OK, the argument on pre hospital intubation has been going on for some time now. Should we or shouldn’t we. How do we train, remain competent and prove that we can do it, successfully every time. Is that 100% success rate a realistic number? What have you done to improve your success? What can be done as an industry to improve and prove our success?
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Show notes:
Take the ETI Skills survey click here
Thanks to Sean M. Kivlehan, MD, MPH, NREMT-P for calling in. Be sure to take advantage of Sean’s CE articles over at EMS World – Continuing Education Articles
Also thanks to Garth from the EMS blog Drug-Induced Hallucinations for sending me some great info and feedback on this topic.
Check out RogueMedic.com for some pre hospital intubation posts that are sure to get the juices flowing.
Finally, here are some articles on the topic that are of interest.
No difference in the time needed or success rates between ETI or King airway: http://www.ncbi.nlm.nih.gov/pubmed/21763247
Paramedic RSI improves neurologic outcomes at 6 months: http://www.ncbi.nlm.nih.gov/pubmed/21107105
Dutch paramedics have a 95% success rate at ETI, even with a low overall number of intubations. ETCO2 is strongly recommended: http://www.ncbi.nlm.nih.gov/pubmed/21612142
Policy Statement from ACEP cautiously supporting prehospital RSI: http://www.acep.org/content.aspx?id=29188
http://blog.dr-exmedic.com/2011/05/13/gcs-8-intubate/
Hi Jim,
A few thoughts on prehospital intubation for you. I’m a medic on an ambulance out here in the greater Portland, Oregon area. We’re not Austin-Travis or Boston or Wake County; no nationally renowned third service here. We’re ALS fire with contracted private ALS ambulance. You know … red and white buses. National company. THAT company. And yet …
We do intubations, and we do them pretty darn well. We do RSI too, for both trauma and medical patients. I don’t have the numbers handy, but I know our intubation success rate is over 90%, and our failed intubation and “failed airway” rate is very low.
How do we do this? I have a few insights.
First, foremost, and last but never least, WAVEFORM CAPNOGRAPHY. It’s mandatory on every intubated patient, and I mean MANDATORY. Three strikes and you’re out. First intubation chart without a couple ETCO2 strips attached (one post intubation and one at transfer of care) gets you a nastygram from QA. Second gets you a meeting with QA, a supervisor, and a written warning in your file. Third gets you a meeting with the medical director and your intubation orders revoked. I don’t think this has happened to anyone.
Second, we have good policies about alternative airways and number of attempts. Two attempts each by two experienced providers, and then the King airway goes in. No ifs, ands, or buts. For cardiac arrest, the usual expectation is that we look with a laryngoscope while compressions are going; if we see it, we put a tube in. If we don’t see it, we put a King in.
Third, we are reminded that “the definition of insanity is doing the same thing with expectation of different results” and encouraged to change something — positioning, blade, add a bougie — on every intubation attempt.
Fourth, we have a hard and fast load-and-go rule for trauma patients. The expectation is if you need to RSI a trauma patient, you will throw them in the rig, get moving, and as you are pushing meds your partner will pull over just long enough for the actual intubation. Then it’s off and moving again. Long scene times on a trauma for airway management will get you a sit-down with QA and the medical director.
Finally, though I’ve mentioned it before, I cannot emphasize enough the role of aggressive, involved Quality Assurance / Quality Improvement. We have a full-time QA staffer and an active medic/MD QA committee. And while I’ve mentioned getting in trouble, generally medics do not automatically get disciplined for clinical issues (except specific ones such as above, where it’s clearly laid out in writing). Instead the focus is on learning, understanding, and individual improvement.
While I think individual competence, training, and experience all play a huge role, and while I do feel like a system with fewer medics will have more experienced providers and thus better success rates, I believe that capnography and QA are the two essential components that will prevent bad outcomes and keep ETI in the hands of paramedics.
And, once you have a patient vomit around a King and end up on a high-frequency oscillating vent, or have the King plain not work, or the combi-tube not fit, and you work in a suburban or rural area with long transport times … well, you will agree that ETI definitely SHOULD be a part of the medic’s toolbag.
