Do we have tunnel vision on endotracheal intubation when managing an airway. Do you feel an extraglottic device would suffice in maintaining an airway

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Chance Gearheart said:
I would have to conjecture here that rather than encouraging medics to use their toolboxes wisely, and stop hitting a nail with a stick of dynamite, to coin an expression, we've been pushing hard to force ETI down people's throat as a defining characteristic of a Medic, rather than something that should only be done with the benefits of it outweigh the risk.
Well, yes. But we need to start by putting the words "risk" and "benefit" in the same sentence (perhaps with "ratio") in paramedic texts. For years, the "gold standard" of paramedic care (sorry Rogue) has been a bunch of if-then statements, rather than a careful weighing of alternatives....
Rogue,

I think we're both frustrated with the lack of research on a whole bunch of things.

I think you've also kind of hit at our biggest disagreement with your question: "How many medics do you know who actually understand that?" I have little problem with the term "gold standard" because I've been hanging out with physicians too long, who understand the limitations inherent in the term "gold standard" and are able to still use it to refer to the best currently-known test/procedure for a given purpose, and who also understand that the "gold standard" is a constantly evolving target. I think what needs to change is not so much the term, as paramedics' understanding of it--because no matter how good or poor the research, there will always be a test/procedure that is considered the referent standard, and renaming it isn't going to change paramedics' understanding of the limitations of a so-called "gold standard." (To use the example of ETI, even if we don't use the term "gold standard" it's still going to be the airway of choice in the short to medium term.)

Can we agree to disagree? (Because I think the only thing we're really disagreeing over is the propriety of the term "gold standard," right?)
dr-exmedic,

I think we're both frustrated with the lack of research on a whole bunch of things.

Yes. There is plenty of research, but a lot of routine things are not studied or are not studied enough.


I think you've also kind of hit at our biggest disagreement with your question: "How many medics do you know who actually understand that?" I have little problem with the term "gold standard" because I've been hanging out with physicians too long, who understand the limitations inherent in the term "gold standard" and are able to still use it to refer to the best currently-known test/procedure for a given purpose, and who also understand that the "gold standard" is a constantly evolving target.

Even a lot ofphysicians do not seem to understand this. Look at who writes the EMS protocols and the way this gold standard is handled.

Q. Why didn't you intubate the patient?

A. It wasn't the right thing to do for that patient.

There are too many places where that exchange will lead to an outcome that defends the honor of the gold standard, rather than the wellbeing of the patient.


I think what needs to change is not so much the term, as paramedics' understanding of it--because no matter how good or poor the research, there will always be a test/procedure that is considered the referent standard, and renaming it isn't going to change paramedics' understanding of the limitations of a so-called "gold standard."

I like the Airway Continuum.

I think that it is so much more appropriate for what the patient needs.

Whether we call it airway management or an airway continuum, the idea of extubation is consistent. Why would anyone withdraw the gold standard?

You would have to believe that there is something better than the gold standard.

Since this is an EMS form, maybe we should limit the terminology to that which is understood by EMS.


To use the example of ETI, even if we don't use the term "gold standard" it's still going to be the airway of choice in the short to medium term.

I am less optimistic about the future of intubation.

Hospitals are recognizing that there may be more liability with intubation than they would like. Increased airway trauma and infection. Can we justify a corresponding increased benefit?

Perhaps the future of RSI is not going to be RSI, but RSA.

This article presents a case in which an air medical flight crew encountered a potentially difficult airway when a trauma patient deteriorated in-flight. The crew elected to sedate and paralyze the patient and place a laryngeal mask airway without a prior attempt at direct laryngoscopy and endotracheal intubation. The term Rapid Sequence Airway (RSA) is coined for this novel approach. This article describes and supports this concept and provides definitions of alternative and failed airways. Rapid Sequence Airway (RSA)--a novel approach to prehospital airway management.
Braude D, Richards M.
Prehosp Emerg Care. 2007 Apr-Jun;11(2):250-2.
PMID: 17454819 [PubMed - indexed for MEDLINE]

Dr. Braude is no enemy of RSI. He has just written a book on the subject.

Rapid Sequence Intubation and Rapid Sequence Airway: An Airway 911 Guide [Paperback]
Darren Braude (Author)


Can we agree to disagree? (Because I think the only thing we're really disagreeing over is the propriety of the term "gold standard," right?)

You are going to kill my reputation, if it gets around that I can be agreeable. ;-)

The language we use does affect what we do. We should use terminology that most clearly communicates what we mean.

