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

- Rogue Medic

Teaching Airway – Part I – comment from Anonymous

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

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

We get it,

No. You do not get it. You misrepresent what I wrote. Maybe others get it and maybe not, but all I can tell from your comment is that you do not get it.

This reminds me of debating other anti-science zealots. You attribute things to me that I never stated, then you argue against those statements – statements I did not make. The argument that you are making is called a straw man. You misrepresent my statements. You point out flaws in the statements that I never made. You then claim that my statements are false.

My position is simple. This is the second to last paragraph from the post you disagree with.

We need to prove that intubation works and prove that we have the skill to be trusted intubating patients.

Can you provide any evidence – real evidence, not some stories of one time at band camp – controlled studes, retrospective studies, observational studies, anything? Where is your evidence of improved outcomes due to prehospital intubation?

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.

you don’t want a medic putting in a tube

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

The specific part of patient care being debated is airway management. Airway management includes intubation as only one of the possible methods. The right method for the patient in the prehospital setting is what matters.

We have presumed that intubation is the right method, because of expert opinion – not because of evidence of benefit.

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 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.

and you’re burnt out from the field and want to stop being a medic.

I guess, when you can read minds, you might lose interest in things like science – since there is no science to support mind reading.

Whether I am burnt out is irrelevant. If I am extra crispy, it is irrelevant. If I am just a little toasty around the edges, it is irrelevant. If I am bright and cheery and always eager to have an opportunity to brighten someone’s day, it is irrelevant.

So how about for the next 6 months I stop tubing my patients.

A better option would be to do a study with a lot of medics, but only those proficient at intubation. Have the medics intubating only every other day to compare outcomes. Otherwise, we can only speculate about outcomes for many of these patients.

The CHF patient that waited a little to long to call now frothing at the mouth, I’ll just have my BLS partner bag while I try to get a line in to start the 4 drugs I need to help them.

CPAP (Continuous Positive Airway Pressure) would be much more appropriate. You should try to get your medical director to write a protocol for it, because research shows that CPAP decreases the need for intubation in CHF (Congestive Heart Failure).

High dose NTG (Nitroglycerin), preferably IV (IntraVenous), but SL (SubLingual) is OK until high dose IV NTG is available. Again, research shows that high dose NTG decreases the need for intubation in CHF.

ACE inhibitors (Angiotensin Converting Enzyme inhibitors, e.g. enalapril or captopril) given SL or IV also has research showing ACE inhibitors decrease the need for intubation.

You may notice that one of the goals of treatment is to reduce the need for intubation, not to intubate. Of course, there are some doctors, who do not keep up with the research. These doctors tend to continue to focus on intubation and furosemide (Lasix). The research shows that these doctors are not encouraging good patient care. I will write a post addressing the treatment of CHF.

Then I’ll try to carry them down 3 flights of stairs on a reeves with a king tube shoved in their throat.

One of the most important things to do with respiratory patients is to sit them upright, unless the patient’s blood pressure is low. Using a Reeves is a bad idea, unless the patient is hypotensive.

When I finally get to transport I dump them in an ER where the resident pulls the Kingtube and gets to try a few times to put in the ETT before the attending finally steps in. Well that sounds a lot better for my patient.

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. Treat the patient with the treatments that decrease the need for intubation. Persuade your medical director to write protocols that permit this. By treating the patient to prevent intubation, and preventing intubation just happens to be good patient care, you get to frustrate that resident.

The resident would probably prefer not to pull the King airway and intubate. The resident would probably prefer to never have a reason to intubate the patient. The resident’s lack of understanding of the appropriate use of a King airway is an education problem. The doctors need to realize that they may not need to replace these airways.

Doctors also used to immediately deflate MAST/PASG (Medical Anti-Shock Trousers/Pneumatic Anti-Shock Garment). The ignorance of the resident does not justify bad patient care by EMS.

Oh, how about the anaphylactic patient that’s not responding to meds. We’ll just wait until we have to cric their neck, because we do that so often and that’s so much easier to practice.

Why do you believe that intubation would make that difference?

How about the asthma patient or the old COPD’er that doesn’t respond to meds. BLS bagging and alternative airways are so much better for transport.

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. There are too many studies showing horrible rates of intubation. I have written about some of these studies here, here, here, here, here, here, here, here, here, here, and here.

You know why they are called alternative airways? They are used as a last ditch effort to get any air into the body.

Please provide some documentation to support your claim about the origin of the term.

Maybe we should use the term alternative paramedic for those not capable of maintaining adequate intubation skills. The research demonstrates that the lack if intubation skill is widespread.

The name alternative airway is not evidence of anything.

Calling them alternative airways has nothing to do with their ability to provide an adequate airway. It has to do with the preconceptions of those naming the device. If they had been named superlative airways, would you demand to use them because the name says superlative?

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.

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

The actions of ill-informed emergency physicians and nurses do not determine the value of prehospital treatments. We need to be able to understand what is best for the patient. We need to base what is best for patients on outcomes research, as much as possible.

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.

We should attempt to have the terminology help us to understand the use of equipment. The research may significantly change the role of alternative airways. The terminology does not determine the outcome of research. The terminology should not limit appropriate care, either.

If they were truly adequate then you could admit the patient to ICU and never move it.

Maybe that is where the research is headed. Maybe some of the ICU patients will be better off with alternative airways, rather than endotracheal tubes.

They are temporary. My ETT can stay in until the patient needs it to be pulled.

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.

Another thing to consider is that the alternative airways may be less likely to result in trauma to the airway, infection of the airway, or other complications.

