Last week the National Association of State EMS Officials (NASEMSO) announced they were soliciting feedback on a revision of the 2007 National EMS Scope of Practice Model.
Contained in the draft (that you can download here) on page 22 line 645 reads “8. Comments received for exclusion from the Practice Model:” and is followed immediately by line 646 that reads “Endotracheal intubation“… and the EMS Internet went CRAZY!!!
There were Facebook rants, Twitter storms (#SaveTheTubes is already taken by Net Neutrality proponents), and even a petition gathering signatures all in the name of saving Endotracheal Intubation. The outpouring was SO intense that the NASEMSO issued a follow-up press release highlighting the fact that this was OPEN FOR COMMENT and NO DECISION has been made (yet) so please, put down your pitchforks and torches!
There are a number of things about this whole situation that I really just want to highlight for a second:
- It is not a secret that paramedic field intubation success rates have been under scrutiny for some time
- There are airway options other than endotracheal intubation which have quicker application and are just as successful
- Remember how we joke about the fire service being all “100 years of tradition unimpeded by progress!”… yeah… that sounds like us right now… “30 years of tradition unimpeded by progress and technical innovation sticking tubes down people’s throats SAVING THEIR LIVES!”
Many people feel the relatively infamous Out-of-Hospital Endotracheal Intubation Experience and Patient Outcomes study that reported an ETI success rate of 77% is to blame. There were indications that ETI success had improved in this 2014 article Evidence-Based EMS: Endotracheal Intubation which reported an 85% success rate, but the earlier study seems to stick in the craw of everyone when field ETI gets discussed. Compared to out of hospital cardiac arrest survival rate of 9.6%, that 85% should actually be a freaking diamond.
Personally, I think the more eye-opening study is a small one from 2009 that compared ETI Placement to King LT-D Supraglotic airway. On the first attempt ETI placement occurred in 58% of the patients, while the King LT-D first attempt placement occurred in 88% of the patients. It illustrates that ETI is not the only way to maintain an airway, at least initially.
Brian Behn posted at EMS QA QI a post titled Why I Am Not Signing The Petition About Intubation. I find myself in agreement with him. There is definitely an education component that can be improved upon. I also think that skill degradation, especially in single tier ALS systems plays a large role in success and failure. Despite what people think, I am not against endotracheal intubation… if it is done correctly and without further delaying the patient to definitive care. Surprisingly, that’s actually a lot to expect for the skill set and the providers performing it… or so it would seem.
Interestingly enough, I literally told someone back in July that this type of proposal was going to happen. They scoffed at the notion, and less than a month later here we are. Of course the truth is that nothing has happened yet, this is simply something that is open for comment.
What I find concerning is that the majority of the conversation is revolving around ONE thing possibly being EXCLUDED, and there seems to be no mention of the MULTIPLE things looking to be INCLUDED. I mean really, who wants to comment on blood glucose monitoring, CPAP, epinephrine, or oral over the counter meds at the EMT level? Who needs to comment on replacing Paramedics and EMTs on ambulances with EMRs for transporting patients??(HINT: Every single one you of reading this) Who cares enough to comment on paramedic blood administration or defining “critical care”??? All of these topics apparently aren’t worthy of the EMS Internet to spend time and energy on… and I find that really pretty depressing.
I also find it disheartening that a petition guaranteeing endotracheal tube manufacturers profits for years to come found more traction in 3 days than a petition to improve the wages of the providers in the industry nationwide found in 30 days. It’s with these screwed up priorities that we will condemn ETI to join backboards in protocols and see it removed from the scope of practice due to the acute lack of educated providers filling our ranks to meet the demand for transportation services.
As usual… feel free to let me know your thoughts in the comments… but leave your ETI propaganda on your Facebook feed…