Airways: Don't Let Them Take It Away!

[x635 4,066]

It seems nowadays pre hospital airways are a big conterversy.

Some noted doctors in the EMS community are saying the Paramedic's shouldn't be doing advanced airways, citing poor performance and not having enough experience.

Personally, I feel that airways are one of the things (most) Paramedics do best. It's one of our MAJOR skills- and one that makes the most difference, IMO.

I also have been reading several studies and articles on this online-it seems that Paramedics have more of a sucess rate at first time endotracheal intubation then in the ED then many doctors and residents. And it's been my experience where Paramedics have been asked by ED docs to intubate in the ER due to their skill.

Granted, I know a lot of doctors don't realize how difficult it is in the field to secure an airway. BUT, if you know your anatomy, keep up on your skills and eduication, and your technique is muscle memory, you shouldn't have an issue in a large majority of your cases. It shouldn't be that difficult, especially nowadays with all the tools we have at our disposal. And, just because we have those tools- we shouldn't be overzealous to intubate when we can foresee a different clinical outcome.

So, just a reminder to my Paramedic friends again...keep your airway skills sharp, your placements clean, be clinically proficient, and documentation excellent so that we can continue to use this vital tool!

[STAT213 332]

Good post Seth. We do need to be careful, because there are those who would like to see us armed with OPAs and BVMs again. Problem is, we can't PROVE prehospital ETT is a good idea. We can say it is, but there is no proof. There no outcome studies proving we help people b intubating them. Heck, there is little EVIDENCE to prove paramedics save people.

That being said, one of the things we have changed in our operating procedures is to have the ETT confirmed on arrival @ the ED by ETco2 and clinical signs BEFORE the patient is moved from our stretcher to the ED stretcher. That way, when the tube is dislodged with the move, the ED doc can't blame us. I do it by positioning myself between the two stretchers and give any grabbing hands a little tap until the ED doc does what I want.

We did educate our hospital about this practice before we showed up and started slapping hands, and they are very on board with it. And, credit goes to San Diego Fire, it was their idea and program that we stole.

Rob

[Guest 40-32 Comms]

Take ET away from the medics? Only if it's because you're making it a BLS skill!

In a nutshell, the ultimate function of EMS is to deliver a (preferably neurologically intact) patient, who is perfusing oxygenated blood, to definitive care in the ED. Everything else is gravy.

Whether you are an ALS or BLS provider (I have been an Intermediate for 9 years, with 9 years before that as a Basic), your primary tasks are: definitive airway and oxygen management, circulatory support, bleeding control, and safe and timely transport.

Someone once said, "It's all about the ABCs. - If you don't manage the Airway, then you can move on to Bury 'em and Call the florist." To me, it seems utterly absurd to talk about removing the gold standard in airway management from the EMS tool kit. If the issue is poor skills performance, then we must address our skills and training issues, not jeopardize the patient by removing a definitive treatment modality.

Multiple clinical studies have shown that endotracheal intubation is fundamentally a mechanical skill that can be mastered by almost any level of provider. However, as with any mechanical skill, the keys to proficiency at any level are repetition (to build muscle memory), ongoing practice, focus on procedure, and proper assessment skills.

STAT213 is certainly correct. One of the major chronic issues in EMS care is a lack of proper clinical studies to argue either for or against the efficacy of any number of treatment modalities and protocols. Unfortunately, the very nature of our endeavor makes it very difficult to obtain that data. We simply do not know who our next patient will be, and the ethics of obtaining informed consent in a critical emergency situation make establishing meaningful control and test patient groups extremely difficult.

Emergency medicine is also unique in that it is arguably the only field where patients are not allowed the opportunity to evaluate their provider’s qualifications before deciding to enter into their care. That places an even greater obligation on us to ensure that we can perform at an optimum level, and to advocate for our patients, even when the issue is our own skills.

Extra flashing lights and loud air horns do not save lives. Skills and clinical judgment do. If we cannot focus ourselves on the things that truly impact our care then we risk losing the skills that can help our patients, and failing as their advocates before we have even begun to provide care.

[firemoose827 324]

I also have been reading several studies and articles on this online-it seems that Paramedics have more of a sucess rate at first time endotracheal intubation then in the ED then many doctors and residents. And it's been my experience where Paramedics have been asked by ED docs to intubate in the ER due to their skill.