At least we use capnography to confirm placement though most ED’s RN’s don’t even know what a proper waveform is.

Which is it? Do you base your treatment on what may be done in the ED, or do you congratulate yourself on using better equipment that the ED?

You claim that it is wrong to use an alternative airway, because the ED will not use your airway. I disagree with your conclusion, here.

You claim that it is right to use waveform capnography, in spite of the ED not using your capnography. I agree with your conclusion, here.

No waveform, then the tube is pulled, PERIOD.

No!

Although waveform capnography is probably the single best form of tube confirmation, it is not perfect. Even waveform capnography results in false positives and false negatives. Since it is not perfect, having it overrule all contrary assessment is wrong and dangerous. I wrote about that particular mistake of airway management in Zero Tolerance V – Autopilot Oversight – Sparrowmict comment.

Learning to tube on a dummy or in the OR is fine but the last 4 tubes I had were made on people in real world situations.

The real world is where EMS works. Using dogma to guide treatment, rather than evidence is not good for real patients.

Vomitus, blood from a GSW pooling in the throat, a patient half under a bed, and one apneic in the grass behind an apartment build at midnight. No pretube waveform, no flicking of eyelashes, no controlled situation, no nothing. Just me and a F’d up patient that needed air.

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. As I have already mentioned, there are plenty of studies showing much less than adequate intubation success rates by paramedics in some systems.

If you want people to have 10 tubes before graduation and 2 a year in the field then fine but YOU are on a mission to stop a skill that has been used to save more people then will ever have showed up on any research report.

I am trying to limit intubation to people who might actually not be dangerous with a tube.

I am trying to limit intubation to patients for whom there is likely to actually be a benefit in their medical outcome.

The seatbelt of a car has saved many more then it’s harmed and it has harmed but do you think we should stop wearing them because of the 3% of the cases where someone couldn’t get out of the vehicle to safety.

I never made any such claim.

You are suggesting that the harm of prehospital intubation is less than the benefit. Not just a little less, but a lot less.

Before you start making claims about Mom, Apple Pie, and how wonderful prehospital intubation is, maybe you should show that the benefit is real. Please, just provide some evidence that there is as much benefit from prehospital intubation as there is harm.

When you can show me data that say medics are missing 25% I might start to agree that something might need to be done but every medic knows this skill.

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)

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]

You claim that there are no studies that show worse than 3/4 prehospital intubation success rate. That is an unacceptable success rate, but the reality is that I have written a bit about this study that only shows 1/2 success. It appears that you like to make dramatic, but completely wrong statements.

I do everything I can to avoid a tube and when I do it, it’s necessary.

I generally agree with this approach, but it seems to contradict your claim that intubation is so good for patients.

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

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

If I haven’t done one in 6 months so what, as a proficient medic I recognized the need, and I have been trained to perform, if I failed then most likely no alternative airway would substitute.

Maybe you would be good after 6 months of not intubating. Would you have had any practice with a mannequin, or with a cadaver, or anything else?

Even if you were still good at intubation after 6 months of not intubating, what about others? The research definitely does not support the belief that going 6 months without intubating is tolerable.

if I failed then most likely no alternative airway would substitute.

Another bold statement. Based on what?

The intubation research, that documents success rates of prehospital intubation, shows a pretty good success rate for alternative airways after the failure of intubation. This is exactly the opposite of what you claim about alternative airways not being able to substitute.

After all my rant answer me one yes or no question. Assuming the way medics are currently trained, do you think medics should intubate? Yes or No?

Which way that medics are currently trained?

If you mean the way that medics are trained as described in this study demonstrating intubation excellence?

This training includes didactic education in endotracheal intubation, alternative airway techniques, and skill simulation. Extensive education is provided in the pharmacology, indications, contraindications, and complications of the paralytic agent used, succinylcholine. Following didactic training, each student must successfully complete a minimum of 20 intubations, in the operating room, under the supervision of a board-certified anesthesiologist. Additionally, paramedics are required to successfully intubate at least one patient monthly for three years, post certification, and one per quarter thereafter. At least one intubation, annually, must be performed under an anesthesiologist’s supervision.

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]

Is that the way medics are currently trained? Yes, but only in some very limited places. Maybe prehospital intubation needs to be limited to places that maintain these standards.

Maybe we just need to stop making excuses for having such low standards.

Maybe we need to stop making excuses for harming patients.

.

Teaching Airway – Part I

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

On Teaching Airway: EMS Educast Episode 33, they have Kelly Grayson as their guest. The first of many times they will have Kelly Grayson as a guest. Hint! Hint!

Kelly says (50 minutes into the 1 hour show, so I am starting at the beginning) –

If you are going to allow paramedics to intubate, and I happen to agree with Bryan Bledsoe on this, . . . unless things change in the way we educate and regulate our EMS providers, within 10 years you are going to see intubation disappear from the paramedic skill set, except for a relatively few very well trained providers.

Since I have made similar comments, I want to point out the way that a lot of paramedics seem to interpret this sentence.

They are going to take our tubes away!

That ignores the really important part of the sentence. The part of the sentence that comes before and after the part I highlighted. That important part is this – unless things change in the way we educate and regulate our EMS providers, . . . except for a relatively few very well trained providers.

The way to prevent having the tubes taken away? If we really want to have intubation in our scope of practice, we need to continually prove that we can intubate well. We need to continually practice and work on learning more, if we expect to be able to prove that we can intubate well.

Many paramedics do not want to be told that. They want to be able to intubate, just because they think wanting to is enough. They want their Nobel Intubation Prize. Well, this isn’t politics, you actually need to do something.

