Thoughts on ETI

Recent discussions in EMS circles have revolved around the idea of removing endotracheal intubation from our standard of care because we seem to not be very good at it or don't do it often enough to remain proficient.

Kelly Greyson's recent article at EMS1.com added fuel to my fire when he discussed the number of intubations medics are asked to get prior to being released into the field.

My program required 10 in the OR and I remembered thinking that was far to few. 

Far too few to be proficient at an airway that was not at comfortable waist height.

Or an airway that didn't have a comfortable chair and clean place to rest my equipment.

Or an airway that hasn't been fasting for a day incase there is vomit.

Or even an airway that started out just fine, then got worse on the stairs while carrying them downstairs in the dark.

We are GROSSLY undertrained compared to our nursing and medical friends and it is directly related to our being considered a trade.  We are put on the bottom of the pile for live intubations, not because we aren't good at it, or do it seldomly, but because we are seen as kids, unskilled laborers with lights and sirens.  In some programs I'm told instructors are having to beg to get OR time for their students.

When I went through the OR for my tubes, I recall having to get permission from the patients and being scared to ask.  Then the Anesthesiologist grabbed the form and took it to each patient and explained to them that if I didn't learn there, with him watching, how would I be able to do it to them in their bedroom in the middle of the night.

Every person signed, even the young lady whom I knew from school.

The Doc understood that of all the folks who need training on ETI, the first ones in the door should be given first shot, because if not now, when?

Did my 10 tubes that day make me a good airway manager? – No.  But it got me over the initial fear of inserting a blade into a living person and looking for real cords.

We are reminded that the gold standard of airway management is not the endotracheal tube, but adequate gas exchange at the cellular level.  A perfect example of this in practice is CPAP.  With this tool we can assist a patient towards a positive outcome without shoving a piece of plastic into their throat, just onto their face.

 

But the more I consider my last few intubation attempts I am constantly distracted by the basketball games on TV.  So and so is 17 for 32 and having a great game.

17/32?

I'm 4/5 on my last few tubes I can recall and felt like a failure.  We shouldn't be "missing a tube" in the field and delivering it to the ER (or the ME in some cases) but using stats like these to take away a tool is insane.

Imagine if a police officer who shot at 5 suspects only hit 4.  Would we be considering taking away his weapon or sending him to the range for more training?

The firefighter who puts out 4 of 5 room and content fires isn't stripped of his hoseline and told to leave firefighting to the insurance company, we train more.

Mailcarrier delivering to the wrong house, bus driver missing a stop, kid at the Starbucks screwing up my order.  Lose the mail van?  Take away the bus?  Take coffee away?  All insane options, but for some reason when we make mistakes the first answer is to take away a vital tool I need available.  For what?  I don't know, but when I need it and it's gone, what will I do then?

We need more training.  We all know it, but no one is going to come by the station and give it to us.

 

More importantly, we need to back away from the airway kit when the BVM is working.  I'm a firm believer in the "start simple" school of airway management, which states that if gas exchange at the cellular level is adequate for tissue perfusion, keep doing what you're doing.  Reassess and act as needed.

If the industry wants to solve the ETI stats by taking the tubes away I can then guarantee a success rate of ZERO.  Instead, let's apply the same metric to IV starts, medication errors and just disband EMS all together, because if you take one tool because we misuse it and don't remediate the provider, the problem will spread.

The problem IS NOT the ability to intubate the trachea, it is poorly trained practitioners using a tool they do not completely understand in a manner that may not even be necessary.

If an MD needs 200 tubes to be considered proficient, then misses repeatedly in the ER, can I take his tubes away if I can sweep in and get it first try with only 10 under my belt in training?

 

Of course not, because if they need that tool another time I want them to have it available.  Now offer me the same consideration and perhaps we can all move forward.

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34 thoughts on “Thoughts on ETI”

  1. If you were 4 for 5 and didn’t know it until the ED, there is a problem.

    If you were 4 for 5, recognized it in the field, switched to an alternative device, and were 5 for 5 in appropriately managing the airway: there is no problem.

    As long as airway management is taught as the continuum that Kelly and yourself advocate, medics should continue to intubate.

    However, education in intubation as a procedure is lacking and its not entirely a function of live practice. Poor technique (“mash the blade all the way in and retract”) and light reading (my book had 2/3 of a page on intubation) make for poor intubators, especially if we’ve had no real practice. Even then, we’re just substituting experience for knowledge. We need to revamp our airway management education along the lines of the bigger STEMI programs.

    Every airway managed appropriately, every time.

    1. I should have clarified. I was successful on first attempt on my last 4 of 5 I can recall. To my knowledge I have never delivered an esophogeal placed ET tube. I have used alternate methods countless times, dropping King tubes quickly when appropriate and bagging mostly. I just thought 80% was barely passing on first attempt. The most recent one was the one I missed but the responding Captain got it first try soon after.

