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

- Rogue Medic

Comment on Irresponsibility and Intubation – The EMS Standard Of Care


I wrote about the petition to protect paramedic incompetence in Irresponsibility and Intubation – The EMS Standard Of Care

Nathan Boone responded with the following comment

You’re forgetting about the rural medic out there.


No. I am not.

Are you suggesting that bad airway management for a longer period of time is less harmful than bad airway management for a shorter period of time?


Where we are with our patients for more then a hour, not 5 mintues.


The harm from incompetent airway management does not depend on distance from the hospital. Intubation even kills patients in the hospital.

You may believe that the efficacy of voodoo is directly related to the distance from the hospital, but it appears to be only your belief that increases.

Voodoo does not work, regardless of the distance from the hospital.

If the paramedic cannot manage an airway, the paramedic should not be permitted to intubate.

Sometimes air- craft isn’t available if its raining or on another call.. You want us to use a bvm and take chance of filling the patients stomic up for over a hour.. Yes we can be extremely careful and do everything in our power not to fill the stomic but there’s some patients out there who have difficult airways where bagging can be extremely difficult and or impossible.


Give incompetent paramedics dangerous tools to try to manage difficult airways because of distance? Wouldn’t it be better to try to make them competent – or to limit intubation to competent paramedics?

Intubation and BVM (Bag Valve Mask) are not the only forms of ventilation.

Rsi does save patients in rural areas, we need intubations..


Maybe. Maybe not. Maybe RSI kills more patients than it saves.

Actually, what I mean to write is, Maybe paramedics using RSI kill more patients than they save.

If you want to claim otherwise, prove it with high-quality research.

Unless you can provide high-quality research, your plastic airway religion is just another alt-med scam.

If your patients are important, then you need to demand that we find out what is best for the patients.

Do I believe that Rsi is risky and their is some medics out there who would rather make the patient more hypoxic then before until they give up and go to a secondary airway..absolutely.. But to take it away from Rural Medics when we can have anything to burn patients to anaphylactic reactions and to take our ONLY definitive airway;away from us..


You seem to think that RSI (Rapid Sequence Induction of anesthesia) becomes less risky the farther you are from the hospital.


Incompetence for a longer period will be expected to cause more harm.

Sometimes the incompetence of the paramedic doesn’t kill the patient.

Trauma patients were significantly more likely to have misplaced ETTs than medical patients (37% versus 14%, P<.01). With one exception, all the patients found to have esophageal tube placement exhibited the absence of ETCO2 on patient arrival. In the exception, the patient was found to be breathing spontaneously despite a nasotracheal tube placed in the esophagus.[1]


The patient clearly did not need intubation.

As with the crash of Trooper 2 in Maryland, the survival of the patient for hours in the woods, in the rain, following the helicopter crash that killed all of the other healthy people on board, was clear evidence that there was no reason to send this patient to the trauma center by air.

The same argument was provided by people, including Dr. Thomas Scalea, the head of Shock Trauma – If you don’t let us have our toys, people will die![2]

The rate of helicopter transport of trauma patients was dramatically cut.

That was almost a decade ago and we are still waiting for the dead bodies.

I expect that the same failure of prophesy will occur, when incompetent paramedics are prevented from intubating.

I expect that the fatality rate will decrease, when incompetent paramedics are prevented from intubating.

I think you’re out of your mind.


Many religious fanatics do.

In the city, I can maybe defend you. But the studies need to be done out in the sticks as well. I believe that we should have to go outpatient surgery every year or 2 or have number set of how many we need in that time period successfully to keep our skills sharp..


Every year or two?


You don’t want to be taken seriously, do you?

This is something that requires a lot of skill and practice, so I get just a tiny bit, every other year. Trust me with your life.

After a Rsi and I have no one in the back but myself for over an hour.., I can place the patient on a vent and care for my patient. If RSI is taken away. I loose the capability to monitor my patient, and would be more focused on bagging my patient, or making sure the secondary away isn’t failing and I’m filling the stomic on the vent, because it can happen.


It is just a staffing issue.

That is different.

Competence isn’t needed when you are in the back by yourself.

Why are you opposed to competence?

Where is a single reasonable argument that intubation improves outcomes?

Where is a single reasonable argument that rural paramedics have an intubation success rate that is above 95%?

Even 95% means that some of your patients don’t end up with a properly placed endotracheal tube. What do you think happens to them?

Does your EMS agency have a better than 95% intubation success rate?