What do we need to do?

Kelly’s immediately follows that with –

If we would pull the trigger and do what is necessary to make every paramedic like those well trained providers we envision intubating in the future. That’s what needs to be done. We need to have far more stringent requirements for intubation in the initial clinical experience. It needs to be far more than 6, or 8, or 10 tubes. If it takes an extra 6 months to get those tubes, then so be it. That’s the price we’re going to have to pay to be taken seriously. And once on the street, if you are not getting say X number of tubes – a tube a month, call it 12 a year – if you don’t get 12 successful intubations, or at least 12 attempts, in a 12 month period, there should be a clinical re-education requirement.

This was followed by Buck Feris saying, Agreed.

Can any of us disagree? Unfortunately, for many a medic/medic wanna be, that is asking too much.

Why should we have to be competent? Isn’t sitting through the classes, getting food for the preceptors as a bribe, and following all of the rules that I agree with – isn’t that enough?

Sure. That is good enough, but only if you work in a really unimportant job, not one where incompetence can kill patients.

We cannot demonstrate that prehospital intubation improves outcomes, but we insist on intubating.

Except for a few, we cannot demonstrate competence (pick almost any EMS intubation study), but we insist on intubating.

Why do we insist on harming our patients?

We need to prove that intubation works and prove that we have the skill to be trusted intubating patients.

We do have to want it. We have to want to work at competence – not whine about being victims and whine about not being given what we want.

.

Too Many Medics? comment from Anonymous

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

Sorry for the long post, but . . .

In the comments to Too Many Medics?, Anonymous wrote:

Grrr. Really trying to make an inflammatory post, aren’t we RM ?

Are you kidding? I tone it down to keep it nice and polite.

Couldn’t find a copy of the ACTUAL study, and I’m never a fan of quoting USA Today as a source of anything, other than maybe a horoscope.

I don’t read horoscopes, but here is the abstract.

Academic Emergency Medicine; Volume 13 Issue s5; May 2006; pages S55 – S56; abstract number 121:

Cardiac Arrest Survival Rates Depend on Paramedic Experience

Michael R Sayre, Al Hallstrom, Thomas D Rea, Lois Van Ottingham, Lynn J White, James Christenson, Vince N Mosesso, Andy R Anton, Michele Olsufka, Sarah Pennington, Stephen Yahn, James Husar, Leonard A Cobb.

The Ohio State University Medical Center, Columbus, OH,
University of Washington, Seattle, WA,
British Columbia Ambulance Service, Victoria, British Columbia, Canada,
University of Pittsburgh, Pittsburgh, PA,
Calgary Emergency Ambulance Service, Calgary, Alberta, Canada,
University of Washington, Seattle, WA,
St. Paul’s Hospital, Vancouver, British Columbia, Canada,
Calgary Emergency Medical Services, Calgary, Alberta, Canada

Objective

Out-of-hospital cardiac arrest (OOH-CA) survival varies widely among communities. We compared OOH-CA survival rates among 5 North American cities to identify factors that influenced survival.

Methods

The AutoPulse Assisted Prehospital International Resuscitation (ASPIRE) Trial was amulticenter randomized comparison of the effectiveness of manual chest compression versus AutoPulse during resuscitation of OOH-CA. Adults with OOH-CA were enrolled in five cities. Survival data collected in each city for patients in the manual arm of the trial were compared. Regression using generalized linear models was used to adjust for covariates.

Results

Younger women with witnessed ventricular fibrillation (VF) arrests in public locations who had short first response times had the best chance of survival. Victims receiving bystander cardiopulmonary resuscitation (CPR) had a trend to better survival. Time to advanced life support (ALS) vehicle arrival was not significant. The mean regression residual by site correlated with cases per paramedic per year (Pearson R = 0.97, p = 0.006).

Conclusions

Significant variation exists among the cities even after known predictors of survival are controlled. A positive correlation exists between more cases treated per paramedic and survival to discharge. Whether that relationship is causal or a marker for some other factor(s) cannot be determined.

Did, however find this nugget in ‘Emergency Medicine News’ from the MD that authored that study. Note his last comment in the excerpt.

Excerpt:

The study was presented at the annual meeting for the Society for Academic Emergency Medicine. Almost instantly, it was the darling of the media, hitting the pages of USA Today under the banner, “Cities that Deploy Fewer Paramedics Save More Lives.”

“It touches a nerve,” said Dr. Sayre in explaining why the findings of an academic presentation made such a splash.

For one thing, it’s a sound bite that sounds too odd to be true: The fewer the paramedics in the system, the more likely patients are to survive.

More Skilled?

He cautioned, however, that what remains unexplained is whether the data reflect a direct result, achieved because a relatively low number of paramedics who administer advanced life support are likely to become more skilled at it or whether the correlation is a sign that something else may be occurring, such as more intensive training among systems that have fewer teams or personnel. “It could be a marker; it could be a causal. We don’t know,” said Dr. Sayre, an associate professor of emergency medicine at Ohio State University Medical Center in Columbus.

Nothing odd about it.

There is no evidence that any of the ALS treatments improve outcomes. So, why would it be important to have paramedics arrive at a cardiac arrest quickly?

The focus should be on excellent BLS care. ALS personnel should understand that and help with the BLS. Many probably do not. In stead, they interfere with the quality of the BLS.

BLS, unlike ALS, has been shown to improve outcomes from cardiac arrest. The longer they focus on the BLS, the better for the patient.