Hi Jim,
I wish I would have known you had this site a long time ago. Anyway you have touched an extremely hot topic where I work. As the above response from Garth stated, we are none of the above mentioned prolific agencies either. I work in a county that has an EMS Agency and we are one of 2 Fire departments that transport. We recently had our RSI privileges taken away due to an interesting find. With the use of RescueNet, we are able to see and record all of the diagnostic tools available to us; ETCO2, SPO2, B/p, and Rhythm and Rate. We have seen SPO2 drop to the teens and patients go into idioventricular rhythms while trying to get a tube. So the end conclusion reached by our Medical Director is that; even though we are establishing the “gold standard” of airway management, we are causing harm to the patient in the long run neurologically. So as a county, we have taken a step back to re-evaluate not only our need, but the way we perform and train for our endotrachael intubation skills.
The only real issue I have with this decision is that our Aero Medical Paramedics are still able to intubate and utilize RSI. As the Medical Officer for my department, I am going to impliment their practices in my department in hopes of regaining our privileges. To start, every paramedic has to perform 10 intubations every shift on all 3 of our manikins( adult, pediatric, and infant). These will be recorded through video laryngoscopy ( we will be purchasing the King Video), this will be our main laryngosope of choice. We will also include a minmum number of O.R. rotations on a yearly basis for our live continuing training. Thorough QA/QI will be conducted on all intubations and training done by our medics. Monthly in-services will also be done covering not only a constant review of the training, but also on the diagnostic tools I mentioned earlier. End tidal capnography is required by the State of Florida to confirm E.T. tube placement, and the use of RescueNet plays a big QA/QI role for us.
One of the most important training points we need to get across to our paramedics is to treat priority one patients as trauma patients in regards to getting them do a definitive care facility in an expidicious manner. We have seen delays in transport times due to the medics trying to facilitate intubation, when many times; the BLS or Supraglottic airways they have in place are adequately ventilating the patient. We do have some rather long transport times ( greater than 15 minutes) so we may fall behind the 8 ball more than places with shorter times.
Finally, to answer your question: are we able to achieve 100% success rate? NO WAY. Video laryngoscopy, training, QA/QI, and experience may get us close, but I believe King County Seattle boasts the best rate at 96%. If you look at their Intubation Privilege Paramedic Program, it is INSANE, and they can’t achieve it.
Take Care, and Be Safe
Hey Randy, thanks for posting and showing that sometimes we do have to step back and re-evaluate what we do. Sometimes thats a whole process like you described and sometimes it can be that one tube you can’t seem to get. So, step back change the blade, positioning, device etc. Good points and while 10 per shift may sound like a lot. Perhaps in the future that can be adjusted according to future training QA/QI tracking.
Feel free to join in on the next podcast. Gonna talk about drug adminstration errors.
Jim
I also wanted to post this email response I got from a Paramedic course coordinator:
Hey Jim:
I was unable to hear the show on Sunday but I was very interested in the topic that was discussed. I did listen to the recording this morning and wanted to share some of my thought with you regarding pre-hospital intubation.
The skill of intubation, performing such a skill and ensuring competency of providers has been a problem without a magic bullet solution for years. If you take a look at the NHTSA Paramedic National Standard Curriculum it states:
“The following goals must be successfully accomplished within the context of the learning environment. Clinical experiences should occur after the student has demonstrated competence in skills and knowledge in the didactic and laboratory components of the course. Items in bold are essentials and must be completed. Items in italics are recommendations to achieve the essential and should be performed on actual patients in a clinical setting. Recommendations are not the only way to achieve the essential. If the program is unable to achieve the recommendations on live patients, alternative learning experiences (simulations, programmed patient scenarios, etc.) can be developed. If alternatives to live patient contact are used, the program should increases in the number of times the skill must be performed to demonstrate competence.”
These recommendations are based on survey data from Paramedic Program Directors and expert opinion. Programs are encouraged to adjust these recommendations based on thorough program evaluation. For example, if the program finds that graduates perform poorly in airway management skills, they should increase the number of intubations and ventilations required for graduation and monitor the results.”
Regarding Intubation specifically:
“The student must demonstrate the ability to safely perform endotracheal intubation. The student should safely, and while performing all steps of each procedure, successfully intubate at least 5 live patients.”
As a Paramedic Program CIC and Clinical Coordinator we are consistently reviewing ways to increase the level of experience that our students receive in class, skill practice lab and field experience. Here are some of the changes we made so that our students receive the required initial training and ensure competency upon graduation.
