Rogue Medic’s Comment Section…

… ain’t big enough for both me and Anonymous.

If you read Rogue Medic, you know that the term gadfly doesn’t quite do him justice. There is nothing he loves more than poking a sharp stick at those in EMS who would gladly accept the status quo, never questioning whether what we do is actually, you know, necessary or not.

And typically, he’ll anger someone with his advocacy for better medical control, or better pain management, or better EMS education, or less reliance on standardized certification exams, or better airway management, or less indiscriminate use of antiarrhythmics, or…

… ah, hell. Let’s just accept it as a given that, on any given day, Rogue Medic is gonna piss someone off about something. That’s what he does.

Not only that, but he’s funny lookin’, too. Kinda like Henry Rollins with a less-talented barber.

But just because the man says things that make many medics and medical directors uncomfortable doesn’t make them any less true. Case in point, an Anonymous (imagine that!) commenter opined in his post Teaching Airway – Part I:

“We get it, you don’t want a medic putting in a tube and your burnt out from the field and want to stop being a medic. So how about for the next 6 months I stop tubing my patients.”

No, you don’t get it, Sparky. You’ve missed the point entirely.

The man isn’t saying we shouldn’t be allowed to intubate patients when necessary.

He’s saying that it is often done unnecessarily, and as a profession, we have a responsibility to get better at it.

Rogue Medic does a credible job of fisking Mr. Anonymous’ comment in his subsequent post, so I won’t repeat it here except to add a few points of my own.

First of all, until paramedics define themselves by a unique body of knowledge rather than by a patch and a skill set, we’re not going to be taken seriously by other health care providers. That body of knowledge is going to require education far broader and deeper than most current EMS educational programs offer.

And the first growing pain in acquiring that body of knowledge is questioning much of the bullshit myth urban legend war stories dogma that currently passes for education in EMS.

Some of us are already there. Others, dinosaurs with one year of experience repeated twenty times, or rookies too ignorant to know that their penis size does not correspond to their willingness to perform an ALS procedure, resist any effort to apply the precepts of evidence-based medicine to EMS.

So allow me to add a few of my replies to Mr. (or Mrs.) Anonymous’ comment:

“We get it, you don’t want a medic putting in a tube and your burnt out from the field and want to stop being a medic.”

Leaving aside the truism that he who resorts to ad hominem attacks has already lost the intellectual argument, I’ll respond to that by saying I’ve met Rogue Medic, and known him for years. And while “pain in the ass” might accurately describe him much of the time, “burnt out and wants to stop being a medic” ain’t in his repertoire.

You’d do better to think of him as Don Quixote, tilting at windmills and speaking uncomfortable truths people such as yourself would rather not hear.

“The CHF patient that waited a little to long to call now frothing at the mouth, I’ll just have my BLS partner bag while I try to get a line in to start the 4 drugs I need to help them.”

There’s this thing called CPAP. Perhaps you’ve heard of it. It ain’t as sexy as a tube, but it’s a helluva lot easier, and better tolerated by the patient, in many cases. Ask the Anonymous Respiratory Therapist which patient will have the less stormy clinical course: the CHFer intubated in the field, or the one where the paramedics applied CPAP in a timely fashion.

And as far as drugs go, they’re overrated. The really important one – nitroglycerin – can be given transdermally or sublingually. ACE inhibitors may be helpful, but as far as Lasix and morphine are concerned, they’re not as effective as we once thought, and of minimal benefit in the prehospital realm. You’d serve the patient better by applying CPAP, aggressively administering nitro, and expediting transport.

You do know that upwards of 90% of the IVs we start in the field are never used for medications or fluids in the hospital, right? Most of my IVs are started to satisfy protocols or to stay on the good side of ER nurses. I’ll bet my last dollar the same is true in your system.

“When I finally get to transport I dump them in an ER where the resident pulls the King tube and gets to try a few times to put in the ETT before the attending finally steps in.”

Then educate the resident and the attending on how to use a bougie to transition from King to ET tube. That way, you never lose an airway. Or do you not know how? And while there are a few EMS systems (Boston EMS comes to mind) out there that have hard numbers to prove that they are as competent or more than the ED residents at intubation, usually the doc -even a resident – is a more skilled intubator than the medic.