I agree with you 100%. I was called for a transport about 10 years ago with a pt in severe respiratory distress. My partner and I, both EMT-CC's at the time, arrived to find the ER staff preparing the pt for RSI. The nurse was giving the SUCCS and the doc was grabbing the ET kit. When we looked at the doc his hands were shaking so bad, I thought he was going to knock himself unconcious with the Laryngoscope! He looked at us pleadingly and we stepped up and intubated the pt for him. He couldnt stop praising us for saving him ( the doc) from embarrassment.

Some docs just dont perform the skill enough either, but you dont see the hospital staff taking the skill away from them. It would be pointless and dangerous to remove that skill from the medics arsenal, with the airway being our primary concern as EMT's.

Good topic.

[Guest alsfirefighter]

I'm with you also. While I understand why when there are studies coming out left and right showing basically there is little to no outcome change for using or not having ETI, I never favor management by removing something. I can attest that myself and the guys I work with have a very high precentage of successful ETI's. Unfortunately for us, all it takes is one bad provider to ruin the great work of 99 others and llets face it they are out there.

[mfkap 0]

As not having used one before, I am asking from a position of the uninformed:

What is the resistance against the combitube? Why do people feel it doesn't work as well as a ET tube for short-term airway management? Shouldn't it, ideally, do the same thing without the potential for oropharyngeal trauma that ET placement can cause?

[ny10570 745]

I'm with you also. While I understand why when there are studies coming out left and right showing basically there is little to no outcome change for using or not having ETI, I never favor management by removing something. I can attest that myself and the guys I work with have a very high precentage of successful ETI's. Unfortunately for us, all it takes is one bad provider to ruin the great work of 99 others and llets face it they are out there.

You nailed it as usual. Much of the research pointing towards the removal of ETI from the field is based on studies out of slower areas and based on airway injury. Often times medics don't have an option past ETI (until recently if ETI failed we only had needle cricothirotomy in NYC). That leads to some rather "agressive" intubation and some potentially significant complications. We are our own worst enemies in that we aren't that great at intubation. There are still a lot of right main stem and esophageal intubations. We all know the right way to do it, I'm not going to start preaching, but if you aren't sure don't do it. Another issue that Stat mentioned is easily addressed without a formal system in place. Don't leave your patients head until you have confirmed the tube is still in place and report it to the attending or who ever it is you're turning the pt over to.

Combi tube is not a definitive airway. If an ET tube is the key to airway management then combi tube is a hammer. The pressures created by the cuffs cause far more damage than the cuff of an ET tube. The dual lumen design makes the device larger and potentially more damaging to a swollen airway. It is not indicated in laryngeal spasm, edema, or airway trauma. It cannot be used in children. All that asside, any area without reliable ALS needs a device like the combi tube. When done correctly with an uncomplicated airway ETI causes no significant damage especially if cuff pressure is measured.

Edited February 12, 2008 by ny10570

[ONEEYEDMIC 68]

I think intubating is a skill you either have or you don't. I think you have to be very confident in yourself to do this skill as well. I have seen many MEDICS as well as DR's not able to get a TUBE. They think they get it, but they don't. The result is they get to the ER and the PT hasn't been getting enough O2 which results in a poor outcome for the PT. Many MEDICS wait on scene way too long attempting to get the TUBE. PRIDE gets in the way. Just TXP and say you couldn't get it. How many times have you heard that a PT was too ANTERIOR? Come on now, not everyone is ANTERIOR. How come people forget that you have simple tricks to help you out. Put a pillow or towel under the shoulders. It helps so much. Have your partner or EMT do CRIC pressure. I don't think they should take it away from EMS. What needs to be done is a study on how many tubes a MEDIC gets in a year. If you are only doing TXP's, your aren't getting that many tubes. Being in a busier place will make your TUBE numbers go up. Now of course you have those BLACK CLOUD people that always get the CARDIC ARREST, MI, CHF, etc...or TRAUMATIC situation. These are the people that don't seem to be able to do this skill.

I happened to like getting TUBES. I knew that I was good at it. Wouldn't mind NASAL either. Thought that it was easier with a CHF PT then trying to force them to open their mouths and get it in their airway. It is also a good feeling when an ER DOC picks you in the ER to do tube rather than a RESIDENT or STUDENT.

