2018 Will prove to be an incredible year for pre-hospital driven studies. As EMS professionals we have to be extremely careful how interpret these studies. I tend to see two approaches to interpreting a possible “practice changing” paper.
“This does not apply to me or my service.”
“Let’s take a closer look.”
Michael Perlmutter (@DitchDoc14) did a blog piece a few months ago suggesting we re-think how we control airways in pre-hospital medicine. Whenever you discuss or propose putting a skill on trial, you will be met with resistance. That being said, yesterday two papers were published comparing the SGA vs ETT in cardiac arrest (PART & AIRWAYS2). I highly anticipate deep scrutinization of the paper by the pre-hospital community. My hope was that by bringing the senior authors on the podcast, I could help the discernible reader avoid assuming false motives and extended assumptions as to the fatality of paramedic intubation.
Strategy vs. Ability
It is worth mentioning that these studies were comparing intubation vs. SGA in CARDIAC ARREST. We know that active chest compressions inherently make intubation difficult. Not only are we commonly unable to ramp the patient appropriately, but we are aiming at a moving target. Not to mention the limited resources/real estate that is often present during a pre-hospital cardiac arrest.
We have to look at this as a strategic move vs. ability. I can relate this to starting an IV on a patient in cardiac arrest. We have the ability to start an IV, but an IO is probably faster/easier in the setting of OHCA. Yet, one wouldn't look at this comparison of strategy vs. ability and assume that paramedics should never start peripheral IVs.
Video vs. Direct
The large confidence interval of video laryngoscopy is obvious to anyone reviewing both studies. I believe that when airway positioning is compromised, one must utilize VL to optimize glottic view & tube delivery. Do the majority of ALS services carry video laryngoscopes? The answer is probably no. I seriously doubt that these services were picked purposely to avoid the use of VL, but yet probably reflects the common theme amongst large departments. Many of these participating fire departments are near my hometown in Wisconsin. I know experience is limited to none with VL. Systems similar would most likely yield the same results found in both studies.
An interesting finding in both of these studies was the percent of aspiration was very similar between ETT & SGA. Honestly this surprised me. I was under the impression that the gold standard ETT would without a doubt protect that airway better than an SGA. I believe that the majority of the aspiration probably occurs in attempting to secure the airway. The SGA was several minutes faster in regard to securing the airway when compared to the ETT. My experience favors a larger gastric port as seen in the King LT. The iGel gastric port can only take a 12 French suction catheter. If decontaminating viscous emesis, this can quickly become a problem.
System vs. System
My immediate reaction to this study was the intubation success rate was incredibly low and would ground most helicopter services if reflected in HEMS. However, I can’t disagree with the insight of strategic cognitive offloading to focus on reversible causes of arrest. I have always believed that if you can’t measure something, you can’t improve it. In this podcast you will see how important it is to frame the results as the authors did. System statistics often reveal holes in your bucket. The way you repair those depends on your interpretation.
I asked Dr. Jeff Jarvis (@DrJeffJarvis) & Michael Perlmutter to come on this podcast, and assist in asking questions from different vantage points. The conversation was phenomenal and enlightening. Dr. Wang & Dr. Benger were kind enough to answer our questions and provide insight into their interpretation.
Links To The Papers