Interruptions in Cardiopulmonary Resuscitation From Paramedic Endotracheal Intubation

Henry E. Wang, MD, MS
Scott J. Simeone, BS, NREMT-P
Matthew D. Weaver, BS, NREMT-P
Clifton W. Callaway, MD, PhD

Presented at the Society for Academic Emergency Medicine annual meeting, May 2008, Washington, DC.
Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA

Study objective

Emergency cardiac care guidelines emphasize treatment of cardiopulmonary arrest with continuous uninterrupted cardiopulmonary resuscitation (CPR) chest compressions. Paramedics in the United States perform endotracheal intubation on nearly all victims of out-of-hospital cardiopulmonary arrest. We quantified the frequency and duration of CPR chest compression interruptions associated with paramedic endotracheal intubation efforts during out-of-hospital cardiopulmonary arrest.

Methods

We studied adult out-of-hospital cardiopulmonary arrest treated by an urban and a rural emergency medical services agency from the Resuscitation Outcomes Consortium during November 2006 to June 2007. Cardiac monitors with compression sensors continuously recorded rescuer CPR chest compressions. A digital audio channel recorded all resuscitation events. We identified CPR interruptions related to endotracheal intubation efforts, including airway suctioning, laryngoscopy, endotracheal tube placement, confirmation and adjustment, securing the tube in place, bag-valve-mask ventilation between intubation attempts, and alternate airway insertion. We identified the number and duration of CPR interruptions associated with endotracheal intubation efforts.

Results

We included 100 of 182 out-of-hospital cardiopulmonary arrests in the analysis. The median number of endotracheal intubation–associated CPR interruption was 2 (interquartile range [IQR] 1 to 3; range 1 to 9). The median duration of the first endotracheal intubation–associated CPR interruption was 46.5 seconds (IQR 23.5 to 73 seconds; range 7 to 221 seconds); almost one third exceeded 1 minute. The median total duration of all endotracheal intubation–associated CPR interruptions was 109.5 seconds (IQR 54 to 198 seconds; range 13 to 446 seconds); one fourth exceeded 3 minutes. Endotracheal intubation–associated CPR pauses composed approximately 22.8% (IQR 12.6-36.5%; range 1.0% to 93.4%) of all CPR interruptions.

Conclusion

In this series, paramedic out-of-hospital endotracheal intubation efforts were associated with multiple and prolonged CPR interruptions.

[Ann Emerg Med. 2009;xx:xxx.]

Benefit to the patient of these interruptions in BLS treatment?

No known benefit.

Cost to the patients of these interruptions in BLS treatment?

Whatever small chance at resuscitation they had is lowered dramatically.

Why?

We have to have more medics, so that they can interfere with BLS care.

Once everybody is a medic, we will probably continue to argue over who has to put up with doing the demeaning BLS stuff, even though that is all that works in cardiac arrest.

From the full text of this journal article:

Assuming the need to reduce endotracheal intubation–associated CPR interruptions, potential strategies include improving paramedic endotracheal intubation skill or altering out-of-hospital airway management techniques. Improving endotracheal intubation skill may prove difficult, given limits in the quantity of paramedic student training and clinical endotracheal intubation experience in the United States.26-28 Although select paramedics attempt endotracheal intubation without stopping CPR chest compressions, the broader feasibility of this technique remains unclear. To minimize CPR interruptions, many EMS agencies have substituted endotracheal intubation with Combitube or King LT airway insertion.13 Select studies suggest the viability of CPR without ventilation, potentially obviating the need for airway management interventions.29,30 The relative effectiveness of these techniques remains unknown.

Why interrupt compressions to intubate?

Why intubate, in cardiac arrest, if an alternative airway is faster?

Why intubate, in cardiac arrest, if an alternative airway is just as good at airway management?

Why rush a medic to a cardiac arrest if the medic makes things worse?

Also, the more medics you need, the less selective you can be in choosing the ones you end up with. If you are going to scrape the bottom of the barrel, because the supply cannot meet the demand, and you will not pay well, you will get bottom of the barrel quality.

Maintaining quality is also important. This study might suggest that PFD (Philadelphia Fire Department) would have an excellent resuscitation rate. From what I was last told, PFD is 250 medics short of being fully staffed. PFD has political obstacles to consistently providing quality care. PFD has some excellent medics, but not because of oversight. The excellent medics are excellent because they work at it on their own. They are balanced by others, who easily dredge up bottom of the barrel analogies.

So, it is not just about numbers. However, the more medics you have, the harder it becomes to maintain quality. The harder it becomes to obtain experience. The combination of quality and experience are important.

More medics means a need for more medical oversight.

Do these everyone a medic systems increase the number of medical directors to keep up with the increase in medics?

Do they aggressively work at simulations to make up for their lack of touch with reality?

This topic will eventually be studied and written about more fully. This particular study is not likely to be published in anything other than abstract form.

Here is a study from Boston, where the number of medics is low and the quality is high:

Volume 52, No. 4: October 2008; Annals of Emergency Medicine; page S153; abstract number 364:

Success Rates in Out-of-Hospital Intubation

Temin E, Harrington L, Mitchell P, Rebholz C, Dyer K, Doyle J, Hughes P, Moyer P/Massachusetts General Hospital, Boston, MA; Boston Medical Center, Boston, MA; Boston Emergency Medical Services, Boston, MA

Background

Previous literature has questioned whether out-of-hospital endotracheal intubation (ETI) success rates can be comparable to those performed in the emergency department (ED). Prior studies report ED success rates ranging from 80%–98% with success rates increasing with the experience of the provider. Large studies on ground out-of-hospital intubation report success rates ranging from 33%-100% and a 77% success rate for rapid sequence intubation (RSI), all after multiple attempts. Although Bulger et al 2002 has reported similar out-of-hospital ETI success rates to the ED, some question whether this success can be reproduced in other services. Boston Emergency Medical Services (BEMS) is a 2-tiered system with all advanced life support (ALS) trucks staffed by 2 paramedics. BEMS has a ratio of 0.5 paramedics to 10,000 population making it one of the lowest ratios in the country.

