The Bougie, has been around for a number of years now. Actually, bougie is a generic name for a number of devices that are shaped like an Algerian candle. Don’t ask.

The one I am talking about today is more formally known as the tracheal tube introducer. Originally developed as an easy way to change ET Tubes in ICU and other units. At some point, about 15 years or so ago the device made it’s way to EMS. Anyone who practiced in the days before any sort of video laryngoscopes were around knows that it can be tough, sometimes impossible to intubate some patients in the field.

As a rule, paramedics are pretty good at intubating under less than ideal circumstances. When we learned to intubate actual patients in the hospital we generally did so in the Operating Room. Conditions in the operating room are ideal for intubation. At least most of the time when the surgery is pre scheduled and the patient has been fully prepped.

The patient has been evaluated prior to going into the OR, so you have a good idea of what difficulties you might face. The light is great, and adjustable. The height of the patient and the person intubating can be adjusted. The patient has been medicated. The patient’s head has been put on a cute little pillow to put the patient’s head at the right angle. It’s nice and clean in there, well sterile actually. Oh, you have trained help standing literally at your shoulder to do anything you need. Did I mention that the patient hasn’t eaten in the 6-8 hours before the surgery is scheduled.

Mostly you don’t have those advantages in the field. I won’t go into stories of intubating patients trapped in an upside down burning car, that is floating down a river towards a waterfall or BS like that. I think I intubated one patient sitting up right in a car in my career. Or maybe it was my partner, I really don’t remember. I did intubate a patient inside a building that was on fire. The Sorta Big City FD had dragged her out of a smoke filled room, down a flight of stairs, and dropped her in the hallway for us to treat. I’m not sure why I elected to intubate her there, but since the fire was two floors above us, the risk wasn’t all that high.

Anyway my point, to the extent I have one, is that field intubations are much different than in hospital intubations. More challenging for the most part. Which is why paramedics who work in busy systems generally have very good airway management skills.

Back to the Bougie. When my former system first adopted them, a lot of us were skeptical to say the least. Since individually each paramedic usually had more than one intubation a month, we were pretty proficient. Since we were one of the very few systems in the state allowed to use drugs to facilitate intubation, every intubation attempt was reviewed by our medical director. That was every one of them, whether medications were used or not.

What’s a good word for scrutiny?

Scrutiny.

While we were beating our chests about how great we were at intubation and airway control, something happened. Well, a couple of things. First we had some promotions, resignations, and retirements among paramedics. Some of the more senior people were no longer treating patients, so they weren’t intubating. The people promoted to replace them weren’t as experienced or proficient.

So, our success rate dropped.

Then, one of the other great innovations in EMS, CPAP was finally approved by the clerks and secretaries who seem to determine medical policy in my state. We were just about the last state in the union to allow paramedics to use CPAP. Even though in about half of the other states, it was considered a BLS level skill, our clerks and secretaries wanted more studies because as you know, human anatomy and physiology differ once you cross state lines.

Once the administrivia was out of the way, we started using CPAP. We liked it, the patient’s liked it, the hospitals liked it. The insurance companies loved it because CPAP resulted in fewer hospital days and complications than intubation. Winners all around.

The only problem was that we were intubating fewer patients, especially fewer living patients. While good for the patients, it was bad for intubation proficiency.

Which brings us back to the Bougie. We started to use it and our success rate went up. Some people, including yours truly, initially only used it on difficult patients. Which meant that we were making a second attempt since we had failed on the first.

After a little bit of time passed, more medics started using the Bougie on the first attempt for every patient. That really improved our first attempt success rate. In addition to being a number, intubating on the first pass is likely to be better for the patient.

Eventually, most of us started using the Bougie and stopped using stylets. Which I generally didn’t use, but stopped using completely once I mastered the not that difficult task of using the Bougie.

Which brings me to this link,

Effect of Use of a Bougie vs Endotracheal Tube and Stylet on First-Attempt Intubation Success Among Patients With Difficult Airways Undergoing Emergency Intubation: A Randomized Clinical Trial.

Among 757 patients who were randomized (mean age, 46 years; women, 230 [30%]), 757 patients (100%) completed the trial. Among the 380 patients with at least 1 difficult airway characteristic, first-attempt intubation success was higher in the bougie group (96%) than in the endotracheal tube + stylet group (82%) (absolute between-group difference, 14% [95% CI, 8% to 20%]). Among all patients, first-attempt intubation success in the bougie group (98%) was higher than the endotracheal tube + stylet group (87%) (absolute difference, 11% [95% CI, 7% to 14%]). The median duration of the first intubation attempt (38 seconds vs 36 seconds) and the incidence of hypoxemia (13% vs 14%) did not differ significantly between the bougie and endotracheal tube + stylet groups.

This was an Emergency Department study, not an EMS study. EDs intubations are somewhere between OR and field intubations in terms of conditions and difficulty. Will these results transfer into the field?

I’m not sure it matters. The Bougie is a great airway management tool. It helps in the pre hospital setting, even now when video laryngoscopes are readily available and not insanely expensive.

It’s a simple and inexpensive device, yet it can have a huge impact on patients and makes providers lives far easier.

