Lookin at some numbers

[mitllesmertz1]

So I was reading through the NIOSH reports on FF fatalities.
I noticed a curious trend.
Pulled out a sheet of paper and started adding.
Here's what I looked at:

FF Fatality reports under "cardiac related".
These were not "trauma" deaths.
Total of 22 reports where CPR was initiated and ALS measures were implemented, from roughly 2005 through 2007.
I counted reports where an "advanced" airway was attempted ( there were a few combitubes placed).
Here's what I found:

7 Completely Failed intubation attempts (BLS used instead)
11 succesful intubations.
(only 8 were succesful on first attempt)
2 of the "succesfuls" were in gut at ED arrival, unrecognized in field.
1 LMA, placed "sideways" at ED arrival, unrecognized in field.
1 dislodged-recognized in field-reintubated.

So, out of 22 reports, 7 failed completely.
2 (and 1 LMA) were either misplaced, or were dislodged, but both unrecognized.

This adds up to a first-attempt succes rate of 8/22, or 36%.
Total succes rate was 11/22, or 50%.
3/22, or 13.6% were unrecognized failures, or unrecognized dislodges.

These weren't some 90 year old that we found down, possible dead for a week.
These were our brothers that died in the Line of Duty, often a witnessed arrest.
And the best we could do was 36% first attempt success?

Does anyone wonder why there is a push nationally to take intubation away from EMT-P?

We need to do better people.


Here's the link to the NIOSH reports I was looking at:
http://www2a.cdc.gov/NIOSH-fire-fighter-face/state.asp?state=ALL&Incident_Year=ALL&Medical_Related=0001&Trauma_Related=ALL&Submit=Submit

[VentMedic]

That is disturbing.

I was just replying to a thread on another forum (EMTlife) about EMT-Bs intubating. Most do not understand the responsibility of intubation and the importance of maintain competency.

This is what I learned from that forum for EMT-Bs/Intubation and I believe this state quoted is Ohio but there are at least 3 other states that have similar statutes:


R9-25-808. Protocol for an EMT-B to Perform Endotracheal Intubation

A. Endotracheal intubation performed by an EMT-B is an advanced procedure that requires medical direction.

B. An EMT-B is authorized to perform endotracheal intubation only after completing training that:

1. Meets all requirements established in the EMT-B Endotracheal Intubation Training Curriculum, dated January 1, 2004, incorporated by reference and on file with the Department, including no future editions or amendments; and available from the Department's Bureau of Emergency Medical Services; and

2. Is approved by the EMT-B's administrative medical director.

C. An EMT-B shall perform endotracheal intubation as:

1. Prescribed in the EMT-B Endotracheal Intubation Training Curriculum, and

2. Authorized by the EMT-B's administrative medical director.

D. The administrative medical director shall be responsible for quality assurance and skill maintenance, and shall record and maintain a record of the EMT-B's performance of endotracheal intubation.


Among the requirements of the training cirriculum are:

3. Attempted a minimum of 3 endotracheal intubations in the prehospital setting.

4. Performed a minimum of 1 successful endotracheal intubation in the prehospital setting.

Of course, if they are only allowed to intubate the pulseless or dead as a protocol, then one could argue what harm can be done.

I sometimes don't understand the mixed messages being sent by different states with different means of appeasing their EMT(P)s by more skill certs and less concern for education to go with the training to adequately prepare them for the responsibility instead of setting them up for failure.

Excellent analysis of the data. I hope you don't mind that I am linking your work to the other forum. Maybe this can bring more realizism to the patients we may be responsible for. Of course, the general public also deserves competent health care providers that maintain proficiency in their skills and education.

[mitllesmertz1]

Good post Vent.
All I can say there is WOW.
3 attempts and 1 successful.
It's funny how I've heard some folks say, "It's just a monkey skill".
I've heard it's actually easy, all levels of providers should be allowed to do it.
But when it really counts, when one of our brothers is in a witnessed arrest, we only make the tube 36% of the time.

[veneficus]

I always like to see these studies. They have been going on for years. Maybe we could do an IV success rate study too. Please indulge my observations.

In order for anyone (EMT-B, Paramedic, anesthesiologist) to be proficent at an invasivle skill that causes harm when it is done improperly it must be practiced with some frequency.

What constitutes practice? In my world, both real and fantasy, paramedics have the opportunity to practice tubes with anesthesia in the hospital. (even after you get out of school) If it shows up you are constantly failing or taking multiple attempts you are directed by your employer to go and practice. It is not punishment, it is remediation. (it is only an ego that would not want to practice when failure was constantly evident.)

I have worked and observed places where the hospitals do not support prehospital staff. I have heard the excuses. "there are residents that need practice...,the liability is too high..., we have to pay people when they are not in the field..., do you know the logistical nightmare of scheduling staff rotations...?" and my all time favorite: "It would make us look like we don't know what we're doing to have to go to the hospital and practice."

Now in Places I have seen that have let's say: an involved medical director, non-punitive QA, a lack of a union and an employer who will kick you to the curb if you constantly underperform, support from the hospitals, and a progressive staff that wants to improve not simply fall into routine; not one person from the medical director down would even consider taking the skill away. Why should they? They can do it?

