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

- Rogue Medic

Intubation Education

Also posted over at Paramedicine 101. Go check out the rest of what is there.

In the article I was writing about[1] (Experts Debate Paramedic Intubation) in my post Experts Debate Paramedic Intubation – JEMS.com, there is a bit of defense of the status quo in intubation and intubation training.

We get hung up on many of the same problems. We think that there is one right way to do things, rather than accept that we are adapting what we do to the different circumstances we are faced with.

We act as if the OR (Operating Room) is the only place that we can obtain good practice. There is no evidence to support this.

There is nothing to show that OR training is superior to morgue training and mannequin training, but we act as if the decreased availability of OR time is the only reason medics can’t intubate competently.

We act as if the only problem with the way we are teaching paramedic school is that the students are not learning. As if this is not a reflection on the teaching.

Teaching means providing information to students in a way that helps the students to understand. If the students do not understand, the teacher did not teach.

Perhaps you do not believe that we do a poor job at intubation education.


Nine hundred twenty-six patients had an attempted intubation. Methods of airway management were determined for 97.5% (825/846) of those transported to a hospital and 33.8% (27/80) of those who died in the field. For transported patients, 74.8% were successfully intubated, 20% had a failed intubation, 5.2% had a malpositioned tube on arrival to the ED, and 0.6% had another method of airway management used. Malpositioned tubes were significantly more common in pediatric patients (13.0%, compared with 4.0% for nonpediatric patients).


Overall intubation success was low, and consistent with previously published series. The frequency of malpositioned ETT was unacceptably high, and also consistent with prior studies. Our data support the need for ongoing monitoring of EMS providers’ practices of endotracheal intubation.[2]

Those numbers may be considered good in many areas – batting average, picking winning stocks, votes in an election. When it comes to airway management, we would be more appropriate if we described failure rates.

These failure rates are unacceptably high.

Overall intubation success was low, and consistent with previously published series.

In other words, the authors believe that this is the expected result of the way we train paramedics to intubate.

Can anyone show that this is not true?

The frequency of malpositioned ETT was unacceptably high, and also consistent with prior studies.

This is the expected result of the way we train paramedics to intubate.

Our data support the need for ongoing monitoring of EMS providers’ practices of endotracheal intubation.

5.2% had a malpositioned tube on arrival to the ED.

5.2% Unrecognized Esophageal Intubations!

Ongoing monitoring Watching is not enough.

We need to dramatically change the way we handle intubation education.


[1] Experts Debate Paramedic Intubation – Should paramedics continue to intubate?
Bryan E. Bledsoe, DO, FACEP, FAAEM | Darren Braude, MD, MPH, FACEP, EMT-P | David K. Tan, MD, FAAEM, EMT-T | Henry Wang, MD, MS | Marc Eckstein, MD, MPH, FACEP | Marvin Wayne, MD, FACEP, FAAEM | William E. Gandy, D, LP, NREMT-P
Thursday, July 1, 2010

[2] A prospective multicenter evaluation of prehospital airway management performance in a large metropolitan region.
Denver Metro Airway Study Group.
Colwell CB, Cusick JM, Hawkes AP, Luyten DR, McVaney KE, Pineda GV, Riccio JC, Severyn FA, Vellman WP, Heller J, Ship J, Gunter J, Battan K, Kozlowski M, Kanowitz A.
Prehosp Emerg Care. 2009 Jul-Sep;13(3):304-10.
PMID: 19499465 [PubMed – in process]


Experts Debate Paramedic Intubation – JEMS.com

In JEMS, there is an article by almost all of the top people in EMS airway management. There are several omitted, who contribute to the understanding of airway management, such as Richard Levitan, MD[1] and Kelly Grayson, CCEMT-P.[2] This is not that much of a criticism, since the people they included are definitely among the top airway management experts.

The article points out some of the problems we have in teaching paramedics/nurses/doctors to use critical judgment. We do a very poor job of educating people to make good decisions. Then we conclude that our failure means that the alternative is rigid protocols – even for doctors.

That is just another example of bad judgment.

What is wrong with the following paragraphs?

An EMT listens over the chest and abdomen with a stethoscope. He says he hears breath sounds over the chest but doesn’t say anything about the presence or absence of breath sounds over the abdomen. An ECG monitor with capnography is attached to the patient. The EMT operating the monitor is unsure how to set the device to measure waveform capnography.

