Sorry for the long post, but . . .
In the comments to Too Many Medics?, Anonymous wrote:
Grrr. Really trying to make an inflammatory post, aren't we RM ?
Are you kidding? I tone it down to keep it nice and polite.
Couldn't find a copy of the ACTUAL study, and I'm never a fan of quoting USA Today as a source of anything, other than maybe a horoscope.
I don't read horoscopes, but here is the abstract.
Academic Emergency Medicine; Volume 13 Issue s5; May 2006; pages S55 - S56; abstract number 121:
Cardiac Arrest Survival Rates Depend on Paramedic Experience
Did, however find this nugget in 'Emergency Medicine News' from the MD that authored that study. Note his last comment in the excerpt.
Nothing odd about it.
There is no evidence that any of the ALS treatments improve outcomes. So, why would it be important to have paramedics arrive at a cardiac arrest quickly?
The focus should be on excellent BLS care. ALS personnel should understand that and help with the BLS. Many probably do not. In stead, they interfere with the quality of the BLS.
BLS, unlike ALS, has been shown to improve outcomes from cardiac arrest. The longer they focus on the BLS, the better for the patient.
Interruptions in Cardiopulmonary Resuscitation From Paramedic Endotracheal Intubation
Benefit to the patient of these interruptions in BLS treatment?
No known benefit.
Cost to the patients of these interruptions in BLS treatment?
Whatever small chance at resuscitation they had is lowered dramatically.
We have to have more medics, so that they can interfere with BLS care.
Once everybody is a medic, we will probably continue to argue over who has to put up with doing the demeaning BLS stuff, even though that is all that works in cardiac arrest.
From the full text of this journal article:
Assuming the need to reduce endotracheal intubation–associated CPR interruptions, potential strategies include improving paramedic endotracheal intubation skill or altering out-of-hospital airway management techniques. Improving endotracheal intubation skill may prove difﬁcult, given limits in the quantity of paramedic student training and clinical endotracheal intubation experience in the United States. 26-28 Although select paramedics attempt endotracheal intubation without stopping CPR chest compressions, the broader feasibility of this technique remains unclear. To minimize CPR interruptions, many EMS agencies have substituted endotracheal intubation with Combitube or King LT airway insertion. 13 Select studies suggest the viability of CPR without ventilation, potentially obviating the need for airway management interventions. 29,30 The relative effectiveness of these techniques remains unknown.
Why interrupt compressions to intubate?
Why intubate, in cardiac arrest, if an alternative airway is faster?
Why intubate, in cardiac arrest, if an alternative airway is just as good at airway management?
Why rush a medic to a cardiac arrest if the medic makes things worse?
Also, the more medics you need, the less selective you can be in choosing the ones you end up with. If you are going to scrape the bottom of the barrel, because the supply cannot meet the demand, and you will not pay well, you will get bottom of the barrel quality.
Maintaining quality is also important. This study might suggest that PFD (Philadelphia Fire Department) would have an excellent resuscitation rate. From what I was last told, PFD is 250 medics short of being fully staffed. PFD has political obstacles to consistently providing quality care. PFD has some excellent medics, but not because of oversight. The excellent medics are excellent because they work at it on their own. They are balanced by others, who easily dredge up bottom of the barrel analogies.
So, it is not just about numbers. However, the more medics you have, the harder it becomes to maintain quality. The harder it becomes to obtain experience. The combination of quality and experience are important.
More medics means a need for more medical oversight.
Do these everyone a medic systems increase the number of medical directors to keep up with the increase in medics?
Do they aggressively work at simulations to make up for their lack of touch with reality?
This topic will eventually be studied and written about more fully. This particular study is not likely to be published in anything other than abstract form.
Here is a study from Boston, where the number of medics is low and the quality is high:
Volume 52, No. 4: October 2008; Annals of Emergency Medicine; page S153; abstract number 364:
Success Rates in Out-of-Hospital Intubation
It is only a matter of time until the research is done. Until then we have to wade through a morass of intubation results from the everybody a medic systems.
