I understand the uproar from both sides. I get that in some cases, medics carrying around an intubation kit are more of liability than an asset. Do I think that these medics represent the majority of us? No. But I also know that the bad typically overpowers the good.

I’m all for “evidence based medicine”, but nobody is saying that the “evidence” shows that intubation is harmful or doesn’t benefit the patients in need of a secured airway. What our “evidence” is showing, is that paramedics intubating can be harmful. If the procedure was so harmful, then why aren’t ER physicians moving away from the skill? OK, so it’s a problem with the person, not the skill. Now granted, I’m just a dumb-ass paramedic, but one would think that if paramedics across the nation are having this problem, then wouldn’t the people in charge of setting our training standards share a large portion of the blame? Look at the most common denominator here.

What people aren’t talking about is the fact that this problem stems much further then airway management. These paramedics aren’t just screwing up intubation, they are the same people that can’t differentiate between pneumonia or CHF. They are the same people that can’t remember a pediatric dose. They are the same people that can’t start IVs, interpret ECG’s, identify signs of shock, etc. These are bad paramedics. Sure there are exceptions to the rule, and I know that I’m going out on a limb by saying this. But if you disagree, then prove me wrong.

I’m really not trying to piss off my fire buddies by saying this, but a lot of these problems come from people going to paramedic school for only one reason. To get hired by a fire department. If you look at paramedic school as a prerequisite as opposed to a goal, then you are dangerous.  To the fire departments that require a paramedic license as a prerequisite to get hired, you are dangerous. And to the departments (fire, 3rd service, private, whatever) who insist that you need to have 4+ paramedics on scene to manage a medical call, you are dangerous. Let me get the record straight here before my hate-mail box fills up, I am NOT blaming this problem on fire-based EMS. What I am saying is that agencies that more or less send people to paramedic school “against their will” and then address the issue of incompetent providers by throwing more of them at each call play a huge part in this.

One thing that I have always admired about public safety agencies is that they train often. Police offers are required to qualify several times a year doing something that they may never do their entire career. Fire their weapon. Fire departments spend most of their time training on the thing they do the least of. Fighting fires. Don’t get me wrong here, I’m not bashing either branch of public safety. What I’m doing is pointing out that they recognize that they don’t perform a skill very often and train often to stay sharp. As EMS providers, the thing we do the least of is treat and transport the critically ill and injured. Ironic isn’t it?

We as providers can’t put all the blame on our employers for not providing training. As care providers, we do have a responsibility to maintain our skills. Getting the airway dummy out once a month and practicing for 30 minutes can do a world of good. Ideally, paramedics would be reviewing their books, reading case studies, participating in base station meetings and taking every opportunity that they can to learn something. But I guess if this was a perfect world then ammo would be cheap and French-Fries would be healthy.

So I guess it goes without saying that I am against removing intubation from our scope of practice. It’s not because of pride. When Lidocaine was replaced by Amiodarone, I didn’t cry or lose sleep. But that’s because science advanced and the rest of the medical community was already making the change. When ER’s, OR’s and ICU’s start kicking the ET tube to the curb, then I’ll be more than happy to follow along. But don’t start cutting my scope down because the guy in the ambulance next to me is incompetent.

We have to address the whole problem. We can’t just keep taking skills away as a means to address these issues. What’s next after intubation? Cardioversion? Defibrillation? Medications? With all the ambulance crashes happening across the country, why not just stop transporting patients? Incompetent providers will still be incompetent providers no matter how many skills you take away.

I took a job as a paramedic supervisor about 3 years ago. Since then, the amount of calls that I run have decreased by more than half. I went from intubating multiple times a month to once every 4-6 months. While my anxiety level has gone up in fear of being out of practice, I still manage to successfully intubate pretty much every time. It’s just not that hard.

Let’s take a look at other skills that we perform far more often than intubation and compare the level of difficulty.

I’ll start with the everyday task of starting IVs. This is arguably more difficult than intubating. The only reason people don’t freak out over it is because it’s not a life-or-death procedure. There are far more people out there with bad veins than there are people with difficult airways. Paramedics miss a hell of a lot more IVs than they do intubation attempts. Sure, you can argue that the volume of people that require IVs is much greater, therefore the numbers are skewed. But think about this: If we start so many IVs every day, shouldn’t we be really good at it? Likewise, if intubation is a skill that is considered to be difficult AND we don’t get to do it very often, then why do so many areas have success rates in the high 90 percentile?

I’ll even take it down a notch and compare intubation to a BLS skill, the traction splint. I will argue any day that applying a traction splint is far more difficult than intubating. Dealing with a screaming patient who just broke a femur exceeds visualizing vocal cords hands down.

I really wish that we would look at solutions to these problems other than taking away the skill. If we have people in the field that can’t handle the simple task of securing an airway, then maybe they shouldn’t be paramedics.

Anyone care to argue?

No way Sean! Say it aint so!

Unfortunately this could be a reality in the near future. In California, there is a large push to pull intubation from the scope of paramedics. In L.A. County, they already removed pediatric intubation. Many of the “higher-ups” are starting to think that the skill is unnecessary in a pre-hospital setting.  Some actually believe that intubation is too risky to be performed by paramedics. Scary thought huh?

This all sparked from a couple EMS systems (I wont mention names) that have a big problem with intubation. Success rates averaging around 60% in these areas having raised quite a few eyebrows. Unfortunately these areas make up a large portion of the state. While it is clear that some areas have a problem, I think that this is the wrong way to go about fixing it.

This trend of “dumbing down” EMS really troubles me. I can’t think of any other profession that takes away responsibilities at the first sign of incompetence. I wouldn’t want cops to have their guns taken away for having a bad day at the range. I would expect that the areas of deficiency be addressed by training, refresher courses, skills labs, etc.

Intubation is an extremely valuable procedure that we do. I mean sure, secondary airways like Combitubes or King Airways WORK but they are counter productive when the receiving ER doc pulls them immediately upon arrival to place an ET tube. It is not a difficult skill and there is absolutely no reason why we can’t be proficient at it.

I know that a lot of this is just talk right now, but it scares me to think that our leaders are even considering it. I want to see EMS continue to move forward and advance. This is certainly not the way to do it.

According to the American Heart Association, other procedures like IV access and medication adminstration can be performed before intubation if adequate ventillations are taking place by means of a bag-valve-mask. While I certainly agree with the concept, I do not feel that it is very practical for situations when EMS is involved. Unlike hospital settings, EMS workers have to deal with bumpy roads, tight corners, environmental factors and limited room in most ambulances. It can be extremely difficult to maintain a good seal and adequately ventilate a patient in those conditions.

Early intubation frees up hands, limits the amount of time suction is needed and allows paramedics to focus on interventions like chest compressions, defibrillation and medication adminstration.

I am not saying that I completely dissagree with the new ACLS guidelines. I simply feel that pre-hospital care was not taken into consideration when they were released. I would be interested to see how much of the Heart Association’s research was done on pre-hospital cases.

As always, feel free to e-mail me with any questions or comments.