Intubation Conundrum

[Paseo Del Norte]

Now that we have multiple studies regarding pre-hospital intubation, I would like to have discussion about the overall efficacy of pre-hospital intubation and rapid sequence intubation. Particularly, I would like to have a physician’s perspective regarding this well debated topic.

While the knee jerk reaction is to take things personally, I really look at this as objectively as possible. Additionally, it may affect me as a pre-hospital provider; therefore, I am in the same boat. In spite of personal feelings, I really do believe there remains clinically significant evidence that in fact points to the realization that we may be causing harm and contributing to overall morbidity and mortality.

One of the questions I ask is; with proper education and use of objective methods for confirming placement (waveform capnography), along with a strict QA/QI program and frequent precepted anesthesia intubation, would the morbidity and mortality change?

In addition, another question I ask is; with reliable alternatives to intubation in the form of supraglottic devices, could a large subset of patients be proper managed with these said devices? I even know of a service or two that has dedicated rapid sequence airway (RSA) protocols in place, where providers perform a modified RSI in special situations such as confined spaces and vehicle entrapment, and place a supraglottic device in lieu of traditional laryngoscopy and endotracheal intubation.

Finally I ask; with alternatives to traditional largygoscopy in the form of fiber optic devices such as the Glidescope and blind intubation techniques such as the ILMA, will the future see a place for the laryngoscope in the pre-hospital environment?

With that, this remains a debated topic with many strong feelings; however, feelings aside, where do you guys see this path going? Clearly, we are doing some things wrong. Therefore, where are we headed?

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[docB]

Excellent questions.

One issue is that while the data seems to indicate that prehospital intubation may not be of benefit we don't know exactly why that is. Many assume that it is due to missed tubes and particularly unrecognized missed tubes. The reaction then would be to advocate capnography, education, helper devices and so on. I don't know that the failure of prehospital intubation to result in improved outcomes is due to missed tubes.

I suspect that we will eventually find that it has more to do with committing to a tube and therefore cutting off the options of other therapies that could have been done had a BLS airway and transport been done. A good example of this would be Bipap for CHF. If a patient gets tubed in the field you've committed them to that course with all the additional morbidity associated with it. I can't try Bipap, etc.

Another issue that is very important for EMTs to know is that a limitation on a therapeutic modality is not a loss. We will always see improvements. It will be incumbent on EMS professionals to adapt and be able to assess patients more critically as we learn about the down sides to traditional modalities. For example we may be seeing a change to a more scoop and run approach to penetrating trauma within a close proximity to a trauma center. That doesn't belittle EMS. It means that the science has improved and we now require a higher degree of assessment skill and adaptability from EMS.

 

[leviathan]

What kinds of patients are being tubed in these studies? If trauma patients, it is probably just the delay to access to definitive care.

 

[MediumDef]

This is just what I remember from looking at the topic a few years ago so I apologize if I punt it but there were a few things that were interesting to me

1)With regards to trauma pt's and especially your low GCS head injury folks it has been shown a few times that a BLS airway is perfectly adequate as mentioned above and that the benefit of "airway protection", which is all your doing since oxygenation isn't usually the problem is more than offset by the many and varied potential morbidities that can arise from poor intubation

2)EMS often takes longer to intubate then in the hospital but more importantly experience more episodes of bradycardia and hypoxia associated with intubation attempts

3)Some services show every bit the success rate of in-hospital intubation but the amount of oversight is prohibitive to the majority of providers, every intubation is associated with immediate medical feedback and they fill out exhaustive forms so they can track the data more efficiently

 

[Paseo Del Norte]

What kinds of patients are being tubed in these studies? If trauma patients, it is probably just the delay to access to definitive care.

Studies are all over the place. General trauma to pediatric head injuries, to general patients are discussed. Unfortunately, esophageal intubation, significant desaturations, significant hemodynamic changes, among other problems seem to be related to some of the outcomes. Delayed scene times may very well effect morbidity and mortality however.

Changing the clinical course is an intriguing concept. In theory it may hold some weight as the OP is correct that once we place a tube, the patient will instantly be at risk for developing the many complications of intubation and ventilator therapy. Therefore, you could assume in theory, that if we intubate patients who do not require intubation, we increase the risk of complications that could have been otherwise avoided.

