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Thu Apr 6 17:51:54 BST 2006

Melissa,

I'm a paramedic, and while I empathize fully with some of your frustration,  
I must respectfully disagree with several of your points.

The evidence surrounding paramedic-performed intubation in the field is  
terrifying. 

The debate isn't in whole about training and experience. Training  doesn't 
always improve things - I have spent perhaps hundreds of hours in  my role 
trying to "train" people how to perform BVM ventilation, and  more recently, 
predict and manage and rescue the difficult and failed  airway. I'm sorry to say, I 
still see hoover-bagging and rather tragic  approaches to capturing and 
controlling the airway. I'm not alone in this  experience. By now I'm sure we've all 
been exposed to, and are hopefully  intimately familiar with Gausche's 2000 
publication of the results of the  California Pediatric Airway Study. As a 
component of that study, an exceptional  training program, facilitated by 
effective and expert faculty, was developed and  provided. Look where it got them. As 
I have seen firsthand, some of the most  experienced clinicians are the most 
arrogant and ignorant. A pervasion of the  mentality "Don't confuse me with the 
facts, I know what I believe!" afflicts our  profession. 

With regard to aspiration, I have to leave science behind and speculate: I  
believe that emesis and aspiration are amongst the most under-reported  
complications of airway management in the field, and it also occurs outside of  the 
setting of cardiopulmonary arrest resuscitation attempts... and I would like  
you to objectively back-up your statement on the effect of prehospital tracheal 
 intubation upon patient morbidity and mortality, and show me ANY  evidence 
(save for a study or two that looked at severe TBI and air  medical transport) 
since ~1984 that supports that claim. If it takes  you a decade and you have 
to embark on a great quest to find the evidence,  we'll all be better for it, 
but, you may find on your journey that reality is  not what you strongly 
believed in your heart to be true.

In my own institution, the members of our critical care transport service  
face the same challenges you describe when you talk about your frustrating day  
in the OR. We get 'skunked' in the OR too - it happens. However, we are 
blessed  with individuals, including anesthesiologists, anesthesia residents, and 
CRNA's,  who freely give their own time to share their experience, as well as  
non-traditional airway experts, including a trauma surgeon who has taken a  
particular interest in airway management who provide our team with important  
learning experiences. We're looking at other ways of getting around the slim  
pickking in the OR, including simulation - we have big plans to utilize  
case-based training specifically related to airway management. This will allow  us to 
let team members play out, in real time, various cases, some of them rare  in 
actual clinical practice, not only practice and develop airway management  
skills, but foster team-building and crisis resource management ability... 

The future of airway management in the field here in the US? Things have to  
change. People are dying needlessly. Some systems do exceptionally well. 
Others  don't. What do I see in common amongst the programs that do well that I  
know of? Good people on the streets, with involved medical directors, supportive 
 EM physicians, and strong PI systems in place.

My personal predictions: Urban systems with rapid transport? No tracheal  
intubation. Supraglottic devices will be used in crash airways (eg codes). A  
responder with RSI, surgical airway skills, etc would be available when needed,  
but, the majority of responders will not be intubating. Suburban and rural  
systems? Certainly these are places where tracheal intubation may have an  
important role in the field, and those places with long transport times are  
perhaps the places that may see actual benefit from  pre-hospital RSI. As I stare 
into my crystal ball, a dichotomy emerges - look at  the environment the 
majority of the major recent studies of out-of-hospital  tracheal intubation take 
place. 

Of course there are paramedics who have exceptionally good airway  management 
abilities. I know emergency medicine physicians who are exceptionally  good 
airway managers. I know anesthesiologists and anesthetists and flight  nurses 
and flight paramedics and respiratory therapists and hospitalists and  
intensivists and pediatricians who are "good" airway managers - and I know MANY  
people in every specialty - anesthesia included - who I wouldn't want near my  
throat with a laryngoscope and tracheal tube even if I were gasping and purple.  
The problem is a number of "good" and "really good" people in a given 
profession  doesn't make up for one poor performer - and there are too many people who  
haven't, and perhaps can't - develop reasonable mastery of these most 
important  skills. 

Perhaps the time is coming for an airway listserve, seeing the amount of  
passion and interest the original query has generated. 

In a message dated 4/6/2006 8:53:17 AM Eastern Standard Time,  
mmarkey at hallrender.com writes:

With all  due respect, I have a different suggestion - how about
anesthetists and  anesthesiologists willingly sharing their knowledge and
giving paramedics  more chances to practice intubation in a controlled
setting 

With all due respect, I have a different suggestion - how  about
anesthetists and anesthesiologists willingly sharing their knowledge  and
giving paramedics more chances to practice intubation in a  controlled
setting (i.e., consider us as important to train as you do  residents,
and stop giving the residents all the tubes).  Last time I  was in the OR
for ET practice, I got 0 chances out of an 8 hour day.   Why?  Because
anesthesia always found a reason to say no -  No,  this patient has caps
on her teeth.  No, this patient is in for elective  surgery.  No, we want
the resident to get some experience.  Not a  very effective investment of
my time.  And not a very appropriate way to  behave, to my thinking.

Experienced paramedics can intubate quite  successfully - and quickly. 
The determining factor is not whether you have  an MD or other degree -
it is the experience.   Experience in  controlled settings helps you
anticipate the problems in the uncontrolled  environment - and helps you
understand when you will be able to get the tube,  and when you just
secure whatever airway you can get and run.

Patients  may or may not have already aspirated - often they haven't,
and the reason  they aspirate is because someone is thumping and pumping
on them.   Having an ET in place saves these patients significant
morbidity and  mortality - and isn't that what this EMS is all about??? 
No, paramedics  shouldn't spend 10 minutes on the scene trying to get an
ET tube in.   That is not the same thing as saying that ET in the field
is  inappropriate.  If you can get a tube quickly, without undue
deprivation  of oxygen, do it.  If you can't, acknowledge you are human,
use an  alternative, and get the patient to definitive care.

The debate about ET  in the field is really a question of ensuring
appropriate training and  experience.  There are lots of medics out there
who would be very happy  to have more experience in controlled settings. 
Any  anesthetists/anesthesiologists willing to help???

"P.S.  If you prohibit pre-hospital intubation absent hundreds  of
intubations (in what time period?), don't forget that residents in  the
EMS fellowships  and flight nurses, etc. won't be able to tube  either,
until they get that many tubes.  In that case, paramedics should  have
the chance to accomplish the same criteria, and we are back where  I
started - it all comes down to providing opportunities for  experience.'
My .02 worth
Melissa

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