A Rant about Paramedic Intubation

A relatively brief and evidence free opinion piece about intubation. As always, feedback is welcomed.

Play in player below, or right click file at bottom of page and select “Save As”

AmboFOAM Intubation Rant Podcast

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7 Responses to A Rant about Paramedic Intubation

  1. rfdsdoc says:

    Reblogged this on PHARM.

  2. kiwimedic says:

    I couldn’t agree more. I am a mere ALS mortal in rural Vic but have intensive care, and therefore advanced airway, experience in another service. Common sense dictates that any skill done poorly is worse than excellent basic care. I have found that the folks I work with, some of whom I rate very highly, do not and have never, used a SGA. In over thirty years! I relate this now to interrupted CPR. Surely a quickly and correctly placed SGA is better than 30:2 because there is no pause in compressions. I may be highlighting ignorance or incompetence here but it just makes sense to me. When well drilled and practiced, an SGA takes no longer than an intubation attempt. I understand your rant is aimed at intubation but we don’t have access to MICA. And on the topic of interruption to CPR don’t get me started on the new AED rules here, why lower the bar to the poor clinicians when you can bring them up? This leads me back to your rant, why are services abandoning intubation because of poorly performed skills when they could up skill their practitioners? Surely we need to take that on board individually, I am a professional and as such, I practice skills, read and listen to any info I can get my hands on in my time off because I want to be good. Our local anaesthetist is only to happy to have us up to theatre to do some airway practice or do an iv round if we are struggling, we have a dummy in a body bag at work and a library. The expectation that it is for work so we should get paid is nonsense. It is for our communities and families so we should be happy to spend one or two of our free hours a month practicing so we meet the bar rather than having it come to us. Good CPG knowledge makes a compliant paramedic, not a competent one. Sorry for turning your rant into one of my own. Keep it up.

  3. Graeme Dalziel says:

    Thanks Robbie for a balanced and informative podcast. You raise some very valid points. I paticularly embrace your comments abour paramedic professionalism and the need to maintain competency by practice and professional self development.

    So true your comments that the literature being mute on prehospital intubation being deleterious when performed by doctors, as we are hardly playing on a level playing field. Prior to RSI, we could only intubate patients awaiting celestial referral.

    A few days ago, I posted a survey question on Twitter to guage concensus on whether paramedics see ETI as a pre ROSC or post ROSC procedure? You commented on the issue nice and succinctly. Totally agree…if it can be successfully achieved without interupting chest compressions, it should be performed.

    In my opinion, the EMCRIT podcast 104 should be compulsory listening, as there is way more to safe intubation beyond passing a tube through the cords.

    Anyhow…great stuff. Look forward to future podcasts and posts

    Graeme Dalziel @scotty592

  4. Steve says:

    Agreed, bad skills will result in bad outcomes. I believe the true question is, even when “perfect” technique is used, does intubation improve outcomes over basic or other airway techniques that are easier to acquire and maintain? It’s not that a plastic tube through the patient’s vocal cords is dangerous, but is it helpful.
    Yes I believe your hypothesis that drugs, tubes, and laryngoscopes in the wrong hands are dangerous is true. My question is are they helpful even in the right hands, do they improve outcomes enough to justify their inclusion in our practice?

    • It is indeed a valid question, but not one that I think has really been answered yet with the current data. My personal experience is that intubation is indeed helpful in many situations. Perhaps not necessarily “life or death” type of helpful (although I would argue that this can sometimes be the case) but certainly useful to me in managing certain types of patients. There may not be true outcome data available for specific situations, but even so this does not necessarily negate the need to have or use the skill.

      For example I don’t know many paramedics, flight or ground who would argue that an intubated, well sedated head injured patient is not safer and easier to manage than one that is thrashing around like a landed fish.

      If we can achieve this in a fashion consistent with best practice, being cognisant of and managing the potential hazards; and do so consistently well, then I see no reason why intubation should not remain in our scope of practice. If, for whatever reason, we cannot achieve this, then perhaps we need to let intubation go. This is clearly something that needs to be decided on a case by case basis as there are many ways to approach the use or otherwise of this skill.

      • Steve says:

        I just keep coming back to something that I was told by one of the airway masters that I learned from, “No patient ever died of hypo-PVCemia. Don’t rush to insert an endotracheal tube, a basic airway IS an airway. Intubation is optional, oxygenation and ventilation are mandatory.”

      • I agree with that sentiment to a point, which is why I am happy that if competency cannot be maintained, removal of intubation from scope of practice may be a valid course of action. Indeed I believe that part of the reason that MICA paramedics in Victoria are able to consistently achieve 97-100% success in intubation is that we recognise when we need to defer to those with more expertise and better equipment to intubate.

        However I also think that the sentiment is somewhat simplistic. The severely acidotic DKA patient with respiratory fatigue having periods of apnea may have a patent airway, but without ventilatory support will die anyway. Perhaps an EGA will suffice in this instance, but intubation is still considered the preferred method of securing an airway and there are many other situations where an EGA is unlikely to be effective. No-one thinks twice about physicians intubating these patients, because we know (or at least we think) that they are able to do so safely and effectively. My point is that if paramedics can also intubate safely and effectively (and we can) why would we call for intubation to be removed?

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