      1. And I figured as much, it is handy to have another medic around when you’re managing an airway. As for your first pass success rate, 5 tubes isn’t really enough to start comparing yourself to other’s percentages. Which was probably Kelly’s and your point!

  2. If you were 4 for 5 and didn’t know it until the ED, there is a problem.

    If you were 4 for 5, recognized it in the field, switched to an alternative device, and were 5 for 5 in appropriately managing the airway: there is no problem.

    As long as airway management is taught as the continuum that Kelly and yourself advocate, medics should continue to intubate.

    However, education in intubation as a procedure is lacking and its not entirely a function of live practice. Poor technique (“mash the blade all the way in and retract”) and light reading (my book had 2/3 of a page on intubation) make for poor intubators, especially if we’ve had no real practice. Even then, we’re just substituting experience for knowledge. We need to revamp our airway management education along the lines of the bigger STEMI programs.

    Every airway managed appropriately, every time.

    1. I should have clarified. I was successful on first attempt on my last 4 of 5 I can recall. To my knowledge I have never delivered an esophogeal placed ET tube. I have used alternate methods countless times, dropping King tubes quickly when appropriate and bagging mostly. I just thought 80% was barely passing on first attempt. The most recent one was the one I missed but the responding Captain got it first try soon after.

      1. And I figured as much, it is handy to have another medic around when you’re managing an airway. As for your first pass success rate, 5 tubes isn’t really enough to start comparing yourself to other’s percentages. Which was probably Kelly’s and your point!

      2. And I figured as much, it is handy to have another medic around when you’re managing an airway. As for your first pass success rate, 5 tubes isn’t really enough to start comparing yourself to other’s percentages. Which was probably Kelly’s and your point!

    2. I should have clarified. I was successful on first attempt on my last 4 of 5 I can recall. To my knowledge I have never delivered an esophogeal placed ET tube. I have used alternate methods countless times, dropping King tubes quickly when appropriate and bagging mostly. I just thought 80% was barely passing on first attempt. The most recent one was the one I missed but the responding Captain got it first try soon after.

  3. If you were 4 for 5 and didn’t know it until the ED, there is a problem.

    If you were 4 for 5, recognized it in the field, switched to an alternative device, and were 5 for 5 in appropriately managing the airway: there is no problem.

    As long as airway management is taught as the continuum that Kelly and yourself advocate, medics should continue to intubate.

    However, education in intubation as a procedure is lacking and its not entirely a function of live practice. Poor technique (“mash the blade all the way in and retract”) and light reading (my book had 2/3 of a page on intubation) make for poor intubators, especially if we’ve had no real practice. Even then, we’re just substituting experience for knowledge. We need to revamp our airway management education along the lines of the bigger STEMI programs.

    Every airway managed appropriately, every time.

  4. I think you missed a major contributing factor to the push to remove ETI-simpler methods. You mentioned the standard being adequate oxygenation, and if a BVM is working, great. By the same token, King airways, LMAs, and combitubes have proven to be effective and require far less training to use effectively. They also take less time to insert. How many times have you seen CPR interrupted repeatedly while a medic makes multiple attempts to insert an ET? The challenges of working in the field-lack of lighting, cramped space, etc contribute to the difficulty of placing an ET, as you mentioned. But those conditions don’t matter to the King.

    1. Indeed, but the King dislikes a wet oropharynx and has a dendency to wander. It is a tool I have and use often but is not a replacement for an ET. We no longer interrupt CPR for intubation, and train that way.

    2. Indeed, but the King dislikes a wet oropharynx and has a dendency to wander. It is a tool I have and use often but is not a replacement for an ET. We no longer interrupt CPR for intubation, and train that way.

  5. I think you missed a major contributing factor to the push to remove ETI-simpler methods. You mentioned the standard being adequate oxygenation, and if a BVM is working, great. By the same token, King airways, LMAs, and combitubes have proven to be effective and require far less training to use effectively. They also take less time to insert. How many times have you seen CPR interrupted repeatedly while a medic makes multiple attempts to insert an ET? The challenges of working in the field-lack of lighting, cramped space, etc contribute to the difficulty of placing an ET, as you mentioned. But those conditions don’t matter to the King.

    1. Indeed, but the King dislikes a wet oropharynx and has a dendency to wander. It is a tool I have and use often but is not a replacement for an ET. We no longer interrupt CPR for intubation, and train that way.

    2. Indeed, but the King dislikes a wet oropharynx and has a dendency to wander. It is a tool I have and use often but is not a replacement for an ET. We no longer interrupt CPR for intubation, and train that way.

