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

- Rogue Medic

The Endotracheal Tube is Just a Backup Airway Device – Part I

We claim that anesthesiologists would not intubate well in the prehospital environment – therefore we should not determine whether intubation is appropriate using anesthesiologists’ criteria.

Really?

Why do we think that anesthesiologists would use an endotracheal tube, rather than use an LMA, or a King, or some other alternative airway device?

Anesthesiologists use LMAs much more frequently than paramedics do, so why should any paramedic assume that an anesthesiologist would not use an LMA?

Bias.

This argument is used because the person making the argument has not thought things through and is viewing the options through his biases. The person making the argument has no good reason for claiming this. The person making the argument wants it to be true.

His bias is that anesthesiologists intubate. Therefore an anesthesiologist must view himself as less of an anesthesiologist if he does not intubate.

That is not the way that good anesthesiologists approach airway management.

That is not the way that good paramedics approach airway management.

The endotracheal tube is just a backup airway device, but we do not have good evidence for when to use it.

The primary airway device is a patent airway – maintained by the patient (or maintained by the the non-patient).

The endotracheal tube does seem to offer better protection from aspiration than some extraglottic airways after the tube is correctly placed.

Does that mean that the endotracheal tube is preferred when vomiting is a concern?

No. A self-maintained patent airway is still much better.

You don’t believe me?

The last time you were vomiting, were you really thinking, Things would be so much better if only somebody would intubate me?

To be continued in The Endotracheal Tube is Just a Backup Airway Device – Part II.

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Comments

  1. Couldn’t have put it better myself, sir. Now please deal with the “we’re working in a difficult environment, so a lower success rate is expected, nay acceptable” argument… 🙂

  2. Actually, I’m one of the ones that says you cannot compare anesthesiologist rates with Paramedic rates, and I will stand by that.

    People (myself included) claim evidence based medicine, and proclaim the need for good studies. You CANNOT come to a logical, fair, and concise conclusion without eliminating ALL variables except for the item you’re testing: Medic vs anesthesiologist in endotrachael intubation success rates.

    It is not only unfair, but silly, to claim that any current study out is a good study when it comes to comparing the two, as that’s just not true. 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.

    • Studies of that type have been done both in (http://emj.bmj.com/content/22/1/64.abstract) and pre (http://emj.bmj.com/content/early/2010/07/23/emj.2009.086645.abstract) hospital. It’s fairly simple to compare who is better at intubation, and unsurprisingly the results match the common sense approach of the anaesthetist who intubated several times a day has better results than the paramedic who intubates a couple of times a month, at most.

      The point of Rogue’s post was not that, however. It’s questioning the necessity of intubating in the first place. And despite being better at it, no anaesthetist would leap to the ET tube as a first line airway in the same way that (some) paramedics do.

      • I know what the point of the post was, and my reply was more in the form of dealing with YOUR reply, which I disagreed 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.

        However, I’m lucky with my agency where we have ET tubes with RSI and DAI, LMAs, Kings, and needle and surgical crichs, and the medical director that lets us decide on when is the best time to use what instead of strict “If A then B”. We also have a MUCH higher than average 1st attempt AND overall success rate.

        • I’m not entirely sure what your argument here is Linus?

          “Put the medic, RRT and anesthesiologist side by side in the OR” – but that is what one of the above papers actually did! http://www.ncbi.nlm.nih.gov/pubmed/15611551?dopt=Abstract

          Unfortunately, you cannot have a RCT where patients who need to be intubated are assigned either an anaesthetist or paramedic, and not just because the two groups have different mental and prescribed indications for intubation. So the key to applying evidence based medicine to pre-hospital care is the (unfortunately imperfect) application of logic. In this case, start with directly comparative studies in theatres, and work from there.

          On a side note, every paramedic I talk to, and every self-reporting system I look at, claims a very high success rate. I just wish we could find that one guy somewhere with the 0% success rate who’s letting the side down…

          • The very fact that the ‘study’ says an LMA secures the airway more “reliably” than an ETT doesn’t make you laugh?

            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?

            • “The very fact that the ‘study’ says an LMA secures the airway more “reliably” than an ETT doesn’t make you laugh?” No. Why should it? What’s most important is air going in and out reliably. If an LMA achieves that quicker and more successfully than an ET tube, than that airway is being secured more reliably.

              Should ET tubes be taken off the streets? No, but on the condition than education is improved so that paramedics a) know when it is appropriate to use one and b) keep their skills updated.

    • Linus:

      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.

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