Study Objective

To assess the proportion of successful paramedic out-of-hospital ETI on adult and pediatric patients in a 2-tiered urban EMS system.

Methods

A retrospective chart review from 7/1/06 to 6/30/07 of ETI data from the Boston Airway Registry was conducted. The primary outcome was the success rate of ETI by number of attempts (blade passing through the lips) overall and for the following subgroups: Cardiac arrest prior to ETI, medically assisted intubation (MAI) (any medication), rapid sequence intubation (RSI) (paralytic and sedative), documented head trauma, and pediatric (age ≤ 12 years old) patients. We used descriptive statistics with 95% confidence intervals for analysis.

Results

ETI was attempted on 569 individuals by 61 paramedics. Two were excluded due to incomplete data. 361/567 (64%) of patients were male, mean age was 56 years. 455/567 (80%) had a cardiac arrest prior to ETI. 97/567 (17%) had ETI attempted with MAI. 77/567 (14%) had ETI attempted with RSI. 107/566 (19%) had documented traumatic injury, of those 73/104 (70%) had documented head trauma. Of the 10 pediatric ETI 4/10 were male, mean age was 2.6 years.

Conclusion

In this EMS system, paramedics achieved high success rates in all ETI, comparable to those reported in ED settings. Further research should determine provider and system factors that contribute to this success.

It is only a matter of time until the research is done. Until then we have to wade through a morass of intubation results from the everybody a medic systems.

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]

Objectives

To determine 1) the success rate of prehospital endotracheal intubation; 2) the unrecognized tube malposition rate; and 3) predictors of tube malposition upon arrival to the emergency department (ED) in the setting of a large metropolitan area that includes 18 hospitals and 34 transporting emergency medical services (EMS) agencies.

Methods

Prospective data were collected on patients for whom prehospital intubation was attempted between September 1, 2004, and January 31, 2005. Endotracheal tube (ETT) position upon arrival to the ED was verified by emergency medicine attending physicians. Missing cases were identified by matching prospective data with lists of attempted intubations submitted by EMS agencies, and data were obtained for these cases by retrospective chart review. Successful intubation was defined as an “endotracheal tube balloon below the cords” on arrival to the ED. Patients were the unit of analysis; proportions with 95% confidence intervals were calculated.

Results

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).

Conclusions

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.

This is not a system with every person on every apparatus a medic, but their success rates are not good. Less than 80% success? 5% unrecognized esophageal tubes? We need to start improving quality or restricting skills to those who can actually demonstrate skill. Adding more medics only makes this quality problem worse. A system that is just doing more of the same is not one you want taking care of those you love.

Here is one from one of the happy everybody a medic Pollyanna places:

Prehospital intubations and mortality: a level 1 trauma center perspective.

Cobas MA, De la Peña MA, Manning R, Candiotti K, Varon AJ.

Department of Anesthesiology, Miller School of Medicine, University of Miami, Miami, Florida 33136, USA. mcobas@med.miami.ed

Background

Ryder Trauma Center is a Level 1 trauma center with approximately 3800 emergency admissions per year. In this study, we sought to determine the incidence of failed prehospital intubations (PHI), its correlation with hospital mortality, and possible risk factors associated with PHI.

Methods

A prospective observational study was conducted evaluating trauma patients who had emergency prehospital airway management and were admitted during the period between August 2003 and June 2006. The PHI was considered a failure if the initial assessment determined improper placement of the endotracheal tube or if alternative airway management devices were used as a rescue measure after intubation was attempted.

Results

One-thousand-three-hundred-twenty patients had emergency airway interventions performed by an anesthesiologist upon arrival at the trauma center. Of those, 203 had been initially intubated in the field by emergency medical services personnel, with 74 of 203 (36%) surviving to discharge. When evaluating the success of the intubation, 63 of 203 (31%) met the criteria for failed PHI, all of them requiring intubation, with only 18 of 63 (29%) surviving to discharge. These patients had rescue airway management provided either via Combitube (n = 28), Laryngeal Mask Airway (n = 6), or a cricothyroidotomy (n = 4). An additional 25 of 63 patients (12%) had unrecognized esophageal intubations discovered upon the initial airway assessment performed on arrival. We found no difference in mortality between those patients who were properly intubated and those who were not. Several other variables, including age, gender, weight, mechanism of injury, presence of facial injuries, and emergency medical services were not correlated with an increased incidence of failed intubations.

Conclusions

This prospective study showed a 31% incidence of failed PHI in a large metropolitan trauma center. We found no difference in mortality between patients who were properly intubated and those who were not, supporting the use of bag-valve-mask as an adequate method of airway management for critically ill trauma patients in whom intubation cannot be achieved promptly in the prehospital setting.

From the full text of this journal article (PHI = Pre-Hospital Intubation):

The significant difference we found in the success of PHI performed in connection with air (67%) and ground transport (33%; P < 0.001) may reflect the deployment to aerial units of paramedics with more experience and skills, including intubation, because it is usually a promotion from the ground units. Although this study did not correlate intubation skills of individual paramedics, data from Germany, where air rescue crews perform ETI three times as frequently as ground crews,1 support this. Therefore, clinical experience of those performing the intubation is invaluable and perhaps the most important piece of the PHI puzzle.

