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

- Rogue Medic

Intubation as a Right – No Practice required

Also posted over at Paramedicine 101. Go check out the rest of what is there.

I was responding to a comment at 9-ECHO-1, by 9-ECHO-1, when I realized I was beginning to combine my responses to How things get done… and Do we make a difference?

As if I don’t already regularly get this little message from Blogger.

Your HTML cannot be accepted: Must be at most 4,096 characters

Your hints are wasted on me, Blogger!

9-ECHO-1 was writing about running a code and keeping it organized and low stress. Something about sitting back with his feet on an ottoman, a drink in his hand, receiving a massage, and . . . Well, he did say that he was sitting back with his feet up on an ottoman. And there is nothing wrong with that. An ottoman could easily be added to crash carts. 🙂

9-ECHO-1’s description of the role of the person in charge at a code is important. We may not want to put our feet up in front of family, but I don’t believe 9-ECHO-1 would do that at a code where family is present. What is important is for the person in charge to communicate clearly to everyone that, This is not a high stress environment.

Stress is the enemy of organization. We have a lot to organize during codes. We have much more to organize, than we have good research to support including in a code, but that will change.

Either there will be some research that supports the Better Resuscitation Through Better Chemistry approach, or AHA/ILCOR will admit that pouring a bunch of cardiotoxic chemicals into a patient, then shaking – not stirring – the patient, is more appropriate for bartenders than for paramedics, nurses, PAs, NPs, doctors . . . .

Although many of us in EMS might appreciate the bump in pay to what a bartender makes.

I have been to some codes that have led me to believe that there is a role for benzodiazepines in the management of cardiac arrest. Not for the patient, but for the EMS personnel exhibiting signs of Tourette syndrome, who show up to treat the cardiac arrest patient. If not benzodiazepines, then this may be an indication for medical marijuana. There might be some problem with the rate and depth of compressions, but that might be less of a problem than the current model of Dr. Fine, Dr. Howard, and Dr. Fine run a code.

Isn’t this supposed to be about intubation?

OK. Back on track, or as close as I an going to get.

9-ECHO-1 wrote –

Place the King airway. In our system EMT-Bs on the ambulance can do this. Attach the ETCO2 and verify the waveform. Me personally, I will admit, I prefer the ET tube. I know, I know, there is all sorts of evidence out there about paramedics and tubes. And they all point to two things- practice and experience. More on that later.

In the comments, I responded –

I agree with you about the intubation. I think that the biggest part of the problem is that the systems studied do not provide excellent oversight of the quality of intubation and BLS. Otherwise, are we supposed to believe that these problems suddenly appeared during the study? More likely that they were there, just unrecognized.

The word unrecognized does not belong in a sentence describing excellent oversight.

9-ECHO-1’s response included –

I have read all of the studies about intubation and its ‘failings’. What I have noticed is that we NEVER PRACTICE. I used to practice all of the time- get me some spare time and a manikin and I would go at it, even practicing with someone doing chest compressions. But we never do that any more. No damn wonder we can’t hit the right hole, and then don’t recognize when it comes out or we missed completely.

I completely agree about practice. I used to spend so much time with the mannequin, that if my classmates weren’t starting rumors about me, they were missing a good opportunity.

I believe that simulations are a great way to avoid doing real harm to real patients. A lot of practice helps to keep the stress level down and the tunnel vision away.

My first live intubation was an asystolic little old lady. We were running lights and sirens to the hospital, because we didn’t know any better. I was riding with a supervisor for orientation vs. see if the new guy can avoid screwing up. We made a rendez-vous with the ambulance, so that they could give the new guy a chance to demonstrate skills on a real live patient.

We still put too much emphasis on the wrong skills.

While the mannequin is not as realistic as we would like, the practice with the laryngoscope and the tube is invaluable, when it comes to manipulating the airway of a real patient. Very handy experience when bouncing down the road about to perform my first tube.

I think that some of my But we did that when we covered airway classmates may be over-represented in the intubation studies with poor success rates/high wrong hole rates.

If medical directors would take more of an interest in the airway management practices of those they authorize to use lethal airways, I might not feel the need to describe endotracheal tubes as lethal airways.

Yearly (even quarterly) observation of mannequin management is not at all oversight of airway management. This is just documentation of an excuse, so that when a medic does mangle airway management, the medical director has an alibi.

It used to be that some schools/employers required medic students/new medics to manage an OR patient’s airway with a BVM before ever being allowed to touch an endotracheal tube. I do not believe in good old days. That is just selective memory. However, we have abandoned some useful practices.

Now it seems that being authorized to intubate means never having to touch a BVM again – even in some all medic systems.

That isn’t airway management.

Also, less than 8 – intubate, is not a rule, just a handy way of teaching one small idea in the much larger concept of airway management. Critical judgment is much more important than cute little rhymes.

If we think that we should be permitted to intubate, we need to put in the effort to become competent at airway management. Then we need to put in the effort to maintain competence at airway management. And we need to put in the effort to demonstrate excellence at airway management. Intubation is a very small part of airway management.

This is not about any right of the paramedic to intubate. This is about not abusing our patients.

I didn’t even get to comments on Do we make a difference? That will be another post.

The Airway Continuum is essential reading for anyone interested in intubation and airway management.