Study Reports Increased Proficiency in Prehospital ETI - Training - @

Study Reports Increased Proficiency in Prehospital ETI

More exposure means more accuracy



Keith Wesley, MD, FACEP | Marshall J. Washick, BAS, NREMT-P | | Friday, August 13, 2010

Review of: Warner KJ, Carlbom D, Cooke CR et al. Paramedic training for proficient prehospital endotracheal intubation. Prehosp Emerg Care. 2010;14:103–108.

The Science:
This study is a retrospective analysis of a prospective cohort of paramedic students and their prehospital endotracheal intubation (ETI) success rates. The goal of the study was to examine the relationship between the number of prehospital ETI attempts and the likelihood of success, specifically on the first pass of an endotracheal (ET) tube. Furthermore, the paramedic program is a university-based program with access to a substantial amount of resources.

The authors reported the following results: Over a period of three years, 56 paramedic students attempted 576 prehospital ETIs. The odds of overall ETI success were associated with cumulative ETI experience (odds ratio [OR] 1.097 per encounter, 95% confidence interval [CI] = 1.026–1.173, p = 0.006). The odds of first-pass ETI success were associated with cumulative ETI experience (OR 1.061 per encounter, 95% CI = 1.014–1.109, p = 0.009).

The authors concluded an increase in success rates for ET tube placement was associated with the number of ETI experiences. They go on to say that first-pass success rates require a substantial number of attempts that may go beyond what most paramedic programs can reasonably provide.

The Street
Medic Marshall: I can hear it now … another nail in the coffin for prehospital intubation. Well, I have to say I’m starting to believe it; I don’t necessarily disagree with the study. How can anyone, in good faith and judgment, honestly believe they can get every tube every time? I certainly can’t, and if it means the patients suffer as a result, then I’m not being the best paramedic I can be. Personally, I think intubation has become more of an ego trip for medics than anything else. Who hasn’t heard one of their colleagues bragging about the number of “tubes” they have under their belt?

This study really highlighted that even in an educational setting, with access to numerous resources, the paramedic students could achieve only a 65% first-pass success rate, and they encountered a need for ET tube placement an average of 29 times per year. I’m sure there are services out there with high rates of ETI attempts for their medics, but they aren’t the norm.

Is there a solution to overcoming the difficulties of and barriers to prehospital ETI? Are $5,000 fiber-optic laryngoscopes the way to go? I don’t know, but tell me which service director is going to shell out that kind of money to stock their entire ALS fleet—even if they were proven to improve ETI rates.

Doc Wesley: By now, every medic reading this column knows how controversial prehospital intubation has become. The question they all ask is, “OK, so what do I need to do to be proficient at this skill?” This study, which comes from one of the highest performing systems in the U.S., indicates that intubation proficiency is related to the frequency that the provider performs it. Well, duh!

Although this comes of no surprise, the point is that the paramedic students in this program performed, on average, 29 intubations in the clinical setting and 10 in the field. Despite this phenomenally high rate, they achieved only a first-pass success rate of 65%.

Most medical directors consider intubation proficiency a 90% first-pass and 95% total success rate. So the question is if students attending a program that allows on average 39 intubation attempts attain only a 65% success rate, what hope is there for the rest of us who don’t have the luxury of providing for our students a similar manner? What do we do with the students and medics we have now who can go one or more years without a prehospital intubation?

I don’t believe there’s a satisfactory answer to these questions, and we may be forced to either accept a lower success rate or reconsider the role of prehospital intubation. 

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Keith Wesley, MD, FACEP

Keith Wesley, MD, FACEP, is the Minnesota State EMS medical director and the EMS medical director for HealthEast Ambulance in St. Paul, Minn. and and can be reached at


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Marshall J. Washick, BAS, NREMT-Pis a paramedic and the peer-review/research coordinator for HealthEast Medical Transportation. He can be contacted at


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