Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Prehospital Advanced Airway – Should Paramedics Be Intubating?

Prehospital Advanced Airway – Should Paramedics Be Intubating?

That is the title of the latest post from Prehospital 12 Lead ECG. What does intubation have to do with 12 Lead ECGs, prehospital, ED, or in the cath lab?

Funny you should ask. The post is about how we approach patient care decisions. Tom B. transcribes a bit of the unfortunately ignored 2003 ACLS Reference Textbook and Experienced Provider Manual and some of The EMS Garage from 11/21/08 on Airway Control.

Tom B. highlights some excellent points as far as assessing quality is concerned. Too many of us ignore intubation quality, unless it is forced on us. Maryland is currently facing this problem with their helicopter program and I have been finding no end of things to criticize there. If we think that we do not need to provide aggressive oversight of all potentially risky interventions, we will harm patients unnecessarily. Not that it is necessary to hurt patients, but some problems will be unavoidable, even with excellent oversight.

Tom B. lists some systems that provide excellent oversight. Even they could be better. This is a job that should have a goal of continual improvement. This is not a job of good enough.

Pennsylvania state protocols[1] require all ALS services to have waveform capnography as of November 01, 2008. This is an excellent move toward eliminating the usual excuses for killing patients with misplaced tubes. The main excuses are:

We can’t afford to do the job the right way.

We’re too good to need that equipment.

We were able to intubate before waveform capnography and airways haven’t changed. So we don’t need that stuff.

Here are the minimum oversight standards from the Pennsylvania ALS protocols:

Performance Parameters:

A. Review all ETI and Alternative Airway Device insertions for documentation of absence of gastric sound, presence of bilateral breath sounds, and appropriate use of a confirmation device.[1]

I also appreciate that they have the assessment of gastric sounds appropriately ahead of assessment of lung sounds. You can listen to lung sounds and not hear anything that will make an immediate difference in treatment. If you listen over the stomach and hear gurgling, is there any reason to leave the tube in place for even one more squeeze of the bag? It does not matter if you think you saw the tube go through the cords.

Teaching people to trust seeing the tube go through the cords is one of the most dangerous things that is taught in EMS. This is incompetence. Almost all misplaced tubes are accompanied by the killer saying, I saw the tube go through the cords.[2]

B. If systems have the capability of recording a capnograph tracing, review records of all intubated patients to assure that capnograph was recorded.[1]

What would be the point of having waveform capnography that does not have the capability of recording?

C. Document ETCO2 reading immediately after intubation, after each movement or transfer of patient and final transfer to ED stretcher.[1]

Also an excellent oversight approach. While waveform capnography does not confirm that the tube is in the trachea (it can be above the cords and less secure, not that we should be using the word secure), it does confirm that the tube is not in the esophagus. This is essential. If you are going to court, that should be enough to convince a lawyer that there is no big money case – at least not against EMS for airway management problems.

One of the quotes that Tom B. provides from The EMS Garage is about how we have come to define paramedics by the ability to intubate.

“I think that’s true, and I hate to say this, but shame on us, because we are the only health care provider group that defines ourself by what we can do that’s unique rather than what good we do the patients.”[3]

This is the most important part of determining what our protocols and scope of practice should be. Does the patient benefit from the intervention? If the treatment is beneficial, are the side effects and complications low enough, when used by EMS, that it is in the best interest of the patient to have EMS use this treatment?

Posts continuing the discussion from this post:

Prehospital Advanced Airway – Should Paramedics Be Intubating? – comment

Prehospital Advanced Airway – Should Paramedics Be Intubating? – comment II


^ 1 Pennsylvania State ALS Protocols
Page 2032 – ALS – Adult/Peds; 12/121 in the pdf page window.
Free PDF
Every ALS ambulance service must carry and use an electronic wave-form ETCO2 detector device1 for confirmation of endotracheal tube/ alternative airway device placement.

The footnote for the excerpt from the protocols is:
1 Colorimetric ETCO2 detectors may give false negative results when the patient has had prolonged time in cardiac arrest. EDD aspiration devices may give false negative results in patients with lung disease (e.g. COPD or status asthmaticus), morbid obesity, late stages of pregnancy, or cardiac arrest. ALS services may consider carrying colorimetric ETCO2 detectors or EDD aspiration devices as back-ups in case of electronic device failure, but must primarily use the wave-form ETCO2 detector as described in this procedure.

^ 2 Waveform Capnography vs. Hubris
Rogue Medic

^ 3 The EMS Garage
Airway Control.



  1. […] – comment Thu, 27 Nov 2008 21:22:39 +0000 By Rogue Medic 1 Comment In response to Prehospital Advanced Airway – Should Paramedics Be Intubating?, was this comment from Divemedic. I am assuming the accuracy of what Divemedic writes, since I was […]