 

[jwk]

This is just what I remember from looking at the topic a few years ago so I apologize if I punt it but there were a few things that were interesting to me

1)With regards to trauma pt's and especially your low GCS head injury folks it has been shown a few times that a BLS airway is perfectly adequate as mentioned above and that the benefit of "airway protection", which is all your doing since oxygenation isn't usually the problem is more than offset by the many and varied potential morbidities that can arise from poor intubation

2)EMS often takes longer to intubate then in the hospital but more importantly experience more episodes of bradycardia and hypoxia associated with intubation attempts

3)Some services show every bit the success rate of in-hospital intubation but the amount of oversight is prohibitive to the majority of providers, every intubation is associated with immediate medical feedback and they fill out exhaustive forms so they can track the data more efficiently

1) LMA's are much easier, placement is in seconds and provides a great airway, and much fewer complications than ETTs.

2) fully agree - you never put them in as fast as you think you do.

3) Pre-hospital will NEVER have "every bit the success rate of in-hospital intubation", regardless of oversight and feedback. Sorry, it just doesn't. That's why far more surgical airways are done in the field than in-hospital - in fact, in 30 years, I've seen one surgical airway in a patientthat couldn't be intubated/ventilated, out of 30,000+ patients I've been involved with.

I trained paramedics in endotracheal intubation in the OR for years, and some of them were very good, but since a variety of excellent supra-glottic airway devices have come along in the last 5-10 years, I think ETTs in the field have much more limited value than was placed on them in years past.

 

[McPoyle]

1) LMA's are much easier, placement is in seconds and provides a great airway, and much fewer complications than ETTs.

2) fully agree - you never put them in as fast as you think you do.

3) Pre-hospital will NEVER have "every bit the success rate of in-hospital intubation", regardless of oversight and feedback. Sorry, it just doesn't. That's why far more surgical airways are done in the field than in-hospital - in fact, in 30 years, I've seen one surgical airway in a patientthat couldn't be intubated/ventilated, out of 30,000+ patients I've been involved with.

I trained paramedics in endotracheal intubation in the OR for years, and some of them were very good, but since a variety of excellent supra-glottic airway devices have come along in the last 5-10 years, I think ETTs in the field have much more limited value than was placed on them in years past.

I know some west coast services have started becoming much more selective in the pts they intubated. Now, this is just from conversations with medical directors-not published studies-but they have improved their first pass success rate by limiting attempts to one. The speculation is that by limiting the number of attempts to one, they are using their other airways (King, Combi, LMA, etc.) for most pts and only attempting intubation in those cases where their confidence level is high enough.

As an aside. I think intubation data-especially in regards to morbidity to mortality-will differ greatly among services. Yes, I got a fair amount of tubes while in training, however once employed at a service my intubation attempts fell off. The last year I was working full time I saw maybe 6-8 patients that I felt warranted this level of airway control. Of these I maybe intubated 2 while electing to use the King airway on the others. Because of this I feel to be in a constant state of re-mediation. I think it takes more to keep up this skill IF a service is going to keep using it. Additionally i have a strong suspicion that most services do not do enough training to keep the skill sharp. Despite this, egos get in the way, chest thumping persists, whenever this question gets brought up.

personally I think EMS really needs something more definitive that will confirm a lot of feelings that we need to be relying on other airways besides ETI. Devices such as the King or LMA provide adequate airway protection for what we do prehospitally and are virtually fool proof as well as being time savers.

I dunno if that makes sense, I'm kind of rambling on...and on... and on...

 

[Paseo Del Norte]

I know some west coast services have started becoming much more selective in the pts they intubated. Now, this is just from conversations with medical directors-not published studies-but they have improved their first pass success rate by limiting attempts to one. The speculation is that by limiting the number of attempts to one, they are using their other airways (King, Combi, LMA, etc.) for most pts and only attempting intubation in those cases where their confidence level is high enough.

As an aside. I think intubation data-especially in regards to morbidity to mortality-will differ greatly among services. Yes, I got a fair amount of tubes while in training, however once employed at a service my intubation attempts fell off. The last year I was working full time I saw maybe 6-8 patients that I felt warranted this level of airway control. Of these I maybe intubated 2 while electing to use the King airway on the others. Because of this I feel to be in a constant state of re-mediation. I think it takes more to keep up this skill IF a service is going to keep using it. Additionally i have a strong suspicion that most services do not do enough training to keep the skill sharp. Despite this, egos get in the way, chest thumping persists, whenever this question gets brought up.

personally I think EMS really needs something more definitive that will confirm a lot of feelings that we need to be relying on other airways besides ETI. Devices such as the King or LMA provide adequate airway protection for what we do prehospitally and are virtually fool proof as well as being time savers.

