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Paramedics: too many esophageal intubation...
In Italy we are trying to introduce the Paramedic figure into the EMS in order to reduce the presence (and the costs!!!!) of the emergency phisicians and nurses in the EMS veichles. This is a long process that last since 1994 and still we weren't able to reach a deal about competences and responsabilities. Talkin with a friend of mine, who is an emergency phisician, about this problem he told me that his opinion about Paramedic's abilities was poor.
He made me the example of the statistical analysis about endotracheal intubation made by paramedics of New York City. He told me that the ratio of esophageal intubation was higher than 60% and that, for this reason, the EMS direction has remove the ET tube in order to introduce the use of the Combitube that is more simple to use.
Is this problem real with paramedics in the USA?
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Replies to This Discussion
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Permalink Reply by Skip Kirkwood on -
There are places where there is inadequate training. There are also places where there are too many paramedics - so that an individual paramedic can go years without ever intubating someone. The real problem is with changes in the practice of medicine - more surgeries (where everyone used to get trained to intubate) are being done without intubation, so there are less opportunities to train physicians, nurses, and paramedics.
The argument is a red herring, however. There are plenty of good alternatives (the King Airway works very well as an emergency airway), and with pre-hospital CPAP there is no need to intubate many people in severe respiratory distress.
If you want to build a good EMS system, you can address the problems described in that study - if you want to.
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Permalink Reply by Bob Sullivan on -
In the US, we foolishly take pride in the fact that if you've seen on EMS system, you've only seen on EMS system. Intubation is a problem is some areas. Another intubation study in Florida was even worse than the one you sited. In other areas, like Seattle and Boston, a few paramedics get lots of practice intubating. There is also strong oversight in those systems. People would get phone calls in the middle of the night is there was a suspected esophogeal intubation.
There are lots of other, arguably more important, clinical performance measures than intubation to measure success. STEMI recognition, CPAP, and pain management are others.
If you're staring an EMS system from scratch, I would look at Australia to use as a model instead of the US. They have a much more organized system than we have here.
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Permalink Reply by Ben Waller on -
It is generally not a problem in places that require ET tube placement confirmation with real-time wave-form end-tidal capnography.
Capnography doesn't solve the problem of paramedics that have difficulty properly placing the ET tube, but it helps avoid the problem of unrecognized esophageal intubations.
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Permalink Reply by EMS_Fanatic on -
I saw on YouTube some documentaries really nice about Australia's EMS, thank you for this information, I'll look about this.
Bob Sullivan said:If you're staring an EMS system from scratch, I would look at Australia to use as a model instead of the US. They have a much more organized system than we have here.
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Permalink Reply by EMS_Fanatic on
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There are many EMS systems with capnography available on the scene?
Ben Waller said:It is generally not a problem in places that require ET tube placement confirmation with real-time wave-form end-tidal capnography.
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Permalink Reply by Skip Kirkwood on
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In our system, capnography is built in to our cardiac monitor/defibrillators, along with SpO2, BP, etc.
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Permalink Reply by Ben Waller on
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Electronic capnography units are common in many U.S. EMS systems, but are not universal.
The system in which I currently am employed uses similar multifunction monitors to what Skip's system uses.
Regardless of who uses them and who does not, ETCO2 is a "best practice" for monitoring airway placement and continued patency.
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Permalink Reply by Geri Jacobson on -
Education is the best practice before the ETCO2 to know why, when and how to intubate. EMS in the US appears to be weak in education and not just in intubation. A device like ETCO2 does not always improve one's ability to know when, why and how to intubate successfully. I think alot of hospitals are happier to see alternative devices, including the BVM, used in the field.
In other countries where Paramedics are well educated like to that of a nurse or even higher, they would expect the same pay. You would then just be replacing the nurse for someone with the same education and same pay. There probably would not be a saving. In countries which utilize nurses, they must have not only the education but also work experience in critical care units. This makes them flexible to expanded roles especially in education and preventative medicine. If you are not putting their education and experience use in multiple areas, they are being under utilized. Finding more ways to utilize their education and skills could offset the expense.
In the US the Paramedics are generally trained in a technical school style for a short time with a focus of a few skills and assessment for specific emergencies. Except for being an EMT, prior experience is not required.
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Permalink Reply by EMS_Fanatic on
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Thank you for all your answers guys! You've been really clear.
