Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

In Defense of Intubation Incompetence – Part II

In response to In Defense of Intubation Incompetence – Part I, there is the following from PA_Medic, which results in this being Part II.
 

1. Ego? Really? Do you really think medics intubate due to ego?

 

I think that medics defend the right to intubate due to ego.

I think that a lot of medics intubate when they should not due to many other reasons – inexperience, ignorance, poor assessment, and the myths that have been passed on by bad instructors.
 

2. Do you think people that read your blog support incompetence in EMS?

 

I think that people with all sorts of opinions will read my blog. Some will read what I write and agree with me. Some will read what I write and rant and rave about how stupid I am. I expect that most will be somewhere in the middle. I have not taken a poll.
 

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.

 

The decision to intubate is often much more complicated[1] than the intubation.

Intubations can become complicated.

Did the medic position the patient well prior to the attempt?

Did the medic assess the patient well prior to the attempt?

Not anticipating a difficult airway.

Not having several back-up plans.

Not being able to deal with problems that inevitably arise when we intubate more than a handful of patients.

Anyone can be taught to intubate, but that does not mean that the person is competent to decide when intubation is appropriate. We do not spend enough time on either ability.
 

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.

 

That is exactly the point.

There is no reason to believe that any patient benefits from incompetent attempts at intubation.

I explained this to Too Old To Work, Too Young To Retire in an earlier discussion.[2] He my idea of medics intubating medics is superlative.[3]
 

Research shows that medics do not do this well.

No, research shows that some medics do not do this well.

 

This is true. That is why I am trying to raise the standards for paramedics, so that these dangerous medics can explore more appropriate career options.

This was not a study by people trying to discredit medics, but by medical directors trying to find out if their medics had a problem with intubation.[4]

When we don’t keep track of what we do, we may find out that it is not as good as we thought.

I can understand why anyone would be reluctant to be intubated by a paramedic – especially someone who works with someone, or more than one someone, who cannot intubate well.

The graph just shows the right place/wrong place rate of 3/1, but the graph does not tell us anything about complications of the intubation attempts.
 

You have not read much of my blog.

I’ve read every post since you started.

 

I thought I was the only one.

If you’ve read every post since I started, how do you come to the conclusion that I discount paramedicine in every post?

My goal is to stop paramedics/medical directors from doing things that are bad for patients and to encourage them to do things that are better for patients.

I strongly encourage more aggressive use of treatments that work – without any medical command permission requirements.

The flip side of this is that we do need to eliminate the treatments that harm patients and/or the people who harm patients.

We cannot be aggressive and be dangerous and still be competent.
 

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.

 

That is one of the reasons we have many options. There is no one airway that is right for everything, not even the endotracheal tube.

When the most common reason for the prehospital use of an extraglottic airway is a failed intubation, is the failure of an extraglottic airway in the same patient any worse than the failure of the endotracheal tube?

When the most common reason for the prehospital use of an extraglottic airway is a failed intubation, is the failure of an extraglottic airway in the hands of the same medic the fault of the extraglottic airway?

To be continued later in Part III.

Footnotes:

[1] complex vs. complicated
Wordwizard.com
dante
Article

The distinction may not be important to most people, but this is one of the things that is important about intubation. The steps that should be taken to properly intubate a patient are complex (it can be broken down into a series of many steps), figuring out what is going wrong with an intubation, when the standard intubation becomes non-standard is complicated. Deciding to intubate, or to use some other means of managing the airway, is complicated. We can try to break it down into steps, flow charts, algorithms, et cetera, but this requires understanding of many different factors.

Why did I use complex, rather than complicated? I don’t know. As Kathry Schulz states in Being Wrong about what it feels like to be wrong – It does feel like something to be wrong; it feels like being right. I don’t know why I made that mistake, but at the time, I appear to have thought that I was right.

[2] Comment on Intubation from TOTWTYTR
Rogue Medic
Article

[3] Grand Prize Dumb Idea
Too Old To Work, Too Young To Retire
Article

[4] Misplaced endotracheal tubes by paramedics in an urban emergency medical services system.
Katz SH, Falk JL.
Ann Emerg Med. 2001 Jan;37(1):32-7.
PMID: 11145768 [PubMed – indexed for MEDLINE]

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