Thursday, 10 June 2010

Take Away

Take a deep breath. You're gonna need it.

As rumours go, this one has been floating through the ether for some time. When it was officially published the other day, I wasn't at all surprised, but I was, still am, more than a little disappointed.

Intubations are no longer going to be a part of the London paramedic's bag of tricks. The single most useful technique we use, the one used in the most critical of patients, is being taken away from us. Let's start at the very beginning.

Intubation (or colloquially "tubing") is a process by which a plastic tube is placed in a patient's airway to protect it. It's used when we need to breathe for the patient, and when we want to stop all manner of gunk, particularly blood or vomit getting into the lungs, effectively drowning the patient. It's used by paramedics mainly in cases of resuscitation attempts - or CPR. If ever there was a time that a patient is likely to vomit, it's when a paramedic is applying brutal repeated pressure to their chest at 100 times a minute.

It is used at other times such as massive trauma when the patient is unconscious enough to allow the intubation to take place. Yes, there are different levels of unconscious, and there are even different degrees of dead, but these are the subject of a completely different discussion.

Now, however, instead of training new paramedics in the skill of intubation, they are only training them up to use LMAs, or laryngeal mask airways. These are good when you need to breathe for a patient, but totally useless if the patient vomits. So in our case, frequently pointless.

These LMAs, whilst brilliant in the hospital setting, will fail to fulfil their purpose out on the road. The reason is simple. In hospital, when a patient is aware of the fact that they're about to be knocked out for an operation, they are starved beforehand. No food in the stomach equals no chance of vomit. The LMA is perfect. You can breathe for the patient without having to go the full invasive method and intubate them. If, however, someone ends up with an emergency operation, where there was no time to starve them first, guess which method of airway protection is used? Correct - the tube.

The trouble with emergency cases is that they are exactly that. Emergencies. The patient will never have starved themselves prior to collapsing or being run over. They will never be considerate enough to think that they'll hold off on having dinner because there might be the possibility of the cavalry in green charging through their front door on a rescue mission, and would really rather prefer that the patient didn't vomit, thereby endangering their own well being, as well as the ambulance crew's uniform.

The arguments for the de-skilling of paramedics are several-fold.

We don't get enough training.

We don't do enough refreshers.

We don't use the skill enough.

We're not good enough at doing it.

The first two I agree with - up to a point. A study, apparently carried out in the USofA, says that the minimum training requirement is a 90% success rate at 57 intubations. The numbers seem a little random to me - but I'm not arguing them. When I did my training, I had to successfully intubate 100% of 25 patients. At least. I think, if I remember correctly, I intubated 40. The only one I failed at was the first one I ever tried. I told the consultant that I couldn't do it. I couldn't see what I needed to see in order to ensure a successful intubation. He huffed and puffed, muttered something, good-naturedly, about these new paramedics, took one look at the patient's throat and found that it WAS an impossible intubation. Even for a seasoned professional. I'm not saying I'm brilliant. But I am saying that I'm honest enough to admit I can't do something. And that in itself is an important skill.

The problem with getting an intubation wrong, is down to what your mother used to tell you when you were a kid. "Don't talk with your mouth full, or the food'll go down the wrong hole." The trachea (air-pipe), and the oesophagus (food-pipe) are next to each other. Well, actually, one in front of the other. If you put the tube down the wrong "pipe", you pump air into the stomach and do nothing for the lungs. It's lethal. It's not a difficult skill to master, but it does need proper training. Not only in how to do it right, but how to recognise and rectify it if you do it wrong.

Training is apparently becoming a problem due to the increased use of LMAs in hospital. The number of intubations is steadily declining, so there are fewer patients going around for paramedics to train on.

So extend the training. Do blocks of hospital theatre training weeks. If it takes a year to get the prerequisite number of intubations, then so be it. Use all the skills you have, and wait with the intubations. If you're lucky and reach that number in two weeks - then off you go into the field and save lives - along with the tubes.

