Removing Intubation

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.

26 thoughts on “Removing Intubation”

  1. Do you have a lot of people who die from incorrect intubation? 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…Do you think taking intubation away from the paramedics is going to happen across other trusts as well?

  2. As an anaesthetic registrar who also still does volunteer ambulance work (that narrows down who I am), I have mixed feelings about this…Intubation is a difficult skill to master. I have only done about 250 intubations (which apparently makes me skilled according to that paper), but I still feel vague anxiety every time I'm passed the laryngoscope. Note the point that they made is that the 57 number was in people anaesthetising in the operating theatre environment, where the table can be moved up and down, the light is good, the patients are (generally) fasted and one has a boogie close to hand. The other point that can be made is that most of the patients will have had an airway assessment prior to induction, which is simply not feasible in the pre-hospital setting.

    Just because one can do something, doesn't mean one should do something. There is not a single shred of evidence that intubating a patient who has had a cardiac arrest improves survival. In saying that, neither is there any evidence that anything apart from defibrillation improves outcome.

    Then there is the flip-side. One of the most stressful things about working in the prehospital environment is the sheer number of things that are a) uncontrolled and b) variable. Being able to put an ETT down and being comfortable that the airway is secured means one less thing to worry about (obviously to an extent).

    There are also certainly patients who would have died without intubation. To stand by and let them die, when you know that they could have been saved would be soul-destroying.

    The reality of prehospital care is that it is governed by people who, in general, do not have an appreciation for what it's really like out there on the road. There has been a significant lack of resourcing for research. The problem that the authors of this report face is that the limited research out there shows no benefit (NB: absence of evidence is not evidence of absence) or increased risks to the patient.

    It's all too difficult…

  3. The point about handwashing didn't state that we were above infection control. The issue was that as we have all had the input in our basic training (and general life training from the way we have been brought up I hope!) then if a refresher was needed it would be far better served as an email/magazine/alert update as opposed to taking up valuable training time which we apparently don't have enough of to practise important livesaving skills.Surely you would agree priority should be given to skill refreshers if it is such a worry that skills will fade and there is limited spaces to train? Or do supposedly autonomous ambulance staff need someone to stand up in front of them each year to tell them how to wash their hands instead of reading it for themselves?

  4. Absolutely. If people aren't following training (without good reason, like there being no CO2 connectors in stock), aren't taught correctly and aren't pulled up by management/training school if they refuse to check properly then that is the fault of both the individual and the LAS.And we shouldn't be allowed to use the skill.

    I think that we need to go further and remove intubation from everyone – after all one of the reasons given was the lack of refreshers and initial training – so why are paramedics still allowed to intubate if the refresher isn't there?

    We should just stop *all* intubation and see what happens to our cardiac arrest success rate.

    Surely that'd be the thing to improve? If survival rates increase then we've done the right thing, if they go down, then perhaps there needs to be a rethink.

    (And if it goes up, then remove the drugs used in cardiac arrest and see if it goes up again.)

  5. I had the exact same discussion with a tech (Laura) the other night. An LMA is a wonderful environment for channelling vomit into the lungs, so if you do get anyone back they have screwed up lungs burnt with stomach acid. Marvellous. Intubation is the way forward, as an anaesthetist at my uni told me. He advocated paramedics doing it and said that LMAs should be avoided in prehospital

  6. Hi Reynolds,In Victoria, Australia we have a two tier system. We have ALS Paramedics, and MICA (Mobile Intensive Care Ambulance) paramedics. MICA training is a course on top of the degree for ALS, and you have to be in the service for several years to qualify for MICA training. Only the MICA qualified people are allowed to use an ETT (and RSI patients with a GCS <8 or <12 on the helicpter). Non MICA crews can use the LMA. In the metropolitan areas a MICA crew will be sent to more severe jobs, in support of an ALS crew. (The metropolitan fire brigade also supports cardiac arrest jobs - they are trained in resus including AED, and by all accounts are very good at it).

    Now the thinking behind the two tier service is the same reasons why LAS appears to be removing ETTs from your training – there isn't enough chances to practice the skill. So in this case, they limit the number of people who can practice it, to make sure they are getting enough chances. Or at least that appears to be the thinking. Out of interest MICAs are also the only ones to do 12 leads, the only ones to give cold fluid therapy and a few other things as well. As a lowly student I have a long way to go though!

    Enjoy the blog!

  7. So the decision to remove isn't affected by all th new student paramedics that they have no spaces in theatres for?Surely we should be increasing or skills portfolio not reducing it. They are putting all this effort into improving the profession by increasing the standard of training at the start (all these uni courses) but then take away a fundamental skill with the reason that more training is needed! Are we going to get respect from the hospital when we blue in a compromised vomit airway?

    Surely we should just be focusing on more training. We don't need to be shown how to wash our hands. How about more important training like intubation

    How many basics drs who aren't gasmen/women regularly intubate? What about their skills fade?

    Yet again patient care is being compromised because we don't have the resources for the training that we desperately need.

