And, what made you change your mind, if at all (might be misreading—I am a bit tired), on your stance with the level of “aggressiveness” you think is all too common in the HEMS world.
My thinking has definitely evolved over the years. As a macho young flight paramedic who worked for an agency that prided itself on being extremely clinically aggressive, I was brought up to think that if there was ever even a slight question, you were always better off intubating than not. This made sense at first but as I developed an interest in EMS research I realized I couldn't square our approach with what I read in the literature. Later I spent some time as the QI guy there, and saw all the reports on our scene call transports. It was clear that we were both flying and intubating a lot of patients who didn't benefit from either and it was then that I started to really question the "fly 'em all, tube 'em all, let the ED sort 'em out" approach that wasn't just the culture where I worked, but was a prevailing thought process in HEMS at the time. The evolution in my thinking continued throughout my tenure at another HEMS program which took a more cultivated and measured approach to patient management, through my anesthesia training and specifically my trauma rotations, and my first few years of practice as a CRNA where I did a lot of airway teaching in the OR. Throughout this whole time I stayed up on all the research related to EMS airway management, which over the years has been quite consistent in what it suggested and largely reflected what I saw in my own educational and clinical experiences. The net result of all this is that I have developed some ideas and opinions on what EMS airway management should look like, and it is quite different than how I was originally taught.
I have definitely seen some positive changes. I think we've gotten better in general at airway management. We certainly have better tools, and I think the uber aggressiveness that I described from back in the day is less common.
Also, it is almost infinitely easier to find current information and learn from smart, experienced people now than it was early in my HEMS career, when youtube and blogs didn't exist and textbooks and journals were pretty much the only sources of info. FOAMed and social media has generally been an amazing educational development for EMS but I see a real problem in some cases with the cult of personality that has developed with a few of the characters. These guys are really smart and generally put out great ideas and information but because of that and their charisma, almost nothing they say is ever even questioned. For instance, why were so many so quick to accept the concept of DSI - where you sedate a full-stomach patient with an unprotected airway - while simultaneously arguing that an LMA is inappropriate as anything other than a rescue device? Why did we abandon sux so quickly even though it's been used with such success for so long and clearly has some advantages over the alternatives? Why all the attention on ketamine as an analgesic all of a sudden when fentanyl works so well and has hemodynamic advantages? I'm not saying that DSI isn't a useful tool or that you can't make good arguments for using roc in RSI or that ketamine isn't useful as an analgesic, I'm just saying that the rapidity with which these new ideas were accepted appears to have a lot more to do with those who were promoting them than the ideas themselves, especially when you consider that in at least some cases these ideas contradicted other thing that we still hold on to, and that those who said "hold on, let's look at this idea a little more critically" were often roundly chastised for not mindlessly and obediently toeing the progressive line.
I'm clearly getting off on a tangent here. Sorry. But it kind of loops back around to my original comments on this thread: Why is it controversial at all to suggest that
sometimes, the best way to manage a difficult airway might be to let the patient wake up? It is because we really just can't conceive of any scenario where that might be appropriate? Are we just too tunnel-visioned on always placing an advanced airway once we decide that's what we should do? If the right FOAMed personality were to make the same suggestion, would there be as much resistance to the idea?
@Carlos Danger (lol, I almost instinctively typed @Remi), what if any advice would you offer yourself in your past HEMS career regarding airway management?
What advice would, or do you offer the local flight crews in your area now? I’m asking because you’ve been in these shoes, and part of the same culture.
People like the early 2000's me often don't like to take advice from people like the me of 2020, unless the advice supports their existing ideas of how they like to do things, or unless it's some edgy new idea. "Slow down, be more measured, be more conservative, be flexible in your thinking, remember that in medicine nothing is black-and-white" isn't a very cool or sexy idea, but it pretty much summarizes my advice for all sorts of things, including airway management.
There's a saying in anesthesia that I think is relevant: "You can always give more, but once you give it, you can never take it back".
