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

- Rogue Medic

The Real Gold Standard Of Airway Management at 510Medic

510Medic has a nice post about The Real Gold Standard Of Airway Management.

The way he started out, I expected a riff on Nixon taking us off the Gold Standard – $35 an ounce due to price control then – now just under $1,300 an ounce. Last week, there was this – Gold Bet: $2500 Over/Under 2012. Even I am not cynical enough to take the over on that.

The Gold Standard 510Medic is writing about should be just as dead as the monetary gold standard.

There are some similarities. Both are inflexible and artificial limitations on change.

The idea that intubation is a gold standard only demonstrates an inability to adapt to what is best for the patient.

The gold standard is supposed to mean what is best for the patient, but does it?

In the emergency department, cardiac arrest patients are only intubated in the old fashioned Bretton Woods style of treatment. I expect the new guidelines to continue to de-emphasize intubation as a method of airway management.

In the operating room, intubation has become much less common.

If the emergency physicians and anesthesiologists are switching to more appropriate airway management methods, why isn’t EMS?

Because we are EMS. It sometimes seems as if you have to kick us in the head to get us to use our heads for anything.

As with helicopter abuse, we are not doing what is best for patients.

As with restrictive protocols, we are not doing what is best for patients.

As with on line medical command permission requirements, we are not doing what is best for patients.

As with cardiac arrest drugs, we are not doing what is best for patients.

As with spinal immobilization, we are not doing what is best for patients.

As with restrictions on prehospital pain management, we are not doing what is best for patients.

Are we surprised that, when it comes to airway management, we are not doing what is best for patients?

Let’s put an end to the Gold Standard terminology.

Airway management is about Ventilation – not Intubation.


You can judge a book by its cover? – JEMS.com

In JEMS there is an article by the editor, A.J. Heightman, with the title You can judge a book by its cover.

There are several problems with this article. Here is a picture that is displayed right next to the title.

If I were to judge JEMS and LA County Fire by this cover image, I could conclude that airway management is not understood by either of them.

The hand over the face is probably to satisfy privacy requirements, but why is the NPA (NasoPharyngeal Airway) being inserted from down around the patient’s chin? Probably because this makes for a better picture, rather than as an example of the technique used by these medics. Of course, if we were to judge a book by its cover this cover picture would be inexcusable.

Picture Credit

Maybe that is not a strong enough hint.

Even better, a real person, awake, and with access to all sorts of weapons. How would you insert the NPA in that person?

Picture Credit

No dragging it along the chin in that photo.

For more on the NPA, read Steve Whitehead’s post at The EMT Spot.[1] There is still a lot to write on this subject.

The title of the post is more of a problem. He wants to judge competence by appearances. As much as I criticize the National Registry of EMTs for their inadequate testing, they do not appear to pretend that showing up in a dress uniform, nice and neat, is any kind of indication of competence.

What impressed me about the L.A. County Station 7 crews was that they cleaned and organized everything, from the tubes in their medical kits to the rims of their wheels.

Silly me. I thought that tubes should be left in their original packaging, not taken out and cleaned every shift, or is it every day (if they do not work 24s), with different crews having different responsibilities, or is it only scheduled on certain days on a rotating schedule?

A crew showing up in a nice clean ambulance and wearing neat, clean uniforms means that the crew has clean uniforms and a clean ambulance and has not yet done anything to alter that. It does not mean anything more than that.

I know too many people who spend much of their time on appearances, but ignore skills, understanding, and other things that make a difference in outcome – if the patient requires any real medical care from competent EMS personnel.

Look at the debates over intubation. Plenty of people argue that they should be allowed to intubate because it would be an insult to take intubation away from them. all they care about is appearance.

If we wish to be allowed to intubate, we should work very hard to maintain and improve our skills – and we should keep our tubes in their original packages.

I don’t know if the tubes described being cleaned include endotracheal tubes, but I do know some people who do open at least one endotracheal tube package at the beginning of a shift. They think it saves time. It probably does, but the amount of time is insignificant and using non-sterile tubes increases the chances of an infection that will make a good outcome less likely.

Another point on judging a book by its cover.

The lubricated nasopharyngeal airway did the trick, and the crews then bagged and supported his airway en route to the hospital. At Cedars-Sinai Medical Center, a team of residents and attending ED physicians intubated the patient in a cleaner, more sterile environment.

Some may argue that the patient should have been intubated on scene. That transporting the patient with only BLS airway management looks bad – makes it look like they can’t intubate. I disagree.

I am not one to encourage judging a book by its cover jumping to conclusions based on superficial, and often inaccurate, information.

We need to improve our assessments – not encourage LGFD[2] thinking.

We need to pay more attention to substance and stop worrying about appearances.

A.J. Heightman and I may disagree on many things, but I do not doubt his integrity. I wrote Reducing Interruptions – How To Send The Wrong Message back in January. This was also about a photograph providing the wrong initial impression. A.J. Heightman, or someone pretending to be A.J. Heightman, responded taking responsibility for the choice of photo. I started my post with –

JEMS has a good article, and it is on an important topic, but whoever decided to use the picture (above) that accompanies the article needs to cut back on the use of the crack pipe, just a little bit, or maybe just cut back while at work.

This is from the response –

From A.J. Heightman, Editor-in-Chief of JEMS
I don’t smoke crack but I allowed the photo

The decision was made to continue CPR and transport him to the hospital. Right or wrong – I chose to allow the photo because it showed the awkward angle everyone tries to do CPR at on current-day max height stretcher position. We sholud have captioned it differently.

It is nice to see someone take responsibility for his actions, rather than blaming a subordinate. Too many times we see subordinates sacrificed on the altar of maintaining appearances.

Is the photo a major problem. No, but it does create a bad impression, especially without a caption to clarify things.


[1] The Art of The Nasopharyngeal Airway
The EMT Spot
by Steve Whitehead

[2] Looks Good From Doorway
Society for Hilariously Inappropriate Treatment a motto.
Another motto is We don’t just talk S#!+, we are S#!+.


Intubation Education

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

In the article I was writing about[1] (Experts Debate Paramedic Intubation) in my post Experts Debate Paramedic Intubation – JEMS.com, there is a bit of defense of the status quo in intubation and intubation training.

We get hung up on many of the same problems. We think that there is one right way to do things, rather than accept that we are adapting what we do to the different circumstances we are faced with.

We act as if the OR (Operating Room) is the only place that we can obtain good practice. There is no evidence to support this.

There is nothing to show that OR training is superior to morgue training and mannequin training, but we act as if the decreased availability of OR time is the only reason medics can’t intubate competently.

