If you despise me and everything I stand for by the end of this post, it’s ok. You may not agree with every point I make in this post. Suffice it to say that this is controversial. Nonetheless, I think we need to leave our egos at the door and have a meaningful conversation about what’s best for our patients. Despite decades of practice and not a small amount of bravado involved with intubation, we should be appraising the evidence with a critical eye and asking ourselves whether intubation by paramedics in the field is in the best interest of the patient. When it comes to airway management, we need look ourselves square in the eye and ask, “are my intentions honourable?”
Endotracheal intubation has been a core paramedic skill since the inception of the profession. To this day, it remains a highly coveted skill by paramedics. We take great pride in the fact that we are granted the privilege to perform this invasive and difficult procedure. In paramedic school, intubation receives the lion’s share of attention within the broader umbrella of training related to airway management. In most programs, some time and attention is given to basic techniques such as face mask ventilation (FMV) with a bag-valve-mask (BVM) and adjuncts such as oro- and nasopharyngeal airways (OPA/NPA), and supraglottic airway devices like the CombiTube, King LTD, and LMA-type devices. However, the most time and attention is almost always given to intubation. In some sense, there is sound logic to this model: intubation is in many ways the most technically difficult of these skills to master, and since intubation often involves the use of neuromuscular blocking agents, it is important to ensure that an endotracheal tube can be placed after spontaneous respiration has ceased.
Unfortunately, the time spent on intubation in paramedic school (even if it does comprise the majority of didactic time devoted to airway management) falls far short of what should be considered standard for a provider attempting intubation. This is even more true for paramedics performing medication-assisted airway management (MAAM). Within the paramedic course itself, there is often minimal time or attention given to human anatomy; this issue is compounded by the fact that few paramedic students have completed a rigorous course in gross anatomy prior to beginning their EMS education. Furthermore, the physiology and pathophysiology related to anesthesia are rarely addressed in great detail, which leaves paramedics ill-prepared to anticipate and mitigate the potential risks and benefits associated with prehospital RSI. The emphasis on intubation in the context of limited education and training time means that FMV and SGAs--often considered inferior “rescue” techniques for cases of failed intubation--are given insufficient time and attention.
Historically, a core component of airway-related training in paramedic school has been time in the operating room (OR) under the tutelage of an anesthesiologist and/or certified registered nurse anesthetist (CRNA). Students were required to perform intubation on live patients; most programs required between 5 and 10 successful intubations. This OR time is a much-anticipated highlight of most paramedic programs, and time spent under the supervision of an airway specialist was invaluable. That said, the idea that a provider (any provider) is competent to manage an airway, much less competent at laryngoscopy, after 10 intubations is laughably absurd. Most emergency medicine residency training programs require a minimum of 50 intubations carried out under heavy clinical supervision and subject to intense review to graduate. Residents in anesthesia programs perform at least 500 intubations in the course of their training. In recent years, numerous paramedic programs have cut OR time completely from the curriculum. As a result, students no longer have the ability to perform their first intubations on human patients under the direct supervision of experts. Clearly, 10 intubations in live patients is hardly sufficient to achieve competence, but it is arguable that the benefit conveyed some benefit nonetheless. In the current era, this has been replaced with practice on mannequins and (if fortunate) in a cadaver lab. Anyone with experience managing airways will know that these training modalities are not equivalent. These issues inherent in paramedic education are compounded by the lack of appropriate education and training for paramedics during their orientation and training period following employment. Even in systems that do have processes in place to assure competence, one must ask if this is sufficient. Studies have shown that for the average paramedic working in a dual-medic system to achieve 100 intubations (100 instances of performing a procedure is frequently cited as a minimum number to achieve competence), that paramedic would need to be presented with 200-250 opportunities to intubate per year, for five years. With the possible exception of a few systems, this is simply not a realistic scenario.
With this discussion of the tremendous differences in training to establish baseline competence for paramedics compared to physicians in mind, we should consider the question of what alternative paradigm exists. We know that pathology does not respect geography: the patient who requires airway management 50 miles from the hospital requires that airway as surely as the same patient in the resuscitation bay at the trauma center. Therefore, some method of airway management must be available in the field. In recent years, tremendous advances have been made in the design of supraglottic airways. In particular, the i-gel has been developed from the classic laryngeal mask airway (LMA) design. The i-gel is placed blindly, and without the need to inflate a balloon cuff. Instead, this device makes use of a thermoplastic polymer that uses body heat to allow the mask gel to conform to airway anatomy, thereby isolating the tracheal opening and facilitating mechanical ventilation. Many LMA designs have been updated to make placement easier, and to facilitate eventual intubation through the device.