A prospective multicenter evaluation of prehospital airway management performance in a large metropolitan region.
This is not a system with every person on every apparatus a medic, but their success rates are not good. Less than 80% success? 5% unrecognized esophageal tubes? We need to start improving quality or restricting skills to those who can actually demonstrate skill. Adding more medics only makes this quality problem worse. A system that is just doing more of the same is not one you want taking care of those you love.
Here is one from one of the happy everybody a medic Pollyanna places:
Prehospital intubations and mortality: a level 1 trauma center perspective.
From the full text of this journal article (PHI = Pre-Hospital Intubation):
The significant difference we found in the success of PHI performed in connection with air (67%) and ground transport (33%; P < 0.001) may reflect the deployment to aerial units of paramedics with more experience and skills, including intubation, because it is usually a promotion from the ground units. Although this study did not correlate intubation skills of individual paramedics, data from Germany, where air rescue crews perform ETI three times as frequently as ground crews, 1 support this. Therefore, clinical experience of those performing the intubation is invaluable and perhaps the most important piece of the PHI puzzle.
The 67% and 33% are a bit misleading. They are the percentages of the overall successful intubations, not the percentage of intubation attempts.
Of the 203 patients, 115 (57%) were transported by air, and within that group, 94 (82%) were properly intubated in the field, and 21(18%) were not. Of the 88 patients who were transported by ground, 46 (52%) were successfully intubated in the prehospital setting and 42 (48%) had a failed PHI (P < 0.001 compared with patients transported by air).
52% is still a number that should not be tolerated in intubation. There are 2 considerations not made clear.
How many of the failed intubations actually had intubation attempts?
How many intubation attempts did they have?
Maybe we need to include another data point? Total intubation attempts.
If almost all of the patients actually had intubation attempts and there were 2 attempts before moving to an alternative/rescue airway and some of the successful intubations were on the second attempt, then the success rate per attempt is possibly much lower than 1 in 3.
How many holes are we dealing with in the airway?
Hush. Let's not be inflammatory. If we throw more medics at it maybe one of them will find the trachea.
In these everybody a medic systems a piñata might live for ever. The patients on the receiving end of the intubation attempts might be jealous of the piñata.
Even the flight crews only intubated 82% successfully. That is about the same as the ground medics in the Denver study above it. It is true that this is trauma, while the others are not limited to trauma.
At least to me, the most important conclusion from that study seems to be (PHI = Pre-Hospital Intubation):
Therefore, clinical experience of those performing the intubation is invaluable and perhaps the most important piece of the PHI puzzle.
What about intubation in the system that had the highest resuscitation rate in the original study - Cardiac Arrest Survival Rates Depend on Paramedic Experience?
Here is an abstract from their 20 year study of intubations. These medics do use succinylcholine. So do the flight crews in Miami. They did break down their results into trauma intubations and medical intubations. How did this system do? They focus on keeping the number of medics low and the quality high. Let's see:
Prehospital use of succinylcholine: a 20-year review.
They intubated 94% of trauma patients successfully over a 20 year period.
From the full text of this journal article is the most likely explanation for the high success rate.
Following didactic training, each student must successfully complete a minimum of 20 intubations, in the operating room, under the supervision of a board-certified anesthesiologist. Additionally, paramedics are required to successfully intubate at least one patient monthly for three years, post certification, and one per quarter thereafter. At least one intubation, annually, must be performed under an anesthesiologist’s supervision.
I will repeat that Paramedic ≠ Intubation. It may be that intubation is the easiest way to measure paramedic quality. On the other hand, it may be that a lack of intubation skills is a good indicator of a lack of overall paramedic quality, rather than the other way around. It seems that many systems have a significant problem with quality. In some of these low quality systems, the attitude does not appear to be to fix the quality problems, but to make everyone a medic. How is more of the same an improvement?
EMS in Boston and Bellingham/Whatcom County take airway management seriously, while the everybody a medic people in Miami average 1 - 3 intubation per medic per year. After however many attempts at intubation, they still only get it half right.
What do the everyone a medic systems do about quality?