If intubation cannot be shown to produce better outcomes than other forms of airway management, should it be prioritized in any way?

If tracheostomy is better, why not trach patients sooner?

If we can wait until the patient demonstrates a need for something as long term as a trach, maybe we should also wait until the patient demonstrates a need for something as long term as an endotracheal tube. Maybe we should not be making that decision with the limited information available in the prehospital setting.

Maybe the benefits of intubation are not apparent in the prehospital setting.

Maybe the vomiting patient would actually be better off with an extraglottic airway and aggressive suctioning, rather than a not always fruitful search for some bubbles to tube. Some airway sooner is better than a delayed airway or a failed airway followed by the same extraglottic airway.

Maybe we will find a way to minimize aspiration with extraglottic devices in the prehospital setting.

Maybe we will actually examine whether intubation in the prehospital setting provides better airway protection than an extraglottic device.

Maybe a less secure, but much faster airway is what is best for patients. Less secure is mostly a problem if we intend to ignore and not reassess the patient.

Maybe we will find that it is possible to provide similar aspiration protection with an extraglottic airway.

Maybe we will find that it is possible to provide superior aspiration protection with an extraglottic airway.

Maybe an anesthesiologist experienced with prehospital intubation would choose to use an extraglottic airway as the primary means of airway management.

As I mentioned, I am not as optimistic about the future of prehospital intubation. As with prehospital use of waveform capnography, I think that the more progressive (science-based) emergency physicians will recognize that the advantages of intubation are overstated.

As you pointed out there is a lot that is not covered by the research. Is anything I mentioned contradicted by good evidence?
Chance Gearheart,

I would agree with your toolbox analogy, but with the reservation that intubation is a tool of uncertain benefit.

I think that we don't know enough about the benefits and risks to be making any kind of definitive statements about intubation, except that there is abundant evidence that some EMS agencies do not know how to provide oversight when it comes to intubation.

Me? Intimidating?

People making definitive statements without any evidence to support these definitive statements should be intimidated.

We deal with patients' lives. We need to know what we are doing, not defer to etiquette.

I have not noticed you promoting opinions as the one and only truth, so I don't see any reason for you to be intimidated.

We should be questioning everything we do. Those who try to discourage continuing questioning of everything we do should be intimidated.

These go along to get along people are the enemies of learning.

These go along to get along people are the enemies of our patients.

We are here to take care of our patients, not to take care of the lowest common denominators of critical judgment.
Rogue,

I really like the idea of RSA and the "Airway Continuum." (Except for the part where the author states that "Effective ventilation is the gold standard of airway management," when clearly effective ventilation is the goal of airway management. There's that term being misused again....)

Nothing you've said is contradicted by any solid research. I completely agree with most everything you've said, and have no doubt that most of the pts who are currently being intubated in most systems would indeed be better served by rapid control of the airway by other, more certain means.

Then they will end up at a hospital, where they will get a tube. :) In the short-and-medium term, it still is the standard in the hospital, and I can think of half a dozen reasons why a tube is better than a supraglottic airway in the ICU, until someone has been on the vent long enough that they're not likely to get better soon...at which point the morbidity from remaining intubated becomes greater than the morbidity from getting trached.

But we're still mostly just disagreeing about the propriety of the term "gold standard." :) Everywhere else, I think we're of one mind.

P.S.: I was at a lecture this morning where they were talking about a study that required 3000 pts to show a statistical difference between 2 tests, and how it took 12 centers 8 years to recruit the required number of pts. No wonder there's as little research as there is. ;)
dr-exmedic,

I really like the idea of RSA and the "Airway Continuum." (Except for the part where the author states that "Effective ventilation is the gold standard of airway management," when clearly effective ventilation is the goal of airway management. There's that term being misused again....)

You'll have to take that up with Kelly. He keeps acting as if it is acceptable to have a mind of his own.


But we're still mostly just disagreeing about the propriety of the term "gold standard." :) Everywhere else, I think we're of one mind.

Does that call for a Hive Five?

Don't worry. I'm keeping my day job.


P.S.: I was at a lecture this morning where they were talking about a study that required 3000 pts to show a statistical difference between 2 tests, and how it took 12 centers 8 years to recruit the required number of pts. No wonder there's as little research as there is. ;)

The problem is not the volume of research, but the volume of high quality research that answers important questions.

We have too much low quality research.

Do we need another intubation study of an EMS system with poor oversight of intubation/airway management to tell us that medics with poor oversight are pathetic and dangerous at intubation?

