List Archives

Thu Apr 6 18:52:10 BST 2006

Well said.

Ben Reynolds, PA-C
Pittsburgh, PA

--- HAXScott at aol.com wrote:

>  
> Melissa,
>  
> I'm a paramedic, and while I empathize fully with
> some of your frustration,  
> I must respectfully disagree with several of your
> points.
>  
> The evidence surrounding paramedic-performed
> intubation in the field is  
> terrifying. 
>  
> The debate isn't in whole about training and
> experience. Training  doesn't 
> always improve things - I have spent perhaps
> hundreds of hours in  my role 
> trying to "train" people how to perform BVM
> ventilation, and  more recently, 
> predict and manage and rescue the difficult and
> failed  airway. I'm sorry to say, I 
> still see hoover-bagging and rather tragic 
> approaches to capturing and 
> controlling the airway. I'm not alone in this 
> experience. By now I'm sure we've all 
> been exposed to, and are hopefully  intimately
> familiar with Gausche's 2000 
> publication of the results of the  California
> Pediatric Airway Study. As a 
> component of that study, an exceptional  training
> program, facilitated by 
> effective and expert faculty, was developed and 
> provided. Look where it got them. As 
> I have seen firsthand, some of the most  experienced
> clinicians are the most 
> arrogant and ignorant. A pervasion of the  mentality
> "Don't confuse me with the 
> facts, I know what I believe!" afflicts our 
> profession. 
>  
> With regard to aspiration, I have to leave science
> behind and speculate: I  
> believe that emesis and aspiration are amongst the
> most under-reported  
> complications of airway management in the field, and
> it also occurs outside of  the 
> setting of cardiopulmonary arrest resuscitation
> attempts... and I would like  
> you to objectively back-up your statement on the
> effect of prehospital tracheal 
>  intubation upon patient morbidity and mortality,
> and show me ANY  evidence 
> (save for a study or two that looked at severe TBI
> and air  medical transport) 
> since ~1984 that supports that claim. If it takes 
> you a decade and you have 
> to embark on a great quest to find the evidence, 
> we'll all be better for it, 
> but, you may find on your journey that reality is 
> not what you strongly 
> believed in your heart to be true.
>  
> In my own institution, the members of our critical
> care transport service  
> face the same challenges you describe when you talk
> about your frustrating day  
> in the OR. We get 'skunked' in the OR too - it
> happens. However, we are 
> blessed  with individuals, including
> anesthesiologists, anesthesia residents, and 
> CRNA's,  who freely give their own time to share
> their experience, as well as  
> non-traditional airway experts, including a trauma
> surgeon who has taken a  
> particular interest in airway management who provide
> our team with important  
> learning experiences. We're looking at other ways of
> getting around the slim  
> pickking in the OR, including simulation - we have
> big plans to utilize  
> case-based training specifically related to airway
> management. This will allow  us to 
> let team members play out, in real time, various
> cases, some of them rare  in 
> actual clinical practice, not only practice and
> develop airway management  
> skills, but foster team-building and crisis resource
> management ability... 
>  
> The future of airway management in the field here in
> the US? Things have to  
> change. People are dying needlessly. Some systems do
> exceptionally well. 
> Others  don't. What do I see in common amongst the
> programs that do well that I  
> know of? Good people on the streets, with involved
> medical directors, supportive 
>  EM physicians, and strong PI systems in place.
>  
> My personal predictions: Urban systems with rapid
> transport? No tracheal  
> intubation. Supraglottic devices will be used in
> crash airways (eg codes). A  
> responder with RSI, surgical airway skills, etc
> would be available when needed,  
> but, the majority of responders will not be
> intubating. Suburban and rural  
> systems? Certainly these are places where tracheal
> intubation may have an  
> important role in the field, and those places with
> long transport times are  
> perhaps the places that may see actual benefit from 
> pre-hospital RSI. As I stare 
> into my crystal ball, a dichotomy emerges - look at 
> the environment the 
> majority of the major recent studies of
> out-of-hospital  tracheal intubation take 
> place. 
>  
> Of course there are paramedics who have
> exceptionally good airway  management 
> abilities. I know emergency medicine physicians who
> are exceptionally  good 
> airway managers. I know anesthesiologists and
> anesthetists and flight  nurses 
> and flight paramedics and respiratory therapists and
> hospitalists and  
> intensivists and pediatricians who are "good" airway
> managers - and I know MANY  
> people in every specialty - anesthesia included -
> who I wouldn't want near my  
> throat with a laryngoscope and tracheal tube even if
> I were gasping and purple.  
> The problem is a number of "good" and "really good"
> people in a given 
> profession  doesn't make up for one poor performer -
> and there are too many people who  
> haven't, and perhaps can't - develop reasonable
> mastery of these most 
> important  skills. 
>  
> Perhaps the time is coming for an airway listserve,
> seeing the amount of  
> passion and interest the original query has
> generated. 
>  
> In a message dated 4/6/2006 8:53:17 AM Eastern
> Standard Time,  
> mmarkey at hallrender.com writes:
> 
> With all  due respect, I have a different suggestion
> - how about
> anesthetists and  anesthesiologists willingly
> sharing their knowledge and
> giving paramedics  more chances to practice
> intubation in a controlled
> setting 
> 
> 
> With all due respect, I have a different suggestion
> - how  about
> anesthetists and anesthesiologists willingly sharing
> their knowledge  and
> giving paramedics more chances to practice
> intubation in a  controlled
> setting (i.e., consider us as important to train as
> you do  residents,
> and stop giving the residents all the tubes).  Last
> time I  was in the OR
> for ET practice, I got 0 chances out of an 8 hour
> day.   Why?  Because
> anesthesia always found a reason to say no -  No, 
> this patient has caps
> on her teeth.  No, this patient is in for elective 
> surgery.  No, we want
> the resident to get some experience.  Not a  very
> effective investment of
> my time.  And not a very appropriate way to  behave,
> to my thinking.
> 
> Experienced paramedics can intubate quite 
> successfully - and quickly. 
> The determining factor is not whether you have  an
> MD or other degree -
> it is the experience.   Experience in  controlled
> settings helps you
> anticipate the problems in the uncontrolled 
> environment - and helps you
> understand when you will be able to get the tube, 
> and when you just
> secure whatever airway you can get and run.
> 
> Patients  may or may not have already aspirated -
> often they haven't,
> and the reason  they aspirate is because someone is
> thumping and pumping
> on them.   Having an ET in place saves these
> patients significant
> morbidity and  mortality - and isn't that what this
> EMS is all about??? 
> No, paramedics  shouldn't spend 10 minutes on the
> scene trying to get an
> 
=== message truncated ===

List Archives

For your convenience, find the Trauma List Archive Below

Rescue Airway Techniques