Approximately a minute later, the EMT states, “There’s something wrong with the monitor.” The paramedic quickly checks the monitor and re-checks placement of the ET tube. He says, “Looks like the monitor’s not working. But the breath sounds are good, so let’s go ahead and get this guy to the hospital.” The patient is then moved to the ambulance and transported to St. Joseph Hospital with mechanical ventilation continued.[3]

When the monitor does not produce a waveform, or confirm what the EMT expected to see, the conclusion is that There’s something wrong with the monitor.

This is bad, because the EMT is already deciding where the problem is. He has made a statement that he will probably feel the need to defend later on. He doesn’t even appear to be considering operator error.

As the patient becomes less stable, the operator error rate increases.

The EMT operating the monitor is unsure how to set the device to measure waveform capnography. Still, he concludes, not that he doesn’t know what he is doing, but that the equipment is wrong.

I’m not the problem! The equipment I don’t understand is the problem!

Not to worry. We still have a paramedic, trained in the use of waveform capnography and drilled in intubation until he talks about it in his sleep. Sorry. Paramedic programs do not seem to drill paramedics on intubation that much, nor do employers, EMS systems, or even medical directors. Intubation is just not taken seriously. Tube placement confirmation and waveform capnography are taken even less seriously

Looks like the monitor’s not working. But the breath sounds are good, so let’s go ahead and get this guy to the hospital.

This is the motto of a serial killer.

It is only a matter of time until someone, who thinks like this, kills and kills again.

Who taught this guy to think like this?

Who hired him to think like this?

What EMS system licensed him to think like this?

What medical director authorized him use this kind of thinking to go out and kill patients?

His paramedic instructor from the local community college is subpoenaed and, during his deposition, reports that it was very difficult for his students to gain access to local hospitals to practice intubation, explaining that students simply learned the procedure on manikins.[3]

So what?

You can learn to intubate competently on mannequins.

You do not need real live dead people to learn to use critical judgment.

The lack of human intubation practice is a pathetic excuse for poor education.

Would this medic have made a better decision about the obvious lack of waveform during his intubation attempt if he had practiced on dozens of live patients?


The education he received does not appear to have included thorough coverage of tube placement confirmation. And that is not even the most important part of intubation.

We spend too much time worrying about intubation, when the real issue is airway management. This medic does not understand airway management – not even a little bit.

This is a systemic problem.

This lack of understanding of airway management begins in EMT/paramedic school, continues with employers, is certified by EMS systems, and is given the Dominus vobiscum of the medical directors.

Then the medic has his license to kill. The question is, Why is anyone surprised when the medic does kill?

We all seem to believe that this series of failures – school to employer to EMS system to medical director – works.

How many people are killed by this misunderstanding?

How many people are killed by this ignorance?

Am I being too harsh on these failures?


Am I going too easy on the medic?

Calling him a serial killer is not exactly killing him with kindness. This is similar to Murder on the Orient Express. There are plenty of fingerprints on the murder weapon. There is plenty of guilt to go around.

Marc Eckstein, MD, MPH, FACEP, EMT-P: The take-home point here is that we need prehospital research that involves prospective randomized controlled trials (RCTs) with meaningful outcome variables, which are decreased morbidity and mortality.[3]

Essential to the study of intubation and airway management is that the researchers control for the quality of the paramedics.

We need to stop looking at intubation as something that is not affected by the quality of the people attempting intubation.

Dr. Eckstein: These alternative airway devices, particularly the King airway, can be placed quickly, and they provide good oxygenation and ventilation. However, they don’t protect against aspiration, which of course is a major concern with emergency airway management, especially in the field.[3]

I disagree about the major concern of aspiration.

Where is the research to support this?

In the studies comparing intubation with basic BVM use, where is the flood of emesis worsening outcomes?

I think that intubation protecting against aspiration is mostly just another EMS myth.

William E. Gandy, JD, NREMT-P: I wholeheartedly agree with Dr. Wang. Yes, the emphasis should be on ventilation—not intubation. Paramedics should be thoroughly schooled in airway evaluation and should have a variety of airway adjuncts, such as bougies, video laryngoscopy and supraglottic airways, available and be willing to use them.[3]

If you have heard Gene (William E. Gandy) talk about airway management, you have heard this over and over.