We act as if the only problem with the way we are teaching paramedic school is that the students are not learning. As if this is not a reflection on the teaching.

Teaching means providing information to students in a way that helps the students to understand. If the students do not understand, the teacher did not teach.

Perhaps you do not believe that we do a poor job at intubation education.


Nine hundred twenty-six patients had an attempted intubation. Methods of airway management were determined for 97.5% (825/846) of those transported to a hospital and 33.8% (27/80) of those who died in the field. For transported patients, 74.8% were successfully intubated, 20% had a failed intubation, 5.2% had a malpositioned tube on arrival to the ED, and 0.6% had another method of airway management used. Malpositioned tubes were significantly more common in pediatric patients (13.0%, compared with 4.0% for nonpediatric patients).


Overall intubation success was low, and consistent with previously published series. The frequency of malpositioned ETT was unacceptably high, and also consistent with prior studies. Our data support the need for ongoing monitoring of EMS providers’ practices of endotracheal intubation.[2]

Those numbers may be considered good in many areas – batting average, picking winning stocks, votes in an election. When it comes to airway management, we would be more appropriate if we described failure rates.

These failure rates are unacceptably high.

Overall intubation success was low, and consistent with previously published series.

In other words, the authors believe that this is the expected result of the way we train paramedics to intubate.

Can anyone show that this is not true?

The frequency of malpositioned ETT was unacceptably high, and also consistent with prior studies.

This is the expected result of the way we train paramedics to intubate.

Our data support the need for ongoing monitoring of EMS providers’ practices of endotracheal intubation.

5.2% had a malpositioned tube on arrival to the ED.

5.2% Unrecognized Esophageal Intubations!

Ongoing monitoring Watching is not enough.

We need to dramatically change the way we handle intubation education.


[1] Experts Debate Paramedic Intubation – Should paramedics continue to intubate?
Bryan E. Bledsoe, DO, FACEP, FAAEM | Darren Braude, MD, MPH, FACEP, EMT-P | David K. Tan, MD, FAAEM, EMT-T | Henry Wang, MD, MS | Marc Eckstein, MD, MPH, FACEP | Marvin Wayne, MD, FACEP, FAAEM | William E. Gandy, D, LP, NREMT-P
Thursday, July 1, 2010

[2] A prospective multicenter evaluation of prehospital airway management performance in a large metropolitan region.
Denver Metro Airway Study Group.
Colwell CB, Cusick JM, Hawkes AP, Luyten DR, McVaney KE, Pineda GV, Riccio JC, Severyn FA, Vellman WP, Heller J, Ship J, Gunter J, Battan K, Kozlowski M, Kanowitz A.
Prehosp Emerg Care. 2009 Jul-Sep;13(3):304-10.
PMID: 19499465 [PubMed – in process]


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.


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.


Experts Debate Paramedic Intubation – JEMS.com

In JEMS, there is an article by almost all of the top people in EMS airway management. There are several omitted, who contribute to the understanding of airway management, such as Richard Levitan, MD[1] and Kelly Grayson, CCEMT-P.[2] This is not that much of a criticism, since the people they included are definitely among the top airway management experts.

The article points out some of the problems we have in teaching paramedics/nurses/doctors to use critical judgment. We do a very poor job of educating people to make good decisions. Then we conclude that our failure means that the alternative is rigid protocols – even for doctors.

That is just another example of bad judgment.

What is wrong with the following paragraphs?

An EMT listens over the chest and abdomen with a stethoscope. He says he hears breath sounds over the chest but doesn’t say anything about the presence or absence of breath sounds over the abdomen. An ECG monitor with capnography is attached to the patient. The EMT operating the monitor is unsure how to set the device to measure waveform capnography.

Approximately a minute later, the EMT states, “There’s something wrong with the monitor.” The paramedic quickly checks the monitor and re-checks placement of the ET tube. He says, “Looks like the monitor’s not working. But the breath sounds are good, so let’s go ahead and get this guy to the hospital.” The patient is then moved to the ambulance and transported to St. Joseph Hospital with mechanical ventilation continued.[3]

When the monitor does not produce a waveform, or confirm what the EMT expected to see, the conclusion is that There’s something wrong with the monitor.

This is bad, because the EMT is already deciding where the problem is. He has made a statement that he will probably feel the need to defend later on. He doesn’t even appear to be considering operator error.

As the patient becomes less stable, the operator error rate increases.

The EMT operating the monitor is unsure how to set the device to measure waveform capnography. Still, he concludes, not that he doesn’t know what he is doing, but that the equipment is wrong.

I’m not the problem! The equipment I don’t understand is the problem!

Not to worry. We still have a paramedic, trained in the use of waveform capnography and drilled in intubation until he talks about it in his sleep. Sorry. Paramedic programs do not seem to drill paramedics on intubation that much, nor do employers, EMS systems, or even medical directors. Intubation is just not taken seriously. Tube placement confirmation and waveform capnography are taken even less seriously

Looks like the monitor’s not working. But the breath sounds are good, so let’s go ahead and get this guy to the hospital.

This is the motto of a serial killer.

It is only a matter of time until someone, who thinks like this, kills and kills again.

Who taught this guy to think like this?

Who hired him to think like this?

What EMS system licensed him to think like this?

What medical director authorized him use this kind of thinking to go out and kill patients?

His paramedic instructor from the local community college is subpoenaed and, during his deposition, reports that it was very difficult for his students to gain access to local hospitals to practice intubation, explaining that students simply learned the procedure on manikins.[3]

So what?

You can learn to intubate competently on mannequins.

You do not need real live dead people to learn to use critical judgment.

The lack of human intubation practice is a pathetic excuse for poor education.

Would this medic have made a better decision about the obvious lack of waveform during his intubation attempt if he had practiced on dozens of live patients?


The education he received does not appear to have included thorough coverage of tube placement confirmation. And that is not even the most important part of intubation.

We spend too much time worrying about intubation, when the real issue is airway management. This medic does not understand airway management – not even a little bit.

This is a systemic problem.

This lack of understanding of airway management begins in EMT/paramedic school, continues with employers, is certified by EMS systems, and is given the Dominus vobiscum of the medical directors.

Then the medic has his license to kill. The question is, Why is anyone surprised when the medic does kill?

We all seem to believe that this series of failures – school to employer to EMS system to medical director – works.

How many people are killed by this misunderstanding?

How many people are killed by this ignorance?

Am I being too harsh on these failures?


Am I going too easy on the medic?

Calling him a serial killer is not exactly killing him with kindness. This is similar to Murder on the Orient Express. There are plenty of fingerprints on the murder weapon. There is plenty of guilt to go around.

