In response to If We Were Really Serious About Intubation Quality, PA_Medic writes –
I’m getting really bored of your anti-intubation posts.
If you are bored, then don’t read my blog. Go be coddled elsewhere.
My posts are not anti-intubation posts.
My posts are criticism of bad intubation.
Why do you defend bad intubation?
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.
Intubation is more complex than OK/Not OK. Patient care is more complex than OK/Not OK.
You really do not appear to see intubation as a complex treatment with many side effects – all of which can affect the patient.
Airway management is more complex than just intubation and OK/Not OK.
Show me the data that suggest that any CHF or respiratory arrest patient benefits from bad intubation.
Show me data that says a BVM keeps vomit out of the lungs with a decreased LOC.
Where is the data that says that incompetent intubation keeps vomit out of the lungs with a decreased LOC (Level Of Consciousness)?
If you work in Pennsylvania, then you are not limited to intubation or BVM. This is one of the benefits of looking at all of airway management, not just whether the tube is in AHole or in BHole.
You seem to be concerned that you might be intubated by someone who is dangerous with a laryngoscope. You don’t seem to care that these medics are harming patients, but when it comes to harming you, that is where you draw the line.
This is not about your patients.
This is about your ego.
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.
Even in the hospital, the doctors who understand resuscitation are using extraglottic airways.
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.
You criticize me for writing the same thing. 😕
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
I don’t know the answer to your question, but the anesthesiologists I know do need to regularly demonstrate competence in many areas of airway management.
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?
That is not what anesthesiologists do.
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?
These are procedures with a very wide range of indications and varying degrees of complications.
Tracheotomy is not in my scope of practice, and if you are a Pennsylvania medic, it is also not in your scope of practice. Crichothyrotomy is only indicated for a can’t intubate/can’t ventilate situation. The complication rate is high. Crichothyrotomy is not like intubation, in a can’t intubate/can’t ventilate situation, the alternative is death. With intubation, there are many alternatives.
There is research on crichothyrotomies that I will address in later posts.
Needle decompression is performed so poorly that there is a need to teach medics how to actually get the needle into the lung.
I wrote about this problem in –
Click on the image to make it larger.
From this study we cannot tell if the number that should be in the place of the double question marks is 42. Maybe it is 32. Maybe it is 22. Maybe it is 12. Maybe it is 2. Maybe it is zero. We don’t know and this study cannot tell us, which is not a fault of the study.
The same problem exists for trying to figure out the number that should be in the place of the single question mark.
We know that of the patients treated for claimed tension pneumothorax, 26% were treated by paramedics so poorly that the needle never even made it to the lung.
Should we assume that all of the patients treated with needles that actually reached the lung did have tension pneumothoraces?
There is nothing in this paper to suggest that.
EJs (External Jugular IVs) are rarely used in EMS outside of cardiac arrest and do not appear to offer much benefit over a peripheral IV.
Intubation is something I would want to observe you practicing repeatedly on a mannequin before deciding whether to allow you to intubate me. This is something that would teach paramedics a lot about the many complications other than your overly simplistic right hole/wrong hole assessment of success.
He was hypoxic, his oropharynx is cut up, he has some vocal cord trauma, there is also some tracheal necrosis due to overinflation of the cuff that was not even lubricated, but the tube is in the right place and we all know that the tube location at the time of transfer is the only thing that matters.
There are a lot of medics who should not be allowed to intubate. This is just one way of identifying them, because the results of the studies on actual patients make it clear that we do not get rid of these dangerous medics.
The King LT is similar to intubation.
Go ahead and use the transcutaneous pacemaker on me. I have had medics pace me to gain experience with the transcutaneous pacemaker. Pacing is another skill that is poorly performed by EMS as well as by nurses and by doctors. Medics are not well trained to assess for transcutaneous pacemaker capture. Medics often do not understand the difference between electrical capture and mechanical capture.
It seems that most often the transcutaneous pacemaker works by producing painful stimulus. Too many people use the sternal rub as a painful stimulus. The sternal rub is one of the mythical procedures so common in EMS. If the patient woke up to a sternal rub, I do not see any reason to consider that as anything other than eyes open to voice.
While we are using treatments on medics, where is my dose of fentanyl? What about Versed?
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.
Research shows that medics do not do this well.
Still you defend those who cannot competently deliver patient care.
Why?
What is it about incompetence that inspires you to defend dangerous medics?
After years of working in the ER and EMS I have seen many ER attendings and residents miss tubes.
I have seen the same thing.
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.
The only patient I have seen die that probably was due to physician airway mismanagement was an asthmatic infant who died the next day.
I have seen a crichothyrotomy due to inability to intubate, although I don’t think there was an inability to ventilate, but I was not attempting ventilation on that patient.
