Re: More Evidence Agaisnt Intubation in TBI

November 2, 2004

So is more training necessary or less excitement while on scene?

Danny L.

Owner/NREMT-P

Panhandle Emergency Training Services And Response

(PETSAR)

Office

FAX

November 2, 2004

So is more training necessary or less excitement while on scene?

Danny L.

Owner/NREMT-P

Panhandle Emergency Training Services And Response

(PETSAR)

Office

FAX

November 2, 2004

So is more training necessary or less excitement while on scene?

Danny L.

Owner/NREMT-P

Panhandle Emergency Training Services And Response

(PETSAR)

Office

FAX

November 2, 2004

I would tend to agree. I still see Basic EMT's, Intermediates and Paramedics

who still feel the 1:1 ratio during a resuscitation as proper, even though new

standards have come about. Excitement and inadequate retraining seem to be

the reasons. I think some forget the saying " If you don't use it, You loose

it. "

That is to say, just because you practiced and learned the skill in

Intermediate and Paramedic classes does not mean you will retain the same

proficiency

after six months of little or no use.

Now after having made that statement I have to ask; In the places the studies

are being done is this a high volume, high intubation area; or is it a medium

or low volume, medium or low intubation area?

Also are we comparing individuals i.e. CRNA Vs Paramedic, or are we comparing

Respiratory Vs Paramedic?

Individuals who do intubations 2 or 3 times a day should not be compared with

those who do intubations 2 or 3 times every 6 months.

Or should they????

Danny L.

Owner/NREMT-P

Panhandle Emergency Training Services And Response

(PETSAR)

Office

FAX

November 2, 2004

I would tend to agree. I still see Basic EMT's, Intermediates and Paramedics

who still feel the 1:1 ratio during a resuscitation as proper, even though new

standards have come about. Excitement and inadequate retraining seem to be

the reasons. I think some forget the saying " If you don't use it, You loose

it. "

That is to say, just because you practiced and learned the skill in

Intermediate and Paramedic classes does not mean you will retain the same

proficiency

after six months of little or no use.

Now after having made that statement I have to ask; In the places the studies

are being done is this a high volume, high intubation area; or is it a medium

or low volume, medium or low intubation area?

Also are we comparing individuals i.e. CRNA Vs Paramedic, or are we comparing

Respiratory Vs Paramedic?

Individuals who do intubations 2 or 3 times a day should not be compared with

those who do intubations 2 or 3 times every 6 months.

Or should they????

Danny L.

Owner/NREMT-P

Panhandle Emergency Training Services And Response

(PETSAR)

Office

FAX

November 2, 2004

I would tend to agree. I still see Basic EMT's, Intermediates and Paramedics

who still feel the 1:1 ratio during a resuscitation as proper, even though new

standards have come about. Excitement and inadequate retraining seem to be

the reasons. I think some forget the saying " If you don't use it, You loose

it. "

That is to say, just because you practiced and learned the skill in

Intermediate and Paramedic classes does not mean you will retain the same

proficiency

after six months of little or no use.

Now after having made that statement I have to ask; In the places the studies

are being done is this a high volume, high intubation area; or is it a medium

or low volume, medium or low intubation area?

Also are we comparing individuals i.e. CRNA Vs Paramedic, or are we comparing

Respiratory Vs Paramedic?

Individuals who do intubations 2 or 3 times a day should not be compared with

those who do intubations 2 or 3 times every 6 months.

Or should they????

Danny L.

Owner/NREMT-P

Panhandle Emergency Training Services And Response

(PETSAR)

Office

FAX

November 2, 2004

I think, that with the literature coming in as it is, medical directors may

have to make decisions whether to allow paramedics to intubate children and

patients with traumatic brain injuries. It may be hard to defend in court

otherwise. But, before we commit hari-kari, we need a randomized-controlled

trial to sort out the problems. Gene may get on me for this, but I think the

problems are these:

1. EMTS develop poor airway skills because the skills are not adequately

emphasized or instructor accept CPR cards as evidence of aiway competency.

