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The Controversy & Complexity of Out-of-Hospital Intubation

Review of: Wang H, Yealy D: "Out-of hospital endotracheal intubation: Where are we?" Annals of Emergency Medicine. 44(5):439-450, 2004.

The Science

Every week, there seems to be more information coming out on the issue of out-of-hospital intubation. How do you decide what is or isn't reliable? In this article, Wang and Yealy try to answer this question. The authors review the current state of the art of out-of-hospital intubation. They examine the methodological flaws and weaknesses of the science, while providing guidance for future research. Wang and Yealy shed light on the lack of understanding that we have on the intricate complexity that is prehospital intubation, and they do so in an unbiased and scientific manner.

The Street

I don't know what the right answer is to the question of whether or not prehospital intubation is right or wrong. We all accept the fact that the procedure is different in the street than it is in the ED. Several recnet studies clearly show that it can be harmful but why? Why do some patients do better if we wait until they get to the ED before intubating them? Is there something in the training and education? Is the quality of medical oversight a factor? Is there a lack of basic airway maintenance skills by ALS providers?

Again, I don't know. These questions have stimulated debate and have fueled report after report of "excellent" intubation success rates in various programs. However, few of these reports have documented the clinical outcome of the patients. Traumatic brain injury has very well-defined outcome measures and therefore has been the focus of recent research. How many COPD and other respiratory distress patients have benefited from prehospital intubation? How do you measure that? Can we extrapolate the information from brain injury patients to those with other conditions?

These are just a few of the many questions regarding prehospital intubation. What I do know is that these two authors are experts in the field of prehospital airway management. Reading this article and pondering the questions they raise will provide you a fundamental understanding of its controversy and complexity.

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