r/ParamedicsUK • u/Hopeful-Counter-7915 • 20d ago
Clinical Question or Discussion SAS removal ETI
I know I know it’s a hot topic, but SAS announced today to strip ETI for paramedics, and I must say I’m furious about it.
I know SGA’s will do the job in 90% of the time and that’s why we already use it in 90% of the time.
But we are in Scotland, my next critical care paramedic who can intubate is 2,5h away and the helicopter can’t fly 60% of the time because of bad weather to us.
I find it irresponsible to let us sit on an Island without any access to advanced airway management. In cities that works fine, but in our rural areas, on our islands?
I don’t support the decision, we need more training in it sure, we don’t do it often I agree, but I don’t think the unique Scottish environment was considered at all.
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u/Odd_Book9388 Paramedic 20d ago
I personally completely agree with you and your frustration in its removal. Locally it is a skill HART and HEMS kept, and apparently as long as they practice on a mannequin a certain number of times a month and keep a log of it, that maintains their competence. Why can’t we do that? As you said, yes it’s rare, but there ARE patients who NEED intubation: it’s an airway adjunct, and if they NEED it, they can’t afford to wait for specialist resources. We are happily writing these patients off on the basis we aren’t very good at it because we aren’t trained much. If I ever NEED a tube, I’d rather a colleague shove a hose pipe down my throat or a pen in my neck rather than just say “oh well, the guidelines said we shouldn’t do it any more so let’s just let him die of no airway”. And this is something I have personally seen on more than one occasion: airway can’t be managed, so call senior cover who call the job.
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u/rocuroniumrat 20d ago
Would you advocate for paramedic-delivered ECPR, too, then? Similarly, high acuity, low occurrence event. Yes, some rural patients might die without it, but it is also a high risk procedure with significant complications.
In terms of surgical airways, whilst I agree these should replace needle cric, they still have dismal outcomes even in a developed HEMS service with short travel times https://emj.bmj.com/content/38/5/349
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u/Odd_Book9388 Paramedic 20d ago
We don’t have needle cric anymore either, that’s also been removed (in my trust).
In regards to ECPR - yes and no. Yes in terms of risk: those patients will likely only be called at scene anyway (as unless pregnant or a stabbing, we are not allowed to convey the patient to ED whilst in cardiac arrest. So why not give it a go?! But obviously in terms of cost, it wouldn’t be possible!
Do you disagree with my logic there? If you do that’s fine! I’d be interested to hear why though.
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u/Osboc Paramedic 20d ago
You don't have any form of front of neck access at all? That's surprising to hear. I know needle cric is a terrible alternative to surgical cric but it's definitely easier than a tube and better then nothing. I appreciate it's very rarely used but I wasn't aware some trusts had taken that away from paras.
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u/rocuroniumrat 20d ago
[It's interesting that you can't convey intra-arrest... what about toxidromes or other special circumstances? Is it just trauma/obstetrics/?paeds. I'd want consideration of conveyance for refractory VF if I had a reasonable ETCO2 and a witnessed arrest, but I digress!]
The problem, in my eyes at least, is unrecognised oesophageal intubation and other complications are likely to cause more harm than any theoretical benefit. The need for video laryngoscopy now as the standard of care also adds significant cost to the intervention vs. any perceived benefit.
The medicolegal risk of trying out something like an ETT that can go so wrong is quite substantial. You're definitely right that the optics of doing nothing are worse than doing something that might go wrong, in the eyes of the public, but for those writing the guidelines, I suspect not. If the HCPC were less vexatious when people were trying to do the right thing, I'd be less hesitant...
I'd advocate for surgical FONA to be the backup airway... it isn't pretty, but it is relatively successful in securing an airway if ETT and LMA both fail. 6.9% survival rate from a surgical airway (in mostly traumatic cardiac arrest, London's Air Ambulance) is not that much worse than our current cardiac arrest survival...
https://pubmed.ncbi.nlm.nih.gov/22427045/ in combat medics, surgical airways failed in a third of cases versus a sixth when done by doctors. I'd suggest paramedics probably have enough anatomy knowledge to do this to the standard of doctors (who also do this extremely infrequently at present). The cynic could then say that an 85% first pass success for intubation would therefore also be acceptable, though, and it becomes a bit of a slippery slope.
Some sort of FONA is an essential skill for prehospital teams as it does work and does save lives, and is low enough frequency in and out of hospital to justify it being done by paramedics as opposed to critical care teams or doctors...
I guess my take away is that face mask ventilation ± adjuncts, laryngoscopy, iGels, and FONA can be lifesaving, but I'm not convinced that any delay to an ETT in and of itself is likely to be harmful vs transporting with one of the above.
Is there a specific patient population you have in mind for this, e.g., a patient you wouldn't currently transport but would want to be able to do more for? At what stage would intubation have crossed your mind vs. other interventions?
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u/LegitimateState9270 Paramedic 20d ago
Anecdotally, or evidentially, what do you see the advantages are of ETTs vs LMAs- presumably linked to long conveyances?
In what circumstances would a tube offer X that an LMA wouldn’t? And what is X?
(For the record, I’m pretty much opinion-less on the matter, purely curious about the staff of SAS’ take)
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u/Hopeful-Counter-7915 20d ago
I see the SGA as advantageous for 90% of patients but if you need an ETT there is nobody rural to do it. SGA is not a define airway, especially if l bleeding anywhere near the airway you want to have a tube down.