If you can’t manage at least 95%, why do you believe you can manage intubation?

Is each intubation on video, or do they just believe whatever you tell them?

If you want to be taken seriously, these are just some of the essential points to address.

This is not a new topic. You might also read the series below:

In Defense of Intubation Incompetence – Part I

In Defense of Intubation Incompetence – Part II

In Defense of Intubation Incompetence – Part III

How Accurate are We at Rapid Sequence Intubation for Pediatric Emergency Patients – Part I

How Accurate are We at Rapid Sequence Intubation for Pediatric Emergency Patients – Part II


[1] Misplaced endotracheal tubes by paramedics in an urban emergency medical services system.
Katz SH, Falk JL.
Ann Emerg Med. 2001 Jan;37(1):32-7.
PMID: 11145768 [PubMed – indexed for MEDLINE]

Free Full Text PDF

[2] Helicopters and Bad Science
Thu, 09 Oct 2008
Rogue Medic



  1. The topic of ET usage is a perennial one and here in the UK, Paramedics in some areas (or more importantly, their employers) are moving away of OOH ET.

    I do a lot of work in Thailand, and we have explored use of King Airway (has + and – points) LMA’s and will be on next visit, taking out iGELS to use in phec environment.

    In my day job in the UK (paeds intensive care retrievals) the med team (Doc and Nurse) will use ET if required, however this is done in a controlled environment (hospital) and pt is not moved until airway and safe secure and patent with correct blood gases and ETO2 at the right number!

    In the rough and ready ‘on the side of the road’ or at a messy cardiac arrest (well they are generally always messy) should a medic be spending time on ET or instead, use an iGEL/LMA to secure and get on with the compressions/shocks/drugs/reversal of H’s and/or T’s?

    • Outside of respiratory causes of cardiac arrest (about 10% of cardiac arrests), there is no benefit to the patient from ventilation, but there is harm.

      We intubate cardiac arrest patients and make bogus excuses for the harm.

      PS – great work on using less invasive, but equally effective, airways.


      • agreed fully – this is a trend that people need to pick up on and there is enough peer reviewed research that supports this position.

        I am a great advocate of KISS – Keep it simple stupid!

        OP/NP airways are generally going to be OK

        There is the question re CO2 in exhaled air measurement, but unless you have the drugs to start working on this, or you are using a vent and have time to stay and play, perhaps this is a moot question.

        The more important aspect of a cardiac arrest is definitive care and this cannot be adequately provided at the roadside, it is the job of the STEMI centre or A&E.

        Thanks for the comments – like to link to each others sites?

  2. This person cannot spell stomach, has no basic command of the English language, and doesn’t understand the difference between “lose” and “loose,” the difference between “there” and “their,” the difference between “then” and “than.” How am I supposed to trust this person to know the difference between the trachea and the esophagus?

    This person wants to administer medications that fundamentally alter the function of the human body. This person wants to administer medications that will paralyze people, eliminating their ability to breathe on their own. How am I supposed to trust this person to know when to use these medications, and more importantly, know when NOT to use these medications, if I cannot trust them to know when to use a comma or capital letters?

    Feel free to call me an educational elitist or a snob or whatever, but I don’t think it’s out of line to want my Paramedic to be one of the smarter people in the room.

    • Windy City Medic,

      You are not an elitist. You have standards.

      On the other hand, we do not have any good evidence that language skills correlate with technical skills, although there are claims that a second language can improve decision making. I apologize for the run-on sentence.

      Similarly, dyslexia may be over-represented among competent medics, nurses, doctors,….

      We don’t have good evidence on this.

      The National Registry of EMTs wants us to believe that they are competent at evaluating competence, but they are clearly not.

      Evaluation of competence is one of our biggest blind spots in medicine and EMS.


      • I can’t demonstrate a clear correlation between language skills and technical skills, but I do believe that basic spelling, grammar, usage, and punctuation are indicative of one’s attention to detail. Attention to detail, I believe, is a good trait in a paramedic.

        I tell my Paramedic students that they will have little credibility before a judge or jury when one of their run reports is subpoenaed if said report is rife with misspellings, unapproved abbreviations, inappropriate use of capital letters, and missing or superfluous punctuation. I don’t believe that every Paramedic should have a Ph.D. in English, but I do believe that a basic command of spoken and written English is a necessary skill in this line of work.

        Moreover, it’s difficult to take someone seriously on a topic of enormous technicality such as the benefits or drawbacks to out-of-hospital intubation when that person cannot properly spell “stomach.”