You may get tired of hearing that airway management is about ventilation, not intubation or oxygenation. If that is the case, then you really do not understand airway management.

If you do not understand airway management, then you do not understand intubation.


[1] Laryngeal view during laryngoscopy: a randomized trial comparing cricoid pressure, backward-upward-rightward pressure, and bimanual laryngoscopy.
Levitan RM, Kinkle WC, Levin WJ, Everett WW.
Ann Emerg Med. 2006 Jun;47(6):548-55. Epub 2006 Mar 14.
PMID: 16713784 [PubMed – indexed for MEDLINE]

Free Full Text Free PDF

[2] The Airway Continuum
The Ambulance Driver’s Perspective
by Kelly Grayson

[3] Experts Debate Paramedic Intubation – Should paramedics continue to intubate?
Bryan E. Bledsoe, DO, FACEP, FAAEM | Darren Braude, MD, MPH, FACEP, EMT-P | David K. Tan, MD, FAAEM, EMT-T | Henry Wang, MD, MS | Marc Eckstein, MD, MPH, FACEP | Marvin Wayne, MD, FACEP, FAAEM | William E. Gandy, D, LP, NREMT-P
Thursday, July 1, 2010


Intubation as a Right – No Practice required

Also posted over at Paramedicine 101. Go check out the rest of what is there.

I was responding to a comment at 9-ECHO-1, by 9-ECHO-1, when I realized I was beginning to combine my responses to How things get done… and Do we make a difference?

As if I don’t already regularly get this little message from Blogger.

Your HTML cannot be accepted: Must be at most 4,096 characters

Your hints are wasted on me, Blogger!

9-ECHO-1 was writing about running a code and keeping it organized and low stress. Something about sitting back with his feet on an ottoman, a drink in his hand, receiving a massage, and . . . Well, he did say that he was sitting back with his feet up on an ottoman. And there is nothing wrong with that. An ottoman could easily be added to crash carts. 🙂

9-ECHO-1’s description of the role of the person in charge at a code is important. We may not want to put our feet up in front of family, but I don’t believe 9-ECHO-1 would do that at a code where family is present. What is important is for the person in charge to communicate clearly to everyone that, This is not a high stress environment.

Stress is the enemy of organization. We have a lot to organize during codes. We have much more to organize, than we have good research to support including in a code, but that will change.

Either there will be some research that supports the Better Resuscitation Through Better Chemistry approach, or AHA/ILCOR will admit that pouring a bunch of cardiotoxic chemicals into a patient, then shaking – not stirring – the patient, is more appropriate for bartenders than for paramedics, nurses, PAs, NPs, doctors . . . .

Although many of us in EMS might appreciate the bump in pay to what a bartender makes.

I have been to some codes that have led me to believe that there is a role for benzodiazepines in the management of cardiac arrest. Not for the patient, but for the EMS personnel exhibiting signs of Tourette syndrome, who show up to treat the cardiac arrest patient. If not benzodiazepines, then this may be an indication for medical marijuana. There might be some problem with the rate and depth of compressions, but that might be less of a problem than the current model of Dr. Fine, Dr. Howard, and Dr. Fine run a code.

Isn’t this supposed to be about intubation?

OK. Back on track, or as close as I an going to get.

9-ECHO-1 wrote –

Place the King airway. In our system EMT-Bs on the ambulance can do this. Attach the ETCO2 and verify the waveform. Me personally, I will admit, I prefer the ET tube. I know, I know, there is all sorts of evidence out there about paramedics and tubes. And they all point to two things- practice and experience. More on that later.

In the comments, I responded –

I agree with you about the intubation. I think that the biggest part of the problem is that the systems studied do not provide excellent oversight of the quality of intubation and BLS. Otherwise, are we supposed to believe that these problems suddenly appeared during the study? More likely that they were there, just unrecognized.

The word unrecognized does not belong in a sentence describing excellent oversight.

9-ECHO-1’s response included –

I have read all of the studies about intubation and its ‘failings’. What I have noticed is that we NEVER PRACTICE. I used to practice all of the time- get me some spare time and a manikin and I would go at it, even practicing with someone doing chest compressions. But we never do that any more. No damn wonder we can’t hit the right hole, and then don’t recognize when it comes out or we missed completely.

