The Great Airway Debate...

[Carlos Danger]

@Remi, is there generally a significant difference pre/in hospital given that both providers are skilled? I've had a pt I didn't intubate because of the immediate risks just to have a doc do it shortly after and have to work an arrest. So does the who (assuming they're experienced) matter as much as the what (the act if intubating)?

I don't know. That's the whole question. It certainly appears to have a bearing on outcomes, if you believe most of the studies.

For the record, I am not against prehospital RSI. I don't think it should be a routine paramedic skill primarily because 1) I don't think it is indicated as often as we think it is, and also 2) I think it is pretty clear that a lot of paramedics just don't have the clinical skill and judgment for such a critical intervention. I do think it has a place, though. We need some good prospective research to help show us when, how, and by whom it should be done.

We frequently talk about "the research" but what do we really mean when we say that? Well, over the past couple of decades there have been many retrospective analyses done on the outcomes of patients who were intubated in the field, vs. similar patients who were not intubated in the field. Probably 15 or so of these are what I would personally describe as "good" studies that really probably should be regarded as telling us something. Some of them were very large. What have these studies told us? The findings are not homogenous but with a pretty high degree of consistency, these studies show us two things: One, that using RSI, prehospital intubation success rates are pretty good (they were dismal before RSI became common). Placing the tube does not seem to be the problem. And two, patients who are intubated in the field have similar or worse outcomes than when like patients were not intubated in the field. Keep in mind that "not intubated" does not mean they didn't receive airway management. Also keep in mind that these are all retrospective studies that can show us relationships between interventions and outcomes, but do not indicate prehospital intubation actually causes worse outcomes. There has only been one large RCT done on prehospital intubation and that was in Australia, where the paramedics are trained differently enough from us here in the US that I don't think you could extrapolate findings from there to here anyway. This study did find some moderate improvements in functional neurological scores in the field-intubated group as opposed to the non-field intubated group, but these improvements were 6 months later, which really makes it impossible to attribute to when they were intubated. For all practical purposes, there were no differences in arrival condition or the overall clinical course between the groups.

Clearly, many agencies and individuals have chosen to simply ignore these studies when formulating their position on whether or not prehospital intubation should be routine. I can understand why, for the most part, though I don't really agree.

So, all that said, back to your question: why does it matter if a patient is intubated in the field by a paramedic, or a short while later by an ED doc? I think it is likely that the experience of the intubator matters more than we realize, in ways that we don't understand. Most of these studies were done on patients who were transported to tertiary centers, which means the receiving teams have a lot of experience with emergency airway management - a lot more than most individual paramedics get. So it could be there are subtle and even as-yet unidentified but important differences between the techniques used by people who intubate all the time, and those who don't, even if those who don't do everything correctly. If similar analyses were done on patients transported to community ED's, the differences in outcomes may not be so great. Another possibility is that there is something in the pathology of some TBI patients that makes them more susceptible to secondary injury very early after the initial insult than they are a little later.

What it all comes down to is that we really need to do the same kind of research in EMS that is done in other areas of medicine.

 

[E tank]

So does the who (assuming they're experienced) matter as much as the what (the act if intubating)?

It does within the confines of the hospital. It would stand to reason it would outside. Anesthesia folk are better than CC folk are better than ED folk (maybe) and nobody is better than ENT for a surgical airway. I don't need a study to establish that I'm more experienced and skilled at airways than an ED physician. But when I can't do it and an ENT breezes in, I'm out pretty fast.

ps....why is this script all frogged up?

 

[StCEMT]

@Remi follow up then. I've seen you mention better success on first pass with paralytics. Do you think that intubation ought to be tightened up a bit more with who does it, but then for those that do intubate prehospitally use RSI? Instead of the wide range of who and how that we currently have....Maybe with something like discussed in this short podcast as an alternative. http://pjmed.libsyn.com/98-rapid-sequence-airway

Do any of the studies do a break down of overall status of injury/medical problem and vitals pre/post intubation? I don't doubt that actual managment/manipulation is definitely a part of it, but how much could be related to poor intubation prep? Ie. Rushing and not making sure the pt is properly preoxygenated and sitting at a safe BP before even touching the laryngoscope. Not that rushing is an excuse, but I have seen that in and out of the hospital first hand.