No.

Will we have more?

Possibly before the end of the year.

If we are going to study intubation, we should limit the systems studied to those with aggressive medical oversight (which is the opposite of on line medical command permission rules). We should look at what systems do to improve/maintain skill.

Maybe we should require a few mannequin intubations at the start of each shift.

I know that there are plenty of people who think mannequin intubations are a waste of time. They should be kept very far away from real patients. We won't practice unless the way we practice is just right. Getting rid of these clowns might do more than any improvement in intubation equipment (affordable video laryngoscopy included).

Maybe we should develop a gold standard for people allowed to intubate. If you are not intubating a certain number of patients per year, say 25, you need to demonstrate perhaps 500 mannequin intubations throughout the year or be considered to be delivering less than the gold standard. Then let the lawyers handle it.

I would prefer to avoid the lawyers, because that is a last ditch effort, but we have clearly demonstrated a lack of ability to police ourselves. And we seem to all work for Lake Wobegon EMS. Everybody's intubation success is above average. All the negative studies seem to look at intubation by medics who do not really exist.

We need to take intubation seriously.

There is no good reason why every intubation should not be treated as a sentinel event.


-

For a look at the amount of research -

Seventy-five trials and eleven systematic reviews a day: how will we ever keep up?
Bastian H, Glasziou P, Chalmers I.
PLoS Med. 2010 Sep 21;7(9):e1000326.
PMID: 20877712 [PubMed - in process]
Free Full Text at PLoS Medicine

A thorough analysis by a medical librarian can be found here.

.
I have read all of the opinions on this page and I have to say that in one way or another I agree with all of them. The way in which we choose to practice is personal to all of us. We all have our perferred methods and pearls of wisdom that we have picked up along the way. Some have been studied and proven, and some we just know work because they have in the past. Some times the infant gets an LMA, sometimes the head trauma gets a king, somtimes you place a king and thead an ETT, and sometimes you just go strait to a tube. The point is we have a merriad of tool to serve a merriad of situations.
It is very easy for a study to say that patients intubated in the field have poor outcomes. Of course they do. When we choose to take control of an airway in the field the patients are ussually in a severe state of decompensation and have a high probability of poor outcome no matter if they are in a tertiary facility or in the ditch. When you look at the volume of intubations that happen in a facility you have to take into account the OR, ER, ellective, etc etc. When you look at EMS field intubations they are all crash or emergent, and due to that the volume pales in comparison. So a study may say at a given hospital 150 intubations were done and only 5% had a poor outcome. But the local EMS service only intubated 40 patients and 40% had a poor outcome. Well of course they did.
I cant speek for anyone else. However in my practice I believe that there is a place for all of these tools. The practitioner has to weigh all of the variables, patient condition, progression of decompensation, travel distance, traffic, possible hospital bypass, difficulty and time frame of intubation etc. Given this we have to choose the right tool for the job which minimizes detrimantal effects on the patient but still acomplishes the goal in the time frame allotted.
It might not be as cool ar as sexy to arrive at the ER with a patient with an extraglottic device. But it might be the apropriate tool for the job.
Soory about my spelling, Its late.
Rogue Medic said:
Maybe we should develop a gold standard for people allowed to intubate. If you are not intubating a certain number of patients per year, say 25, you need to demonstrate perhaps 500 mannequin intubations throughout the year or be considered to be delivering less than the gold standard. Then let the lawyers handle it.
I would be all in favor of that (and perhaps I'd let each real intubation count for so many mannequin ones, so that someone who got 24 doesn't have to do as many as the person who only got 1--and maybe 1 tube on the electronic "difficult airway" mannequin, for those places lucky enough to own one, would count as 5 on the standard "dumb" one). :)

Here's a class that's headed in the right direction. Please ignore the fact that there are no classes scheduled right now. :(
I would prefer to avoid the lawyers, because that is a last ditch effort, but we have clearly demonstrated a lack of ability to police ourselves. And we seem to all work for Lake Wobegon EMS. Everybody's intubation success is above average. All the negative studies seem to look at intubation by medics who do not really exist.
A shared frustration, and don't forget the "it's different in the field" crowd...ignoring the fact that field tubes haven't been compared to hospital tubes in years, if ever....
Seventy-five trials and eleven systematic reviews a day: how will we ever keep up?
I thought figure 2 was really striking.