The 67% and 33% are a bit misleading. They are the percentages of the overall successful intubations, not the percentage of intubation attempts.

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).

52% is still a number that should not be tolerated in intubation. There are 2 considerations not made clear.

How many of the failed intubations actually had intubation attempts?

How many intubation attempts did they have?

Maybe we need to include another data point? Total intubation attempts.

If almost all of the patients actually had intubation attempts and there were 2 attempts before moving to an alternative/rescue airway and some of the successful intubations were on the second attempt, then the success rate per attempt is possibly much lower than 1 in 3.

How many holes are we dealing with in the airway?

Hush. Let’s not be inflammatory. If we throw more medics at it maybe one of them will find the trachea.

In these everybody a medic systems a piñata might live for ever. The patients on the receiving end of the intubation attempts might be jealous of the piñata.

Even the flight crews only intubated 82% successfully. That is about the same as the ground medics in the Denver study above it. It is true that this is trauma, while the others are not limited to trauma.

At least to me, the most important conclusion from that study seems to be (PHI = Pre-Hospital Intubation):

Therefore, clinical experience of those performing the intubation is invaluable and perhaps the most important piece of the PHI puzzle.

What about intubation in the system that had the highest resuscitation rate in the original study – Cardiac Arrest Survival Rates Depend on Paramedic Experience?

Here is an abstract from their 20 year study of intubations. These medics do use succinylcholine. So do the flight crews in Miami. They did break down their results into trauma intubations and medical intubations. How did this system do? They focus on keeping the number of medics low and the quality high. Let’s see:

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]

Emergency Medical Services, Bellingham/Whatcom County Washington, WA 98225, USA. mwayne@cob.org

Objective

To determine the safety and efficacy of succinylcholine, as an adjunct to endotracheal intubation, administered by paramedics trained in its use.

Methods

Retrospective review of 1,657 consecutive patients, aged 16 years or older, receiving prehospital succinylcholine administered by paramedics. In this community of 175,000 people, trained paramedics intubated both medical and trauma patients with the assistance of succinylcholine. Main outcomes measured were success of intubations, complications of the procedure and/or the drug, and use of alternative methods of airway management.

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.

Conclusion

Paramedics trained to use succinylcholine, to assist the process of endotracheal intubation, can safely intubate a high percentage of patients.

They intubated 94% of trauma patients successfully over a 20 year period.

From the full text of this journal article is the most likely explanation for the high success rate.

Following didactic training, each student must successfully complete a minimum of 20 intubations, in the operating room, under the supervision of a board-certified anesthesiologist. Additionally, paramedics are required to successfully intubate at least one patient monthly for three years, post certification, and one per quarter thereafter. At least one intubation, annually, must be performed under an anesthesiologist’s supervision.

I will repeat that Paramedic Intubation. It may be that intubation is the easiest way to measure paramedic quality. On the other hand, it may be that a lack of intubation skills is a good indicator of a lack of overall paramedic quality, rather than the other way around. It seems that many systems have a significant problem with quality. In some of these low quality systems, the attitude does not appear to be to fix the quality problems, but to make everyone a medic. How is more of the same an improvement?

EMS in Boston and Bellingham/Whatcom County take airway management seriously, while the everybody a medic people in Miami average 1 – 3 intubation per medic per year. After however many attempts at intubation, they still only get it half right.

What do the everyone a medic systems do about quality?

Miss.

A lot.

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Paramedic = Intubation IV

Still on the topic of paramedics and lack of intubation success begun in Paramedic = Intubation I, Paramedic = Intubation II, and Paramedic = Intubation III.

What if the numbers in the research are misleading?

They are misleading. That is one of the reasons I write so much about them.

Look at the many ways we might describe an intubation attempt:


  • Any opening of the intubation kit.
  • Any attempt to visualize the airway, even if there is no use of a laryngoscope or endotracheal tube.
  • Any insertion of the laryngoscope in an attempt to visualize the airway, even if just to determine if it is appropriate to attempt to intubate.
  • Any airway use (BVM, LMA, CombiTube, King LT, crichothyrotomy, endotracheal tube), even if intubation was never attempted.

We do not even remotely have agreement about what is an attempt at intubation.

For example, I arrive to find a patient supine with a patent airway, but depressed respirations. I initiate BVM ventilation while assessing for other potential life threats. My partner gets a history, list of medications, et cetera. The rest of the assessment shows a cachectic elderly male with no signs of trauma, supine on the floor. Ventilation by BVM is adequate with good chest rise and no abdominal distention. I transfer BVM to my BLS partner. My partner ventilates the patient successfully, while we move the patient to the ambulance. Even though this patient has plenty of whiskers and dentures, which we removed, he is not showing any signs of any complications that would indicate problems with ventilation. En route, I start an IV and draw bloods, back when the hospitals would accept our blood draws. Now I don’t start an IV unless I anticipate a specific need.

Back to the purpose of this little anecdote. In some of these intubation studies, this would be described as an unsuccessful intubation attempt, even though I never attempted intubation. We need to be careful in the way we discourage appropriate airway management by using language that is critical of those managing the airway appropriately.

Did I do anything wrong?

No.

The emergency physician was not happy, because he wanted an intubated patient. Apparently, he does not consider it important for BLS personnel to get experience managing an airway. He did not make any statement to acknowledge the nice ventilation job being done by my partner. He does not consider airway management important, unless the tube is in the right place.

The endotracheal tube was in the right place.

The tube was still in my intubation kit, unopened.