Marc Eckstein, MD, MPH, FACEP, EMT-P: The take-home point here is that we need prehospital research that involves prospective randomized controlled trials (RCTs) with meaningful outcome variables, which are decreased morbidity and mortality.[3]

Essential to the study of intubation and airway management is that the researchers control for the quality of the paramedics.

We need to stop looking at intubation as something that is not affected by the quality of the people attempting intubation.

Dr. Eckstein: These alternative airway devices, particularly the King airway, can be placed quickly, and they provide good oxygenation and ventilation. However, they don’t protect against aspiration, which of course is a major concern with emergency airway management, especially in the field.[3]

I disagree about the major concern of aspiration.

Where is the research to support this?

In the studies comparing intubation with basic BVM use, where is the flood of emesis worsening outcomes?

I think that intubation protecting against aspiration is mostly just another EMS myth.

William E. Gandy, JD, NREMT-P: I wholeheartedly agree with Dr. Wang. Yes, the emphasis should be on ventilation—not intubation. Paramedics should be thoroughly schooled in airway evaluation and should have a variety of airway adjuncts, such as bougies, video laryngoscopy and supraglottic airways, available and be willing to use them.[3]

If you have heard Gene (William E. Gandy) talk about airway management, you have heard this over and over.

You may get tired of hearing that airway management is about ventilation, not intubation or oxygenation. If that is the case, then you really do not understand airway management.

If you do not understand airway management, then you do not understand intubation.


[1] Laryngeal view during laryngoscopy: a randomized trial comparing cricoid pressure, backward-upward-rightward pressure, and bimanual laryngoscopy.
Levitan RM, Kinkle WC, Levin WJ, Everett WW.
Ann Emerg Med. 2006 Jun;47(6):548-55. Epub 2006 Mar 14.
PMID: 16713784 [PubMed – indexed for MEDLINE]

Free Full Text Free PDF

[2] The Airway Continuum
The Ambulance Driver’s Perspective
by Kelly Grayson

[3] Experts Debate Paramedic Intubation – Should paramedics continue to intubate?
Bryan E. Bledsoe, DO, FACEP, FAAEM | Darren Braude, MD, MPH, FACEP, EMT-P | David K. Tan, MD, FAAEM, EMT-T | Henry Wang, MD, MS | Marc Eckstein, MD, MPH, FACEP | Marvin Wayne, MD, FACEP, FAAEM | William E. Gandy, D, LP, NREMT-P
Thursday, July 1, 2010


The Blame Game

Over at Confessions of a Street Pharmacist, Divemedic has a post with the title, The blame game. That’s right. I showed absolutely no imagination in coming up with a title for this post. Go read the post, because I am only going to copy parts of the post here. I am assuming that everything in the post is accurate, but I have no reason to believe it is not, since I have encountered similar behavior to what Divemedic describes.

He complained that the pacing was painful, and so I gave him 2mg of valium to take the edge off. His BP was now 100/62, and I thought we had done OK.

Then he went into respiratory arrest.

Diazepam (Valium) is a benzodiazepine and has the potential for causing respiratory depression. You gave 2 mg. That is such a small dose that it is not likely to have a significant effect on respiratory drive, unless he was tiny. If the patient was ready to stop breathing from working too hard to breathe, then it was probably only a matter of time until he stopped breathing. The diazepam could have contributed, but the intubation may have been inevitable. The BP and CO2 numbers (below) suggest that he was still perfusing well, which indicates that his circulation received a benefit from your treatment with the pacemaker. I do not see any reason to place any blame on your actions.

I prefer fentanyl (Sublimaze) for pacemaker pain. It has less of an effect on blood pressure than morphine or benzodiazepines, but it can have even more of a respiratory depressant effect. If sticking to benzodiazepines, and many people prefer to to use them for pacemaker pain, I prefer to use midazolam (Versed), since it wears off much more quickly than lorazepam (Ativan) or diazepam. Similarly, a big advantage is that fentanyl wears off quickly. For EMS, we do not want drugs that last a long time. We want to be titrating to effect. We can always give more (depending on protocol and amount carried).

I tubed him, and his EtCO2 looked good, and over the next few minutes, his O2 sats went from the 70’s into the upper 90s. His lungs sounded wet, but the clinical signs were there. CHF, maybe? We delivered him to the ED with vitals of: HR 80(paced), Resp 12(BVM via ETT), BP 110/70, SaO2 96, EtCO2 42.

With a misplaced tube, it is extremely unlikely to have improved oxygen saturation. There are a couple of possible reasons for the number to increase with a misplaced tube.

1. The pulse oximeter was not getting a good reading before the intubation, but was afterward. Even though the sat may be slowly dropping, when there is at least one inaccurate reading, there may appear to be a positive trend, but that is just due to an error in one, or more, readings.

2. An esophageal intubation should not lead to improved oxygenation. However, the act of inserting a laryngoscope blade and a tube may provide enough painful stimulus to inspire the patient to breathe spontaneously and adequately around a tube that is placed in the esophagus and not obstructing the airway. The tube would not be providing any benefit other than painful stimulus. Painful stimulus may be all that the patient needs, but that does not justify an endotracheal tube misplaced and unrecognized in the esophagus. The pacing may have the same effect of painful stimulus, but the patient seems to have had the respiratory arrest after capture was obtained with the pacer.

On the topic of pacemakers, it is likely that the improved cardiac output from many paced patients is not due to successful capture, but to painful stimulus. That is a topic all to itself.

Wet sounding lungs can mean many different things, but if he does have CHF, positive pressure ventilation works wonders, as long as we do not drop the blood pressure by raising his intrathoracic pressure high enough to impair venous return.

The ER doc listened to the lungs, and consulted with the RT. They decided to extubate. I pointed them to the EtCO2, and the Doc said “That stuff isn’t accurate. You are in the stomach.”

“That stuff isn’t accurate. You are in the stomach.”

Strike One!

This clown doctor needs a big tattoo on his forehead to warn people to stay away.

Accuracy-wise, waveform capnography is the most reliable method of confirmation available. The false negative rate is very low. For example false negatives might from an obstructed sample port, equipment not connected properly, equipment malfunction, a very dead patient produces little, if any CO2, . . . .

The false positive rate is almost zero. For example from a lot of air in the stomach from a lot of mouth-to-mouth ventilation. The exhaled CO2 is going into the stomach, to be returned later, when oxygen is pumped into the stomach. The possibility that consuming a lot of carbonated beverages prior to intubation would similarly result in a reservoir of CO2. Not that anybody would ever substitute carbonated beverages for the almost mandatory pre-arrest Mylanta. The patient is hooked up to the nasal cannula form of CO2 sampling device and is still spontaneously breathing around an esophageal tube well enough to produce good CO2 numbers and waveform. The monitor is showing a waveform from a simulator, rather than the patient. Although I spend a lot more space on the false positives, they are much less likely than the false negatives.

