Being a skilled intubator is NOT the skill of putting the tube in the trachea, it's the ability to know when a tube is NOT the right choice and being able to quickly move to an SGA or a surgical airway. In my world, with a highly unfavorable LEMON score, chances are the patient might not even get a blade in his mouth, and certainly wouldn't be a candidate for RSI.
This is probably the most reasonable and mature thing I've ever seen written on an EMS forum about airway management. If more paramedics thought this way, we would not have the problems we have with airway management.
Some people need definitive airways and the ETT is the gold standard for a definitive airway. I am always going to give at least one attempt for an ETT before going for a king, and I'm damn sure not going to cut someone unless I have absolutely no other choice.
This is a terrible way to approach airway management. It's a cookie-cutter mentality that doesn't use any critical thinking and is the exact opposite of what should be taught. Most paramedics seem to be taught to think this way though, and it is probably a direct result of the lack of experience that I address below.
On a personal note, I feel the reason our overall percentages are so low can be attributed to paramedic mills nationwide that each crank out hundreds of paramedics annually with no standardized method to ensure that students even had a solid grasp on this relatively simple skill.
Airway management is only simple until it's not. Sure, it
usually goes well and most patients are not a difficult intubation. But I'm not sure how anyone can read the literature on paramedic intubation and then say with a straight face that it is a "simple skill". If it were so simple, the research would look a whole lot different, and we wouldn't be having this discussion.
The reason overall percentages are so low is obvious, really: paramedics receive very minimal initial training in airway management, and then go on to do it only occasionally. That's not how you get good at anything. I'd argue that it takes most people 100 actual, live intubations to reach a novice level of experience, and at least three times that, maybe even four or five times that, using different tools and techniques, to become an expert. Very few paramedics have that type of background, so the only ones who are really, truly good at it are the very few who do somehow gain that much experience, plus the relatively small percentage who for some reason just have the aptitude to master the skill with much less experience than it takes most.
Lastly, I find the focus on first attempt success rate to be inappropriate. First, I think it puts undue pressure on that first tube, but most importantly there are just times when you get in there and it's not what you expected.
The focus on first-attempt success comes from the fact that each successive attempt is less and less likely to be successful.
Why do you ever need to "change" things on subsequent attempts? Why not just do it right the first time?
The point behind the "first attempt should be your best attempt" approach is that whatever changes you are making should have been done before the first attempt was made. Whatever tool you had to use on your second or third attempt to finally get it, you should have just used on your first attempt.
Take the time to do your positioning CORRECTLY before the first attempt. Use the right blade and the right tube on your first attempt. Use the bougie on your first attempt. Use VL if you have it - yes, on the first attempt. A prehospital RSI is not the time to screw around.