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Permalink Reply by BostonMedic109 on -
I believe I can speak to this issue from both perspectives,having retired from Boston EMS after 35 years in clinical and educational roles and having been educated in Firenze and serving for a brief period with the Miscordia. Initial training and ongoing oversite is the key to successful airway management. An emphasis should be on "airway management" and not a specific skill ie intubation. The problem with intubation in this country has been the dilution of quality training, many programs don,t have or require live OR monitored intubations, lack of real oversite (not peer review) and the "cowboy" mentality of ,"i,m gonna get the tube in" . Like the advertisment for the a credit card where Alex Baldwin assures the pilot he can fly the plane "because I've played a pilot many times" Many of our paramedics have either never done it all or at best never developed profeciency, and unfortunately not having significant oppurtunities either never develope or maintain profeciency. Instead of focusing on endotracheal intubation, focus on airway management with the myriad of techniques available and integrate good evaluation and monitoring such as capnometry etc. Bottom line ETI is a well recognized technique but it isn' the only one and what should be dwelled upon is patient care. If you want/care to make the investment upfront and ongoing tracheal intubation has a place in pre-hospital if you won't or can't make the commitment alternative approaches which often be equivalent should be investigated.
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Permalink Reply by Joe Smith on -
I do not disagree that there needs to be an improvement in education in the field, I see ETCO2 being taught now in most places. Geri is correct that using a tool does not give one the ability to know when to intubate, that's another discussion entirely. I work with many RN's who come into the department without an understanding of ETCO2 monitoring (besides + or - readings), it is not well taught on both sides. I do get a bit tired about hearing how bad EMS or Paramedics are trained or perform, every profession has it's bad apples, but to paint the profession with 1 brush is hyperbole. In some states Paramedics are not properly trained, I can say the same for RN's who come out of school without the ability to perform. Medics are working in-hospital all over the country now, in Cath Labs, in ICUs, in EDs, on transport teams, and more. My medic students are trained for 18 months, yes not as long as RNs, but they are required to have A&P II and Micro before they start - they are missing the elective college courses for sure. In practice when they work side by side, both are good providers and take good care of their patients. Geri: could we get off the hammering of the short comings of the profession that this site is all about, and focus on improvements to patient care? Have you worked in EMS? Do you hold and EMS license? How many years have you been on the streets at 2am providing care? The jobs are both similar and different, and without knowledge of both from personal experience it's hard to take one seriously.
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Permalink Reply by Geri Jacobson on
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Joe you failed to read my post about the education of Paramedics in other countries. You read what you wanted to read and ignored how EMS is throughout most of the US.
You also said that ETCO2 is now being taught in EMS. It had not been before and neither was 12-Lead EKGs. Many EMS agencies still do not have 12 Lead EKGS. Last ACLS book by the AHA stated only 50% utilized them. I believe that number is still less for ETCO2.
We also have had to train Paramedics who get an ER Tech position to do 12-Leads and to draw blood. I don't know of any Paramedic program that teaches critical care concepts to make them qualified to do everything in a cath lab or ICU. The CCEMTP is only a 2 week course and does not cover very much in any depth. Are you saying all Paramedics know how to set up a PA catheter and IABP fresh out of school? No Paramedic comes out of school ready to do everything just like RNs.
You can scream good and bad providers on all sides but without a consistent baseline for education it is difficult to make any comparison. I am sure the 600 hour Paramedic from Texas will say they are just as qualified and maybe even better than your 18 month Paramedic with all that book learning also.
The national average for Paramedic training is still from 600 - 1200 hours. 18 months does not say if it is a part time program with 1000 hours stretched out over that time. Our LVN programs can stretch out their 1500 hours to 18 months also by having a part time program instead of the usual 10 - 12 months 5 days/week. 18 months of education is inadequate for any hospital position taking care of critical care patients. This is why RNs are now becoming BSN degeed (4 years), RTs are a minimum of an Associates, PTs in the ICUs are doctorate, SLPs are Masters degreed and the Paramedics who work in the Cath Lab must now get the Associates degree for CVT or find another job. Very few are even grandfathering them in. This is to keep up with reimbursement and accreditation standards. It is not about egos and I can do it in less time with more skills than you. Accrediting agencies want to ensure the insurances and the public the most educated and qualified person is providing care.
My background is both hospital and flight with scene response. Most of the RNs do hold a Paramedic cert which can be easily obtained. It is not a requirement. Our teams are RN/RN configuration which is also what most of the transport teams are. The CCTs are RN/2 EMTs and sometimes an RT. RNs do work the night shift and can be assigned a flight to a scene or critical care transport at 0200. I fail to see why that is any different than in the daytime. The biggest difference is that we will also be working in the hospital either in the ICU or ED instead of sleeping between calls so going out at 0200 to a trauma is not a big deal.
Do you have a BSN or CVT degree?
Skills are easily taught but the knowledge takes time and it seems in EMS the ambulance companies and FDs want to get their people certified as Paramedics as quickly as possible. Some ambulance companies and FDs even have their own Paramedic training programs bypassing college classes like Anatomy and Physiology except for the overview.
You can also brag about how exceptional your one program is but until EMS gets some consistency in all 50 states for education or even the national exam and levels, it is difficult to do any comparison except for a few skills. Just being able to intubate does not make you superior especially when several others can also intubate including nurses. However, when a nurse is on a transport team, there are usually a minimum for competency which is tracked.
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