Do we have tunnel vision on endotracheal intubation when managing an airway. Do you feel an extraglottic device would suffice in maintaining an airway
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....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.
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.
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]
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?)
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....)
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. ;)
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). :)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.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.
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 thought figure 2 was really striking.
It's really amazing, too, how often really crappy studies actually get published in journals.
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....