    We have endtidal monitoring to prove tube placement. Run refresher courses emphasising the priority of bls over getting a tube in

  8. I think your first statement hit the nail on the head! I waited 6 months following my initial paramedic training and assessments before I got into theatres to intubate real patients. Add to that, the theatres are not intubating as many patients and you get paramedics coming out having not even reached the magic number of 25.Then add on the layer of no back up assessment or training and you have a situation where if things go south when you have to use this underused skill, you be hung out to dry as you are deemed to have had the proper training.

    The Scottish service are trying to implement 'skill refresher courses' these are conducted at only one location for our division and they are voluntary. Should it be on a day you are working you will not be given time off to go and do.

  9. It's a tricky question, and one I alluded to in the post. Basically, *nothing* is proven to be any good in a cardiac arrest except for compressions and electricity. So the benefits of intubation have not been proven.So even if you are tubing people 'technically' correctly, you are maybe not doing the compressions that are doing all the work (or rather, your mate is getting knackered and is slipping into ineffectual compressions).

    As for other trusts… I don't know – from what I've seen other trusts do things very differently (and often much better) than London.

  10. Exactly – sometimes an ET tube makes you happy when you are lugging a ROSC headfirst down X flights of stairs. Likewise the protection against aspiration is something that makes us happy.You hit the nail on the head that the small amount of research shows no benefit, but that this doesn't mean that there is no benefit.

    I could go on for *hours* about the risk/benefit thoughts on both sides of the ALS/BLS+defib argument as well as the ethical problems of doing research where there is a double blind administration of placebo rather than epi. But at the end of the day the reason why this is being removed is because there is no clinical governance.

    As an anaethetist, how much governance do you have? In London at least us ambulance people have *none* – and that is the real reason behind the removal of intubation.

    And because we have no governance, I think that it is right that it is not encouraged.

    (In short, we need more research because while prehospitally ETI as an *option* is very probably rather handy there is no proof and anyway you'd need the training and updating that we just aren't getting).

  11. Do you have someone below ALS Paramedic? Because your ALS paramedic sounds like our EMT-3 only without the ability to do 12 leads.

  12. here in the Pacific Northwest (Oregon and Washington), our medical program directors require a quarterly airway management training. We arrive at 8 am, review respiratory anatomy and physiology, discuss cases of bad tubes, and then we are given fresh pig airways (trachea with lungs attached) where we practice intubations. Then, after we have successfully intubated the pig airway, we are given pig skin to cover the trachea and we practice needle and surgical airways. We also have to have 12 successful field intubations yearly, and if we don't reach that number we have to sign up for an OR rotation where we have to spend 8 hours intubating every patient that comes in. We also have RSI protocols here, which means that in order to be approved to perform RSI we have to pass a specific RSI written and practical test. All of this is by order of the MPD-if any medic misses the quarterly training, you are taken off shift until you have taken it-and it is only offered two days each quarter, so you can be damn sure that every single medic i work with shows up on one of those two days to get the training done. That is unbelievable to me that an essential skill from the paramedic toolbox is being removed solely due to “lack of evidence.” The majority of medical treatments have a lack of evidence to back them up-drugs are developed daily that have very little research supporting the claims. thank god my MPD is so progressive-he gives us a new drug, he watches the results from our care, and either leaves the drug if it is shown to have good results or removes it if the results aren't any better than what we had before. I am sorry to hear that this is the direction the ambulance service is heading in the UK. Good luck.

  13. Is that based on 'Prehospital intubations and mortality: a level 1 trauma center perspective' (2009) set in Ryder Trauma Centre? Because the data from that doesn't really prove an awful lot. Of the 203 patients intubated, 63 were counted as failed intubations; ie ones that the paramedic on scene wasn't happy with and either reintubated or swapped to an LMA (they don't disclose what the split between the groups is). Another 25 of the 203 patients (12%) were discovered to have misplaced tubes on arrival at hospital and there is no explanation of whether the paramedics involved had access to capnography. Regardless I don't think 25 failed intubations in the US is enough to really make such a wide ranging decision.Meanwhile a 2010 systematic review says “We included 5 trials enrolling a total of 1559 patients. No individual study showed any statistical difference in outcomes between the TI and AAT groups” where TI is intubation and AAT is alternative airways.

    A recent, tiny, report on using iGels (a particular type of LMA), Pre-hospital resuscitation using the iGEL, found that in the 12 instances it was used it didn't work effectively and all the patients were instead intubated successfully by the onscene paramedic (who had capnography available).

    So yes, more UK based research is needed and removing the skill before anything is proved puts patients suffering from burns, anaphylaxis and acute asthma at increased risk. And we need to have all the kit (boogies, capnography etc) to give us the best possible chance on those occasions when a tube in the trachea is the only thing thats going to support the airway.

  14. My point is, have we ever had the skill to a satisfactory level given the limited training and lack of clinical governance?

  15. Noone below ALS. Except for us lowly (university) students. Is there somewhere I could read up about how your system works?