  6. I think you missed a major contributing factor to the push to remove ETI-simpler methods. You mentioned the standard being adequate oxygenation, and if a BVM is working, great. By the same token, King airways, LMAs, and combitubes have proven to be effective and require far less training to use effectively. They also take less time to insert. How many times have you seen CPR interrupted repeatedly while a medic makes multiple attempts to insert an ET? The challenges of working in the field-lack of lighting, cramped space, etc contribute to the difficulty of placing an ET, as you mentioned. But those conditions don’t matter to the King.

  7. Rhode Island is a strange place. Zero tube placements before heading into the field. I got my first tube in the back of the truck, zero supervision. And, as a bonus, you get to be in charge of a rescue with six (6) successful IV’s.

    My first few months were interesting

  8. Rhode Island is a strange place. Zero tube placements before heading into the field. I got my first tube in the back of the truck, zero supervision. And, as a bonus, you get to be in charge of a rescue with six (6) successful IV’s.

    My first few months were interesting

  9. Rhode Island is a strange place. Zero tube placements before heading into the field. I got my first tube in the back of the truck, zero supervision. And, as a bonus, you get to be in charge of a rescue with six (6) successful IV’s.

    My first few months were interesting

  10. It’s a continuum, like I’ve stated before.

    My sense of it is that many of those screeching loudest about keeping ETI because it is an “essential” skill, probably utilize it inappropriately. Few seem to get that you can actually make a patient’s clinical course more problematic with a properly placed endotracheal tube. It is not a benign procedure, even when you hit the hole you were supposed to.

    That lack of perspective is, as Christopher stated, a direct result of the lack of initial airway education in most paramedic programs. All too many programs suck at teaching how to insert the tube, which is the most easily remedied problem.

    Much more problematic is teaching medics enough to know when, why and why not to insert a tube. That is going to take much more than “you must insert X number of tubes to complete the program.”

    The way I see this going is, in 10 years or less, intubation is no longer going to be a core skill for paramedics. Instead, it will be an optional one determined by state and system medical directors who have taken the time and effort to see that their medics are educated and trained adequately in the procedure. Intubation will be a skill confined to a much smaller cadre of paramedics, and we will have brought those restrictions on ourselves.

    I’m no longer entirely convinced that’s a bad thing.

  11. It’s a continuum, like I’ve stated before.

    My sense of it is that many of those screeching loudest about keeping ETI because it is an “essential” skill, probably utilize it inappropriately. Few seem to get that you can actually make a patient’s clinical course more problematic with a properly placed endotracheal tube. It is not a benign procedure, even when you hit the hole you were supposed to.

    That lack of perspective is, as Christopher stated, a direct result of the lack of initial airway education in most paramedic programs. All too many programs suck at teaching how to insert the tube, which is the most easily remedied problem.

    Much more problematic is teaching medics enough to know when, why and why not to insert a tube. That is going to take much more than “you must insert X number of tubes to complete the program.”

    The way I see this going is, in 10 years or less, intubation is no longer going to be a core skill for paramedics. Instead, it will be an optional one determined by state and system medical directors who have taken the time and effort to see that their medics are educated and trained adequately in the procedure. Intubation will be a skill confined to a much smaller cadre of paramedics, and we will have brought those restrictions on ourselves.

    I’m no longer entirely convinced that’s a bad thing.

  12. It’s a continuum, like I’ve stated before.

    My sense of it is that many of those screeching loudest about keeping ETI because it is an “essential” skill, probably utilize it inappropriately. Few seem to get that you can actually make a patient’s clinical course more problematic with a properly placed endotracheal tube. It is not a benign procedure, even when you hit the hole you were supposed to.

    That lack of perspective is, as Christopher stated, a direct result of the lack of initial airway education in most paramedic programs. All too many programs suck at teaching how to insert the tube, which is the most easily remedied problem.

    Much more problematic is teaching medics enough to know when, why and why not to insert a tube. That is going to take much more than “you must insert X number of tubes to complete the program.”

    The way I see this going is, in 10 years or less, intubation is no longer going to be a core skill for paramedics. Instead, it will be an optional one determined by state and system medical directors who have taken the time and effort to see that their medics are educated and trained adequately in the procedure. Intubation will be a skill confined to a much smaller cadre of paramedics, and we will have brought those restrictions on ourselves.

    I’m no longer entirely convinced that’s a bad thing.

  13. I disagree that we are a trade, we are in fact a skill set in search of a trade and someday hoping to be a profession. The proficiency of the practitioners of that skill set varies incredibly, and not even by delivery mode. There are excellent third service systems, private systems, even fire based systems. Conversely there are horrid examples of all three.

    There is also a huge variation in paramedic training. My course was a full year, six months of didactic, five months of clinical, two weeks of full time field internship. It was grueling, but I learned a lot. I think it made me a better paramedic, but the education process has to be continuous and career long. I see a lot of resistance to that, again, across delivery models.

