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Get With It

Posted on 14 March 2011

Dear Sirenhead,

I’ve been a paramedic for 10 years. I’m a good provider and do a great job managing my patients’ airway needs. But it seems like every time I open a magazine, there’s a study or doctor saying paramedics are dangerous and field intubation should be taken away. Are we headed back to just throwing people on stretchers and driving fast?

Don’t Take My Tube


Dear Don’t Take My Tube,

What is it about the endotracheal tube (ET) that stirs such emotion in us? A study comes out indicating field intubation may not be all it’s cracked up to be, and medics rant and rave like Parisians to the Bastille!

Have you ever read Who Moved My Cheese? by Spencer Johnson? The short version is that a couple of mice live in a maze, and one day things change. One of the mice adapts; the other goes hungry. Which one are you?

It’s amazing just how many tools and techniques have passed away—the esophageal obturator airway, MAST and the choke-saver to name a few. All of these devices were the standard of care at one point, but then someone moved the cheese.

Science, and research specifically, have a huge impact on the changes we face. Look how many times CPR has changed. From back-pressure arm lift, to ventilations with compressions, to fast and hard compressions with limited ventilation, each change was based on the scientific findings of the time. As science progresses, we change course to see if it helps our patients.

Look at all of the great scientific findings in just the past few years: therapeutic hypothermia,video laryngoscopy, 12-lead ECGs and portable ultrasounds. Some will make great improvements on patient outcome. Those that don’t will change.

We scream that we want to be a respected part of the medical community, not just a bunch of stretcher jockeys. We want to deliver evidence-based medicine—until that evidence takes away something cool that we get to do. Then we get our britches in a knot and stomp our feet. Cut it out! If you like your ET tube and you think it’s good for your patients, do something about it.

Poor field intubation results come from two places: the intubation process itself and post-intubation management. Training, experience and quality assurance are the keys to success.

For the earliest paramedic programs, such as the Freedom House Ambulance Service instructed by the late Peter Safar, the standard was a small number of medics, a large quantity of training and intense medical oversight. These seem to be the characteristics of the best programs in 2009. Coincidence? Probably not.

Many programs spend fewer hours (money) on initial and continuing education, especially in today’s tough economy. There’s less opportunity to access cadaver labs, operating rooms and patient simulators for skill maintenance.

There’s a perception that more is better, so jurisdictions put paramedics on every apparatus they own. But if there are more paramedics, there’s often less opportunity to perform skills in the field. Data from a 2006 study of five major cities showed that EMS programs with more paramedics per capita had lower “save” rates. I don’t buy the implication this study makes, but I bet in the “better programs,” they had substantial training, close medical oversight andconsiderable skill maintenance.

So what can you do to save your ET tube? Five easy things.

Do what’s best for your patient. If the patient needs a tube, put it in and manage it well. If they can be managed with an oral airway and bag-valve mask, use them.

Be responsible for and highly critical of your patient care. Review every call on your own. Talk to the emergency physician. Run the tough ones by your peers and medical director. Don’t be defensive. Find the holes in your boat and fix ‘em.

Take charge of your training. Find your weak points and seek out classes or mentors tohelp you improve. Don’t use the excuse that your department won’t pay for it. There are always ways to find (and offer) free, cheap or cost-efficient training. Take every opportunityto practice your skills: manikins, cadaverlabs, hospital rotations and station drills.

Know and follow your protocols. Don’t just regurgitate them, understand them. Don’t likeyour protocols? Find a professional and science-based way to change them. Get involved in protocol reviews.

Keep up with science. Read scientific studies that may impact the care you provide to your patients. What new techniques and devices that might make their way into your hands? Accept the fact that some things will pass away.

The message here is take charge of your professional life. If you wait for someone to bring you cheese, you might go hungry. Until next time, be careful out there.

Tell Someone Who Cares

Got a question or complaint? Let Sirenhead hear all about it.  He’ll answer you with 124 dB of traffic-stopping noise. E-mail sirenhead@elsevier.com, and then brace yourself!

Reprinted from JEMS Vol. 34, Issue 12 with the permission of Elsevier Inc., copyright 2009. For more information or to subscribe, visit www.jems.com.

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2 Responses to “Get With It”

  1. Andrew Burt says:

    Tubing has its place within the field, however the checks need to be in-place once a tube has been successfully passed. Such as End tidal C02, C Collar, having the tube checked once arriving at the ED by the DR who is taking over the care. Getting Him/her to sign paper work that the breath sounds were present over all lung fields. This is so that at a later stage the tube is dislodged Paramedics can not be blamed for poor tube placement.
    Some Drs are very quick to point the finger at Paramedics regarding tubing, Lots focus on the negative issues. There appears to be limited data about how many successful tubes are placed by Paramedics in trying conditions, that actual improve the condition off the patient, and even less data about the number of people who are alive due to the skills of the Paramedic who treated them in the first place.
    Regards Burty

  2. GC says:

    If ETTs are such a bad device, then maybe we should take them away from everyone including doctors.


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