I dunno if that makes sense, I'm kind of rambling on...and on... and on...

I think you are making great sense. I fly for a service with RSI guidelines in place, and you almost have to back me into a corner before I will look at RSI as an option. So much can go wrong and I dare say that we are not doing enough tubes to be truly adapt at managing difficult airways.

Anecdotally, I am not sure how well the classic LMA's do in the pre-hospital environment. They are quite fickle and are particularly prone to dislodgment, not to mention you cannot perform gastric decompression with the older LMA's. The LMA Supreme potentially has much to offer. I am a big fan of the dual cuff supraglottic airways such as the Esophageal Tracheal Combitube and King LTD-S for pre-hospital application. The King in particular has much to offer both the paramedic and ER physician. Good for continuity of care if you will. For you can look at using an exchange catheter or bougie to exchange the King out after ER or ICU arrival. If the bougie does not work, you leave the King in place and go with a fiber optic option. In addition, the gastric suction port and all nitrile cuff construction with low mucosal pressures are desirable features for both pre-hospital and facility use. I am not a big advocate for exchanging a functional supraglottic device in the field however. Something about explaining why I pulled a perfectly functioning device to the court room takes away all of the appeal.

With the advance in alternative technology, I think we should at look long and hard at the proliferation of these devices and the clinical implications and outcomes. I would love to be involved in a large study where we can compare outcomes and complications between these devices, bag mask management, and ETI.

Funny; however, the more experience I gain and more autonomy of practice that is given to me, I find my decisions to be more conservative in nature. Years ago as an EMT, I would have jumped at the opportunity to intubate any patient for nearly any reason, now I hesitate to even consider intubation.

 

[pseudoknot]

Funny; however, the more experience I gain and more autonomy of practice that is given to me, I find my decisions to be more conservative in nature. Years ago as an EMT, I would have jumped at the opportunity to intubate any patient for nearly any reason, now I hesitate to even consider intubation.

I think that's wise.

One thing that always strikes me when this topic comes up: most paramedics tell me that intubation is pretty simple once you get the hang of it. Anesthesiologists, who do it many times every day, regard it as a much more difficult skill to master. I think that says a lot. *


* if the conclusion you drew was that paramedics are better at intubation than anesthesiologists, please think about it longer...

 

[McPoyle]

I think that's wise.

One thing that always strikes me when this topic comes up: most paramedics tell me that intubation is pretty simple once you get the hang of it. Anesthesiologists, who do it many times every day, regard it as a much more difficult skill to master. I think that says a lot. *


* if the conclusion you drew was that paramedics are better at intubation than anesthesiologists, please think about it longer...

I think a lot of this stems from the culture of EMS. We (yes I too have been guilty of this in the past) gravitate towards people who spew "information" and views that seem to validate our profession somehow. Now, what do I mean? My last medical director is a great example of this, he was uber aggressive, wanted to add additional meds and procedures to our repertoire.
The expectation was there that if we saw the opportunity to do an advanced procedure, such as RSI, that we should seize this opportunity-regardless of the fact that there may be another solution. A bit of a cowboy compared to the director who he replaced, the previous MD had been much more conservative, in my mind more reasonable. Guess which one had a better reception? The cowboy (who incidentally hadn't practiced clinically in years) of course.

I think very often the field tries to do too much, and expect great results, despite very little education and a lack supportive continuing education.

 

[Dwindlin]

In 4 years the only patients I tubed were full arrests. We had access to CPAP so I had that option for bad CHF/COPD and for trauma I would generally use much faster options (LMA, Combi tube) in order to keep things moving in a timely manner.

Full arrest I would take the time to tube because more often than not they weren't going to the ER anyways so on scene time was less of a factor imo. My service was also fortunate to have the LP12's with capnography, so we had good confirmation devices on the occasions we did go ahead and intubate.

Edit: Just as an aside, I mentioned the CPAP. I think this was the best piece of equipment we ever purchased. This thing was amazing at turning around some bad COPD/CHF pts in the pre-hospital setting. I had some frequent fliers who would literately be begging to be put on it sometimes.

