I’m sure the headline of this article will have many people lighting up their torches and sharpening their pitchforks, but hear me out before you burn my village down. Most of us have heard and most likely participated in the heated debate about whether or not paramedics should be intubating in the field. If you’ve been reading my blog for any amount of time, you know that I’m no exception. Do I think our industry falls short when it comes to airway management training? You bet. Do I think the solution is to eliminate intubation from the standard scope of practice? No, I don’t. However, we are going to be left with little choice unless we get over ourselves and make the necessary changes to improve our competency in airway management.
I recently read an article by Dr. Minh Le Cong on the Prehospital and Retrieval Medicine blog asking what the “gold standard” of airway management is for paramedics[ref] Prehospital Airway Management – What is the Gold Standard? | Prehospital and Retrieval Medicine
–http://prehospitalmed.com/2014/07/18/prehospital-airway-management-what-is-the-gold-standard/[/ref]. Had I read this article 10 years ago, I would have been painting my face, soaking my torch in kerosene and rallying the villagers to start the witch-hunt. Now after a decade of involvement in management, Q.A. and EMS education, I simply nod my head in agreement. Let’s face it guys, we have some serious work to do. Our educational systems, clinical sites, monitoring procedures, and most importantly, attitudes are all killing us when it comes to airway management.
Allow me to elaborate….
Initial advanced airway management training for paramedic students is highly inadequate. Studies have shown that it takes ER physicians anywhere from 18-35 successful monitored intubations to be considered “competent” and somewhere around 47 to be “good”[ref]Laryngoscopic Intubation: Learning and Performance | PubMed
–http://www.ncbi.nlm.nih.gov/pubmed/12502974[/ref]. Anesthesia residents obviously require much more. Paramedic students? Well, the National Standard Paramedic Curriculum recommends 5. Mind you, paramedics traditionally perform the skill with much less frequency and in much less desirable environments, yet we are expected to be “competent” in the skill. Do you see a problem with that? This is unacceptable and we have to find a way to change this. Having said that, I have to point out some serious obstacles that we face in gaining more monitored experience.
Hospitals and anesthesiologists aren’t exactly making this easy for us. We already have to compete against medical students for intubations during O.R. rotations and fewer and fewer anesthesiologists are allowing paramedics to perform the skill under their supervision. That’s a huge problem and I could write several blog posts on that topic alone. We are also missing out on opportunities as alternative airway devices are taking the place of ET tubes in many procedures. Clearly, getting over this hurdle isn’t going to be easy but something will have to change if we are going to increase our educational standards.
Another issue we have is continuing education and monitoring. Once our paramedics clear their initial training, many of our systems just cut them loose and hope for the best. A few years back, I worked for an EMS service that has a very unique coverage area. Depending on your assignment, you could find yourself working in a busy metropolitan area, or an extremely rural area with a very small call-volume. I knew a few paramedics in the rural stations that went nearly 2 years without attempting intubation. Nothing personal against those paramedics, but do you honestly think they possess the competence and / or confidence to handle a difficult intubation? More importantly, do you think anyone was watching over them to make sure they were practicing the skill enough to maintain competency? The system I mentioned only deploys one paramedic to every call. Imagine a fire-based system that deploys several paramedics to every call. We’ve already established that our paramedics aren’t intubating enough when they are the only advanced provider on scene, imagine having to split that skill between 4 paramedics.
We need to be monitoring our paramedics to make sure they are performing the skill enough to maintain competency. If they aren’t, we need to bring them in for monitored practice and refreshing. We also need to be doing quarterly airway training. The Law Enforcement community figured out a long time ago that most of their officers will go their entire career without firing a shot. They also recognized that if that time came, they had better be able to react appropriately and hit their target. That’s why they have to qualify with their firearms quarterly. We need to be doing the same.
One of the biggest things we need to change is our attitudes towards airway management. Back in 2010, there was a panel discussion on JEMS.com about the issue. I think William Gandy hit the nail on the head when he said: “Paramedics should be thoroughly schooled in airway evaluation and should have a variety of airway adjuncts, such as bougies, video laryngoscopy and supraglottic airways, available and be willing to use them“[ref]Experts Debate Paramedic Intubation | JEMS
–http://www.jems.com/article/patient-care/experts-debate-paramedic-intub[/ref]. The 4 words to take away from that sentence are “WILLING TO USE THEM”. I’m going to come right out and plead guilty to previously possessing the mindset that airway management revolved around direct laryngoscopy and that the use of any additional tools somehow made me less of a paramedic. Many of us in EMS still possess that mindset and it is killing patients.
If police officers approached every aggressive subject thinking “should I shoot him?” as opposed to “how can I stop the threat?” we would have a lot more officer-involved shootings. The same goes for airway management. We think we are doing our patients good by intubating everyone that presents with anything above a moderate level of distress. The truth is, we aren’t. In the cases where intubation is actually indicated, we have a huge potential to save a life. However, using the tool prematurely or inappropriately can be extremely detrimental and often fatal. For example; the bad CHF or COPD cases. These people often can’t come off the ventilators and therefore wind up dying in the ICU. In those specific cases, we need to be trying everything from medications to CPAP before even considering intubation. Just like the law enforcement analogy, we can’t approach every patient thinking: “Should I tube them?” Or even worse: “Can I tube them?” We need to be thinking about how we can improve ventilation and oxygenation.
When it comes to intubating, we have this terrible habit of making it as difficult as we possibly can. Every time I hear the “we intubate in ditches while it’s raining” BS, I wan’t to choke someone. Why on Earth would anyone elect to intubate anyone in anything but the most convenient and practical location possible? I’ll tell you why: Because we don’t take it seriously. While there are those select few times that we will find ourselves forced to intubate in difficult environments, they are extremely rare and should be avoided at all costs. With every time that we place a blade we are causing damage, pain and potentially negative neurological effects such as increased ICP. We need to be approaching every case with the intention to intubate on the first try. That means having suction ready, having different size blades nearby, properly positioning the patient and using apneic oxygenation. It also means getting off our high-horse and using every available tool to make the intubation as easy and safe as possible. Got a bougie? Use it! Got a video laryngoscope? Then why in God’s name are you using a regular laryngoscope? The “I don’t need it” attitude is dangerous and it kills patients.
If you’re a paramedic working in the field, don’t wait for your employer to hold your hand and force you to practice. You can be the change we need. Stay up to date on your skills. Take 30 minutes each month and go practice on the airway manikins. Talk to your medical director and ER docs and see what you can learn. Whatever you do, don’t just sit around and complain that “The Man” is trying to take away your ability save lives and stamp out disease. If you read the previously mentioned JEMS panel, you will see that nobody is out to abolish prehospital intubation…..yet. That can and will change if we continue down this path.