@E tank is that at first pass success, good outcome, or both? Guess I am just wondering if there comes a point where provider A can do it faster/easier than provider B, but the difference long term is none because both can competently manage the airway and beyond that is just a point of diminishing returns. This is probably more specific to your environment, I realize there is definitely a difference in ability between myself and an experienced ED doc.

 

[E tank]

is that at first pass success, good outcome, or both?

Not hard to get out into the tall weeds, is it? Outcome studies are great, but to have any relevance at all you need 100,000+ study subjects, which means you need big meta analysis efforts that don't exist (that I'm aware of).

The question really needs to be, in my opinion, does the tube go in the right place the first time? As simple as that sounds, it isn't so simple. Observational studies are raked with all kinds of biases as @Remi points out above (and see the latest go round on ETCO2 from this weekend) They're useless if not down right dangerous taken on their own and even meta analyses can be down right false if even one significant study has catastrophic flaws (I'm thinking of the European experience with perioperative beta blockade...google it if you're curious).

IMHO the reality is that these questions have to be answered at the local/state level where folks know their own people. They'll still be wrong some of the time.

 

[VFlutter]

One caveat is that we should be focusing more specifically on "Definitive Airway Sans Hypoxia and Hypotension on the 1st Attempt" (DASHH-1A). I sometimes see people focus too much on first past success without mentioning the latter. Sometimes people miss the forrest for the trees and push an attempt for the sake of first past success at the cost of compensation. Although increased attempts have higher complication rates and worse outcomes but sometimes discretion is the better part of valor.

 

[E tank]

One caveat is that we should be focusing more specifically on "Definitive Airway Sans Hypoxia and Hypotension on the 1st Attempt" (DASHH-1A).

That is an issue in anesthesia training programs with experienced preceptors literally at the elbows of the operators. It happens every July with CA-1's and SRNA's. If it happens there, good luck dealing with that in the field.

 

[VentMonkey]

“Attention To Detail”

I was taking an ACLS refresher last week and went over the Kiwi-grip (figure 9) technique with a handful of paramedics. A couple of things stuck out in my mind:

1. Most of them still seemed unfamiliar with the Bougie, let alone the one provider/ one-handed method of insertion. This was a controlled environment mannequin with a grade 1 view you could easily go spelunking down. I think that an intubation with a Bougie regardless of the anticipated difficulty goes without saying.

2. (perhaps the most concerning) They seemed to still be caught up in the skill alone. No one took the time to set up the tube tamer underneath the head, have their equipment available, and anywhere that was at all times easily accessible to them, etc.

Until we approach advanced airway management with what I call the “IV approach” where we scout people’s airways religiously like some do with people’s veins; or learn what ramping entails, where and how the tragus should line up with the sternum, shoulder elevation placement, terms like RSA, and when that’s most applicable, set suction up, or learn the SALAD technique—what on earth are we doing with an endotracheal tube?

My short answer is: collectively, nothing good.

There’s no foundation for advanced airway management among the majority of our field paramedics. I think many have been misled in thinking that the gold standard= an ETI rather than it equaling to prevent hypoxia until an ETI can be safely, and properly performed.

Sadly many of my peers don’t seem to have any self-motivation for learning these things on their own, yet wonder why things go awry. I am sure blaming the equipment, or their partner, or whatever foolish arrogance they portray next time one fails at something that can often be prevented with self-motivated education, and reflection will further illustrate our overall competence as field providers...

...astonishing.

 

[EpiEMS]

Until we approach advanced airway management with what I call the “IV approach” where we scout people’s airways religiously like some do with people’s veins

I have to ask...does anybody look at somebody as "less of a paramedic" because they used an IO rather than getting an IV in a critical patient? I think people see others as "lesser" when they use an SGA over ETI...
This goes back to culture - a macho culture, a culture of anecdotes...etc., no?

 

[DesertMedic66]

There are many issues with the way that intubation is taught. My college has one of the better medic programs in SoCal but our training on intubation was taught by another ground paramedic who has no extra training. We were shown what a bougie looks like and then never actually used it. There was never any talk about ramping or making sure all the axis align properly. Intubation was always considered the gold standard.

Then when these new providers go out they receive no new training or information regarding intubation.

 

[VentMonkey]

I have to ask...does anybody look at somebody as "less of a paramedic" because they used an IO rather than getting an IV in a critical patient?

On a critical patient where vascular access is absolutely pertinent? I hardly doubt it matters.

On a more personal note, the location of the IO, or even IV access can be more of an issue in-flight depending on the airframes cabin setup. Vascular access can always be re-established in-flight if absolutely necessary, though.

I think people see others as "lesser" when they use an SGA over ETI...

Yes, this is very much prevalent with many providers, namely the older “stuck in their ways” types; we all have these providers at our services.

For me, the blind airways become more about situational dependency, and whether or not the provider used sound judgment, or just blind sticks every airway without much critical thinking. Our local FD’s are slightly notorious for this.

This goes back to culture - a macho culture, a culture of anecdotes...etc., no?

It’s merely one of many examples of the egocentric culture that is EMS, yes.

There are many issues with the way that intubation is taught. My college has one of the better medic programs in SoCal but our training on intubation was taught by another ground paramedic who has no extra training. We were shown what a bougie looks like and then never actually used it. There was never any talk about ramping or making sure all the axis align properly. Intubation was always considered the gold standard.

Then when these new providers go out they receive no new training or information regarding intubation.

This is exactly the info I was looking for here. Our local JC’s paramedic program seems to put the same amount of “effort” into showing their students fundamentals surrounding advanced airway management. If you (the student) don’t even know what the list of fundamentals includes, you shouldn’t be allowed to proceed with invasive airway management.

I liken it to the foundation that a house is built upon. Without such a solid foundation, how sturdy is the house? Pretty simple logic, IMO.

All in all, I still believe that the average ground paramedic has zero business performing endotracheal intubations, and the commonly displayed lackadaisical efforts and attempts often confirms such suspicions.

 

[Tigger]

I have to ask...does anybody look at somebody as "less of a paramedic" because they used an IO rather than getting an IV in a critical patient? I think people see others as "lesser" when they use an SGA over ETI...
This goes back to culture - a macho culture, a culture of anecdotes...etc., no?

I would like to say that this doesn't happen, but of course it does. I'd like to say that it doesn't matter to me, but subconsciously I think it is often the reason that people try one more attempt on just about anything.

 

[VFlutter]

I would like to say that this doesn't happen, but of course it does. I'd like to say that it doesn't matter to me, but subconsciously I think it is often the reason that people try one more attempt on just about anything.

It drives me crazy me when we arrive on scene and get in the ambulance with a paramedic whom has attempted drug assisted intubation multiple times and insists on "one more look" before we do anything. You called us for a reason, we have RSI and VL, let us use our tools. It does not make you less of a provider to defer to the more experience or better equipped person.

 

[Tigger]

It drives me crazy me when we arrive on scene and get in the ambulance with a paramedic whom has attempted drug assisted intubation multiple times and insists on "one more look" before we do anything. You called us for a reason, we have RSI and VL, let us use our tools. It does not make you less of a provider to defer to the more experience or better equipped person.

It has not gotten quite to that point here. We've either got people with previous CC experience or younger people (like myself) who went through a solid program that was taught by the closest individuals we have to subject matter experts in the area. I am surprised to learn that many medic programs are taught by single instructors. My instructor only taught the topics she couldn't get someone who was truly awesome at teaching them to come in for. The guy that taught our airway portion teaches difficult airway classes on the side and actually knows how to educate as well. Maybe I'm just lucky...

But I will admit I will still look for an IV rather than jump to an IO because that is the silly expectation here. And some airway nightmares are affected by this attitude for sure, though we have not had that happen with RSI in the 15 years we've been doing it and we have internal documentation to back that up.

I was pretty angry as a new medic to be told that I "must" intubate a cardiac arrest with a nightmare of an airway. An iGel would have been just fine for the bariatric patient down in a cluttered garage but no, we MUST tube all the patients. Of course it went "sideways" and while the patient was eventually intubated I am embarrassed to have been present for the procedure. The goal was purely to secure a tube, everything else be damned. Fortunately it was not a particularly viable patient but that attitude is anger inducing.

