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Also posted over at Paramedicine 101. Go check out the rest of what is there.
On Teaching Airway: EMS Educast Episode 33, they have Kelly Grayson as their guest. The first of many times they will have Kelly Grayson as a guest. Hint! Hint!
Kelly says (50 minutes into the 1 hour show, so I am starting at the beginning) -
If you are going to allow paramedics to intubate, and I happen to agree with Bryan Bledsoe on this, . . . unless things change in the way we educate and regulate our EMS providers, within 10 years you are going to see intubation disappear from the paramedic skill set, except for a relatively few very well trained providers.
Since I have made similar comments, I want to point out the way that a lot of paramedics seem to interpret this sentence.
They are going to take our tubes away!
That ignores the really important part of the sentence. The part of the sentence that comes before and after the part I highlighted. That important part is this - unless things change in the way we educate and regulate our EMS providers, . . . except for a relatively few very well trained providers.
The way to prevent having the tubes taken away? If we really want to have intubation in our scope of practice, we need to continually prove that we can intubate well. We need to continually practice and work on learning more, if we expect to be able to prove that we can intubate well.
Many paramedics do not want to be told that. They want to be able to intubate, just because they think wanting to is enough. They want their Nobel Intubation Prize. Well, this isn't politics, you actually need to do something.
What do we need to do?
Kelly's immediately follows that with -
If we would pull the trigger and do what is necessary to make every paramedic like those well trained providers we envision intubating in the future. That's what needs to be done. We need to have far more stringent requirements for intubation in the initial clinical experience. It needs to be far more than 6, or 8, or 10 tubes. If it takes an extra 6 months to get those tubes, then so be it. That's the price we're going to have to pay to be taken seriously. And once on the street, if you are not getting say X number of tubes - a tube a month, call it 12 a year - if you don't get 12 successful intubations, or at least 12 attempts, in a 12 month period, there should be a clinical re-education requirement.
This was followed by Buck Feris saying, Agreed.
Can any of us disagree? Unfortunately, for many a medic/medic wanna be, that is asking too much.
Why should we have to be competent? Isn't sitting through the classes, getting food for the preceptors as a bribe, and following all of the rules that I agree with - isn't that enough?
Sure. That is good enough, but only if you work in a really unimportant job, not one where incompetence can kill patients.
We cannot demonstrate that prehospital intubation improves outcomes, but we insist on intubating.
Except for a few, we cannot demonstrate competence (pick almost any EMS intubation study), but we insist on intubating.
Why do we insist on harming our patients?
We need to prove that intubation works and prove that we have the skill to be trusted intubating patients.
We do have to want it. We have to want to work at competence - not whine about being victims and whine about not being given what we want.
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13 Comments:
Thanks for listening and commenting on the show. I will definitely be asking Kelly back for future shows. Anything specific you would like him to discuss?
We get it, you don't want a medic putting in a tube and your burnt out from the field and want to stop being a medic. So how about for the next 6 months I stop tubing my patients. The CHF patient that waited a little to long to call now frothing at the mouth, I'll just have my BLS partner bag while I try to get a line in to start the 4 drugs I need to help them. Then I'll try to carry them down 3 flights of stairs on a reeves with a king tube shoved in their throat. When I finally get to transport I dump them in an ER where the resident pulls the Kingtube and gets to try a few times to put in the ETT before the attending finally steps in. Well that sounds a lot better for my patient. Oh, how about the anaphylactic patient that's not responding to meds. We'll just wait until we have to cric their neck, because we do that so often and that's so much easier to practice. How about the asthma patient or the old COPD'er that doesn't respond to meds. BLS bagging and alternative airways are so much better for transport. You know why they are called alternative airways? They are used as a last ditch effort to get any air into the body. If they were truly adequate then you could admit the patient to ICU and never move it. They are temporary. My ETT can stay in until the patient needs it to be pulled. At least we use capnography to confirm placement though most ED's RN's don't even know what a proper waveform is. No waveform, then the tube is pulled, PERIOD. Learning to tube on a dummy or in the OR is fine but the last 4 tubes I had were made on people in real world situations. Vomitous, blood from a GSW pooling in the throat, a patient half under a bed, and one apnic in the grass behind an apartment build at midnight. No pretube waveform, no flicking of eyelashes, no controlled situation, no nothing. Just me and a F'd up patient that needed air. If want people to have 10 tubes before graduation and 2 a year in the field then fine but YOU are on a mission to stop a skill that has been used to save more people then will ever have showed up on any research report.
