Saturday, July 3, 2010

Big Boys taking our toys

So I was reading an article/blog written by Rogue Medic. If you haven't checked him out, you should. He's incredible! Some of the things he writes about are just fantastic. He brings an interesting spin to the EMS Table. Anywho, he posted about Customer Service in the EMS application. (Here's the link:

What struck me was about the idea that intubation success was not taken seriously, and he sited various examples. I agreed with his entire article, but the comment about taking away of the tubes struck a nerve. I was from a state that tried it for a while and failed miserably, so here's my retort for that particular side of the coin:

The taking away of the "ALS" Airway like Endotracheal Intubation is a double edged sword. Yes, there are a lot of medics out there who suck at it because it's not a skill that is done often enough to gain proficiency. The problem is, there's nothing in place to allow us to get better at it.

Flight Medics, Nurses, Doctors, what have you, are given the opportunity, and in some companies, are required to go in hospital every month to obtain ten intubations. The state I used to live in required all Flight Medics and Flight Nurses to go in hospital and get 10 tubes either in the ER or the OR.

Now try to call a hospital and get in to their ER or OR to "steal" tubes away from the interns, residents, and Flight Providers, you may get shot on site.

Medics have a hard enough time while precepting getting ER/OR time in when they have to, let alone any other time.

The mentality of, if-they-don't-do-it-let's-take-it-away won't work. Think for a moment about your drug box and all the other little Para-toys we have in our scope of practice.

You know that Hare Traction splint? We hardly use it, so since we don't that means we're not proficient in it, so let's get rid of it.

OB Kits? That's what hospitals are for. Since EMT's and Medics don't deliver them on a regular basis, let's trash those as well.

Needle Decompression/Needle Crich Kits? Nope, just taking up space. Trash that.

Drug wise? Well, Dopamine, Dobuatime, those clumsy Mark 1 (or whatever addition your on) kits, Versed (for those services that carry other drugs that can stop seizures)...the list goes on and on. If our ambulances were subject to usage reviews, at the end of a year, we'd have no equipment!

You take away intubation and you add another "mindless" airway adjunct, fine. You're still going to run into the same problem; lack of usage.

Also, when the docs sit around in their Fat Cat Pow-wow and decide which toys they're going to take away because of failed usage, they just look at numbers. They don't look at Paramedic Smith who was trying to intubate a kid while upside down, in a ditch, in the dark, at 3 am while generators were going, and all he could see by was the little bulb at the end of his blade. They don't look at Paramedic Johnson who was trying to intubate a smoke inhalation victim whos' airway was swelling shut because his service took away the expensive TTJ's and needle cric. equipment for "lack of use". All they see is a missed intubation.

Where is our hands on, remedial training? I'd love to be able to go in to the ER/OR once a month, hell, once every three months and get to practice. I got kicked out of OR's while precepting for my Medic because I wasn't a nursing student/person who wears flight suits to work/person who wears a lab coat to work.

If this mentality continues, we can expect to go backwards in time, back to when we were throwing someone in back and hopping up front.

I'm not throwing a temper tantrum because they want to take *my* tubes away, I'm pissed off they want to take my ability to save lives in an effective manner away. Why don't we take something away from the IV's. Doctors turf that out to Nurses and IV Tech's and lowly Interns. When was the last time you saw a full fledged doctor do an IV on someone besides a cut down or a femeral stick? I bet if someone stood up and said they wanted to take IV's away from doctors, we'd have a herd of stampeeding white coated Angrius Doctoriis and the creation of "IV Remediation" classes would begin.

I ask all medics and other Pre-Hospital providers who can make someone chew plastic, to stand up for your right to do it. If you let them take tubes away, what else are they going to take away from you?


  1. You know, I have yet to hear anything even remotely positive about this whole situation. When are the "bigwigs" going to clue in?
    You hit it right on the head when you said they just look at numbers...if they have a problem with the lack of skills, the solution should be more training, not taking equipment away.
    Can you imagine if that's how parents treated their children? Little Johnny doesn't do so well at tying his shoes, so let's just give him velcro shoes for the rest of his doesn't solve the problem, it just pretends that it doesn't exist and raises a whole generation to believe that they don't have to try. If this keeps up, the next EMS generation is going to look much the same way.

  2. While I'm happy to disagree with Rogue Medic from time to time (idealism v realism) I have to defend him here. If you go back through his archives you may note that he does not advocate taking intubation away from medics in general. Just taking it away from incompetent medics. His big emphasis on this has been that most? medical direction takes a head-in-the-sand mentality toward dangerous providers and those medical directors see the solution as restricting the skill rather than providing the training to maintain adequate proficiency.

    Of course, I differ with him in some of this interpretation of the EMS intubation "studies." And yes, I know that the plural of anecdote isn't data. The issue that I take with many of those studies is that they use inconsistent definitions of "successful." They look intubation rather than airway management. [Confession time: I rarely intubate patients anymore. With the exception of cardiac arrests, I usually make use of medications and mechanical devices like CPAP.]

    But on topic, when the studies consider an appropriately ventilated patient with an "alternative airway" in place to be a failed intubation, I take issue with that. I have had patients whose anatomy did not lend itself to intubation with the equipment that my service carries. I placed a combitube instead and delivered them appropriately oxygenated to the hospital while treating their other issues. Was this a "failed" attempt? No. This was appropriate management of an airway within the limitations of the equipment that I was carrying.

    If this were my only patient for the analysis period, does this mean that my intubation rate is 0%? Yes, but that is misleading. It also means that my airway management was 100%, just utilizing a different means than that being measured. Does it mean that I shouldn't be allowed to intubate? Hardly. It means no more or less than I could not intubate a particular patient and managed the airway with an alternate device. Like cutting a seatbelt with my lockblade when the blade of the purpose built "seatbelt cutter" in the unit was rusted and dull, or when I couldn't get the angle to cut it with shears.

  3. The only "failure" that should matter when looking at prehospital intubation is an unrecognized intubation failure. That is a failure to appropriately assess (reassess) one's patient, and reflects poorly on the medic overall. That being said, how are those "unrecognized failures" being recorded for the study? Most likely by radiography in the ED.

    Radiography involves (generally) a portable X-ray, which in turn involves placing the "film" behind the patient's chest and taking the "photo." If the tube is misplaced in this X-ray, the tube is considered an unrecognized failure. Do you see a problem with this? I do. Tubes can be dislodged by patient movement. This is why we are supposed to (and I do) reassess ventilation quality after each patient move. The radigraphic technician does not do this s/he moves the pt, plces the film, shoots, moves the patient again to remove the film, then leaves.

    To call the studies "flawed" is like calling the sun "a little bright."

    What it comes down to is this: in every profession there are people who get by at the minimum level of competency, those who excel, and those who cannot even consistently perform at the minimum. Attempts to limit an entire profession by the performance of those who fail to meet the standards is insane. No profession would be allowed to do anything. Heck, look at ambulance drivers' (not Ambulance Driver's) performance and you should conclude that with the egregious behavior of some, none of us should be on the road at all.

    You have a point about equipment utilization though. With the amount of 911 abuse we see, the ambulance itself is the only piece of equipment consistently on each call. If we reduce our equipment to that, we'd be a lot cheaper to run and probably have a different name..."taxi." Of course, there's a reason that I'll call in to the hospitals as "Cabulance" with some fares.