2. Paramedics are not getting enough intubation practice (programs have too

few hours and curriculum enhanced)

3. Inadequate operating room exposure (thanks to the trial lawyers)

4. Failure to recognize skill decay ( " I can intubate as good as

anybody--regardlessmif I haven't done it in 6 momths " )

5. Ego

6. Adrenalin (paramedics tend to not adequately ventilate and oxygenate

prior to ET placement and tend to hyperventilate the patient once intubated.

7. Inadequte use of wave-form capnography.

8. Lack of research that would have shown light on the problem before the

practice was so well-entrenched.

9. Paramedics think that failure to place an ET tube is a sign of failure

and are thus reluctant to use other airway devices.

10. Paramedics are poorly prepared to manage the difficult airway and not

familiar with other techniques (gum elastoc bougie, retrograde intubation)

and so on.

When I went to paramedic school in 1975 (and taught it from 1979-1983), we

often got the ET mannikins out and required prtactice and check-offs, This

may not be occurring.

This begs the question: are the negative outcome studies seen with

prehospital RSI a function of basically poor airway skills or of the

procedure itself. I am beginning to think the former.

E. Bledsoe, DO, FACEP

Midlothian, TX

Re: More Evidence Agaisnt Intubation in TBI

So is more training necessary or less excitement while on scene?

Danny L.

Owner/NREMT-P

Panhandle Emergency Training Services And Response

(PETSAR)

Office

FAX

November 2, 2004

I have a feeling that although the resulting numbers led to no real clue as

to why, it has to do with the poor intubation techniques that I see in the

field and hospital, almost on a daily basis. When you do not do more that 3 to

4

intubations a year, your technique, success rate both decrease, while your

lack of O2 to the brain during multiple unsuccessful attempts and poor

oxygenation with BVM (open airway to the lungs) increase. We have a 98% success

rate

and it has to do with multiple intubations a day.

I also remember when we first started RSII techniques that the ER doc's were

somewhat upset for various reasons, but it actually turned out that they were

mainly upset that they were not allowed to charge the $400 for their

intubation.

Only what I have seen and no more,

Andy

November 2, 2004

I have a feeling that although the resulting numbers led to no real clue as

to why, it has to do with the poor intubation techniques that I see in the

field and hospital, almost on a daily basis. When you do not do more that 3 to

4

intubations a year, your technique, success rate both decrease, while your

lack of O2 to the brain during multiple unsuccessful attempts and poor

oxygenation with BVM (open airway to the lungs) increase. We have a 98% success

rate

and it has to do with multiple intubations a day.

I also remember when we first started RSII techniques that the ER doc's were

somewhat upset for various reasons, but it actually turned out that they were

mainly upset that they were not allowed to charge the $400 for their

intubation.

Only what I have seen and no more,

Andy

November 2, 2004

In a message dated 11/2/04 6:45:53 PM Central Standard Time,

bbledsoe@... writes:

This begs the next questions:

How many live OR intubations does your program require prior to garuation?

How many field intubations and/or ED intubations does your program require

before graduation?

BEB

E. Bledsoe, DO, FACEP

Midlothian, TX

RE: More Evidence Agaisnt Intubation in TBI

Funny... I was thinking 30 should be a minimum, and 50-100 more adequate.

------------

JRB

Jeff Brosius,

B.S., NREMT-P, FP-C

Phoenix, AZ

" Middle of the night, middle of nowhere, middle of a storm? Let's get to

work. "

Mine actually required 4. I got 8. That was back in 1992. Not sure what

the programs specify these days.

Danny L.

Owner/NREMT-P

Panhandle Emergency Training Services And Response

(PETSAR)

Office

FAX

November 2, 2004

In a message dated 11/2/04 6:45:53 PM Central Standard Time,

bbledsoe@... writes:

This begs the next questions:

How many live OR intubations does your program require prior to garuation?

How many field intubations and/or ED intubations does your program require

before graduation?

BEB

E. Bledsoe, DO, FACEP

Midlothian, TX

RE: More Evidence Agaisnt Intubation in TBI

Funny... I was thinking 30 should be a minimum, and 50-100 more adequate.

------------

JRB

Jeff Brosius,

B.S., NREMT-P, FP-C

Phoenix, AZ

" Middle of the night, middle of nowhere, middle of a storm? Let's get to

work. "

Mine actually required 4. I got 8. That was back in 1992. Not sure what

the programs specify these days.

