Sunday, July 11, 2010

The Great Intubation Debate (Part 1)

First off, let me say two things. Number One: I am so excited as an EMS provider that Paramedics and EMT's alike (both ground based Medics, Flight Medics, and those who work in hospital) are concerned about something so important; Intubation. We are all well aware that there needs to be a system wide change in how Intubations are taught, handled, and "scored" in the field. Number Two: I have to say the posts on this subject that I have seen are excellent! Please don't take offense to me disagreeing with your post; if I didn't like the content and thought you were so way off base I never would've given it a second thought to even write a rebuttal.

Anywho, Rogue Medic wrote about Intubation Education. Go ahead and read it, it's very well written and has a lot of great points.

Now, RM states: We act as if the OR (Operating Room) is the only place that we can obtain good practice. There is no evidence to support this.

There is nothing to show that OR training is superior to morgue training and mannequin training, but we act as if the decreased availability of OR time is the only reason medics can't intubate competently.

The decreased availability of OR time is not the only reason medics can't intubate well, but it is a big one. When was the last time you saw a mannequin with a severe facial deformation? A trachea so anterior or posterior that no matter how hard you apply crichoid pressure or manipulate their head back to the point of turning them into a lighted Pez dispenser can you even get a glimmer of cords?

When was the last time you saw a mannequin with cords so discolored and raw from years of smoking unfiltered Marborlo 100s and the wracking emphasemic cough that has them looking more like raw pieces of hamburger, or little slivers of charcoal?

As for the morgue, I can honestly say that my state did not allow anyone below an RN into the morgue; I tried to get in. Also, yes, the Coroner may have done some sort of ER time when s/he went through med school, but what type of advice can you get from them on intubating a live patient? When was the last time they held a blade and tube in their hands and intubated something that wasn't already cold and stiff?

The OR/ER is the only place, in my opinion, to get real world intubating practice. You have someone who does nothing but makes people really sleepy, then makes them chew plastic all day long. You get the smokers, those suffering such severe kyphosis of the spine that you can't get the head and neck to go into the sniffing position, those with Mallampati scores no less than 3. You just can't get that on mannequins.

We act as if the only problem with the way we are teaching paramedic school is that the students are not learning. As if this is not a reflection on the teaching.

Teaching means providing information to students in a way that helps the students to understand. If the students do not understand, the teacher did not teach.

Unfortunately, Paramedic classes are made up of a multitude of students. You have those who have been through Medic class over a half a dozen times, if not more, those who have never been in the field...the ones who's ink isn't even dry on their EMT card before they hopped in class, the know-it-all's who have been in the field since before Christ turned water into wine and they're just doing class because they want to be just like their childhood hero's from Emergency!, and then the ones who are being medics for all the right reasons.

Now let us say that you have six of each of these students. The first six have been taught over and over again how to intubate on a mannequin, so therefore believe that they are "good" at it, and have done their required OR time to the point that the CRNA's know them by name. They're just doing whatever the good instructor/doctor/nurse tells them so they can move on and maybe pass the final this time

The Second Six: The Eager Beavers: They can barely hold the blade before they make a mess in their pants. Their whole EMS existance has revolved around this one golden moment that they tune EVERYTHING out just so they can put that blade between the plastic lips of the mannequin. They'll say "Yes! I understand!" just to put that blade in. Instructors take that as the newbie screwing up and they get some remedial training, but even then that may be taken as a grain of salt by someone who, once they get their first tube, no matter how badly they fudged it up, think that's the way to do it.

The Third Six: They've seen every Medic in the world intubate, so they claim. Most of these students will claim that they, as mere EMT's, had a blade thrust in their hands because the Medic had his hands ripped off/maimed or was incapacitated somehow, and they managed to intubate the haemophiliac great-grandmother of 30 who was on her way to church and was in an accident that turned her jaw to mush, but somehow, he intubated her perfectly. I seriously doubt they even pay attention during any of the lectures and get lucky when they sink a tube correctly.

The Fourth Six: The Baby Medics: These Medic Students may have seen an intubation, but were too busy focusing on patient care to really pay attention. They have the thought process, maybe even the mechanics, but are listening at rapt attention during the lecture, and are the ones seen staying after class to get help on how to intubate.

Also, everyone needs to remember that Medic Classes are taught by PEOPLE Usually they are Medics with years of experience who have intubated at least 3 people before they started teaching. They also have their own nuiances to make it easier for them to Intubate, but may confuse the hell out of those who are trying to learn them.

Intubation education does need to be overhauled. On scene is not the time to learn how to intubate through ecchymosis, through Le Forte Fractures, through junk in the airway, through anything else than what was given to them by the mannequins and instructors. OR/ER time is needed for the sheer fact that, live tissue responds a certain way. You can't get the same feel off a (really) dead person or a mannequin.

Pediatric Mannequins are even worse. I heard more times than not from my instructors: "If you can intubate the mannequin, you can intubate a live baby."

That's a lie. The first time I ever stuck a blade into a (deceased unfortunately) babys' mouth, I was amazed at how much it wasn't like a mannequin. Just the feel, how you had to manipulate the blade, everything. My first adult intubation was an elderly female who went into cardiac arrest. Her trachea was so screwed up from numerous throat surgeries that it didn't even look like a trachea. The vocal cords didn't look like cords; hell, there wasn't any white to be seen really. The occasional little sliver, but it looked like a brown crescent moon.

What needs to happen is EMS instructors need to try and create as many real world scenarios that they can. If that means taking an endotracheal tube, cutting it so it fits in the airway and looks like the throat is swelling. Yes, I know that they make Sim-Mans', but here is the price break down:

Sim-Man: 27,395.00$
ACLS Scenarios: 4,194.00$
The Peripheral Kit that makes it do all it does: 7,495.00$
The Compressor to make it breathe, swell, and bleed: 3,300.00$

Now, if you are a little stand alone community college, there's no way you can even pretend to pay for the Sim-Man, let alone anything else including mantience. Also, having used a Sim-Man before, it is realistic to a point. You still have the perfect Mallampati once you get through the trismus and ecchymosis. The swelling is so overdone that it doesn't even look real anymore and when the "swelling" goes down, it abates completely within moments and intubation is easy.

In closing, while the lack of OR time is not to blame for the lack of success of Intubation, the lack of "live practice patients" is. Paramedics and Paramedic Students need face time with real body parts in various states of trauma and disrepair. At the fire scene is not the time to see first hand just how bad airway burns can get.

Most of all, on scene is not the time to realize that your instructors were wrong, that intubating the baby mannequin is not like a real baby.

This goes out to the students and practicing Medics: Do what you need to do to learn how to intubate. Don't leave it up to your instructors, or feel as if you know everything there is to know. YOU are the only thing standing between a good, open airway, or a dead patient. Ask questions, find classes, whatever you have to do.

Instructors: Don't lie to your students. You may think you are making them more comfortable and easing their fears of screwing up, but in reality, you are placing bad ideas in their head. If you say it's easy, then those who screw up will give up too easily, and those who manage to get a tube will think that all tubes will be that easy. Be creative and do something to challenge your students in the airway portion of the class; you already make up fun and bizzare rhythm combinations for ACLS, and make PALS seem fun with how you mix up scenarios and present it.

Airway isn't the module to skimp on. Airway is not just about shoving things in peoples' mouths and noses and hoping for the best. It's about being competent and good at what you're doing.

Have Fun and Be Safe.


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