There are plenty of non-EMS people who are bad at intubation. How does that excuse EMS incompetence?
Your defense appears to be –
I am dangerous, but others are even more dangerous, therefore I should be allowed to continue being dangerous.
That is a bogus argument.
You are making an argument for completely banning intubation.
I have not argued that intubation should be banned, but that we need to remediate those who can be remediated and eliminate those who cannot be remediated.
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.
Nobody is perfect, so if I don’t practice and if I complain about high standards, everybody will let me get away with this. Waaa!
That is the problem.
This appears to be a threat to your ego.
You do not appear to care about your patients.
You only seem to care about someone assessing your competence.
You don’t seem think that you are up to it.
Why is extra practice an insult?
Extra practice is good for us and good for our patients.
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 paramedicine in every post.
You have not read much of my blog.
I do write about improving EMS.
I don’t write to make excuses for incompetent EMS.
If you want excuses for incompetent EMS, go elsewhere.
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 a blog about war stories, there are some excellent ones out there, but war stories is not what I do.
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.
I do write to help move EMS forward, but I am often opposed by those devoted to staying in/returning to the Dark Ages.
You do not seem to be able to recognize that –
When I write about having medics think, I am promoting better EMS.
When I write about medics using judgment in the administration of opioids, sedatives, nitrates, calcium, and others, I am promoting better EMS.
When I write about the recklessness and irresponsibility of on line medical command permission requirements, I am promoting better EMS.
When I write about the things that we need to do better, such as intubation, I am promoting better EMS.
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.
Thank you for making my point that your comment is just about your ego.
To be continued later (with responses to other comments) in Part II and probably in a Part III.
SWG42EUNJUGZ
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Rogue,
We keep looking for studies to show good and keep providing studies that prove bad intubation stats for medics; I have an observation formulated into a question.
Have you or some of the other readers ever been part of or witnessed a field paramedic intubation go through the ED doors that was misplaced? – lets not get picky if it went a little too deep.
Are we (paramedics) really “that bad”? Or are we being made out to be “that bad”?
I personally have never witnessed an unrecognized misplaced tube go through the ER doors. This is just in my experience anyways. If the ETT attempt went south or a tube went misplaced it was always quickly recognized and we would correct the problem or then happily go to the transglottic airways or supraglottic back-ups.
I also don’t think field intubations are in any way comparable to the mass majority of hospital/surgical intubations. It should go without saying that a spinal injured patient or an airway full of blood, vomit and foreign bodies complicate the paramedic intubation nearly every time. The only thing they (anesthesiology) logically have going for them is muscle memory. This could be obtained by anyone with relentless practice on even a manikin. In my area the ER docs commonly will look to the paramedic as their back up, those without too big of and EGO.
I am never against having a procedure done to me that I would do to a patient. I just want to be dying for it to happen.
The hospital is allowed (not all medics are) the proper medications proper positioning and the environment for better success rates. The hospital also has more sophisticated expensive tools than any laryngoscope,
Should I give them an intubation cookie?
Are our judgments really accurate?
I personally dont think that Intubation is rocket science, what’s the deal? You might be onto something with the EGO comment
Chris,
I have seen doctors check the placement of the tube and state that they are just repositioning the tube as they reintubate.
I also know some medics who would only get the tube between the cords if they were told that is wrong place to put the tube.
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I think that too many of us are that bad.
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When even an excellent system like Bellingham County added waveform capnography, their unrecognized intubation rate dropped. The only case they had after requiring the use of waveform capnography was when a medic decided that he/she was too good to use the waveform capnography (or forgot or whatever other excuse was used by the medic at the time).
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That is the story that a lot of medics tell, but if the cases are reviewed, these turn out to be a minority of intubations.
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Intubating thousands of patients produces only muscle memory in anesthesiologists, but intubating dozens of patients produces excellence in paramedics?
Anesthesiologists also deal with far more patients with difficult airways than EMS does. The location is not the only thing that makes an airway difficult. Ditto vomit, blood, and immobilization.
If the location is the problem, move the patient, rather than miss the tube.
If blood/vomit is the problem, suction the airway, rather than miss the tube.
Then there is the obvious – if these do not work, use an extraglottic airway.
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Muscle memory is important. Medics ignore this and patients suffer.
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Many hospitals may discourage this out of liability concerns, but there is probably some ego involved as well.
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Maybe that should be the case for patients, too.
We should only do things to patients if the patients are dying.
Since very few of our patients are dying, this would cut back dramatically on procedures performed by medics. No more IV Life Line to pull the patient back from the Jaws of Death.
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Maybe you should intubate in a hospital.