We definitely don't have enough refreshers. Certainly not on intubations. We have courses reminding us how to do CPR, how many compressions, what drugs, what's changed since the last refresher. But we never go back to theatres to intubate live people. A manequin is one thing. A patient is real and has a different feel and knack to tubing. I'd love the chance to go back, once a year, and intubate under the guidance of a consultant anaesthetist. By the same logic, I shouldn't be allowed to put a patient's arm in a sling either. I know one is not a life-changingly-critical as the other, but the logic is the same.

On average, a paramedic will intubate a 3-4 times a year. A few more if you tend to be a little like me and attract more trouble than the average paramedic. It's not a lot. There are pieces of kit on the ambulance I haven't used more than once in my career. Literally. That doesn't mean that I won't use them if I have to. I have the skill, I know how to use it, and use it I will. I feel it's also important for a paramedic to arrange their own refreshers on less-frequently used equipment. To take out pieces of kit they haven't used for ages and just re-educate themselves in it's purpose and function. Clearly this isn't possible with intubations. However, intubating only a handful of times a year does not mean that I lose the skill. It doesn't mean I don't know what I'm doing, and it certainly doesn't mean I forget how to recognise whether I've done it right or wrong.

We're lucky in London. We're one of the very few services in the country (as far as I have managed to discover) that uses a piece of kit called End Tidal CO2 monitor. I'm not going to go into the ins and outs of how it works, but very simply, when you attach this to the end of a tube, it is an almost guaranteed assurance of the success of the intubation. You get a reading - it's in, you don't get a reading, you've missed. Simple as that. If you get a very high reading, chances are that the patient's started breathing on their own. Good news all round. There are fail-safe methods of ensuring a tube is done right. Any paramedic worth their salt will know them, check them, double check them, and know that if they've done it wrong, that they start again. Or, in the rare cases of seemingly impossible or even very difficult intubations, recognises their own limitations and works with what they can.

I've only once out on the road seen a paramedic miss an intubation.

That one time, it was recognised very quickly and fixed. I don't know where the data comes from that we're not good enough at it. My personal experience, the only one I have to go on, tells me otherwise. There have been tubes that I couldn't get, only two if I remember correctly. I blame my legs for one of them. There was a smaller paramedic on scene who could fit more easily into the restricted area round the patient's head and intubated them with no problem. The other I just couldn't see what I needed to see to ensure the tube was going down in the right place. I stuck with an LMA and prayed the patient didn't vomit. I vaguely remember being lucky. That time.

The cynics amongst us will blame the doctors. They're trying, at least some of them, to regain their superiority and would love to see paramedics bounced back to the stone age where we literally pick a patient up, throw them on the back of a truck and race them into hospital quick enough for super-docs to save their lives.

Those same cynics will also say that it's nothing more than a money-saving exercise. Less training means less spending, both on the training itself and the kit that it entails once qualified.

The establishment will claim that as they cannot guarantee training and proficiency, that they are taking the skill away. Future paramedics therefore won't be trained. Current paramedics will be allowed to go on using it for now, but my suspicion is that the equipment will slowly be used up and never replaced. A de-facto de-skilling.

It's a backwards step for an organisation that aims and claims to be a world-leader.

To me, instead of striving to better at we do, and extend our range of skills, this is a move in the wrong direction, a move to limit our abilities further.

I think it's a mistake. A step towards those who see paramedics as nothing more than World-War-I stretcher bearers, and away from those with a vision of modern, skilled, experts in pre-hospital care.

I hope it will be rethought at some time in the near future.

I hope that lessons will be learnt, and I hope that as a Service, London will rethink it's training strategy.

Most of all, I just hope that this is one take-away that we don't all, patient and paramedic alike, learn to later regret.

21 comments:

Pie said...

I worked in A&E down here for a while, (I'm a student nurse in Southampton) and we had quite a few patients brought in who were intubated by paramedics and they were never wrong. And all of them were patients who NEEDED intubation and would have died without it... Even if it's a skill you don't use often, that doesn't mean it should be taken away.
Do you think taking intubation away from the paramedics is going to happen across other trusts as well?
Also - re doctors/A&E staff wanting tubing to be taken away, I wouldn't agree. It's fantastic when a patient comes in that we know will need tubing, and it's already done, it's in the right place and ready to go. It speeds everything up once they're in hospital.