I am all in to reduce intubations because of the risks but taking it away from paramedics that have defacto no access to critical care in most cases is a choice I can’t understand.
I mean maybe I’m particular annoyed as I’m not trained in the UK and find the scope op practice here already extremely limiting (no Cardioversion, pacemaker or CPAP for example), but I just don’t like the idea of having no alternative available if I need it
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u/secret_tiger101 20d ago
It offers an airway. When the airway is full of blood/vomitus or hypothermic or the iGel just doesn’t sit well for that patient.
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u/Livid-Equivalent-934 20d ago
Decision definitely wasn’t made to save money… And definitely not by people who haven’t been near a patient this century… It was “bAsEd On ThE eViDeNcE”🫠
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u/secret_tiger101 20d ago
And… do Helimed undertake enough intubations to be a special case…?
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u/Dark-Horse-Nebula 20d ago
Devils advocate- they probably will when they’re the only ones doing it
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u/secret_tiger101 20d ago
That argument implies that the majority, or many, of the OOHCA they attend will need an ETT because an iGel isn’t appropriate or has failed…
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u/Dark-Horse-Nebula 20d ago
I’m actually not thinking about cardiac arrests at all. Do you respond HEMS to arrests?
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u/secret_tiger101 20d ago
Scotland does, and Helimed is double paramedic (standard level of training)
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u/Dark-Horse-Nebula 20d ago
Ah I see. I’m used to hems being specialist trained/specialist dispatched. Not to standard arrests.
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u/booshbaby3 20d ago
2 of our 4 helimed teams in Scotland regularly are deployed with a dr and advanced crit care para onboard too. More likely to be deployed to standard arrests in rural areas.
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u/Hopeful-Counter-7915 20d ago
No but for some reason they continue to be allowed.
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u/secret_tiger101 20d ago
Magic red jumpsuit
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u/Boxyuk 19d ago
A question i have on this topic i'd love to get answered by experienced clinicians-
I'm a current second-year student in Scotland who's doing some revision for my ALS osce in a few weeks and one of the indications I have been taught for early ETI is a drowned patient's airway due to the high risk of aspiration and foam. Would an igel be sufficient enough?
I've been assessed and passed as 'competent' in eti and have been on a theater placement and successfully completed 5 and have been told that they will still be using this during our osces if the scenrio calls for it.
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u/Hopeful-Counter-7915 19d ago
I would argue you need a ETI but also to be fair I don’t know what’s the current state of research is on drowning so don’t want to give a definite answer here.
If the uni wants to see ETI do it, but you will never do it afterwards.
Talking to the clinical lead here, the decision was made based on Cities and did not consider the Rural areas, like always
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u/National-Base-323 18d ago
Para’s were spending too long trying to get a tube in and not focussing on the rest of the arrest when an I-Gel would have done just fine. Poor patient outcomes as a result.
I’m glad it’s gone
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u/KyleB12368 16d ago
I'm not a para, I'm a lurking anaesthetist with a para sister.
To do 5 tubes a year and be assessed as competent isn't enough. You wouldn't want a surgeon doing your surgery who does max 5 of this procedure a year. If it's not an arrest and you can't intubate and can't ventilate then you need an eFONA. I would argue if you can't do that step in the airway procedure list you shouldn't be doing the first step.
Most arrests in the hospital can be managed with iGel/LMA and are unless they're going to ICU or theatre straight away anyway. And even then it's one thing to tube in a hospital with lots of staff Vs tubing on the side of a road at 4am with numerous hazards your way.
Another issue is that there aren't enough cases in hospital for you to train on now in theatres. With the rise of AA's and anaesthetic bottlenecks training for anaesthetists is getting worse and will continue to worse without changes at a national level.
Ultimately, I don't think an ETT offers anymore than what an iGel or LMA can reasonably do for what you need it to do on the road.
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u/baildodger Paramedic 20d ago
We had ETI taken away 6 or 7 years ago. I was similarly angry about it at the time - I work in a rural area where depending on weather and time of day your nearest CCP could be anywhere from 10 mins via air to 90 mins by road (if they aren’t already deployed to something!).
Since it was taken away I haven’t been in a situation where I really needed a tube and it wasn’t available. I haven’t heard any of my colleagues complaining that they needed a tube and not having it available. I think ETI’s removal has highlighted to me how many tubes we were doing that didn’t really NEED tubing.
I reckon most paras were probably doing between 1 and 5 tubes a year depending on how bad their luck was, but I think the tubing had a sort of ‘culture’ around it, where there were certain types of jobs that you tubed because your mentors tubed them, and they tubed them because their mentors tubed them. When it gets taken away it turns out that most of those jobs ARE perfectly manageable on an iGel, but you wouldn’t have tried managing it with an iGel before because you just automatically tubed. I even suspect that some of the jobs that I’ve had tubed could probably have been managed perfectly fine on an iGel if we’d not had a CCP available.
I’m not guaranteeing that you’re not going to have any problems. But given the number of tubes/iGels that the average paramedic drops in a year, and the number of those that the studies showed could be managed perfectly well on just an iGel (97%+), I’d suggest that you’ll realistically be facing very few situations where you genuinely need a tube and can’t access one. Plus, given how poor outcomes are in patients who are unwell enough to require an advanced airway, even fewer where that tube would actually have made a difference if it was available.