Having said that let me call attention to the primary rule of medicine. "first,do no harm." Does it harm patients to use an OPA and a BVM? No. Does it harm a patient to properly place a cuffed endotracheal tube to prevent aspiration and other complications? (like a huge ICU bill) Certainly not. Does it cause harm to try and intubate somebody? Possibly it could, but they are not considered small errors. The real harm is done when you don't notice the attempt has failed or pretend it didn't.

I think that lower standards for EMS providers is a bad idea. We should raise them. Maybe instead of taking away the skill, more effort should be put on developing it. Maybe by reducing the people authorized, not offering excuses for lack of controlled practice, maybe even lowering the ego a few notches and saying "I do not think I am good atgetting tubes (for whatever reason) I will sign up for some more practice," The tube success would increase. Who cares the level of provider doing it, as long as they can?

There is no excuse not to notice and remove/correct a dislodged tube in this day in age. There are a myriad of practical and required checks.

Now having worked prehospital I know in an OR with the table perfectly adjusted, and all the hands and lights you could want, intubation is easier. It is not so easy on the floor of the mobile home without electricity, a mouth full of vomit, an ineffective hand/mechanical suction (if you even have one), and a screaming/flailing family member. But this is where judgement comes into play. "What are the chances if I get this tube it will not dislodge?" Maybe better to bag the patient with an OPA, and remove them to a more stable location like right outside the truck. (I didn't say in the truck because I am all to aware of trying to squeeze between the captain's chair and the cot)

As for LMAs in my opinion they should stay in surgery, where they belong. A better question: why is a needle cric. still allowed and taught? I challenge anyone without a mechanical device to try and bag through a 14 gauge needle. Nevermind capnography, look for chest rise. How about the percutaeous trach kits? That damn tissue requires some force to punch through. Tell me in the prehospital setting on your first cric, you are going to have the nerve to push through skin and tissue to the trachea. (war story) Took a fair bit of "coaching" from the surgeon standing next to me telling me to not be such a ***** and press like I mean it on a surgical cric where I had cut the skin and didn't have to bluntly dissect it. (in a surgical environment not upside down in a ditch at 3am) But i see no study suggesting paramedics don't cric people.

[lifevsdeathuk]

"These weren't some 90 year old that we found down, possible dead for a week.
These were our brothers that died in the Line of Duty, often a witnessed arrest.
And the best we could do was 36% first attempt success?"

No social engineering here? Or maybe some of a different kind? Our brothers matter (most, only, not sure)LOL

[veneficus]

I have had experience of providing and have been on the receiving end of care of "brothers and sister". There was definately an increase in the anxiety level in both circumstances. From me because I wanted to absolutely be giving my best effort, and I am sure when I was the patient the same applied to my coworkers. So I am not sure this is a gold standard to measure to. I think it would be good to compare this to the averages for intubating non fire/ems patients and see where the numbers stand.

A significant portion of my last post was focused on actual practice of the skill. If a provider tubes 1 patient a year, he/she is not going to have the same proficency that a provider tubing 12 a year will have no matter who the patient is. Plus much was left out of this data and only the raw numbers tabulated. Was it a basic tubing a cardiac arrest patient and the medic was the patient? We can only speculate.

While I also understand the zeal of wanting to do better for our fellows, It may be foolish to think that suddenly because of who we are providing care to our proficency increases irregardless of our desire. That would infer we were doing lesser for our other patients. As I eluded to earlier, the emotion involved may actually lessen our ability.

In order to do the best for our patients and fellows, we need to do our best to adopt the legal profession's idea of "without passion or predudice."

To further any profession it is important to always see the forest from the trees.

[Ridryder911]

[/B] of the "succesfuls" were in gut at ED arrival, unrecognized in field.
1 LMA, placed "sideways" at ED arrival, unrecognized in field.
1 dislodged-recognized in field-reintubated.

Does anyone wonder why there is a push nationally to take intubation away from EMT-P?

We need to do better people.


[/url]

Part of the problem in education is that we are still ..."training" instead of educating our students. Many are still assuming the primary goal should be skills. Yes, skills are definitely important, but it widely known that one can improve and master them by practice alone. The knowledge of what is behind the skill is the most important. Being able to understand the whole picture of respiratory involvement is just as important as placing a tube into an orifice, knowing how to manage the airway if intubation does fail, or better yet how to possibly avoid intubating altogether.

Now, I do wonder how an LMA is placed sideways, is it even physically impossible? As well, why do EMS still not enforce the use of EtCo2, in which should immediately along with good assessment capabilities determine esophageal intubations?

R/r 911

[emt161]

Our Basics can get an ET license after an 8 hour class and one successful hit on Fred the Head.

They may intubate for any apneic patient above 1 month old.

Now, granted- we also have a non-paramedic ALS licensure level that is so widespread that the chances of any Basic even getting the opportunity to put their hands on the ET kit are infinitesimal.

But that doesn't change the fact that the ALS level doesn't have any more advanced ETI requirements either. 95% of my entire state's population is served by ALS personnel that have never intubated, run a code, or pushed a drug on a live patient prior to setting foot on a truck. The clinical requirements set by the state consist of 10 successful IV starts supervised by a nurse in a hospital setting and 10 hours (coincidentally, the length of a firefighter's day shift) observation on an ALS unit, with no actual patient care participation allowed. The end.

The fact that said personnel are 95% firefighters only makes it better. *rolls eyes*