The exception to that rule is any first-year resident you encounter in the month of July, or any time I am the medic in question. Because I am an airway samurai, baby. I can fall down a flight of stairs and intubate five people on the way down. Last shift, I was checking my laryngoscope and stumbled, accidentally intubating my partner.

Never run with an open laryngoscope, kiddies. That’s a helpful hint from your Uncle Ambulance Driver.*

“Oh, how about the anaphylactic patient that’s not responding to meds. We’ll just wait until we have to cric their neck, because we do that so often and that’s so much easier to practice.”

I teach an approach to airway management that is an interventional continuum. Go read it. And like any fluid continuum, there are red flag conditions that warrant skipping certain steps. The wise medic recognizes those instances.

Then again, the wise medic would also realize that Rogue Medic isn’t advocating doing away with intubation. And frankly, your assertion otherwise makes me think you’re not a very wise medic.

“You know why they are called alternative airways? They are used as a last ditch effort to get any air into the body. If they were truly adequate then you could admit the patient to ICU and never move it.”

Fact: The average ICU stay for an intubated CHF patient is 7-9 days, and that presumes they don’t get ventilator acquired pneumonia – something that happens to 25% of them. The Medicare DRG for CHF caps out at 5 days. The hospital eats the cost of those remaining 2-4 days. If the patient gets VAP, which CMS now considers a “never event” that they refuse to reimburse for, the cost of care skyrockets.

There is no way around it: intubated patients are huge money-losers for hospitals, and sliding that tube through the cords, while admittedly a huge adrenaline rush for the medic, often means a stormier clinical course for the aptient.

You CAN negatively impact patient outcome with a correctly
placed endotracheal tube. If you doubt that, hopefully some of the respiratory therapists and doctors that read this blog can convince you otherwise. I welcome their comments.

“At least we use capnography to confirm placement though most ED’s RN’s don’t even know what a proper waveform is. No waveform, then the tube is pulled, PERIOD.”

On that we agree, partly. EMS is way ahead of the curve on waveform capnography. We understand more about its effective use than just about anyone in the hospital, save the anesthesiologists. It is not, however, as you seem to be saying, foolproof.

“If want people to have 10 tubes before graduation and 2 a year in the field then fine but YOU are on a mission to stop a skill that has been used to save more people then will ever have showed up on any research report.”

He’s on no such mission, but your paramedical testosterone has blinded you to any other interpretation. And if you think 10 tubes before graduation and 2 tubes a year thereafter is anything close to what we need to maintain clinical competence, then you have no understanding whatsoever of how unskilled you actually are.

“When you can show me data that say medics are missing 25% I might start to agree that something might need to be done but every medic knows this skill.”

Dude, read the research. There are FAR more studies that show paramedics are deficient at intubation than there are that say they do it well – and many of those deficient systems are in major cities, not East Podunk, Idaho. Instead of sticking your fingers in your ears and commenting in a metaphorical “La la la la la, I can’t heeeear yoouuu…” why don’t you acknowledge the problem, and see how the rest of EMS can copy those systems that do it well? Because believe me, brother, they stand out like diamonds in a coal bin.

If your EMS system is that good at ETI, then browbeat your medical director into publishing a study, so that the rest of EMS can emulate what you’re doing. Until then, your electronic chest-thumping isn’t helping your cause.

“After all my rant answer me one yes or no question. Assuming the way medics are currently trained, do you think medics should intubate? Yes or No?”

You’re casting a pretty wide net, because clinical requirements vary so widely around the country, but I’ll use the minimums suggested in the 1998 Paramedic National Standard Curriculum: 5 successful attempts on live patients.

Keep in mind that a great many -probably a majority – of paramedic programs only require that minimum standard.

So yeah, if we can agree that 5 tubes prior to hitting the street is, to use your words, “the way most medics are currently trained,” do I think they should be allowed to intubate?

Fuck no.

Do you?

* The preceding paragraph was brought to you by my good friends arrogance and egotism. And all of you know that no post of mine would be complete without them.

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