Brittany Grandfield, BSN, RN, CFRN, CEN, Flight Nurse.
Ok, here we go… Lots of controversy over the recent article titled, “Comparing Intubation Success Between Flight Nurses and Flight Paramedics in Helicopter Emergency Medical Services”, published by the Air Medical Journal in their November/December 2023 issue.
I can’t tell you how many comments on social media remarked that this article “should have never been published,” “useless,” or comments comparing the “number” of paramedic intubations to nurse intubations.
I enjoyed the funny comments, including “medics be stealing” or “the medic hip-checked.” We also had optimistic comments regarding the utility of having a paramedic/nurse duo in flight, equal pay, and humbled nurses admitting that their current counterpart medic is better at intubation.
I may be on a lonely island, but I found the data from this study very interesting and think it deserves some conversation… (looks around and ducks)
My blog aims to analyze this article as objectively as possible, given the data presented, and then give potential perspectives that could benefit the future of HEMS regarding this matter.
I am a nurse. I have been a nurse since 2013. An Emergency Nurse since 2016 with prehospital experience starting in 2019 with a ground service where I was a paramedic-exempt nurse at the beginning of 2019. As of October 2019, I have been a Flight Nurse for two flight services. Recently, I became a Paramedic Instructor for my local college in January. I have prehospital experience including the ability to intubate, for only the last 5 years.
Let’s start with what this study is
This study is of a single service with three (3) bases in southeastern Wisconsin and northern Illinois. Data was pulled from June 2013 to June 2018. During this time, 5,451 charts were reviewed. Of the 5,451 charts, 322 were identified as an intubation performed by a paramedic or a nurse. A paramedic was identified as the primary intubator in 285 cases, and the nurse was the primary intubator in 37 of the identified cases. Of those 322 intubations, 19 were identified as unsuccessful. Paramedics had 14 unsuccessful intubations. The Nurse had 5 unsuccessful intubations. I made a chart of this data for us visual learners below.
Total: 322 Intubations
The program's overall success rate was 303/322 successful intubations. 94.% Intubation success rate (Strong Work!)
Paramedics: 271/285 successful intubations. 95 % Intubation success rate
That is roughly 57 Intubations per year over 5 years.
Nurses: 32/37 successful intubations. 86 % intubation success rate
That is roughly 7.5 Intubations per year over 5 years
Wow. Take a movement. Those are very, very interesting numbers.
Take a moment to be annoyed by the paramedic vs nurse intubation numbers—271 VS 32. You might be surprised, shocked, annoyed, or unfazed.
First, I congratulate this company on having the idea to look at the numbers and be one of the few HEMS companies to specifically target and look at data regarding intubation success as it relates to professional roles (paramedic/nurse).
This article aims to determine whether a difference exists between Flight Nurses and Flight Paramedics in intubation attempts and success rates. The numbers demonstrate that there is.
This study might suggest one HEMS service and not universally applicable to other services or geography.
This flight program acknowledges the mentality that “the medic owned the airway.”
Nurses did not frequently intubate, offering little ability to maintain their skills on live patients.
Quarterly intubations of 3/3/3 are required on adults, pediatrics, and neonates; however, they are mainly done on mannequins.
During Orientations, new crew members must do a minimum of 10 live intubations in the operating room before being cleared to intubate in the field.
Only recently, over the last few years, has the medical director stressed the need for alternate intubations.
The conclusion of this article…drum roll…. (Not shockingly states): “Flight paramedics performed more intubations with greater success than flight nurses.”
I am glad they acknowledged that this might be a base culture rather than a universal or widespread geographical topic. While I appreciate this acknowledgment, the two air medical services I have worked for could also support this data. I am by no means saying that they would be the same, but I am saying that the numbers might be similar or not far off. Meaning that data from the bases and companies I have flown for might also show a large intubation gap between Nurses and Paramedics. I say this because of first hand experiences with MANY bases I have worked at.
“The Medics owned the airway.” Mentality"
I have very much seen this. This is no surprise. With both this flight service and others that I have seen, I know it to be true that the paramedic love to intubate. I have seen nurses decline an airway because they don’t want to intubate or do not feel comfortable intubating difficult airways. I have also seen it from my perspective of a nurse wanting to intubate and having to argue (respectfully) with the paramedic about who will intubate. When I first started, this was the norm. I see a trend four years later of each of us wanting to alternate depending on when the last intubation was, which is excellent, in my opinion.
“Nurses did not frequently intubate, offering little ability to maintain their skills on live patients.”
285 intubations compared to 37. Big difference, right? This data could be beneficial after we giggle at the huge discrepancy. Of the 285 intubations, Paramedics were successful 271 times for a 95% success rate. On the other hand, nurses were successful 86% of the time, with 32 of 37 intubation attempts being successful.
The frequency most certainly has a direct correlation to overall success rates. I do not think anyone can argue that while the initial intubation education for paramedics is vastly different from nurses… which is like nothing lol. Paramedics must have a required number of intubations before graduating from paramedic school. They have live intubation experience, train on manikins during class, and have a whole section dedicated to intubation during their schooling. With that, they must pass skills check-offs during schooling and pass.
Nurses need more airway education (not even just inutbation) during nursing school. To my knowledge, intubation is not in the nurses’ scope of practice anywhere without an exception of some form. From experience, some emergency departments would not even allow the nurse to administer a paralytic. That is how low-frequency airway management is as a nurse. A vast difference in education, right?
This flight service noted during orientations that new crew members are required to do a minimum of 10 live intubations in the operating room before being cleared to intubate in the field. This is excellent for new crew members. Both paramedics and nurses. At some point, we have to establish a baseline for both clinicians. Some paramedics come with little to no intubation experience, which is necessary for the overall success of a clinician new to the HEMS world. If anything, I would encourage this flight company and ALL flight companies to consider a separate educational opportunity for the nurse in addition to their new hire orientation.
This article notes, “Only recently, over the last few years, the medical director has stressed the need to alternate intubations.” Since this article was published in 2023 while the data was collected from 2013 to 2018, only time will tell if this will become the new norm. I can note that since starting HEMS in 2019, the culture is shifting to an alternation in intubations vs. a “medics owned the airway mentality.” The medical director noted this issue and suggested a change. Growth starts with acknowledging an issue and making a change.
My last DEBATABLE topic will address what we all want to discuss—Nurse vs Medic. This article contributes positively to the HEMS industry. Promoting two things.
Paramedics and Nurses are a beneficial partnership that, in combination, promotes positive patient outcomes concerning each’s education and experience.
Regarding the HEMS industry, a shift should be made to equal compensation for an equal partnership between the Flight Nurse and the Flight Paramedic.
In conclusion, we shouldn't be so quick to judge and try analyzing the situation before jumping to harsh conclusions. Having perspective can make a world of difference. Change doesn’t happen overnight, and if we are unwilling to speak up about an issue for fear of judgment and criticism, then the problem will persist. Thank you to this flight service for recognizing a shortcoming, putting pen to paper, and doing the work to collect this data. I know it’s not a comfortable thing to acknowledge an issue. Lastly, Medics… Share the airways, and Nurses… start intubating more; the airway is part of our jobs.
Brittany Grandfield, Flight Nurse
Thompson, Gregory, et al. “Comparing intubation success between flight nurses and flight paramedics in Helicopter Emergency Medical Services.” Air Medical Journal, vol. 42, no. 6, 2023, pp. 436–439, https://doi.org/10.1016/j.amj.2023.07.004.
Link to Article: