The Great Airway Debate...

[CANMAN]

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.

Totally agree! Like I said we didn't encounter too many issues, but if we did I felt 110% supported with inserting ourselves and taking over if it needed to be handled in that fashion and we would make up and worry about the PR fall out later once the patient was transported.

 

[CANMAN]

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.

Sure I can understand that. It all depends where you're at and what services are available. While some of the ground crews we would interact with had RSI or DAI it was typically one provider and the difference in airway management experience between our provider's and those of the ground services was well known.

 

[TXmed]

I can tell you in texas, most of the ground providers THINK theyre just as good at airway management as air medical providers. And they think that even as we rescue airway after airway from them.

 

[RocketMedic]

I reckon there's a lot of 'expectations' in airway management that lead to negative outcomes because some people 'expect' that the tube must be an ET tube; or that it will fail and that we shouldn't attempt ET intubation, or that the SGA will fail, or that someone will take offense that something wasn't done in a certain way. I think that this problem is worsened by closed cultures and competitive, masculine cultures that place a high value on task accomplishment. I think that it is worsened even more by non-holistic educational processes that boil intubation down to a "Mongo stick tube in Fred" 'skill' that is primarily taught to clear testing stations. On the other hand, there's also the opposite approach which is just as dangerous- the "we don't intubate here because we don't trust you to do it successfully" approach. I'd suggest that both the "tube at all costs" and the 'thou shalt ignore the existence of intubation' schools are both wrong.


Worse, although I like, use and trust the current generation of SGAs with a lot more airways than I did the old 37/41 Fr. Combitube duo I started with, I also find myself becoming less and less familiar with ET intubation, despite diligent efforts to practice and one of the company's more aggressive users of ET intubation. It's a lot like the introduction of GPS- it essentially killed universal compass/map/star reading for infantrymen and naval personnel as a core competency, because who really does that every day when GPS is a thing? Technological progress in airway management has not wholly removed the need for ET intubation yet, but it's come a long way, and we are seeing the results of that realignment now. If a college-going, EMTlifer like me who realizes this is still feeling the cobwebs, what about the average medic that doesn't care a lick about these things until they're staring at them?


But worst of all? I think that we have become afraid of the ET tube. I think that a lot of providers from EMT to P to RN to MD hear so much about the evils and pitfalls of the tube that they become afraid of the process and the methodology, to the point that discussions of airway management end not in "let's intubate them", but to "call that guy who is good at intubating people". Sure, we support it with scientific findings and studies and papers and the like, and we're definitely not wrong to point out that intubation used to be too frequent, is dangerous, and is/was often poorly-done- but we're also forcing it into that role because we are deemphasizing it and expecting people to remember how to do it perfectly without realistic sustainment training (which no one wants to provide due to cost and effort required). Fear is contagious, and before you know it, you have two or three generations of providers who look at the ET tube as an object to be avoided unless in extremis, like the crike kit or levophed "leave-em'-dead" drips. These anecdotally-trained, risk-averse providers don't understand airway management beyond the skill and the basics of the equipment, and that means that most of them are either going to shove in an SGA and hope it works without an understanding of the underlying factors that determine that or they'll go in with the ET tube and muck about in airways trying to make Grandma into Fred's Head. Fear is not really a good teaching tool.