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

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Comments from drastic on Intubation Improvement

In If We Were Really Serious About Intubation Quality, I wrote –
 

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.

 

In response, drastic wrote a few comments.
 

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!

 

People are intubated for elective procedures in controlled settings, so I do not accept the life or death requirement. There are several videos of awake intubation for, demonstration purposes, available.[1],[2]
 

[youtube]bDRTzmuwMnQ[/youtube]
 

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

 

We can always discuss other possibilities. What is most important is that we eliminate the routine poor mangement of airways that is so common in so many places.
 

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.

 

In the US, we tend to have a view that more medics are better, but let me rephrase that –

Less experience is better.

We have some places where half a dozen US paramedics will show up to treat a single uncomplicated patient.

US paramedic is the equivalent title to the Australian MICA paramedic, but usually without the equivalent experience, probably without the equivalent education, yet still with the authorization to intubate. In intubation studies, US paramedics have success rates that vary from 52%[3] to 95.5%.[4]

The highest success rates are in tiered response systems, not in the everybody on the truck is a medic systems.
 

I responded with a request for information about success rates and drastic replied with –
 

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

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

 

While we expect that flight crews will have excellent intubation success rates, that is not always the case[5]
 

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

 

This is the paper I began to write about on Thursday.[6],[7] I was fortunate in being able to obtain a copy from drastic. Thank you.

This is a study of some excellent intubation by ground paramedics using RSI (Rapid Sequence Induction/Intubation) and deserves a lot of attention. 97% success rates. Zero unrecognized esophageal intubations. Zero crichothyrotomies. I will be writing a lot more about this.

What are they doing right that so many others are not (based on published studies)?
 

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 would love to see that paper, when it is available.
 

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.

 

If we have an unacceptably high rate of infection, then we need to fix the infection rate, not hope that there is no evidence of infection until after the patient is in the ICU.

If hypoxia is a problem during a stable intubation in a controlled environment, then maybe we should not permit intubation on sick people in far less controlled environments. Ditto trauma.

I do not see ethics as a problem. We treat patients with things that have absolutely no evidence of benefit, but we claim that we cannot study them also because of ethics. I wonder if there are people in medicine who understand 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?

 

The study in footnote [1] is the study that shows the worst numbers I have seen, both ground crew and flight crew success rates, but there are plenty of other studies. The studies showing high success rates are the ones that are hard to find.
 

I should add, that while I am opposed to you in this particular facet, I agree completely with your attitude. Skills maintenance is so important and it is our responsibility to ensure that we are competent at the skills we claim to hold.

 

I think that there are a lot of people with a similar attitude. They think that my suggestion is too aggressive, but they do realize that it is our responsibility (as well as the responsibility of our medical directors and QA/QI/CYA departments) to provide the highest quality intubation practical.

Footnotes:

[1] EMCrit Podcast 18 – The Infamous Awake Intubation Video
EMCrit
January 27, 2010
Article and video

[2] Awake Endotracheal Intubation
Dr. Michael Bailin
YouTube

[3] Prehospital intubations and mortality: a level 1 trauma center perspective.
Cobas MA, De la Peña MA, Manning R, Candiotti K, Varon AJ.
Anesth Analg. 2009 Aug;109(2):489-93.
PMID: 19608824 [PubMed – indexed for MEDLINE]

Of the 88 patients who were transported by ground, 46 (52%) were successfully intubated in the prehospital setting and 42 (48%) had a failed PHI (PreHospital Intubation)

[4] Prehospital use of succinylcholine: a 20-year review.
Wayne MA, Friedland E.
Prehosp Emerg Care. 1999 Apr-Jun;3(2):107-9.
PMID: 10225641 [PubMed – indexed for MEDLINE]

Results
Paramedics successfully intubated 95.5% (1,582) of all patients receiving succinylcholine, 94% (1,045) of trauma patients, and 98% (538) of medical patients. They were unable to intubate 4.5% (74) of the patients. All of these were successfully managed by alternative methods. Unrecognized esophageal intubation occurred in six (0.3%) patients. The addition of capnography and a tube aspiration device, in 1990, decreased the incidence of esophageal intubations.

[5] Prehospital intubations and mortality: a level 1 trauma center perspective.
The same as footnote [1] above.

Of the 203 patients, 115 (57%) were transported by air, and within that group, 94 (82%) were properly intubated in the field, and 21(18%) were not. Of the 88 patients who were transported by ground, 46 (52%) were successfully intubated in the prehospital setting and 42 (48%) had a failed PHI (P < 0.001 compared with patients transported by air).

Even though the flight crew success rate was dramatically better than the ground EMS intubation success rate, it is still unacceptably low. What is the difference between the flight crews with 82% intubation success and the ground crews with 95+% intubation success or the flight crews with 95+% intubation success?

[6] Prehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury: a randomized controlled trial.
Bernard SA, Nguyen V, Cameron P, Masci K, Fitzgerald M, Cooper DJ, Walker T, Std BP, Myles P, Murray L, David, Taylor, Smith K, Patrick I, Edington J, Bacon A, Rosenfeld JV, Judson R.
Ann Surg. 2010 Dec;252(6):959-65.
PMID: 21107105 [PubMed – indexed for MEDLINE]

[7] Prehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury – Summary
Rogue Medic
Article

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