He then ordered the nurse to discontinue the pacing, and give 0.5mg epinephrine and 0.5mg atropine. I showed him the original strip and pointed out the original rhythm.

Strike Two!

Discontinuing pacing that has both electrical and mechanical capture is a very bad idea, unless you are just doing so temporarily to assess the underlying rhythm before resuming pacing. Discontinuing pacing to give a toxic dose – perhaps a lethally toxic dose – is irresponsibly dangerous.

I would suspect that the doctor, by giving both atropine and epinephrine, exacerbated an MI. A 500 mcg bolus (0.5 mg = 500 mcg), to a patient with a pulse, is way outside of the ACLS guidelines of 2 mcg/minute to 10 mcg/minute by infusion. I don’t know what happened, but I have never seen a slow push of epinephrine. Even assuming that the epinephrine was given over a full minute, that doctor still gave 50 times the maximum dose for a living patient.

I started the last paragraph with the assumption that he had both electrical and mechanical capture with the pacemaker. If there is any question about whether this is the case, the waveform capnography gives a pretty good indication of the quality of circulation. There is more that I would want to know to make a more definite statement, but I do not doubt that he had full pacemaker capture. That the patient coded after discontinuation of the pacing, and the addition of an extremely toxic dose of epinephrine only adds to the confirmation that the EMS treatment was appropriate.

Maybe the doctor placed the tube in the esophagus, since he clearly does not know how to confirm tube placement. Expecting correct placement (if he did attempt to re-intubate) from Dr. Deadly would be an example of unreasonable optimism. We might as well allow him to be the only unreasonable person in the room.

Picture Credit[1] You know how to make it bigger.

To create a continuous infusion of epinephrine hydrochloride for treatment of bradycardia or hypotension, add 1 mg (1 mL of a 1:1000 solution) to 500 mL of normal saline or D5W. The initial dose for adults is 1 µg/min titrated to the desired hemodynamic response, which is typically achieved in doses of 2 to 10 µg/min. Note that this is the nonarrest infusion preparation and dose (ie, for bradycardia or hypotension).[2]

What if Dr. Deadly was assessing the patient as pulseless and was giving the dose for cardiac arrest, so the dose could be appropriate.

Let’s see if the AHA has a mostly dead dose for doctors, who just can’t commit to a full milligram in cardiac arrest –

It is appropriate to administer a 1-mg dose of epinephrine IV/IO every 3 to 5 minutes during adult cardiac arrest (Class IIb). Higher doses may be indicated to treat specific problems, such as ß-blocker or calcium channel blocker overdose. If IV/IO access is delayed or cannot be established, epinephrine may be given by the endotracheal route at a dose of 2 to 2.5 mg.[3]

It looks as if Dr. Deadly was using a dose of epinephrine that is half of an adult cardiac arrest dose combined with a dose of atropine that is half of an adult cardiac arrest dose. Dr. Deadly appears to be a complete half wit.

Maybe he was giving the appropriate dose of atropine for a living patient combined with a ridiculously inappropriate dose of epinephrine for a living patient

Maybe he was, but I would rather not speculate about the motives of this malpractitioner. He could be 50 times more witless. At least if we use the ratio of his dosing to the actual recommended doses.

What about dopamine? The chart includes dopamine.

Dopamine is just epinephrine light. It is a little more complicated than that, but the dopamine is going to be much weaker than the epinephrine. Dopamine is also not to be given as a bolus to live patients.

As I was leaving, the doctor came out and informed her that her husband had passed away. He then told her, right in my presence, that if the paramedic had not placed the tube incorrectly, her husband may have lived. I felt about three inches tall.

Strike Three!

He blames others for his incompetence.

At least the doctors reviewing the case were able to recognize the signs of a properly placed tube.

Did you tell the family that the outcome of the complaint against you was that you did nothing wrong. If anyone killed this patient, I would suspect that the doctor, by giving both atropine and epinephrine, exacerbated an MI. A 500 mcg bolus, to a patient with a pulse, is way outside of the ACLS guidelines of 2 mcg/minute to 10 mcg/minute by infusion. I don’t know what happened, but I have never seen a slow push of epinephrine. Assuming that the epinephrine was given over a full minute, that doctor gave 50 times the maximum dose for a living patient.

It is difficult to tell a lot of what is going on without the strips and other information. Not that anyone needs to be blamed, but when those taking care of patients are clueless people, such as Dr. Deadly, patients seem to die more often.

While I intended to start by saying nice things about the review board for recognizing that you did the right thing, I am disappointed if they failed to report this doctor to the state medical board.

People, who automatically blame others for their mistakes, such as Dr. Deadly, seem to do this because they have a lot of practice making very bad mistakes. They also seem to be incapable of learning.


^ 1 Management of Symptomatic Bradycardia and Tachycardia
Circulation. 2005;112:IV-67 – IV-77.
2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Part 7.3: Management of Symptomatic Bradycardia and Tachycardia
Free Full Text . . . . Free PDF

^ 2 Monitoring and Medications
Circulation. 2005;112:IV-78 – IV-83.
2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Part 7.4: Monitoring and Medications
Medications for Cardiovascular Support
Free Full Text . . . . Free PDF

^ 3 Management of Cardiac Arrest
Circulation. 2005;112:IV-58 – IV-66.
2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Part 7.2: Management of Cardiac Arrest
Medications for Arrest Rhythms
Epinephrine and Vasopressin
VF and Pulseless VT
Free Full Text . . . . Free PDF


Second comment from Anonymous on Teaching Airway – Part I

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

There is also a thoughtful analysis of airway management and intubation in Airways and ET tubes… at 9-Echo-1.

In the comments to Teaching Airway – Part I – comment from Anonymous, Anonymous writes –

Hi, me again…Nothing brings out a good post from you better than BS. Your best posts come from you when you’re challenged.

Thank you.

So I get to respond to your post…

Science shows us what works. Anecdote can show us areas to examine scientifically, but basing treatment on anecdote is bad patient care. We need to base treatments on science.

Yes, but studies can’t be started and performed without anecdotal evidence to steer research. We have to do a few things wrong to figure out what’s right.

I agree. Although there may be some research that is begun without some anecdotal evidence to support it, that is probably rare.

We do have to do a few things wrong to figure out what’s right. We spend too much time on punishing mistakes, rather than looking for ways to avoid those mistakes. We are taking the wrong approach to figuring out what is right.

