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

- Rogue Medic

Experts Debate Paramedic Intubation – Comment from TOTWTYTR

In the comments to Experts Debate Paramedic Intubation – JEMS.com, there is the following comment from Too Old To Work, Too Young To Retire.

Keep in mind that it is possible for the ETCO2 to malfunction and the tube to be good.

Absolutely.

This is why competently trained people are essential. The clowns in the article seem to have just decided that the negative feedback they were receiving was wrong.

Maybe they just didn’t want any negative feedback.

Maybe they just can’t deal with conflicting information.

Maybe they are just not competent.

Maybe all three.

Too bad they can’t just ignore the negative feedback with patient outcomes.

Conflicting information should lead us to seek out even more information.

Conflicting information should lead us to doubt our assessments.

Conflicting information should lead us to decide that we are wrong, rather than to decide that we are right.

If I am not comfortable that the tube is in, the tube comes out. I can try again or I can use another method of ventilation, and probably BVM ventilation between attempts.

According to the article, they made no reasonable attempt to verify placement by other means, except lung sounds. This suggests a very broad range of lack of skill – auscultation, intubation, and critical judgment.

There are so many forms of tube confirmation that are available that unrecognized esophageal intubation should not happen – even without waveform capnography.

One way to confirm if the attachment is working is to blow through it before connecting it to the tube, or after connecting it to the tube, if you feel that the attachment is not working. You don’t need to put your mouth on it to get a reading. Another possibility is to just change the attachment.

I’ve been using Capnography for about 10 years now, and have had a few instances where the sampling line became contaminated and therefore useless.

Yes. This is not unusual when a patient vomits. Or it can be damaged inside the packaging. Or someone can step on it. Or the line can kink. There are many ways for the equipment to fail.

We should always carry several spares for this anticipated complication.

It is also possible, but rare, to have a false positive. I had one. The capnography waveform and numbers were good, but the other assessments contradicted the capnography. The only responsible thing to do was to pull the tube.

That is exactly what this medic should have done. If the equipment is faulty, I can reintubate. Unless I have an extremely good reason to believe that the equipment is faulty, that tube is coming out.

In those cases I’ve had the second medic (another reason to operate with two medics per ambulance) listen to confirm my placement.

I have never had a problem listening to lung sounds, assessing chest rise vs. abdominal rise, attaching waveform capnography, et cetera with a basic EMT assisting me.

I don’t even see a need for an experienced medic to have any assistance while intubating. Yes, things go much more smoothly, when I have assistance, but things do not always happen as planned. If they did, we would not have jobs.

We also carry a second sampling line for cases like this.

You never have 2 patients in a row in need of intubation? Or do you restock at the hospital.

BTW, I always listen over the abdomen first, before I listen over the lungs. That way if the tube is in the esophagus, I’ll hear it before several breaths go into the stomach.

I agree. I have had many arguments with people who defend listening to either lung first. They do not understand airway management and they are prone to overestimation of their own abilities. Both of which can be lethal.

In practice, the listen to the lungs first people will usually go back and forth between the lungs several times before they listen over the stomach. That is assuming that they ever get to the stomach before the patient produces a fountain of emesis in the tube.

Much better for the patient to just start by looking for evidence that the tube is in the wrong place. That is the responsible thing to do.

They also teach other people this form of bad judgment.

They can argue to the death about it – the patient’s death.

It’s a matter of training, education, and experience. The problem seems to be that too many medics are trained, not educated, and have little experience because they work in systems with a plethora of paramedics and dearth of patients needing intubation. Which results in a very low paramedic to intubation ratio, which makes the likelihood of undetected error higher.

All are important problems that we need to try to eliminate from EMS.

However, these practices are defended by many. Often they are defended by those with the power to change them.

If medics are not getting enough experience, we need to either limit the skill they are not getting experience with, limit the medics, or both.

Having more, but less skilled, paramedics is a bad idea.

Skill dilution can only be prevented with a lot of practice. In systems with high concentrations of medics, that means taking medics off of the street for significant periods of time to maintain skills.

Having medics use critical judgment, rather than calling and asking for permission to do something that they are trained to do based on assessments they are also trained to do. This is considered bad by some people. There is no evidence to support requirements for medical command permission. We have progressed from having to call even for oxygen and IVs to some places having no medical command permission requirements, but some people persist in promoting this interruption and delay of patient care.

Similarly, there are many people who seem to think that medics do not need to maintain their skill. As if meeting the minimum number of continuing education hours and remaining current in the alphabet courses means that a paramedic is competent.

Absentee medical directors act as if they believe this.

If we were to look at the record of every unrecognized esophageal intubation, I would bet that almost all of the medics/nurses/doctors who placed those unrecognized esophageal tubes have met those minimum requirements. Probably over 90% would be my guess.

Minimum requirements did not prevent this incompetence.

Original education training did not prevent this incompetence.

Continuing education training did not prevent this incompetence.

Alphabet courses did not prevent incompetence.

A medical director’s signature did not prevent incompetence. The medical director’s signature is one thing that is needed for this kind of incompetence.

All of the above are probably needed for this incompetence. Again, my guess is over 90% of the time these actions to prevent incompetence will have been satisfied by the person behaving incompetently.

So, why do we act as if these are in any way going to prevent incompetence?

We are using the wrong criteria for competence.

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