Is it time we give up endotracheal intubation?
Not one of the 30 medics I informally polled had intubated more than three people before being cleared to practice
By Kelly Grayson
The kid was unconscious, her neck still livid with the ligature marks of the coaxial cable she had used to hang herself. Her mother had found her just in time, and somehow managed to lift her up enough with one arm to release the tension on her makeshift noose, while cutting the cable with the other.
The fire department had arrived first, begun CPR, and secured her airway with a Combitube. By the time we arrived, she had a strong pulse, and had started to regain some respiratory effort of her own. En route to the hospital, my trainee, smart enough not to mess with a perfectly patent airway device, administered sedatives and continued assisted ventilation.
The Emergency Department physician, concerned about potential laryngeal edema, opted to transition from our supraglottic airway to endotracheal intubation. My trainee, seeing the opportunity for a little intubation practice in a controlled setting, asked for permission to perform the procedure.
All of the ED staff knew him as an EMT-B, but in reality he was a newly-minted paramedic on his 10th of 12 required paramedic clearance shifts. The ED physician, a long-time EMS medical director himself, looked at him speculatively for a moment, shrugged, and said, "If it's within your scope of practice, be my guest."
I hovered nearby, ready to intervene in case of trouble, while my trainee ordered the Combitube removed and deftly intubated a 16-year-old girl with laryngeal edema already beginning to occlude her airway.
After the procedure, I slapped him on the back and congratulated him, "Good job on the tube. You displayed excellent technique."
"Thanks," he breathed, hands shaking slightly. "That was my first intubation on a human patient."
Turns out, my trainee wasn't unique. Over the next three months, while attending several continuing education courses, I conducted an informal poll of all the new medics I could find. All of them had been trained within the last five years. Graduates of at least five paramedic education programs were represented, and three of those were nationally accredited by CoAEMSP.
And not one of the 30 medics I polled had intubated more than three people before being cleared to practice.
The 1999 Paramedic National Standard Curriculum required a minimum of five successful intubation attempts, an egregiously low standard. Anesthesiology residency programs require over 400 successful intubations. CRNA students are required to perform over 200. So why is it that we consider five to be enough practice for a paramedic student who will almost assuredly perform them under more challenging conditions?
And it seems that, even with the bar set so low, most programs' graduates don't even meet that standard. My trainee, a graduate of an accredited paramedic program, told me that his classmates were having such a difficult time scheduling O.R. rotations that their program coordinators had decreed that the minimum five successful intubations could be performed on a high-fidelity patient simulator.
Now, I'm a big fan of Sim Man, but he ain't adequate replacement for live intubation practice. Anyone who believes otherwise might as well insist that proficiency at playing Call of Duty on your Playstation qualifies one to be an Army squad leader in Afghanistan.
When I did my paramedic clinical training, shortly after the Earth had cooled and the curriculum was written on papyrus leaves, I performed 34 successful intubations in the Operating Room, despite having to schedule around CRNA students, RT students, and anesthesiology residents. Some of my classmates did more than that. I've probably done a couple hundred since then. I somewhat jokingly refer to myself as an airway samurai, but compared to even the rawest anesthesiology resident, I still haven't even begun to prove myself.
Fifteen years after I got my patch, the environment had changed significantly. I faced considerable obstacles in scheduling my students for clinical shifts to get adequate intubation practice. In the end, I had to hire outside anesthesiologists to officially "bless" my students before they'd be allowed to intubate surgery patients. I had my students do clinical rotations at the local veterinary practices to simulate pediatric intubations. Some of them intubated freshly euthanized stray cats at the local animal shelter.
But one way or another, they got the practice I required of them. I could see the handwriting on the wall, and so I also encouraged my students to become proficient with supraglottic airways. They inserted far more laryngeal mask airways during their clinical rotations than they did endotracheal tubes.
In contrast, none of the medics in my informal poll had even asked to insert a LMA in their clinical rotations. Not only did they lack proficiency at endotracheal intubation, they also ignored a perfect opportunity to gain proficiency with the most commonly used supraglottic airway in the hospital setting. When asked why not, the most common answer was that it was not a clinical requirement — not even in the purportedly superior, accredited programs.
This poses the question in the title of this column: If that is all the effort we're going to devote to teaching invasive airway management, is it time we just gave up endotracheal intubation altogether?
It seems that every day, new evidence comes to light that paramedics — as most are currently trained — are not capable of reliably inserting an endotracheal tube in the proper hole. Add to that the growing body of evidence that invasive airway management does not improve patient outcomes, and the growing popularity of CPAP, and the pool of patients that may benefit from ETI grows ever smaller.
At least one large, metropolitan EMS agency, once featured on the cover of JEMS and often lauded for its clinical excellence, no longer allows paramedic students to perform ETI when doing clinical rotations with their agency. Their reasoning? Because we don't get enough ETI attempts to remain proficient ourselves.
And thus, they sacrifice the seed corn in favor of the current crop. There is but one predictable end result of that policy, and that is within the next five years, their intubation proficiency will nosedive, or they'll have to abandon the procedure altogether.
Still, any suggestion that we are not proficient at ETI triggers a chorus of indignant screeches and experiential anecdotes (read: war stories), as if the willingness to insert an endotracheal tube somehow corresponded to penis size.
Well, for the male paramedics, anyway.
I'm not sure why we insist on approaching patient care as if paramedicine were little more than a patch and a skill set, but unless we adopt a more reasonable approach to airway management, I fear that endotracheal intubation will soon go the way of rotating tourniquets.
Except that, some patients may still benefit from prehospital ETI. We need research to identify that body of patients, and the commitment to educating paramedics to appropriately apply what is becoming a rarely used, but still potentially lifesaving skill.
There are pockets of excellence in EMS that demonstrate that, with a commitment to training, we can be as proficient at ETI as the ED physicians to whom we're bringing our patients. If you're a medic in one of those systems, what's your approach? How do you manage the training and CQI? What tools and toys work the best? Can you back it up with research?
Because God knows, the rest of us could use your advice.