  16. I do see your point but if we waited for reasonable training we wouldn't do much! Facetious, yes, but we're meant to be responsible adults who recognise if we're struggling and look for help ourselves. It might be difficult to get that support from management but there's usually someone on the road who can make useful suggestions.To me the fact that some intubations are difficult or impossible doesn't necessarily mean we shouldn't intubate anyone. I think we should move away from automatically tubing everyone and use LMAs and other adjuncts where possible but I would rather be able to try and fail than never have the opportunity in those hideous and rare jobs where it's just you and your crewmate and the airway's disappearing before your eyes.

    But this is what we do; we make the most of bad kit, training and situations. I think it's part of why we do the job and means that we'll never hold management to ransom for better training etc because we do everything in our power to avoid putting our patients at risk. And I bet they thank their lucky stars for that most days.

  17. The other big difference is that MICA possess the ability to perform RSI / Intubation facilitated by sedation. Also there are the ACOs and CERT below ALS ( in some places).-Another student paramedic-

  18. Mmm NSW and QLD still have post employment training diploma level entry. Not sure about other states. Victoria hasn't for eight years.Wasn't sure whether LAS does RSIs or not.

  19. I think you are being a bit harsh.1. Intubation is difficult skill and paramedics do it rarely, therefore are less good at it/take longer.

    2. Due to the rise of LMAs, intubations aren't as common in hospitals now so it would be impossible to train all paramedics to the required standards. Unless of course patients having elective procedures are intubated (which is more dangerous) purely for training purposes.

    3. The evidence of benefit for 'dead' intubations without drugs in the prehospital enviroment is negligble. Due to the difficuties in training mentioned above it wouldn't be possible to train all paramedics to do RSI, and I certainly wouldn't want someone who RSIing me who does a handfull of them a year! You would also need to train RSIing paramedics to be able to deal with failed intubation post RSI so surgical airways etc. Simply not possible as these are rare procedures even in a trauma centre.

    4. LMAs are actually very good, safe and easy to use. The airway isn't fully protected but it is signifcantly protected. Some newer modifications to the LMA may increase aspiration protection

    5. If intubation is a required skill in the field (which is very questionable) could train paramedics to do blind intubations via intubating LMA as an airway of last resort.

    Also at least at the hospitals I have worked LMAs are used in hospital arrests particulalry the fancy igel lma which is also explicitly mentioned in the resus council guidelines

  20. Sorry, I meant the Community Emergency Response Teams and the Ambulance Community Officers.In rural Victoria, in areas which don't have the workload to justify a full time ambulance crew (of ALS or MICA paramedics), there are volunteer community emergency response teams who provide a first response in a marked SUV. They provide treatment up to an advanced first aid level (plus 7 drugs; Aspirin, Salbutamol, Penthrane (methoxyflurane), Epinephrine, Glyceryl Trinitrate, Glucose paste and Oxygen) until the arrival of a normal ambulance for more advanced treatment and transport. They have 60 hours of initial training and they update their skills twice a year.

    Then there are the Ambulance community officers. In areas which are too busy for a CERT (I think it's more than 100 calls per year) but which still don't have the workload for a fulltime ambulance crew you can have ACOs. These are paid members of Ambulance Victoria, on an as needed basis. They can work 2 ACO's or 1 ACO, 1 fulltime ALS paramedic. The ACOs take an Ambulance Victoria vehicle when they are on call. If a call comes in, the ACO leaves home/work, drives to the scene and may then transport the patient to hospital. ACOs may not be used at any one station for more than 20 working hours per week; if the average call load is greater than this, a fulltime ALS crew will be employed.

    The big differences between CERT and ACO are pay, ACOs are paid per hour spent on a callout. Also ACOs have more training, may transport patients and may travel under lights and sirens.

    I hope that makes it clearer…

    -TJ-

  21. I agree with you apart from the handwashing comment. Everyone needs to respect infection prevention and control no matter who you are.

  22. Tom,As an avid view of the Clinical Audits that are done by the LAS on a monthly basis (as well as a practicing para) I think there is a clear reason for the move. Policy on inutbation has been clear for sometime and yet the audited level of use of endtidal Co2 monitoring is not showing 100%. It's simple, you put the tube down, and you use the Co2 to confirm placement. If we can't get that right what are the chances of checking placement in the other ways that are also required?

    Incorrect placement that is not recognised = death.

    I think we can only blame ourselves when this skill is finally removed.

    DSO

  23. I too have mixed emotions about this, primarily because we currently have no option other than ETT for pediatric intubation. Nobody has really brought up the other alternative airways such as Combitube and King Airway. Combitubes are nice blind insertion airways for adult arrest patients and require very little cessation of CPR for just about anyone to place. King airways come in pediatric sizes and also allow for insertion of an OG tube, so they offer a good compromise.I personally find a great deal of frustration with the whole ET thing. People seem quick to criticize the lack of success with Paramedic intubation, but our system offers almost no opportunity to practice this skill other than with cardiac arrest patients. No OR time (after your initial certification). No cadaver lab or animal intubation opportunities. No ER time. It's almost like you're setup to fail.

  24. we use the combi tube in WV – great for securing an airway when you don't have a paramedic on every street corner – the squad I run with (one paramedic in a squad of 20 EMT basics) has made several saves using the combi tube and I as surprised not to see them or the King used more often.

Leave a Reply

Your email address will not be published. Required fields are marked *