Thursday, December 24, 2009


In the prehospital setting, we are taught that airway comes first. A before everything else. And as paramedics, we're taught that the definitive airway, when we need to protect it, is a properly placed endotracheal tube.

But is this really the best for our patients? Certainly an ET tube is the right definitive airway for the hospital, but a plethora of recent studies suggest that paramedic intubation success rates are relatively poor. I'm not even talking about the effect on morbidity and mortality; it appears to be a fact that we're no good at getting the tube in the right hole on the first try.

A prospective multicenter evaluation of prehospital airway management performance in a large metropolitan region.
Denver Metro Airway Study Group.
Prehosp Emerg Care. 2009 Jul-Sep;13(3):304-10.

"Nine hundred twenty-six patients had an attempted intubation. ... For transported patients, 74.8% were successfully intubated, 20% had a failed intubation, 5.2% had a malpositioned tube on arrival to the ED, and 0.6% had another method of airway management used. Malpositioned tubes were significantly more common in pediatric patients (13.0%, compared with 4.0% for nonpediatric patients)."

Review of endotracheal intubations by Ottawa advanced care paramedics in Canada.
Tam RK, Maloney J, Gaboury I, Verdon JM, Trickett J, Leduc SD, Poirier P.
Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada.
Prehosp Emerg Care. 2009 Jul-Sep;13(3):311-5.

"The study population comprised 1,029 intubated patients ... ETIs were successful for 64.6% (95% CI: 61.7, 67.5) of the first attempts; 79% of successful intubations were achieved within two attempts."

We get upset when we read these studies. What are they saying? We can intubate people! Our skills are solid! And yet, the numbers would seem to indicate this is not the case.

Many, many people have weighed in on this issue, and a few recent calls I've run have made me ponder these issues. I cannot argue that some of the data out there shows that paramedics are bad at intubating people, and there's no doubt that we're not doing our patients any favors by screwing around in the field.

The questions I want to ask are why are we bad at intubating people and how can we do better?

There are some of the local first responder agencies I work with that prefer alternative airways. The King Airway, in particular, has become popular lately. While I feel that the King is a great rescue device, I see red when I hear agencies espouse a culture of de-emphasizing ET intubation in favor of just "tossing in a King." Here's the facts in my experience: King airways allow you to ventilate and oxygenate a patient, so they're good for the purpose of a rescue device. They get the job done temporarily. They do NOT protect a patient's airway and lungs against vomit. If you bag too forcefully, you WILL end up with subcutaneous emphysema in your patient's neck. They do NOT always work, and if "Insert Tab A" is your ONLY plan, when that doesn't work you are hosed. (Yes, I'm looking at you, Mr. Non-Transporting Firefighter Paramedic.)

The three major reasons paramedics have issues intubating patients, in my opinion, are EXPERIENCE, VERIFICATION, and TOOLS AND TECHNIQUES.

Experience is the biggest factor. We don't perform enough intubations to be truly proficient. A physician will perform hundreds, if not thousands of intubations before they are even out of residency. A paramedic may perform ten, if they're lucky. Maybe more, in a good paramedic training program. This is not near enough. No wonder we're no good. If we expect to be good at intubation, we need to do a LOT more of them.

Verification is the second most important factor. I firmly believe that there is NO, zip, zero excuse for a misplaced ET tube in this day and age. If your agency isn't using continuous waveform capnography, you're behind the times. Visualization, lung sounds, tube misting, sure, but ETCO2 is the gold standard. You cannot have a misplaced tube with a good ETCO2 waveform on your monitor. If every patient you secure a tube in has that waveform, you won't misplace tubes. It's as simple as that.

Tools and techniques are the final factor in why we don't get our tubes in the right place. When's the last time you pulled out a bougie? Are you proficient using both Miller and Mac blades? Do you have a video laryngoscope? When's the last time you practiced -- let alone performed -- a NASCAR intubation, a digital intubation, or your surgical airway procedures? Do you know two-person intubation techniques to improve visualization? Do you know exactly how and when to use your rescue techniques and devices? If you answered NO to any of these questions, I don't think you should be intubating people in the field.

All of these ideas are nice, but how can we actually implement them, and do better at airway management? For the answer, I've got one more paper.

