There has been a bit of a debate in the comments to The Endotracheal Tube is Just a Backup Airway Device – Part I.
Nickopotamus writes –
Now please deal with the “we’re working in a difficult environment, so a lower success rate is expected, nay acceptable” argument…
I don’t entirely agree. The OR is as close to an ideal environment as the anesthesiologists can make it. EMS does not operate under such ideal circumstances.
A lower intubation success rate is expected, but the goal is not intubation. The goal is airway management. We should use the means that will best manage the patient’s airway, which does not mean that the ETT (EndoTracheal Tube) is the primary device. The ETT may sometimes be the best means of managing the airway.
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In response, Linus writes –
Any and every study that does not put a medic and anesthesiologist (and lets just add RRTs too) in the same exact scenario shall be discredited and laughed at immediately as being unscientific and not being evidence based medicine.
Put the medic, RRT and anesthesiologist side by side in the OR. That is the only true and legit way to conduct a study and find out if we ARE as competent, or incompetent, as people claim and believe.
That would matter, if medics did intubate patients in the OR (Operating Room), but paramedics only practice in the OR.
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Nickopotamus mentions a couple of studies that examine this question. First –
METHODS: Patients undergoing general anaesthesia were studied. Paramedics trained in laryngeal mask use and endotracheal intubation participated in the study. A Portex disposable laryngeal mask was inserted and removed, followed by a Portex endotracheal tube. Time taken from beginning of the procedure to ventilation of the patient was recorded.
CONCLUSIONS: Even under optimal conditions, 30% of attempts at intubation by paramedics were unsuccessful. A disposable laryngeal mask has a higher success rate in securing the airway and overall, secures the airway more reliably than endotracheal intubation.[1]
Even in an ideal environment, the intubation rate is unacceptable. There may be a lot to say about this study (I will go into more depth on this another time), but Table 2 provides the important information.
As you can see in the red oval, the 4 patients with Grade III Cormack and Lehane views could not be intubated in the OR by these paramedics. The Cormack and Lehane grading is shown in the image below.
The dark red line shows the rapid deterioration of intubation success with worsening airway views.
The dark green line shows only a gradual decrease in LMA (Laryngeal Mask Airway) success for the same worsening airway views.
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Image source.[2]
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Second –
This aim of the study was to evaluate the tracheal intubation success rate of doctors drawn from different clinical specialities performing RSI in the pre-hospital environment.[3]
Results 4362 active missions were flown. RSI was performed in 200 cases (4.6%, 3.1/month). Successful intubation occurred in 194 cases, giving a failure rate of 3% (6 cases, 95% CI 0.6 to 5.3%).[3]
97% intubation success?
Maybe anesthesiologists and emergency physicians do not suck at intubation in the prehospital environment.
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Linus responds with –
On the same token, whilest “no anaesthtist would leap to the ET tube as…. some medics might”, again, not quite fair. Some places, all they have IS ET tubes. Some might even have Combis.
It is important to be fair – fair to the patients, not to the paramedics.
We are supposed to be using what is best for the patients.
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Later, Linus states –
The very fact that the ‘study’ says an LMA secures the airway more “reliably” than an ETT doesn’t make you laugh?
Of course not.
We need to be looking at what the research is telling us about what works, not looking for research that agrees with our biases.
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ETTs shouldn’t be the only airway we have. But they shouldn’t be taken off the streets either.
Otherwise, what do we do with say, burned airway patients? Just cric them all?
Is a burned airway going to be well managed by someone just because the person has an ETT?
Maybe the use of the ETT leads to more damage to the patient’s already burned airway.
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MV responds to Linus with an excellent comment –
As a patient, why exactly would I care about your ability to intubate in the OR? Precisely what relevance would such a study have to a non-OR environment?
OR studies would be useful to determine what works under ideal situations. Field studies would be useful to determine what works best in the field. Studies will never be perfect and good studies don’t have to be. As studies approach perfection, they are likely to become less than useful in the real world because they have to become very specific.
Does this mean that paramedics shouldn’t intubate?
Not necessarily.
We should know what our intubation success rates are.
Any service that does not track its intubation success rates should probably be prohibited from intubation.
Isn’t this the modern equivalent of the doctors going straight from the morgue to the delivery room without washing their hands? They could deny that there was a problem as long as they did not track the infection and death rates. Many continued to deny there was a problem even after the increased fatality rates were documented.
There is good evidence that paramedics can intubate at very high success rates.
RESULTS: Paramedics successfully intubated 95.5% (1,582) of all patients receiving succinylcholine, 94% (1,045) of trauma patients, and 98% (538) of medical patients. They were unable to intubate 4.5% (74) of the patients. All of these were successfully managed by alternative methods. Unrecognized esophageal intubation occurred in six (0.3%) patients. The addition of capnography and a tube aspiration device, in 1990, decreased the incidence of esophageal intubations.