So don't take this skill away. Monitor how many are being done SUCCESSFULLY in the field. Right Mainstem is kind of successful. That could be from moving the PT or just the ride to the ER. At least the PT was getting some O2 and the belly didn't look like a VOLCANO.

[x635 4,066]

Alternative airway devices are great and all, but still NOTHING tops direct largynoscopy. RSI is only working to help that, where the systems have it in place.

There are extreme situations where you may not be able to get an airway, but there are also many different tools to assist with DL and make the placement easier. Every agency should invest in devices, especially ones like the Bougie, a form of stylet that is used widely in Europe, is cheap, and easy to use. You slide it in the airway, it is designed to go right into the trachea. After that, you slip the tube right over that and into the airway.

Another part about intubation is the bagging....the situation, adreanaline is pumping, and we tend to bag WAY too much. Remember, proper ventialtions (10/min), HELP the patient. 30/min adversly affects the patient. Except in head trauma.

Also, let's not forget the Bag valve mask with OPA and 100% O2 is also a great way to maintain and airway worse comes to worse.

[mfkap 0]

Alternative airway devices are great and all, but still NOTHING tops direct largynoscopy. RSI is only working to help that, where the systems have it in place.

There are extreme situations where you may not be able to get an airway, but there are also many different tools to assist with DL and make the placement easier. Every agency should invest in devices, especially ones like the Bougie, a form of stylet that is used widely in Europe, is cheap, and easy to use. You slide it in the airway, it is designed to go right into the trachea. After that, you slip the tube right over that and into the airway.

Another part about intubation is the bagging....the situation, adreanaline is pumping, and we tend to bag WAY too much. Remember, proper ventialtions (10/min), HELP the patient. 30/min adversly affects the patient. Except in head trauma.

Also, let's not forget the Bag valve mask with OPA and 100% O2 is also a great way to maintain and airway worse comes to worse.

I wonder why you say that alternate airway devices don't top an ET tube? Aside from times when it is not indicated, the combitube has been proven to be statistically identical to the ET tube in blood O2 levels(1), and they have the advantage of being statically faster from start to O2 delivery(2), and have a higher success rate in placement(3). You also can avoid the problems of tubes moving, misplaced tubes, etc. Also, OPA and BVM has been shown to have much worse patient outcomes and lower blood O2 levels (1,2,3). Yet when I have seen a medic who can't get a tube, they don't reach for the combitube, they sit there and try to tube 2 more times? I understand the reasons to not lose the ability to use an ETA, but at some point it seems like the EMS ego takes priority over patient outcome. For an uncomplicated cardiac arrest, when every second counts, why is the combitube not reached for first (or immediately second)?

(1)http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&uid=8214838&cmd=showdetailview&indexed=google

(2)http://cat.inist.fr/?aModele=afficheN&cpsidt=14650396

(3) http://www.ncbi.nlm.nih.gov/sites/entrez?d...;indexed=google

[NWFDMedic 58]

I understand the reasons to not lose the ability to use an ETA, but at some point it seems like the EMS ego takes priority over patient outcome. For an uncomplicated cardiac arrest, when every second counts, why is the combitube not reached for first (or immediately second)?

There is no advantage in time for placing a Combitube versus an endotracheal tube, so I really don't get your argument here. The equipment takes longer to assemble and the same time to insert/inflate.

There are obviously cases where the ETT is necessary and the Combitube is inappropriate, so why would you even think of using a Combitube on an "uncomplicated cardiac arrest"? There are three things that generally make a provider better with his ET intubations. The first is technique. If you don't have that, you need practice. The second is experience. The third is confidence, which usually comes as a result of good technique and experience. I don't ever want to see the day where we're placing Combitubes in cardiac arrests without attempting an ETT, because we'll be losing the techniques, skills, and confidence that medics require when you get that really tough tube on an anaphylactic patient. (Of course, you shouldn't be spending time trying to get a tube that is that difficult when you have alternate methods.)

As far as time is concerned, where do you get the idea that seconds count in an uncomplicated cardiac arrest? By the time you get to inserting an ETT, you should have already applied whatever electrical treatment is necessary, and the patient should already be oxygenated and circulating to the best of our CPR ability. The tube (or any advanced airway) is more of a luxury and convenience than anything else, it's not a lifesaving tool in cardiac arrests.