The emergency physician wanted to intubate the patient, not because I couldn’t, but because the emergency department is much more limited in airway management resources, when it comes to non-intubated patients. I could have avoided this by intubating the patient prior to going in to the ED. It isn’t as if I’ve never intubated in the parking lot to protect the patient from certain emergency physicians, who are less than skilled at airway management.

I thought it would be good to show the doctor that some of the EMTs are excellent at airway management. I overestimated this particular emergency physician.

This emergency physician will probably get over it.

Maybe this emergency physician will even learn.

It isn’t as if this would be a difficult tube – cachectic edentulous* patients can sometimes be intubated orally even without the use of a laryngoscope. Just with positioning of the airway.

This is one of the reasons that the AMA needs to create a separate specialty of prehospital medicine. The differences between emergency medicine and prehospital medicine are tremendous. This physician is/was medical director for several ALS services. He should have had a better understanding of EMS, but he did not. If some emergency physicians are this ignorant of good patient care, how can we expect the medics to understand good patient care? The medics have so much less education.

A smarter EM physician would have had me intubate the patient, while being observed by the physician. As I mentioned, when it comes to EMS supervision and airway management, this EM physician was not known for his smarts, but for his temper. Who knows, maybe he has changed. That’s me – the hopeless optimists. 🙂

How do we do research on airway management, when many of the doctors do not understand what they are studying?

Paramedic Intubation.

Intubation Airway Management.

^ *
Cachectic = wasted away, frail, exhibiting signs of poor nutrition.
Edentulous = toothless, having lost teeth.

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Paramedic = Intubation III

As paramedics, we have become so identified with intubation that we have trouble thinking of EMS without intubation.

Maybe we will retain intubation, but only as an advanced paramedic skill. In some systems, no medics will intubate. In some systems, few medics will intubate. In some systems, a lot of medics will intubate. In some systems, all medics will intubate.

The differences among these various approaches will be based on how much time/effort/money/other resources we are willing to put into training/oversight.

This may be something that many medics will oppose, feeling that all medics have the right to should be permitted to intubate.

This is the wrong approach. We need to address what is best for the patient, not what we feel is best for the status of the medic. We are not the priority. Our skills are not the priority. The patient is the priority.

We need to address how the patient may benefit from the skills we allow paramedics to use. We need to decide if we are willing to do what is necessary to acquire and maintain those skills. If we are not willing, then we have already made the choice about whether paramedics should intubate.

Paramedic Intubation.

Intubation Airway Management.

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Prehospital Intubations and Mortality – comment from RevMedic

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

RevMedic is not a name that signifies driving very fast – revving the engine – but that is what pops into my head every time I see his name. I know. I am by-passing St. Peter. I am not collecting 72 virgins. I am going straight to the great big tanning bed. This is not news.

RevMedic does all sorts of photography in the Newberg, Oregon area. If you need a photographer with some common sense, he seems like the guy to call.

Anyway RevMedic knows his stuff. Here is his comment on the post Prehospital Intubations and Mortality – comment from Herbie.

“I would much rather see medics using a BVM during their OR time, than intubating. Good BVM use is far more important than intubation skill.”

Absolutely. I can’t tell you how many times I’ve seen ineffectual ventilations with a BVM. There sits the EMT (at any level), blissfully unaware of the air blasting out from underneath the mask and not paying attention to the lack of a seal.

How is it that we graduate EMTs and medics, who are not skilled at airway management?

How is it that we graduate EMTs and medics, who do not understand airway management?

It isn’t as if the courses suggest that there is a skill that comes before airway.

Excellent BVM use is all about assessment.

BVM excellence is the cornerstone of airway management.

Without excellence in the use of the BVM, the rest of airway management does not matter.

I prefer to do some of the bagging with patients who need ventilation. It is a skill that needs to be used, to be maintained. This also sets a good example for everyone else. This demonstrates to everyone else that, at least as far as I am concerned, skill with a BVM is a priority.

We also will find that some of the patients do not need to be intubated. Intubation should not be for the benefit of the medics. Intubation should be for the benefit of the patients.

There was another event where I was bagging the patient in preparation for intubation. I was having trouble getting an adequate seal, and asked for another set of hands. We had 4 PARAMEDICS in the rig, and the other three were solely concerned with getting the intubation equipment set up, preparing the drugs, etc. I had to repeat myself several times and finally loudly call one by name and DEMAND his/her assistance, before we achieved adequate ventilations.

One of the best uses for a separate pulse oximeter is to throw the machine at someone, when you need there attention. It can be very effective. It also demonstrates how little importance should be attached to the machine. It is just a tool, a slow tool, that should not be warning you that something happened, but should confirm what you already know from your continuous assessments.

One of the problems with these studies of systems that have horrible intubation success rates, is that their BVM use is probably just as bad. How much of the bad outcome is due to BVM incompetence, rather than the inability to put a tube in the right hole?

If we make the patient hypoxic enough in our focus on the intubation, does it matter if we are successful with the intubation?

No, it does not.

If we allow the patient to vomit and aspirate in our focus on the intubation, does it matter if we are successful with the intubation?

No, it does not.

RevMedic finishes up with:

BVM is the lost art of airway control.

There is only one appropriate response to that:

Amen.

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PediCap Product Recall


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

This is the Pedi-Cap.

For comparison, here is the Pedi-Cap next to its big brother/sister, the Easy Cap II.

It is tiny. To give you another idea of the size, here it is being used on an itty-bitty baby, who could fit in my hand.


