The EMS roundtable: Expert insights on airway management
EMS1 columnists debate the topic of airway management and outline the current trends and what the future may hold
Airway management is obviously a pretty broad area. But let's begin by discussing the current state of the market. To narrow it down a little, let's focus specifically on how it relates to both medics and agencies in particular.
Meet the Experts
Kelly Grayson is a critical care paramedic in Louisiana. He has spent the past 18 years as a field paramedic, critical care transport paramedic, field supervisor and educator.
Art Hsieh teaches at the Public Safety Training Center, Santa Rosa Junior College in the Emergency Care Program. Since 1982, Art has worked as a line medic and chief officer in the private, third service and fire-based EMS.
James J Augustine is medical advisor for Washington Township Fire Department in the Dayton, Ohio, area. He is Director of Clinical Operations at EMP Management in Canton, Ohio, and a clinical associate professor in the Department of Emergency Medicine at Wright State University.
There is a Chinese proverb that goes, "May you live in interesting times," and that’s where EMS is right now in regard to airway management: interesting times. Never before have we had so many airway management tools, yet so little education and practical experience in airway management.
We've got new medics graduating from accredited programs who have never intubated anything other than Sim Man, and the DOT curriculum up until a couple of years ago required only five successful intubations.
Today's medic students have far more competition for intubation attempts in clinical rotations than they did even 10 years ago, while at the same time the number of intubations is dwindling.
At least one major EMS agency no longer allows paramedic students to intubate, because their line medics aren't getting enough attempts to maintain proficiency themselves.
I think your average medic these days, with the exception of a few pockets of excellence here and there, is significantly less skilled at endotracheal intubation than medics of 10 or 15 years ago.
To some extent, we are in an age of airway paradox. On one hand, there are more ways to manage an unstable or crash airway today then a decade ago.
Simultaneously, the research shows that they may not necessarily be better than some of the basic approaches we've used previously. With this in mind, it is important for providers and agencies to carefully evaluate how a device works and its effectiveness.
There have never been as many products, procedures and monitors available to assist in managing an emergency patient's airway and ventilation. It is getting difficult for medical directors and operational leaders and R&D staff to make the decisions regarding purchase, training, upkeep and quality assurance.
It also can result in the "airway box" portion of the first-in bag becoming very large. It can also be difficult to accommodate the preferences of the many members of the department, who may each want a different product.
Therefore, it can be desirable to establish a policy that will result in the most necessary number of products needed to accomplish airway management for the spectrum of patients the agency serves.
This allows agencies to better establish and maintain a training program that gives providers the knowledge and skills to capture an airway, provide ventilation and monitor the airway until delivery to the hospital.
Moving on to the product side of things, what are the key things agencies need to consider when beginning the purchasing process?
Deficiencies in training cannot be corrected with equipment; a two-hour training session from a rep on a new device is different to a comprehensive two or three-day airway management course for all members.
Here's the bottom line: Agencies need to consider frequency of use, the cost and frequency of skills training and maintenance, and support from the vendor when making a purchase.
They also need to consider at least familiarizing their local emergency department with the device, because after all, those are the people who are going to receive patients with these airways in place.
The least important consideration should be per-unit cost, even though that's what most agencies consider first. You shouldn't look at it as a $100 device you're only going to use a dozen times a year. You should look at it as a $1,200/year insurance policy against a multimillion dollar failed airway lawsuit — and that kind of coverage is invaluable.
Most of all, do your homework, because some of these new devices are very good.
Cost — always an issue. Some of the devices out there can cost a small fortune. What is the cost to benefit analysis? Replacement — the initial capital outlay on a specific device may be relatively low. However, to replace the disposable components can become fairly expensive. Training — what will it take for providers to become proficient in the new equipment? What will be the retention rate of the training? How often should ongoing refresher training occur?
The agency leaders need to establish whether the products serve the needs of the patients routinely served in the community. Agencies serve populations that have different clinical needs. Some serve many trauma patients, some have a lot of pediatric patients, some have a lot of elderly patients in extended care facilities, etc.
Some have short treatment and transport times, others have very long distances and lengthy times to provide care. Some have staffs that are heavy in ALS personnel, while many have a predominance of BLS providers.
Some have staffs that serve much of their time in hospitals, and get a lot of secondary training in those positions. All these factors come into play for the important decisions. There must be the financial and human resources to support the purchase, training, upkeep and quality assurance of the airway products and monitors.
What are the most common mistakes medics make and the pitfalls they need to be aware of? In addition, what do agencies need to be aware of when selecting new equipment?
The most common mistake I see — in new and old medics alike — is looking at airway management as an all-or-nothing proposition; an oral airway is just something for their EMT partner to do while they get their laryngoscope assembled.