[INIT915 1,119]

Yet when I have seen a medic who can't get a tube, they don't reach for the combitube, they sit there and try to tube 2 more times? I understand the reasons to not lose the ability to use an ETA, but at some point it seems like the EMS ego takes priority over patient outcome.

I have to agree, and I've seen it first hand. Many see the failure to place an ETT as a personal and professional failure and will do whatever it takes to place it. Arriving at the ED with a Combitube is seen as "weak" (for lack of a better term).

[ny10570 745]

If you show up with a combi tube in place on an uncomplicated arrest you really need a good excuse as to why you could not intubate your patient. If you can't get it done now then how are you going to get it done when the conditions suck and the pt isn't lying out on the floor in front of you. Yes I understand there times when it just isn't going to happen but they need to be few and far between.

[INIT915 1,119]

If you show up with a combi tube in place on an uncomplicated arrest you really need a good excuse as to why you could not intubate your patient. If you can't get it done now then how are you going to get it done when the conditions suck and the pt isn't lying out on the floor in front of you. Yes I understand there times when it just isn't going to happen but they need to be few and far between.

Why would you need an excuse?

[Guest alsfirefighter]

I understand the reasons to not lose the ability to use an ETA, but at some point it seems like the EMS ego takes priority over patient outcome.

With all due respect...provider to provider...but I've seen this comment passed along several times on this topic and in general throughout my career. Maybe its I just don't get it, being I'm of similiar thought as oneeye that I don't feel uncomfortable with any patient you will throw in front of me and if comes down to intubation I don't even think twice about it. I take 2 attempts with a good ventilatory period between and I do not take more time then I need to, you either get it or you don't. After that I go to an adjunct airway device. HOWEVER...unless you specifically know a Paramedic who specifically demonstrates or verbalizes this type of mentality, no one should judge what the reasons are behind a medic trying to secure an airway. For we are the only ones who know what decisions we have to make in addition to running a scene, directing other providers on scene, etc.

Here's a question that can be posed for the Combitube lovers: If they are so quick and effective why aren't they used as first line airway control/management in the hospital setting for cardiac arrest as well?

I will grab a Combitube, King airway (excellent for tactical medics), PtL etc first when (god forbid) the protocols lead that way or they can make one that will definately make entry in to the trachea a high percentage of applications so I have the option of medication adminstration by that means. Other then that I have used them as my first choice in intricate trauma incidents where direct laryngoscopy was extremely difficult or not able to be performed, ie. patients pinned upright in a car seat in respiratory arrest while awaiting extrication from a vehicle.

I'm not sure where the timeline comes into play, but it doesn't seem to take me very long to open 3 packages (ETT, stylette, ambu tube holder) and to unfold my laryngoscope to turn the light on. The 4th package gets used with either and that's my CO2 connector for my LP12.

Some of it comes down to experience based on solid training in ETI techniques and practice. Its alot more then just sticking a blade in someones mouth and pushing hard. Good medics get difficult tubes because they have been trained correctly, have had experience dealing with these issues and remeber the techniques like oneeye mentioned to faciliate intubation. Cric pressure is a tremendous help, the towel/sheet method works when appropriate, I even had one arrest where I had a partner lift the patient by both arms causing the head to flex posteriorly as far as possible and it gave me a direct view.

Don't get me wrong...I'm not bashing anyone for their argument of adjunct direct airway control devices. They have their place and I use them. However, I can find a study to state anything...I am a medical professional, I train hard, I study hard and I work hard to be a professional every time I step through the door of my firehouse and give quality effective medical care to all my patients. There is no ego involved...for those of you that know me, compulsive yes, demanding yes, if you operate based on ego..check it at the door or find another profession.

[mfkap 0]

Here's a question that can be posed for the Combitube lovers: If they are so quick and effective why aren't they used as first line airway control/management in the hospital setting for cardiac arrest as well?

I will grab a Combitube, King airway (excellent for tactical medics), PtL etc first when (god forbid) the protocols lead that way or they can make one that will definately make entry in to the trachea a high percentage of applications so I have the option of medication adminstration by that means. Other then that I have used them as my first choice in intricate trauma incidents where direct laryngoscopy was extremely difficult or not able to be performed, ie. patients pinned upright in a car seat in respiratory arrest while awaiting extrication from a vehicle.