 

[McPoyle]

Just as an aside, I mentioned the CPAP. I think this was the best piece of equipment we ever purchased. This thing was amazing at turning around some bad COPD/CHF pts in the pre-hospital setting. I had some frequent fliers who would literately be begging to be put on it sometimes.

Same here, I remember seeing pts shortly after getting this, that I would have strongly thought about tubing in the field, and after a few minutes of CPAP they looked much better-i assume this was buying them fewer ICU days etc.

 

[docB]

Same here, I remember seeing pts shortly after getting this, that I would have strongly thought about tubing in the field, and after a few minutes of CPAP they looked much better-i assume this was buying them fewer ICU days etc.

And the data would back you up on this. Although it has really been studied only as far as the ED. We don't have many (any?) studies on this phehospital but I think that extrapolating the results is reasonable.

 

[Paseo Del Norte]

And the data would back you up on this. Although it has really been studied only as far as the ED. We don't have many (any?) studies on this phehospital but I think that extrapolating the results is reasonable.

I suspect doing a retrospective review of patients who were intubated in the "field" and comparing morbidity and mortality to ER intubations provided we can match similar patient conditions would be possible.

I am not aware of any large prospective studies that look at this concept. However, I agree that we can make assumptions. However, it would be worth while to compare pre-hospital intubation M&M to in-hospital.

I emphasize I am in no way against EMS; however, we should be critical of what we do and how it ultimately effects patient outcomes. All too often, we transfer patient care happy to have a patient with a pulse. Should we not strive to provide techniques and have modalities that lead to well documented increases in patient outcomes?

 

[docB]

I suspect doing a retrospective review of patients who were intubated in the "field" and comparing morbidity and mortality to ER intubations provided we can match similar patient conditions would be possible.

I am not aware of any large prospective studies that look at this concept. However, I agree that we can make assumptions. However, it would be worth while to compare pre-hospital intubation M&M to in-hospital.

I emphasize I am in no way against EMS; however, we should be critical of what we do and how it ultimately effects patient outcomes. All too often, we transfer patient care happy to have a patient with a pulse. Should we not strive to provide techniques and have modalities that lead to well documented increases in patient outcomes?

Of course we need to try to follow the best practices as indicated by EBM but it's a tall order. Rather than retrospective studies for something like this, where the intervention would seen to be very helpful and has been proven in studies in the ED, I'd like to see a prospective study. The way to study this would be to track all the critical CHFers for a period of time (6 mos to a year) then institute prehospital CPAP or BiPAP and study the same population for the subsequent time frame.

The barriers are money and the fact that as you get farther from the ED, ie. the ICU for a week then the floor for a week then rehab, etc. you'll get less and less buy in and help from the docs and other caregivers. Docs outside of the ED have little interest in and even less knowledge about EMS.

 

[Dwindlin]

Is there any chance anyone could link any of the Prehospital intubation studies? Historically I have had issues finding research articles when I search, and history has repeated itself with this topic.

 

[leviathan]

Here's a great site I found with evidence for a variety of EMS interventions. Just follow any guideline's "Level of Evidence" link to its right. There's a few for difficult intubation and confirmation of intubation:

http://emergency.medicine.dal.ca/ehsprotocols/protocols/toc.cfm

 

[Dwindlin]

Here's a great site I found with evidence for a variety of EMS interventions. Just follow any guideline's "Level of Evidence" link to its right. There's a few for difficult intubation and confirmation of intubation:

http://emergency.medicine.dal.ca/ehsprotocols/protocols/toc.cfm

Much appreciated.

 

[jbar]

try google scholar. I just searched "prehospital intubation" and got dozens of hits.

 

[Paseo Del Norte]

Agree, a quick google search will help. In addition, you should look at a Pubmed subscription. It will make finding and looking at articles much easier IMHO.

 

[Dwindlin]

try google scholar. I just searched "prehospital intubation" and got dozens of hits.

Seems like when I do this I get a bunch of articles that are unrelated. As in somewhere in the article it will mention "prehospital" or "intubation" versus what I am actually looking for.

 

[pseudoknot]

Seems like when I do this I get a bunch of articles that are unrelated. As in somewhere in the article it will mention "prehospital" or "intubation" versus what I am actually looking for.