 

[EpiEMS]

@Tigger @Chase
Certainly seems like you've seen what I'm describing - hard to put a word on it, I suppose, but I'd think machismo works.

How do we fix this issue? Better protocols?

 

[Tigger]

@Tigger @Chase
Certainly seems like you've seen what I'm describing - hard to put a word on it, I suppose, but I'd think machismo works.

How do we fix this issue? Better protocols?

Doubtful. Part of rolling out new protocols is learning who the old dogs are, and they just aren't going to change. Honestly there is a huge difference right around the 10 year mark here. Folks who have been doing it longer seem to be totally resistant to change and we'll just be better off when they're gone.

 

[StCEMT]

It drives me crazy me when we arrive on scene and get in the ambulance with a paramedic whom has attempted drug assisted intubation multiple times and insists on "one more look" before we do anything. You called us for a reason, we have RSI and VL, let us use our tools. It does not make you less of a provider to defer to the more experience or better equipped person.

Had to do that a few times recently, the past few weeks I think have been at least two tubes and one cric by an MD shortly after arrival. Everything worked out, so no need for me to get bent out of shape about it.

 

[TXmed]

One caveat is that we should be focusing more specifically on "Definitive Airway Sans Hypoxia and Hypotension on the 1st Attempt" (DASHH-1A). I sometimes see people focus too much on first past success without mentioning the latter. Sometimes people miss the forrest for the trees and push an attempt for the sake of first past success at the cost of compensation. Although increased attempts have higher complication rates and worse outcomes but sometimes discretion is the better part of valor.

I just wanted to echo this statement.

 

[CANMAN]

It drives me crazy me when we arrive on scene and get in the ambulance with a paramedic whom has attempted drug assisted intubation multiple times and insists on "one more look" before we do anything. You called us for a reason, we have RSI and VL, let us use our tools. It does not make you less of a provider to defer to the more experience or better equipped person.

That's unfortunate that situation even takes place once you arrive. Under our state protocols when we arrive on scene we are automatically the highest level provider's and all interventions will be performed by us. We generally don't encounter that problem too often. I get the customer service aspect, but in those situations have your crew attempted a courteous but stern "no we are here and going to take over now, you guys have done a great job thank you"?

 

[Tigger]

That's unfortunate that situation even takes place once you arrive. Under our state protocols when we arrive on scene we are automatically the highest level provider's and all interventions will be performed by us. We generally don't encounter that problem too often. I get the customer service aspect, but in those situations have your crew attempted a courteous but stern "no we are here and going to take over now, you guys have done a great job thank you"?

I’m glad that doesn’t happen here. N=a few but the “prestigious flight service” is far more likely to get themselves into a problem than many of the ground crews. Most of the mountain services have been or are soon to provide their own CCT and have providers with comparable experience and education to that of the flight crews. These folks are unfortunately not airway pros that many think they are, especially when we get two ICU nurses who “don’t really do airway” between the two. This is in stark contrast to the true CC practitioners that I encourtered in New England. It’s unfortunate that that isn’t the standard, but industry competition plays a role.

When you’re over an hour by ground, at a certain point the helicopter is for expedited transport and sometimes it’s ok to admit that.

 

[E tank]

That's unfortunate that situation even takes place once you arrive. Under our state protocols when we arrive on scene we are automatically the highest level provider's and all interventions will be performed by us. We generally don't encounter that problem too often. I get the customer service aspect, but in those situations have your crew attempted a courteous but stern "no we are here and going to take over now, you guys have done a great job thank you"?

Scene control and command seems to be a hands off topic when it comes to medical control. It speaks to very weak leadership with regard to the medical direction of the local system. From the issues raised here to the perennial issue of fire not relinquishing medical control to the private or 3rd service ambulance crew, the physician/nurses in charge need to grow some cajones. A pi**ing match over a sick patient is a disgrace and it falls squarely in the lap of the medical director. It is a very frustrating situation that has existed for a very long time in a lot of jurisdictions.