I'm not sure where the timeline comes into play, but it doesn't seem to take me very long to open 3 packages (ETT, stylette, ambu tube holder) and to unfold my laryngoscope to turn the light on. The 4th package gets used with either and that's my CO2 connector for my LP12.

I just want to state for the record that I am not a huge advocate of the Combitube, but more of a person who sees people operate with blinders on. I have personally seen time wasted by medics where a combitube could have done the trick. I have also seen more than 2 or 3 of the "tubes shifted" incidents, which I am sure everyone has. And I am not a paramedic, but a medical professional as well. I have a similar volume of training and experience when compared to a medic, and enough training to know what is right and wrong when being done by a paramedic. Now on to the questions:

They aren't used in the hospital setting because it is not an ideal piece of equipment. It has its problems, mostly when left in for prolonged periods. Also, as a medic, I can guess you might tube someone once a week if I am being generous. Most code teams in a hospital have an anesthesiologist on it, and they do, conservatively, more tubes as a resident than a paramedic does in their career. If you are talking about the ER docs, doctors have ego's too. Oh, and some have the video laryngoscopes.

As you say, you are a medical professional. And I am sure you have read the 3 peer-reviewed studies that indicate that epi has the same level if it is put in the lungs or the stomach, if the stomach dose is exactly 10x the lung dose. So I am not sure how the meds down the tube argument matters.

And the timeline probably has to due with the second shot you take at putting in the ET tube vs. the combitube, as well as the time taken in placement of the ET tube.

Again, I am not saying that combitubes are better. I am saying that putting in a combitube is considered "weak" and a poor performance, and this has more to do with ego than current medical research. If I am the person that is coding on the floor, and my arthritis makes it hard to see the chords, I would rather you spend 30 seconds getting a combitube in than 3 minutes with a medic trying to get the right angle for the ET tube.

[Guest alsfirefighter]

I am saying that putting in a combitube is considered "weak" and a poor performance, and this has more to do with ego than current medical research. If I am the person that is coding on the floor, and my arthritis makes it hard to see the chords, I would rather you spend 30 seconds getting a combitube in than 3 minutes with a medic trying to get the right angle for the ET tube.

And what I am saying is if the above type of conditions exist where you operate something is wrong at a higher level. I never look at the use of any adjunct airway device as "weak" nor poor performance but rather a good decisions if I cannot successfully facilitate intubation. As far as code teams...the 2 hospitals I worked for didn't always send an anesthesiologist to codes and with 1 being I worked in the OR I've seen the gambit of intubation "techniques" and volume doesn't always mean sound practice.

Have I skimmed the study you mentioned about epi...yes...what does it mean to me...nice to know information being I can't administer it in that fashion. I have to use what I am authorized to do.

Funny you should mention the video laryngoscopes...the rep was in the ED I primarily transport too several weeks ago and I sat through the little spiel and played with it and when asked what I thought I almost had to giggle. Does everything have to be like a video game today?

[WAS967 97]

Funny you should mention the video laryngoscopes...the rep was in the ED I primarily transport too several weeks ago and I sat through the little spiel and played with it and when asked what I thought I almost had to giggle. Does everything have to be like a video game today?

We had similar. We had the guy in the ER showing of his little device (not the one with the detachable vide screen, but the one with the little view scope on it) and the guy was VERY cavalier about "how well" it got the tube in. If we really wanted a good device to play with for intubation, we'd all be carrying endoscopes.

Hokey religions and ancient weapons are no match for a good laryngoscope at your side, kid.

Edited February 18, 2008 by WAS967

[Guest paramedico987]

PRO:

I don't have to carry the 10 pound tube roll anymore...

CON:

Lots of people are gonna die.

[helicopper 1,050]

Great thread! I'm almost certain that there is a correlation between volume in an ALS system and success at intubation but regardless of where you operate, a major consideration is patient movement after the tube is placed. This speaks volumes about the need to frequently assess tube placement during and after patient movement/transport/transfer to the ED. I like the policy STAT mentioned so the tube is verified by the ED doc before the patient is bounced from stretcher to stretcher.

[ny10570 745]

Biggest correlation between success and failure with any treatment has nothing to do with call volume. Its service size. In a service were the Med Director knows his medics and can train all of them personally the success rate climbs tremendously.