Photo credit

This device is a simple piece of litmus paper. CO2 (Carbon diOxide) is acidic. In the presence of CO2, this paper will change from Purple to Yellow. The concentration of CO2 determines how yellow the paper becomes.[1]

Some of the problems with this are due to it being nothing more than a piece of litmus paper with a supposedly airtight plastic cover, airtight except for the connections. When litmus paper becomes moist, it does not do what we want it to do in the presence of CO2. It does not tell us if there is any CO2 present.

We are looking for the CO2 because that indicates that the tube is connected with a place that either has a reservoir of CO2, or to a place that is capable of exchanging CO2 for O2 (Oxygen).

If you have been providing mouth-to-mouth ventilation, but have been filling the belly, rather than the lungs, that would be one source of a CO2 reservoir at the end of the esophagus. After a while, the CO2 should be removed. In the mean time, you may be misled into leaving the tube in the esophagus and ventilating the stomach. This may not turn out well.

Contraindications
• Not to be used for detection of hypercarbia.
• Not to be used to detect main stem bronchial intubation.
• Not to be used during mouth-to-tube ventilation.
• Should not be used to detect oropharyngeal tube placement.
Standard clinical assessment must be used.[2]

This is a description of a problem with the Pedi-Cap.

Began ventilating patient with pedi-cap and peds ambubag. Patient began to desaturate immediately. Could not force air thru ambu with Pedicap on. Removed pedi cap and ventilation was accomplished. O2 sats improved. Manufacturer response (as per reporter) for CO2 detector, Pedi-Cap “size of the paper in the detector was dimensioned incorrectly causing the device to have a higher flow resistance.” Testing other lots to see if same problem exists.[3]

Let’s look at this step-by-step.

Began ventilating patient with pedi-cap and peds ambubag.

No problem, yet.

Patient began to desaturate immediately.

Not a good sign. PALS (Pediatric Advanced Life Support) teaches a 4 step assessment for sudden deterioration of an intubated patient using the mnemonic DOPE (not something to say out loud in front of family). D = Dislodged; O = Obstructed; P = Pneumothorax; E = Equipment failure.

Could not force air thru ambu with Pedicap on.

That would be D for Dislodged. E does not really apply, since that is supposed to be for patients on a ventilator, but use whatever works.

Removed pedi cap and ventilation was accomplished.

Problem solved, but I am guessing that the reason for the assessment of CO2 has not been addressed.

O2 sats improved.

I’m assuming that the CO2 was evaluated in some way. Maybe they just kept ventilating and figured that the response to ventilation with bagging was confirmation enough. The immediate improvement in oxygen saturation is unlikely to be a false positive.

Manufacturer response (as per reporter) for CO2 detector, Pedi-Cap “size of the paper in the detector was dimensioned incorrectly causing the device to have a higher flow resistance.” Testing other lots to see if same problem exists.


Image modified from the Nellcor product manual.

Nice work by the person ventilating the patient in quickly recognizing a problem and reacting appropriately.

August 14, 2009

Dear Valued Customer,

We are informing you of an urgent voluntary medical device recall regarding the PediCap End-Tidal CO2 Detector (PediCap and PediCap 6).

We have received a customer report in which they experienced difficulty manually ventilating an intubated patient through the PediCap. While we continue to investigate, we believe that a recent modification to the PediCap End-Tidal CO2 Detector may result in increased resistance to airflow through the PediCap. This could result in ineffective ventilation of the patient and/or inadequate detection of CO2 levels, so that the indicator paper will not change color.

Although we have received no reports of patient injury, we have determined that all PediCap and PediCap 6 End-Tidal CO2 Detectors from the lots listed below must be returned. We are requesting your assistance in conducting this activity. Please review your inventory and segregate any product with the affected lot numbers and return affected product according to the directions below[4]

Likewise, it is nice to see a company responding with a recall, rather than waiting for a patient to be injured. Only one week between the FDA notice and the company recall. While it could be faster, some companies will keep denying problems even after there are a bunch of dead bodies from their product.

Footnotes:

^ 1 CO2 detection sheet
Nellcor
Free PDF

^ 2 Pediatric End-Tidal CO2 Detector PediCap®
Nellcor
Free PDF

^ 3 FDA Medical Product Safety Report
FDA
08/07/2009
I cannot get Blogger to accept the html for a link to the FDA page. Cut and paste this link:

http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/medsun/medsun_details.cfm?ID=%25″-O%3D%25_X%20%0A

^ 4 URGENT MEDICAL DEVICE RECALL for PediCap™ End-Tidal CO2 Detectors
Covidien (owner of Nellcor)
August 14, 2009
Free PDF

All necessary information, to contact the company, is in the pdf. Also included are the numbers of all of the lots involved.

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Paramedic = Intubation II

To continue on the topic of paramedics and lack of intubation success begun in Paramedic = Intubation I.

Why is it so hard to improve?

Explanations exist; they have existed for all time; there is always a well-known solution to every human problem — neat, plausible, and wrong. H. L. Mencken.

Unfortunately, Mr. Mencken appears to have anticipated the problems with EMS airway management.

We seem to produce medics faster than the NR can produce Not Responsible EMT-P patches.

Do we need a lot of medics?

No.

In a lot of places, we have so many medics, that the medics average only about one intubation per year, per medic. In other places – places with much fewer medics – the intubation success seems to be dramatically better. In these places, where medics are less common and used more carefully, medics are much less likely to be compared with blind squirrels. At least as far as paramedic skills are concerned.

So we just need to get rid of a lot of medics?

We do, but that is only a part of the solution to airway management.

Paramedic Intubation.

Intubation Airway Management.

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