Independent Judgement

In case you haven’t heard yet, California is working towards officially introducing (pdf) (underlined is new legislation. Some of it is cleaning up a mess left from moving EMT-II to AEMT) Advanced Practice Paramedics and Critical Care Paramedics as state levels. While scanning over the proposed legislation, the following line from the proposed Critical Care Paramedic scope of practice struck me as odd.

“1. perform digital and nasotracheal intubation;” -pg 11

Wait, shouldn’t the scope of practice (albeit the basic scope of practice for all paramedics) be “intubation?” If paramedicine is a profession, shouldn’t paramedics be entrusted with the independent judgement to determine, based on their education, training, experience, available tools, and their assessment of the patient, how specifically they intubate? If a paramedic believes that the totality situation calls for digital intubation or a gum bougie or any of the other method instead of or supplemental to direct laryngoscopy, shouldn’t that be the imperative of the professional paramedic? Furthermore, provided standard concerns are met like maintaining oxygenation, isn’t the goal of putting an appropriately sized tube into the slightly larger (and correct) tube, and the ensuing confirmation, more important than how that is achieved?

Could some of the issues with paramedics intubating be, in part, because the wrong tools are being used? If you only have a hammer, then everything is a nail. That’s fine, provided you’re dealing with nails or wooden pegs. However when you get to screws, sure a hammer may work, but why not use a screw driver?

Why is the skill of direct laryngoscopy more important and sacred than the intervention of intubation when other skills can achieve the same goal? Furthermore, if paramedics cannot be trusted to pick the correct mechanical skill when providing the intervention of intubation, what does that say about paramedics, and why are paramedics not fighting back?

On a side note, I’m sure I’ll have more than one person think I’m a complete idiot for this, and the ensuing implication about EMS’s current status between technical trade and profession. Feel free to call me an idiot in the comment section (or email, but the comment section lets you drive the discussion), I don’t mind and without discussion nothing changes. My only request is that you take a minute to call me an idiot, take a second minute to explain why I’m an idiot.

About Joe Paczkowski

I am an EMT and a second year medical student at Western University of Health Sciences, College of Osteopathic Medicine of the Pacific (COMP).
This entry was posted in Clinical EMS, EMS Levels, EMS Operations, EMS: A Profession and tagged , , , , , , , . Bookmark the permalink.

9 Responses to Independent Judgement

  1. VinceD says:

    I’m of the same opinion, and firmly believe all providers should be trained in direct laryngoscopy, and then allowed to choose one alternative technique (nasal, bougie, lightwand, digital, etc…), one alternative airway device (LMA, Combitube, King LT, etc…), and one cric technique (open, Seldinger, bougie aided, neddle…) in which to become expert. We need to have options, but there are just too many techniques out there for protocols to cover and providers to be fully practiced on, so by allowing medics to determine on their own which few paths to pursue and excel at, it truly encourages excellence.

    For example, I am mannequin-trained in both digital and nasotracheal techniques for blind intubation, but I would likely never consider using them on an actual patient who I could not intubate directly because I am just not comfortable enough to use them in an emergency setting. I have never even SEEN them used, let alone performed them on actual patients. On the other hand, I’ve also never used a bougie on a live (or dead) patient, but would be much more comfortable using that technique in an actual emergency, but it is just not an option in my region (same with the lightwand).

    Two of the most important factors for determining success when performing any manual procedure are provider comfort and confidence, so including protocols that encourage the use of techniques in which that providers are poorly trained or experienced while discouraging the use of other options is only setting them up for failure.

  2. Theo says:

    Situations that require digital are normally reserved for tactical applications, in order to limit the use of light or in confined spaces. If you get into a situation that requires digital intubation you should consider contacting medical control, who Im sure will facilitate your request.

    • Thanks for the comment.

      Just to clarify the point, it’s not just about digital intubation. What about all of the other tools and techniques that can be used for orotracheal intubation? If digital requires specific approval, then what about the other techniques (e.g. gum bougie)? If all of the non-laryngoscope techniques require special authorization such as this, then is there even a point in CEs for airway management? After all, what good is a CE if you can’t implement what you learn?

    • medic7714 says:

      If you get into a situation that requires digital intubation, you don’t have time to ask for permission!

  3. medick says:

    Here on the left coast we having been preforming nasal intubation for years. I’m not a fan of digital intubation, I’d rather use the tomahawk method than put my fingers in someones mouth. Instead of just create a NEW level of paramedic provider, why not just train your medics to do the job. Outside of CA., medics having been as I stated earlier, doing this skills for quite awhile. You can’t just create a new level of paramedic w/o advancing the education. To just add some monkey skills w/o the additional education is not very progressive.

    Of course, when the majority of paramedics in CA are also fire fighters, the point is moot. The majority of them will be unwilling to obtain the required education to go with the added skills.

  4. Pingback: Should EMS Use Nasotracheal Intubation | Rogue Medic

  5. Christopher says:

    I’m with VinceD, I’ve been trained in digital and nasotracheal intubation and have performed them countless times on mannequins. That being said, I cannot conceive of a situation where I would use them outside of my other techniques available. Bougie, KingLT, NPA/BVM, bougie-cric…probably the only instance is limiting jaw opening trauma, even still I’d prefer NPA/BVM over wasting time on an NTI.

    Unfortunately digital and nasotracheal intubation are used so rarely it doesn’t seem logical to include them in our protocols as highlighted choices. Although, I do agree if a provider is competent and confident there is no reason they should not be allowed to attempt them.

  6. SOCAL says:

    California adopted Nasotracheal Intubation many years ago as an optional scope because it was easier than amending Title 22. many of the changes you are reading have been in practice as optional skills for many years, however since many of these are optional they vary from county to county. for instance when my county added CPAP many years ago we removed NTI due to low frequency and difficulty. I have never seen a need for NTI since CPAP was introduced. they may however need it in USAR medicine (which I am actively involved in) due to potential confined space. in a 22inch drain culvert you may in fact be lying on top of your patient with no way to position yourself behind their head. in CA this is however a moot point as we are trained to the FEMA medical specialist scope to circumvent CA EMSA. all in all I love the new proposals in CCP and APP and feel that they will greatly improve the pre hospital care and career ladder for EMS professionals. now lets just see if they ever actually get implemented and used. I can tell you that all the USAR medics will continue to use FEMA due to its increased scope, however all the RTFs and task forces have our own team Medical directors so med-control to do off label stuff is only a phone call away (and no MICN, yay)

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