CONCLUSION: Paramedics trained to use succinylcholine, to assist the process of endotracheal intubation, can safely intubate a high percentage of patients.[4]
Why do we tolerate medical directors who allow dangerous paramedics to attempt to intubate even though the medical director should know these paramedics are dangerous?
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Footnotes:
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[1] Securing the prehospital airway: a comparison of laryngeal mask insertion and endotracheal intubation by UK paramedics.
Deakin CD, Peters R, Tomlinson P, Cassidy M.
Emerg Med J. 2005 Jan;22(1):64-7.
PMID: 15611551 [PubMed – indexed for MEDLINE]
Free Summary and References with link to Free Full Text PDF from PubMed Central
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[2] Rapid airway access
Sérgio L. AmantéaI; Jefferson P. PivaII; Malba Inajá RodriguesIII; Francisco BrunoIV; Pedro Celiny R. GarciaV
Print version ISSN 0021-7557
J. Pediatr. (Rio J.) vol.79 suppl.2 Porto Alegre Nov. 2003
doi: 10.1590/S0021-75572003000800002
Free Full Text Article from Jornal de Pediatria.
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[3] Should non-anaesthetists perform pre-hospital rapid sequence induction? an observational study.
Fullerton JN, Roberts KJ, Wyse M.
Emerg Med J. 2010 Jul 26. [Epub ahead of print]
PMID: 20660897 [PubMed – as supplied by publisher]
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[4] Prehospital use of succinylcholine: a 20-year review.
Wayne MA, Friedland E.
Prehosp Emerg Care. 1999 Apr-Jun;3(2):107-9.
PMID: 10225641 [PubMed – indexed for MEDLINE]
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The issue with intubation on Grade III/IV airways could relate back to initial education and techniques. Bimanual laryngeal manipulation was something I only heard about a year after getting out of school! Additionally, the proper head positioning for optimal optics w.r.t. viewing the cords was never covered. Proper patient positioning (which in this study was likely done being in the OR, external auditory meatus to sternal notch) was really not addressed. Stylette shaping, the list goes on…
For a true Grade III/IV view, I find it odd that a device such as a Gum Bougie wasn’t utilized to help “ensure” successful placement. If I can’t see the cords (POGO of 0%), its really a crap-shoot anyways with a traditional ETT and stylus. Successful intubation requires a plan for success.
Also, I am interested to know the root causes for the LMA failures. Were they given the opportunity to use a blade to facilitate LMA placement (i.e. potentially alleviate the tip bending issues)?
The problem is EMS education, or actually training which passes for education. I was shocked to learn that in my neck of the woods most paramedic students get only the minimum mandated 10 intubations in the OR. I don’t know if they are even required to get one intubation in the field before taking the state certification exam. Since we aren’t a NR state, I don’t know what the NREMT requires. 10 intubations is nothing. During my clinical time I did almost 50 OR intubations and that didn’t really prepare me for attempting intubation in the field. The CRNA who was my mentor in the OR told me to expect to do about 200 intubations before I felt really comfortable and he was right.
If we want to be considered and treated as professionals, then we need to improve paramedic education. It’s ridiculous that after taking the paramedic program and passing the tests to become certified we are then expect to take ACLS, PALS, NALS, AMLS, PHTLS or ITLS, ABLS, and other merit badge courses. All of that material should be included in the paramedic program.
People talk and blog about taking associates and bachelors programs in “EMS” to improve our professional standard. How about we concentrate on better educating ALS personnel and stop the trend of a so called paramedic on every ambulance, engine, and rescue truck in the country? More is not better, better is better.
BTW, the reason we intubate burn patients early is because we want to protect their airway against the frequent occurrence of edema at and below the level of the chords. The only two alternatives that do that are intubation or a surgical airway. An LMA will not do that, nor will any of the other “rescue” airways out there.
No medic I know uses a Mallampati exam before intubating, and I know a lot of medics with 25 or more years of experience. It really doesn’t matter because we are going to attempt (and likely succeed) intubation when necessary. We do track our intubation success rates and over all it is 90+ % successful. That’s a function of a lower number of paramedics seeing more acute patients every year because we are NOT an all ALS system.
I think you are really missing the mark in understanding what these studies mean. They don’t mean that paramedics shouldn’t be intubating. They do mean that we need to drastically revamp paramedic education. Unfortunately, I just don’t see that happening.
Rogue, in this we completely agree. I came up with the same conclusions but under different circumstances that really made things quite simple. (No, this is NOT evidenced based medicine, but you know how I rely on that!)
In the mid-1970’s there was NOTHING more controversial than paramedics using ET intubation in the field. Those Docs who pushed for it had to push an awful long time and the end result was this: An E.T. tube was put in place when all other options had been eliminated or tried, and if was done, it was done right.
Just ONE case gone askew could roll a bunch of heads!
“Discernment” that’s something they teach now, don’t they?