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

- Rogue Medic

Paramedic = Intubation IV

Still on the topic of paramedics and lack of intubation success begun in Paramedic = Intubation I, Paramedic = Intubation II, and Paramedic = Intubation III.

What if the numbers in the research are misleading?

They are misleading. That is one of the reasons I write so much about them.

Look at the many ways we might describe an intubation attempt:

  • Any opening of the intubation kit.
  • Any attempt to visualize the airway, even if there is no use of a laryngoscope or endotracheal tube.
  • Any insertion of the laryngoscope in an attempt to visualize the airway, even if just to determine if it is appropriate to attempt to intubate.
  • Any airway use (BVM, LMA, CombiTube, King LT, crichothyrotomy, endotracheal tube), even if intubation was never attempted.

We do not even remotely have agreement about what is an attempt at intubation.

For example, I arrive to find a patient supine with a patent airway, but depressed respirations. I initiate BVM ventilation while assessing for other potential life threats. My partner gets a history, list of medications, et cetera. The rest of the assessment shows a cachectic elderly male with no signs of trauma, supine on the floor. Ventilation by BVM is adequate with good chest rise and no abdominal distention. I transfer BVM to my BLS partner. My partner ventilates the patient successfully, while we move the patient to the ambulance. Even though this patient has plenty of whiskers and dentures, which we removed, he is not showing any signs of any complications that would indicate problems with ventilation. En route, I start an IV and draw bloods, back when the hospitals would accept our blood draws. Now I don’t start an IV unless I anticipate a specific need.

Back to the purpose of this little anecdote. In some of these intubation studies, this would be described as an unsuccessful intubation attempt, even though I never attempted intubation. We need to be careful in the way we discourage appropriate airway management by using language that is critical of those managing the airway appropriately.

Did I do anything wrong?


The emergency physician was not happy, because he wanted an intubated patient. Apparently, he does not consider it important for BLS personnel to get experience managing an airway. He did not make any statement to acknowledge the nice ventilation job being done by my partner. He does not consider airway management important, unless the tube is in the right place.

The endotracheal tube was in the right place.

The tube was still in my intubation kit, unopened.

The emergency physician wanted to intubate the patient, not because I couldn’t, but because the emergency department is much more limited in airway management resources, when it comes to non-intubated patients. I could have avoided this by intubating the patient prior to going in to the ED. It isn’t as if I’ve never intubated in the parking lot to protect the patient from certain emergency physicians, who are less than skilled at airway management.

I thought it would be good to show the doctor that some of the EMTs are excellent at airway management. I overestimated this particular emergency physician.

This emergency physician will probably get over it.

Maybe this emergency physician will even learn.

It isn’t as if this would be a difficult tube – cachectic edentulous* patients can sometimes be intubated orally even without the use of a laryngoscope. Just with positioning of the airway.

This is one of the reasons that the AMA needs to create a separate specialty of prehospital medicine. The differences between emergency medicine and prehospital medicine are tremendous. This physician is/was medical director for several ALS services. He should have had a better understanding of EMS, but he did not. If some emergency physicians are this ignorant of good patient care, how can we expect the medics to understand good patient care? The medics have so much less education.

A smarter EM physician would have had me intubate the patient, while being observed by the physician. As I mentioned, when it comes to EMS supervision and airway management, this EM physician was not known for his smarts, but for his temper. Who knows, maybe he has changed. That’s me – the hopeless optimists. 🙂

How do we do research on airway management, when many of the doctors do not understand what they are studying?

Paramedic Intubation.

Intubation Airway Management.

^ *
Cachectic = wasted away, frail, exhibiting signs of poor nutrition.
Edentulous = toothless, having lost teeth.



  1. […] written about some of these studies here, here, here, here, here, here, here, here, here, here, and here. You know why they are called alternative airways? They are used as a last ditch effort to get any […]