I see this as a reflection of insecurity and ignorance by those in charge. Those in charge are insecure because of their ignorance. Maybe they just do not know how to do things well, but they do not seem to be doing the right things to learn how to do things well. One easy way to learn how to do things well. Find somebody doing it well, and ask them for some ideas. In Too Many Medics? comment from Anonymous, I included the abstracts from 2 systems that demonstrate excellence at intubation.

One of our big problems is that we do not look at bad outcomes as opportunities to learn how not to keep making the same mistake. We look at bad outcomes as an excuse to punish somebody. Why learn from our mistakes, when we can deny that we made a mistake, and punish someone else for our mistake? Win – Win? Right?

That has never been my position. I want medics to use the right tool to accomplish the job. The job is patient care.

I know and I really don’t expect anything less from you. I’m not doing this for the check.

I need the paycheck, but I could probably make more in a different line of work. If I had gone into a different line of work, I would have less debt at the end of the month.

There are some medics, that I do not want to be allowed to intubate. Those are the medics, who do not intubate competently. According to the studies of prehospital intubation, there are a lot of these medics out there.

I agree 100%, but how do you sort them out, in a city wide system, with poor medical command, that sometimes barely has a budget to even staff trucks.

That is probably the thing that is going to have the greatest effect on who should intubate. A system, like the one you describe, will have a lot of horrible medics, but do nothing to get rid of them. Or just a little more than nothing.

A system that gets rid of maybe one bad medic a year, but has a couple dozen bad medics, and has them training new medics, is not likely to stop getting worse. That is a system that is not getting better, but getting much worse. Everybody sees that the bad medics are tolerated. Sure they sacrifice one every year, or maybe every other year, just so they can say that they do something about bad quality. They make it seem as if they are doing something significant, but what they really are doing is telling everyone that they are not serious, or that they really are too stupid to understand.

Who are they?

They are the medical director, the chief, the CEO, the City Manager, the QA/QI/CYA department, the union, and all of their accomplices.

Anyone, who has one of those jobs is responsible for eliminating bad patient care. All of them have that responsibility, but few seem to do anything significant to eliminate bad patient care.

The same medics that keep the CPAP (Continuous Positive Airway Pressure) stuffed under the seat because “we’re right down the street from the hospital, we’ll just use meds” attitude. I’ve seen it and it’s scary.

I’m NOT supporting these systems, but how do you change it?

That is a good question. There needs to be somebody who just insists that patient care be the priority. That needs to come from the top. When the bosses get on camera and defend horrible care, there is no reason to expect things to change until that boss is gone, and probably some others, too.

I have no problem with competent medics intubating when it is appropriate. We are learning that intubation may not be appropriate for some patients, who used to be routinely intubated. We need to learn more about when intubation is appropriate.

Yes, again I agree, in fact I use CPAP, NTG (NiTroGlycerin), and Ace inhibitors on a regular basis and I don’t drop a tube, in fact most, are turned around at the hospital. The CHF I described carried down on the Reeves was unresponsive and wasn’t going to fit in a stairchair, so yes, my partner bagged, I put in a line, NTG paste w/3 sprays in a foamy mouth (no IV NTG), Lasix (which I rarely give because CPAP works so well), and Captopril 125. Then I suctioned the pt and tubed while waiting for fire to help carry out my pt. The pt waited to long. Indicated for intubation. I saw that pt again, alive, and good for them. You’ve had that pt before, most medics have.

Was that pt saved by the tube? No idea, yep, no idea. Would CPAP work, no. Would a KingLT which we carry work, maybe, no idea, didn’t use it. I saw need for a tube and did it because it was indicated, could I have just bagged that pt, sure, would have been a bitch, but it could be done. I have even used the ramp on the KingLT to place a successful tube, it’s was pretty cool actually. The problem is these patients are still presenting while science and training catch up or figure out what’s best for the patient and when you FINALLY get people comfortable the rules change. Little and large systems seems to continue to fail, and most likely to “follow the dollar” where other systems seem to always be on top of things.

There are patients like that. Sometimes they do not have time to call, because the onset is so rapid. The train wrecks will not necessarily be any better, regardless of what we do. Positive pressure ventilation (CPAP) is probably the most important treatment for this patient. Next most important is high dose NTG. 10, 20, 50, 100 NTG sprays – whatever it takes. As long as the blood pressure does not dramatically drop. I have given over 50 NTG sprays and still not had the systolic pressure drop to even 200, in some patients. We are unnecessarily afraid of NTG. Hypertensive CHF patients tend to be resistant very resistant to the effects of NTG. The only reason not to be giving 3 to 5 sprays/tabs at a time to hypertensive CHF patients is having a bad protocol.

The NTG paste makes no sense. You are applying it to the skin to be absorbed by the circulation to the skin, but the patients skin signs indicate that the circulation to the skin is just not there.

Pale – due to a lack of hemoglobin reaching the skin.

Cool – due to a lack of the warmth from blood reaching the skin.

Diaphoretic Sweaty – due to the large amounts of adrenaline being released by a body in hypoxic panic. The adrenaline shunts the circulation away from the skin.

The circulation needs to pick up the NTG from the paste on the skin to take it to where it is needed in the pulmonary circulation. It is not needed on the outside of the skin, unless we are looking for ways to accidentally expose our coworkers to NTG.

A great example of this is when someone is suturing a laceration and injects lidocaine with epinephrine (epinephrine is adrenaline). The skin around the injection site becomes more pale, as you are watching. This is what is going on to all of the skin on the pale, cool, sweaty patient. This is one reason that it does not make sense to use NTG paste. The other reason is that the low dose of the NTG paste is like trying to make the tide rise by urinating in the ocean. With precise enough tools, we may be able to measure a minuscule difference, but it does not make any noticeable difference. The epinephrine is shunting the blood away from the skin, not the lidocaine. The lidocaine is for pain relief. The epinephrine is to minimize bleeding during suturing.

As far as educating residents and stopping them from pulling my KingLT, the second you find an answer to that then post it immediately, I’m up for anything with that.

The best way to educate the residents is to educate the attendings. Maybe I have been spoiled, but I have found that the attendings are willing to look at different ways of doing things, if you present it to them in a way that makes sense. You may find that it takes several years to get them to actually change things, but I have found that they are willing to listen. Then it becomes a matter of politics. How do you identify the attending most likely to do something about it? Doctors are more likely to listen to other doctors. Good reasons coming from a medic are less likely to persuade a bunch of doctors, than the same reasons coming from another doctor.

If you are worried about the resident being able to do something that you might not be permitted to do, then there is an excellent way to frustrate them.

I get that secret smile when I turned the pt prior to arrival also.

