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Readers Discuss Pros & Cons of Prehospital Intubation

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This month, readers respond with varying viewpoints on a July JEMS feature article by Tony Garcia, BS, BSN, RN/EMT-P, that defends the use of prehospital endotracheal intubation (ETI) in the field (“Addressing Airway Issues: How to keep ETI a prehospital skill.”) Some agree that ETI is an essential prehospital skill, while others question its value.

I agree with Garcia’s views in the article. It’s about time someone points out the obvious: Education and training is what’s needed in all areas of clinical practice that require knowledge, skill and judgment. I’ve worked in critical care for almost 30 years as a transport clinician, a paramedic and a registered respiratory therapist. I have close to 1,000 intubations. But much more importantly, I’ve learned what airway management really means. Intubation without all the other skills is dangerous, but all the other skills without intubation is an equally dangerous problem.

If paramedics have a hard time managing the airway, then the responsibility sits with those responsible for educating them, as well as the clinical world, for providing the tools (i.e., exposure) needed to develop and maintain the skill. It’s not a reflection of some false deficiency in a paramedic’s capability.
Canadian Medic
Via JEMS.com

This article, although well-prepared and informative, misses the mark. Its focus, like the desire of most of the paramedics I’ve spoken to, is to retain the ability to intubate, at all costs. I think the dialogue has to shift away from focusing on what skill the physicians will take away toward one that focuses on what works and what actually saves lives.

And this dialogue has to be evidence-based, which is a relatively new, but crucial, concept in the practice of prehospital medicine. Evidenced-based and literature-supported practice is a new-comer to EMS, but well-written literature is pouring in quickly these days.

It’s becoming clear that intubation in many situations hurts our patients, and in many others it makes no difference. It’s not about our pride, our tradition or our wants. At all costs, it’s about helping—not hurting —our patients.

Intubating asthmatics, aspirin overdoses and patients in diabetic ketoacidosis (DKA) are high-risk intubations with complex vent management strategies that present a struggle to the emergency department and critical-care doctors. Trauma and pediatric intubations are repeatedly reported in the literature to be harmful if done in the field.

Mounting evidence suggests that intubating the typical prehospital cardiac arrest patient doesn’t increase, and might even reduce, survival rates. The list goes on. And although some patients will likely benefit from prehospital intubation, such as those suffering severe burns, anaphylactic shock or facial trauma, it’s not always the best intervention.

I believe intubation has a role in the arena of prehospital medicine. But EMS providers and medical directors have to refocus the dialogue and remember that EMS care is medical care, and it should be shaped by the best available medical evidence, not by our own desires or traditions. It’s not about us; it’s about our patients.
David Cummins, MD
Valparaiso, Indiana

Author Tony Garcia, BS, BSN, RN/EMT-P, responds:
I appreciate a healthy debate; it keeps the mind sharp. Although here, I’m not sure Dr. Cummins and I are that far apart. I tried to maintain a certain degree of neutrality while writing the article since I’ve witnessed the good, bad, and the ugly of ETI, both in the field and in the hospital. However, I’m a firm believer that the “art” of airway management has been lost to an over-emphasis in ETI.

Dr. Cummins is correct; evidenced-based medicine is here to stay within prehospital care, and it’s a bitter pill for some to swallow. Gone are the days of extrapolating prehospital-based medicine to the field. Yes, some studies have demonstrated that intubating pediatric and trauma patients has reduced survival rates.

However, we must keep in mind that intubating kiddos and trauma patients is a low-frequency/high-difficulty procedure, and the outcomes, if the study were to evaluate the practice in the emergency department, might prove to be similar. We must also understand that one, unreproduced study is not necessarily science.

The answer, I believe, is through a two-tier educational process. The first tier is learning the psychomotor skill itself. When I attended paramedic school in the 1980s, I was required to spend a week (40 hours) in the operating room under the supervision of an anesthesiologist, where I was required to perform a minimum number of “live” intubations. Now, some students graduate with minimal human intubations and some, not any at all. Tier two is all about critical thinking—learning to appreciate when “less is more” in caring for patients.

Airway management is all about oxygenation and ventilation and not inserting a tube. Sometimes a little O2 and bag-valve mask magic go a long way.

CORRECTION
In the September JEMS Case of the Month (“Detective Work: How a complete scene & patient history spared multiple lives), we incorrectly referred to CO monitoring as being non-evasive instead of non-invasive. We apologize for the error. JEMS

This article originally appeared in October 2011 JEMS as “Letters.”

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