I completely agree about practice. I used to spend so much time with the mannequin, that if my classmates weren’t starting rumors about me, they were missing a good opportunity.

I believe that simulations are a great way to avoid doing real harm to real patients. A lot of practice helps to keep the stress level down and the tunnel vision away.

My first live intubation was an asystolic little old lady. We were running lights and sirens to the hospital, because we didn’t know any better. I was riding with a supervisor for orientation vs. see if the new guy can avoid screwing up. We made a rendez-vous with the ambulance, so that they could give the new guy a chance to demonstrate skills on a real live patient.

We still put too much emphasis on the wrong skills.

While the mannequin is not as realistic as we would like, the practice with the laryngoscope and the tube is invaluable, when it comes to manipulating the airway of a real patient. Very handy experience when bouncing down the road about to perform my first tube.

I think that some of my But we did that when we covered airway classmates may be over-represented in the intubation studies with poor success rates/high wrong hole rates.

If medical directors would take more of an interest in the airway management practices of those they authorize to use lethal airways, I might not feel the need to describe endotracheal tubes as lethal airways.

Yearly (even quarterly) observation of mannequin management is not at all oversight of airway management. This is just documentation of an excuse, so that when a medic does mangle airway management, the medical director has an alibi.

It used to be that some schools/employers required medic students/new medics to manage an OR patient’s airway with a BVM before ever being allowed to touch an endotracheal tube. I do not believe in good old days. That is just selective memory. However, we have abandoned some useful practices.

Now it seems that being authorized to intubate means never having to touch a BVM again – even in some all medic systems.

That isn’t airway management.

Also, less than 8 – intubate, is not a rule, just a handy way of teaching one small idea in the much larger concept of airway management. Critical judgment is much more important than cute little rhymes.

If we think that we should be permitted to intubate, we need to put in the effort to become competent at airway management. Then we need to put in the effort to maintain competence at airway management. And we need to put in the effort to demonstrate excellence at airway management. Intubation is a very small part of airway management.

This is not about any right of the paramedic to intubate. This is about not abusing our patients.

I didn’t even get to comments on Do we make a difference? That will be another post.

The Airway Continuum is essential reading for anyone interested in intubation and airway management.


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.


Paramedic = Intubation III

As paramedics, we have become so identified with intubation that we have trouble thinking of EMS without intubation.

Maybe we will retain intubation, but only as an advanced paramedic skill. In some systems, no medics will intubate. In some systems, few medics will intubate. In some systems, a lot of medics will intubate. In some systems, all medics will intubate.

The differences among these various approaches will be based on how much time/effort/money/other resources we are willing to put into training/oversight.

This may be something that many medics will oppose, feeling that all medics have the right to should be permitted to intubate.

This is the wrong approach. We need to address what is best for the patient, not what we feel is best for the status of the medic. We are not the priority. Our skills are not the priority. The patient is the priority.

We need to address how the patient may benefit from the skills we allow paramedics to use. We need to decide if we are willing to do what is necessary to acquire and maintain those skills. If we are not willing, then we have already made the choice about whether paramedics should intubate.

Paramedic Intubation.

Intubation Airway Management.


Prehospital Intubations and Mortality – comment from RevMedic

Also posted over at Paramedicine 101. Go check out the rest of what is there.

RevMedic is not a name that signifies driving very fast – revving the engine – but that is what pops into my head every time I see his name. I know. I am by-passing St. Peter. I am not collecting 72 virgins. I am going straight to the great big tanning bed. This is not news.

RevMedic does all sorts of photography in the Newberg, Oregon area. If you need a photographer with some common sense, he seems like the guy to call.

Anyway RevMedic knows his stuff. Here is his comment on the post Prehospital Intubations and Mortality – comment from Herbie.

“I would much rather see medics using a BVM during their OR time, than intubating. Good BVM use is far more important than intubation skill.”

Absolutely. I can’t tell you how many times I’ve seen ineffectual ventilations with a BVM. There sits the EMT (at any level), blissfully unaware of the air blasting out from underneath the mask and not paying attention to the lack of a seal.