You lost me on that one.

As I have repeatedly stated, I do not wish to remove intubation from the paramedic scope of practice. However, I definitely do not want dangerous medics intubating.

I really do know that, and I agree. I have family that I really wouldn’t want some of these medics even touching them.

I kind of figured that.

Maybe we should use the term alternative paramedic for those not capable of maintaining adequate intubation skills.

True, but I have seen a few attendings reach for a LMA because they couldn’t get an ETT placed. What is their standard for maintaining skills? Are they are judge? I’ve taken many ACLS classes over the years and every ED doc shows up but shows no initiative and participates. Here’s your card doc, oh and did I mention your codes, run like 1998.

The hospital decides what their rules are. Some restrict some skills to only certain doctors, while others may not have any restrictions for any doctor, as long as the doctor maintains a state license and malpractice insurance. Most are probably somewhere in between these extremes. It has been my experience that some ED attendings, board certified in EM, are scary at intubation and airway management in general. Others are great. I have sat in the parking lot to intubate some patients, because they were not responding to medical treatment, I knew that they would be intubated soon, and I knew who was the on duty attending. Why subject the patient to that doctors obligatory 2 or 3 failed intubation attempts, followed by a call to anesthesia and a waltz-by intubation, when they could come in with a tube in place and have less iatrogenic harm?

Some doctors just do not seem to get airway management. We all have our blind spots. I keep trying to minimize mine.

As we have learned more about airway management, we have come to realize that the Gold Standard is not intubation. We old timers were taught that intubation is the Gold Standard, but we were taught a lot of other things that are just plain wrong. The Gold Standard is what is best for the patient. The gold Standard is excellent patient care.

I’m not that old, and would NEVER disagree with that statement.


Where is the evidence that prehospital intubation is better patient care than prehospital alternative airway use?

I’ve got none, and I’m not going to claim it, they are really new prehospital, around here anyway. LMA’s have been around for awhile but as far as I know no squad, at least in my area ever carried them. However I’m sure your reply will have a stat.

I will have to follow up with some posts on prehospital LMAs. There are services using them. There has been research on prehospital LMA use, but it is going to take a while to go through it and come up with something thorough.

Maybe research will end up showing that replacing the alternative airway is indicated some of the time, but not indicated other times. We do not currently have research to determine which is better.


After all, anesthesia seems to be leading the way in airway management, and they are increasing their use of LMAs. That may be where the rest of in-hospital airway management is headed.

You do not appear to be familiar with ICU care. Patients with the need for long term ventilation will have the endotracheal tube replaced by a tracheotomy tube. Apparently, the doctors do not consider your endotracheal tube to be permanent.

I’ve suctioned enough of them, I am aware for long term, in my head I was focusing on pt’s that should have turned around and are only on a vent for a few days to a week. The patient that I knew would probably turn around if we were all aggressive on in the beginning, the CHF pt who was just to weak, but after being medicated, tubed, and cleared out, would allow the tube to be pulled assuming all the ABG values looked good.

Even that may change. VAP (Ventilator Associated Pneumonia) is a big concern in hospitals. It seems to fall into the never event category. As Ambulance Driver mentioned, hospitals are paying attention to the cost of care. They are going to try to cut down on costs, so I expect that we will see a lot more use of LMAs in the hospital, even if they don’t improve outcomes or expenses, but because they might and hospitals are all about saving money.

No waveform, then the tube is pulled, PERIOD.

Yeah, even I slapped myself for that statement, I got out of control. Let me explain what I was thinking. If I place a blind tube and don’t see a good waveform then the tube is pulled. This is on a patient that should show an ETCO2 reading. I could expand on it more but I think you get the jist.

Please send video of you slapping yourself. I am not above cheap sensationalist publicity. 😉

As I understand it, unless there are conflicting assessments, if there is no good wave form, the tube should be pulled. At least, that is the way I approach confirmation, and I get the impression that we agree.

Again, I do not wish to remove intubation from the paramedic scope of practice. More important is that, I definitely do not want dangerous medics intubating.

Again, how do we fix it?

I think the first thing is that we need agreement on what should be minimum standards, but that has to come mostly from the medical directors.

We need research to show what the differences are between places that intubate well and those that, even though the service may have some people who are great at intubation, the service overall does a horrible job of intubating patients. To do that we need well done research, which you get into below.

We need very well done research in places that intubate well, that are large enough to show what conditions are likely to benefit from intubation. There will always be good reasons for deviating from the typical treatment, but we do not even have research to clearly show that intubation does not cause harm.

We probably need a separate designation for medics permitted to intubate. I don’t know if it should be like the EMT-D add on for defibrillation, or whether it should be something like the critical care paramedic certification, with an broader scope of practice than whatever the regular paramedic would be. There are many ways of handling this.

I think this would be an important part of what Ckemtp is trying to do with EMS 2.0 over at Life Under the lights. My initial impression was that this is just going to be another passing fad, but I think he might be on to something. We need to transform EMS from a trade to a profession. Airway management is one of the areas, where EMS really needs to push the doctors to improve. We do not have the authority to change the rules, but I don’t see any reason to let that stop me. EMS 2.0 is also covered in Ckemtp, EMS 2.0 – Momentum Building, Happy Medic, Medic999, Too Old To Work, Too Young To Retire, Ambulance Driver, and even The Fire Critic and Firegeezer.

Waveform capnography?

EMS – Yes, usually. In Pennsylvania, it is mandatory for ALS.

ED – No. Some places have it, but most do not seem to use it.

One-on-one observation of patients for heavy sedation/aggressive pain management?

EMS – Yes, what are we going to do, leave?

ED – No, this requires rearranging staffing and will be done, if necessary, but is certainly not the baseline level of care. Generally, each ED nurse has 3 patients, or more.

These are just a couple of examples of ways EMS should be pushing patient care forward. As I wrote in EMS Needs to Be a Separate Medical Specialty – Now – Part I.

cont still…damn restrictions…

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)

Scary stats, but failed why? Attempted but unable to place or, attempted and misplaced. That’s a big difference. If I miss a tube and I can’t get it, if I’m still able to oxygenate the pt to keep the stats up then it’s still successful, I just may not be able to move on to additional treatments. It sucks but it happens. If I misplace a tube then I’m killing my patient and think I’m helping. If I stick a blade in the patients mouth, it’s an attempt if I try to tube or not, even if it’s to suction to even clear an airway. If I have to do this on 5 of 10 patients then I’m at a 75% success/failure attempt rate. Data can be manipulated to favor for or against. It all looks bad on a pie chart, something we all learned in statistics at college.