Mitch P. said...

I agree. There is a push here to take away intubation in general and Rapid Sequence Intubation in particular. Video Larnyscopy has brought success rates to 100% where it is used. The only problem with it is that it is expensive. Many EMS systems here will not justify the expense. An LMA is ineffective in full stomach intubations in my opinion. Increasing training is good, but many Operating Rooms car Paramedic students due to "liability" reasons or they want Med students or nurse anesthesiology students to have priority. So medics don't get the live tube practice that they want. It is a troubling situation. I really think video larynscopy is the solution, if the equipment were reasonably priced.

Sean said...

Did this reasoning behind this decision take into account the ratio of successful EMS intubations or the success ratio of in-hospital intubations?
I had to meet with the local Trauma Committee here in New Orleans once. Long story short, paramedics had a MUCH higher success ratio than the doctors in the hospital - two "missed" intubations in six months, including mine (which turned out to NOT be a missed tube)! Interestingly, one of the local TV news stations was doing a story on "medical mistakes" at the same time that TWO emergency room patients, intubated BY THE DOCTORS, were discovered to have missed intubations.
You might want to bring up the sources of the study's "evidence" leading to the prohibition of field paramedics intubating. In my first-hand experience, field paramedics had a higher success ratio intubating than did the doctors in the hospital.

Anonymous said...

People will die with this vital skill being removed. I also predict that, where patients die due to aspiration, the rate of PTSD will increase leading to good people leaving or harming themselves.

Not a good decision.

Anonymous said...

Get over yourselves guys.

The decision is based on the available evidence that paramedic intubation is not a skill that can be maintained safely.

There is no evidence that it makes any difference to patient outcomes.

UK paramedics do not perform Rapid Sequence Induction - this is for senior anaesthetists and emergency physicians only.

The only people you can intubate without drugs are the newly dead, and the nearly dead - and neither group does very well in the long run.

chriscpritchard said...

Hmm, the main problem I can see with this is... that intubation is a required competancy in order to register with the HPC, so LAS will have to teach it otherwise they shouldn't be accreditted. Whether they allow their paras to use said skill is a different matter entirely.

@EMTTom said...

Seems like instead of fixing a problem LAS feel they have, they are accepting it and almost embracing it, not trying to fix it. The action they are taking on the back of discovering a 'problem' is to identify it and enhance it.

The problem LAS think they have - not enough training to ensure good intubation.

LAS's solution - don't train intubation.

WHAT?!

@EMTTom said...

Anonymous 2 - the "available evidence" is American. It bears no real comparison to UK paramedics or UK paramedic training. Don't forget that US training can differ from State to State.

Not that US training is any lesser to UK training (I'm not saying that), but there is no guarantee that every US EMS provider included in the evidence trains to the level that NHS paramedics are trained to.

The only people we defibrillate or BVM are the newly dead/nearly dead - so why do we bother if neither group does very well.

By your logic, if we're not going to intubate to prevent death by aspiration because the patients concerned don't often 'do well' in the long run, should we forget about CPR as well?

Transport Jockey said...

I have to ask, why LMA and not MLAs? At least with MLAs you have a viable airway for prehospital use.

And are you serious that so few services use ETCo2? I thought that was becoming a more standard piece of kit.

Paramedic student said...

Taking away the skill of intubation is a ridiculous movement.

Where was the 'research' gathered? Did paramedics have capnography, positubes, common sense to use an LMA if they were struggling with an ET tube?

Lack of regular training I feel is a key issue that needs to be adressed with all paramedic skills. We might intubate 3-4 times a year but probably use a domway splint, suction, t-pieces, needle cric, chest decompression skills, IOs and most paediatric equipment even less. Shall we just scrap these skills and bits of equipment as well?

