As I was reading my Twitter feed before my shift started I noticed something. Loads of my fellow London Ambulance people were talking about intubation. I had no idea why.
It only took me a while to hear the rumour, then manage to get back onto station, then find on the internal website the bulletin that they were all talking about.
Since the start of Paramedic training, one of the things that has been a main thrust of their qualification is the skill of intubation. Intubation is the passing of a plastic tube into a patient’s airway in order to breathe for them. This protects the airway from becoming blocked and, more importantly in CPR, prevents vomit from entering the lungs thereby buggering any chance of successful resuscitation.
The bulletin is entitled ‘The future direction of airway management in the London ambulance service’.
It mentions that in 2008 JRCALC looked at the research, which is mostly American, and made the recommendation that paramedics should not be intubating patients. JRCALC doesn't seem to have many actual ambulance people involved in it – but perhaps this is a cheap shot and I think this only because I can't seem to get much information when I Google the names that aren't obviously doctors, nurses or midwives.
What immediately leaps out at me is that if they are looking at American research you are comparing apples with oranges. From the research I have read, the success rate in America depends on the training and continuing education of the staff, something that varies across the different companies providing ambulance services and also that varies from state to state.
The consensus seems to be that you need practice, and you need regular refreshment courses and continuing assessment to be safe to intubate.
There is thought that intubation can immediately reduce your chance of surviving a cardiac arrest, mostly because while someone is faffing around with a plastic tube the things that work – compression and defibrillation, aren't being done. But this is an issue that could take up a week's load of blogposts on it's own, so I'm not really going to touch on it.
In theatres, with a nicely starved patient undergoing an elective operation the airway of choice is something called an LMA – and this is great. It's easy to insert and it protects the airway. Unfortunately it doesn't protect against vomit very well. This is why you starve surgery patients, if there is no food in the stomach, no food is coming up your throat to then swill down into your lungs.
Rather unfortunately, most of our patients who decide to stop breathing and need CPR haven't had the foresight to starve themselves for eight hours. When you do CPR you often get vomit. Loads of vomit. Vomit that, if it enters the lungs will damage them in a really nasty fashion. As well as drowning you.
To protect against vomit going into your lungs, you really need proper intubation. And an LMA isn't going to cut it.
Unfortunately it's harder to train someone to intubate than it is to pop down an LMA.
Of course, if your patient isn't vomiting then you don't even need an LMA, most often a basic airway technique will be enough.
The next time I blue light a cardiac arrest into hospital, I'll ask the anaesthetist if they are going to use an LMA or intubate, and why they make that decision. That should hopefully highlight the clinical need for intubation.
So, let’s look at London, and why I think that – while we are right to stop teaching paramedics intubation, it is just a symptom of a much wider problem.
To be good at intubation you need practice, you also need to have something called Clinical Governance. This means that someone or some policy will be in place so that your clinical skills can be evaluated so that it is certain that you are performing to your best.
One way in which this can be done is by having a clinical lead shadow you at work, watching you and making observations as to how your clinical practice can improve.
We don’t have this in the London Ambulance Service.
In eight years I have had one of these ‘ride outs’.
This, quite simply, is not good enough.
Imagine the simpler skill of taking a blood pressure – for the past eight years I could have been doing it wrong, placing it around the wrong part of the arm for example. There would be numbers on my paperwork, but they would have no resemblance to reality.
Unless someone complains, or another member of staff tells someone about my risky behaviour, I could be doing this for many more years to come.
Now extend this to intubation, a much more technical task that has severe repercussions if someone does it wrong i.e someone will almost certainly die.
Our paramedics do around 25 intubations during their training, which is under half the recommended number (57). Once they have done that they are given a tube and told to go and intubate people out in the wild.
Once the initial training is over that’s it. There are no refresher courses, there is no chance to go into hospital to practice (because in non-emergency situations other airway protection techniques are better, the LMA I mentioned earlier for example), and there is no way of knowing if the paramedic is even doing it right in the first place.
So, it is a good thing that intubation is being devalued and no longer being taught. But the reason behind it not being taught is purely because we don’t teach it right in the first place, and there is no system in place for paramedics to keep their skills fresh.
And that is just wrong.
So, what does this mean for the future?
New paramedics will no longer be taught intubation. More people will die from cardiac arrest from inhaling their own vomit, but perhaps we'll see a reduction in death from incorrect intubation – I suspect that in the long term deaths will increase, if only because you are more likely to vomit than suffer an incorrect intubation (and all the paramedics I've worked with are fastidious about checking that they have performed a correct intubation). However only time, and counting the gravestones, will tell.
Older paramedics will continue to be allowed to intubate, but any suggestion of a refresher course will be off the table as the skill is now devalued. I would also suspect that the ambulance service will just stop buying the tubes used in intubation. No stock on station means that you can't use the skill anyway.
It'll be interesting to see what happens should the newspapers get wind of this – that or the response to a 'My child died because…' headline.
I doubt the press office will admit that the reason this skill has been removed is because the London Ambulance Service cannot train, supervise or refresh their staff correctly.
This removal of a skill because we cannot correct train, assess and update our staff ties in rather nicely to a series of posts I'll be publishing from Monday.