Go to PubMed (http://www.ncbi.nlm.nih.gov/sites/entrez) and search for "prehospital intubation" and you will get a lot of relevant and irrelevant hits. If you look at some of the ones that are more relevant, you can also find others by looking at the papers they cite. You may also get more mileage by using the advanced search function and limiting your search to titles or something like that.

It's really good to work on developing your search skills now while you have time. Down the road it's great to be able to find out answers on your own, and a lot of people have trouble with this.

 

[leviathan]

Google Scholar sucks. Use PubMed and MeSH.

 

[jbar]

Pub med is better, but someone should at least try googling their topic before they give up and say that they can't find anything. Google scholar is a good final stop after doing a pub med lit search to make sure you haven't missed anything.

 

[EMTP2DOC]

I agree with you guys. I see intubation fading in its use. I also agree that CPAP was one of the best pieces of equipment my service has ever provided. With this being said, I think the greatest obstacle is going to be EMS providers. For some reason intubation is perceived as an EMS right of passage of sorts. The ALS mentality has us wearing blinders. Look at the gross changes in ACLS guidelines. It embraces BLS much more than in the past, and many times it’s set at a higher priority than ALS interventions. I can’t tell you how many classes I’ve helped instruct where there is more concern about the tube than performing the basics (quality CPR). I know when I went through paramedic school I was taught that intubation was the answer to controlling an airway. Where I work, we are usually no more than 10-15 minutes away from an ER. I imagine most of the time a pt’s airway could be controlled adequately with BLS interventions; expediting transport to the ER. I also know this is where ego comes in. Because of this macho- I can do this in the rain, upside down in a burning car- attitude, some paramedics elect to delay transport to get the tube. He/she doesn’t want to be seen providing a BLS skill because in his/her mind it is equated with insufficient skill and failure. Some are more concerned about how they look to other pre-hospital providers than doing what is best for the pt. I don’t want to come off like I’m saying this about the whole of EMS. There are many providers out there doing exactly what’s being discussed, and there are services that still might require the every now and then intubation. I just think beneficial changes are on the way and I hope we are able to overcome the opposition to ultimately do what’s best for the pt.

 

[leviathan]

Jbar - Agreed about Google Scholar. In 1st semester we had to do a research course and use PubMed to find literature...I often cheated and just did a Google Search, and then worked backwards to figure out how to find it with PM.

EMTP2DOC - Last ACLS course I took they were emphasizing BLS like crazy. We didn't even intubate in the megacodes; we just shoved an LMA or King Airway down. I honestly wonder if this is a better option, unless you're good enough to tube the patient without needing to stop chest compressions.

 

[Paseo Del Norte]

Jbar - Agreed about Google Scholar. In 1st semester we had to do a research course and use PubMed to find literature...I often cheated and just did a Google Search, and then worked backwards to figure out how to find it with PM.

EMTP2DOC - Last ACLS course I took they were emphasizing BLS like crazy. We didn't even intubate in the megacodes; we just shoved an LMA or King Airway down. I honestly wonder if this is a better option, unless you're good enough to tube the patient without needing to stop chest compressions.

The evidence is still dodgy regarding supraglottic devices versus traditional PPV during a cardiac arrest. Granted, having an airway in place does free up a set of hands.

 

[csmmedic]

Look at the gross changes in ACLS guidelines. It embraces BLS much more than in the past, and many times it's set at a higher priority than ALS interventions.

The emphasis on good quality CPR is not just because paramedics should not be intubating, it is because that is where the science is pointing us. I got a chance to read the whole ECC book for the current guidelines, very interesting. I am really curious as to what the next revision to ACLS is going to look like (its due to come out soon).

As far as paramedics intubating, I do not foresee the latest research as the death of the practice. However, new medics must be instructed that failure to intubate is not a failure, it is failure to ventilate that is a failure. With capnograpghy, better simulation technologies, quality CE/refreshers conducted a few times a year, and revised indications for the procedure, intubation may be a tool we keep in the box.

However, as Dr. Bledose has pointed out recently, the lack of operating room intubations may spell the end for the practice.

 

[emtcsmith]

Here is a good question....So I opt for a King-LT airway when advanced airway intervention is necessary. 15min later we arrive at the ED, its pulled and ETI is preformed. Did I do anything but delay care by placing this BLS airway?

If you can't intubate, and can't properly ventilate with a BVM, then maybe a "rescue airway" is necessary. But otherwise I don't feel comfortable just simply dropping the bls airway for a skill (ETI) within my scope of practice.

