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

- Rogue Medic

In Defense of Intubation Incompetence – Part III

A continuation of In Defense of Intubation Incompetence – Part II. PA_Medic responded to Part I with –

If the patient woke up to a sternal rub, I do not see any reason to consider that as anything other than eyes open to voice.

Your kidding me right? Your going to discount AVPU now? When was the last time you picked up an ETOH overdose? Maybe yelling in the ear from one inch away = painful stimuli.


How is the appropriate classification of a response to a sternal rub as the equivalent of a response to voice in any way discounting AVPU?

I am discounting the pain produced by a sternal rub as insignificant. Not quite a massage, but not effective as a painful stimulus. Only a small percentage of patients will respond to a sternal rub as a painful stimulus.

I arrive on scene.

Sternal Rubber – He is unresponsive to deep painful stimulus!

I apply real painful stimulus.

The patient opens his eyes and responds.

Rogue Medic – What kind of painful stimulus did you use?

Sternal Rubber – A sternal rub, of course.

Rogue Medic – A sternal rub is more useful as a way of producing an abrasion on the chest (lifting up patient’s shirt to show the abrasion) which we now need to explain in documentation. Since the shirt was tucked in, I am guessing that none of you checked for any abrasion, and then tucked the shirt back in.

Picture credit.

EJs (External Jugular IVs) are rarely used in EMS outside of cardiac arrest and do not appear to offer much benefit over a peripheral IV.


Really? Come deal with the diabetics and hypovolemic shootings/stabbings in my local. IV’s are nice if you can get it or they have limbs. IO’s are nice as well


Considering the safety and efficacy of IO (IntraOsseous) access, there is not much reason for EJs.

A lack of ability to deliver large fluid boluses to patients with uncontrolled hemorrhage may be better for patients.

Why is extra practice an insult?

Did I ever say that? I encourage it!!!


You wrote – Guess we have to send you with the IV team in the hospital to make sure you know how start a line because you must be out of practice because you failed.

You present this as if it were an insult to be sent with the IV team to work on IV skills – also known as practice.

This discussion all started with my suggestion of a way to improve intubation practice, so it is easy to see your comments as critical of requirements for practice.

Signs of incompetence –

Listening to the lungs before listening to the belly.


I don’t know how you were taught to intubate but I confirm lung sounds while using the BVM before intubation. After placing the tube, sometimes blind or with a Bougie, I hook up the end tidal and listen to the L lung and compare it to what I heard while using the BVM. If I hear no sound I listen to the belly quickly. If absent I listen to the R lung comparing it to what I heard before assuming I’m to deep. With all breaths I’m watching the belly for expansion. If I can only hear sounds in the right then I am to deep. Reposition and start back from L lung to R lung to belly. 8-10 seconds max.


The first place I want to listen to is the place that can tell me most quickly if I am in the wrong place.

That place is the belly.

Too often I see people listen over one lung, then the other, then go back and listen again to the first lung, then listen again to the second lung, then listen to the belly and realize that the tube is not where they want it to be.

Risk management is more about looking for evidence that we are wrong, than looking for evidence that we are right.

If I listen to the belly first, hear gurgling and pull the tube with only one breath in, there is less likelihood that the patient will vomit, or have other negative consequences of an esophageal intubation.

If I listen to either lung first, do I have enough information to pull the tube after just one ventilation?


If this is a misplaced tube, I will put more air into the stomach before I will recognize my mistake.

Maybe the patient vomits with just one breath. I have had that happen.

Maybe the patient will vomit with the second breath. I would never know that, if there are gurgling sounds over the belly with the first breath, by using my method. You would be dealing with vomit in the airway.

Maybe the patient will not vomit no matter how many breaths are delivered to the stomach. There are patients with unrecognized esophageal intubations and flat waveform capnography readings, who have their stomachs ventilated, but they do not vomit.

By comparing the sounds of lung sounds during bagging (and I am assuming listening to the lungs without bagging for those patients not being bagged for a lack of ventilation), you do avoid the problem of trying to figure out what unfamiliar sounds are, since you have a baseline for comparison. Why not do the same thing with the belly, too, and listen to the belly first?