Even prior to these advancements, Darren Braude and his group in New Mexico were making use of SGAs for initial airway management in the prehospital arena. Instead of attempting to place an endotracheal tube for patients requiring advanced airway management by EMS, Braude’s group made use of supraglottic airways to achieve airway control. This was done in the setting of helicopter EMS (HEMS), with arguably the sickest group of patients that EMS can be called upon to treat. SGAs were also used in the context of MAAM--these were not SGAs placed in patients in cardiac arrest. Their data is compelling: compared to endotracheal intubation, the incidence of successful placement on first attempt is higher and the rate of global complications is no higher. Other systems have been similarly successful. Further strengthening the argument for SGAs in place of endotracheal tubes is the reality that numerous studies have demonstrated that prehospital intubation is associated with decreased rates of successful resuscitation in the setting of out-of-hospital cardiac arrest. Not only that, but in a manner similar to airway management in patients not in cardiac arrest, the incidence of first pass success using SGAs is higher than that of endotracheal intubation in patients who are in cardiac arrest.
Having laid out a range of issues associated with paramedic-performed intubation, is it time to transition to an airway management paradigm in which endotracheal intubation is no more? It depends. In this, as in so many things, the aphorism that, “if you’ve seen one EMS system, you’ve seen one EMS system” holds true. Paramedic HEMS systems in Australasia and the United States have demonstrated that paramedics can provide prehospital intubation safely and effectively. HEMS paramedics in Victoria have long been a shining standard of what intubation performed by paramedics can be. Their success and complications rate equal or exceed that of physicians performing the same skill in the same environments. Similarly, led by Dr. Jeff Jarvis (a paramedic himself), paramedics in Williamson County, Texas are performing prehospital intubation using a system of Delayed Sequence Intubation (DSI) combined with video laryngoscopy and are achieving outstanding results. It is clear that paramedics can perform prehospital intubation safely and effectively. So if these systems are doing it, why is it not the norm?
What is lacking in many systems is the rigorous initial and ongoing training, quality assurance and improvement (QA/QI), and close medical director oversight that characterizes the systems mentioned here. In those systems, paramedics are taught to a level appropriate to the substantial risk inherent to the procedure, and are tested on a regular basis to ensure ongoing competence. There is use of cognitive aids such as call-and-response checklists, a team-based approach with roles clearly defined, and attention paid to the significant human factors at play when the decision is made to undertake intubation in the field. Of critical importance, all cases are critically reviewed, with an eye to opportunities for future improvement. There is a commitment to investment in education, training, and equipment necessary to perform prehospital intubation safely.
So, if your system has processes in place for detailed education and training regarding anatomy, physiology and pathophysiology, rigorous QA/QI processes, and strong medical director oversight, your program might be right to begin or continue the practice of prehospital intubation by paramedics. Unfortunately, it seems there is a relative shortage of systems that meet this description. For these systems, SGAs may be a superior alternative. With first-pass success rates of 90% or higher and data demonstrating no increase in complications when compared to intubation, patients may be better served by a supraglottic airway device as the advanced airway of choice. In the opening, I noted that intubation by paramedics remains a highly coveted skill, and that most paramedics take pride in the privilege we are granted to perform it. In the interest of full disclosure, it should be noted that I fall squarely into this category: I continue to intubate, and I do it well. But I must admit that these days I am not so sure that I should continue to do so. Are you?
Disclosure: I have no financial conflicts of interest to disclose. Unfortunately, there is a dearth of wealthy individuals and corporations willing to pay a paramedic-turned-medical student exorbitant sums for my opinions and/or endorsements.
Michael Perlmutter has worked in EMS for the last ten years. He has been an EMT in Southern California, and a paramedic in a busy 911 system in the Twin Cities of Minnesota. He also worked as a flight paramedic for three years before hanging up his wings to begin medical school at the University of Minnesota Medical School in Minneapolis, MN. He is interested in Emergency Medicine, EMS Medicine, and Critical Care. His research interests include advanced airway management, sepsis care, and the many uses of ketamine. He is an avid consumer and contributor to the Free Open Access Medical Education (#FOAMed) movement. He observes, comments, and contributes via his Twitter handle @DitchDoc14.