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EMS can be better

Why do we still Intubate?

with 7 comments

Seriously. If we are so bad at it, why don’t we just stop?

Opportunities for intubation in the field are rare, I’ll argue that they’re too rare to gain or maintain mastery of the skill, even in very busy systems. And please don’t try to tell me that intubating a mannequin is the same as intubating a person. It is risible to think that intubating the same plastic thing 10 times is equivalent to 10 completely different field intubations (different airway anatomy, different airway secretions, different amounts of vomit, different patent positions, different scene lighting, etc).

There are safe, effective, proven alternatives to intubation, including King LT, CombiTube, LMA, and plain old BVM with OPA/NPA. I’m not even convinced anyone needs RSI, no matter how long your transports.

Throwing the rest to the wind and completely playing devils advocate, I’ll offer that the only reason we still try to intubate is because of some macho paramedic thing: “you can’t take away my toys or I won’t be as cool.”

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Written by ben

June 10th, 2009 at 10:09 am

Posted in rants

7 Responses to 'Why do we still Intubate?'

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  1. I don’t know why I haven’t responded to this already (probably thought that I already had, since I write so much on the topic).

    Medics can be great at intubation – better than emergency physicians. They just have to do the work to acquire and maintain the skills. They need to have medical directors, who do not let them feel comfortable about anything less than a 90% success rate (including trauma).

    Intubating Fred the Head is not bad practice. We just need to be creative in practicing, because we can’t play with real airways. It isn’t the same as intubating a real patient, but that doesn’t mean that it is not good practice. we need better simulators and research on what is good practice.

    We make excuses for our lack of success, rather than improving our skills. We blame anesthesiologists for not giving us OR time, as if that would make the difference, but it would not.

    We ignore BLS airways as beneath us. Nothing is beneath us.

    We should insist that medical directors have quality standards for intubation. No REAL quality standards, not some check-off box stuff. For example, if you are intubating with less than 95% success, you need to have observed practice, at least on a mannequin, regularly until your stats improve. It isn’t punishment.

    Or you are not allowed to carry intubation equipment.

    We either do something ourselves, or we eliminate intubation from our scope of practice.

    Rogue Medic

    17 Sep 09 at 7:47 pm

  2. Thank you, RM. My chief frustration with intubation is the attitude that some in our field have towards it. The “intubation is what separates the medics from everyone else” and “intubation makes us special” type of attitudes have got to go.

    I agree that we can be good at this, but the only way to get good at it is through regular in vivo training. It would take a lot to convince me that intubating a mannequin, even 500 times, is truly effective practice for anything other than rehearsing the physical movements of intubation setup and procedure.

    I believe there was a paper a few years ago insisting that this is not the case and manneqin training is just as effective experience as live intubation. I also believe there might have been some political motive behind this paper. I’d love the chance to read it.

    ben

    18 Sep 09 at 8:09 am

  3. Intubation makes us special.

    I hadn’t thought of it quite that way before, but your point is valid. As is the Rogue’s, and his statement about the ignorance of BLS airways is quite true. I’d even take that a step further and say that as ALS providers we ignore the usefulness of BLS airways at our peril.

    Besides – I always thought that what made Paramedics “special”, for lack of better word, is the assessment skills we develop, not the tools at our disposal. Granted, basic and intermediate-level providers are supposed to have well-developed assessment skills, and I know some who really do. On the other hand, I know some Paramedics whose assessment skills rival those of many nurses and physicians.

    I suppose it depends on which point of view you take. Personally, if I had to make a choice, I’d rather have the strong assessment skills. While it’s nice to have tools, you have to have the ability to practice with them, especially when it comes to something as critical as airway management. And it’s true – opportunities to intubate people don’t come around as much as we’d like.

    Great post – and a great blog. Mind if I add you to my blogroll?

    Walt Trachim

    6 Oct 09 at 10:03 am

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