Airway management is an entire spectrum of assessments and interventions, and one only need go as far along that spectrum as you need to effectively manage the airway. I teach it as the Airway Continuum.
Ask most medics, "What is the Gold Standard of airway management?" and they'll answer, "Endotracheal intubation."
The true Gold Standard is adequate oxygenation and ventilation, and it is not tied to a specific device. If you didn't attempt an intubation, that doesn't make you a bad medic. It only makes you a bad medic if intubation was the only thing that would have managed the airway. Otherwise, there's no shame in using an OPA or a supraglottic airway.
Be proficient with the tools your agency uses, and know when to use them. Don't inflict an unnecessary invasive procedure on a patient just because you know how.
Think carefully about why a purchase is being considered. Often the equipment is a solution in search of a problem. What is the device intended to do? Does it make that procedure that much easier, safer, more reliable or cheaper? Or is it just the next "big" thing that turns out to be a fad? Medical equipment is becoming more complicated and more costly. We have to be sure that there will be some measurable outcome associated with its use.
More money spent on more and more products does not necessarily equate to better quality patient care. It can be better to have a small number of products, and spend a lot of time on training to use those products and monitoring the patient when those products are in use.
Another important consideration is using devices that mesh with the products being used in the local hospitals, and that hospital staff are comfortable in using them.
The EMS providers cannot purchase and use devices that hospital staff cannot accommodate. That is also an expensive choice when risk management considerations are put into play.
I was involved in a case where the emergency department staff were overheard by the patient's family saying, "We don't know how to use those stupid devices that EMS uses, and that is probably why the patient died." That is an incredibly expensive decision at that point.
What do you identify as being the current main trends in the airway management market — and what does the future hold?
With CPAP dramatically decreasing the number of CHF patients that need intubation, and the de-emphasis of ETI in cardiac arrest, and the ease of use of supraglottic airways, I think endotracheal intubation is a dying art, at least in prehospital care. We just don't do it enough to be good at it.
Oh, there are some bright spots; a few agencies with high volume, active medical direction and strong CQI that do intubation very well, a few continuing education courses that address the deficiencies in airway education that should have been covered in paramedic school, but they're few and far between.
And it's a touchy subject, too. It often seems that, as a profession, we identify ourselves by what we do, and not what we know, and if anyone suggests doing less – even if research supports it – you’d think we stomped their puppy. It’s almost as if, when you question the efficacy of intubation, or our skill at performing it, people take it as a personal insult.
I agree with Bryan Bledsoe that, in the near future, we're going to see more agencies dropping ETI, and eventually the skill will be confined to a small cadre of very highly trained medics, if we're allowed to do it at all.
Honestly, that probably needs to happen at a lot of agencies right now, but if it happens to us profession-wide, we'll have no one but ourselves to blame.
In response to the market, I do think equipment manufacturers are more carefully evaluating a product before it goes to market. There seems to be more studies and research on the effectiveness of a device than in decades past.
The previous comment still applies — make sure that the research supports the use of the device in the way you intend. Follow the data to the viewpoint of patient outcomes. It's possible to show that the device might be easier to use, and more reliable, but how does it affect patient outcome?
With so many products on the market nowadays, you need to remember the basic principles we've already outlined.
Final thoughts time: What's your takehome message for the roundtable?
We need, as a profession, to acknowledge that we're not as skilled at airway management as we once believed, and take real steps to address our deficiencies.
If you feel that statement doesn't apply to your agency, fine. Do a study, and publish your results. We need success stories and best practices to emulate, not knee-jerk reactions of, "ZOMG, they’re trying to take our laryngoscopes away! Over my dead body!"
Nobody knows the challenges we face in EMS like the people who practice it. If you think ETI is a skill you need and you're afraid of it being taken away, then we need to prove we can do it well, and appropriately. If we can't, then at least demonstrate that we're mature enough as a profession to recognize our shortcomings and correct them ourselves.
At the end of the day, any piece of equipment is only as good as its operator's ability to know when to use it, rather than just how to use it. Effective airway management is based in the ability for the EMS provider to critical judge when a device is most suitable for a specific patient.
One size never fits all, and neither can one approach to airway management be effective for all patients. It's clear that whatever can be found in our airway toolbox, that we know why, when and how we use each device or procedure.
All of these product decisions have risk management elements to consider. The agency leaders must have financial and human resources to support the training, maintenance and quality assurance of the airway products and monitors.
If there are mistakes made, or a product fails, or it is perceived that the program elements led to a bad patient outcome, it can be devastating to patient care and to the maintenance of public confidence.
The purchase price of the devices will pale in comparison to the loss of personnel, public confidence, and money in a lawsuit.