In my recent EMS Bubble tirade I called for studies to prove my theories. Well, as the old adage goes, “You should be careful what you wish for.” Those of you who keep up with Tom Reynolds may have seen his most recent blog post where he explains how intubation is being taken away from the London Ambulance Service. They have done this based on many of the American studies that have come out casting doubt on EMS intubations. Tom seems to be angry about the move, and I get that. I used to feel like him. But now, to be honest I am very interested to see what is going to happen. I am suspicious that there will be no change in patient outcome.
My blog is about the human side of things, and so I would like to talk for a moment about the human side of these studies that are casting doubt on our airway skills. Most paramedics are very reactionary when you discuss taking away intubation. Most students are too. But if you have taken ACLS in the last few years, you may have noticed that there is a big push to downplay intubation when ventilation can be adequately performed in a BLS fashion. Please take note that this advice is meant for everyone, not just EMS.
I cannot tell you how many ACLS instructors I know who simply ignore this and teach classes the same old way. So wide spread is this rebellion of the new standards that many instructors I talked to were unaware of the mindset completely and were suspicious or argumentative when I tried to talk about it. One particular instructor was so vehement that all patients should be intubated immediately that I took the time to sit down and cue up certain passages in the videos and point to certain passages in the ECC Guidelines book. (After having to make this argument several times, I am shocked to find out how many ACLS instructors have never bothered to familiarize themselves with the ECC Guidelines text or read ‘Circulation’ in an attempt to stay current.) This instructor simply became angry, got up and left. I heard various reports that he was going around town saying I was crazy. Ah…Kentucky.
But make no mistake, since the 2005 update to AHA guidelines, it is quite alright to take a code to its completion without intubating the patient. Why is this? Because providers spend so long attempting to get a ‘vanity intubation’ that they are terribly late in doing such useful things as chest compressions and defibrillating the patient. So I drilled it into my students’ heads during scenarios that it was perfectly reasonable to take a full arrest into the hospital without intubation. Now don’t read this the wrong way. If there is copious vomit, or some sort of ventilation issue, make it your mission in life to intubate. However, if the patient’s chest goes up and down when you use a BVM, and you see a squiggly little line on your monitor, you may have other priorities.
So what has happened? My students went to do their internships. And what do they see on the streets? Immediate intubations. Even if it means forgoing other procedures. So widespread is this tunnel vision, so wide spread is the fetish for this procedure involving a plastic tube that my students have started to question me. One of them said, “Buckman, no one but you and your instructors teach it this way. What’s the old expression? 50,000 Frenchman can’t be wrong? You can point to all the studies you want, people intubate first and ask questions later.”
I have walked into classes full of people and taken informal poles. I will say, “Everyone raise your hand if you have seen a medic forego CPR and ventilation for at least two minutes to get a tube?”
Everyone in the room will raise their hand.
“Okay, now keep them up if you have seen a medic forego chest compressions and ventilations for up to four minutes to get a tube?”
Over half of the room will still have their hand raised.
“Alright, how many of you have seen this go on for six minutes?”
Many hands will still be raised.
“Eight? Ten?”
Even here, hands are still raised.
“Okay. Remember what I have just taught you. What did I just say about maintaining perfusion pressures during CPR? Isn’t this simply tantamount to killing your patient? Okay, let’s go back a minute. I want to remind you that brain death occurs within 4 to 6 minutes. Okay, everyone who has seen a medic forego CPR and ventilation for 4 minutes or longer while they were jacking around trying to get a tube in, raise your hands again. Get them up. Leave them up. Now look around the room people. Everyone with their hands up has seen a medic kill someone. Cold blooded murder. Think about that.”
I have seen it happen. You have seen it happen.
I once had an intubated patient in the back of my rig. (There was standing water up to the teeth when I opened her mouth, so the tube was warranted.) Another medic was helping me with the code and she took the head. She was bagging the patient a mile a minute. I told her to slow down. She rolled her eyes at me and continued to bag at a ridiculous rate. Something like thirty times a minute. I got impatient with her.
“Have you had ACLS in the last few years?!?! I know you have. Hyper inflating the chest reduces perfusion pressure. You are hurting the patient for no reason. Slow it down.”
She looked at me with indifference, “Yeah, I have seen that in a couple of books. It’s all garbage. She hasn’t been breathing in a while. What she needs is air. I’m giving it to her. I do all my codes the old fashioned way. I don’t care what the new damn CPR classes say. I learned it this way, and I am going to keep doing it this way.”
Some people I know think that I can be pretty rough on people sometimes. So I won’t incriminate myself here by telling you what I did to this woman. Let’s just say that after I spoke with her she sat in the wheel well away from the patient and anything sharp for the remainder of the run. The patient was then ventilated 12 times a minute…and still died. Ha! The joke is on all of us!
So what is the take home here? The maturity of our EMS providers has kept us from learning new things and doing what is right. There are many doctors who see this infantile behavior that we demonstrate, and draw the obvious conclusion. Why do you think these field intubation studies were started and funded? All studies start with a hypothesis. If a few physicians witnessed our infantile disregard for the basics, how do you think this hypothesis was formulated?
I’m not sure if the London Ambulance Service has the same maturity problems I have witnessed time and time again in Texas and Kentucky. I don’t know if they have medics who ignore basic life saving procedures for minutes while they try and get a piece of plastic inserted to make themselves feel better. But we are about to find out. Wikipedia just told me that as of July, 2007 London has a population that exceeds 7 million. This is it. This is the big guinea pig we have been waiting for. I dare say that the London Ambulance Service covers a large enough sample of people to make an interesting study about what happens when a toy is taken away from a child. Tom, if your people are more mature, I apologize. If your providers don’t act like this, I would imagine that you would be livid with our American studies right about now.
Ah…I can almost feel the anger flowing through readers as they take this in. But just for the record. I think intubation would be an indispensible tool in the field if it were done properly. I feel as if I do it properly. It would be a shame to remove that from my bag of tricks. There are instances that I can think of where it would be sorely needed. But I also have to be honest. BVM’s work just fine. King Airways work just fine. And I can think back to several situations where I have seen a medic kill every brain cell in a poor patient’s head trying to do an unnecessary procedure. I wish I hadn’t seen that. I wish EMS was an industry full of well educated, well spoken, thoughtful people who read the ECC Guidelines out of curiosity and were familiar with the scientific method. I have also heard that people in hell want ice water. I will be watching London.
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