others arms. Intubation is a skill that is not without consequences even when properly done.

    Drastic & PA medic made a great points about life and death, and Tim is wrong because most elective surgeries now use adjunct airways other then an ET tube ( LMA etc and many more are on the way), DIRECTLY BECAUSE OF THE COMPILATIONS from Intubations. In over 50% of all procedures requiring sedation the airway is managed by something other than an ET tube.

    To have it done it while sedated, well I know most systems view us as replaceable, but this idea takes it a little too far…

    Should we who have to preform a critical skill have regular assessments and training? ABSOLUTELY

    Should we risk the well being of a coworker to sharpen or WORSE PROVE OR DISPROVE those skills? That’s just plain stupid.

    If this was a post to get a discussion going, great. However is you actually BELIEVE this is a practice due serious consideration, time to hang up your stethoscope, you’ve lost your ability for critical reasoning.

  10. Regarding your idea that we intubate each other, yes VIRGINIA that is INSANE (and no there is no Sanity-clause),

    You keep referring to “Trust” as if that is a data point that needs to be considered.

    May I remind you here that this is not a breakout session in a conference where we try to fall into each others arms. Intubation is a skill that is not without consequences even when properly done.

    Drastic & PA medic made a great points about life and death, and Tim is wrong because most elective surgeries now use adjunct airways other then an ET tube ( LMA etc and many more are on the way), DIRECTLY BECAUSE OF THE COMPILATIONS from Intubations. In over 50% of all procedures requiring sedation the airway is managed by something other than an ET tube.

    To have it done it while sedated, well I know most systems view us as replaceable, but this idea takes it a little too far…

    Should we who have to preform a critical skill have regular assessments and training? ABSOLUTELY

    Should we risk the well being of a coworker to sharpen or WORSE PROVE OR DISPROVE those skills? That’s just plain stupid.

    If this was a post to get a discussion going, great. However is you actually BELIEVE this is a practice due serious consideration, time to hang up your stethoscope, you’ve lost your ability for critical reasoning.

  11. I am curious from a skill development, retention, and performance stand point if it would be better to do 12 consecutive co-worker intubations in one month or one intubation per month.

    My hypothesis is that skill development, retention, and performance will be greater for paramedics that do 12 intubations in one day compared to paramedics that do 1 intubation on 12 different days.

    Any suggestions on recruiting the control group and the study group?

  12. Worst. Idea. Ever.

  13. This is fucking retarded. I can’t believe you actually posted this, much less that you actually got positive responses. Just stupid.

Trackbacks

  1. [...] Every medic with intubation as a skill shall intubate, and be intubated by, another medic EVERY MONT… [...]

  2. [...] If We Were Really Serious About Intubation Quality If We Were Really Serious About Intubation Quality – we would require that each medic be intubated by a different medic at least once a month. [...]

  3. [...] response to If We Were Really Serious About Intubation Quality, PA_Medic writes – I’m getting really bored of your anti-intubation [...]

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