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Often our judgments are not accurate.
Often our observations are not accurate.
This is why we set up controlled studies to minimize the effect of our biases on the results.
This is how we know that so many tubes are placed in the esophagus. If we asked medics if they ever screw up, the results would be unrecognizably different.
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A lot of medics agree with you. They do not practice, because they assume they are God’s Gift to Intubation and that practice is for those beneath them.
As long as there are medics with that attitude, there will be studies showing horrible success rate, double digit unrecognized esophageal intubation rates, and plenty of other complications of intubation.
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When we assume that we know something, rather than actually finding out the truth, we become dangerous. That is ego/bias/ignorance all combining to hurt our patients.
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Rogue,
o I have seen doctors check the placement of the tube and state that they are just repositioning the tube as they reintubate.
This almost sounds like a resident who needed his “recommended” intubations.
Was the tube actually misplaced, you didn’t say?
So if this is correct, in your vast experience You have never seen a misplaced tube go into the ED doors? No one I know including myself ever has just as an observation.
I have seen “docs” reintubate when the tube is CORRECTLY placed. Based on my experience with docs “reintubating” I’m back to wondering if EGO is a possible contributing factor to these poor numbers. I don’t think there is a doc/EMS conspiracy- but I’m just saying.
o I also know some medics who would only get the tube between the cords if they were told that is wrong place to put the tube.
I think these are the medics you are ACTUALLY talking about. These are the medics that need to be remediated or stopped all together from doing the procedure.
o Intubating thousands of patients produces only muscle memory in anesthesiologists, but intubating dozens of patients produces excellence in paramedics?
There are many advantages to seeing that many airways no doubt. The word ONLY should not have been used here. I will not elaborate, that was my bad.
I think if paramedics did 1000 ETTs they would be just as good as anyone who does 1000 ETT. As of currently Paramedics are EXPECTED to be as good as an anesthesiologist with the allotted “12” you suggest. Discounting muscle memory time on a manikin of course.
o We should only do things to them if they are dying.
Treat patients ONLY if they are dying? What about preventing death and further injury, risk vs. gain? Maybe I am misunderstanding or perhaps ONLY does not work here either.
o Maybe you should intubate in a hospital.
This is obviously NOT my intension. If ETT was a puzzle and pieces were missing, how can I be expected to produce a complete puzzle every time or even at all?
Maybe if you want to RSI you should get your CRNA Had to get a little defensive, it’s fun. Don’t eat me.
o A lot of medics agree with you. They do not practice, because they assume they are God’s Gift to Intubation.
• Confidence is knowing you can handle most of what a call will throw at you and the knowledge of when to call for help when you need to.
Cockiness is falsely believing you know everything.
-Dan Limmer
Muscle memory/reputation even with a manikin is a start, experience is few and far between. I work to be the best I can at all times getting practice through teaching and personal interest. I think you bit me a little on this one. So please don’t take what I said the wrong way. By “Not rocket science” All I mean is ETT shouldn’t be so difficult in that tubes shouldn’t be going unrecognized when misplaced. Most of us are good at what we do and know how to recognize a misplaced tube, capnography seals the deal so we can now prove it.
Maybe we as a profession we should let up on the aggressive ETT procedures due to some of these newer airways (KING) and ETT complications (risk vs. gain). This is being implemented already in ACLS 2010 AHA guidelines suggesting BLS airways and Kings airways prior to consideration of placing ETT. I know not so many years ago this would have been pretty much the first priority.
Chris,
Attendings, not residents.
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I don’t know. The patients weren’t mine.
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I have never misplaced a tube, that I know of, and gone into the ED with it.
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How would a medic know if the tube was in the wrong place if the medic leaves the tube in the esophagus assuming that the tube is in the trachea?
It appears to me that the attendings were going out of their way to protect the egos of the medics who misplaced tubes in the esophagus by pretending that the placement was just being adjusted.
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And people keep telling me that they do not exist.
The research shows that they are producing a lot of unrecognized esophageal intubations.
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If paramedics had more experience, paramedics would be better at intubation?
Never discount muscle memory time on a mannequin. Mannequin practice is ignored by too many paramedics at the expense of the patients.
There are many things we can do with mannequins that we cannot do with real patients. Not taking advantage of this is one of the big mistakes that most medics make.
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You stated – I am never against having a procedure done to me that I would do to a patient. I just want to be dying for it to happen.
If you are opposed to having paramedic procedures should be done to you if you are not dying, then we should probably consider that the procedures are too risky for a patient who is not dying.
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Are you claiming that there really are a lot of unrecognized esophageal intubations, but that it is understandable with the inability to use RSI and video laryngoscopy?