An analysis of advanced prehospital airway management.
Bulger EM, Copass MK, Maier RV, Larsen J, Knowles J, Jurkovich GJ.
Department of Surgery, Harborview Medical Center, Seattle, Washington 98104, USA.
J Emerg Med. 2002 Aug;23(2):183-9.

"The results showed there were 2700 patients intubated... The indications for intubation included medical emergency in 82% of patients and traumatic injury in 18%. Fifty percent of patients were intubated with the use of succinylcholine. The overall oral intubation success rate was 98.4% and definitive airway access was achieved in all but 12 patients (0.6%), with 30 patients receiving surgical airway access (1%). The successful intubation rate for patients receiving paralytic agents was 97.8%."

Wow! Look at that! Paramedics can intubate people! So what the heck is so difference about the system in Seattle, that they have such success rates?

The system in Seattle is tiered, with a small number of ALS ambulances backing up a larger system of BLS first responders and BLS ambulances. The initial training program for ALS providers in this system is extensive and stringent. While there are some unrelated issues with this system, the fact is that a SMALL number of HIGHLY TRAINED paramedics can and do intubate people effectively.

What's the implication? First off, I'm sorry, but paramedics need to get the hell off fire engines. We need to reduce the number of paramedics in almost every EMS system, and removing ALS first responders is the way to start. More and more studies are coming out which question the efficacy of ALS for critical patient (cardiac arrests and trauma patients in particular). First responders need to focus on solid BLS skills -- that's where the lives will be saved.

Second, every patient does not need an ALS ambulance. While systems need to have effective triage tools and constant, vigilant QA to make sure that the patients who need ALS get it, there's nothing wrong with BLS transport. Simple logic says that if you reduce the number of paramedics in a system, those paramedics who remain will see more critical patients and perform more procedures.

Finally, we need to change paramedic education. Three terms at a community college is ridiculous. Two years of full time college to be a paramedic. End of story. If that's too much time for you, if that's too hard, TOO BAD. We have too many medics, I said it above, and making the entrance and educational requirements tougher will only improve the quality of our providers.

We need to change our systems from paramedic-saturated over-ALS'd behemoths where each medic is maybe managing one or two airways a month, to lean, mean, highly-trained and highly-experienced systems with a small number of medics who can consistently, effectively manage airways the right way, the first time, definitively.


Drew Rinella said...

Yeah? With who's money?

new medic 09. said...

How many of those misses did the ER docs struggle with? Or use the glide scope with or have the chance to RSI and properly sedate the patient?

I agree that Paramedics as a 2 year program is not that long, in Ontario that is for the basic life support level - which differs from province to province. The third year is your advanced levels - and we do x number of tubes in the OR during clinical shifts.

I am totally an advocate of the best practice is BLS, and that it is a bonus to have ALS, but I also believe that we need more studies and proof that what we do is right or wrong, or needs changed. How many of these studies and how much of our practice is based on hospital settings.

One thing I agree with - the programs don't need to be 50 - 75 students. I think it should be much more selective and focus on high level of training and skill.
Thanks for the discussion.
- new medic 10.

Victoria said...


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Hailey said...

Hi There!
Love your blog. I am a BLS/EMT(Technically a PCP, Primary Care Paramedic) in British Columbia. We have the system you are proposing, with ALS (Acute Care Paramedics) cars responding to key worded calls like "Chest Pain" and "Shortness of Breath" as well as able to respond to a PCP care requesting help (bad airways, call went sideways etc). But these cars are only in cities. I work in rural Northern BC, where transport time is sometimes 2 hours to a hospital. When you are 10-15 minutes to any hospital I don't see a need to stay on scene for 20 minutes to do an intubation. Where I DO see a need is in rural areas like mine. The downside is the ALS car working out of those stations are not going to get the high ALS call volume that they need to stay practiced. What can you do? I wish though that BC would let its PCPs perform alternate airway maneuvers (Like the king or a combi) for situations like mine. I think change is coming though, and Seattle seems to be a leader in a few things Pre-hospital care (CPR success rates I know is another area they seem to excel in). Great article, and great writing in your blog, you have another follower! :D