I thought we were supposed to be moving forward as a profession not back!!

As a paramedic student currently doing my theatre placement in the South West, I've found most of the anaesthetists very supportive and willing to teach. Would be a real shame if I had to compromise patient care by using an LMA when a gold standard ET tube is required.

Anonymous said...

One step forward and five steps back for LAS.

Instead of removing intubation, we should be asking ourselves why we are only intubating patients who are dead or almost dead.

Serious trauma, ROSC and a variety of other patients with a reduced LOC would benefit from the definitive airway that is offered by an ET tube, yet in the UK, we either leave them to gag on the tube or extubate. At least in the states they can perform drug assited intubation and offer gold standard airway management to those patients who need it.

Michael (Paramedic Student) said...

It's very unfortunate that this has happened.

The College of Paramedics (British Paramedic Association) recently published a response paper to the JRCALC Airway Management paper, it can be seen here:

http://emj.bmj.com/content/27/3/167 and they conclude:

Given the magnitude of the change in the scope of practice for paramedics suggested by the JRCALC and its Airway Working Group, the CoP does not believe that the evidence adopted by either body in making their recommendations is of a sufficiently high standard.

The CoP Council does believe that there is sufficient evidence to warrant further review of the training and practice of prehospital intubation, but feels that this applies equally to the practice of all professional groups without anaesthetic qualifications working in this setting, and that the further research we have recommended in
this position paper must be undertaken before any robust conclusions can be reached or any changes to practice made.


chriscpritchard - Intubation is apparently not a HPC competency required to register as a paramedic.

Ian said...

Anonymous (the second) - You really need to get your facts strait.

@EMTTom is totally correct that the "evidence" that they are basing this descison on is American. Not only that, the original paper from JRCALC (a body in the UK who guides paramedic practice) which initially stated that we should have the skill removed was totally ripped apart for it's poor quality and unconvincing research by the College of Paramedics. The research used was not good research and could not be used to infer anything about UK practice. Also, the NCEPOD report which critisised pre-hospital airway management is also rather shoddy and can't be taken seriously. There is no good quality UK based evidence which advocates removing intubation would be benificial. True, there is none to say it would be benificial to keep it, but until good quality evidence is produced, should we be making such rash moves?

What I find most bemusing, and to be honest what winds me up the most, is that they are removing this skill on the back of evidence which is poor, only to replace it with a device that has NO prehospital resarch on it! This is insane.

The LAS have failed to consider other devices like Airtraq which make intubation almost childs play (no really, using Airtraq is amazing - have intubated patients with simulated Grade 4 airways - the hardest to intubate that even consultant anaesthatists strugle with!). There are neumerous other devices like combitube and intubating LMA but having tried all of these devices in the class room, the only one I found that was of real benifit, and most of my classmates agreed, was Airtraq. Bloody good device.

I fear that this move is all down to a massive recruitment recently and now they have hundreds of students who need tube placements and can't find enough places for them. It's not right.

Interestingly, and rather sadly, 2 days ago I had to put an IO needle into the leg of a 6 month old in cardiac arrest. It was one of the old Cook needles, not the new EZ-IO that we have been trained in but "oh supprise" the kit still is not available. So I ask you - when was the last time you did that? I can guarantee (unless you are really unlucky) that you will do far more tubes than IO's - but I only ever been trained to do IO on a simulated leg. Never on a real patient. So - if I'm not doing enough tubes, what about the IO's!!

This whole mess is a farce and I really hope that other trusts don't go the same way and our professional body, the College of Paramedics, fight this as hard as they can.

Oh, and chriscpritchard - there is NO requisite on the HPC website for a Paramedic to intubate. Check the Standards of proficiencey for paramedics. All they say is you must do everything you have been trained to do. Unfortunately.

Anonymous said...

I don't know if you've thought about either of these points:

http://www.bestbets.org/bets/bet.php?id=1907 - "LMA appears to offer better outcomes compared to bag-mask ventilation, but not ETI in experienced individuals."