How is it that we graduate EMTs and medics, who are not skilled at airway management?

How is it that we graduate EMTs and medics, who do not understand airway management?

It isn’t as if the courses suggest that there is a skill that comes before airway.

Excellent BVM use is all about assessment.

BVM excellence is the cornerstone of airway management.

Without excellence in the use of the BVM, the rest of airway management does not matter.

I prefer to do some of the bagging with patients who need ventilation. It is a skill that needs to be used, to be maintained. This also sets a good example for everyone else. This demonstrates to everyone else that, at least as far as I am concerned, skill with a BVM is a priority.

We also will find that some of the patients do not need to be intubated. Intubation should not be for the benefit of the medics. Intubation should be for the benefit of the patients.

There was another event where I was bagging the patient in preparation for intubation. I was having trouble getting an adequate seal, and asked for another set of hands. We had 4 PARAMEDICS in the rig, and the other three were solely concerned with getting the intubation equipment set up, preparing the drugs, etc. I had to repeat myself several times and finally loudly call one by name and DEMAND his/her assistance, before we achieved adequate ventilations.

One of the best uses for a separate pulse oximeter is to throw the machine at someone, when you need there attention. It can be very effective. It also demonstrates how little importance should be attached to the machine. It is just a tool, a slow tool, that should not be warning you that something happened, but should confirm what you already know from your continuous assessments.

One of the problems with these studies of systems that have horrible intubation success rates, is that their BVM use is probably just as bad. How much of the bad outcome is due to BVM incompetence, rather than the inability to put a tube in the right hole?

If we make the patient hypoxic enough in our focus on the intubation, does it matter if we are successful with the intubation?

No, it does not.

If we allow the patient to vomit and aspirate in our focus on the intubation, does it matter if we are successful with the intubation?

No, it does not.

RevMedic finishes up with:

BVM is the lost art of airway control.

There is only one appropriate response to that:



Paramedic = Intubation II

To continue on the topic of paramedics and lack of intubation success begun in Paramedic = Intubation I.

Why is it so hard to improve?

Explanations exist; they have existed for all time; there is always a well-known solution to every human problem — neat, plausible, and wrong. H. L. Mencken.

Unfortunately, Mr. Mencken appears to have anticipated the problems with EMS airway management.

We seem to produce medics faster than the NR can produce Not Responsible EMT-P patches.

Do we need a lot of medics?


In a lot of places, we have so many medics, that the medics average only about one intubation per year, per medic. In other places – places with much fewer medics – the intubation success seems to be dramatically better. In these places, where medics are less common and used more carefully, medics are much less likely to be compared with blind squirrels. At least as far as paramedic skills are concerned.

So we just need to get rid of a lot of medics?

We do, but that is only a part of the solution to airway management.

Paramedic Intubation.

Intubation Airway Management.


Paramedic = Intubation I

I was involved in a recent discussion about RSI and intubation and airway management, not on any blogs, but in the real world. I do see some progress in addressing priorities, but there still seems to be this sacred cow of intubation as an essential part of being a paramedic.

Intubation separates the men from the rest.

The rest?

The boys, the girls, the nurses, the basics, the fire fighters, the police, the garbage men sanitation engineers, the postal workers, the rest. The non-medics. The rest. The people who do not intubate. Them. This is the great claim to fame of paramedics. Yet, if you look at all of the people listed in the rest, almost all of them are paid significantly more than paramedics. This is like being a Vice President – we are given this fancy title, but we have to accept a big cut in pay. As paramedics, we don’t seem to have a problem with this, as long as we can still intubate. Even if it is only about once a year, in a good year.

Basic EMTs resuscitate patients more often than that.

Intubation separates the men from the rest.

Yes, the role of gender, or manliness, is often worked into conversations about intubation. I do not know why, since I have never used my genitalia in any airway maneuver, at least not on the job.

Even when considering the possible ways to improve intubation, paramedic = intubation seems to be taken for granted. Look at all of the research that shows a lack of intubation success by paramedics. The list of studies is longer than this post, so I won’t list them in this post.

Something needs to be done.


Not because it is a QA/QI/CYA check-off box.

Not because it makes us look bad.

Not because it might be taken away from us.

Because our patients deserve better.

Paramedic Intubation.

Intubation Airway Management.