Recent discussions in EMS circles have revolved around the idea of removing endotracheal intubation from our standard of care because we seem to not be very good at it or don't do it often enough to remain proficient.
Kelly Greyson's recent article at EMS1.com added fuel to my fire when he discussed the number of intubations medics are asked to get prior to being released into the field.
My program required 10 in the OR and I remembered thinking that was far to few.
Far too few to be proficient at an airway that was not at comfortable waist height.
Or an airway that didn't have a comfortable chair and clean place to rest my equipment.
Or an airway that hasn't been fasting for a day incase there is vomit.
Or even an airway that started out just fine, then got worse on the stairs while carrying them downstairs in the dark.
We are GROSSLY undertrained compared to our nursing and medical friends and it is directly related to our being considered a trade. We are put on the bottom of the pile for live intubations, not because we aren't good at it, or do it seldomly, but because we are seen as kids, unskilled laborers with lights and sirens. In some programs I'm told instructors are having to beg to get OR time for their students.
When I went through the OR for my tubes, I recall having to get permission from the patients and being scared to ask. Then the Anesthesiologist grabbed the form and took it to each patient and explained to them that if I didn't learn there, with him watching, how would I be able to do it to them in their bedroom in the middle of the night.
Every person signed, even the young lady whom I knew from school.
The Doc understood that of all the folks who need training on ETI, the first ones in the door should be given first shot, because if not now, when?
Did my 10 tubes that day make me a good airway manager? - No. But it got me over the initial fear of inserting a blade into a living person and looking for real cords.
We are reminded that the gold standard of airway management is not the endotracheal tube, but adequate gas exchange at the cellular level. A perfect example of this in practice is CPAP. With this tool we can assist a patient towards a positive outcome without shoving a piece of plastic into their throat, just onto their face.
But the more I consider my last few intubation attempts I am constantly distracted by the basketball games on TV. So and so is 17 for 32 and having a great game.
17/32?
I'm 4/5 on my last few tubes I can recall and felt like a failure. We shouldn't be "missing a tube" in the field and delivering it to the ER (or the ME in some cases) but using stats like these to take away a tool is insane.
Imagine if a police officer who shot at 5 suspects only hit 4. Would we be considering taking away his weapon or sending him to the range for more training?
The firefighter who puts out 4 of 5 room and content fires isn't stripped of his hoseline and told to leave firefighting to the insurance company, we train more.
Mailcarrier delivering to the wrong house, bus driver missing a stop, kid at the Starbucks screwing up my order. Lose the mail van? Take away the bus? Take coffee away? All insane options, but for some reason when we make mistakes the first answer is to take away a vital tool I need available. For what? I don't know, but when I need it and it's gone, what will I do then?
We need more training. We all know it, but no one is going to come by the station and give it to us.
More importantly, we need to back away from the airway kit when the BVM is working. I'm a firm believer in the "start simple" school of airway management, which states that if gas exchange at the cellular level is adequate for tissue perfusion, keep doing what you're doing. Reassess and act as needed.
If the industry wants to solve the ETI stats by taking the tubes away I can then guarantee a success rate of ZERO. Instead, let's apply the same metric to IV starts, medication errors and just disband EMS all together, because if you take one tool because we misuse it and don't remediate the provider, the problem will spread.
The problem IS NOT the ability to intubate the trachea, it is poorly trained practitioners using a tool they do not completely understand in a manner that may not even be necessary.
If an MD needs 200 tubes to be considered proficient, then misses repeatedly in the ER, can I take his tubes away if I can sweep in and get it first try with only 10 under my belt in training?
Of course not, because if they need that tool another time I want them to have it available. Now offer me the same consideration and perhaps we can all move forward.
Comments
If you were 4 for 5, recognized it in the field, switched to an alternative device, and were 5 for 5 in appropriately managing the airway: there is no problem.
As long as airway management is taught as the continuum that Kelly and yourself advocate, medics should continue to intubate.
However, education in intubation as a procedure is lacking and its not entirely a function of live practice. Poor technique ("mash the blade all the way in and retract") and light reading (my book had 2/3 of a page on intubation) make for poor intubators, especially if we've had no real practice. Even then, we're just substituting experience for knowledge. We need to revamp our airway management education along the lines of the bigger STEMI programs.
Every airway managed appropriately, every time.
My first few months were interesting
My sense of it is that many of those screeching loudest about keeping ETI because it is an "essential" skill, probably utilize it inappropriately. Few seem to get that you can actually make a patient's clinical course more problematic with a properly placed endotracheal tube. It is not a benign procedure, even when you hit the hole you were supposed to.
That lack of perspective is, as Christopher stated, a direct result of the lack of initial airway education in most paramedic programs. All too many programs suck at teaching how to insert the tube, which is the most easily remedied problem.
Much more problematic is teaching medics enough to know when, why and why not to insert a tube. That is going to take much more than "you must insert X number of tubes to complete the program."
The way I see this going is, in 10 years or less, intubation is no longer going to be a core skill for paramedics. Instead, it will be an optional one determined by state and system medical directors who have taken the time and effort to see that their medics are educated and trained adequately in the procedure. Intubation will be a skill confined to a much smaller cadre of paramedics, and we will have brought those restrictions on ourselves.
I'm no longer entirely convinced that's a bad thing.
There is also a huge variation in paramedic training. My course was a full year, six months of didactic, five months of clinical, two weeks of full time field internship. It was grueling, but I learned a lot. I think it made me a better paramedic, but the education process has to be continuous and career long. I see a lot of resistance to that, again, across delivery models.
Intubation is a symptom of a systemic problem. The reason that it's so high profile is that the stakes are so high. Nonetheless, the problem is no less severe when it comes to trauma care, STEMI recognition, Stroke recognition, and just about every other area of EMS. Another symptom of the problem is all of the alphabet courses that are out there to make up for the shortcomings of EMS education. In an ideal world, all of that would be included in the paramedic curriculum.
The King works great...sometimes. We need a way to practice our ETI skills more regularly though.
LM (Sam the EMT's old partner)