1. We have acquired and currently us the most advanced simulation manikins available. Some of the features include: the ability to perform head tilt chin lift, jaw thrust, oral and nasopharyngeal suctioning, bag mask ventilation, orotracheal and nasotracheal intubation, placement of combitube or LMA and other airways, endotracheal intubation, retrograde intubation, fiberoptic intubation, transtracheal jet ventilation, needle and surgical cricothyrotomy, variable lung compliance, airway resistance, right mainstem intubation, and stomach distention. Complications include can’t intubate/ can ventilate, can’t intubate and can’t ventilate, tongue edema, pharyngeal swelling, laryngospasm, decreased cervical range of motion, and trismus. The simulator also provides ETCO2, SPO2 with live waveform readings the student can see. The simulator is completely wireless and notifies the instructor when a student performs a procedure, even if it is not verbalized. For example when a student checks for a radial pulse the simulator recognizes this and it shows up on the instructors screen.
2. We have explored additional options for the operating room clinical component for our students. Experience in a clinical facility that is affiliated with a learning institution increases the chance that the student will be able to practice. Issues in the operating room including use of the LMA, other student health care providers, liability and informed consent of the patient has been barriers we are aggressively trying to overcome.
3. We require our student to attend an 8 hour Medical Examiner Clinical Rotation. We have an agreement with the OCME in Queens and even though for some of our students it may be a 2 hour trip it has been a learning experience second to none. I personally attend all OCME rotations so that I ensure the experience includes an extensive airway review with hands-on experience. I am currently trying to convince the OCME to allow the students to practice intubations on the cadavers prior to autopsy.
4. We have identified an ongoing issue in the clinical education of paramedic students relating to clinical training in health care facilities. We are exploring the possibility of providing preceptors in the facilities we contract with so that students are trained by EMS professionals instead of relying on other health care providers that are proficient in their area of education but are not aware of what is expected of an EMS provider. I believe placing a preceptor in the facility and providing a conduit for student and facility staff to collaborate will provide an experience that will be beneficial to the student, staff and patient.
As you know all regions have advanced airway procedures outlined in specific protocols. It is painfully obvious that EMS has a history of taking a reactive rather than proactive way of thinking. A suburban county for example had an intubation “error rate” of 25% at one point. To combat this issue REMSCO required all advanced providers to show proficiency every year by returning to 1 of the 3 EMS academies and demonstrate the skill on a manikin under the supervision of an instructor. I am unable to find anything that shows a decrease in that number since procedure was enacted. I am very supportive of re-education of a provider and solving the problem rather than having the skill completely removed from use.
Here is an example of what worries me as a provider, educator and maybe an eventual consumer of an EMS service. In a large urban EMS System the medication Lasix had been used for years for patients suffering from pulmonary edema. Lasix was a standing order medication with a dose ranging from 20-80 mg IVB. In a surprising move when protocols were being updated and training was implemented to ensure providers were aware of the changes lasix was removed from standing orders and placed in medical control options. When questions were made of the change the response was that of a parent talking to a child. Lasix was removed from standing orders because providers were inappropriately administering it to patients with pneumonia or other respiratory conditions. The consequence was an increase of mortality of these patients due to electrolyte imbalance complications. In this example the problem was identified but the solution of just removing it from standing orders does not fix the problem. A process of educating the providers on the long term risks associated with Lasix administration, identification and assessment of patients that would qualify for the medication as well as review of lung sounds and a review of outcomes post review would have been beneficial to the providers and in the end to the patients we serve.
The use of alternative airway devices and adjuncts has had a detrimental affect on the basic technique and skill of providers. While I am a proponent of “plan B” it has become a crutch for some providers. The thought process of “I don’t have to be good at ETI because I have __________” is not the standard I want to see as a professional. The same goes with other “crutches” (auto BP cuffs, 12 leads that interpret for the provider, SPO2, ETCO2) that have been provided under the disguise as adjuncts. The best skill a provider has is the ability to perform a comprehensive patient assessment and recognizing S/S of a condition, treating that condition and adjusting your treatment to the response of the patient. While I do understand and appreciate these adjuncts I am aware they have pitfalls that when relied on 100% can lead to horrific consequences.
Each EMS system, service and individual provider has a responsibility to the people they serve to provide the highest quality of care possible. Part of that responsibility is to identify deficiencies and correct them as needed. A good QA/QI program is a start but just having it on paper is just as useful as having a guard dog without teeth. Removing skills and procedures that have been supported by medical research as not beneficial is a required component of providing medical care. On the other hand removal of skills and procedures because of an identified issue that can be corrected within our own profession is unacceptable.