    Intubation is a symptom of a systemic problem. The reason that it’s so high profile is that the stakes are so high. Nonetheless, the problem is no less severe when it comes to trauma care, STEMI recognition, Stroke recognition, and just about every other area of EMS. Another symptom of the problem is all of the alphabet courses that are out there to make up for the shortcomings of EMS education. In an ideal world, all of that would be included in the paramedic curriculum.

  14. I disagree that we are a trade, we are in fact a skill set in search of a trade and someday hoping to be a profession. The proficiency of the practitioners of that skill set varies incredibly, and not even by delivery mode. There are excellent third service systems, private systems, even fire based systems. Conversely there are horrid examples of all three.

    There is also a huge variation in paramedic training. My course was a full year, six months of didactic, five months of clinical, two weeks of full time field internship. It was grueling, but I learned a lot. I think it made me a better paramedic, but the education process has to be continuous and career long. I see a lot of resistance to that, again, across delivery models.

    Intubation is a symptom of a systemic problem. The reason that it’s so high profile is that the stakes are so high. Nonetheless, the problem is no less severe when it comes to trauma care, STEMI recognition, Stroke recognition, and just about every other area of EMS. Another symptom of the problem is all of the alphabet courses that are out there to make up for the shortcomings of EMS education. In an ideal world, all of that would be included in the paramedic curriculum.

  15. I disagree that we are a trade, we are in fact a skill set in search of a trade and someday hoping to be a profession. The proficiency of the practitioners of that skill set varies incredibly, and not even by delivery mode. There are excellent third service systems, private systems, even fire based systems. Conversely there are horrid examples of all three.

    There is also a huge variation in paramedic training. My course was a full year, six months of didactic, five months of clinical, two weeks of full time field internship. It was grueling, but I learned a lot. I think it made me a better paramedic, but the education process has to be continuous and career long. I see a lot of resistance to that, again, across delivery models.

    Intubation is a symptom of a systemic problem. The reason that it’s so high profile is that the stakes are so high. Nonetheless, the problem is no less severe when it comes to trauma care, STEMI recognition, Stroke recognition, and just about every other area of EMS. Another symptom of the problem is all of the alphabet courses that are out there to make up for the shortcomings of EMS education. In an ideal world, all of that would be included in the paramedic curriculum.

  16. As a paramedic going to a respiratory therapy program, the very scary intubaters are the ER docs one was arguing that the tube was in the right place while 3 of us around him were saying that it was in the belly, after three attempts and a few broken teeth later he finally let someone else try.

  17. As a paramedic going to a respiratory therapy program, the very scary intubaters are the ER docs one was arguing that the tube was in the right place while 3 of us around him were saying that it was in the belly, after three attempts and a few broken teeth later he finally let someone else try.

  18. As a paramedic going to a respiratory therapy program, the very scary intubaters are the ER docs one was arguing that the tube was in the right place while 3 of us around him were saying that it was in the belly, after three attempts and a few broken teeth later he finally let someone else try.

  19. I completely agree HM. I did 5 tubes and a nasal during my one OR rotation. I got no field tubes or even ER tubes during my precepting time. My first “real” tube was on a code in the field as a released medic. My current department’s philosophy (or really my EMS Captain’s philosophy which is what goes when he’s on scene with me) is to insert a King Airway on cardiac arrests. Yes, we still have ETI for respiratory issues but our primary airway is the King…why? We very well may run a call with just ourselves as the ALS provider. The King in Virginia is a BLS skill and one of the BLS firefighters can insert it. My worry is that I haven’t done an airway in so long that if I NEED to do it will I still be proficient? We can’t do OR rotations anymore because of liability and other BS excuses. Part of the reason I continue working at my part-time job despite it being almost 2 hours away is that ETI is still highly regarded as the airway of choice.

    The King works great…sometimes. We need a way to practice our ETI skills more regularly though.

    LM (Sam the EMT’s old partner)

  20. I completely agree HM. I did 5 tubes and a nasal during my one OR rotation. I got no field tubes or even ER tubes during my precepting time. My first “real” tube was on a code in the field as a released medic. My current department’s philosophy (or really my EMS Captain’s philosophy which is what goes when he’s on scene with me) is to insert a King Airway on cardiac arrests. Yes, we still have ETI for respiratory issues but our primary airway is the King…why? We very well may run a call with just ourselves as the ALS provider. The King in Virginia is a BLS skill and one of the BLS firefighters can insert it. My worry is that I haven’t done an airway in so long that if I NEED to do it will I still be proficient? We can’t do OR rotations anymore because of liability and other BS excuses. Part of the reason I continue working at my part-time job despite it being almost 2 hours away is that ETI is still highly regarded as the airway of choice.

    The King works great…sometimes. We need a way to practice our ETI skills more regularly though.

    LM (Sam the EMT’s old partner)

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