The Airway Continuum

Kelly, why is it that some paramedics seem to view airway management as an all-or-none proposition? I’ve been an EMT for less than a year, and it seems that nearly every paramedic I’ve ridden with wants to go straight for the ET tube. You know, cops have a Use of Force Continuum, and they’re legally responsible for choosing the appropriate degree of force for a given situation. It seems to me that EMS could adopt a similar approach to airway management.

That’s a pretty astute observation from a rookie EMT, isn’t it?

My friend Wes Ogilvie, an attorney and fledgling paramedic, is full of such observations. Some of them, like the Airway Continuum, are gems. Others, like his idea of placing advertising decals on the ceiling above the ambulance cot — If you can read this, you may be entitled to a cash settlement! — may be a little too progressive.

Wes’ experiences, gained from working alongside medics in a large metropolitan EMS system widely recognized for its clinical excellence, mirror my own. All too many paramedics consider endotracheal intubation to be the gold standard of airway management.

It isn’t.

Effective ventilation is the gold standard of airway management. Our profession needs to remove the stigma attached to not getting the tube, or not even going for the tube. We’ve all said it or heard it before, either from our peers or from ED staff:

Didn’t try to intubate? Tsk, tsk. He’s not a very aggressive medic, is he?

In the EMS lexicon, that’s like being branded with the scarlet letter. To be reluctant to utilize invasive airway management is to be considered timid — afraid to act. It’s almost an EMS mantra: “Do something, even if it’s wrong.”

Aggressive medics save lives, stamp out disease and pestilence, and rip people away from the jaws of the Grim Reaper at least twice a shift, and they do it wielding a gleaming laryngoscope with all the skill and panache of an airway samurai.

Timid medics obsessively read their EMS pocket guides between calls. Timid medics prefer BLS transfers to a cardiac arrest. Timid medics use supraglottic airways more often than endotracheal tubes. Timid medics actually attach a mask to their bag-valve device. Timid medics are wimps and unworthy stewards of the legacy of Johnny Gage and Roy Desoto.

I’m as guilty as anyone of perpetuating the stereotype. I own a T-shirt emblazoned with a laryngoscopic view and the logo “Just Tube It.” My personal mantra is, “I can fall down a flight of stairs and accidentally intubate five people on the way down.” I stand firmly on the side of endotracheal intubation being an essential paramedic skill. But here’s the caveat: Only when it’s necessary.

The practice of prehospital endotracheal intubation is coming under increased scrutiny in medical literature. Journals are rife with studies showing that paramedics are seriously deficient in their invasive airway management skills. Some EMS systems, recognizing their deficiencies, have gone so far as to designate a supraglottic airway as their preferred method of ALS airway management. I believe it’s entirely likely that, in the not-too-distant future, prehospital endotracheal intubation will be limited to the skill sets of a handful of specially trained and credentialed paramedics.

If that happens, we’ll only have ourselves to blame. Whether the culprit is complacency, a lack of solid QI, existing skills rusting out, or deficiencies in initial education, paramedics are not as talented at airway management as we’d like to believe. It’s also disingenuous to use our austere environment as an excuse for poor success rates. Either you can intubate, or you can’t. No excuses.

When police officers respond to emergencies, they do not use their gun on every call. In fact, it’s a rare percentage of calls that actually involve a use of force, much less the use of a firearm. From day one of the police academy, officers are indoctrinated with the concept of the Use of Force Continuum. The continuum shows the levels of force available to officers, but designates that they only to use the force necessary to make an arrest and/or deal with a threat.

Compare this with how many ALS providers deal with airway management. Too many advanced providers believe that the only tool they have to manage an airway is endotracheal intubation. The reality is that the ET tube is but one tool in the EMS airway management toolbox, ranging from simple positioning of the patient all the way to establishing a surgical airway.

Our airway management skill set defines the tools available to us. Just as in law enforcement, those tools and options may be dictated in some part by local laws and department policies. However, the paramedic must choose the appropriate tool to manage the airway for that particular patient in every specific case.

In many cases, if not most, the appropriate tool will not be an endotracheal tube. As a conceptual tool, the Airway Continuum gives us a unique opportunity to change our thinking about airway management, and the police officer’s Use of Force Continuum gives us a ready-made template to emulate. In my fevered imagination, I picture our Airway Continuum to look something like this (with the law officer’s Use of Force Continuum alongside for comparison):

Use of Force Continuum

Level One: Officer presence
Level Two: Verbal communication
Level Three: Control holds/restraints
Level Four: Chemical agents
Level Five: Non-lethal force
Level Six: Lethal force!

Airway Continuum

Level One: Positioning, oxygen
Level Two: Suctioning, Beta agonists
Level Three: NIPPV or CPAP
Level Four: BLS airway adjuncts
Level Five: Supraglottic airways
Level Six: Endotracheal intubation!

In law enforcement agencies, employment of a Level Five or Level Six intervention triggers an automatic internal review of the incident to determine if the officer’s actions were justified. EMS agencies should adopt a similar mechanism for any call that resulted in invasive airway management. Like the law officers, we should also be required to pass an annual qualification with our airway tools, especially if we only use them a few times a year.

Law enforcement officers who improperly apply the wrong level of force are subject to liability. Similarly, EMS providers who improperly manage the airway are subject to liability.

There will come a day when some enterprising personal injury lawyer sues an EMS provider for successfully establishing an airway. He’ll claim injuries stemming from a perforated esophagus from the initial unsuccessful attempt, or assign us partial blame for the ventilator-associated pneumonia his patient acquired in the ICU. He’ll ask us nasty, uncomfortable questions about why we didn’t choose a less invasive method, or use CPAP. Mark my words; it’s only a matter of time.

Until that day comes, try to remember that the goal isn’t intubation. The goal is ventilation. If you manage to achieve that, then you’ve served your patient well.

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