On intubations

The skill of intubations for first responders has been a controversial issue since pretty much it’s inception. I recently came upon an article that had many good points to it. The article did mention that it is their opinion that if certain things are not done soon EMS could face intubations being done away with for most.

Here’s the link to that post:

http://medicmadness.com/2014/08/paramedics-going-lose-intubation/

I’m going to say that I agree with a lot of what this post has to say. It is definitely a good read and everyone in EMS should check it out. The author of the article correctly points out some deficiencies in training that most paramedics suffer when it comes to intubations. Not only training before your a paramedic and going through school, but also after a paramedic gets licensure and begins working. I have a few items I would consider highly important to all EMS agencies and should be implemented as soon as humanly possible to mitigate litigation as well as assure patent airways for all our patients.

1. Its true intubation is a skill learned with a lot of time and you need many successful intubations to become proficient. Ongoing training should include mandatory quarterly checks on intubations in all age ranges and emphasis placed on proper technique. I sincerely believe that I was not adequate at intubations until at least 5 years into EMS. That will diminish if you don’t intubate regularly, that’s just a fact. You might be able to jump on a bike and know how to ride it after years of not riding a bike, but you will not be as good as someone who rides it all the time.

2. In line ETCO2 should be an absolute criteria for agencies that have the ability to RSI. Furthermore it should be implemented in all agencies where intubations are permitted. There is no better criteria for assuring an intubation has been done correctly. Yes, visualization of the vocal chords and watching your tube pass through the vocal chords is great and should be the top priority for the person inbutating, but that is only beneficial to one person. No one else will be able to testify that they also witnessed it. We need checks that everyone can see and since we don’t have the ability to shoot a chest X-ray in the field we should all be proficient in end tidal CO2 reading. Everyone should be shown how not only to establish in-line CO2 monitoring on their monitor but also how to activate waveform monitoring. Not all monitors do this automatically.

3. Reporting on out of hospital intubations should be better maintained and on a national level. We really don’t know how many intubations are being done correctly and how many are being missed. There is no definite guidelines on how to maintain records. In Texas, for example, agencies are supposed to maintain all PCRs for a period no less than 5 years. There is not a clear database for patient information, however, and most studies are done in select cities many times not even accurately describing all the systems in those cities. The same goes for those that are advocating against out of hospital intubations or attempting to advocate to keep intubations on our trucks. Both groups have very limited data and statistics. Local systems in our area have computer databases for this information but the systems don’t talk to each other in this aspect. (I am currently waiting for some definitive statistics about intubations from these companies.)

A major hurdle comes not only from EMS companies and what they think is cost effective or good for business but also from each of us in the field. I see it all the time when medics don’t push themselves to learn better techniques. This doesn’t just stop with EMS, I’ve seen personally some doctors that don’t practice and then fail in intubations that are vital for the patient. All I can say is don’t be that medic, don’t be that healthcare provider. Don’t be the one that leads us away from being respected with our skills. If something happens and you are not able to establish that airway know your alternatives and learn from that experience. I completely agree with the writer above that says nothing but constant practice and real world experience will get you to the competency level we should all be at.

If anyone has any further suggestions feel free to let us know. We would love to hear your thought on intubations and what could help guarantee patent airways for all our patients. Thank you for all you do out there and stay safe.

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