 

[Paseo Del Norte]

Here is a good question....So I opt for a King-LT airway when advanced airway intervention is necessary. 15min later we arrive at the ED, its pulled and ETI is preformed. Did I do anything but delay care by placing this BLS airway?

If you can't intubate, and can't properly ventilate with a BVM, then maybe a "rescue airway" is necessary. But otherwise I don't feel comfortable just simply dropping the bls airway for a skill (ETI) within my scope of practice.

I am not sure your argument is totally valid. Placing an ETT may be within your scope of practice; however, when we look at the big picture, we must ask: "Is what we are doing helping or hurting?" As it stands, we have allot of evidence that states we are not really helping and in many cases actually adding insult to injury and illness.

Additionally, these airways are being used by physicians in the operating theatre on a frequent basis. While the environment is different, the literature is full of cases where these devices effectively ventilated and oxygenated patients with a multitude of pathologies that are encountered by EMS providers. Additionally, youtube is littered with videos of morbidly obese patients who no doubt have multiple co-morbidities being effectively managed with these devices.

Additionally, I do not agree with your notion that you delayed care by opting against placing an ETT. Our job as pre-hospital providers is to establish effective ventilation and oxygenation, not necessarily correct and definitively manage every problem. If you effectively ventilated and oxygenated with a supraglottic device, you did a good job. Placing an ETT should not be the ultimate prize or outcome.

Finally, I am not sure I would consider a supraglottic device a "BLS" procedure. Placing these devices do not negate clinical decision making, assessment, and knowledge of patient pathology and anatomy. Clearly, we should treat these devices like ET tubes, from waveform capnography monitoring, to securing, to assessing placement and patient response. I would not consider these modalities basic tasks by any means.

While I may seem totally against EMS intubation, I am simply asking people to put egos on the shelf and consider the current base of evidence. We can cry about Mr. Wong hating on EMS; however, we should still ask if what we are doing is helpful. If not, perhaps we need to reexamine the status quo?

 

[McPoyle]

Here is a good question....So I opt for a King-LT airway when advanced airway intervention is necessary. 15min later we arrive at the ED, its pulled and ETI is preformed. Did I do anything but delay care by placing this BLS airway?

If you can't intubate, and can't properly ventilate with a BVM, then maybe a "rescue airway" is necessary. But otherwise I don't feel comfortable just simply dropping the bls airway for a skill (ETI) within my scope of practice.

Nope, the single greatest thing we do for our patients prehospitally is.. well.. get them to the hospital in a condition that is hopefully not any worse than we found them. Now, if that means putting in a less definitive airway that serves the exact same purpose, then thats what we do. We ignore our slightly more ignorant chest thumping coworkers who proclaim "But we CAN intubate..." and we do whats in the best interest of our patients-and this very often is not a procedure from our ALS bag but more basic maneuvers that take less time and have a higher success rate.

The King is not a "rescue" airway for prehospital providers. This airway is secure, has a low failure rate, and expedites transport to definitive care. For what we do in the field it is ideal. Bear in mind that once you get to the ED they are able to change this out for an ETT with extra hands, higher proficiency, while at the same time initiating the care the pt. needs-none of which will be done in the field.

 

[docB]

I think we're not giving enough credit to EMS the the things that we do that do help. I do not buy into the extreme rhetoric of some who are saying that we should go back to some kind of "ambulance driver" model. That's just silly.

The real value of EMS and EMTs is the unique skill set they bring to the scene in the field. No one else is trained to deal with the scene issues, transportation and medical treatment as they are.

And let's keep in mind that the current controversy over EMS intubation is less likely to result in a nationwide removal of the skill. We are more likely to see an even higher degree of professionalism demanded of EMS in that they will be required to factor in additional assessment and environmental issues (e.g. transport time) to decide what the best modality is for their patient.

 

[csmmedic]

We are more likely to see an even higher degree of professionalism demanded of EMS in that they will be required to factor in additional assessment and environmental issues (e.g. transport time) to decide what the best modality is for their patient.

I agree. I hear of some changes at the national level coming soon demanding more education for paramedics, and it excites me. Part of the reason I went back for pre-reqs for medical school is because I could not stand the level of "professionalism" of some of my co-workers, and I could not stand their views on medicine in general. I am all for bettering the field.