There are far more expensive devices in EMS that do far less for patients. They might be cool and sexy, but they really don’t improve patient outcomes.

Which, in medicine is the measure of the true value of a device.

As most of my regular EMS readers know, I know work in the Quality Improvement part of EMS. The company I work for has a unique approach to the subject as we take an educational approach to working with our clients.

Unlike typical QI, we don’t do any finger wagging when we meet with a medic or EMT to discuss a call that has questions or from which an issue has arisen.

That extends to the first part of the process, which is the PCR review. Auditors are taught during their orientation to avoid pejorative words and phrases. They are instructed to take the review as an opportunity to point out issues and offer solutions.

During initial classes with the services field staff we spend a lot of time going over documentation. In general, EMS education on documentation is pretty poor. Paramedic students might get a couple of hours of classroom, EMTs get almost none. I don’t know of any programs that have their students write reports as part of the classroom experience.

We have found that the 4-5 hours we spend on documentation issues have a positive effect on documentation. In turn, that has a positive effect on patient care because the EMTs and medics put more thought into their documentation and thus more thought into what they are doing. We don’t want them to turn into “protocol monkeys” but knowing what’s in the protocols and why it’s there is part of the job.

One thing we don’t do is comment or score on spelling, punctuation, sentence structure, etc… We do suggest that the providers use SOAPIE or CHART formats as it gives a well defined structure to the reports.

I do mention that while we don’t score on those factors, we sometimes laugh at what we see.

Once the providers realize that those formats work well, reports improve and scores for both the individuals and the services improve.

Sometimes when doing a review (everyone that works for the company does reviews), I have to bite my figurative tongue at some of the things I read.

Then, there is this,

m1 dispatched to above location for a m pt with daphretic. u.o.a pt was alert x 3. pt was having a hard time walking around. nursing staff called ems. pt has a history of crones and anxiety. pt is not taking any meds for it. pt had this since he was 16. pt as no primary dr. pt was placed on our stretcher via Stand and pivot. pt was placed on the monitor and showed nsr. pt was soaked from head toe from sweat. pt has abd pain and he has not eating anything for a few days. pt bg was 132 mg/dl. iv was attempted but not started. 12 lead was unreadable pt was shaking. pt was transported to XXX. en route pt vitals were taken and noted. pt lungs were clear and heent was normal. u.o.a pt was taken to room 25 where verbal and written report was given to the nursing staff

This is supposed to be a medical report. I had to read it three times before I could figure out what was going on. Actually, that’s not true. I read it three times and STILL couldn’t figure out what was going on.

My comments started out “Spelling aside…” and went on to point out that this was a very confusing narrative. I also noted that the care appeared to be appropriate, but that it was very incomplete. Keep in mind that treatments and procedures are documented in a different section of the report, so that part was okay.

That being said, the narrative is the most important part of the report. The drop down lists can’t tell the whole story. The narrative has vital details and must be written clearly. This was a report fail. A total report fail.

I winced at the thought of a doctor, nurse, or billing coder reading this.

Many people in EMS pride themselves in the profession of EMS. That includes me, because I worked in one of few systems that has been determined by an independent arbiter to be staffed by professionals. I won’t go into the details as they aren’t germane to today’s subject, but the elements of EMS as practiced in my former agency met the legal definition of “profession”. As opposed to trade. Which EMS for the most part isn’t either.

For the most part, EMS is a skill set. Some people do EMS full time and it’s their agency’s sole function. Others are fire departments or police departments that also do EMS. Or something else that also does EMS.

If you consider EMS a profession and yourself a professional, then you want to look and act the part. Clear, accurate documentation is part of that. The narrative above does not present the author as a professional. I don’t know what it does present the author as, but I can’t think of it as anything other than a person who writes a sloppy report. By extension, a sloppy report represents sloppy care.

I remember a police case from some years back. The officer who wrote that report also did a sloppy job. When it went to trial, defense counsel tore the report and by extension the work of the officer, apart. The result was an acquittal of a person who was otherwise caught red handed. By the time the lawyer got done tearing the report apart, the officer looked like a clown. Why that report wasn’t reviewed by a supervisor and corrected, I never found out.

I would not want to be the paramedic or his employer if the report I audited was ever called into question by a regulatory agency, court, or even a physician.

Quite bluntly, my eight year old grandson could write a better report.

The moral of the story, if there is one, is this. What your write in your report is a reflection of your abilities as an EMS provider. I am not the best speller in the world, but I use one tool that very few people in EMS seem to use. That is spell check. Even if the PCR system has a poor spell check, and many of them do, most providers I know have a smart phone. Which is a great tool for checking the spelling of not only medical terms, but common words as well.

The struggle to have EMS recognized as a medical profession started before I was in EMS, continued throughout my career, and is still going on as I type this.

Illiterate reports like this don’t help at all.

This all sounds very preachy, I know. Still, writing a decent report is not that hard. It’s not even EMS specific. Writing is something that is taught from Kindergarten on and an adult who is out in the working world should not be writing a document like this.

With that, I’ll step off my soapbox and await your comments.