I think there are plenty of problems with the data from Miami, but nobody has come out and provided documentation of these flaws. There is one very interesting rumor that I have heard. I do not like dealing in rumors, but I am hoping that somebody reading this will be able to document this, or get the medical director(s) involved to set the record straight, at least if the rumor is true.

The rumor is that in at least one of the services studied, the medical director strongly encouraged the use of alternative airways as true alternatives to intubation, rather than as back up airways, for airway management. However, the way the success/failure of intubation was determined was based on just two things. Was there any kind of airway intervention – BVM, CombiTube, LMA, crichothyrotomy, endotracheal tube, unrecognized esophageal tube. If any of those methods of airway management were being used, but there was not a properly placed endotracheal tube, this was considered a failed intubation.

After two ETI attempts, placement of a Combitube is considered as a rescue airway measure.

For this study, members of the Department of Anesthesiology assessed the airways of patients at their admission to the trauma bay. We defined prehospital airway management as paramedics having had an active role in managing the patient’s airway through a variety of approaches, including ETI, laryngeal mask airway (LMA), and Combitube and/or cricothyroidotomy.We defined a failed PHI as the improper localization of an endotracheal tube (ETT) on arrival at the trauma center or the need to use alternative rescue devices for airway management after intubation attempts.

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]

If the CombiTube is used as an initial airway measure, it is definitely not a rescue airway measure. If the doctors assessing the intubations were not familiar the way that airway management was being performed, then their determination of all CombiTubes as failed intubation attempts would be wrong.

From the way I read the study, if a CombiTube, or LMA, salesperson happened to stop at an accident scene and placed an airway, but the patient was transported by a BLS ambulance (no endotracheal tubes anywhere on the ambulance), this might have been classified as a failed endotracheal tube attempt. They might have presumed that paramedics were involved in the management of the airway, since they consider the ConbiTube to be only a rescue airway, rather than an alternative airway. I don’t think they would have done the same for a BLS crew transporting with just BVM airway managment if no ALS was available. From the system design, it is possible that all 911 ambulances have a medic on board. Still, there is no good reason why a BLS interfacility transport ambulance could not arrive on scene, deliver excellent care, realize that the closest ALS is at the hospital, and transport. BVM only. No possibility of endotracheal tube. According to the study, it might be classified as a failed intubation attempt.

Well, that is the thing that bothers me the most. Is the rumor true?

If the rumor is true, how many patients classified as having missed endotracheal tube attempts, never had any endotracheal tube attempts?

If the rumor is true, how can the researchers publish this without disclosing that variable? A variable that should have been controlled for, but if the rumor is true, a variable that was not controlled for.

You claim that you know that it is necessary. How do you know?

Only by experience, discussions with our command doc, and in my training and education I’ve receive to date that I’m acting in the best interest of my pt.

This is one of the reasons we need to have good research. It is unfortunate, but apparently medical school does not do a good job of preparing doctors to interpret research. If they cannot even interpret the research correctly, what is the research they design going to look like? We need to start doing a much better job of educating people about research and the scientific method.

You also claimed that there is no research showing worse than a 75% prehospital intubation success rate.

Again, results can be biased.


The difference between good research and bad research is that the good research goes to extremes to exclude the influence of bias. Bad research may not recognize bias, or may come up with pathetic excuses for using the biased methodology. Not that there aren’t other ways of creating bad research.

Some of the reasons I started this blog are:

To educate people about research.

To get people to discuss research.

To get people to look critically at research, rather than just say, That is too complicated for me.

To get people to seek out research to persuade doctors of better ways to provide patient care.

For your last regarding how medics should be trained and certified I agree, but is it possible and should MD’s/Residents be held to the same standards.

I think that doctors should be held to higher standards than medics. This is one of the reasons for having EMS as a separate medical specialty. Sort of a way of saying, If you want to make contributions to EMS, this is the background you need to have. If you do not meet the criteria for board certification as an EMS physician, then go away. We still have too many non-emergency medicine physicians in the EDs, but this would be a start.

We are facing a lot of misunderstanding/obstacles from doctors, who think they understand EMS, even though they do not. That is one thing holding EMS back. Our patients deserve better.

Should we add a new cert level?


Forget about EMS 2.0, we’re going straight to EMS 3.14159 . . . . Well Vince may enjoy the math humor, even if not many others do. 🙂

I think that we need to be continually assessing the appropriateness of the different levels. Just because this is the way things have been done, does not mean that it is the way things should be done. There will be a lot of change in EMS. We should be doing things to try to make the changes good for the patients. Maybe a different certification. Maybe just more widespread use/recognition of the EMP-CC (critical care) level. Maybe much fewer medics and a lot more medical directors growing a set (metaphorically only, since some are women). We need to have an organization with the authority and the understanding to keep us moving in the right direction. I do not see the DOT (Department of Transportation) as that organization. Anything that combines EMS with firefighting, police, homeland security, or any other Wouldn’t it be cool if we could be used as an excuse for them to syphon off money for their pet projects? agency.

Love your posts, I’ve read them all. You too AD.

Thank you. As you have noticed, I enjoy a good debate. I think that we will not change things until we have identified all of the problems. I certainly do not have all of the answers. I don’t even have all of the questions. You contribute a lot to the discussion.

I’m on your side I promise. You really could take my blade away, I really do only tube as a last resort and I like Mystery Medic’s idea. Glidescopes are nice.

You point out one of the problems. The ones in need of having intubation taken away are the ones who will fight to the death (the patient’s) to keep intubation, but will resist any refresher/retraining/minimum requirements. They do not get that this is about the patients, not about making medics feel good, briefly, before going back to the routine calls that we do not feel challenged by.

I have not used the Glidescope. I have read good things about it. I think that it has the same potential for leading to bad outcomes as anything else – too much focus on the airway, as if the airway is not connected to a patient. A patient, who might not even have primarilly an airway problem. How many patients suffer anoxic brain damage because of intubation attempts? This is something that we should be able to avoid with excellent oversight, but we do need that oversight.

What do you feel about walking a pt to the bathroom around a corner in the house after getting diltiazem for rapid Afib that reduces and refuses to go with you to the hospital unless she can pee, assuming she is is on O2 and the monitor. Had a partner almost have her own stroke on my decision.

I have probably induced a few TIAs in partners, nurses, doctors, et cetera. If the patient has the capacity to make informed decisions about her own care, she may do pretty much anything that we think is unwise/dangerous.

We can pretend that we know that allowing a patient to do something, that we think is a bad idea, will kill them or make them much worse, but we do not know that. We can present them with all of the information about why we think it is a bad idea, but unless we are abducting the patient, or been given power of attorney, or have involuntarily committed them, . . . we do not have the authority to force the patient not to do what we think is unwise, nor do we have the authority to force patients to do something that we think is essential.