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Plenty of people tell me that if I want to do things that are within the paramedic scope of practice in many places, sometimes even where I work, without engaging in the fraud of medical command permission requirements, I should become a doctor. How is this different?
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There appear to be a lot of cocky medics placing unrecognized esophageal tubes.
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I agree with you.
I see medics and doctors spend way too much time trying to prove that esophageal tubes aren’t in the esophagus.
We all place tubes in the esophagus at some point. The difference between competent and killer is in quickly recognizing that the tube is in the wrong place.
Signs of incompetence –
Listening to the lungs before listening to the belly.
Not using waveform capnography immediately.
Ignoring signs of a misplaced tube and looking for something to contradict those indications of a misplaced tube.
There are plenty of others.
We are experts at deceiving ourselves. We deceive ourselves much more often than we realize.
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I disagree about being good at recognizing a misplaced tube. I have seen medics and doctors delay pulling obvious misplaced tubes, because they were trying to find some sort of evidence that the obvious esophageal tube was not in the esophagus, rather than pulling the tube and treating the iatrogenic hypoxia.
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I agree. We need to put the patient first.
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Great conversation and insight. Thank You
Chris,
Thank you, too.
It is only by considering/discussing/trying the options available to us, that we will find what works and improve.
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<quoteMy posts are not anti-intubation posts.
My posts are criticism of bad intubation.
This song is not a rebel song……
oops, typo
<quoteMy posts are not anti-intubation posts.
My posts are criticism of bad intubation.
This song is not a rebel song……
vince,
I don’t think that anyone is intentionally defending bad intubation.
I do think that there is a lot of disagreement about what bad intubation is.
Bad intubation is a lot more than just putting the tube in the wrong hole.
Similarly, horrible intubation is a lot more than just unrecognized esophageal intubation (leaving the tube in the wrong hole).
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1. Ego? Really? Do you really think medics intubate due to ego?
2. Do you think people that read your blog support incompetence in EMS?
Intubation is more complex than OK/Not OK. Patient care is more complex than OK/Not OK.
Deciding to intubate is complex due to risks short term and long term. The procedure shouldn’t be.
Show me the data that suggest that any CHF or respiratory arrest patient benefits from bad intubation.
I believe that’s called death. They should benefit from correct intubation.
Research shows that medics do not do this well.
No, research shows that some medics do not do this well.
You have not read much of my blog.
I’ve read every post since you started.
Even in the hospital, the doctors who understand resuscitation are using extraglottic airways.
Yes, and I have seen those fail to secure an airway pre-hospital and in-hospital.
If the patient woke up to a sternal rub, I do not see any reason to consider that as anything other than eyes open to voice.
Your kidding me right? Your going to discount AVPU now? When was the last time you picked up an ETOH overdose? Maybe yelling in the ear from one inch away = painful stimuli.
Tracheotomy is not in my scope of practice.
That was my mistake. I mistyped. Medic error. Our crich kit is a trach without a balloon. Worthless argument.
EJs (External Jugular IVs) are rarely used in EMS outside of cardiac arrest and do not appear to offer much benefit over a peripheral IV.
Really? Come deal with the diabetics and hypovolemic shootings/stabbings in my local. IV’s are nice if you can get it or they have limbs. IO’s are nice as well.
Why is extra practice an insult?
Did I ever say that? I encourage it!!!
Signs of incompetence –
Listening to the lungs before listening to the belly.
I don’t know how you were taught to intubate but I confirm lung sounds while using the BVM before intubation. After placing the tube, sometimes blind or with a Bougie, I hook up the end tidal and listen to the L lung and compare it to what I heard while using the BVM. If I hear no sound I listen to the belly quickly. If absent I listen to the R lung comparing it to what I heard before assuming I’m to deep. With all breaths I’m watching the belly for expansion. If I can only hear sounds in the right then I am to deep. Reposition and start back from L lung to R lung to belly. 8-10 seconds max.
Reality is there are bad apples in every profession. My wife has saved more patients as a nurse due to bad MD orders then most hospitals want to know. It’s not placing blame or supporting incompetence. It’s reality. There are medics that suck. Period. Show me any job that doesn’t have 5-10 percent of people getting fired due to incompetence or laziness. Unfortunately our mistakes can kill.
I get mad when one subject like intubation gets targeted because it’s an easy target.
Apathy hurts more patients in our profession then intubation ever will!!!
Wanna meet at Brothers for a slice and a beer for a real conversation?
You listen over the epigastrium before the lung fields to minimize bias. Then you go left side, then right side. The goal of auscultation is to catch errors early, and the order is specific to reduce bias. With end-tidal attached during intubation (best practice) auscultation over the epigastrium will help limit insufflation.