Danny L.

Owner/NREMT-P

Panhandle Emergency Training Services And Response

(PETSAR)

Office

FAX

November 2, 2004

Has anyone noticed the in the subject line for this thread the word " against "

is misspelled?

Maybe that's why we don't intubate right??? :-)

Cristi

November 2, 2004

Has anyone noticed the in the subject line for this thread the word " against "

is misspelled?

Maybe that's why we don't intubate right??? :-)

Cristi

November 2, 2004

This begs the next questions:

How many live OR intubations does your program require prior to garuation?

How many field intubations and/or ED intubations does your program require

before graduation?

BEB

E. Bledsoe, DO, FACEP

Midlothian, TX

RE: More Evidence Agaisnt Intubation in TBI

Funny... I was thinking 30 should be a minimum, and 50-100 more adequate.

------------

JRB

Jeff Brosius,

B.S., NREMT-P, FP-C

Phoenix, AZ

" Middle of the night, middle of nowhere, middle of a storm? Let's get to

work. "

November 2, 2004

This begs the next questions:

How many live OR intubations does your program require prior to garuation?

How many field intubations and/or ED intubations does your program require

before graduation?

BEB

E. Bledsoe, DO, FACEP

Midlothian, TX

RE: More Evidence Agaisnt Intubation in TBI

Funny... I was thinking 30 should be a minimum, and 50-100 more adequate.

------------

JRB

Jeff Brosius,

B.S., NREMT-P, FP-C

Phoenix, AZ

" Middle of the night, middle of nowhere, middle of a storm? Let's get to

work. "

November 2, 2004

This begs the next questions:

How many live OR intubations does your program require prior to garuation?

How many field intubations and/or ED intubations does your program require

before graduation?

BEB

E. Bledsoe, DO, FACEP

Midlothian, TX

RE: More Evidence Agaisnt Intubation in TBI

Funny... I was thinking 30 should be a minimum, and 50-100 more adequate.

------------

JRB

Jeff Brosius,

B.S., NREMT-P, FP-C

Phoenix, AZ

" Middle of the night, middle of nowhere, middle of a storm? Let's get to

work. "

November 2, 2004

98% on 1st attempt. We average 4 intubations a day for the service. That is

running 3-4 trucks a day. I do have records of other services that I also do

QA/QI reports for that average in the low teens on 1st attempts. These

services do not have the training time nor do they seek it. They get one a

month

in the field and mainly do transports.

andy

November 2, 2004

98% on 1st attempt. We average 4 intubations a day for the service. That is

running 3-4 trucks a day. I do have records of other services that I also do

QA/QI reports for that average in the low teens on 1st attempts. These

services do not have the training time nor do they seek it. They get one a

month

in the field and mainly do transports.

andy

November 2, 2004

98% on 1st attempt. We average 4 intubations a day for the service. That is

running 3-4 trucks a day. I do have records of other services that I also do

QA/QI reports for that average in the low teens on 1st attempts. These

services do not have the training time nor do they seek it. They get one a

month

in the field and mainly do transports.

andy

November 2, 2004

Andy,

What do you mean by " multiple intubations a day " . Is that for your service

or each medic? Actual intubations or mannequins? Is the 98% success rate

on first attempt or 15th? Just curious on the specifics of your stats?

Chambers, LP

-- Re: More Evidence Agaisnt Intubation in TBI

I have a feeling that although the resulting numbers led to no real clue as

to why, it has to do with the poor intubation techniques that I see in the

field and hospital, almost on a daily basis. When you do not do more that 3

to 4

intubations a year, your technique, success rate both decrease, while your

lack of O2 to the brain during multiple unsuccessful attempts and poor

oxygenation with BVM (open airway to the lungs) increase. We have a 98%

success rate

and it has to do with multiple intubations a day.

I also remember when we first started RSII techniques that the ER doc's were

somewhat upset for various reasons, but it actually turned out that they

were

mainly upset that they were not allowed to charge the $400 for their

intubation.

Only what I have seen and no more,

Andy

November 2, 2004

Andy,

What do you mean by " multiple intubations a day " . Is that for your service

or each medic? Actual intubations or mannequins? Is the 98% success rate

on first attempt or 15th? Just curious on the specifics of your stats?

Chambers, LP

-- Re: More Evidence Agaisnt Intubation in TBI

I have a feeling that although the resulting numbers led to no real clue as

to why, it has to do with the poor intubation techniques that I see in the

field and hospital, almost on a daily basis. When you do not do more that 3

to 4

intubations a year, your technique, success rate both decrease, while your

lack of O2 to the brain during multiple unsuccessful attempts and poor

oxygenation with BVM (open airway to the lungs) increase. We have a 98%

success rate

and it has to do with multiple intubations a day.

I also remember when we first started RSII techniques that the ER doc's were

somewhat upset for various reasons, but it actually turned out that they

were

mainly upset that they were not allowed to charge the $400 for their

intubation.

Only what I have seen and no more,

Andy

November 2, 2004

Andy,

What do you mean by " multiple intubations a day " . Is that for your service

or each medic? Actual intubations or mannequins? Is the 98% success rate

on first attempt or 15th? Just curious on the specifics of your stats?

Chambers, LP

-- Re: More Evidence Agaisnt Intubation in TBI

I have a feeling that although the resulting numbers led to no real clue as

to why, it has to do with the poor intubation techniques that I see in the

field and hospital, almost on a daily basis. When you do not do more that 3

to 4

intubations a year, your technique, success rate both decrease, while your

lack of O2 to the brain during multiple unsuccessful attempts and poor

oxygenation with BVM (open airway to the lungs) increase. We have a 98%

success rate

and it has to do with multiple intubations a day.

I also remember when we first started RSII techniques that the ER doc's were

somewhat upset for various reasons, but it actually turned out that they

were

mainly upset that they were not allowed to charge the $400 for their

intubation.

Only what I have seen and no more,

Andy

November 3, 2004

" Require " and students actually " get " are two different stories. This

discussion has come up at the Education Committee, and it is at least a

statewide problem. While our students HAVE to have the opportunities to learn

on live patients in a precepted setting, most programs in Texas are now having

extreme difficulty getting these exposures due to attitudes of nurses and

physicians at the hospitals and, yes, even attitudes by Paramedics in the field

who are precepting Intermediate and Paramedic students. I have had students

come back from OR rotations telling me they were told to sit in the waiting room

because they " weren't going to intubate in MY OR. " (And then the next day I had

a student with a differnent group who got 5 tubes.) Attempts to resolve the

issues have gone without any change and the issues had nothing to do with

student appearance, contact with the staff, or any prior problems with EMS

students in those locations. It is just attitude. I have had students on 911

trucks in busy cities needing tubes who are told by the company designated

preceptors, " No student is going to get MY tube. " So the students all across

the state are struggling.

Why???? Some, especially in the hospitals, blame it on potential liability.

Well, we have tried to explain that the anesthetist precepting is covered as an

" instructor " under our malpractice insurance automatically. Doesn't faze them.

Second, the response is, " We are not a teaching hospital " - whatever that is.

But the hospital administration has willingly signed clinical affililation

agreements with the schools. (But of course, the administrations seem to have

very little control over the anesthesiologists who seem to hold all the cards.)

As for the other reasons, it mainly boils down to attitude and due to upper

management at the hospitals and EMS agencies not properly teaching their

personnel what is expected of them when they are precepting ANY student. Since

many of these sites and agencies precept for multiple EMS, nursing, respiratory,

and other schools, you would think they would have good precepting programs in

house. And most are NOT willing to allow you to come in and do it for your

program because they don't have time for that.

So is this possibly a part of the problem we are discussing??? Damn right it

is. We are trying to be the best we can be but cannot get hospitals especially

to grasp what we need for our students to get. And as for sending employees to

these facilities for intubation practice, NOT!

Just my thoughts on a morning with an upper respiratory infection starting.....

Sorry. LOL

Jane Hill

--------- RE: More Evidence Agaisnt Intubation in TBI

Funny... I was thinking 30 should be a minimum, and 50-100 more adequate.

------------

JRB

Jeff Brosius,

B.S., NREMT-P, FP-C

Phoenix, AZ

" Middle of the night, middle of nowhere, middle of a storm? Let's get to

work. "

November 3, 2004