How much do we want to gamble on the tube not being misplaced?

When I gamble, I want to compare what I can gain with what I can lose. Listening to a lung first is a gamble with nothing to win.

It used to be that medics would complain that waveform capnography is for wimps. Now we understand that not using waveform capnography if for idiots. These medics may not be wimpy, but they are idiots and their patients are not better for it.

Reality is there are bad apples in every profession. My wife has saved more patients as a nurse due to bad MD orders then most hospitals want to know. It’s not placing blame or supporting incompetence. It’s reality. There are medics that suck. Period. Show me any job that doesn’t have 5-10 percent of people getting fired due to incompetence or laziness. Unfortunately our mistakes can kill.


You see the problem as only 5% to 10%. I think that it is dramatically higher.

I get mad when one subject like intubation gets targeted because it’s an easy target.


Intubation is an easy target because it is done so poorly by so many medics and because the consequences can be so serious and because there is so little evidence that there is any benefit.

Apathy hurts more patients in our profession then intubation ever will!!!


I thought that the problem was that I am not apathetic enough about intubation.

Wanna meet at Brothers for a slice and a beer for a real conversation?


OK. Bryn Mawr or Philadelphia?



  1. I hope you’ll agree with this but it’s unfair to compare success/failure rates of paramedics to ER doctors and anesthesia. Studies should only reflect within the profession to find out why some organizations have a higher success rate then others. Why? Glad you asked. It’s comes down to training (# of attempts on complex patients more frequently), environmental situations, number of staff, other responsibilities, and money. The first is easy. They do it all day. They have the chance to evaluate airways in depth while patients are awake, talking, and can be informed from possible complications from medical records and decide before hand the best airway for a patient prior to the initial attempt so when they are called to the ER for an emergency they do it in their sleep. Two, lets face it, ER doctors and anesthesiologist work under optimal situations. Right height, best light, and a controlled environment allows them to focus on one thing, the airway. Not so for EMS. In a car, on the floor in a bathroom, on the stretcher in the rig, and who knows where else (not using this as an excuse for poor airway management BTW). Third, staff, if you work in an OR or ER you have access to personnel who understand what you need when you ask. It’s a lot harder to ask an EMT whose card has barely dried to assist you on scene. Fourth, the anesthesiologist is in charge of pain management, sedation, and airway management only. Nothing starts or continues unless they feel all three are secured. The fifth should be obvious, it all comes down to money. Money for training and money for equipment. Compare the hospital budget for airway equipment to that of the paramedic department. Who has access to every tool and medication available for airway management.? There are many tools available to EMS to lower failure rates of intubation but most are not affordable because an EMS budget is spread thin to cover the minimal requirements of a state licensed paramedic unit. My hospital based system can afford more then a city based system. It’s doesn’t mean we are better but we may have another tool to use on a more complex airway. There are blades with bulbs better and brighter and glide/video scopes and I bet most systems cannot afford them but I bet the OR can. We need to compare system to system only. What does M3**-7 do that M5**-7 doesn’t to have such a higher success rate. You mentioned IO’s. What is the success rate of IO gun vs. placing it by hand? Sometimes tools do allow for a higher success rate assuming proper training. It’s all situational in EMS. If I’m a single medic with a BLS crew and PD and overseeing an airway, directing CPR, intubating, placing a line, and giving medication then sometimes being at the head of a patient and putting an EJ is easier then hand pushing an IO into a ankle because that’s what my budget affords. Luckily I don’t run into that to often. Let’s look at our profession as a whole and only our profession to see who’s doing it better and learn from them. What did they do to improve?

    I was thinking more like Drexel Hill around the corner…

  2. I will sometimes press on the chest after intubation with my ear to the end of the ETT and listen for a whoosh of air. If I’m worried the ETT is in the esophagus, this avoids insufflating the stomach with air and risking regurgitation and aspiration. It’s quick, easy, immediate, and it would be hard (but not impossible) to have enough air in the esophagus to give a false positive.