They haven't actually said why an LMA is better than an ETT in the review but some other benefits of experience seem to have been overlooked - it isn't necessarily the ability to correctly place the tube they're worried about.

Take a jigsaw for example, you can do it 100 times over and still complete it each time but chances are you're a lot quicker at it the 100th v the first time and perhaps thats where the benefit of experience factors in - the speed of placing the tube rather than the positioning. It takes approx 20s to place an LMA v 90s for an ETT which means less time off the chest and better survival rates...

Also, while you're all worried about an LMA failing to protect against aspiration, have a look at this too. http://www.anesthesia-analgesia.org/content/91/6/1431.full

The researches conducting the study tested different ventilatory pressures on dogs in cardiac arrest to see whether it affected aspiration rates.

It's not a perfect study BUT they found that higher ventilatory pressures reduced the rates of aspiration so I suppose you could reason that the pressure is more important in preventing aspiration than the device used to secure the airway.

Ventilatory pressures with LMAs are only slightly lower than that of an ETT tube so, you know so, jus' sayin'

flobach said...

And apparently ECPs will not be part of the LAS workforce soon either...

Michael (paramedic student) said...

Anonymous (3 I think)

90s to do an ETT!!! I just completed my hospital placement and from bag off to tube in and ventilation was never more than 30seconds!!!! People don't die from not getting tubed, they die from lack of ventilation. Any paramedic knows when to stop a tube attempt and get ventilation started again.

Also, compressions should continue during tube placement. So it's a mute point in comparing lma's to tubes.

TOTWTYTR said...

Unfortunately, this trend will continue for several reasons.

First, as in the UK, ORs in the US are intubating fewer patients. When I was in medic school, about 20 years ago, I performed 42 intubations. Now, I'm told that students are limited to no more than 10 because there are so few.

Second, the studies, as poor as most of them are, are the only "science" out there on pre hospital intubations. That's changing as more systems start to track skills more effectively. The problem is that we're late to the game and a lot of timid medical directors are going with the science that exists.

Third, from what I've seen, paramedic education in general is getting worse as we approach the "dime a dozen" mentality that some used to have about BLS personnel.

I think that many systems will pull intubation from their skill sets, at least for a while. If the systems that maintain high clinical standards continue to publish their numbers, it might change.

Michael said...

TOTWTYTR... your third point about education may be true for the US. In the UK we are attempting to move away from this and more and paramedics are being trained in University with a 3 years degree.

Eventually, you will not be able to register as a UK paramedic with a University Degree...

TOTWTYTR said...

Michael,

I always wonder what a two or three year degree adds to a paramedics training? My medic program was a full year and included an anatomy and physiology course as well as in hospital and in ambulance clinical rotations. It was also a full time program, as in 30+ hours per week of didactic and 40 hours per week of in hospital and in ambulance rotations.

So, what does a two or three year paramedic program entail?

Paul said...

Hey, shame to hear that. At the risk of repeating info already stated, why was the choice made earlier not to include RSI's?

Also its always a battle between statistics

http://www.ncbi.nlm.nih.gov/pubmed/10225641
here is one saying that prehospital tubes with sux were successful 95% of the time (20 year study)

Here is one that says that between 20-40% have errors

http://www.ncbi.nlm.nih.gov/pubmed/16522604?dopt=AbstractPlus&holding=f1000,f1000m,isrctn

Sure, medic exposure rate is always going to vary from service to service (depending on call volumes, if able to help out in rural ER Depts attached to some services, extra training provided)

And glad to see Paramedic education becoming more and more degree orientated, here in Canada its 2 years to get your paramedic, with about 1 year of pre-requisite steps to take before being able to take it


Anyways great writing, really like reading this blog

Anonymous said...

I know in the US as EMT-IVs (one step below paramedic) we use "blind" intubation techniques, such as a pharyngeal tracheal lumen (PTL) airway, or a Combi Tube, the former used for massive bleeding, and only needing an ambu-bag for cuff inflation. Is the LAS restricting use of these devices as well?