It's really amazing, too, how often really crappy studies actually get published in journals.
dr-exmedic,

I would be all in favor of that (and perhaps I'd let each real intubation count for so many mannequin ones, so that someone who got 24 doesn't have to do as many as the person who only got 1--and maybe 1 tube on the electronic "difficult airway" mannequin, for those places lucky enough to own one, would count as 5 on the standard "dumb" one). :)

There are many possible ways of doing this. We do not know enough to know what is the best. However, we do have plenty of evidence of what does not work.

Here's a class that's headed in the right direction. Please ignore the fact that there are no classes scheduled right now. :(

A couple of other airway courses to consider.

Practical Emergency Airway Management - Dr. Levitan is one creative and considers EMS unimportant, but this course is a bit too expensive for EMS.

SLAM - Street Level Airway Management is much more affordable, but still not cheap.

Of course, what is the value of the material?

How much is it worth to improve our airway skills?

How valuable is it to our employers?

SLAM has a nice motto, except this leads to the discussion of does anything ever come before A in the ABCs?

"If your patient can’t breathe, nothing else matters!"

-

I thought figure 2 was really striking.

There is a lot in the article, but my favorite part is this quote -

And 20 years later, Andrew Duncan launched a publication summarising research for clinicians, lamenting that critical information “…is scattered through a great number of volumes, many of which are so expensive, that they can be purchased for the libraries of public societies only, or of very wealthy individuals” [3].

That was written in 1773.

That is 237 years ago.

It's really amazing, too, how often really crappy studies actually get published in journals.

Amen!
dr-exmedic,

A shared frustration, and don't forget the "it's different in the field" crowd...ignoring the fact that field tubes haven't been compared to hospital tubes in years, if ever....

That is only used to attempt to discredit any criticism of EMS intubation.

The corollary to that is -

If "it's different in the field," then why shouldn't it be done differently in the field?

This points out the bias of a lot of people looking at intubation.

It's not ______ when we do it.
So this is the same discussion we (paramedics) were having 3 1/2 years ago when i was starting this career, and i suspect we will be having in 20 years when (knock on wood) I am ELECTIVELY retiring...

We (paramedics) think that our job (and dignity) are based on whether we do all these "sexy" skills. Who cares if you can intubate a patient if it INCREASES THEIR MORTALITY RATE? I could teach my 3 year old black lab to intubate someone if he HAD to do it 500 times a year! But i cant teach him the thought process behind it, and thats the only reason my dog wont ever be a paramedic (that and the lack of opposible thumbs)... :) A monkey can intubate someone! The point is that PARAMEDICS need to have the thought process behind their decisions, this mentality of "Push the purple box Roy" HAS TO CHANGE! My Medical Director recently changed King LT (in the presence of cardiac arrest) to an EMT-B skill. Lot of Paramedics didnt like this. I said "i dont care AS LONG AS, you teach them when to, when not to, and most importantly WHY to do it, or not do it. Numerous studies have shown that PREHOSPITAL INTUBATIONS NEGATIVELY EFFECTS PATIENT OUTCOMES (and Im not naive to the fact that these statistics may be artificially high due to the criticality of the patients we intubate)... Many more studies have shown that there are multiple different ways to MANAGE an airway. And that perhaps the majority of these can be done with BLS measures...

(Look at "Out of Hospital Intubation. Where Are We?" By Dr. Wang.)

I can hear the shriek of the crowd (*read as angry mob*).

Crowd (*again read as angry mob, armed with pitchforks and torches*) - "Blasphemy! He's saying ALS isnt better then BLS!!!!"

Even AHA has said this...
http://circ.ahajournals.org/cgi/content/full/112/24_suppl/IV-58

Is it needed sometimes? Absolutely. But probably not as often as we think it is. And we definitely dont maintain the level of compentancy we should. Its a tool. Use it when its needed.
However, our practice should not be based on whether or not you perform some skill.

We, for some reason, hold ETI near and dear to our hearts... as this sacred skill that "you better not take away from us". I still havent figured out why. For thousands, well at least hundreds, of years doctors used leechs as a standard of care for many illnesses. It is still very rarely used, but IS NOT THE STANDARD OF CARE ANYMORE... (Dr-Exmedic- whens the last time you phlebotimized a patient with leechs?) Why not? Because doctors realized it was probably bad for MOST patients! They adapted to this finding and changed their practice accordingly. Are they still used? Sure. But not routinely.

We will never become "professionals" or more respected in the medical community if we (as a PROFESSION) cant learn to adapt or practice of medicine

Keep the tool in the box, so its there WHEN you need it. But EDUCATE our people about when to, and when not use the tool!

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