I will write more about this, because it is important and we seem to be very poorly prepared to deal with patients who do not agree with us. I just graduated EMT/medic/nurse/doctor school and I know everything. Usually the person making such an assertion is demonstrating that they actually are the most ignorant person in the room, but they often get their way, because they are the most insistent/intimidating/arrogant person in the room. Except when I am there. 😉

Then the follow up to Ambulance Driver’s comment.

Yeah I gotta fess up. I worked very hard on that first post to A) piss you off a little because I enjoy your follow up to BS and trolls and B) because I think if shows what many medics still really think.

Nothing to apologize for. We need to have good debates about what is best for patients. We currently have to rely mostly on expert opinion, because the research is too often inadequate to answer the question of what is best for the patient or what are the right requirements for intubation.

I still believe current research is biased and I would love to see a wide scale study in direct favor of the patient with all aspects of the pros/cons of intubation.

Research will always have problems, but it is still the best method we have of answering the questions of what is best for the patient. I would like to see that research, too.

I see turmoil in our future. We as medics are expected to learn more every year and that makes it harder to be proficient in the skills we already perform. We do this all without getting a pay raise, my cost of living increase alone was frozen for another year.

That is a problem. We do need to have medics dedicated to EMS. Not cross-trained as anything else. There is too much that we need to do to maintain proficiency to have paramedic be something done in addition to another job that people think is interchangeable, or related, or a way of saving money. These are generally not people you would want providing care for any real patient, yet they make decisions about how that care is delivered. Politicians are the enemies of EMS.

Tom Peters writes about this problem, but not as an EMS topic. He asks the question, Do you suffer from too much talent?

In EMS, we seem to act as if we have such talented medics, that cross-training in another field is not going to interfere with their ability to provide excellent care.

Maybe we just don’t care about excellent care – until we are the patients (or our families). Isn’t a 52% intubation success rate, even if partially inaccurate (12% esophageal intubations is also ridiculous) worse than bad patient care?

Do we suffer from too much talent?

Hope no hard feelings, RM, great follow-up 🙂

I do not take criticism personally, so there would be no reason for hard feelings. I like it when you make me think.

Thank you.

Other blog posts commenting on this, by others and by me, in order of posting, have been –

The Airway Continuum at EMS1.com by Kelly Grayson, AKA Ambulance Driver. 11/06/07

Teaching Airway: EMS Educast Episode 33 at EMS EduCast. 10/02/09

Teaching Airway – Part I at Rogue Medic. 10/10/09

Teaching Airway – Part I at Paramedicine 101. 10/10/09

Teaching Airway – Part I – comment from Anonymous at Rogue Medic. 10/11/09

Teaching Airway – Part I – comment from Anonymous at Paramedicine 101. 10/11/09

Rogue Medic’s Comment Section… at A Day In The Life Of An Ambulance Driver. 10/11/09

Paramedics and intubation at 9-Echo-1. 10/12/09

Attention all Companies at The Happy Medic. 10/12/09

Snapshot from the Paramedic Battlefield at Firegeezer. 10/12/09

Have You Seen This? at The Fire Critic. 10/12/09

Comment On A Comment at Too Old To Work, Too Young To Retire. 10/13/09

Airways and ET tubes… at 9-Echo-1. 10/14/09

EMS as a Profession? at The Fire Critic. 10/20/09

Airway comments by Rachel at Rogue Medic. 10/21/09

Airway comments by Rachel at Paramedicine 101. 10/21/09


Airway comments by Rachel

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

So there I am sitting at home, still not finished with my response to the most recent comments from Anonymous – 3 parts, due to Blogger’s character limit (4,095 characters if I remember correctly – not as limiting as Twitter’s 140, but . . . ), when I receive a comment from Rachel of Rachel’s Rants. Well, it made me smile like the Grinch on Christmas Day.


This has been a debate among a bunch of crazy old men. I am assuming about Anonymous, but I do not think I am wrong about age or gender. Working in EMS pretty much guarantees the crazy part. As for Ambulance Driver, while he is creeping up on AARPville more slowly than I am, he did just put another candle on the cake.

The comment from Rachel is a bit different. She is a young woman and a relatively new paramedic. 3 years worth of new. Well, here is the comment to Teaching Airway – Part I. I do not need to add much to show you why it puts a spring in my step and whatever other optimistic metaphors might apply.

I have come across your blog from 9-Echo-1’s site and I have to say as a 3 year medic, I’m all for more training on intubation or even just taking that skill out of the scope of practice altogether.

Of course, my Y chromosome translates that to A man’s got to know his limitations. With the squint and everything. This may be the most important thing to understand in EMS, although it might be better to translate it to – A paramedic’s got to know his limitations. Or her limitations.

During my 3 years I’ve only had 2 chances to intubate. I’m glad to say that I currently have a success rate of 100% as confirmed by ED docs but still only 2 chances in 3 years? If we are going to provide that level of care then we really need more practice.

And it is not just the opportunity to intubate, but the quality of education, the refresher training, and the quality of oversight.

I read some of the other comments here and WOW. What happened to treating each patient the way you would want someone to treat your family. Just because I know how to do a skill does not mean I should or even that my patient needs ME to do that skill.


I would feel much better, if the patient was my family member, having a tube placed at the hospital in a more controlled setting with providers that probably have done it more than twice in the last few years.

Another excellent point.

The next two parts I switched to bold text. They deserve extra attention.

I’ve said this before sometimes the best intervention is a BASIC one.

Right there, you boiled AD’s Airway Continuum down to one sentence.

I know hard concept for some to understand. Too often I see medics treat very aggressively and while sometimes that is indicated it should not be standard operating procedure.

I agree. Although I do not think that aggressive is the right word. I consider myself to be very aggressive in not using treatments that are not indicated. I often receive criticism from some other people in EMS, from some nurses, and from some doctors. Rarely from my medical directors. While I may be forgetting something, I don’t think that I ever received much criticism from a medical director for under-treating a patient.

We need to figure out which patients are surviving to the hospital because of us, which are surviving to the hospital in spite of us, and how to tell the difference. This is where assessment combined with good research will make a big difference in what we do – and maybe a big difference in patient outcomes.

Anyway, go read Rachel’s blog. She only posts about a once a month, but they are worth reading.

PS. Ambulance Driver has a new address for his blog A Day In The Life Of An Ambulance Driver, with a new banner that has more pictures of KatyBeth, Yay! Maybe there will be a blog from her, something like A Day In The Life Of An Ambulance Daughter.