The seatbelt of a car has saved many more then it's harmed and it has harmed but do you think we should stop wearing them because of the 3% of the cases where someone couldn't get out of the vehicle to safety.
When you can show me data that say medics are missing 25% I might start to agree that something might need to be done but every medic knows this skill. I do everything I can to avoid a tube and when I do it, it's necessary. If I haven't done one in 6 months so what, as a proficient medic I recognized the need, and I have been trained to perform, if I failed then most likely no alternative airway would substitute.
After all my rant answer me one yes or no question. Assuming the way medics are currently trained, do you think medics should intubate? Yes or No?
Greg,
It is an excellent show. I don't have any particular topics, but with Kelly, you can just wind him up and let him go. He will keep a show interesting, even if it does not go where you expected it to go.
Anonymous,
I posted my response at Teaching Airway - Part I - comment from Anonymous.
I'm no rocket scientist but I do get it. I agree with Rogue Medic's perspective as i have witnessed some really dodgy practice out there in the field. I lot of paramedics seem to have a very strong sense of entitlement when it comes to tracheal intubation. As health professionals we need too lift the bar, get with the program and do some continuing education and professional development. We need to start acting in the best interests of our patients and dispense with self interest and competitiveness. We need to become accustomed to risk/benefit analysis and become proactive, judicious clinicians who make clinical decisions based on sound rationale, after a period of reasoned thought. I do get it.
Well, I just can't let Anonymous' comment stand. My reply here.
Scotty,
I'm no rocket scientist but I do get it. I agree with Rogue Medic's perspective as I have witnessed some really dodgy practice out there in the field. A lot of paramedics seem to have a very strong sense of entitlement when it comes to tracheal intubation.
Thank you.
That entitlement attitude is a big problem. It doesn't matter if it is in EMS, or elsewhere. Being given something that is not earned is bad for the recipient. In this case, it is even worse for the patients of the recipient of the gift/handout/largess/attempt to level the playing field.
As health professionals we need too lift the bar, get with the program and do some continuing education and professional development. We need to start acting in the best interests of our patients and dispense with self interest and competitiveness. We need to become accustomed to risk/benefit analysis and become proactive, judicious clinicians who make clinical decisions based on sound rationale, after a period of reasoned thought.
Absolutely.
The big question is, "Why would someone oppose becoming better able to help patients?"
Yet, some people oppose becoming better.
I do get it.
Yes, you do.
AD,
Well, I just can't let Anonymous' comment stand. My reply here.
Thank you for the link.
Great post. You make some points that I did not.
Why would someone oppose the notion of helping to improve patient outcome is a perplexing question...no an enigma? Wish I knew the answer. Part of the answer may be that maybe we are not attracting and employing paramedics with "the right stuff" with a "desire to do the right thing". That is a different barrel of monkeys and is worthy of further debate in itself. From my own experience, the right paramedic does the right thing built on good foundational knowledge and good professional mentoring by an experienced "right" paramedic.
Scotty,
I agree.
Part of the problem is the way we handle education. I have been listening to some other EMS EduCast episodes and Buck (I think it was Buck) has mentioned that the more highly educated students tend to have more problems with the National Registry test. That EMS is set up with a trade school education, even though the job requires a deeper understanding than the trade school education can provide.
IMO, the testing is designed to help the student, who memorizes, but does not understand. NR is a test, where memorization is rewarded, at the expense of understanding. The NR test is something that must be eliminated if we wish to improve patient care.
I have come across your blog from 9-Echo-1's site and I have to say as a 3 year medic, I'm all for more training on intubation or even just taking that skill out of the scope of practice altogether. During my 3 years I've only had 2 chances to intubate. I'm glad to say that I currently have a success rate of 100% as confirmed by ED docs but still only 2 chances in 3 years? If we are going to provide that level of care then we really need more practice. I read some of the other comments here and WOW. What happened to treating each patient the way you would want someone to treat your family. Just because I know how to do a skill does not mean I should or even that my patient needs ME to do that skill. I would feel much better, if the patient was my family member, having a tube placed at the hospital in a more controlled setting with providers that probably have done it more than twice in the last few years. I've said this before sometimes the best intervention is a BASIC one. I know hard concept for some to understand. Too often I see medics treat very aggressively and while sometimes that is indicated it should not be standard operating procedure.
Rachel,
I could not limit my comments, so I posted them in Airway comments by Rachel and Airway comments by Rachel. One is here and one is on Paramedicine 101.
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